nanaokunote

700021591

230831

[exam findings]

• 2023-06-28 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in both rib cages, maxilla, mandible, some C-, T- and L-spine, right sternoclavicular junction, bilateral shoulders, elbows, and knees.
• 2023-06-27 MRI - larynx
  • Impression (Imaging stage): T: T3(T_value) N: N1(N_value) M: M0(M_value) STAGE: ____(Stage_value)
• 2023-06-27 SONO - abdomen
  • Liver cyst, right lobe
  • Gall stone
• 2023-06-27 EGD
  • Reflux esophagitis LA Classification grade A
  • Hiatal hernia
  • Heterotopic gastric mucosa, upper esophagus
  • Superficial gastritis, s/p CLO test
  • Dudenal ulcer and ulcer scar, bulb
• 2023-06-08 Patho - tonsil and/or adenoid
  • Labeled as “left tonsillar tumor”, excisional biopsy — poorly differentied squamous cell carcinoma.
  • Section shows poorly differentied squamous cell carcinoma. Margin (+).
  • IHC stains: EBER (-), p16 (+), HPV (-).
• 2023-06-03 Nasopharyngoscopy
  • Finding: left odynophagia for months
  • Conclusion: left tonsillar tumor+, airway patent
• 2023-02-01 Neurosonography
  • Mild atheromatous lesions in R CCA bifurcation and ICA.
  • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows except elevated flow velocity in R M1 (PS/ED= 124/42 cm/s)

[MedRec]

• 2023-07-04 SOAP Hemato-Oncology He JingLiang
  • P: Tx: Bio-RT (erbitux weekly)
• 2023-07-04 SOAP Ear Nose Throat Huang YunCheng
  • O: staging cT3N1M0, p16+, stage II suggest CCRT
• 2023-07-04 SOAP Radiation Oncology Chang YouKang
  • A: IMP: Left tonsillar caner, PD SqCC, with left level II LAP metastasis, cT3N1M0, p16+, stage II.
  • Plan: CCRT to left ORX tumor and level II LAP for 7140cGy/34 fx is suggested for locoregional control. CT simulation on 7/04; possible treatment toxicity is told; diet education is given.
    • Refer to Medical Oncology for Bio-RT (weekly cetuximab).
• 2023-07-01 SOAP Oral and Maxillofacial Surgery He ChengHan
  • Problem:
    • Squamous cell carcinoma of left tonsil
    • retained root of tooth 38 and 48
  • Plan:
    • explain the risk/benefit of dental extraction prior to radiotherapy
    • sign the informed consent
    • block anesthesia of bilateral mandible
    • complicated extraction of tooth 38 and 48
    • medication
    • teach him how to do home care
  • Prescription
    • Acetal (acetaminophen 500mg) 1# PRNTID
    • amoxicillin 250mg 2# Q8H
• 2023-06-26 ~ 2023-06-28 POMR Ear Nose Throat Huang YunCheng
  • Discharge diagnosis
    • Malignant neoplasm of tonsil, unspecified
  • CC
    • left odynophagia noted for months
  • Present illness
    • This is a 79-year-old man with past history of prostate cancer status post operation
    • He had been suffered from left odynophagia for months. No dysphagia or hemoptysis was noticed. He was then brought to our OPD for help. Scope showed smooth nasopharynx with left tonsillar tumor. Excision of the tumor was done, and the pathology report prooved malignancy. Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of left tonsillar cancer, the patient was admitted for cancer work-up.        
  • Course of inpatient treatment
    • After admission, serial tests were arranged for tumor staging work up. Abdominal sonography showed right hepatic cyst. Upper GI pandescopy revealed no evidence of metastatic lesion. Consulted OS for dental evaluation was done, and tooth extraction will be arranged on this W6. Under relative stable condition, the patient was dishcarged with OPD follow up
  • Discharge prescription
    • cephalexin 500mg 1# Q6H
    • Acetal (acetaminophen 500mg) 1# Q6H
• 2023-06-03 SOAP Ear Nose Throat Huang YunCheng
  • S: left odynophagia for months
  • O: NP scope: left tonsillar tumor, Np was smooth
  • Prescription
    • Comfflam Spray (benzydamine) 3 puff TID MOSP
• 2021-01-11 SOAP Ear Nose Throat Huang YunCheng
  • S
    • lump in throat for long time, patient has strong gap reflex, hard to assess NP and larynx by mirror
    • cough and sorethroat for few days with purulent NR
  • O
    • Nasopharyngoscope findings: Smooth NP, Laryngx: mild edematous change of laryngeal mucosa
  • Prescription
    • Nasonex Aqueous Nasal Spray (mometasone) 2 puff QD
    • Actein Effervescent (acetylcysteine 600mg) 1# BID

[surgical operation]

[radiotherapy]

[immunochemotherapy]

• 2023-07-21 - cetuximab 400mg/m2 400mg 2hr (CCRT)
  • acetaminophen 500mg PO
• 2023-07-14 - cetuximab 400mg/m2 400mg 2hr (CCRT)
  • acetaminophen 500mg PO
• 2023-07-07 - cetuximab 400mg/m2 400mg 2hr (CCRT)
  • acetaminophen 500mg PO

700282560

230831

[diagnosis] - 2023-04-06 admission note

• Acute promyelocytic leukemia, not having achieved remission
• Gout, unspecified

[lab data]

2023-06-28 CMV IgM Nonreactive
2023-06-28 CMV IgM Value 0.04 Index
2023-06-28 FLT3/ITD Presence of mutation * 2023-06-28 NPM1 Undetectable
2023-06-28 PML-RARA 0.0000
2023-06-28 BCR／abl Undetectable
2023-06-28 CMV viral load assay Target not detecetedIU/mL

2023-04-22 CMV IgM Nonreactive
2023-04-22 CMV IgM Value 0.08 Index
2023-04-22 CMV_IgG Reactive
2023-04-22 CMV_IgG Value 49.0 AU/mL

2023-02-01 CMV viral load assay Target not detecetedIU/mL

2023-01-27 CMV_IgG Reactive
2023-01-27 CMV_IgG Value 22.8 AU/mL
2023-01-27 CMV IgM Nonreactive
2023-01-27 CMV IgM Value 0.12 Index

2023-01-20 BM chromosome analyz
- CYTOGENETICS LABORATORY REPORT - Chromosome Analysis： - Tissue Examined：Bone marrow - Staining Method：G-Banding - Colony number：NA - Bands level：350 - Chromosome Counts： - 45-()、46-(20)、47-()、Other-() Total-(20) - Karyotype：46,XY[20] - Interpretation： - Analysis of this bone marrow sample shows a male having 46,XY[20] karyotype. No chromosomal abnormality was detected. - Note： - ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

2023-01-17 FLT3-D835 Undetectable
2023-01-12 PML-RARA Presence of mutation *

2023-01-12 BCR/abl Undetectable
2023-01-12 FLT3/ITD Presence of mutation * 2023-01-12 NPM1 Undetectable

2023-01-10 CMV IgM Nonreactive
2023-01-10 CMV IgM Value 0.21 Index
2023-01-10 CMV_IgG Reactive
2023-01-10 CMV_IgG Value 11.8 AU/mL
2023-01-10 Anti-HBc Nonreactive
2023-01-10 Anti-HBc-Value 0.70 S/CO
2023-01-10 HBsAg Nonreactive
2023-01-10 HBsAg (Value) 0.33 S/CO
2023-01-10 Anti-HCV Nonreactive
2023-01-10 Anti-HCV Value 0.13 S/CO

[exam findings]

• 2023-06-01 CXR
  • Increased lung markings on both lower lung are noted.
• 2023-06-20 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Acute myeloid leukemia
  • Microscopically, it shows hypercellularity of marrow (approximately > 95%). Blasts are markedly increased in numbers (> 40%) and highlighted by CD34 and CD117.
  • Immunohisotchemical stain reveals CD138 (focal+, 1~2%), MPO (+), CD71 (focal+, sparse), CD61 (focal+, sparse), TdT (focal +).
• 2023-04-07, -02-27, -02-21 Body fluid cytology - CSF
  • negative
• 2023-02-02 SONO - abdomen
  • splenomegaly
  • accessory spleen
• 2023-01-19 Patho - bone marrow biopsy
  • Bone marrow, iliac, s/p chemotherapy, biopsy — hypocellularity.
  • IHC stains: CD117: <1 %; CD34: <1 %; MPO: 45-50%, CD61: <5 %; CD71: 45-50 % (of the nucleated cells).
  • REFERENCE: S2023-00105: Bone marrow, biopsy — Compatible with acute myeloid leukemia
  • Section shows piece(s) of bone marrow with 10% cellularity and M:E ratio of approximately 1:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are reduced in number.
• 2023-01-10 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (143 - 44) / 143 = 69.23%
    • M-mode (Teichholz) = 69
  • Conclusions
    • Dilated LV; normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR; mild PR.
    • PICC catheter in right atrium.
• 2023-01-03 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with acute myeloid leukemia
  • The sections show hypercellular marrow (90%). The marrow space is replaced by a population of medium to large-sized immature cells with oval nucleus and moderate amount cytoplasm. The CD71+ erythroid precursors are marked decreased. Increased CD34+ and/or CD117+ blasts, constitue 40% of marrow cells. Some of blasts are positive for MPO (50%). Scattered CD68+ cells (10%) can be found. The finding is compatible with acute myeloid leukemia. Suggest bone marrow smear evaluation and clinic correlation.
• 2023-01-02 CT - abdomen
  • History and indication: Suspect perirectal abscess
  • IMP:
    • Wall thickening of rectum with adjacent fat stranding suspected malignancy.
    • Some LNs (up to 0.9cm) at paraaortic region.
    • Some calcifications at right adrenal gland.
    • Splenomegaly with focal low attenuation suspected infarct.
• 2023-01-02 Anoscopy
  • Findings
    • Stool color: normal
    • Rectal mucosa: normal
    • Anal canal: abnormal
  • Impression
    • Bloody mucus in rectum
    • Rectal edema at left & right lateral, anterior wall

[consultation]

• 2023-07-28 Colorectal Surgery
  • Q
    • The 37 y/o man has AML /p chemotherapy with neutropenic stage. Due to anal pain and swelling, so we need your help for management.
  • A
    • This is a 37- year old man with anal pain for days
    • DRE:
      • anal fissure over 6 and 12 o’clock region, swelling over anal region
      • no obvious abscess formation
    • A: perianal pain and anal fissure, R/I AML induced
    • P:
      • warm water sitz bath
      • alcos anal ointment topic use
      • pain control
      • control underlying disease
• 2023-07-05 Denatal
  • Q
    • This 37 year old male is a case of Acute promylocytic leukemia status post induction chemotherapy with D3A7 on 2023/01/09, Consolidation chemotherapy with D3A7 plus weekly IT on 2023/02/20, transformation to Acute myeloid leukemia, FLT3/ITD mutation in 2023-06. FLAG was administered on 2023/06/21-27. However, a swelling mass was noted on left buccal. We need your expertise for further management, thanks
  • A
    • Patient complains of left lower facial pain.
    • Take panoramic radiography for examination.
    • #35 suspect dental caries with no symptoms.
    • Oral hygiene instructions with ultra-soft tooth brush.
    • Suggest follow up closely and visit dental OPD endodontic clinic if symptoms persist.
• 2023-05-02 Dermatology
  • Q
    • for skin rash, redness and itchy around waist, and bilateral groins due to suspect allergy
    • This 36 y/o male patient is a case of acute promyelocytic leukemia post induction chemotherapy. Due to neutropenia fever, so gave antibitic with Cefepime, Targocid treatment since 2023/04/19, then he suffered from skin rash, rednessand itchy around waist, and bilateral groins due to suspect allergy.
    • We would like to consult your expertise, thank you!
  • A
    • The patient had sufferred from erythematous macules with hyperpigmentation change over trunk and axilla.
      
    • Under the impression of frictional eczema with secondary candidasis infestation.
    • The following suggetion:
      • keep regional body dry and clean.
      • Zalaine cream 1 tube topical QN use for large area of the pigmetation lesions and Mycomb cream 1 tube topical bid use over itchy lesions.
      • consider sinbaby lotion 1 bot topical PRN use for body occlussion/pruritus control.
• 2023-03-15 Colorectal Surgery
  • Q
    • This is a 36 years old male with acute promylocytic leukemia and perineal abscess under chemotherapy
    • He suffered from intermittent perianal pain and swelling. High fever was noted and perianal pain progressed. He denied diarrhea or constipation. He visited our CRS outpatient department for help. Digital rectal examination showed no blood on the finger, nor palpable mass in the distance of finger length, nor palpable abscess cavity. Anoscopy showed normal color stool, normal rectal mucosa, while bloody mucus in rectum, rectal edema at left & right lateral, anterior wall were noted.
    • We would like to consult your expertise, thank you!
  • A
    • DRE: mild tendernes(+), no definite perianal abscess or fistula formation, mild hemorrhoids
    • A: Anal pain, R/O perianal infection
    • P:
      • Neomycin ointment bid use
      • Because no definite perianal abscess or fistula formation, surgical intervention is not necessary at present
      • CRS OPD follow-up
      • Please inform us if any problems
• 2023-03-07 Infectious Disease
  • Q
    • Backline controlled antibiotics, consultation with an infectious disease specialist is required.
  • A
    • This is acse of AML with neutropenic fever.
    • Agree with your use of mepem and targocid.
    • Please adjust antibiotic according to culture results and clinical conditions.
• 2023-01-28 Colorectal Surgery
  • Q
    • This 36 y/o male patient is a case of acute promyelocytic leukemia post induction chemotherapy with WBC tending to improve but still in severe neutropenic stage. We need your expertise for anal pain evaluation and recommendation, sincerely thanks.
  • A
    • I’ve visited this case.
    • PR: left lateral perianal superficial fistula tract and shallow ulcer, well drained  no abscess formation and no perianal infection sign
    • Suggestion
      • Treat underlying disease
      • Biomycin oint topical use
      • Pain control using NSAID or Paran (acetaminophen) if no contraindication
• 2023-01-03 Hemato-Oncology
  • Q
    • For suspect acute leukemia,
    • This 36 year old man without underlying history was admitted with suspect perianal abscess.
    • Digital rectal examination showed no blood on the finger nor palpable mass in the distance of finger length. No palpable abscess cavity.
    • Anoscopy showed normal color stool, normal rectal mucosa, bloody mucus in rectum, rectal edema at left & right lateral, anterior wall.
    • Lab data showed
      • WBC (163720), Blast (66%), promyelocyte (3%), myelocyte (1%), metamyelocyte (1%)
      • Hb (9.4), PLT (26000), Cr (1.56), total bilirubin (2.6), AST (75), ALT(65)
      • Under the impression of suspect perianal abscess and suspect acute leukemia, he was admitted to our ward for further care.
  • A
    • Recommendation:
      • bone marrow with special stain, flowcytometer and chromosome study is indicated for this patient.
      • alkalinzation of urine with sodium bicarbonate to prevent tumor lysis syndrome
      • emperic antibiotics

[chemotherapy]

• 2023-07-19 - fludarabine 30mg/m2 50mg NS 100mL 30min D1-6 + cytarabine 2000mg/m2 4200mg NS 500mL 4hr D1-5 (FLAG, Q4W)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-6
• 2023-06-21 - fludarabine 30mg/m2 50mg NS 100mL 30min D1-6 + cytarabine 2000mg/m2 4200mg NS 500mL 4hr D1-5 (FLAG, Q4W)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-6
• 2023-04-12 - [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal)
• 2023-04-07 - daunorubicin 45mg/m2 90mg NS 100mL 30min D1-3 + cytarabine 2000mg/m2 4000mg NS 500mL 3hr Q12H D1-5 + [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal) D1
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
• 2023-02-27 - [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal)
• 2023-02-23 - daunorubicin 45mg/m2 80mg NS 100mL 30min D1-3 + cytarabine 200mg/m2 390mg NS 500mL 24hr D1-7
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3
• 2023-02-21 - [cytarabine 50mg + methotrexate 12mg + hydrocortisone 30mg] IT (intrathecal)
• 2023-01-09 - idarubicin 12mg/m2 24mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 200mg NS 500mL 24hr D1-7
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1

Granocyte (lenograstim 250ug) CGRAN01

• 2023-03-03 ~ 2023-03-14
• 2023-01-18 ~ 2023-01-31

G-CSF (filgrastim 150ug) CGCSF01

• 2023-03-03 ~ 2023-03-14
• 2023-01-18 ~ 2023-01-31

2023-01-13 - tretinoin 50mg

[note]

Rydapt (midostaurin) https://www.uptodate.com/contents/midostaurin-drug-information

• Dosing - Adult - Acute myeloid leukemia (AML), FLT3-positive: Oral:
  • Induction: 50 mg twice daily on days 8 to 21 of each induction cycle (in combination with daunorubicin and cytarabine); administer a second induction cycle if there is definitive evidence of (clinically significant) residual leukemia.
  • Consolidation: 50 mg twice daily on days 8 to 21 of each 28-day consolidation cycle (in combination with high-dose cytarabine) for 4 consolidation cycles.
  • Maintenance (off- label): 50 mg twice daily on days 1 to 28 of each 28-day maintenance cycle for 12 cycles or until relapse, whichever occurs first.

Chemotherapy regimens for relapsed or refractory acute myeloid leukemia (AML) in adults — 2023-07-04 - https://www.uptodate.com/contents/image?imageKey=HEME%2F82823

• Cytarabine plus daunorubicin
  • Common nonhematologic side effects seen in the majority of patients include stomatitis (mostly mild), alopecia, nausea and vomiting (10 percent severe), and diarrhea (mostly mild). Daunorubicin can be associated with an infusion reaction and cardiac arrhythmias; a flu-like syndrome and rash due to cytarabine may be seen during induction.
  • Re-induction with cytarabine plus daunorubicin will produce a complete remission in approximately 50 percent of patients with a first remission lasting longer than one year[1].
• High-dose cytarabine (HiDAC)
  • The most common nonhematologic toxicities are nausea and vomiting, abnormal liver chemistries, diarrhea, conjunctivitis, rash, and cerebellar dysfunction. Toxicity is high in most patients over the age of 60 years.
  • HiDAC may be effective in 35 to 40 percent of patients resistant to conventional dose cytarabine regimens[2].
• High-dose cytarabine plus mitoxantrone (HAM)
  • In addition to the side effects described for HiDAC above, nonhematologic toxicities include stomatitis, infections, and neutropenic fever. Infrequent transient, mild cardiac failure and tachyarrhythmias have also been reported.
  • If an anthracycline (eg, daunorubicin) was not used during initial induction, the combination of HiDAC plus the synthetic anthracycline analogue, mitoxantrone, may produce higher response rates than HiDAC alone[3].
• High-dose cytarabine plus etoposide
  • In addition to the side effects described for HiDAC above, nonhematologic toxicities include hepatic toxicity, peripheral neuropathy, and anaphylactic-like reaction.
  • HiDAC plus etoposide results in similar response rates as HiDAC alone with a nonsignificant trend towards longer remission duration[4].
• Mitoxantrone plus etoposide
  • Nonhematologic toxicities include stomatitis, nausea, infections, and neutropenic fever. Infrequent transient, mild cardiac failure and tachyarrhythmias have also been reported.
  • Mitoxantrone and etoposide given together for five days is a commonly used regimen to treat refractory or relapsed AML and has demonstrated complete response rates of approximately 40 percent[5].
• Mitoxantrone, etoposide, cytarabine (MEC)
  • Side effects are similar to those described for mitoxantrone plus etoposide above, but also include hepatic dysfunction.
  • MEC demonstrates a trend towards higher complete response rates for patients <60 years old and those with unfavorable risk cytogenetics when compared with mitoxantrone plus etoposide alone[6].
• Gemtuzumab ozogamicin (GO) as a single agent or plus cytarabine and mitoxantrone
  • Serious adverse reactions to GO include fatal anaphylaxis, hemorrhage, teratogenicity, and hepatic injury including sinusoidal obstruction syndrome (also known as hepatic veno-occlusive disease), plus side effects similar to mitoxantrone plus cytarabine, above.
  • GO as a single agent or in combination with mitoxantrone plus cytarabine can achieve complete remission in up to 25 to 35 percent[7].
• Fludarabine, cytarabine, plus G-CSF (FLAG)
  • Studies including older adults have reported mild nonhematologic toxicity, most commonly with mucositis.
  • FLAG has reported complete remission rates of 45 to 55 percent in patients with primary refractory or relapsing AML[8].
• Cladribine, cytarabine, G-CSF (CLAG)
  • Nonhematologic toxicity is generally mild to moderate (grade I/II) and includes fever/infection, mucositis, nausea and vomiting, diarrhea, and alopecia.
  • CLAG results in a complete remission in approximately 50 percent of patients, with a median duration of response of 16 weeks[9].
• Cyclophosphamide plus high-dose etoposide
  • The most common non-hematologic toxicities include fever/infection, mucositis, hepatic toxicity, and hemorrhagic cystitis.
  • Approximately 42 percent of patients with resistant AML will achieve a complete remission[10].
• Patients with resistant or relapsed AML should be encouraged to enroll on a clinical trial. While a number of chemotherapy regimens have been used for patients with resistant or relapsed disease, none results in acceptable long term remission rates. Many of these combinations are dose-intensive and cannot easily be applied in older patients. Since these regimens have not been directly compared, a choice is primarily based upon clinical experience and patient co-morbidities. A selection of these regimens is described above. Although response rates are presented for some of these regimens, an individual’s chance of responding to a particular regimen is influenced not only by prior exposure to chemotherapy but also by other patient- and leukemia-associated factors. In theory, the preferred regimen to treat relapsed AML would exclude agents at dose levels which the patient has been exposed to recently.

Cytarabine — 2023-04-12 - https://www.uptodate.com/contents/cytarabine-conventional-drug-information

• Dosing: Adult - Note: Antiemetics may be recommended to prevent nausea and vomiting; IV doses >1,000 mg/m2 are associated with a moderate emetic potential. Consider hydration and antihyperuricemic therapy to prevent tumor lysis syndrome.
  • Acute lymphoblastic leukemia (off-label dosing):
    • Induction regimen, relapsed or refractory: IV: 3,000 mg/m2 over 3 hours daily for 5 days (in combination with idarubicin [day 3]).
    • Dose-intensive regimen: IV: 3,000 mg/m2 over 2 hours every 12 hours days 2 and 3 (4 doses/cycle) of even numbered cycles (in combination with methotrexate; alternates with Hyper-CVAD).
    • CALGB 8811 regimen:
      • Early-intensification phase: SUBQ: 75 mg/m2/dose days 1 to 4 and 8 to 11 (4-week cycle; repeat once).
      • Late-intensification phase: SUBQ: 75 mg/m2/dose days 29 to 32 and 36 to 39.
    • Linker protocol: Adults <50 years of age: IV: 300 mg/m2/day days 1, 4, 8, and 11 of even numbered consolidation cycles (in combination with teniposide).
    • CALGB 10403 regimen (as part of multi-agent, multicourse chemotherapy; refer to protocol for further details):
      • Adults <40 years of age:
        • Remission consolidation phase (course 2): IV, SUBQ: 75 mg/m2 on days 1 to 4, 8 to 11, 29 to 32, and 36 to 39.
        • Delayed intensification phase (course 4): IV, SUBQ: 75 mg/m2 on days 29 to 32 and 36 to 39.
  • Acute myeloid leukemia remission induction
    • Standard-dose; in combination with other chemotherapy agents): IV: 100 mg/m2/day continuous infusion for 7 days or 200 mg/m2/day continuous infusion (as 100 mg/m2 over 12 hours every 12 hours) for 7 days.
    • 7 + 3 regimens (a second induction course may be administered if needed; refer to specific references): IV: 100 mg/m2/day continuous infusion for 7 days (in combination with daunorubicin or idarubicin or mitoxantrone) or (Adults <60 years) 200 mg/m2/day continuous infusion for 7 days (in combination with daunorubicin).
    • Low-intensity therapy (off-label dosing):
      • Adults >=65 years of age: SUBQ: 20 mg/m2/day for 14 days out of every 28-day cycle for at least 4 cycles or 10 mg/m2 every 12 hours for 21 days; if complete response not achieved, may repeat a second course after 15 days.
      • Adults >=60 years of age (and ineligible for intensive chemotherapy): SUBQ : 20 mg/m2 once daily on days 1 to 10 every 28 days (in combination with venetoclax) until disease progression or unacceptable toxicity.
      • Adults >=55 years of age (and unsuitable for intensive therapy): SUBQ : 20 mg (flat dose) twice daily on days 1 to 10 every 28 days (in combination with glasdegib) until disease progression or unacceptable toxicity.
  • Acute myeloid leukemia consolidation (off-label use):
    • 5 + 2 regimens: IV: 100 mg/m2/day continuous infusion for 5 days (in combination with daunorubicin or idarubicin or mitoxantrone).
    • 5 + 2 + 5 regimen: IV: 100 mg/m2/day continuous infusion for 5 days (in combination with daunorubicin and etoposide).
    • Single-agent: Adults <=60 years of age: IV: 3,000 mg/m2 over 3 hours every 12 hours on days 1, 3, and 5 (total of 6 doses); repeat every 28 to 35 days for 4 courses.
  • Acute myeloid leukemia salvage treatment (off-label use):
    • CLAG regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with cladribine and G-CSF); may repeat once if needed.
    • CLAG-M regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with cladribine, G-CSF, and mitoxantrone); may repeat once if needed.
    • FLAG regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with fludarabine and G-CSF); may repeat once if needed.
    • GCLAC regimen: Adults 18 to 70 years:
      • Induction: IV: 2,000 mg/m2 over 2 hours once daily for 5 days (in combination with clofarabine and filgrastim; administer 4 hours after initiation of clofarabine); may repeat induction once if needed.
      • Consolidation: IV: 1,000 mg/m2 over 2 hours once daily for 5 days (in combination with clofarabine and filgrastim; administer 4 hours after initiation of clofarabine) for 1 or 2 cycles.
    • HiDAC (high-dose cytarabine) ± an anthracycline: IV: 3,000 mg/m2 over 1 hour every 12 hours for 6 days (total of 12 doses).
    • MEC regimen: IV: 1,000 mg/m2/day over 6 hours for 6 days (in combination with mitoxantrone and etoposide) or
      • Adults <60 years of age: IV: 500 mg/m2/day continuous infusion days 1, 2, and 3 and days 8, 9, and 10 (in combination with mitoxantrone and etoposide); may administer a second course if needed.
  • Acute promyelocytic leukemia induction (off-label dosing): IV: 200 mg/m2/day continuous infusion for 7 days beginning on day 3 of treatment (in combination with tretinoin and daunorubicin).
  • Acute promyelocytic leukemia consolidation (off-label use):
    • In combination with idarubicin and tretinoin: High-risk patients (WBC >=10,000/mm3): Adults <=60 years of age:
      • First consolidation course: IV: 1,000 mg/m2/day for 4 days.
      • Third consolidation course: IV: 150 mg/m2 every 8 hours for 4 days.
    • In combination with idarubicin, tretinoin, and thioguanine: High-risk patients (WBC >10,000/mm3): Adults <=61 years of age:
      • First consolidation course: IV: 1,000 mg/m2/day for 4 days.
      • Third consolidation course: IV: 150 mg/m2 every 8 hours for 5 days.
    • In combination with daunorubicin:
      • First consolidation course: IV: 200 mg/m2/day for 7 days.
      • Second consolidation course:
        • Age <=60 years and low risk (WBC <10,000/mm3): IV: 1,000 mg/m2 every 12 hours for 4 days (8 doses).
        • Age <50 years and high risk (WBC >=10,000/mm3): IV: 2,000 mg/m2 every 12 hours for 5 days (10 doses).
        • Age 50 to 60 years and high risk (WBC >=10,000/mm3): IV: 1,500 mg/m2 every 12 hours for 5 days (10 doses).
        • Age >60 years and high risk (WBC >=10,000/mm3): IV: 1,000 mg/m2 every 12 hours for 4 days (8 doses).
  • Chronic lymphocytic leukemia (off-label use): OFAR regimen: IV: 1,000 mg/m2/dose over 2 hours days 2 and 3 every 4 weeks for up to 6 cycles (in combination with oxaliplatin, fludarabine, and rituximab).
  • Hodgkin lymphoma, relapsed or refractory (off-label use):
    • DHAP regimen: IV: 2,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) for 2 cycles (in combination with dexamethasone and cisplatin).
    • ESHAP regimen: IV: 2,000 mg/m2 day 5 (in combination with etoposide, methylprednisolone, and cisplatin) every 3 to 4 weeks for 3 or 6 cycles.
    • Mini-BEAM regimen: IV: 100 mg/m2 every 12 hours days 2 to 5 (total of 8 doses) every 4 to 6 weeks (in combination with carmustine, etoposide, and melphalan).
    • BEAM regimen (transplant preparative regimen): IV: 200 mg/m2 twice daily for 4 days beginning 5 days prior to transplant (in combination with carmustine, etoposide, and melphalan).
  • Non-Hodgkin lymphomas (off-label use):
    • BEAM regimen (transplant-preparative regimen): IV: 200 mg/m2 twice daily for 3 days beginning 4 days prior to transplant (in combination with carmustine, etoposide, and melphalan) or 100 mg/m2 over 1 hour every 12 hours for 4 days beginning 5 days prior to transplant (in combination with carmustine, etoposide, and melphalan).
    • Burkitt lymphoma:
      • CALGB 9251 regimen: Cycles 2, 4, and 6: IV: 150 mg/m2/day continuous infusion days 4 and 5.
      • CODOX-M/IVAC regimen:
        • Adults <=60 years of age: Cycles 2 and 4 (IVAC): IV: 2,000 mg/m2 every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
        • Adults <=65 years of age: Cycles 2 and 4 (IVAC): IV: 2,000 mg/m2 over 3 hours every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
        • Adults >65 years of age: Cycles 2 and 4 (IVAC): IV: 1,000 mg/m2 over 3 hours every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
      • Hyper-CVAD alternating with high-dose methotrexate/cytarabine regimen:
        • Adults <60 years of age: Cycles 2, 4, 6, and 8: IV: 3,000 mg/m2 every 12 hours days 2 and 3 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate and leucovorin), alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) plus rituximab (in cycles 1 to 4) and CNS prophylaxis.
        • Adults >=60 years of age: Cycles 2, 4, 6, and 8: IV: 1,000 mg/m2 every 12 hours days 2 and 3 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate and leucovorin) alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) with rituximab (in cycles 1 to 4) and CNS prophylaxis.
    • Mantle cell lymphoma:
      • R-DHAP regimen: Adults <=65 years of age: IV: 2,000 mg/m2 every 12 hours on day 2 (total of 2 doses/cycle) every 3 weeks (in combination with rituximab plus dexamethasone and cisplatin) for 4 cycles or 2,000 mg/m2 every 12 hours on day 2 (total of 2 doses/cycle; in combination with rituximab plus dexamethasone and cisplatin) alternating with R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) for 6 cycles (3 cycles each of R-CHOP and R-DHAP).
      • RBAC regimen: IV: 500 to 800 mg/m2 over 2 hours (starting 2 hours after bendamustine) on days 2 through 4 every 28 days for up to 6 cycles (in combination with rituximab and bendamustine).
      • Nordic regimen:
        • Adults <=60 years of age: IV: 3,000 mg/m2 over 3 hours every 12 hours for a total of 4 doses (in combination with rituximab) for 2 cycles alternating with Maxi-CHOP (dose-intensified CHOP) for 3 cycles (total of 5 cycles).
        • Adults >60 years of age: IV: 2,000 mg/m2 over 3 hours every 12 hours for a total of 4 doses (in combination with rituximab) for 2 cycles alternating with Maxi-CHOP for 3 cycles (total of 5 cycles).
      • Hyper-CVAD alternating with high-dose methotrexate/cytarabine regimen:
        • Adults <=60 years of age: Cycles 2, 4, 6, and 8: IV: 3,000 mg/m2 every 12 hours days 3 and 4 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate, leucovorin, and rituximab), alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, dexamethasone, and rituximab).
        • Adults >60 years of age: Cycles 2, 4, 6, and 8: IV: 1,000 mg/m2 every 12 hours days 3 and 4 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate, leucovorin, and rituximab) alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, dexamethasone, and rituximab).
    • Relapsed or refractory non-Hodgkin lymphomas:
      • DHAP regimen:
        • Adults <=70 years of age: IV: 2,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) every 3 to 4 weeks for 6 to 10 cycles (in combination with dexamethasone and cisplatin).
        • Adults >70 years of age: IV: 1,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) every 3 to 4 weeks for 6 to 10 cycles (in combination with dexamethasone and cisplatin).
      • ESHAP regimen: IV: 2,000 mg/m2 over 2 hours day 5 every 3 to 4 weeks for 6 to 8 cycles (in combination with etoposide, methylprednisolone, and cisplatin).
  • Primary CNS lymphoma (off-label use): IV: 2,000 mg/m2 over 1 hour every 12 hours days 2 and 3 (total of 4 doses) every 3 weeks (in combination with methotrexate and followed by whole brain irradiation) for a total of 4 courses or 3,000 mg/m2 (maximum dose of 6,000 mg) over 3 hours on days 1 and 2 every 4 weeks for 2 cycles (administer cytarabine after 5 to 7 cycles of the induction R-MPV regimen [rituximab, methotrexate, leucovorin, vincristine, and procarbazine] and whole brain radiation therapy) or 2,000 mg/m2 over 2 hours every 12 hours days 1 to 4 (total of 8 doses) as consolidation therapy (in combination with etoposide); cytarabine/etoposide is administered following remission induction with methotrexate, leucovorin, temozolomide, and rituximab.
  • Meningeal leukemia: Intrathecal therapy: Note: Optimal intrathecal chemotherapy dosing should be based on age rather than on body surface area (BSA); CSF volume correlates with age and not to BSA. Dosing provided in the manufacturer’s labeling is BSA-based.
  • Off-label uses or doses for intrathecal therapy:
    • CNS prophylaxis (ALL): Intrathecal: 100 mg weekly for 8 doses, then every 2 weeks for 8 doses, then monthly for 6 doses (high-risk patients) or 100 mg on day 7 or 8 with each chemotherapy cycle for 4 doses (low risk patients) or 16 doses (high-risk patients) or 70 mg on day 1 of remission induction cycle 1 (adults <40 years of age).
      • or as part of intrathecal triple therapy (TIT): Intrathecal: 40 mg days 0 and 14 during induction, days 1, 4, 8, and 11 during CNS therapy phase, every 18 weeks during intensification and maintenance phases.
    • CNS prophylaxis (APL, as part of TIT): Intrathecal: 50 mg per dose; administer 1 dose prior to consolidation and 2 doses during each of 2 consolidation phases (total of 5 doses).
    • CNS prophylaxis (Burkitt lymphoma; component of CODOX-M/IVAC regimen): Intrathecal: 70 mg on days 1 and 3 of cycles 1 and 3 (CODOX-M cycle).
    • CNS prophylaxis (Burkitt lymphoma; component of Hyper-CVAD alternating with cytarabine/methotrexate regimen): Intrathecal: 100 mg on day 7 of each 21-day treatment cycle.
    • CNS leukemia treatment (ALL, as part of TIT): Intrathecal: 40 mg twice weekly until CSF cleared.
    • CNS lymphoma treatment: Intrathecal: 50 mg twice a week for 4 weeks, then weekly for 4 to 8 weeks, then every other week for 4 weeks, then every 4 weeks for 4 doses.
    • CNS treatment (Burkitt lymphoma; component of CODOX-M/IVAC regimen): Intrathecal: 70 mg on days 1, 3, and 5 of cycles 1 and 3 (CODOX-M cycle) and 70 mg on days 7 and 9 of cycles 2 and 4 (IVAC cycle).
    • Leptomeningeal metastases treatment: Intrathecal: 25 to 100 mg twice weekly for 4 weeks, then once weekly for 4 weeks, then a maintenance regimen of once a month or 40 to 60 mg per dose.
  • Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance.

FLAG-IDA for acute myeloid leukemia — 2023-07-04 - https://aml-hub.com/medical-information/flag-ida-for-acute-myeloid-leukemia

FLAG-Ida for Acute Myeloid Leukaemia (AML) — 2023-07-04 - https://media.leukaemiacare.org.uk/wp-content/uploads/FLAG-Ida-for-Acute-Myeloid-Leukaemia-AML-Web-Version.pdf

FLAG (fludarabine + high-dose cytarabine + G-CSF): an effective and tolerable protocol for the treatment of ‘poor risk’ acute myeloid leukemias — https://pubmed.ncbi.nlm.nih.gov/7526088/

• Twenty-eight patients with poor prognosis acute myeloid leukemia (AML) received therapy with two courses of fludarabine 30 mg/m2/day + ara-C 2 g/m2/day (days 1-5) and G-CSF 5 mg/kg/day (FLAG) (from day 0 to polymorphonuclear recovery).

==========

2023-08-01

[pancytopenia]

Rydapt (midostaurin 25 mg) 2# PO Q12H has been initiated since 2023-07-28. The package insert recommends taking the medication with food. Please ensure that the patient takes the medication with food Q12H.

The following adverse drug reactions and incidences are associated with midostaurin:

• Hematologic and oncologic:
  • Anemia (60%; grade >=3: 38%)
  • Leukopenia (61%; grade >=3: 19%)
  • Lymphocytopenia (66%; grade >=3: 42%)
  • Neutropenia (49%; grade >=3: 22%)
  • Thrombocytopenia (50%; grade >=3: 27%)
• Hepatic:
  • Hyperbilirubinemia (29%)
  • Increased gamma-glutamyl transferase (35%)
  • Increased serum alanine aminotransferase (31%)
  • Increased serum alkaline phosphatase (39%)
  • Increased serum aspartate aminotransferase (32%)

Since pancytopenia had already developed before this drug administration, it would be difficult to distinguish to what extent the subsequent pancytopenia would gradually be attributed to midostaurin (if any).

2023-07-27

[pancytopenia]

Both fludarabine and cytarabine, which are components of the FLAG regimen, are known to cause bone marrow suppression, especially fludarabine.

The patient received two cycles of the FLAG regimen, one on 2023-06-21 and the other on 2023-07-19. The first cycle resulted in a 5-day period (2023-06-28 to 2023-07-02) of WBC < 1K/uL, and the second cycle resulted in WBC < 1K/uL since 2023-07-24, which has not yet returned to levels above 1K/uL. Thrombocytopenia was previously mentioned in the pharmacist’s note. The HGB levels show a similar trend to the PLT levels. In addition, the patient has received several blood transfusions this year on different dates (2023-01-02, 2023-01-06, 2023-01-11, 2023-01-18, 2023-01-22, 2023-01-26, 2023-01-28, 2023-01-30, 2023-02-03, 2023-03-03, 2023-03-07, 2023-03-11, 2023-03-17, 2023-04-14, 2023-04-18, 2023-04-22, 2023-04-26, 2023-04-30, 2023-06-19, 2023-06-28, 2023-07-17, 2023-07-21, 2023-07-25) and also received G-CSF in the first quarter of this year.

2023-07-07

The FLAG regimen was initiated on 2023-06-21. However, the current thrombocytopenia event had started even before the regimen was administered. Visually estimating the platelet count before and after the FLAG administration, the values were approximately within the range of 50 +- 25 K/uL, and there was no clear downward trend. This is because the patient had received multiple transfusions to maintain PLT a certain level.

2023-07-06 PLT 55 x10^3/uL
2023-07-04 PLT 25 x10^3/uL
2023-07-02 PLT 48 x10^3/uL
2023-06-30 PLT 23 x10^3/uL
2023-06-28 PLT 62 x10^3/uL Blood Transfution
2023-06-26 PLT 37 x10^3/uL
2023-06-25 PLT 47 x10^3/uL
2023-06-24 PLT 73 x10^3/uL
2023-06-23 PLT 28 x10^3/uL Blood Transfution 2023-06-22 PLT 40 x10^3/uL
2023-06-21 PLT 54 x10^3/uL FLAG 2023-06-20 PLT 47 x10^3/uL
2023-06-19 PLT 19 x10^3/uL Blood Transfution 2023-06-08 PLT 70 x10^3/uL
2023-05-04 PLT 247 x10^3/uL
2023-05-02 PLT 176 x10^3/uL
2023-05-01 PLT 137 x10^3/uL Blood Transfution (2023-04-30)

The risk of bleeding generally increases with platelet counts below 40 to 50 K/uL, but there isn’t a strong linear correlation between platelet count and bleeding risk. If major or life-threatening bleeding occurs, platelet transfusions should be administered without delay.

2023-07-04

[FLT3 inhibitors]

• Laboratory data from 2023-01-12 and 2023-06-28 indicated the presence of FLT3/ITD mutation.

• There are two FDA approved FLT3 inhibitors for AML included in the National Health Insurance Medication Reimbursement Regulations, namely:

  • Midostaurin (such as Rydapt)
    • This is reserved for use in combination with standard induction and consolidation chemotherapy in adult patients newly diagnosed with FLT3 mutation positive AML.
    • Patients with acute promyelocytic leukemia (APL) must be excluded.
    • For first-time use during the standard induction period, pre-examination is not required, and it is limited to two courses. If complete remission is not achieved after two courses, further use is prohibited.
    • For continuous use, it must be approved after pre-examination. Applications must include the results and date of the FLT3 mutation positive test, the record of chemotherapy prescription, and the evaluation of treatment effect. Each renewal application is limited to two courses and must include the evaluation results from the previous treatment to confirm no disease progression. The total treatment courses are capped at six per patient.
    • If a patient undergoes hematopoietic stem cell transplantation, this drug will no longer be covered.
  • Gilteritinib (such as Xospata)
    • This is restricted to use in adult patients with FLT3-mutated relapsed or refractory acute myeloid leukemia (R/R AML) who are planning to undergo hematopoietic stem cell transplantation. It is limited to use before transplantation, with a maximum of six treatment courses per patient. Patients must have received at least one chemotherapy course including an anthracycline drug.

• Currently, Rydapt is a temporarily procured drug at our hospital, and Xospata does not have a built drug code yet. If any of these two drugs is considered further use, a temporary procurement procedure must be carried out.

2023-04-19

[neutropenia follow-up]

• The patient received daunorubicin for a 3-day course and cytarabine for a 5-day course at a dosage of 2000mg/m2 with 4000mg every 12 hours, on 2023-04-07. The patient’s WBC count dropped below 1000/uL beginning on 2023-04-14. As a result, lenograstim at 250ug and filgrastim at 150ug have been given daily from that date onwards. However, the patient’s WBC count has not yet returned to normal levels at this time.
  • 2023-04-18 WBC 0.10 x10^3/uL
    
  • 2023-04-16 WBC 0.15 x10^3/uL
    
  • 2023-04-14 WBC 0.56 x10^3/uL
    
  • 2023-04-12 WBC 1.51 x10^3/uL
• The patient is in good spirits and has no chills. His diet and sleep are satisfactory, and his diarrhea symptoms have improved as of the morning of 2023-04-19.
• Please remain vigilant for any signs of infection.

2023-04-12

[leukopenia]

• On 2023-01-09, the patient started a regimen containing anthracycline and cytarabine (idarubicin for 3 days + cytarabine for 7 days), which led to more than 2 weeks of leucopenia with a WBC count of less than 1000/uL. More than 5 weeks later, on 2023-02-23, the second dose was shifted to daunorubicin for 3 days and cytarabine for 7 days. This time, the duration of WBC less than 1000/uL was approximately halved to 1 week. Although the patient was administered G-CSF (filgrastim 150ug) and Granocyte (lenograstim 250ug) on 2023-03-03, WBC count did not appear to increase soon after.

• On 2023-04-07, the patient received daunorubicin for 3 days and cytarabine for 5 days at a more intensive dose of 2000mg/m2 amounting to 4000mg every 12 hours. After the administration, the WBC count has not dropped below 1000/uL and there has been a reduction in the severity of leukopenia to date.

• WBC lab data

  • 2023-04-12 WBC 1.51 x10^3/uL
    
  • 2023-04-10 WBC 4.54 x10^3/uL
    
  • 2023-04-06 WBC 13.52 x10^3/uL
    
  • 2023-03-24 WBC 6.18 x10^3/uL
    
  • 2023-03-17 WBC 7.11 x10^3/uL
    
  • 2023-03-15 WBC 8.61 x10^3/uL
    
  • 2023-03-13 WBC 1.41 x10^3/uL
    
  • 2023-03-11 WBC 0.49 x10^3/uL
    
  • 2023-03-09 WBC 0.54 x10^3/uL
    
  • 2023-03-07 WBC 0.48 x10^3/uL
    
  • 2023-03-05 WBC 0.83 x10^3/uL
    
  • 2023-03-03 WBC 0.73 x10^3/uL
    
  • 2023-03-01 WBC 1.58 x10^3/uL
    
  • 2023-02-27 WBC 2.56 x10^3/uL
    
  • 2023-02-23 WBC 5.71 x10^3/uL
    
  • 2023-02-20 WBC 8.15 x10^3/uL
    
  • 2023-02-08 WBC 6.31 x10^3/uL
    
  • 2023-02-03 WBC 13.64 x10^3/uL
    
  • 2023-02-01 WBC 18.52 x10^3/uL
    
  • 2023-01-30 WBC 3.21 x10^3/uL
    
  • 2023-01-28 WBC 1.06 x10^3/uL
    
  • 2023-01-26 WBC 0.56 x10^3/uL
    
  • 2023-01-24 WBC 0.66 x10^3/uL
    
  • 2023-01-22 WBC 0.34 x10^3/uL
    
  • 2023-01-20 WBC 0.24 x10^3/uL
    
  • 2023-01-18 WBC 0.28 x10^3/uL
    
  • 2023-01-16 WBC 0.63 x10^3/uL
    
  • 2023-01-14 WBC 0.44 x10^3/uL
    
  • 2023-01-13 WBC 1.02 x10^3/uL
    
  • 2023-01-11 WBC 43.50 x10^3/uL
    
  • 2023-01-10 WBC 83.37 x10^3/uL
    
  • 2023-01-09 WBC 89.32 x10^3/uL
    
  • 2023-01-08 WBC 90.19 x10^3/uL
    
  • 2023-01-06 WBC 90.16 x10^3/uL
    
  • 2023-01-04 WBC 93.88 x10^3/uL
    
  • 2023-01-02 WBC 163.72 x10^3/uL

2023-01-13

• There was neutropenia of grade 2 (2023-01-13 1.02K/uL) as well as suspected tumolysis syndrome (2023-01-11 P 7.3mg/dL, Ca 2.0mmol/L, uric acid 8.3mg/dL) in this patient. please consider whether G-CSF is necessary in the next few days.
• Rolikan (sodium bicarbonate) has been prescribed since 2023-01-13. The role of urinary alkalinization with either acetazolamide and/or sodium bicarbonate is unclear and controversial. In the past, alkalinization to a urine pH of 6.5 to 7 or even higher was recommended to increase uric acid solubility, thereby diminishing the likelihood of uric acid precipitation in the tubules. However, this approach has fallen out of favor for the following reasons: 1. There are no data demonstrating the efficacy of this approach. In addition, the only available experimental study suggested that hydration with saline alone is as effective as alkalinization in minimizing uric acid precipitation.; 2. Alkalinization of the urine has the potential disadvantage of promoting calcium phosphate deposition in the kidney, heart, and other organs in patients who develop marked hyperphosphatemia once tumor breakdown begins. (ref: https://www.uptodate.com/contents/tumor-lysis-syndrome-prevention-and-treatment).
• Febuxostat is administered to this patient currently. The level of uric acid has decreased to 3.8 mg/dL as of 2023-01-13.

700348601

230831

[lab data]

• 2023-07-27 LDH 150 U/L
  
• 2023-07-20 B2-Microglobulin 2197 ng/mL
  
• 2023-07-18 BM chromosome analysis - cytogenetics laboratory report
  • Chromosome Analysis:
    • Tissue Examined: Bone marrow
    • Staining Method: G-Banding
    • Colony number: NA
    • Bands level: 400
    • Chromosome Counts: 45-()、46-(20)、47-()、Other-() Total-(20)
    • Karyotype: 46,XY[20]
  • Interpretation：
    • Analysis of this bone marrow sample shows a male having 46,XY[20] karyotype. No chromosomal abnormality was detected.
• 2023-07-13 B2-Microglobulin 2254 ng/mL
  
• 2023-07-12 LDH 142 U/L

[exam findings]

• 2023-06-28 CXR
  • Spondylosis of the T-spine
  • Enlargement of cardiac silhouette.
• 2023-06-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 17.3) / 81.3 = 78.72%
    • M-mode (Teichholz) = 78.7
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with mild MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
• 2023-06-26 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy
  • Sections show 30-35 % cellularity. The M/E ratio is about 3/1 - 4/1. Megakaryocytes are found about 2-10/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells.
  • The immunohistochemical stains of CD3 and CD20 show mixed lymphoid cells, and no aggregation of lymphoid cells.
• 2023-06-26 Whole body PET scan
  • Increased FDG uptake in the stomach, compatible with the primary B-cell lymphoma of stomach.
    
  • Increased FDG uptake in the left axillary lymph nodes, probably reactive nodes.
    
  • Increased FDG accumulation in the left ureter and colon, probably physiological uptake of FDG.
    
  • B-cell lymphoma of stomach, stage I, by this F-18 FDG PET scan.
• 2023-06-23 Patho - stomach biopsy
  • Stomach, low body to proximal antrum, biopsy — Diffuse large B cell lymphoma
  • Histology type: diffuse large B cell lymphoma characterized by dense lymphoid infiltration consists of large atypical lymphocytes
  • Immunohistochemistry: CD20(+, diffuse), CD3(-), CD10(-), CK(-), Bcl-6(+), Bcl-2(-), C-MYC (+, >30%), Cyclin-D1(-) and Ki-67(>90%) for tumor
• 2023-06-23 CT - chest
  • Indication: B-cell lymphoma
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • The lung fields are clear.
      • Non-specific lymph nodes are found at paratracheal region is found.
      • Patent airway is found.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Diffuse wall thickening at gastric body is found. Gastric lymphoma is compatible.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • IMp: Compatible with gastric lymphoma without chest nor mediastinal involvement.
• 2023-06-23 EGD
  • Gastric tumor, Borrmann type III, low body to proximal antrum, s/p biopsy
  • Superficial gastritis
• 2023-05-31 CT - abdomen gastric filling with water
  • Findings:
    • There is segmental wall thickening at the greater curvature side of the gastric body, measuring 2.2 cm in wall thickness.
      • Malignant lymphoma is highly suspected.
      • Please correlate with gastroscopy.
    • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidneys.
    • There is no evidence of ascites or lymphadenopathy.
    • There is no bowel wall thickening, and no bowel obstruction.
    • The abdominal aorta and IVC are grossly unremarkable.
    • There is no evidence of intrinsic or extrinsic bladder mass.
    • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • Malignant lymphoma in the gastric body is highly suspected.
      • Please correlate with gastroscopy.

[MedRec]

• 2023-07-19 SOAP Hemato-Oncology
  • P: Arrange admission for R-CHOP on 2023-07-19
• 2023-07-07 SOAP Metabolism and Endocrinology
  • A/P
    • Educate complications: poor wound healing, hyperlipidemia, CAD/Stroke/DKD/retinopathy..
    • Diet and exercise control
    • Encourage SMBG
    • F/u OPH. QY and dentist Q6M
    • Check
      • TG/LDL/TCHO Q6M (2023/)
      • H1c, AC Q3M (2023/)
    • Medication:
      • metformin 2000, amayl BID -> metformin BID, amaryl BID, trajenta QD, 1M one touch
    • Educate hypoglycemia (in the event of hypoglycemia (below 70 mg/dL), drink a bottle of Yakult or YiMei’s small BaiJi fruit juice. Each serving contains approximately 10~15 grams of sugar. After 15~20 minutes, measure the blood sugar again, or consider having your main meal earlier.)
    • Goal:
      • SMBG: <65y/o/mutliple underlying - A1c 7.5-8.0%;AC 100-130mg/dl; PC 180mg/dl
      • BP <140/90mmHg, DKD < 130/80mmHg
      • Lipid: TCHO<160mg/dl, non-HDL<130mg/dl, HDL > 40(male), 50(female), TG< 150mg/dl
    • Side effects education
      • metformin: GI discomfort, renal function, Vit B12 deficiency
      • statin: hepatic dysfunction, myopathy, renal dose.
      • fibrate: gallstone, myopathy, GI upset, rash, pruritis
  • Prescription
    • Uformin (metformin 500mg) 2# BID
    • Trajenta (linagliptin 5mg) 1# QD
    • Amepiride (glimepiride 2mg) 1# BIDAC
• 2023-06-21 ~ 2023-07-04 POMR Hemato-Oncology
  • Discharge diagnosis
    • Diffuse large B-cell lymphoma of gastric, stage I, Bcl-6(+), Bcl-2(-), C-MYC (+, >30%) and Ki-67(>90%) s/p chemotherapy with R-COP from 2023/06/27
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
    • Chronic viral hepatitis B without delta-agent
    • Anemia due to antineoplastic chemotherapy
    • Constipation, unspecified
  • CC
    • For examine and prepare chemotherapy.
  • Present illness
    • This 72-year-old man patient suffered from epigastric pain in 2023/02. No body weight loss, night sweat and fever. PES on 2023/05/13 at LMD showed middle body huge ulcer s/p biopsya and GRED, grad A, R/O advanced gastric cancer. Gastric pathology showed malignant B-cell lymphoma, Immunostains for CK(AE1/AE3), CD20 and CD3 are also performed. Abdominal CT on 2023/05/31 showed malignant lymphoma in the gastric body is highly suspected. Now, he was admitted for further treatment and prepare chemotherapy.
  • Course of inpatient treatment
    • After admitted, Check PES on 2023/06/23 showed gastric tumor, Borrmann type III, low body to proximal antrum, s/p biopsy and superficial gastritis. Stomach, low body to proximal antrum, biopsy showed diffuse large B cell lymphoma, Immunohistochemistry: CD20(+, diffuse), CD3(-), CD10(-), CK(-), Bcl-6(+), Bcl-2(-), C-MYC (+, >30%), Cyclin-D1(-) and Ki-67(>90%) for tumor.
    • Chest CT on 2023/06/23 showed compatible with gastric lymphoma without chest nor mediastinal involvement.
    • Bone marrow study on 2023/06/28 and pathology showed negative for malignancy.
    • Whole body PET scan on 2023/06/28 showed primary B-cell lymphoma of stomach with left axillary lymph nodes metastasis, B-cell lymphoma of stomach, stage.
    • Check 2D echo on 2023/06/27 showed M-mode (Teichholz) = 78.7, 1. Normal AV with no AR 2. Normal MV with mild MR 3. Concentric LVH 4. Preserved LV and RV systolic function 5. Mild PR, mild TR, normal IVC size.
    • Consilt GS on 2023/06/26 for Port-A catheter insertion on 2023/06/28.
    • Chemotherapy with COP (Cyclophosphamide 750mg/m2, Vincristine 1.4mg/m2, Prednisolone 60mg/m2)(C1) on 2023/06/29~2023/07/03. NS 1000ml IVF hydration. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
    • Major Illness applied on 2023/07/03. Type 2 diabetes mellitus without complications with Diet control and check finger sugar, Glimepine 2mg 1# po BIDAC and Metformin 500mg 2# po BID. Essential (primary) hypertension with Norvasc 1# po QD and Aspirin 1# po QD. Chronic viral hepatitis B without delta-agent(2023/06/21 Anti-HBc showed Reactive) with Vemlidy 1# po QD. Anemia(Hb:7.5g/dL) with BT P-RBC 2u on 2023/07/03, 2023/07/04. Constipation with MgO 2# po TID, Sennoside 2# po HS and Bisadyl supp 1# RECT PRNQD. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/07/04 and OPD followed up later.
  • Discharge prescription
    • MgO 250mg 2# TID
    • Through (sennoside 12mg) 2# HS
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Bisadyl supp (bisacodyl 10mg) 1# PRNQD
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
• 2023-06-06 SOAP Hemato-Oncology
  • O
    • 2023/05/31 CT: Abdomen gastric filling with water: Malignant lymphoma in the gastric body is highly suspected
  • P
    • Admission for EGD, Chest CT, PET-CT, bone marrow, lab HBV/HCV, LDH, UA. Port-A insertion.
• 2023-05-30 SOAP General Surgery
  • S
    • epigastric pain for 3 months
    • BW: 75 kg
    • DM+ with 10 yrs
    • H/T with TX 10 yrs
  • O
    • UGI scope: middle body huge ulcer
    • path: malignant B cell lymphoma
    • arrange CT scan

[immunochemotherapy]

• 2023-08-14 - rituximab 375mg/m2 680mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + doxorubicin 50mg/m2 75mg + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-21 - rituximab 375mg/m2 680mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + doxorubicin 50mg/m2 75mg + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-29 - cyclophosphamide 750mg/m2 1300mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 100mg QD PO D1-3 (COP Q3W)
  • dexamethasone 4mg + + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-08-15

The patient renewed his prescription on 2023-08-03 for metformin, aspirin, bisoprolol, amlodipine, and atorvastatin. Comparing with the active medication list, statins are not listed. Lab results from 2023-08-04 indicated no hyperlipidemia. Thus, there are no identified issues with medication reconciliation.

2023-08-04 Cholesterol total 148 mg/dL
2023-08-04 Triglyceride (TG) 95 mg/dL
2023-08-04 LDL-C 95 mg/dL
2023-08-04 HDL-C 43 mg/dL

700382066

230830

[lab data]

2023-08-14 CMV viral load assay Target not detecetedIU/mL

2023-08-09 CD45+Total leukocyte 329085 /uL
2023-08-09 %CD34+ 0.41 %
2023-08-09 CD34+ Count 1350 /uL

2023-08-09 CD45+Total leukocyte 25806 /uL
2023-08-09 %CD34+ 0.10 %
2023-08-09 CD34+ Count 26 /uL

2023-08-09 HPC Ratio 0.41 %
2023-08-09 HPC# 0.1050 10^3/ul

2023-08-08 CD45+Total leukocyte 367310 /uL
2023-08-08 %CD34+ 0.31 %
2023-08-08 CD34+ Count 1140.0 /uL

2023-08-08 RPR/VDRL Nonreactive
2023-08-08 HIV Ab-EIA Nonreactive
2023-08-08 Anti-HIV Value 0.07 S/CO

2023-08-08 Anti-HCV Nonreactive
2023-08-08 Anti-HCV Value 0.09 S/CO

2023-08-08 HBsAg Nonreactive
2023-08-08 HBsAg (Value) 0.27 S/CO

2023-08-08 CD45+Total leukocyte 22719 /uL
2023-08-08 %CD34+ 0.10 %
2023-08-08 CD34+ Count 24.0 /uL

2023-08-08 HPC Ratio 0.34 %
2023-08-08 HPC# 0.0820 10^3/ul

2023-07-18 IgG (blood) 732 mg/dL

2023-06-06 Free Light Chain κ/λ, (blood) ratio
2023-06-06 FKLC 9.6 mg/L
2023-06-06 FLLC 86.8 mg/L
2023-06-06 FK/FL ratio 0.11 ratio

2023-06-01 B2-Microglobulin 1862 ng/mL

2023-05-31 IgG (blood) 867 mg/dL

2023-05-23 CD45+Total leukocyte 216525 /uL
2023-05-23 %CD34+ 0.13 %
2023-05-23 CD34+ Count 285 /uL

2023-05-23 CD45+Total leukocyte 36136 /uL
2023-05-23 %CD34+ 0.02 %
2023-05-23 CD34+ Count 6 /uL

2023-05-23 HPC Ratio 0.04 %
2023-05-23 HPC# 0.018 10^3/ul

2023-05-22 CD45+Total leukocyte 243730 /uL
2023-05-22 %CD34+ 0.31 %
2023-05-22 CD34+ Count 760 /uL

2023-05-22 HPC Ratio 0.18 %
2023-05-22 HPC# 0.094 10^3/ul

2023-05-03 Free Light Chain κ/λ; (blood) ratio
2023-05-03 FKLC 11.2 mg/L
2023-05-03 FLLC 53.5 mg/L
2023-05-03 FK/FL ratio 0.21 ratio

2023-04-27 B2-Microglobulin 1275 ng/mL

2023-04-26 IgG (blood) 782 mg/dL

2023-04-11 CD45+Total leukocyte 246285 /uL
2023-04-11 %CD34+ 0.08 %
2023-04-11 CD34+ Count 200 /uL

2023-04-11 CD45+Total leukocyte 24252 /uL
2023-04-11 %CD34+ 0.01 %
2023-04-11 CD34+ Count 2 /uL

2023-04-11 HPC Ratio 0.15 %
2023-04-11 HPC# 0.036 10^3/ul

2023-04-10 CD45+Total leukocyte 191835 /uL
2023-04-10 %CD34+ 0.11 %
2023-04-10 CD34+ Count 205 /uL

2023-04-10 CD45+Total leukocyte 30658 /uL
2023-04-10 %CD34+ 0.02 %
2023-04-10 CD34+ Count 6 /uL

2023-04-10 HPC Ratio 0.21 %
2023-04-10 HPC# 0.062 10^3/ul

2023-03-31 Free Light Chain κ/λ; (blood) ratio
2023-03-31 FKLC 9.4 mg/L
2023-03-31 FLLC 55.1 mg/L
2023-03-31 FK/FL ratio 0.17 ratio

2023-03-25 B2-Microglobulin 1833 ng/mL

2023-03-24 IgG (blood) 621 mg/dL

2023-03-13 Free Light Chain κ/λ; (blood) ratio
2023-03-13 FKLC 9.6 mg/L
2023-03-13 FLLC 87.3 mg/L
2023-03-13 FK/FL ratio 0.11 ratio

2023-03-04 B2-Microglobulin 1701 ng/mL
2023-03-03 IgG (blood) 880 mg/dL

2023-02-23 Influenza A Ag Negative
2023-02-23 Influenza B Ag Negative

2023-02-08 Free Light Chain κ/λ; (blood) ratio
2023-02-08 FKLC 15.1 mg/L
2023-02-08 FLLC 231.25 mg/L
2023-02-08 FK/FL ratio 0.07 ratio

2023-02-04 B2-Microglobulin 2002 ng/mL

2023-02-03 IgG (blood) 757 mg/dL

2022-12-22 Free Light Chain κ/λ; (blood) ratio
2022-12-22 FKLC 13.4 mg/L
2022-12-22 FLLC 287.5 mg/L
2022-12-22 FK/FL ratio 0.05 ratio

2022-12-17 B2-Microglobulin 2642 ng/mL

2022-12-16 IgG (blood) 1463 mg/dL

2022-11-29 HBsAg Nonreactive
2022-11-29 HBsAg (Value) 0.41 S/CO
2022-11-29 Anti-HCV Nonreactive
2022-11-29 Anti-HCV Value 0.24 S/CO
2022-11-29 Anti-HBc Reactive
2022-11-29 Anti-HBc-Value 6.61 S/CO
2022-11-29 Anti-HBc IgM Nonreactive
2022-11-29 Anti-HBc IgM Value 0.09 S/CO
2022-11-29 Anti-HBs 9.54 mIU/mL

2022-11-24 CD2 NA
2022-11-24 CD3 61.7
2022-11-24 CD4 19.9
2022-11-24 CD5 75.6
2022-11-24 CD7 82.3
2022-11-24 CD8 52.2
2022-11-24 CD10 12.5
2022-11-24 CD11b NA
2022-11-24 CD13 NA
2022-11-24 CD14 3.9
2022-11-24 CD15 NA
2022-11-24 CD16 NA
2022-11-24 CD19 19.5
2022-11-24 CD19/kappa 7.27
2022-11-24 CD19/Lambda 9.4
2022-11-24 CD20 25.7
2022-11-24 CD23 18.9
2022-11-24 CD25 16.5
2022-11-24 CD33 NA
2022-11-24 CD34 6.9
2022-11-24 CD38 85.2
2022-11-24 CD56 29.1
2022-11-24 CD103 NA
2022-11-24 CD117 NA
2022-11-24 CD138 16.2
2022-11-24 FMC7 19.3
2022-11-24 HLA-DR NA
2022-11-24 MPO NA
2022-11-24 TdT NA
2022-11-23 BM chromosome analyz see attachment

• Chromosome Analysis:
  • Tissue Examined: Bone marrow
  • Staining Method: G-Banding
  • Colony number: NA
  • Bands level: 350
  • Chromosome Counts: 45-(1)、46-(11)、47-()、Other-() Total-(12)
  • Karyotype: 46,XY[11]
  • Interpretation: Analysis of this bone marrow sample shows a male having 46,XY[11] karyotype. There was no significant clonal chromosomal abnormality detected. However, from 12 cells analyzed, one cell with 45,X,-Y was observed. No clinical significance can be ascribed to this single finding at the present time. Only 12 cells were available for chromosomal analysis due to low mitotic index.

2022-11-10 Free Light Chain κ/λ; (urine)
2022-11-10 Total Volume(24hr) 4500 mL
2022-11-10 FKLC 28.8 mg/L
2022-11-10 FLLC 6875 mg/L
2022-11-10 FK/FL ratio 0.004189

2022-11-08 IgD; <46.7 U/mL

2022-11-08 Free Light Chain κ/λ; (blood) ratio
2022-11-08 FKLC 14.0 mg/L
2022-11-08 FLLC 2725 mg/L
2022-11-08 FK/FL ratio 0.01 ratio

2022-11-07 Protein EP; (urine)
2022-11-07 Protein (Urine) 334 mg/dL
2022-11-07 Albumin(Urine) 4.8 %
2022-11-07 Alpha-1 0.9 %
2022-11-07 Alpha-2 1.1 %
2022-11-07 Beta 2.8 %
2022-11-07 Gamma 90.4 %
2022-11-07 A/G Ratio (Urine) 0.1

2022-11-05 Protein EP;
2022-11-05 Protein, total 8.8 g/dL
2022-11-05 Albumin 35.0 %
2022-11-05 Alpha-1 1.8 %
2022-11-05 Alpha-2 9.7 %
2022-11-05 Beta 8.6 %
2022-11-05 Gamma 44.9 %
2022-11-05 M-peak Positive
2022-11-05 A/G Ratio 0.50

2022-11-05 Protein, total 9.0 g/dL
2022-11-05 Albumin 35.3 %
2022-11-05 Alpha-1 2.4 %
2022-11-05 Alpha-2 9.5 %
2022-11-05 Beta 8.5 %
2022-11-05 Gamma 44.3 %
2022-11-05 M-peak Positive
2022-11-05 A/G Ratio 0.50
2022-11-05 IgG/A/M Kappa/Lambda IgG + Lambda chain
2022-11-05 IgE 13.4 IU/mL

2022-11-04 B2-Microglobulin 2800 ng/mL

2022-11-03 IgG (blood) 4374 mg/dL
2022-11-03 IgA 95 mg/dL
2022-11-03 IgM 34.0 mg/dL
2022-11-03 Total protein 9.4 g/dL

[MedRec]

• 2023-08-23 SOAP Metabolism and Endocrinology Guo XiWen
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Mixed hyperlipidemia [E78.2]
    • Obesity, unspecified [E66.9]
  • Prescription
    • Zulitor (pitavastatin 4mg) 1# QOD
    • Uformin (metformin 500mg) 1# TID
    • Canaglu (canagliflozin 100mg) 1# QDAC
• 2023-07-30 ~ 2023-08-10 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Multiple myeloma, IgG lambda type s/p posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 on 2022/11/07, Bone marrow, site unspecified, biopsy (11/7 22) revealed Plasma cell myeloma, immunohistochemical stain profiles: CD138(+, > 60%), lambda light chain(+), kappa light chain(-), CD20 (focal+, < 3%), CD34(-), MPO(focal+), CD71(focal+), CD117(focal+). S/P autologous stem cells collection on 4/10-4/11 23 & C1 C/T with Endoxan
    • Type 2 diabetes mellitus without complications
  • CC
    • for collect stem cells
  • Present illness
    • This 63-year-old man, a patient of multiple myeloma, IgG lambda type s/p posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 on 2022/11/07, suffered from bilateral flank pain for 6 days and he visited to our hema OPD for evaluation and survey.
    • Image study with abdominal CT (10/30 22) showed Osteolytic change of T10 r/o metastases. A patchy density (2.6cm) at left lingual lung. Bil. minimal pleural effusions. EGD (10/31 22) revealed duodenal ulcers. Chest CT (11/2 23) revealed old lung TB with tiny granulomas. no lung or medistinal tumor.favor metastatic lesion in spine and left ilium, origin?, d/d multiple myeloma and T-spine MRI (11/4 22) showed Multiple spinal metasases as described, esp T10 with paraspinal and intraspinal involvement and T10-spine, frozen section (11/7 22) proved no evidence of metastatic carcinoma. Bone marrow, site unspecified, biopsy (11/7 22) revealed Plasma cell myeloma,immunohistochemical stain profiles: CD138(+, > 60%), lambda light chain(+), kappa light chain(-), CD20 (focal+, < 3%), CD34(-), MPO(focal+), CD71(focal+), CD117(focal+).
    • Soft tissue, T10-spine, tumor excision (11/10 22) proved hematoma with lymphocytes, leukoyctes and plasma cells, Immunohistochemical stain reveals CD138(+ at plasma cells).
    • The laboratory showed tatal protine : 9.4g/dl, IgG: 4373mg/dl, B2-Microglobulin:2800ng/ml on 11/4 22 -> 2642ng/ml on 12/17 22 -> 2002ng/ml on 2/4 23 -> 1701 ng/ml on 3/4 23 -> 1833ng/ml on 3/25 23. IgG/A/K/M kappa/Lambda: Protein, total: 9.0 g/dL Albumin L 35.3 %, Alpha-1 2.4 %, Alpha-2 9.5 %, Beta L 8.5 %, Gamma H 44.3 %. The FKLL:15.1mg/L, FLLC: 231.25mg/L on 2/8 23, FKLL:9.6mg/L, FLLC: 87.3mg/L on 3/13 23.
    • He received posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 on 2022/11/07. He also received VTD C1W1 (20221128), C1W2 (20221205), C2W1 (20221216), C2W2 (20221223), C3W1 (20230106), C3W2 (20230113), C4W1 (20230203), C4W2 (20230210), C5W1 (20230303) and Xgeva (20230303).
    • Autologous stem cells collection after GCSF mobolization on account of multiple myeloma after VTD threatment with VGPR on 4/9 23. The HPC#: 0.062 10^3/ul, HPC Ratio: 0.21%, CD34+count: 6/ul, %CD34+: 6/ul, CD45+ total leukocyte: 30658/ul on 4/10 23 & HPC#: 0.036 10^3/ul, HPC Ratio: 0.15%, CD34+count: 2/ul, %CD34+: 0.01/ul, CD45+ total leukocyte: 24252/ul on 4/11 23.
    • Last time, he received chemotherapy with Endoxan 2000mg/m2 was given on 5/11 23.
    • Collect stem cell was done on 5/22-5/23 23.
    • CD34+ count: 760/UL, CD34+: 0.31%, CD45+ total leukocyte: 243730/uL on 5/22 23 CD34+ count: 285/UL, CD34+: 0.13%, CD45+total leukocyte: 216525/uL on 5/23 23. Double lumen was removed on 5/24 23.
    • This time, he was admitted for collect stem cell under Mozobil on 2023/07/30.
  • Course of inpatient treatment
    • After admission, echocardiography was done for prepare BMT later. D/L insetion was done, but failure. Portable was done, showed tracheal deviation to left side, but no pneumothorax. Re-on D/L over left inguinal area on 8/7. GCSF 750mcg sc qdac on 8/5-8/8. Mozobil 24mg at 10pm on 8/7-8/8. Collection stem cell at 9am on 8/8-8/9. Removed D/L smooth and no hematoma. Under the stable condition, he can be discharged on 2023/08/10.
    • PBSC:
      • CD34: 4.18kg x10^6
      • Total CD34: 311.05 x10^6
• 2022-10-31 POMR Hemato-Oncology Wan XiangLin
  • Discharge diagnosis
    • Multiple myeloma, IgG lambda type
    • Suspect multiple myeloma with bone metastasis
    • Gastrointestinal hemorrhage, unspecified
    • Anemia, unspecified
    • Pleural effusion, not elsewhere classified
    • Type 2 diabetes mellitus without complications
    • Hyperlipidemia, unspecified
    • Constipation, unspecified
    • Hypermagnesemia
    • Enlarged prostate with lower urinary tract symptoms
  • CC
    • Due to bilateral flank pain since May, progression in July, and worse weakness unable to sit up and when changing position pain recently.
  • Present illness
    • This is a 63 y/o male with underlying diseae of DM and dyslipidemia. This time, he was admitted due to Bilateral flank pain for 6 days.
    • According to the patient, he had bilateral flank pain since May, progression in July, and worse weakness unable to sit up and when changing position pain recently. He had went to ER and neuro OPD and pain killer was given. However, the patient said no improvement. And the pain was progressed and radiated to epigastric region. He also stated tarry stool for one week. He denied fever, cough, rhinorrhea, dyspnea, chest pain, dysuria, incontinence. Due to above symptoms, he came to ER for help.
    • At ER, BP: 143/77; HR: 76; Temp: 36.5; RR: 16; Con’s: E4V5M6, SpO2: 97%. PE showed pale conjunctiva, epigastric tenderness. Lab showed Hb:7, CRP 8.57. Blood transfusion and PPI were given.
    • CT showed 1. Osteolytic change of T10 r/o metastases. 2. A patchy density (2.6cm) at left lingual lung. Bil. minimal pleural effusions.
    • Upper GI showed 1. Reflux esophagitis LA Classification grade A 2. Superficial gastritis, s/p CLO test 3. Duodenal shallow ulcers, bulb 4. Duodenal polyps, bulb.
    • Under impression of Upper GI bleeding with anemia, he was admitted to our ward for further treatment.
  • Course of inpatient treatment
    • After admission, Rivotril 0.5mg HS, Mefno 200mg TID for lower back pain, Tramacet 37.5 & 325mg/tab 1# PO Q6H, and Limadol 100mg/amp 1amp IVD PRNQ6H for pain control were prescribed. The patient tolerated soft diet since 2022/11/01, and oral PPI was prescribed.
    • We followed tumor markers on 2022/11/02, and CEA, CA199, SCC, PSA, CA125, AFP were within normal range. Chest CT on 2022/11/02 showed old lung TB and metastatic lesion in spine and left ilium, r/o multiple myeloma.
    • Lab data on 2022/11/02 revealed (Hb:9.9), (serum Ca: 2.2), (Serum IgG: 4374), (Serum IgA: 95), (Urine protein: 334mg/dl).
    • Skull PA on 2022/11/02 revealed multiple punch out lesions.
    • Pelvis AP view on 2022/11/02 revealed bony metastases in bilateral ilium and pubic bone.
    • Long Bones series performed on 2022/11/02 revealed osteolytic lesions in bilateral humerus.
    • Pathology report of bone marrow biopsy on 2022/11/03 revealed plasma cell myeloma.
    • Spine MRI on 2022/11/04 revealed multiple spinal metasases T6, T10-T12, L1-5, S1-3 verteral bodies, esp T10 with paraspinal and intraspinal involvement.
    • On 2022/11/07, posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 were performed, and he tolerated the surgery well. However, he suffered from dysuria after operation, so foley tube was re-inserted on 2022/11/09.
    • On 2022/11/10, we consult urology department for the dysuria, and they suggested UFR/PVR + TRUS and Urief 1# po QD.
    • On 2022/11/15, we had well explained further management plan including target therapy and stem cell implantaion to patient and his family 11/15.
    • We also consulted Radiation Oncology Department for T10 radiotherapy. The radiotherapy started on 2022-11-16.
    • Due to improving status, chemotherapy with Velcade 1.3 mg/m2 at D1, 4, 8, 11 and thalidomide 1# HS D1-21, dexamethasone 20mg BID started on 11/28, the patient tolerated the chemotherapy well.
    • Severe anemia with Hb:6.3 was noted, so we transfused LPRBC 2 units on 2022/11/28 and 2022/11/29 respectively. Foley was removed on 2022/11/30 and he had no urinary difficulty. Surgical staples were also removed after radiotherapy on 2022/12/01.
    • Under stable condition, he discharged on 2022/12/01 outpatient follow up and further treatment were also arranged.
  • Discharge prescription
    • Thado (thalidomide 50mg) 1# HS (2022-11-28 ~ 2022-12-18 D1-21)
    • Canaglu (canagliflozin 100mg) 1# QDAC
    • Mefno (mephenoxalone 200mg) 1# TID
    • Rivotril (clonazepam 0.5mg) 1# HS
    • Uformin (metformin 500mg) 1# TID
    • Urief (silodosin 8mg) 1# QD
    • Zulitor (pitavastatin 4mg) 1# QN
    • Wecoli (bethanechol 25mg) 1# TIDAC
    • Ulstop (famotidine 20mg) 1# BID
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
    • Lactul (lactulose 666mg/mL) 20mL PRNTID
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Limeson (dexamethasone 4mg) 5# BID (2022-12-01 18:00)
    • Through (sennoside 12mg) 2# HS
    • bisacodyl supp 10mg 2# PRNQD RECT
• 2017-01-10 SOAP Metabolism and Endocrinology Guo XiWen
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Mixed hyperlipidemia [E78.2]
  • Prescription x3 Uformin (metformin 500mg) 1# TID

==========

2023-08-30

[family meeting minutes prior to ASCT]

On 2023-08-30 at 10:15 in the ward conference room, Dr. Gao chaired a family meeting with the patient and his relatives. Attendees included the patient himself, his wife, and his daughter, while his son joined via phone. Dr. Gao explained the treatment plan, the importance and potential risks of autologous stem cell transplantation as a treatment method, and allowed family members to ask questions freely during the meeting.

Overall, the family seemed supportive, and the patient indicated that he would be willing to use a nasogastric tube if necessary during the transplantation treatment. His daughter asked if mouthwash could alleviate symptoms of oral mucositis, to which Dr. Gao responded that mouthwash could help maintain oral cleanliness but couldn’t completely prevent or mitigate the condition, which is mainly caused by conditioning agents.

After the meeting, some casual conversation with the family revealed that the patient was a chef and had run his own business in the past. After retiring, he assisted with religious services in several temples. He is also a vegetarian and has no objections to the hospital’s food offerings.

[Evomela (melphalan) as conditioning regimen prior to HSCT for multiple myeloma]

The recommended dosing schedule is IV 100 mg/m2 daily for 2 days on day -3 and day -2 prior to autologous stem cell transplantation on day 0. Ref: Hari P, Aljitawi OS, Arce-Lara C, et al. A Phase IIb, Multicenter, Open-Label, Safety, and Efficacy Study of High-Dose, Propylene Glycol-Free Melphalan Hydrochloride for Injection (EVOMELA) for Myeloablative Conditioning in Multiple Myeloma Patients Undergoing Autologous Transplantation. Biol Blood Marrow Transplant. 2015;21(12):2100-2105. doi:10.1016/j.bbmt.2015.08.026

700557074

230830

[MedRec]

• 2023-08-24 SOAP Hemato-Oncology He JingLiang
  • A:
    • Squamous cell carcinoma, moderately differentiated, of the urinary bladder, stage pT3aN0(cM0), stage IIIA, s/p Robotic-assisted pelvic organ preserving radical cystectomy with neobladder reconstruction.
    • Squamous cell carcinoma of the right kidney, stage pT4(cN1M0), stage IV, with para-aortic LNs metastases, s/p LPS right radical nephroureterectomy, and s/p radiotherapy.
  • Prescription
    • Through (sennoside 12mg) 1# HS
    • codeine phosphate 15mg 1# PRNQ12H
    • Roumin (prochlorperazine maleate 5mg) 1# TID
    • Limadol (tramadol 100mg) ST IM
    • OxyNorm (oxycodone 5mg) 1# PRNQ4H
    • Decan (dexamethasone 4mg) ST IM
    • Axcel Cream (acyclovir) TID TOPI
    • Limeson (dexamethasone 4mg) 1# QD
• 2023-08-04 SOAP Cardiology
  • Diagnosis
    • Hypertensive heart disease without heart failure [I11.9]
    • Anxiety state,unspecified [F41.9]
    • Other insomnia [G47.00]
    • Mixed hyperlipidemia [E78.2]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
  • Prescription
    • Uformin (metformin 500mg) 0.5# QD
    • Concor (bisoprolol 5mg) 1# QD
    • Pravafen (pravastatin 40mg, fenofibrate 160mg) 1# QD
    • Doxaben XL (doxazosin 4mg) 1# QD
    • Trajenta (linagliptin 5mg) 1# QD
• 2022-02-20 ~ 2022-03-08 POMR Urology
  • Discharge diagnosis
    • Malignant neoplasm of bladder, status post robotic-assisted radical cystectomy with neobladder reconstruction, pT3N0M0
    • Bladder cancer, stage IIIA
  • CC
    • Pain after voiding. Hematuria.
  • Present illness
    • This is a 62-year-old female with underlying disease:
      • Type II Diabetes Mellitus under medication control for 7 years
      • Hypertension under medication control for 8 years
      • Hyperlipidemia under medication control for 7 years
    • She had Bladder cancer, SqCC and urinary tract infection. She felt pain after voiding and had hematuria. She came to OPD for help. At OPD hydronephrosis and urinary tract infection was diagnosed on 2021/12/09. Therefore, transurethral resection of bladder tumor was done on 2021/12/12. SqCC of bladder was diagnosed after biopsy. Therefore, admitted to Urology ward for Robot-Assisted Radical Cystectomy with neobladder on 2022/02/23.
• 2021-12-12 ~ 2022-12-15 POMR Urology
  • Discharge diagnosis
    • Benign neoplasm of bladder status post transurethral resection of bladder tumor on 2021/12/13
    • Right hydronephrosis status post right  uretetroscopy on 2021/12/13
    • Urinary tract infection with Pseudomonas aeruginosa
  • CC
    • freqency, gross hematuria, lower abdominal pain for days.
  • Present illness
    • The 59-year-old woman had history of 1) Hypertension under medication control for years; 2) Right patellar lateral sublaxation s/p arthroascopic lateral release on 2009/06/10; 3) Right back mass excision on 2011/11.
    • According for this patient statement, freqency, gross hematuria, lower abdominal pain for days. She visited our urologic clinic for help where urinalysis showed WBC=50-59/HPF, RBC=20-29/HPF, OB=3+. Renal sonography revealed severe right hydronephrosis. Under the impression of right hydronephrosis, we advised the patient to receive right URS exam. After well explaining, the patient agreed. This time, she was admitted for further evaluation and management.
  • Course of inpatient treatment
    • After admission, transurethral resection of bladder tumor and right URS exam was performed on 2021/12/13. A large papillary tumor with hypervascularity was noted in right lateral wall of bladder with right ureteral orifice invasion was noted. Post-operatively, continuous irrigation of bladder with normal saline was given. Intravesical chemotherapy with Mitomycin was done. Slight urine color was noted and removed Foley tube done smoothly. With fair urination and stable condition, she was discharged today and follow up at urologic clinic.
• 2017-03-10 SOAP Cardiology
  • Diagnosis
    • Hypertensive heart disease without heart failure [I11.9]
    • Anxiety state,unspecified [F41.9]
    • Other insomnia [G47.00]
    • Mixed hyperlipidemia [E78.2]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
  • Prescription
    • Norvasc (amlodipine besylate 5mg) 1# QD
    • Eurodin (estazolam 2mg) 1# HS
    • Vytorin (ezetimibe 10mg, simvastatin 20mg) 0.5# HS
    • Concor (bisoprolol 5mg) 1# QD

[chemotherapy]

• 2023-08-10 - gemcitabine 400mg/m2 600mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-07-28 - gemcitabine 400mg/m2 600mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-07-14 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) (low Gemzar)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-06-16 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) (low Gemzar)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-06-02 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 40mg NS 500mL 3hr (low Gemzar)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-05-24 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 40mg NS 500mL 3hr (low Gemzar)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-12-14 - mitomycin-C 30mg/m2 30mg BI 1hr

==========

2023-08-30

In the last three months, all medical records on PharmaCloud are from this hospital. Currently, no medication reconciliation issues have been identified.

700715400

230830

[objective]

• exam finding
  • 2022-07-21 CT - abdomen, pelvis
    • Mild regression of S-colon cancer and liver metastases. S/P S-colon stenting. Dilatation of colon.
  • 2022-05-05 CT - abdomen, pelvis
    • Much regression of S-colon cancer and liver metastases.
  • 2022-01-22 CT
    • Findings
      • Huge heterogeneous soft tissue mass at both lobes of liver up to 12.5cm is found.
      • s/p sigmoid colon stent placement. The sigmoid colon wall is thick. Some lymph nodes (n＝4) is found.
    • Imp:
      • Sigmoid colon cancer s/p stent placement and liver mets.
    • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T3N2M1
  • 2022-01-20 Patho - colon biopsy
    • Colon, sigmoid, biopsy - Adenocarcinoma, moderately differentiated
    • IHC: EGFR(+), PMS2(focal +), MLH1(+), MSH2(+), and MSH6(+).
    • Section shows pieces of colonic tissue with tumor necrosis, tubulovillous glands and scant invasive irregular neoplastic glands.
  • 2022-01-19 Colonoscopy
    • Colon cancer, sigmoid colon, with acute obstruction s/p self expandable metal stent placement and biopsy
    • Mixed hemorrhoid
• lab data
  • 2022-02-18
    • All-RAS mutation not detected (wild type)
    • BRAF mutation not detected (wild type)
    • EGFR G719X mutation not detected
    • EGFR Exon19 deletion not detected
    • EGFR S768I not detected
    • EGFR T790M not detected
    • EGFR Exon20 insertion not detected
    • EGFR L858R not detected
    • EGFR L861Q not detected
• consultation
  • 2022-07-21 colon and rectal surgery
    • Q
      • Lower abdomen pain VAS 10 for 2 days
      • Hx of sigmoid cancer with multiple liver metastasis
      • Deny abd op hx
    • A
      • S/O
        • S colon cancer with obstruction and multiple liver s/p stent by GI
        • low abdomen pain and no solid stool for 1~2 days
        • CT: favored solid stool stuck in stent
      • A/P:
        • suggested medical treatment + maybe st enema
        • T loop colostomy if no improving
  • 2022-01-21 hematology and oncology
    • please check AntiHbc for chemotherapy HBV evaluation
    • if proven colon cancer, for advanced metastasis colon cancer, systemic therapy is indicated. Ex: FOLFOX+/-avastin or FOLFIRI+/-avastin, +ceftuximab if KRAS wide type, consider IO if dMMR/MSI-H
    • pending pathology result and we wound like to follow up this case
  • 2022-01-19 colon and rectal surgery
    • This is a case of sigmoid cancer with obstruction, multiple liver metastasis. I’ve discussed with the patient and her families, palliative stent is indicated. After colonic stent, palliative chemotherapy and target therapy will be arranged.
• chemotherapy
  • 2022-07-13 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr (FOLFIRI plus panitumumab)
  • 2022-06-29 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr
  • 2022-06-15 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr
  • 2022-06-01 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr
  • 2022-04-27 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr
  • 2022-04-13 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr
  • 2022-04-01 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2022-03-23 - panitumumab 6mg/kg 90min
  • 2022-03-18 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2022-02-24 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2022-02-11 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2022-01-24 - irinotecan 120mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

[assessment]

• Irinotecan has been titrated up from an initial 2/3 recommended dose to its current recommended dose with normal liver function lab results as of 2022-07-21.
• It has been found that patients taking canagliflozin are more likely to develop genitourinary fungal infections (females: 11% to 12%; males: 4%), and those who do develop such infections are more likely to suffer recurrences. Additionally, pioglitazone has been associated with upper respiratory tract infections. Infection signs should be monitored as usual.

220401

[assessment]

• a patient diagnosed with sigmoid colon cancer s/p stent placement and liver mets transferred from Cardinal Tien Hospital on 2022-01-19 and start receiving FOLFIRI since 2021-01-24 (plus panitumumab since 2022-03-23).
• lab data reported on 2022-02-18 revealed that RAS and BRAF were both wild type and that no EGFR mutations were found. pathology results on 2022-01-20 indicated pMMR and EGFR(+). the patient is receiving appropriate treatment with no issues currently.

700152752

230824

[lab data]

2023-06-19 RPR/VDRL Nonreactive
2023-06-19 HIV Ab-EIA Nonreactive
2023-06-19 Anti-HIV Value 0.05 S/CO
2023-06-19 Anti-HBs >1000.00 mIU/mL
2023-06-19 HBsAg Nonreactive
2023-06-19 HBsAg (Value) 0.30 S/CO
2023-06-19 Anti-HCV Nonreactive
2023-06-19 Anti-HCV Value 0.07 S/CO
2023-06-06 HBsAg Nonreactive
2023-06-06 HBsAg (Value) 0.27 S/CO
2023-06-06 Anti-HCV Nonreactive
2023-06-06 Anti-HCV Value 0.08 S/CO
2023-06-06 Anti-HBc Reactive
2023-06-06 Anti-HBc-Value 4.98 S/CO
2023-05-30 CEA (NM) 1908.200 ng/ml

[exam findings]

• 2023-08-15, -07-21, -06-08, -06-02, -06-01 CXR
  • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Old fracture of right clavicle S/P long screw fixation shows good alignment and good union.
• 2023-07-31 T-L spine Lat
  • Increased kyphosis of thoracolumbar spine.
  • Degenerative change of the spine with marginal spur formation.
• 2023-06-09 All-RAS + BRAF mutation
  • Tissue Block No.: S2023-11068
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-06-05 Patho - colon biopsy (Y1)
  • Intestine, large, sigmoid colon, 30 cm AAV, cm from anal verge, biopsy — Adenocarcinoma
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2023-06-05 Colonoscopy
  • Mixed hemorrhoid was noted.
  • A tumor lesion is loacted at S-colon (30cm AAV) with nearly lumen obstruction
• 2023-06-02 Patho - lung transbronchial biopsy
  • Lung, ? side, CT-guide biopsy — consistent with metastatic moderately differentiated adenocarcinoma from colorectal origin
  • Sections show alveolar lung tissue with infiltration of cribriform tumor glands.
  • The immunohistochemical stains reveal CK7(-), CK20(focal +), CDX2(+), and TTF-1(-). The results are consistent with metastatic moderately differentiated adenocarcinoma from colorectal origin.
• 2023-05-26 CT - chest
  • Indication: multiple lung nodules, nature?
  • Chest CT with and without IV contrast ehnancement shows:
    • Diffuse necrotic nodules are found at both lungs up to 2.4cm at right lower lobe. lung meta is considered.
    • Small lymph nodes are found at mediastinum.
    • Scoliotic alignment of the thoracolumbar spine is noted.
  • Imp: Bilateral lung meta. Colon cancer meta is favored.
• 2023-05-25 Lower G-I Series (Colon filling study)
  • Administration of contrast medium from anus. Opacification of rectosigmoid colon. Fistula formation with urinary bladder.
  • Impression: Fistula between sigmoid colon and urinary bladder.
• 2023-05-19 CT - abdomen
  • CC: urine turned sticky with bubbles
    • Urine Culture: Enterococcus faecalis and Escherichia coli: >100000. suspect fistula between intestine and urinary bladder
    • History: menopause, ATH
  • Findings:
    • There is segmental wall thickening of the sigmoid colon, measuring 6 cm in size, with caudal extension into the urinary bladder (diffuse wall thickening and gas content c/w fistula formation).
      • Adenocarcinoma of the sigmoid colon with urinary bladder invasion (T4b) is highly suspected.
      • Please correlate with colonoscopy and cystoscopy.
    • There are seven enlarged nodes in the adjacent mesocolon that are c/w metastatic nodes (N2b).
    • There are multiple variable size soft tissue masses on both lungs, the largest one 2.1 cm at RLL, that are c/w lung metastases (M1a).
      • There are several kissing metastatic nodes in retrocaval space (M1b).
      • In addition, there is a soft tissue nodule 2 cm in the omentum at right upper pelvis that is c/w tumor seeding (M1c).
    • Right renal stones (< 5mm). There are several renal cysts on left kidney and the largest one measuring 2 cm in size at left middle pole para-pelvic area.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M1c(M_value) STAGE:IVC(Stage_value)
• 2022-11-28 CT - abdomen
  • History and indication: insist on confirm renal stone before go abroad
  • Non-contrast CT of abdomen-pelvis revealed:
    • Some nodules (up to 9mm) at bil. basal lungs.
    • Right renal stones (3-4mm). Nodules (5mm, 7mm) at left kidney.
    • Atherosclerosis of iliac arteries.
  • IMP:
    • Some nodules (up to 9mm) at bil. basal lungs.
    • Right renal stones (3-4mm). Nodules (5mm, 7mm) at left kidney.
• 2022-09-28 MRA - brain
  • Old insults (ischemic?) in left cerebellum. Nasopharyngeal mucosal thickening. Suggest ENT check-up.
• 2022-05-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (103 - 24) / 103 = 76.70%
    • M-mode (Teichholz) = 76.6
  • Conclusion:
    • Dilated Ao
    • Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Poor echo window
• 2022-02-15 Bone densitometry - spine
  • L-spines BMD (AP view) performed by DXA revealed:
    • AP L-spines, BMD of L1-4 0.657 gms/cm2, about 3.3 SD below the peak bone mass (65%) and 0.4 SD below the mean of age-matched people (93%).
  • IMP: osteoporosis
• 2022-02-15 L spine Ap + Lat. (including sacrum)
  • Maintained bony alignment
  • Disc space narrowing at L4/5
  • Facet degeneration of lumbar spine

[consultation]

• 2023-06-13 Radiation Oncology
  • Q
    • For evaluation of RT
    • This is a 71 female, had past history of Colon-vesicle fistula; Hypertension; Psoriasis (regular OPD f/u at NTUH)
    • This time was admitted to our ward for cancer survey. CT guide Biopsy and colon scope biopsy had proven maligancy last week.
    • Colon Ca with lung metastasis (Colorectal Carcinoma, Imaging stage T4bN2bM1c, STAGE:IVC)
    • We need your expertise for evaluation of RT, thank you
  • A
    • A: Adenocarcinoma of the sigmoid colon, EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)C, stage T4bN2bM1c (IVC), with colon-vesicle fistula and lung metastases.
    • P: The treatment modality and the possible effects of radiotherapy were well explained. I need to further discuss with the patient and her family.
      • Addendum (2023-06-14): Concern the possible effects of radiotherapy on fistula, after discussed with the patient and her family (younger brother and son), radiotherapy was not planned.
• 2023-06-12 Urology
  • Q
    • For colon-vesicle fistula before chemotherapy.
    • This is a 71 female, had past history of Colon-vesicle fistula; Hypertension; Psoriasis (regular OPD f/u at NTUH)
    • This time was admitted to our ward for cancer survey. CT guide Biopsy and colon scope biopsy had proven maligancy.
    • Colon Ca with lung metastasis (Colorectal Carcinoma, Imaging stage T4bN2bM1c, STAGE:IVC)
  • A
    • The aim of surgical excision of fistula is to reduce infection rate during chemotherapy
    • There is still large amount of metastatic lymph and lung lesion
    • There is high risk of residual tumor on urinary bladder or urine leakage after fistula resection
    • The more urinary bladder resection will reduce residual cancer but increase risk of urine leakage after bladder repair
    • Colonstomy may reduce fecal contamination to urinary bladder
    • colonstomy may be a feasible alternative
    • The benefit and risk of procedure will explain to her

[surgical operation]

• 2023-06-15
  • Surgery
    • T loop colostomy
  • Finding
    • dilatation of T colon
    • omentum adhesion to low abdomen.
  • Procedure
    • After GA, abdomen skin is prepare.
    • Incision over RUQ and check bleeding.
    • Lysis of omentum adn free T colon
    • Fix T colon to skin.
    • clean stool in colon and suture.

[chemotherapy]

• 2023-08-03 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4650mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-07-21 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-07-09 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-06-27 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

==========

2023-08-24

After examining both PharmaCloud and HIS5 records, no medication discrepancies were found.

Erbitux (cetuximab) was first administered on 2023-08-03 in conjunction with the 4th dose of the FOLFIRI regimen which began on 2023-06-27 (2023-06-09 no variant detect in the KRAS/NRAS gene). Based on the CEA lab data, the decreasing trend suggests that the regimen has been effective so far.

2023-08-23 CEA (NM) 457.140 ng/ml 2023-08-04 CEA (NM) 962.760 ng/ml 2023-07-14 CEA (NM) 1473.200 ng/ml 2023-07-14 CEA (NM) 1508.900 ng/ml 2023-05-30 CEA (NM) 1908.200 ng/ml

2023-07-24

As of the current date, the patient’s oral Alinamin-F (vitamin B complex) and Bokey (aspirin) prescriptions, which were refilled for 30 days on 2023-07-15, are not listed in the active medication list. To ensure patient appropriate treatment, it is advisable to recheck the necessity of these medications.

2023-06-26

• According to the PharmaCloud records, the patient received treatment for acute sinusitis from a local ENT clinic on 2023-05-25 and was provided with a 3-day short-term prescription that is no longer valid. This does not pose a medication reconciliation issue.

• On 2023-05-08, the patient was prescribed Evista (raloxifene 60mg) 1# QD and Celebrex (celecoxib 200mg) 1# QD by our hospital’s orthopedic department, both on a refillable basis. Currently, Evista is included in the patient’s active medication list. Celebrex has been replaced by Deflam-K (diclofenac 25mg) 1# QD, which does not seem to present any medication reconciliation issues. The adjustments are in alignment with the patient’s current health status.

• A fistula between the sigmoid colon and the bladder was seen on 2023-05-25 in the lower GI series. A urine culture obtained on 2023-06-13 confirmed the presence of both Enterococcus faecalis and Escherichia coli, both greater than 100,000 CFU/cc. After a T-loop colostomy on 2023-06-15, the stool culture on 2023-06-19 showed only the presence of normal flora, with no non-intestinal pathogens identified.

• The lab results from 2023-06-06 and 2023-06-19 indicated that the patient tested positive for Anti-HBc and Anti-HBs, suggesting a past HBV infection. Given this, if immunosuppressive chemotherapy is planned, prophylactic antiviral therapy with either Baraclude (entecavir 0.5mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25mg) 1# QD is recommended, at least for the duration of the chemotherapy. This measure can help prevent potential reactivation of the HBV infection due to the immunosuppressive effects of chemotherapy.

  • ref: “Pharmacy FAQ - Hepatitis B reactivation and screening” http://www.bccancer.bc.ca/pharmacy-site/Documents/Pharmacy%20FAQs/Pharmacy-FAQ-Hepatitis-B.pdf

700720541

230824

[lab data]

2023-02-14 Anti-HBc Nonreactive
2023-02-14 Anti-HBc-Value 0.14 S/CO
2023-02-14 Anti-HBs 0.00 mIU/mL
2023-02-14 Anti-HCV Nonreactive
2023-02-14 Anti-HCV Value 0.06 S/CO
2023-02-14 HBsAg Nonreactive
2023-02-14 HBsAg (Value) 0.33 S/CO

[exam findings]

• 2023-05-04 Patho - uterus with or without SO non-neoplastic/prolapse Y1
  • PATHOLOGIC DIAGNOSIS
    • Endometrium, low uterine segment, radical hysterectomy — Undifferentiated carcinoma
    • Myometrium, uterus, ditto — Tumor invasion, less than half thickness
    • Cervix, uterus, ditto — Stromal invasion
    • Ovary, left, ditto — Free of tumor invasion
    • Fallopian tube, left, ditto — Free of tumor invasion
    • Ovary, right, ditto — Free of tumor invasion
    • Fallopian tube, right, ditto — Free of tumor invasion
    • Lymph node, L’t iliac, dissection — Free of tumor metastasis (0/8)
    • Lymph node, L’t oburator, ditto — Free of tumor metastasis (0/7)
    • Lymph node, R’t iliac, ditto — Free of tumor metastasis (0/3)
    • Lymph node, R’t oburator, ditto — Tumor metastasis (0/7)
    • Lymph node, L’t paraaortic, ditto — Free of tumor metastasis (0/2)
    • Lymph node, R’t paraaortic, ditto — Free of tumor metastasis (0/7)
    • Parametria, bilateral — Free of tumor invasion
    • Omentum, partial omentectomy — Free of tumor invasion
    • AJCC Pathologic stage — pT2N0, if cM0, stage II / FIGO stage II
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: radical hysterectomy
    • Specimens include: uterus with bilateral adnexa, partial omentum, pelvic and paraaortic lymph nodes
    • Specimen size:
      • uterus: 6.7 x 5.2 x 5.0 cm in size, 72 gm in weight
      • right ovary: 1.8 x 1.6 x 0.7 cm
      • left ovary: 1.9 x 0.9 x 0.6 cm
      • right fallopian tube: 6.3 cm in length, 0.4 cm in diameter
      • left fallopian tube: 5.5 cm in length, 0.5 cm in diameter
    • Tumor site: low uterine segment
    • Tumor size: 3.7 x 2.7 x 2.4 cm
    • The myometrium: 1.2 cm in thickness, tumor invasion less than half thicknes
    • The cervix: endocervical stroma is invaded by tumor
    • Bilateral adnexa: no remarkable change
    • Omentum: 5.5 x 4.5 x 1.0 cm, no remarkable change
    • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs, right obturator LNs, L’t paraaortic LNs and R’t paraaortic LNs
    • Representative sections as A: L’t iliac LNs, B: L’t obturator LNs, C: R’t iliac LNs, D: R’t obturator LNs, E: L’t paraaortic LNs, F: R’t paraaortic LNs, G1: R’t F-tube, G2: R’t ovary, G3: L’t F-tube, G4: L’t ovary, G5: R’t parametrium, G6: L’t parametrium, G7-G8: uterine corpus to cervix, G9-G15: tumor, G16: cervix and H: omentum
  • MICROSCOPIC EXAMINATION
    • Histology type: endometrioid undifferentiated carcinoma
    • Histology grade: undifferentiated
    • Depth of invasion: less than half thickness of myometrium
    • Lymphovascular invasion: Not identified
    • The cervical stroma involvement: Present
    • Resection margins of the cervix: Free, 1.7 cm away from tumor
    • Additional pathologic findings: moderate tumor-infiltrating lymphocytes
    • Lymph nodes: free of tumor metastasis (0/35) in total number
    • Vaginal stump: free of tumor invasion
    • Perineural invasion: Not identified
    • Ascites: Negative for malignancy
    • Immunohistochemistry: CK7(+), PAX-8(+), Vimentin(+), ER(+), P16(-), P40(-) and P53(wild type) for tumor
• 2023-04-20 MRI - pelvis
  • Findings: Soft tissue tumor in the uterine cervical region, regression size (from 4.8cm to 3cm) as compare with MRI study on 2023-02-09. Clinical biopsy proven cervical malignancy.
  • Impression: Cervical malignancy with regression size.
• 2023-02-20 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 26 dB HL; LE 13 dB HL.
  • RE normal to moderate SNHL.
  • LE normal to mild mixed type HL.
• 2023-02-09 MRI - pelvis
  • Finding: Soft tissue tumor in the uterine cervical region, 4.8cm. Clinical biopsy proven cervical malignancy.
  • Imaging Report Form for Cervical Carcinoma
    • Impression ( Imaging stage ) : T:T1b3(T_value) N:N0(N_value) M:M0(M_value) STAGE IB3 (Stage_value)
  • Impression: Cervical malignancy, cstage T2a2N0M0.
• 2023-01-31 CT - abdomen
  • Finding: Soft tissue tumor, 5.3cm in the uterine cervical region, r/o cervical myoma.
  • Impression: Cervical region tumor, myoma?
• 2023-01-30 Patho - cervix biopsy
  • Labeled as “cervix”, biopsy — poorly differentiated carcinoma.
  • Section shows poorly differentiated carcinoma with solid nests and papillary-like structures.
  • IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-).
• 2023-01-30 Gynecologic ultrasonography
  • A mass:47x31mm, RI:0.59

[MedRec]

• 2023-07-07 SOAP Rheumatology Chen JunXiong
  • S: 2023 0707 urticaria flare last day first attack over limbs, trunk, under regular chemothrapy
  • O: acute urticaria
  • Prescription
    • Xyzal (levocetirizine 5mg) 1# HS
    • Allegra (fexofenadine 60mg) 1# TID
    • Compesolon (prednisolone 5mg) 2# PRNBID
• 2023-06-15 SOAP Hemato-Oncology Xia HeXiong
  • Plan: CCRT with weekly carboplatin (due to impaired renal function, and self pay) followed by TP x 3 cycles
• 2023-06-01 SOAP Radiation Oncology Huang JingMin
  • A: Undifferentiated carcinoma of the uterine cervix, stage cT2a2N0M0, s/p neoadjuvant chemotherapy and surgery (Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomy).
  • P: Radiotherapy is indicated for this patient with the following indicators: stage cT2a2, s/p neoadjuvant chemotherapy and surgery
    • Goal: curative
    • Treatment target and volume: pelvic area
    • Technique: VMAT/IGRT +/- IVRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, +/- 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-06-08.
• 2023-05-02 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of endometrium
    • Endometrial cancer,stage II, post radical hysterectomy on 2023-05-03
    • Paralytic ileus
  • CC
    • intermittent postmenopausal bleeding for 6 months        
  • Present illness
    • This 55 y/o woman, G0P0, sex +, menopause in 2021. She had MEDICAL history of hyperlipidemia without control. She denied any food or drug allergy, and anticoagulants or hormone use. She had regular pap smear in 2021 and the result showed WNL.
    • Abnormal postmenopause bleeding was noted by patient for 6 months. According to patient statement, the discharge was pink initially. Then, the color change to brown and pus-like content, with increasing volume. No pain or burning sensation. She denied fever, weight loss, poor appetite, urinary frequency or urgency, dysuria, nocturia.
    • She came to our GYN OPD for help on 2023/01/30. PV revealed necrotic tissue and mass at os.
    • Biopsy was done and showed poorly differentiated carcinoma. IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-).
    • CT in 2023/01/31 showed 5.3 cm tumor in cervical region. She was diagnosed as poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
    • After 3 cycles of neoadjuvant chemotherapy (Intaxel + Carboplatin), she was admitted for radical hysterectomy on 2023/05/03.   - Course of inpatient treatment
    • The patient was admitted on 2023-05-02 due to cervical cancer.
    • She underwent Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomyon 2023-05-03.
    • The pathology stage: Endometrium, low uterine segment, radical hysterectomy — Undifferentiated carcinoma. AJCC Pathologic stage — pT2N0, if cM0, stage II / FIGO stage II.
    • The GYN tumor board conference suggest the patient to receive CCRT on 2023-05-11.
    • Postoperative course was uneventful. Self voiding was smooth. She was discharged on 2023-05-24. Her follow up appointment is scheduled on 2023-06-01.
  • Discharge prescription
    • Naproxen (naproxen 250mg) 1# PRNQ6H
    • Anxiedin (lorazepam 0.5mg) 1# PRNHS
    • cephalexin 500mg 1# QID
    • MgO 250mg 1# QID
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
• 2023-02-17 ~ 2023-02-22 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3
  • CC
    • for chemotherapy
  • Present illness
    • The 54 y/o woman has been well in the past. Menopause on 2021.
    • This time, her vagina has yellow-green discharge since 2022/09/09. Due to symptoms persisted for a while without improvement, so she came to our GYN OPD for help and pelvis MRI showed Cervical malignancy, cstage T2a2N0M0 on 2023/02/09.
    • Pathology showed poorly differentiated carcinoma. IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-) on 2023/2/3.
    • Port-a insertion on 2023/2/9. Under the impression of poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
    • Plan as Neo-adjuvant x 3th then radical surgery then adjuvant treatment, so she was admitted for first chemotherapy as self paid of TP on 2023/02/17.
  • Course of inpatient treatment
    • After admission, she received 24H CCr and PTA before neo-adjuvant x 3th then radical surgery then adjuvant treatment.
    • Premedication as Dorison 20mg q6h x 2 dose since 2/20 2300 and 2/21 0500.
    • C1 selfpaid of Intaxel (175mg/m2) + Carboplatin (AUC 6) on 2023/2/21.
    • Under the stable condition, she can be discharged on 2023/2/22. OPD follow up is arranged.
  • Discharge prescription
    • Mopride (mosapride citrate 5mg) 1# TID
    • Roumin (prochlorperazine maleate 5mg) 1# TID
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
• 2023-02-14 SOAP Hemato-Oncology Xia HeXiong
  • P: Admission for C/T with PF or TP
• 2023-02-10 SOAP Obstetrics and Gynecology Huang SiCheng
  • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-02-09. Neo-adjuvant x 3th then radical surgery then adjuvant treatment
• 2023-02-07 SOAP Urology You ZhiQin
  • S: cervical cancer, for r/o bladder invasion
  • O: CUS: no bladder invasion
• 2023-02-06 SOAP Obstetrics and Gynecology Zhu ChunHong
  • O: 2023/01/31 CT ABD: Soft tissue tumor, 5.3cm in the uterine cervical region, r/o cervical myoma. Impression: Cervical region tumor, myoma? - interpretation about report, most possibility was cervical cancer

[surgical operation]

• 2023-05-03
  • Surgery
    • Diagnosis: poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
    • Procedure: Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomy
  • Finding
    • Uterus: Avfl, 5x3 cm; cervix:enlarged with multiple papillary tissues.
    • RAD: grossly normal.
    • LAD: grossly normal.
    • CDS: little ascites s/p washing cytolgy, no adhesion bands.
    • Right parametrium: size : 3 cm, Induration (-);
    • Left parametrium: size : 3 cm, Induration (-);
    • Vagina cuff: 3 cm , gross tumor (-), section margin free (+)
    • Bilateral pelvic/ paraaortic lymph nodes: Enlarged
    • Omentum: multiple hard, infracolic omentectomy was done.
    • Adhesion between pelvic wall and bowels, s/p adhesiolysis
    • Estimated blood loss: 600ml
    • Blood transfusion: pRBC 2u
    • Complication: none  

[radiotherapy]

[chemotherapy]

• 2023-08-24 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 550mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-08-03 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-26 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-20 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-13 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-06 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-29 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-23 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-08 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-03-18 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-02-21 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-08-24

After examining both PharmaCloud and HIS5 records, no medication discrepancies were found.

701373652

230823

[diagnosis] - 2023-03-23 admission note

• Adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 ~ 2023/02/21, plus Panitumumab from 2023/02/21, progression of LNs, bones and liver metastases s/p FOLFOX from 2023/03/09
• Localized skin eruption due to drugs and medicaments taken internally
• Chronic viral hepatitis B without delta-agent
• Iron deficiency anemia, unspecified
• Hypertension
• Constipation, unspecified
• Encounter for antineoplastic chemotherapy

[past history]

• Hypertension for many years, regular medication with Norvasc                   

[allergy]

• NKDA

[family history]

• No known congenital disease was noted  
• No cancer in his family  

[lab data]

• 2022-11-18 Anti-HCV Nonreactive
  
• 2022-11-18 Anti-HCV Value 0.07 S/CO
  
• 2022-11-18 Anti-HBc Reactive
  
• 2022-11-18 Anti-HBc-Value 6.67 S/CO
  
• 2022-11-18 Anti-HBs 74.91 mIU/mL
  
• 2022-11-02 HBsAg(nuclear medicine) Negative
  
• 2022-11-02 HBsAg Value(nuclear medicine) 0.446

[exam findings]

• 2023-06-08 CT - abdomen
  • S/P colon operation. Mild regression of LNs and liver metastases. Stable condition of bony metastases.
• 2023-03-09 CT - abdomen
  • History and indication: Adenocarcinoma of sigmoid colon with liver metastasis
  • IMP: S/P colon operation. Progression of LNs, bones and liver metastases.
• 2023-02-03 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spot in the right rib cage and increased activity in the maxilla, mandible, L4-5 spines, bilateral shoulders, sternoclavicular junctions, hips and knees in whole body survey.
  • IMPRESSION:
    • Increased activity in the L4-5 spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Some faint hot spot in the right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2022-12-15 All-RAS + BRAF mutation
  • Tissue block No. S2022-19716 A3
  • RESULTS
    • All-RAS:
      • There was no variant detect in the KRAS/NRAS gene.
    • BRAF
      • There was no variant detect in the BRAF gene.
• 2022-12-15 KUB
  • There are Eqivocal osteoblastic change at L-spine and bilateral ilium that may be bony metastases? Please correlate with bone scan.
• 2022-12-08 ECG
  • Left anterior fascicular block
  • Minimal voltage criteria for LVH, may be normal variant
  • Septal infarct, age undetermined
• 2022-11-30 Patho - liver bipsy needle/wedge
  • Liver, CT guide biopsy — Metastatic adenocarcinoma, consistent with colorectal primary
  • The sections show moderately differentiated adenocarcinoma, composed of nests columnar neoplastic cells, arragned in glandular and cribrifrom patterns, in fibrous stroma. Dirty tumor necrosis is present.
  • IHC shows: CK7(-), CK20(focal +) and CDX2(+). The finding is consistent with metastatic colorectal adenocarcinoma.
• 2022-11-29 Patho - peritoneum biopsy
  • Labeled as “LN at retroperitoneum”, CT guided biopsy — poorly differentiated carcinoma.
  • IHC stains: CK (+), Ki-67 (15%), trypsin (-), CK20 (-), S-100 (-), CD56 (-), LCA (-), CD3 (-), CD20 (-), chromogranin A(-), synaptophysin (-).
  • Section shows round blue cell tumor with pseudo-lumina or pseudo-rossette-like pattern.
• 2022-11-10 - Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, sigmoid colon, laparoscopic sigmoid colectomy —- Adenocarcinoma, moderately differentiated
      
    • Resection margins: free
    • Lymph node, mesocolic, dissection -
      • Negative for malignancy (0/24)
      • Four tumor deposits are seen
    • Lymph node, IMA / SMA, dissection —- Not received
    • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1c(if cM0) or pStage IVB, pT3N1c(if cM1b(by CT finding)); please correlate with the clinical presentation.
  • Gross Description:
    • Operation procedure: laparoscopic sigmoid colectomy
    • Specimen site: sigmoid colon
    • Specimen size: 10.5 cm in length
      
    • Tumor size: 6.5 x 5.0 x 1.5 cm; annularly ulcerated
    • Tumor location: 2.6 cm and 1.5 cm away from the two resection margins, respectively.
    • Depth of invasion grossly: mesocolic soft tissue
    • Mucosa elsewhere: a polyp measuring 0.7 x 0.5 x 0.4 cm is seen
    • Macroscopic Tumor Perforation: Not identified
    • Sections are taken and labeled as: A1: colon, non-tumor; A2: polyp; A3-6: tumor; A7-10: lymph node, mesocolic; B: proximal cut end; C: distal cut end.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: very close, Distance of tumor from margin: < 1 mm
        
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Present
    • Tumor Budding: Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: not available
    • Tumor Deposits: Present, Specify number of deposits: 4
    • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 0/24
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
      • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
      • Regional Lymph Nodes (pN): pN1c: No regional lymph nodes are positive, but there are tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic, or perirectal/mesorectal tissues.
      • Distant Metastasis (pM): CT finding: if cM1b: Metastasis to two or more sites or organs is identified without peritoneal metastasis
    • Additional Pathologic Findings
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
      • A tubulovillous adenoma is seen.
• 2022-10-31 CT - abdomen
  • History and indication: Advanced sigmoid cancer (15-20AAV), s/p tattooed
    
  • Findings
    • Wall thickening of S-colon with adjacent fat stranding and regional LAP. Enlarged LNs at retroperitoneum.
    • Poor enhancing tumors in liver.
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • Collapse of gallbladder.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral basal lungs.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)

[consultation]

• 2023-03-23 Dermatology
  • Q
    • The 74 y/o man has adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 plus Panitumumab from 2023/02/21. Red hot swelling sensation over face s/p target therapy with Panitumumab.
    • For paronychia and keloid with pus on the chest, sent culture on 2023/03/22, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • The patient had sufferred from paronychia with granulation formation over toenail and keloid with seocndary wound formation over chest.
      
    • Under the impression of paronychia with granulation, keloid with seocndary wound & bacterial infection.
      
    • The following sugeetion:
      • paronychia over fingernail, Tetracycline onit 1 tube topical bid use.
      • for limbs and hand xerosis, sinphraderm cream 1 tube topical QN use.(enahcne mositurization)
      • for keloid wound, keep wound CD and might consider Siliverzine cream 1 tube antibiotic use for wound occlusion effect.
• 2023-03-09 Dermatology
  • Q
    • The 74 y/o man has adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 plus Panitumumab from 2023/02/21. Red hot swelling sensation over face s/p target therapy with Panitumumab. follow up in your OPD on 2023/03/02.
    • For red hot swelling sensation over face, We need your consultation for evaluation. Thanks a lot!!!
  • A
    • The patient had sufferred from facial flush with scales and pruritus. Besides, dry xerosis was noted over lower legs.
      
    • Under the impression of seborrheic dermatitis and xerotic dermatitis
    • The following sugeetion:
      • for fisuriform wound protection, Tetracycline onit 1 tube topical bid use first.
      • for facial erythema, Free gel 1 tube topical bid use over erythematous rash over face (Can be used extensively on the face).
      • for itchy papules and sclaes, Mycomb cream 1 tube topical PRN bid use.

[MedRec]

• 2023-03-30 SOAP Dermatology
  • S: refill medication use
  • Prescription
    • Allegra (fexofenadine 60mg) 1# BID
    • Free Gel (metronidazole) BID TOPI
    • tetracycline BID EXT
• 2023-03-22 SOAP Hemato-Oncology
  • O: Cancer Treatment Chemoradiotherapy/Targeted Therapy Side Effects Assessment (2023-03-22)
    • Skin rash: G2: Moderate rash, or single moist desquamation, mostly in skin folds and moderate edema
• 2023-03-02 SOAP Dermatology
  • S: red hot swelling sensation over face, cancer target therapy.
  • O: Bilateral facial flush with tightness and burning sensation for weeks.
    • Impression: rosacea
  • P:
    • Education about drug side effec and explain
    • Strongly suggested OPD f/u
  • Prescription
    • Allegra (fexofenadine 60mg) 1# BID
    • doxycycline 100mg 1# BID
    • Free Gel (metronidazole) BID TOPI
• 2023-01-05 SOAP Hemato-Oncology
  • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-11-22
    • target + chemotherapy due to partial obstruction then re-evaluation of liver resection
• 2022-11-17 SOAP Hemato-Oncology
  • O: Now on FOLFIRI +/- anti-EGFR
  • P: After SDM with patient for the selection of bevacizumab or cetuximab/panitumumab, patient choice cetuximab/panitumumab
• 2022-11-03 SOAP Colorectal Surgery
  • A: Suggest colectomy first then target + chemotherapy due to partial obstruction

[surgical operation]

• 2022-11-09
  • Surgery: 3D Laparoscopic sigmoid colectomy    
  • Finding: Sigmoid cancerwith nearly total obstruction, much stool in proximal colon and D-colon dilatation

[immunochemotherapy]

• 2023-08-22 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-31 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-18 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-29 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-16 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-31 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX, Oxa 75)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-04 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX, Oxa 65)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-11 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-23 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-09 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-21 - panitumumab 6mg/kg 500mg NS 250mL 1hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-03 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-16 - irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-26 - irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-12 - irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

[note]

Acneiform eruption secondary to epidermal growth factor receptor (EGFR) and MEK inhibitors 2023-04-12 https://www.uptodate.com/contents/acneiform-eruption-secondary-to-epidermal-growth-factor-receptor-egfr-and-mek-inhibitors

• Acneiform eruption is the prototypical cutaneous adverse reaction associated with all epidermal growth factor receptor (EGFR) inhibitors, which include monoclonal antibodies and oral small molecules used for the treatment of certain advanced or metastatic cancers, such as non-small cell lung cancer (afatinib, erlotinib, gefitinib, osimertinib, mobocertinib, necitumumab, amivantamab), pancreatic cancer (erlotinib), breast cancer (lapatinib, neratinib), colon cancer (cetuximab, panitumumab), and head and neck cancer (cetuximab). Acneiform eruption is also one of the most frequent adverse effects of inhibitors of the EGFR downstream mitogen-activated protein kinase kinase (MEK) signaling pathways MEK1 and MEK2 (eg, trametinib, cobimetinib, binimetinib, selumetinib), especially when used as monotherapy.
• Several studies have noted an association between acneiform eruption and increased overall response rate or survival.
• Preemptive therapy
  • We suggest prophylactic oral antibiotics in conjunction with topical corticosteroids for patients initiating treatment with EGFR inhibitors. Treatment is started on the same day as EGFR inhibitor therapy and continued for six weeks. We typically use doxycycline 100 mg twice a day, minocycline 100 mg daily, or oxytetracycline 500 mg twice daily for six weeks. Alternative antibiotics include cephalosporins (eg, cefadroxil 500 mg twice daily) or trimethoprim-sulfamethoxazole (160 mg/800 mg twice daily).
  • A low-potency topical corticosteroid (eg, hydrocortisone 2.5%, alclometasone 0.05% cream) is applied twice daily to the face and chest.

==========

2023-08-23

After reviewing HIS5 records, there are no medication reconciliation issues. PharmaCloud is not accessible currently.

2023-08-01

There are no medication reconciliation issues after review of PharmaCloud and HIS5 records.

2023-06-30

According to the PharmaCloud database, our hospital has been the only medical institution providing care and prescriptions for this patient over the past three months. The Hemato-Oncology department is solely responsible for the patient’s recent medications. Hence, no medication reconciliation issues were detected.

2023-05-04

• An episode of leukopenia with a WBC count of less than 3K/uL (2.92K/uL on 2023-05-03) was observed for the first time since the patient started chemotherapy in mid-December 2022. It is important to closely monitor the patient’s WBC and check whether the leukopenia persists.
• Over the past 7 months, the patient’s anemia has improved with the administration of Foliromin (ferrous sodium citrate). Given the expected decrease in marginal benefit of iron supplementation as the mean corpuscular volume (MCV) approaches 100 fL, it is recommended to either discontinue the medication or decrease the frequency from twice daily (BID) to once daily (QD) and/or assess body iron stores such as ferritin, transferrin to ensure that iron levels are adequate.
• The patient’s rash, which is a side effect of the EGFR inhibitor panitumumab, is currently being managed with self-provided topical ointments without complications.

2023-04-12

• Lab data on 2023-04-06 showed normal readings.

• The patient’s anemia has improved with the use of Foliromin (ferrous sodium citrate) for the past 6 months. It is recommended to either discontinue or reduce the frequency of the medication from twice daily (BID) to once daily (QD) due to an expected decline in the marginal effect of iron supplementation, as the mean corpuscular volume (MCV) is approaches 100 fL.

  • 2023-04-06 HGB 12.0 g/dL
    
  • 2023-03-22 HGB 11.7 g/dL
    
  • 2023-03-07 HGB 11.8 g/dL
    
  • 2023-02-21 HGB 11.5 g/dL
    
  • 2023-02-02 HGB 11.3 g/dL
    
  • 2023-01-05 HGB 10.1 g/dL
    
  • 2022-12-22 HGB 9.9 g/dL
    
  • 2022-11-28 HGB 8.5 g/dL
    
  • 2022-10-31 HGB 7.2 g/dL
    
  • 2023-04-06 MCV 96.6 fL
    
  • 2023-03-22 MCV 94.2 fL
    
  • 2023-03-07 MCV 92.3 fL
    
  • 2023-02-21 MCV 93.8 fL
    
  • 2023-02-02 MCV 88.2 fL
    
  • 2023-01-05 MCV 82.4 fL
    
  • 2022-12-22 MCV 79.4 fL
    
  • 2022-11-30 MCV 76.7 fL
    
  • 2022-11-28 MCV 77.9 fL
    
  • 2022-10-31 MCV 71.7 fL

• In late Feb/early Mar 2023, the patient developed a localized skin eruption secondary to the epidermal growth factor receptor (EGFR) inhibitor panitumumab. He is currently adequately being treated with a topical regimen of tetracycline, metronidazole, silver sulfadiazine, and urea.

2023-03-24

• Although the CT scan on 2023-03-09 showed progression of lymph nodes, bone, and liver metastases, the CEA readings have been trending down towards normal. The two trends are not consistent with each other.
  • 2023-03-22 CEA 2.67 ng/mL
    
  • 2023-03-08 CEA 6.12 ng/mL
    
  • 2023-01-06 CEA 7.53 ng/mL
• The chemotherapy regimen was changed from FOLFIRI to FOLFOX on 2023-03-09. The FOLFIRI regimen was used a total of five times prior to the change.
• The patient has been experiencing continued dermatologic adverse reactions, and a dermatologist has been consulted on 2023-03-23. To alleviate these symptoms, the dermatologist has prescribed topical medication for the patient.
• Other FOLFOX-related adverse events, in addition to the dermatologic adverse events caused by panitumumab, are not significant. Mild anemia, loss of appetite and constipation all have corresponding medications.

2023-03-08

• 2022-11-10 a segment of colon was surgically removed due to a tumor that tested positive for EGFR.
• 2022-12-15 no variants were detected in the KRAS/NRAS genes.
• The patient is eligible for reimbursement for panitumumab and combination therapy with FOLFIRI or FOLFOX as a first-line treatment for metastatic colorectal cancer with EGFR RAS gene wildtype. The patient received his first dose of panitumumab during his previous hospitalization during 2023-02-21 ~ 23.
• Panitumumab can cause various dermatologic adverse reactions. Skin or ocular toxicity from panitumumab typically develops after 12 days and resolves in about 14 weeks. The severity of dermatologic toxicity is predictive of response, with grades 2 to 4 skin toxicity correlating with improved progression-free survival and overall survival compared to grade 1 skin toxicity (Peeters 2009; Van Cutsem 2007). The patient developed a red, hot, and swollen sensation on his face and saw our dermatologist who prescribed oral fexofenadine, doxycycline, and topical metronidazole for one week on 2023-03-02. The prescription is only valid until 2023-03-09. It is recommended to check if the dermatologic symptoms have improved before deciding whether to refill the prescription.

2022-12-01

• 2022-11-30 Hemoglobin 8.2 g/dL, MCV 76.7 fL, Ferritin 9.5 ng/mL, 2022-11-29 iron-bound Fe 36 ug/dL. Initialization of Foliromin (ferrous sodium citrate 50mg/tab) 1# QD is recommended.
• 2022-11-30 the SBP remained around 170 ~ 190 mmHg under the single antihypertensive agent Norvasc (amlodipine 5mg/tab) 1# QD. An addition of Labtal (labetalol 200mg/tab) 1# BID might be an option to alleviate hypertension.

700178859

230822

(not completed)

[MedRec]

• 2023-05-08 ~ 2023-05-11 POMR General and Gastroenterological Surgery
  • Discharge diagnosis
    • Suspicious of right papillary thyroid carcinoma status post bilateral thyroidectomy, parathyroidectomy, right neck lymph node dissection on 2023/05/09
    • Adenocarcinoma of D-colon with multiple liver and lung metastases, cT4aN1bM1b, stage IVB status post Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy on 2023/04/13, pT4aN0M1b, Stage IVB, status post Port-A implantation on 2023/05/09
  • CC
    • Glucose hypermetabolism at thyroid gland at whole body PET scan during evaluation of colon cancer was noted about 2 months ago
  • Present illness
    • This 59-year-old female had history of Adenocarcinoma of D-colon with multiple liver and lung metastases, pT4aN0cM1b, stage IVB status post Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy on 2023/04/13.
    • After discharge from CRS ward, she was regular follow up at our GS and CRS OPD. According our multidisciplinary cancer conferrence, after colon surgery, she will receieve thyroid surgery, adjuvent chemotherapy and staged lung surgery. She denied any symptoms such as hoarseness, difficulty swallowing or pain at neck. Physical examination revealed some small firm nodules at right neck. Recently thyroid sonography on 2023/03/28 revealed 1. Heterogeneous right thyroid nodule, with calcifications, 1.6x1.2cm. 2. Tiny right thyroid nodules, 0.18x0.17cm, 0.24x0.17cm. 3. Left thyroid cyst, 0.83x0.49cm, Biopsy of right thyroid nodule revealed suspicious for papillary carcinoma. After discussion with patient, she will bilateral total thyroidectomy.
  • Course of inpatient treatment
    • After admission, pre-op preparation and anesthesia assessment was done. bilateral thyroidectomy, parathyroidectomy, right neck lymph node dissection and port-A implanatation were done smmothly on 2023/05/09. After operation, no specific complain except for mild wound pain was done. Follow up lab data revealed mild decreased serum calcium, so calcium supplement was given. Little ammount discharge from J-P drainage was noted. Under relative stable condition, we arranged her discharge on 2023/05/11 and OPD follow up.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Antica syrup (orciprenaline, bromhexine, doxylamine) 10mL TID
    • calcium carbonate 500mg 4# QID
    • Strocain (oxethazaine polymigel 5mg) 1# TIDAC
    • U-Ca (calcitriol 0.25ug) 1# TIDAC
• 2023-04-11 ~ 2023-04-20 POMR Colorectal Surgery
  • Discharge diagnosis
    • Adenocarcinoma of D-colon with multiple liver and lung metastases, cT4aN1bM1b, stage IVB status post Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy on 2023/04/13, pT4aN0M1b(0/20), G2, LVI(+), PNI(-), CRM(-), Stage IVB
    • Hypertension
    • Hyperlipidemia
    • Highly suspect right thyroid cancer
  • CC
    • diarrhea and bowel habit change since last year.
  • Present illness
    • This 59 y/o female patient with 1. D-colon cancer with liver and lung metastases 2. suspicious papillary carcinoma 3. Htn was quite well until she suffered from diarrhea and bowel habit change since last year. She visited our OPD for help and colonoscopy was done.
    • Colonoscopy showed a large circumferential tumor with near lumen obstruction was noted at sigmoid colon, s/p biopsy8. A 2cm advanced pedunculated polyp was noted at sigmoid colon (7-8cm below the tumor), s/p biopsy3. Pathology findings showed Adenocarcinoma, moderately differentiated in S-colon and villous adenoma 7 cm below the tumor.
    • Abdominal CT showed a segmental circumferential asymmetrical wall thickening at the sigmoid colon with irregular contour, measuring 6.5 cm in size(T4a). In addition, there are two enlarged nodes in the adjacent mesocolon (N1b). There is a poor enhancing mass 2.2 cm in S5 of the liver. Metastasis (M1a) is highly suspected.
    • In addition, there is a soft tissue nodule 1.1 cm in RML or RUL of the lung that may be lung metastasis (M1b).
    • This time, she admitted to our ward for preoperative preparation and surgical treatment. 
  • Course of inpatient treatment
    • After admission with ward routine and pre-op study were done. After well explain the risk of surgery including heart, lung complications and risk of leakage. Operation of Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy under general anesthesia were performed on 112/04/13. NPO and adequate IV fluid supplement. Chewing cookies, toast, rice with gum was started at op day. Early activity is encouraged. The wound healing well and no erythema change. She had flatus passage and abdominal wound pain subsided. She started to take oral diet well and no abdominal discomfort after meal. He had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. His abdominal wound pain had got much better. Drain is clear ascites and removal of JP drain. In stable condition, he was discharged on 112/04/20 and will receive OPD follow up next week.
  • Discharge prescription
    • Meitifen (diclofenac 75mg) 1# BID
    • Urosin (atenolol 100mg) 1# QD
    • Ulstop (famotidine 20mg) 1# BID
    • MgO 250mg 2# BID
    • Through (sennoside 12mg) 1# HS
• 2023-03-31 SOAP Colorectal Surgery
  • S
    • Vomiting and diarrhea during Chinese New Year >> relieved by fasting and rest
    • 2023-02-11: LLQ intermittent pain, soft loose stool; anemia was noted at LMD
    • 2023-03-13: referred from GI Dr for newly found a tumor of S-colon with impending obstruction, bloody stool and change in bowel habit for 1+ years
    • 2023-03-18: CT showed distal D-colon cancer with possible liver and lung metastases, arrange PET or more infomration
    • 2023-03-24: for PET report (Liver, lung metastases, and R/O thyroid tumor), can pass loose and liquid stool, no abdomen pain
    • 2023-03-31: Thyroid sono-biopsy showed suspicious papillary carcinoma, refer to GS, favor combined colon and hepatic surgery first followed by chemotherapy therapy + target therapy and lung and thyroid surgery
  • O
    • Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-03-28
    • Referring to the General Surgery (GS) and Cardiothoracic Surgery (CS) Outpatient Department (OPD), the General Surgery team has scheduled a thyroid ultrasound with a possible biopsy. Depending on the results, a staged surgery plan is anticipated, which may also include chemotherapy.
  • A
    • D-colon cancer with liver and lung metastases
    • suspicious papillary carcinoma
  • P
    • admission (2023/04/11), albumin use, prepare colon, ERAS? inform GS, colectomy + partial hepatectomy (2023/04/13)

[immunochemotherapy]

• 2023-08-22 - Avastin + FOLFIRI
• 2023-08-02 - Avastin + FOLFIRI
• 2023-07-04 - Avastin + FOLFIRI
• 2023-05-31 - Avastin
• 2023-05-29 - FOLFIRI

==========

2023-08-04

On 2023-07-09, the patient refilled her repeat prescription for atenolol and valsartan to manage her primary hypertension. This prescription was originally issued by JingMei Hospital on 2023-06-15. Both medications have been added to the active medication list, and there are no reconciliation issues detected.

700893323

230822

[lab data]

2023-07-24 Anti-HCV Nonreactive
2023-07-24 Anti-HCV Value 0.25 S/CO
2023-07-24 Anti-HBc Reactive
2023-07-24 Anti-HBc-Value 6.92 S/CO
2023-07-24 Anti-HBs 7.37 mIU/mL
2023-07-24 HBsAg Nonreactive
2023-07-24 HBsAg (Value) 0.27 S/CO

[exam findings]

• 2023-08-01 Patho - gingival/oral mucosa biopsy
  • Oral cavity, root of tooth 37, biopsy— acute and chronic inflammation
• 2023-07-26 Tc-99m MDP bone scan
  • A hot spot in the left 5th rib, and increased activity in bilateral femurs, tibiae, and left ankle, the nature is to be determined (post-traumatic change or other nature ?), suggesting folllow-up with bone scan in 3 months of reinvestigation.
  • Suspected benign lesions in both rib cages, maxilla, mandible, some T- and L-spine, L-S junction, bilateral shoulders, and hips.
• 2023-07-26 Patho - gingival/oral mucosa biopsy
  • Lower lip, left, incisional biopsy — Squamous cell carcinoma, moderately differentiated
  • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident. Tumor necrosis with bacterial colonies can be found also.
• 2023-07-25 MRI - nasopharynx
  • Findings
    • Tumor mass in left low lip and left buccal region, up to 33 mm.
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • Multiple enlarged LNs in left level I-II space, some of them clustered.
    • No evident bony destructive lesion.
  • IMP: Left buccal and low lip CA, T2N2bMx stage IVA.
• 2023-07-14 Ribs Bilat.
  • fractures at left 2nd and 5th ribs
• 2023-07-14, -04-14 SONO - abdomen
  • Liver cirrhosis, with splenomegaly
• 2023-03-17 Nerve Conduction Velocity, NCV
  • Findings: The NCV study showed (1) Prolonged distal motor latency in most sampled nerves. (2) Decreased CMAP amplitude in bilateral median and bilateral peroneal nerves. (3) Slowing motor and sensory conduction velocity in most sampled nerves. The F wave study showed prolonged latency in most sampled nerves. The H reflex study showed both prolonged. The QST study showed abnormal heat and cold sensation in lower limb.
  • Conclusion: The above findings suggest sensorimotor polyneuropathy and small fiber disease. Advise clinical correlation.
• 2023-03-11 L-spine AP + Lat (including sacrum)
  • compression fracture at L2 vertebral body
  • moderate decreased disc space in the L5/S1 disc.
  • blurred nargins of the L5 vertebral body.
• 2022-11-21 CT - abdomen
  • Swelling of the cecum, ascending colon is found. Colitis is considered.
  • Dilated esophagus with out-poutching at lower third esophagus is found. Diverticulum or othere is considered.

[MedRec]

• 2023-08-16 SOAP Oral and Maxillofacial Surgery He ChengHan
  • P: The subsequent chemotherapy was arranged by Dr. Xia HeXiong from the Hematology-Oncology department. Oral UFUR
  • Prescription
    • UFT (tegafur 100mg, uracil 224mg) 2# BID
• 2023-08-08 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • 24 hours CCr, audiometry, 5-FU in D5W
    • Refer to CS Chief Hsieh for Port-A implantation
• 2023-07-24 ~ 2023-08-01 POMR Oral and Maxillofacial Surgery He ChengHan
  • Discharge diagnosis
    • Squamous cell carcinoma of left lower gingiva and lower lip, cT2N2bM0, cstage IVA
    • Inflammatory conditions of jaws
    • Hyperkalemia
    • Cirrhosis of liver
    • Splenomegaly
    • Gout, unspecified
    • Essential (primary) hypertension
    • Functional dyspepsia
    • Functional intestinal disorder
  • CC
    • I had PROTRUDING mass lesion of my left lower lip for 1+ months.
  • Present illness
    • According to his statement, the present illness should be traced back to 1+ moths. This 54 year-old male patient, he felt an unhealed and protruding mass lesion of his left lower lip. He did not pay attention to it it in the beginning. Until he FOUND OUT THE MASS on his left lower lip KEPT GROWING and it because much more painful and swelling than it was. He visited to our oral & Maxillary clinic on 2023/07/17, which mouth finding showed protruding, ulcerative mass of left lower lip with induration, more than 2.5cm large. No palpable neck mass was palpated. Suspected malignancy of left lower gingiva and lower lip was impressed. After we had adequately explained the finding and treatment plans to the patient. He was admitted to ward for tumor survery and further management.
  • Course of inpatient treatment
    • After admission, we had arrange physcial examination was done and hyperkalemia (K+ 6.6 mmol/L) was found. RI infusion, hydration and Kalimate were prescribed. Incisional biopsy of left mandibular gingiva under local anesthesia on 2023/07/25. The pathology report showed squamous cell carcinoma. Then we had arrange tumor survey for him. The nasopharynx MRI showed tumor mass in left low lip and left buccal region, up to 33 mm, cT2N2bM0, cstage IVA. Abdomen sona showed liver cirrhosis, with splenomegaly. Whole body bone scan no evidence of distance metastasis. Another, his Anti-HBc(+) with cirrhosis. Due to the result of tumor work-up, we had consulted GI men and oncologist. We had well explained patient`s treatment plans in the future to patient and his family.
    • Complicated extraction of tooth 37, 38 and sent for pathological examination under local anesthesia on 2023/08/01. kept antibiotic agent and analegsic agent were prescribed. Ice packing and cool soft diet was educated.
    • Because of his general condition were stable, he was discharged and OPD follow up.
  • Discharge Prescription
    • UFT (tegafur 100mg, uracil 224mg) 2# BID
    • Acetal (acetaminophen 500mg) 1# Q4H
    • amoxicillin 250mg 2# Q8H
    • Parmason Gargle Solution (chlorhexidine) QD GAR
• 2023-07-17 SOAP Oral and Maxillofacial Surgery He ChengHan
  • S
    • The patient mentioned that the swelling of the lower left lip only started in the last two weeks.
    • betel nut chweing: more than 20 years, on and off
    • PH: anemia under iron Tx; left ribs fx
    • Allergy: keto
  • O
    • Protruding, ulcerative mass of left lower lip with induration, more than 2.5cm large
    • no palpable neck mass was palpated
    • tooth 36 severe attrition, dentinal hypersensitivity was noted.
    • Panoramic findings:
      • Missing: 13
      • Impaction: nil
      • Crown and Bridge: 14
      • Caries: nil
      • Periodontal condition: chronic periodontitis
    • extensive bony destruction of left posterior mandible
  • Assessment:
    • suspected malignancy of left lower gingiva extenidng to left lower lip
  • Plan:
    • explain the current condition to the patient
    • arrange incisional biopsy
• 2023-06-10 SOAP Neurology Xu BoRen
  • S
    • Alcholism
    • Slow progressive four limb weakness or four since 2022/10
    • arthritis
    • sphincter problem (+)
    • 2023/03/11
      • marked improved of limb weakness, no sphincter problem now
      • need cane to walk
      • The patient doesn’t see the original infectious disease specialist and wants me to prescribe the medication from there.
    • 2023/03/24
      • stable, no further weakness
    • 2023/06/10
      • stable
  • O
    • 2023/03/11 Suggest GI OPD for gall bladder or liver disease
  • A/P
    • General weakness, hypo Mg related
    • may taper PPI and Fe next time
  • Prescription x3
    • Anxiedin (lorazepam 0.5mg) 1# TID
    • Cardilol (propranolol 10mg) 1# BID
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Feburic (febuxostat 80mg) 1# QD
    • Rich (lansoprazole 30mg) 1# QDAC 20221121 EGD GERD LA-A doudenal ulcer scar
    • Through (sennoside 12mg) 2# HS
    • Utapine (quetiapine 25mg) 0.5# HS
    • MgO 250mg 1# TID
    • Acetal (acetaminophen 500mg) 1# PRNBID
    • Kentamin (B1 50mg, B6 50mg B12 500ug) 1# QD
• 2023-01-14 SOAP Infectious Disease
  • S
    • Visit for refill medicine as usual.
    • History: alcoholism.
  • P
    • Symptomatic treatment as needed.
  • Prescription
    • Anxiedin (lorazepam 0.5mg) 1# QID
    • Cardiolol (propranolol 10mg) 1# BID
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Feburic (febuxostat 80mg) 1# QD
    • Takepron (lansoprazole 30mg) 1# QDAC 20221121 EGD GERD LA-A doudenal ulcer scar
    • Through (sennoside 12mg) 2# HS
    • Utapine (quetiapine 25mg) 0.5# HS
    • Acetal (acetaminophen 500mg) 1# PRNQD
• 2018-01-11 SOAP Rheumatology and Immunology
  • Diagnosis
    • Gout, unspecified [M10.9]
    • Carpal tunnel syndrome [G56.00]
    • Peptic ulcer, site unspecified, unspecified as acute or chronic, without haemorrhage or perforation [K27.9]
    • Essential hypertention, unspecified [I10]
    • Unspecified inflammatory polyarthropathy [M06.4]
  • Prescription
    • colchicine 0.5mg 1# QD
    • Feburic (febuxostat 80mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQD
• 2017-11-04 SOAP Rheumatology and Immunology
  • S
    • acute urticaria after medication from ER (for SOB)
    • HBV told(?)
    • Crea:1.5->1.2->1.4
    • UA:5.8
    • ANA(-)RF(-)CCP(-)B27(-)
    • alcoholism
    • susp. drug allergy
    • steroid contraindicated due to possible HBV carrier
    • suggest hold current medication
    • suggest ER visit if necessary
    • suggest avoid alcohol
  • O
    • Drug allergy: NSAID, PCN
    • PH: gout? RA? (erosion?)
  • Diagnosis
    • Allergic urticaria [L50.0]
  • Prescription
    • Sinbaby Lotion (zinc oxide, diphenhydramine, dibucaine hydrochloride, dl-camphor) BID TOPI
    • Welizen (famotidine 20mg) 1# BID
    • Kefen KFT112 (ketotifen 1mg) 1# HS
    • Estimin (ebastine 5mg) 1# BID

[chemotherapy]

• 2023-08-22 - docetaxel 40mg/m2 0mg NS 250mL 1hr + cisplatin 40mg/m2 0mg NS 500mL + fluorouracil 2000mg/m2 0mg NS 500mL 46hr (TPF Q3W) [TEMP]
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2

==========

2023-08-22

[reconciliation]

Recent MCV and MCH levels have consistently been on the upper end of their normal range, suggesting that iron deficiency anemia is less probable. The ongoing use of the iron supplement Foliromin (ferrous sodium citrate) may be reduced.

2023-08-21 MCV 92.3 fL
2023-07-24 MCV 93.0 fL
2023-07-14 MCV 92.6 fL
2023-06-10 MCV 92.3 fL
2023-08-21 MCH 31.0 pg
2023-07-24 MCH 30.6 pg
2023-07-14 MCH 30.2 pg
2023-06-10 MCH 30.6 pg

701377724

230822

[exam findings]

• 2023-07-25 MRI - pelvis
  • Findings
    • S/P hysterectomy.
    • S/P double J catheter, right side.
    • Unremarkable change of the liver, spleen, pancreas and both kidneys.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
  • Impression:
    • S/P hysterectomy.
    • S/P double J catheter, right side.
    • Suggest follow up.
• 2023-07-20 CT - abdomen
  • History and indication: Malignant neoplasm of cervix uteri
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy.
    • Atrophy of left kidney. S/P right side double J catheter insertion. Fat stranding along right renal pelvis and ureter.
    • S/P Port-A infusion catheter insertion.
    • Grade 4 fatty liver.
  • IMP:
    • S/P hysterectomy. No evidence of tumor recurrence.
    • S/P right side double J catheter insertion. Fat stranding along right renal pelvis and ureter.
• 2023-07-10 Bladder Sonography
  • PVR 6 mL
• 2023-06-23 All-RAS + BRAF gene mutation analysis
  • Cell block No: F2022-00402 FsA1
  • RESULTS：
    • ALL-RAS: Detected (KRAS codon 12 GGT>TGT, p.G12C)
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-15 Pure Tone Audiometry, PTA
  • Reliability FAIR
    • Average RE 23 dB HL; LE 15 dB HL.
    • RE WNL with 2k Hz A-B gap.
    • LE normal to moderate SNHL with 4k Hz A-B gap.
• 2023-04-28 PET
  • Two glucose hypermetabolic lesions in the left pelvic side wall region, compatible with recurrent malignancy.
  • Glucose hypermetabolism in two left paraaortic lymph nodes and a left common iliac lymph node, compatible with metastatic lymph nodes.
  • Glucose hypermetabolism in some bilateral supraclavicular lymph nodes, suggesting distant lymph node metastases.
  • Glucose hypermetabolism in the right hip joint. Inflammation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2023-04-17 MRI - pelvis
  • Clinical history: 50 y/o female patient with cervical adenocarcinoma s/p CCRT.
  • With and without contrast enhancement MRI: Pelvis
    • S/P hysterectomy.
    • There is focal soft tissue (1.5cm) in left pelvic side wall region, r/o recurrent tumor.
      
    • Mild left hydronephrosis.
    • T2 hyperintensity lesions, up to 2cm in left pelvic cavity, r/o lymphocele.
    • There is paraaortic lymph node (1.4cm) in the paraaortic region, r/o paraaortic lymph node metastasis.
  • Impression:
    • S/P hysterectomy with lymphocele in left pelvic cavity.
    • R/O recurrent tumor in left pelvic side wall region.
    • R/O metastatic lymph node in paraaortic region.
• 2023-01-11 CT - abdomen
  • S/P hysterectomy.
  • There is no evidence of tumor recurrence.
• 2022-12-31, -12-07 SONO - nephrology
  • Right hydronephrosis
• 2022-10-14 Intravenous Pyelography, IVP
  • Intravenous pyelography and post-voiding study:
    • S/P double J catheter insertion in place, right side.
    • Mild right hydronephrosis.
• 2022-08-29 Patho - uterus with or without SO non-neoplastic/prolapse
  • Diagnosis:
    • Utrus, cerivx, hysterectomy with frozen section (F2022-402FS) and separated “cervix” tissue (S2022-14312G) — adenocarcinoma, grade 3. with exocervical margin and parametrial invasion.
      • IHC stain: p16 (30-40% neoplastic glands show nuclear staining; Correlation of HPV molecular test might be considered), Vimentin (-), p53 (+, abberant), Napsin-A (-), ER (+, 25 %, strong intensity)
    • Uterus, endometrium, hysterectomy — involved by tumor, lower uterine segment
    • Uterus, myometrium, hystrectomy — myomas x2. No malignancy
    • Lymph node, bilateral pelvic and para-aortic, dissection (S2022-14312A-F) — free, for details, see microscopic description.
    • Adnexae, bilateral, salpingo-oophorectomy (S2022-14312H-I) —free
    • Omemtume, omentectomy (S2022-14312J) — free.
    • pT2b, at least. pN0 (if cM0); FIGO pathological stage: IIB, at least.
  • Gross description:
    • Procedure (select all that apply) - staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy)
      • Uteurs: 10 x 7 x 5 cm with cauliflower shaped tumor occupying cervix and endocervix (details see below) and two myomas up to 1.5 x 1.2 x 1.2 cm in size. Left ovary: 2.5 x 2 x 1.5 cm. The tube: 4.5 x 0.8 x 0.8 cm. Right ovary: 2.5 x 2 x 1.5 cm; right tube: 4.5 x 0.8 x 0.8 cm; Omentum: 21 x 10 x 2cm. Bilateral adnexae and ometum are grossly free.
        
    • Tumor Size:
      • Greatest dimension: 4.5 cm
      • Additional dimensions (centimeters): 2.5 x 2.5 cm, involving distal cut end and bilateral para-metrium.
    • Tumor Site (select all that apply)- cerivx and endocervix, involving lower uterine segment, distal cut end and bilateral para-metrium.
    • Sections are taken and labeled as:
      • Tissue for frozen section: F2022-402FSA1-3: cervical tumor.
      • Tissue for formalin fixation:
      • F2022-402 Uteurs: A1-2: myomas; A3-10: additional sampling of cervical tumor (with margins inked in black); A11-12: tumor involving serosal surface.
      • S2022-14312 A: 01: left iliac lymph nodes; B: 02. left obturator lymph nodes; C: right iliac lymph nodes; D: right obturator lymph nodes; E: left para-aortic lymph nodes; F: right para-aortic lymph nodes; 07: separated tissue laveled as “cervix”; H1-2: left adnexa; I1-2: right adnexa; J: omentum.
  • Microscopic Description:
    • Histologic Type - Adenocarcinoma, NOS, p16: <70%.
      
    • Histologic Grade: G3: Poorly differentiated
    • Stromal invasion:
      • Depth of stromal invasion: 9 mm, to deep 1/3 of the cervix.
    • Silva Pattern of Invasion (applicable only to invasive endocervical adenocarcinomas):
      • Pattern C: Glands or papillary structures with little intervening stroma or mucin lakes with tumor cells within the cervical stroma and filling a 4x filed (5mm)
    • Other Tissue/ Organ Involvement (select all that apply):
      • Bilateral parametrium - involved
      • Bilateral ovary - free
      • Bilateral fallopian tube - free
      • Omentum- free
    • Margins:
      • Ectocervical Margin: Not Free (Cancer present)
      • Radial (Circumferential) Margin: Not Free
    • Lymphovascular Invasion: Present
    • Regional Lymph Nodes: described as follows
      • Site: (Positive: positive nodes number/total number) (Negative: 0/total number33) :
      • Pelvic Lymph Nodes:
        • Right iliac: Negative: 0/ 4
        • Left iliac: Negative: 0/ 5
        • Right obturator: Negative: 0/ 12
        • Left obturator: Negative: 0/ 5
        • Para-aortic Lymph Nodes:
        • Right para-aortic: Negative: 0/ 2
        • Left para-aortic: Negative: 0/5
    • Distant Metastasis: (if cM0).
      • NOTE1: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.” … “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, Medical Department and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
    • Additional Pathologic Findings :None identified
    • Special Study: p16 immunohistochemistry: (30-40% neoplastic glands show nuclear staining)
    • Comment(s)- correlation of HPV molecular test might be considered.
• 2022-08-27 CT - abdomen
  • Imaging Report Form for Endometrial Carcinoma
    • Impression ( Imaging stage ) : T:Tx(T_value) N:Nx(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2022-08-27 Gynecologic ultrasonography
  • Findings
    • Uterus Position: AVF
      • Size: 77 x 58 mm
      • Myoma: 24 x 15 mm, 22 x 18 mm
    • Endometrium
      • Thickness: 10.6 mm
    • Adnexae
      • ROV Size: 38 x 18 mm
      • LOV Size: 22 x 15 mm
  • IMP: R/O hematoma accumulation at cervix 49 x 35 mm
• 2022-06-08, -06-03 Gynecologic ultrasonography
  • IMP
    • Adenomyosis
    • Uterine myoma
• 2022-05-03 Gynecologic ultrasonography
  • Other: RT adnexae free
  • IMP
    • R/O Mild Adenomyosis
    • Uterine myoma

[MedRec]

• 2022-08-28 ~ 2022-09-13 POMR Obstetrics and Gynecology Huang SiCheng
  • Discharge diagnosis
    • Malignant neoplasm of cervix uteri, unspecified
    • Acute posthemorrhagic anemia
  • CC
    • Heavy and continued menstrual bleeding with dysmenorrhea for 2 months
  • Present illness
    • This 50-year-old lady, G0P0, no sexual history, without any systemic disease, was admitted to our ward for ATH and possible BSO in figuration of malignancy due to heavy and continued menstrual bleeding for 2 months.
    • According to the patient, she had been at her usual health status until last year, her menstrual cycle had stopped for half year, but another menstrual cycle began again since 2021/12/24, and the period had persisted until now. About 6 months ago (2022/02), she visited GYN OPD, and myoma was noticed. Her menstrual cycle was regular then, with duration/interval of 6-7/26-28 days. At OPD in 2022/05, GYN sonar was done and showed mild adenomyosis and myomas in size of 1.7x1.2cm and 2.1x1.2cm. In 2022/06, her menstrual amount increased a lot with blood clots, and she visited our ER, and she would change her night sanitary pad per 5 minutes then. GYN sonar was also done and showed adenomyosis and myomas in size of 2.5x2.4cm and 3.2x2.2cm. She also received blood transfusion. CA-125 showed 46.3U/mL. In 2022/08, she started to notice dysmenorrhea, too. And painkillers could not relieve her pain. For these 2 days, she again experienced large amount of vaginal bleeding and came to our ER.
    • At our ER on 08/27, her vital signs were T/P/R: 35.4/98/20, BP: 130/80 mmHg. Her Hb decreased from 9.3 to 8.5 in a day, and she received blood transfusion 4U. GYN sonar showed hematoma accumulation at cervix in size of 4.9x3.5cm. Today, she fainted at ER toilet, and Hb decreased from 9.4 to 8.5 in 7 hours. Due to above condition, she was admitted to our ward for ATH and possible BSO in figuration of malignancy and received further management.
  • Course of inpatient treatment
    • After admission, emergent staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy) was done on 8/28. Because she had anemia and mild loss of blood during the surgery, blood transfusion with pRBC was done. Bilateral drainage tube were inserted during the surgery. A total amount of 50ml clear red fluid was drained. However, drainage increased on 9/1 (vs amount on 8/31) with a yellowish color and was sent to measure its creatinine level. Creatinine result was 22.2mg/dL, suggesting a possible urinary tract injury.
    • The patient did not have unstable vital signs, abdominal pain, or other peritoneal signs. A Foley catheter was inserted. GU doctor was consulted and abdominal CT was arranged on 9/3. Right distal ureteral leak was reported. We had well exaplained the current condition, including the benefits of surgery, to the patient with GU man on 9/4. After discussed, laparoscopic urinary tract repair surgery will perform by GU surgeon on 9/6. Followed lab on 9/4 show hypoalbuminemia and hypokalemia and self paid albumin and potassium supplement were prescribed.
    • Note
      • 2022/09/05: pathology report
        • Cervical cancer, adenocarcinoma, grade 3
        • Complicated with exocervical margin and parametrial invasion.
        • Staging: pT2bN0Mx, FIGO stage: IIB
      • 2022/09/06: double J insertion
      • 2022/09/08: Gynecological Cancer Discussion Meeting
        • Oncology radiation contacted for the planning of further treatment
      • 2022/09/12: Cystography via foley catheter
  • Discharge prescription
    • Ceficin (cefixime 100mg) 2# BID
    • Metrozole (metronidazole 250mg) 1# QID
    • MgO 250mg 2# QID
    • Through (sennoside 12mg) 1# HS
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# QID if wound pain
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID

[consultation]

• 2022-09-09 Radiation Oncology
  • A
    • A: Adenocarcinoma, grade 3, of the uterine cervix, with exocervical margin and parametrial invasion, stage pT2bN0 (cM0); FIGO pathological stage: IIB, s/p staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy).
    • P: CCRT is indicated for this patient with the following indicators: exocervical margin and parametrial invasion, stage pT2bN0 (cM0); FIGO pathological stage: IIB, and staging surgery
      • Goal: curative
      • Treatment target and volume: pelvis
      • Technique: VMAT/IGRT and IVRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, 5040cGy/28 fractions of the cervical and parametrial involved margin area, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface area by IVRT.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her sister. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0930, 2022-9-22.
• 2022-09-09 Infectious Disease
  • Q
    • This 50-year-old lady, G0P0, no sexual history, without any systemic disease. This is a case of cervical Cancer, adenocarcinoma, grade 3.with exocervical margin and parametrial invasion. pT2b, at least. pN0 (if cM0); FIGO pathological stage: IIB, at least. Status post hysterectomy and bilateral salpingo-oophorectomy on 2022/08/28. Complicated with right distal ureteral leak post double J insertion on 2022/09/06. We sent ascites (drainage from cul-de sac) for bacteria culture. The report showed growth with pseudomonas putida. As a result, we need your expertise and help for antibiotic use. Thank you.
  • A
    • Ascites culture: Pseuodomonas putida, Chryseobacter indologens
    • Cr: 0.51, CRP:0.43
    • Impression: Complicated intra-abdominal infection is impressed
    • Suggestion:
    • Empirical antibiotics with finibax 500mg iv q8h is suggested
    • Please adjust antibiotics according to clinical condition and culture susceptibility results.
• 2022-09-02 Urology
  • Q
    • This 50-year-old lady diagnosed with endometrial tumor r/o malignancy and received staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection+ para-aortic lymphnode dissection + infracolic omentectomy ) on 2022/08/28.
    • Bilateral drainage tube were inserted during the surgery.
      
    • However, drainage increased and we had sent this fluid to check its creatinie. Cr was 22.2mg/dL and urinary tract injuries should be considered.
    • As we discussed at phone, we need your help for evaluation. Thanks a lot!
  • A1
    • This 50 y/o female received staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy) on 2022/08/28. Increasing drainage amount with suspected urine leakage was found today. Since she still had urine output aroung 500ml/8hr, complete transection of ureter was not likely. Please arrange CTU for further evaluation first.
  • A2 2022-09-03 13:33:52
    • CT showed right lower ureter leakage
    • The deficit of ureter may be 2.5cm in ureter reimplantation setting
    • Surgical repair may be carried out on 2022/09/06 afternoon
    • Therefore, we may have plenty of time to explain situation to her and her family.
• 2022-08-28 Obstetrics and Gynecology
  • A
    • GYN Note
      • still hypermenorrhea with blood clots
      • stronly requested admission
    • Hb-9.4 post blood transfusion packRBC 4u
    • sex[-]
    • Imp:
      • uterine myoma
      • adenomyosis
      • cervical lesion?
      • anemia
      • hypermenorrhea with blood clots
    • Plan
      • Phone contact with Professor Huang SiCheng
      • Arrange admission under service of Professor Huang SiCheng
• 2022-08-27 Obstetrics and Gynecology
  • Q
    • Returning visit 2022-08-27 19:48
    • Excessive vaginal bleeding, hospitalization requested.
  • A
    • Due to persistent symptoms, she visited our ER again, and we were consulted for evaluation.
    • C.C.
      • Massive vaginal bleeding with blood clots for 2 days. The patient needs to be wrapped in an adult diaper, as sometimes it immediately becomes full when standing up.
    • Physical examiantion
      • Vital signs stable, afebrile
      • Active vaginal bleeding (+)
      • Pad: moderate amount of bleeding, with scanty blood clots
    • Lab
      • WBC: 7.66K
      • Hb: 9.3 -> 9.1 -> 8.5 g/dL (08/27 1am -> 7am -> 8pm)
    • Image
      • US: (1) EM: 10.6mm (2) Uterine myomas: 24X15mm, 22X18mm (3) Adenomyosis
    • Impression
      • Abnormal vaginal bleeding, cause to be determined
    • Suggestion
      • Please recheck CBC after transfusion is completed. If Hb improves and her vital signs are stable, may consider discharge with medication.
      • Please prescribe Naposin 1# TID X 2 days + Ergometrine 1# BID x 2 days after discharge. Please be sure to inform the patient to continue taking the other medications prescribed earlier, but please stop Keto and start taking Naposin! (This has been communicated to the patient, please remind again, thank you)
      • OPD follow-up at Dr. Zeng’s clinic on W3.
      • The patient has been fully informed that this is a case of abnormal bleeding. Emergency treatment will be given in the emergency room and life signs will be ensured to be stable. Further examinations and treatment will be carried out in the following outpatient follow-up. The patient expressed that they would like to return to Dr. Zeng’s clinic.
• 2022-08-27 Obstetrics and Gynecology
  • Q
    • Triage Level: 2 Vaginal bleeding > Heavy vaginal bleeding
      • The chief complaint is vaginal bleeding starting from 5 o’clock in the evening.
      • Menstrual period started on 2021/12/14 and has not stopped till now,
      • no trauma or other concerns, GYN Dr. Shao Zhixuan said to hang in the department of internal medicine first.
      • Also experiencing menstrual pain.
  • A
    • This 50y female, sex(-), LMP: 2021/12, D/I: 5/28-30, history of adenomyosis s/p Visanne use and Leuplin on 2022/08/13, intermittent vaginal bleeding and spotting since 2021/12, episodes of massive vaginal bleeding twice in 2022/06, was admitted this time due to massive vaginal bleeding with blood clots tonight.
    • S:
      • denied systemic disease or surgical history
      • mild dizziness, no SOB
      • intermittent vaginal bleeding and spotting since 2021/12
      • massive vaginal bleeding with blood clots tonight
    • O:
      • TAS + TRS: UT 77x61x58mm, ant 22x18mm, post 24x15mm, RO 38x18mm, LO 22x15mm, R/O hematoma at cervix 49x35mm
      • PE: hymen was intact, blood clots (+), pelvic exam cannot be approached
      • BP: 130/80, HR 98, Hb: 9.3
    • A:
      • DUB, R/O perimenopausal status; cervical lesion cannot be ruled out
    • P:
      • pRBC 2u was given at ER
      • Please prescribe NSAID (keto, naproxen…), transamine, oxytocin for uterine contraction; Fe supplement after discharge
      • Consider further image for cervical lesion such as CT or MRI
      • Suggest F/U at Dr. Zeng LunNa OPD next week and discuss if surgical intervention is needed
• 2022-06-04 Obstetrics and Gynecology
  • A
    • KEEP Acetaminophen PO, Ergonovine PO, Transamin PO for 3 days
    • OPD follow-up, already booked an appointment with Dr. Tseng on Wednesday
    • The patient visited emergency room yesterday and came to the emergency room again today for the same reason. Additional prescription of Visanne, 1 tablet orally at bedtime for 5 days (please remind the patient to take it before sleeping)
    • Please take a blood sample, Please check LH, FSH, E2, CA125
• 2022-06-03 Obstetrics and Gynecology
  • Q
    • Triage Level: 3 Vaginal bleeding > Coagulation abnormality - moderate or mild bleeding. Family said the patient’s period has been going on for 6 months and seeing a doctor hasn’t helped. Just now there was a particularly large amount of blood loss, causing dizziness and weakness.”
      • large amount of vaginal bleeding just now
      • Changing a diaper every five minutes
      • denied sex intercourse
      • no abd pain, no chest pain, no N/V, no diarrhea
    • 2022/05/03 Gynecologic ultrasonography
      • Uterus: 10.0 x 5.3cm
      • Myometrum: Anterior/Posterior wall: 2.07/2.03 cm
      • myoma: 1.7x1.2cm, 2.1x1.2cm
      • EM: 0.81cm
      • Mild Adenomyosis
  • A
    • S
      • 49y/o, female, sex(-), LMP: 2021/12/14
      • Hx: Adenomyosis, Danazol since 5/3
      • vaginal bleeding for 6 month
    • O:
      • pregnancy test (-), WBC: 7420, Hb: 7.7
      • CRP: 1.64,
      • sono: Uterus: 11.2x5cm, EM: 0.54
      • myoma: 33x23mm, 22x15mm
      • bilateral adnexa free
      • CDS: no fluid
    • IMP:
      • Adenomyosis
      • Uterine myoma
    • P:
      • Acetaminophen PO, Ergonovine PO, Transamin PO for 3 days
      • OPD follow

[surgical operation]

• 2022-12-20
  • Surgery
    • Endoscopic internal dilatation of right ureter    
  • Finding
    • Right lower ureter stricture, no contrast extravasation during retrograde pyelography    
    • A 7Fr. 24cm DBJ inserted to right ureter
• 2022-08-28
  • Surgery
    • Diagnosis: endometrial tumor r/o malignancy s/p staging surgery.
    • Operation: staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy)   - Finding
    • endometrial tumor r/o malignancy s/p staging surgery.
    • Frozen: malignancy
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder, peritoneum dut to tumor mass accupied, severe adhesion to bowel. frzen pelvis.
    • Adnexa:
      • LOV: 3x2x2 cm, smooth surface.
      • ROV: 3x2x2 cm, smooth surface.
      • Fallopian tube: bilateral grossly normal
    • CDS: invisible due to tumor mass occupied
    • Ascites: bloody, minimal
    • Bilateralpelvic lymph nodes: normal(-), enlarged(-), indurated(+)
    • Bilateralpara-aortic lymph nodes: normal(-), enlarged(-), indurated(+)
    • Omentum: grossly normal
    • Insert two JVAC over cu-de-sac
    • After the operation, optimal debulking surgery was achieved.
    • R0: no residual tumor
    • Estimated blood loss:
    • Blood transfusion: PRBC 6u FFP 6u
    • Complication: nil.

[radiotherapy]

[chemotherapy]

• 2023-08-22 - bevacizumab 15mg/kg 1200mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-27 - bevacizumab 15mg/kg 1200mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-04 - bevacizumab 15mg/kg 1200mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-09 - bevacizumab 15mg/kg 1200mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-16 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr (If NHI approved, Avastin will be changed to 1200mg)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-17 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-10 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-03 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-27 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-20 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-13 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1

G-CSF

• Granocyte (lenograstim 250ug)
  • 2023-08-09 ~ 2023-08-10 OPD 2D
  • 2023-07-31 ~ 2023-08-02 IPD 3D
  • 2023-07-10 ~ 2023-07-12 IPD 3D
  • 2023-07-13 ~ 2023-07-15 OPD 3D
  • 2023-06-14 ~ 2023-06-16 IPD 3D
  • 2023-05-25 ~ 2023-05-27 OPD 3D

==========

2023-08-22

[reconciliation]

Currently, the patient’s medication records are not accessible on PharmaCloud. However, after reviewing the HIS5 records, no medication reconciliation issues were found.

[leukopenia]

At this time, the patient is not experiencing severe leukopenia. Any leukopenia events that have occurred since the start of the [bevacizumab paclitaxel cisplatin] regimen on 2023-05-26 have been treated with G-CSF administrations without reducing the dose of paclitaxel or cisplatin.

• 2023-08-16 WBC 3.31 x10^3/uL
• 2023-08-09 WBC 2.66 x10^3/uL * 2023-08-09 2-day G-CSF
• 2023-07-20 WBC 6.37 x10^3/uL 2023-07-31 3-day G-CSF
• 2023-07-13 WBC 1.05 x10^3/uL ** 2023-07-10 6-day G-CSF
• 2023-07-03 WBC 4.49 x10^3/uL
• 2023-06-21 WBC 3.73 x10^3/uL
• 2023-06-14 WBC 3.03 x10^3/uL 2023-06-14 3-day G-CSF
• 2023-06-01 WBC 5.07 x10^3/uL
• 2023-05-25 WBC 1.16 x10^3/uL ** 2023-05-25 3-day G-CSF
• 2023-05-11 WBC 6.21 x10^3/uL
• 2023-05-01 WBC 7.21 x10^3/uL

2023-07-04

Based on the PharmaCloud database, this patient has exclusively attended our hospital for outpatient and inpatient services across the departments of urology, obstetrics and gynecology, radiation-oncology, and hemato-oncology in the past three months. No issues were found during medication reconciliation.

2023-06-09

[reconciliation]

• According to the PharmaCloud database, this patient has only visited our hospital for outpatient and inpatient services in the departments of urology, obstetrics and gynecology, radiation-oncology and hemato-oncology in the past three months. No medication reconciliation issue identified.

[more intensive hydration]

• Serum creatinine and BUN both show an upward trend and BUN has exceeded the upper limit of normal. Hypomagnesemia was also observed. Cisplatin-induced nephrotoxicity might present as kidney injury and/or as electrolyte disturbances (eg, hypomagnesemia). A total of 1350mL of fluid was supplemented during the regimen administration (NS 250mL before cisplatin, 100mL simultaneously with bevacizumab, 500mL simultaneously with cisplatin, D5W 500mL with paclitaxel), this already takes hydration into consideration. It might be considered increasing the NS volume (for instance, introducing 500mL of NS both before and after the administration of cisplatin), and encourage the patient to hydrate more during the day.
  • 2023-06-01 Creatinine 0.84 mg/dL
    
  • 2023-05-25 Creatinine 0.85 mg/dL
    
  • 2023-05-13 Creatinine 0.82 mg/dL
    
  • 2023-05-11 Creatinine 0.75 mg/dL
    
  • 2023-05-01 Creatinine 0.78 mg/dL
    
  • 2023-04-26 Creatinine 0.79 mg/dL
    
  • 2023-04-13 Creatinine 0.86 mg/dL
    
  • 2023-03-16 Creatinine 0.60 mg/dL
    
  • 2023-02-16 Creatinine 0.57 mg/dL
    
  • 2023-01-19 Creatinine 0.50 mg/dL
    
  • 2023-06-01 BUN 31 mg/dL
    
  • 2023-05-25 BUN 22 mg/dL
    
  • 2023-05-01 BUN 19 mg/dL
    
  • 2023-04-13 BUN 19 mg/dL
    
  • 2023-03-16 BUN 13 mg/dL
    
  • 2023-02-16 BUN 15 mg/dL
    
  • 2023-01-19 BUN 10 mg/dL
    
  • 2023-06-01 Mg (Magnesium) 1.8 mg/dL
    
  • 2023-04-26 Mg (Magnesium) 2.2 mg/dL

[leukopenia]

• This patient last received paclitaxel and cisplatin on 2023-05-15 and a WBC nadir of 1.16K/uL was noted on 2023-05-25. Paclitaxel carries a Boxed Warning regarding bone marrow suppression and recommends frequent peripheral blood cell counts for all patients receiving the drug. Granocyte (lenograstim 250ug) was administered for three consecutive days starting on 2023-05-25.

• According to the reimbursement guidelines of the Taiwan National Health Insurance, the use of G-CSF is allowed for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an absolute neutrophil count (ANC) of less than 500/uL after chemotherapy. This patient meets the specified criteria (neutrophil 14.7%), so G-CSF can be prescribed to manage leukopenia following this round of chemotherapy.

  • 2023-06-01 WBC 5.07 x10^3/uL
    
  • 2023-05-25 WBC 1.16 x10^3/uL
    
  • 2023-05-11 WBC 6.21 x10^3/uL
    
  • 2023-05-01 WBC 7.21 x10^3/uL
    
  • 2023-05-25 Neutrophil 14.7 %

701455726

230822

[diagnosis] - 2023-03-09 admission note

• Pancreatic ductal adenocarcinoma with doudoenal obstruction with several mesenterric tumor seeding cT4N2M1, stage IV, status post laparoscpe vagotomy with gastrojejunostomy on 2022/10/31 and chemotherapy with FOLFIRINOX from 2022/12/07
• Chronic viral hepatitis B without delta-agent
• Essential (primary) hypertension
• Gastro-esophageal reflux disease with esophagitis
• Diarrhea, unspecified
• Unspecified hemorrhoids

[past history] - 2023-03-09 admission note

• Hypertension in 2004 with Nifedipine S.R. 30mg 1# PO QD and Urosin 100mg 1# PO QD control.   

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-07-13 CT - abdomen
  • History and indication:
    • Pancreatic ductal adenocarcinoma with doudoenal obstruction with several mesenterric tumor seeding cT4N2M1, stage IV.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P gastro-jejunal bypass. Much regression of pancreatic cancer but still presence duodenum, SMV and portal vein invasion. Some LNs at retroperitoneum.
    • Liver cysts (up to 0.9cm).
    • Focal fat stranding along D-colon.
    • Right thyroid nodules (up to 2.0cm).
  • IMP:
    • S/P gastro-jejunal bypass. Much regression of pancreatic cancer but still presence duodenum, SMV and portal vein invasion. Some LNs at retroperitoneum.
• 2023-06-07 All-RAS + BRAF mutation
  • Tissue Block No: S2022-17588
  • RESULTS：
    • ALL-RAS: Detected (KRAS codon 12 GGT > GAT, p.G12D)
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-03-11 CT - abdomen
  • Clinical history: 52 y/o male patient with pancreatic canceer
  • With and without contrast enhancement CT of abdomen–whole:
    • S/P gastroenteral anastomosis and stenting.
    • There is still pancreatic head malignancy (around 3.5cm) with adjacent vascular involvement.
    • There are small liver nodules, suspected liver cysts.
    • Thyroid nodule, 2.1cm in right lobe, suspected thyroid goiter.
  • Impression:
    • Pancreatic malignancy with adjacent vascular involvement.
    • S/P gastroenteral anastomosis and stenting.
    • Suspected liver cysts. Suggest follow up.
• 2022-12-05 Standing KUB
  • S/P metalic autosuture projecting at left middle abdomen.
  • S/P endoscopic gastrojejunostomy.
• 2022-11-01 Patho - peritoneum biopsy
  • Labeled as “mesentery”, excision — ductal carcinoma.
  • Specimen submitted in formalin consists of 1 piece(s) of tan, irregular tissue measuring 0.5 x 0.4 x 0.3 cm. All for section(s) in one cassette(s).
  • Section shows markedly fibrotic tissue with ductal carcinoma.
  • IHC stains: CA-19-9 (weak +), CK19 (+), compatible with pamcreatic origin.
• 2022-10-24 Panendoscopy
  • Diagnosis
    • Status post endoscopic gastroenterostomy with LAMS placement (note: LAMS, lumen-apposing metal stent)
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric ulcer, LAMS site
    • Edematous duodeanl mucosa, bilateral loop
  • Suggestion
    • consider tubular SEMS (note: SEMS, self-expandable metallic stent)
• 2022-10-24 ERCP, Endoscopic Retrograde Cholangiopancreatography
  • Indication: For LAMS revision
  • Symptoms: vomiting
  • Premedication: Buscopan 20mg + Alfentanil 0.25mg IV
  • Anesthesia: IV anesthesia
  • Diagnosis:
    • Gastric outlet obstruction, s/p endoscopic gastroenterostomy with successful LAMS placment but poor functionality,
    • s/p double pigtail stenting
  • Suggestion:
    • Suggest further metal stent placement for definite treatment.
    • Liquid diet.
• 2022-10-21 CT - abdomen
  • History:
    • 20221009 CT：pancreatic uncinate process cancer 3.6 cm with adjacent duodenum invasion (causing gastric outlet obstruction), SMA, SMV and portal vein invasion. Some LNs at retroperitoneum. cT4N2M0, cstage:III
    • 20221018 EUS guided gastroenteral anastomosis is achieved with hot AXIOS LAMS under guidance of EUS and fluoroscopy.
  • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
  • Findings:
    • S/P gastroenteral anastomosis with hot AXIOS LAMS self expanding metal stent. However, the stomach still shows marked distention with fluid collection.
      • please correlate with clinical condition.
    • Prior CT identified pancreatic uncinate process cancer with gastric outlet obstruction is noted again, stationary.
    • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
    • There is no ascites or lymphadenopathy.
    • There is no bowel wall thickening, and no bowel obstruction.
    • The abdominal aorta and IVC are grossly unremarkable.
    • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
  • IMP:
    • S/P gastroenteral anastomosis with hot AXIOS LAMS self expanding metal stent. However, the stomach still shows marked distention with fluid collection.
• 2022-10-20 Upper GI series
  • Findings
    • S/P gastric stenting.
    • The contrast medium passage from oral cavity through esophagus to stomach, stasis of contrast medium in the stomach with passage of some contrast medium into the duodenum.
  • Impression:
    • S/P gastric stenting, partial gastric obstruction.
• 2022-10-18 EUS, Endoscopic Ultrasonography
  • Indication: pancreatic cancer with gastric outlet obstruction
  • Symptoms: refractory vomiting
  • Pre-EUS diagnosis: Gastaric outlet obstruction
  • Diagnosis
    • Pancreatic cancer, uncinate process, with gastric outlet obstruciton s/p AXIOS LAMS (2 cm)
    • trivial ascites
  • Suggestion
    • standing abdomen tomorrow
• 2022-10-13 Needle Aspiration Cytology - pancreas
  • Pancreas: adenocarcinoma
• 2022-10-13 Patho - pancreas biopsy
  • Pancreas, head, EUS-FNB — ductal adenocarcinoma
  • Microscopically, it shows ductal adenocarcinoma composed of neoplastic ductal glands with invasive growth pattern and surrounding fibrous stroma. The tumor shows nuclear hyperchromasia, pleomorphism and increased N/C ratio.
• 2022-10-12 EUS, Endoscopic Ultrasonography
  • Indication: panc head tumor
  • Symptoms: severe abdominal pain
  • Pre-EUS diagnosis: Panc cancer
  • Diagnosis
    • Highly suspected pancreatic head cancer, s/p CH-EUS & EUS/FNB (A)
    • Duodenal narrowing, IDA to proximal 3nd portion, with partial obstruction, s/p biopsy (B)
    • Pancreatic head cystic lesion
    • Reflux esophagitis LA Classification grade D
    • Post NG insertion
    • Ascites
• 2022-10-11 Panendoscopy
  • Indication: Abdominal distention
  • Premedication: Xylocaine local spray
  • Anesthesia: No anesthesia
  • Diagnosis
    • Suboptimal study due to much food residual retention in stomach and duodenum, favor gastric outlet obstruction cause by uncinate process tumor
    • Reflux esophagitis LA Classification grade C
  • Suggestion
    • Arrange EUS-FNB for uncinate process tumor
    • Please keep NG tube decompression for this patient
• 2022-10-11 SONO - abdomen
  • Indication：Pancreatic lesion
  • Diagnosis (poor echo window)
    • Pancreatic tumor, uncinate process
    • suspected calcified spot, right lobe
    • Duodenal 3rd portion and gastric lumen was dilated
  • Suggestion
    • Arrange EUS-FNB for pancrease tumor
• 2022-10-09 CT - abdomen
  • History and indication: suspect GI tract cancer
  • Findings
    • A poor enhancing tumor (3.6cm) at ucinate process of pancreas with adjacent duodenum, SMA, SMV and portal vein invasion. Some LNs at retroperitoneum.
    • Liver cysts (up to 0.9cm).
    • Small nodules at RLL.
    • Distention of stomach and duodneum.
    • Focal fat stranding along D-colon.
    • Normal appearance of spleen, adrenals and kidneys.
    • Normal appearance of gallbladder.
    • Right thyroid nodules (up to 2.0cm).
    • Intact bony structures.
    • No ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • S/P NG tube indwelling.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)

[MedRec]

• 2022-11-28 ~ 2022-12-08 POMR Hemato-Oncology
  • Discharge diagnosis
    • Pancreatic head and neck carcinoma with lymph node metastasis, T4N2M0, stage III
    • Malignant neoplasm of head of pancreas
    • Essential (primary) hypertension
    • Hypokalemia
    • Diarrhea, unspecified
    • Chronic viral hepatitis B without delta-agent
    • Fever, unspecified
    • Hypomagnesemia
  • Course of inpatient treatment
    • After admitted, IVF supplementation for poor appetite. Hypokalemia (K:2.9 -> 3.2 -> 3.7mmol/L) with 0.298% KCl in NS 500ml IVF BID from 2022/11/28~2022/12/07. Hypomagnesemia (Mg:1.7 -> 2.1mg/dL) with MgSO4 1pc iv QD from 2022/11/30~2022/12/07. Diarrhea with Smecta 1pk po TIDAC and Ufunin 1# po PRNQ6H. Fever, R/O sepsis with Antibiotic with Tapimycin 4.5gm iv Q6H from 2022/11/30~2022/12/07 and Panadol 1# po PRNQ6H for BT > 38’C. Chemotherapy with FOLFIRINOX (Oxalip 65mg/m2, Campto 120mg/m2, LV 300mg/m2, 5FU 300mg/m2, 5FU 300mg/m2 and 2400mg/m2) (C1D1) from 2022/12/05~2022/12/07. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2022/12/08 and OPD followed up later.
  • Prescription
    • Mopride (mosapride citrate 5mg) 1# TID
    • Smecta (dioctahedral smectite 3mg) 1# TIDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • loperamide 2mg 1# PRNQ6H (for diarrhea > 2 times)
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Protase (pancrelipase 280mg) 1# TID
• 2022-11-22 SOAP Hemato-Oncolgoy
  • Tx Plan: Neoadjuvant C/T with FOLFIRINOX followed by surgical intervention

[consultation]

• 2022-10-13 General and Digestive Surgery
  • Q
    • Under the impression of abdominal distened suspect GI tract lesion, he was admitted to ordinary ward for further evaluation and management.
      
    • Due to Abdominal CT was reported Pancreatic carcinoma T4N2M0, STAGE:III. EUS FNB of pancreas was performed on 20221012, the pathology was pending. We need your surgical evaluation, thank you
  • A
    • A case of pancreatic head tumor with SMA invation
    • further operation with indication of double bypass or endo stent
    • if pt want to operation, we will take over for this case
• 2022-10-14 Hemato-Oncology
  • Q
    • This 51-year-old male has the histories of 1) Hypertension, 2) Gastric ulcer. He suffered form abdmnial distened after eating and body weight lose about 8kg since 2022/07. This time, he suffered from epigastric pain for 7 days. Poor appetite, nausea with vomiting were noted. He visited local medical clinic for help. But the symptoms did not improved. This time, he sufferred from vomiting 3 times with coffee ground vomitus since 20221007 midnight. He denied tarry stool passage, dizziness, chest tightness/pain, diarrhea/constipation, dysuria/frequency found.
    • The patient was sent to our ER for help. COVID19 rapid test showed Negative. At ER, BT:36.2C, BP:143/109 mmHg, PR:90/min, RR:18/min, SpO2:95% under room air. Con’s:E4V5M6. Physical exam showed pink conjunctiva, no JVE or bruit, symmetric chest wall expansion, breath sound:clear, Abdomen:soft, distension, epigastric tenderness, no muslce guarding or rebounding pain, normoctive bowel sound, no flank knocking pain, no lower leg pitting edema, no wound lesion, normal skin turgor and no skin rash found. Under the impression of abdominal distened suspect GI tract lesion, he was admitted to ordinary ward for further evaluation and management.
      
    • Due to Abdominal CT was reported Pancreatic carcinoma T4N2M0, STAGE:III. EUS FNB of pancreas was performed on 20221012, the pathology was pending, we need your evaluation and advice.
  • A
    • A case of pancreatic tumor with underlined HTN, GU is noted. I am consulted for the further evaluation and management.
    • My suggestions:
      • Well discuss with patient and family
      • May Consider Bypass and excisional tissue proof first.
      • May consider neoadjuvant chemotherapy first followed by OP (if feasible) or CCRT

[surgical operation]

• 2022-10-31
  • Surgery
    • laparoscpe vagotomy with GJbypass
    • excision of mesenteric tumor suspected seeding
  • Finding
    • pancreatic ca with doudoenal obstruction and several mesenterroc tumor seeding (PCI:1/39)

[chemotherapy]

• 2023-08-07 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-07-10 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-06-05 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-05-22 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-05-04 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-04-12 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-03-24 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-03-09 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-02-20 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 540mg NS 500mL 2hr + fluorouracil 300mg/m2 540mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-02-06 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 275mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2023-01-03 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 275mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2022-12-19 - oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + irinotecan 150mg/m2 275mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
• 2022-12-05 - oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 225mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3

FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-06-06 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F79571

• Cycle length: 14 days.

• Regimen

  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin).
    • Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 180 mg/m2 IV
    • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 400 mg/m2 IV bolus
    • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
    • Day 1
  • FU
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

Modified FOLFIRINOX chemotherapy for pancreatic cancer 2023-06-06 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F109546

• Cycle length: 14 days.

• Regimen

  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 150 mg/m2 IV
    • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

==========

2023-08-22

Currently, the patient’s medication records are not accessible on PharmaCloud. However, after reviewing the HIS5 records, no medication reconciliation issues were found.

2023-08-08

The active medication list includes a repeat prescription by our gastroenterologist for Protase (pancrelipase), Dicetel (pinaverium bromide), and Gaslan (dimethylpolysiloxane). However, Urosin (atenolol) and nifedipine, which were refilled on 2023-07-26, are not currently being used as the patient’s blood pressure has not shown an elevation during this hospitalization. There are no medication reconciliation issues identified.

2023-07-11

The local pharmacy refilled atenolol and nifedipine on 2023-07-01. They are included in the active medication list, and no medication reconciliation issues were found.

2023-06-06

• According to the PharmaCloud database, the refillable prescription for the patient’s primary hypertension, which was filled on 2023-04-29, has now expired. Additionally, the patient’s TPR panel does not display any instances of elevated blood pressure during this current hospitalization. Therefore, no issues have been found during the medication reconciliation process.

2023-05-23

• There was a refillable prescription for nifedipine and atenolol to treat the patient’s primary hypertension that was filled on 2023-04-29 for another 28-day course. These two drugs, nifedipine and atenolol, are not currently on the patient’s formulary, which violates medication reconciliation principles. However, the patient’s blood pressure readings from the TPR panel have remained relatively stable during the hospitalization. It is recommended that the patient’s blood pressure continue to be monitored and that reintroduction of these medications be considered based on future blood pressure readings and the patient’s overall clinical condition.

2023-05-05

• The patient appears to be tolerating the current treatment regimen well, with the exception of occasional episodes of leukopenia and diarrhea. However, these side effects have been manageable and reversible with the appropriate medications.

2023-04-13

• The patient’s WBC count has shown a decreasing trend since the start of the FOLFIRINOX regimen and is unlikely to fully recover at the current dose and interval.
  • 2023-04-12 WBC 2.50 x10^3/uL
    
  • 2023-04-06 WBC 3.85 x10^3/uL
    
  • 2023-03-21 WBC 3.68 x10^3/uL
    
  • 2023-03-09 WBC 2.55 x10^3/uL
    
  • 2023-03-02 WBC 3.21 x10^3/uL
    
  • 2023-02-16 WBC 4.53 x10^3/uL
    
  • 2023-02-06 WBC 3.51 x10^3/uL
    
  • 2023-01-31 WBC 5.03 x10^3/uL
    
  • 2022-12-29 WBC 4.07 x10^3/uL
    
  • 2022-12-15 WBC 5.02 x10^3/uL
    
  • 2022-12-05 WBC 5.26 x10^3/uL

2023-03-27

• On 2023-03-21, the patient’s WBC count remained at 3.68K/uL, which was an increase compared to 2.55K/uL on 2023-03-09 while receiving the same dose-reduced FOLFIRINOX regimen at a Q2W interval.
• The patient experienced 5 bowel movements on 2023-03-23 and 2023-03-25, and 3 on 2023-03-26. Loperamide 2mg TIDAC was prescribed and effectively mitigated the diarrhea.
• A low serum K level (3.1mmol/L) was noted on 2023-03-21, and potassium supplements have been properly prescribed to address this issue.
• As of 2023-03-27 at 08:37, the patient’s blood pressure was recorded as 103/63mmHg. If the patient continues to maintain a relatively low blood pressure for an extended period of time, the discontinuation of Urosin (atenolol) may be considered while continuing nifedipine, with regularly monitoring of blood pressure.
• There are no issues with the active prescription.

2023-03-10

• Protase (pancrelipase 280mg/cap) is properly prescribed as 1# PO BID. Pancrelipase itself has the potential to cause various gastrointestinal signs and symptoms, including but not limited to abdominal pain, abnormal stools, constipation, diarrhea, duodenitis, dyspepsia, flatulence, frequent bowel movements, gastritis, nausea, and vomiting. It is recommended to monitor these symptoms.

• The patient is receiving a dose-modified FOLFIRINOX regimen, which includes a lower dose of oxaliplatin (85mg/m2 reduced to 75mg/m2) and irinotecan (180mg/m2 reduced to 150mg/m2). Despite the reduction in dosage, recent lab data shows a trend towards leukopenia, which should be closely monitored.

  • 2023-03-09 WBC 2.55 x10^3/uL
    
  • 2023-03-02 WBC 3.21 x10^3/uL
    
  • 2023-02-16 WBC 4.53 x10^3/uL
    
  • 2023-02-06 WBC 3.51 x10^3/uL
    
  • 2023-01-31 WBC 5.03 x10^3/uL
    
  • 2022-12-29 WBC 4.07 x10^3/uL
    
  • 2022-12-15 WBC 5.02 x10^3/uL
    
  • 2022-12-05 WBC 5.26 x10^3/uL

2023-02-22

• The patient has been admitted to receive his 5th FOLFIRINOX treatment, and he has been tolerating the treatment well.
• Adjuvant therapy with a modified FOLFIRINOX regimen led to significantly longer survival than gemcitabine among patients with resected pancreatic cancer, at the expense of a higher incidence of toxic effects. (ref: FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer. N Engl J Med. 2018;379(25):2395-2406. doi:10.1056/NEJMoa1809775). Please continue to closely monitor the patient for any signs of adverse reactions.

2022-12-01

• For this patient with a pancreatic CA with duodenal obstruction, a lumen-apposing metal stent revision was performed on 2022-10-24 and he is currently being treated with piperacillin and tazobactam for suspected sepsis.
• There was a low level of K, Na, Mg, and Ca in the serum on 2022-11-30, possibly due to diarrhea (bowel movements 7 times on 28 and 4 times on 30). If the readings continue to decline, electrolyte supplements might be beneficial.
• The regimen FOLFIRINOX might be delayed or at least initialized with a lower dose of irinotecan if the patient continues to experience diarrhea.

700016937

230821

{pancreatic head cancer}

[exam findings]

• 2023-06-05 Tc-99m MDP bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed hot spots in several T- and L-spine, and increased activity in the maxilla, mandible, bilateral shoulders, S-I joints, hips, knees, and feet, in whole body survey.
  • IMPRESSION:
    • Hot spots in several T- and L-spine, the nature is to be determined (severe DJD or other nature ?), suggesting follow-up with bone scan in 3-6 months for investigation.
    • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, S-I joints, hips, knees, and feet.
• 2023-03-13 CT - abdomen
  • Indication: Pancreatic head cnacer (or Ampulla of Vater cancer) , pT3bN1 (3/28) cM0, pStage IIIA, s/p Whipple’s surgery
  • Abdominal CT with and without enhancement revealed:
    • s/p colon cancer op. and Whipple op.
    • Minimal soft tissue at mesenterric root is found. Post op. change? Suggest follow up.
    • Increased intestinal gas is found.
  • Imp:
    • s/p colon cancer op. and Whipple op.
    • Minimal soft tissue at mesenterric root is found. Post op. change? Suggest follow up.
• 2023-03-10, -02-01, 2022-12-21 CXR
  • Spondylosis of the T-spine
• 2023-02-14 MRI - brain
  • Indication: Malignant neoplasm of ampulla of Vater
  • Imp:
    • No acute infarct. No brain nodule or metastasis
    • Brain atrophy with bilateral periventricular ischemic/aging white matter change.
• 2022-10-27 CXR
  • Ground glass opacity in bilateral lower lungs.
• 2022-10-25 CXR
  • Bilateral pleural effusion.
  • Ground glass opacities in bil. lungs.
• 2022-10-21 Patho - pancreas total/subtotal resection
  • Diagnosis:
    • Small intestine, ampulla of Vater, Whipple operation — Adenocarcinoma, moderately differentiated; AJCC 8th edition: pStage IIIA, pT3bN1(if cM0)
      • Pancreas, head, Whipple operation — Adenocarcinoma, by direct invasion
      • Common bile duct, distal, Whipple operation — Adenocarcinoma, by direct invasion
      • Stomach, partial gastrectomy — Negative for malignancy
      • Lymph node, peri-pancreas, dissection — Adenocarcinoma, metastatic (3/10)
      • Lmph node, peri-gastric, dissection — Negative for malignancy (0/13)
        
    • Pancreas head, excision — Negative for malignancy
    • Lymph node, site ?, excision — Negative for malignancy (0/1)
    • Lymph node, retroperitoneal cavity, excision — Negative for malignancy (0/4)
  • Gross Description:
    • Procedure: Pancreaticoduodenectomy (Whipple resection), partial pancreatectomy: Pancreas: 4.7 x 3.7 x 3.0 cm; Duodenum: 16.0 cm in length; Lessser curvature: 6.0 cm in length; Greater curvature: 9.0 cm in length; Common bile duct: 4.5 cm in length;
    • Tumor Site: ampulla of Vater and invasion to pancreatic head, duodenum, distal common bile duct, peri-pancreatic soft tissue
    • Tumor Size: 2.4 x 2.0 x 1.5 cm.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma; The immunohistochemical stains reveal CK7(+) and CK20(-).
    • Histologic Grade (applies to ductal carcinoma only) :G2: Moderately differentiated
    • Tumor Extension: Tumor invades ampulla of Vater, duodenal wall, pancreas head, peripancreatic soft tissues, distal common bile duct
    • Margins
      • All margins are uninvolved by invasive carcinoma and high-grade intraepithelial neoplasia
      • Distance of invasive carcinoma from closest margin: 2 mm.
      • Specify: posterior peripancreatic soft tissue resection margin
        
      • Gastric resection margin: 10 cm; Distal small intestine margin: 10.5 cm; Pancreatic margin: 3.5 cm; Common bile duct resection margin: 3.5 cm; Anterior peripancreatic soft tissue margin: 0.8 cm
    • Lymphovascular Invasion: Present
    • Perineural Invasion: Present
    • Regional Lymph Nodes: Number involved/examined: peri-pancreatic: 3/10; peri-gastric: 0/13; lymph node, site ?: 0/1; LN retroperitoneal: 0/4
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable): not applicable
        • Primary Tumor (pT): pT3b: Tumor extends into peripancreatic soft tissue
        • Regional Lymph Nodes (pN): pN1: Metastasis in one to three regional lymph nodes
        • Distant Metastasis (pM): if cM0
    • Additional Pathologic Findings: None identified
• 2022-10-07 Patho - duodenum biopsy
  • Diagnosis:
    • Major papilla, biopsy — adenocarcinoma, modertaely differentiated
  • Microscopically, it shows modertaely differentiated adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei,pleomorphism, and high N/C ratio.
  • Immunohistochemcial stain reveals CK(+), p53(focal+, 40%), Ki-67 index: 30%.
• 2022-10-07 Endoscopic Ultrasound, EUS
  • Prominent major papilla, favor ampulla vater tumor, s/p biopsy
  • CBD dilatation
  • Reflux esopgagitis Gr.A
  • Duodenal shallow ulcers, bulb and SDA
• 2022-10-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 7) / 53 = 86.79%
    • M-mode (Teichholz) = 87
  • Adequate LV,RV systolic function with normal wall motion
  • Impaired LV relaxation
• 2022-10-04 MRI - pancreas
  • History and indication: An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD
  • Findings
    • A soft tissue tumor (1.5x2.2cm) at pancreatic head.
    • S/P PTCD. Liver and renal cysts (3-5mm).
  • IMP: A soft tissue tumor (1.5x2.2cm) at pancreatic head suspected malignancy.
• 2022-10-01 Percutaneous Transhepatic Cholangial Drainage, PTCD (drainage)
  • Dilatation of the biliary tree (by CT images).
  • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
• 2022-09-30 CT - abdomen
  • History: T-COLON CA S/P R HEMICOLECTOMY 2005-07-21, cT3N1M0
    • 2022-09-24 Urine looked like black tea, Total bilirubin: 16.88 mg/dL (normal: < 1)
  • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD and pancreatic head area is suspected and it causing marked dilatation of the proximal CBD, CHD, and IHDs.
      • The pancreatic duct appears normal in size.
      • Cholangiocarcinoma at the distal CBD is highly suspected.
      • In addition, There are few enlarged nodes in the peripancreatic head area that may be metastatic nodes.
      • There are few enlarged nodes in left para-aortic space that may be non-regional metastatic nodes? Please correlate with PET scan.
    • S/P cholecystectomy, S/P right hemicolectomy, and S/P near total right hepatectomy? please correlate with clinical history.
    • Others
      • There is no focal abnormality in the spleen & both kidney.
      • There is no ascites.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • CHOLANGIOCARCINOMA at the distal CBD is highly suspected.
    • Please correlate with ERCP (Endoscopic Retrograde CholangioPancreatography) and EUS.
• 2022-09-24 SONO - kidney
  • bilateral renal stones
  • right hydronephrosis
• 2022-08-27 Transrectal Ultrasound of Prostate, TRUS-P
  • benign prostatic hyperplasia

[MedRec]

• 2023-03-24 SOAP Hemato-Oncology
  • S: Owing to Leukopenia (WBC:2890, seg:33, ANC:971) was noted on 3/24 23 and hold C/T.
• 2022-12-17 SOAP Hemato-Oncology
  • A: Pancreatic head CA (or Ampulla of Vater CA) , pT3bN1 (3/28) cM0, pStage IIIA, s/p Whipple’s Op on 2022-10-20

[consultation]

• 2022-11-08 Urology
  • Q
    • for urinary pain and persisted U/A Bact 2+
    • This 73 years old male had the history of
      • T-colon cancer (T3N1M0, Duke’s C2) s/p right hemicolectomy + LN dissection on 2005-07-21, Cholecystectomy and Partial hepatectomy.
      • Ampulla of vater cancer s/p whipple with LN dissection on 2022/10/20
      • BPH with Cystitis by cystoscopy on 2022/10/01 and keep medication control
    • This time, he still sufferred urinary pain and oral medicaiton with Uropin support. But the symptom still persisted. On the other side, U/A with Bact 2+ and U/C still pending. Fever was also noted on 2022/11/05-06. Lab data with no leukocytosis but CRP showed 9.45. We need your help for evaluation for infection status. Thanks for your time!!
  • A
    • We will arrange non-invasive evaluation (UFM PVR)
    • sometimes the pain still painkiller
    • He has high bilirubin and good renal function
    • some painkiller with less burden on liver may be helpful
• 2022-10-07 Ophthalmology
  • Q
    • for DM retinopathy
  • A
    • For DR survey
    • T-colon cancer, newly-diagnosed DM
    • O
      • od s/p phaco + IOL insertion
      • os old trauma with K scar
      • BCVA od 1.0 os 0.1(NCCLENS)
      • IOP 17/17
      • Pupil 3/3 +/+
      • conj icteric ou
      • K od clear os linear scar from paracentral to peripheral
      • AC D/cl ou
      • Lens od pciol os ns++
      • Fd c/d 0.3 , disc pinkish, no DR change ou
    • A
      • No DR change at present ou
    • P
      • Control sugar
      • inform the risk of DR change, if worsen vision, come back asap
      • regular f/u yearly
• 2022-10-06 Metabolism and Endocrinology
  • Q
    • This 73 years old male had the history of T-colon cancer (T3N1M0, Duke’s C2) s/p right hemicolectomy + LN dissection on 2005-07-21, Cholecystectomy and Partial hepatectomy.
    • This time, he came to ER for dark urine, lethargy, poor appetite, poor activity and diarrhea for 2 months. Referred to ER from GI OPD due to high bilirubin. At MER, vital sign: BP:119/73; P:101; BT:36.4; RR:18; Con’s:E4V5M6, SPO2:97%, the CXR showed no active lung lesion. The KUB shows no ileus. Lab data revealed abnormal liver function. The abdomen CT reported 1. An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD and pancreatic head area is suspected and it causing marked dilatation of the proximal CBD, CHD, and IHDs.
    • The pancreatic duct appears normal in size. Cholangiocarcinoma at the distal CBD is highly suspected. In addition, There are few enlarged nodes in the peripancreatic head area that may be metastatic nodes. Under the impression of obstructive jaundice, he was admitted to our ward for further evaluation and treatment.
    • Due to HbA1C:8.0, we need your help
  • A
    • We were consulted for blood sugar control.
    • O:
      • BH: 165 cm, BW: 75 kg
      • Diet: TPN and try low fat, soft diet
      • Medication in OPD: nil (newly diagnosed)
      • Medication during hospitalization: Oliclinomel + RI 16U, Januvia 1# QD
      • Na: 134, K: 3.7
      • ALT: 61, TBI: 28.95
      • BUN/Cr: 19/0.93 (eGFR: 84.65)
      • F/S:
        • Date 10/4 10/5 10/6
        • QDAC 153 179 170
        • QLAC 202 321 222
        • QNAC 265 272
        • HS - -
      • Blood glucose: 182 mg/dL
      • HbA1c: 8.0
      • Urine ACR: unavailable
      • OPH OPD: nil
    • A: Type 2 DM, newly diagnosed
    • Suggestions:
      • DC Januvia. Avoid any other oral anti-diabetic agent
      • Adjust to 20U RI in each Oliclinomel
      • Use Apidra PRNTIDAC with sliding scales
        • F/S 201~250, Apidra 2U
        • F/S 251~300, Apidra 3U
        • F/S > 300, Apidra 4U
      • Check lipid profile, urine ACR
      • Consult OPH for DM retinopathy
      • At present no need nutritionist for DM diet education (self-paid TWD 600) (to consult right before discharge after appetite recovering)
      • Contact us if needed. I’d like to follow up this patient. Meta-OPD F/U.

[surgical operation]

• 2022-10-20
  • Surgery
    • Whipple operation with partial gastrectomy
    • retroperitoneal LN3,4sd,5,6,7,8,9,12,13,16 dissection
    • adhesivelyiss for 4 hrs due to previous rt hemicolectomy with LNdissection for T-colon ca and liver resection
  • Finding
    • severe small bowel adhesion
    • pancreatic head tumor 2 x 1.8 cm under papilla vater
    • CBD: 2.0 cm in diameter
    • P-duct 0.3cm with soft pancreas parenchyma
    • multiple LNat dodenal ligament and paraaorta area

[chemotherapy]

• 2023-07-12 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Irino 80% and LV, 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-05-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Irino and 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-04-25 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Irino and 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-04-03 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-03-10 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2400mg/m2 4075mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-02-14 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2022-12-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

Modified FOLFIRINOX chemotherapy for pancreatic cancer 2023-05-19 https://www.uptodate.com/contents/image?imageKey=ONC%2F109546

• Cycle length: 14 days.
• Regimen
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 150 mg/m2 IV
    • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-19 https://www.uptodate.com/contents/image?imageKey=ONC%2F79571

• Cycle length: 14 days.
• Regimen
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 180 mg/m2 IV
    • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 400 mg/m2 IV bolus
    • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
    • Day 1
  • FU
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

==========

2023-08-21

Our endocrinologist’s repeat prescription (issued on 2023-06-05) for Trajenta (linagliptin) is currently on the active medication list, and there are no discrepancies noted.

2023-07-13

The patient recently refilled his prescription for Trajenta (linagliptin) on 2023-07-10 for managing his T2DM. This drug is accurately included in the active medication list, with no reconciliation issues identified.

2023-06-20

• According to the PharmaCloud database, all of this patient’s medical requirements have been addressed at our hospital over the past three months. As a result, no issues with medication reconciliation have been detected.

• The patient’s DM is currently managed with Trajenta (linagliptin 5mg) 1# QD. He had an increased preprandial serum glucose level of 170mg/dL on 2023-06-20 at 06:24. The most recent HbA1c level was 5.7% on 2023-05-31. This sudden rise could be a temporary fluctuation and is worth continuous monitoring.

2023-05-19

• The patient, with a body surface area (BSA) of 1.69 m2 calculated from a recorded height of 165 cm and weight of 62.2 kg (2023-05-18), is currently receiving a modified FOLFIRINOX regimen. This regimen includes oxaliplatin and irinotecan, but omits bolus fluorouracil.
• The dose of oxaliplatin is 100mg, which is equivalent to 59mg/m2, approximately 69% of the standard dose of 85mg/m2. Likewise, the dose of irinotecan is 200mg, equivalent to 118mg/m2, approximately 65% of the standard dose of 180mg/m2. The frequency of the treatment is every three weeks, in contrast to the standard every two weeks.
• The patient has a relatively advanced age of 73 years and a fair ECOG performance status of 1. He has had only one episode of leukopenia with WBC < 3K/uL (2.89K/uL on 2023-03-24). No other significant adverse events have been recorded. An abdominal CT scan performed on 2023-03-13 showed soft tissue at the root of the mesentery.
• Given these factors, and in the absence of contraindications or other clinical concerns, it might be beneficial to consider a gradual dose escalation. This could be done with the aim to bring the dose closer to the standard levels, in order to optimize therapeutic effect.

2023-03-13

• Since 2022-12-19, the patient has been receiving FOLFIRINOX with a reduced dosage of oxaliplatin (85 -> 60mg/m2) and irinotecan (180 -> 150mg/m2), skipping the 5-FU bolus to prevent adverse reactions. Bilirubin (direct and total) returned to normal range in 2022-12, but ALT readings have fluctuated between normal and not exceeding 110U/L after treatment. As of the 2023-03-10 lab data, BUN 29mg/dL, Creatinine 0.95mg/dL, and eGFR 82.60. No dosage adjustment is currently needed for the patient’s FOLFIRINOX regimen.

2023-02-02

• It was noted that the blood sugar level did not exceed 180 mg/dL, which was an improvement over the prior hospital stay.

• Renal sonography (2022-09-24) found bilateral renal stones, and calcium oxalate crystals in urine (2023-02-01). Primary hyperoxalurias are rare inborn errors of glyoxylate metabolism characterized by the overproduction of oxalate, which is poorly soluble and is deposited as calcium oxalate in various organs. The kidney stones in this patient should be less likely to be associated with primary hyperoxaluria.

  • Patients with kidney stones should consume enough fluids to consistently produce at least 2 liters of urine per day. At the present time, the patient is being hydrated with NS 500mL Q12H since this hospital admission.
  • It is recommended that all patients with calcium oxalate stones limit their intake of high oxalate foods, supplemental vitamin C, sucrose, and fructose. However, excessive restriction of oxalate is unlikely to be beneficial. Patients should continue to consume a variety of fruits and vegetables while avoiding those that are very high in oxalate. Intake of sugar and/or fructose increases urine calcium independently of calcium intake and has been associated with an increased risk of kidney stones.
  • Urine pH was 5.5 (2023-02-01) WNL, however, calcium oxalate stones are not pH dependent in the physiologic range. In recent lab results, there were no readings for calcium, oxalate, citrate, and uric acid in urine.
  • In the event that high urine calcium is detected, it is recommended that patients with recurrent calcium oxalate stones who have higher than desired urine calcium be treated with a thiazide diuretic in order to lower urinary calcium excretion.
    • All patients receiving a thiazide diuretic should maintain a low-sodium diet, which is essential for the diuretic to effectively lower urinary calcium.
    • Urinary calcium and sodium excretion should be monitored after the institution of thiazide therapy. A repeat 24-hour urine collection should be performed one to two months after initiating therapy.
    • If the urine calcium does not fall as desired or the thiazide is not well tolerated, an alternative therapy is administration of 40 to 60 mEq of alkali per day as potassium bicarbonate or potassium citrate (citrate is rapidly metabolized to bicarbonate).

700324847

230821

[exam findings]

• 2023-05-27 MRI - brain
  • No brain nodule or metastasis.
• 2023-05-15 KUB
  • Bilateral pleural effusion.
  • Presence of ileus.
  • Intact bony structure(s).
• 2023-05-15 CXR
  • Bilateral pleural effusion.
  • Ground glass opacities in bil. lungs.
• 2023-05-12 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Loculated bilateral pleural effusion at bilateral interlobular fissure and lower hemithorax is found.
      • Consolidation over right lower lobe and left lower lobe is found.
      • Enlarged lymph nodes are found at bilateral paratracheal region.
      • Patent airway is found.
    • Visible abdomen:
      • Moderate ascites formation is found.
      • Increased intestinal gas is found.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
  • IMp:
    • Pneumonic patch at both lungs with bilateral massive pleural effusion.
    • Moderate ascites formation.
• 2023-05-12 CXR
  • Bilateral Pleura effusion.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Enlargement of cardiac silhouette.
• 2023-05-05 SONO - CXR
  • Echo diagnosis:
    • right side minimal amount of pleural effusion
    • left side small amuont of pleural effusion, 600cc serosangious fluid was drained out for symptom relief.
• 2023-04-24 SONO - breast
  • Suggestion and Plan
    • Calcifications in right breast.
    • R/O enlarged lymph nodes in left axillary region, suggest biopsy.
      
  • BI-RADS: Category 4a: low suspicious abnormality-biopsy should be considered.
• 2023-04-22 MRI - pelvis
  • With and without contrast enhancement MRI:
    • Cystic tumor, 8.6cm in right adnexa, with mural soft tissue, r/o right ovarian malignancy.
    • Another cystic tumor, with internal hemorrhage, 2.8cm in left adnexa, r/o ovarian malignancy with hemorrhage.
    • There are enlarged lymph nodes in bilateral obturator regions and right common iliac region, r/o lymph nodes metastasis.
    • Presence of ascites.
    • There are soft tissue tumors in the mesentery, r/o peritoneal carcinomatosis.
    • Left pleural effusion.
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T: T3c_(T_value) N: N1b(N_value) M: M1(M_value) STAGE: IV (Stage_value)
      
  • Impression:
    • Ovarian cystic tumor with carcinomatosis and lymph nodes, left pleural effusion, r/o ovarian malignancy with carcinomatosis, lymph nodes metastasis and left pleural effusion. cstage T3cN1bM1.
• 2023-04-20 Gynecologic ultrasonography
  • R/O Pelvis mass: 101 x 78mm (Multuple papillary, solid mass: 26 x 25mm)
  • R/O LT Ovarian mass
• 2023-04-19 CT - abdomen
  • Findings:
    • There is ascites and soft tissue nodules in the omentum. Carcinomatosis is suspected. Please correlate with ascites cytology.
    • There is a mild hyperdense lesion in the pelvis at pre-contrast CT, measuring 9.1 x 10.4 x 8.5 cm (width x depth x cranial-caudal length) in size, and poor enhancement in portal venous phase images except suspicious few ill-defined enhancing mural nodules.
      • The uterus shows posterior displacement by the upper described mass.
      • Cystic adenocarcinoma of the ovary is highly suspected.
      • Please correlate with GYN. sonograph, MRI and CA125.
    • There is a mild hyperdense lesion in left adnexa at non-enhanced CT, measuring 3.4 cm in size, and it shows poor enhancement in portal venous phase images except a mural nodule shows enhancement.
      • Cystic tumor of left ovary is highly suspected.
      • The differential diagnosis includes left ovarian cyst with hemorrhage.
    • S/P pigtail catheter implantation at right CP angle.
      • There is massive left side Pleura effusion.
  • Impression:
    • Carcinomatosis is suspected. Please correlate with ascites cytology.
    • Cystic adenocarcinoma of the ovary is highly suspected. Please correlate with GYN. sonograph, MRI and CA125.
• 2023-04-18 CT - chest
  • Findings
    • moderate Lt pleural effusion and residual minimal Rt pleural effusion s/p pigtail drain placement.
    • lungs:extensive, patchy and centrilobular ground-glass opacities with interbular septal thickening, at both lower lobes.
      • minimal patchy ground-glass opacities at LUL.
      • dependent relaxation subsegmental atelectasis at LLL.
    • Mediastinum and hila: many enlarged LNs in the visceral space and left anterior prevascular space.
    • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents: normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • mild ascitic fluid and dirty omentum.
    • Visualized bones: unremarkable.
  • Impression:
    • bilateral lower lobes lung edema or pneumonitis and transudative left pleural effusion, due to connective tissue disease?
    • abdominal ascites, cause? due to lesion in pelvic cavity?
• 2023-04-18 Cell block - pleural effusion
  • Cytological diagnosis: Malignancy
  • Smears and cell block show clusters of pleomorphic tumor cells. Metastatic carcinoma is favored. Please correlate with the clinical presentation.
• 2023-04-17 Cell block - pleural effusion
  • Cytological diagnosis: Malignancy
    
  • Smears and cell block show clusters of pleomorphic tumor cells. The immunohistochemical stains reveal CK7(+), CK20(-), PAX8(+), WT-1(+), TTF-1(-), Napsin A(-), p40(-), GATA3(-), Calretinin(-), and CD56(-). The results are consistent with metastatic carcinoma from ovary. Please correlate with the clinical presentation.
• 2023-04-15 SONO - chest
  • Echo diagnosis:
    • Pleural effusion, massive amount, right, s/p pig-tail insertion
    • Pleural effusion, massive amount, left, s/p thoracentasis (1100ml)
• 2023-04-14 ECG
  • Sinus tachycardia
  • Anteroseptal infarct, age undetermined
  • Abnormal ECG
• 2018-05-16 Gynecologic ultrasonography
  • Suspected RT ovarian cyst
  • Suspected LT endometrioma

[MedRec]

• 2023-05-15 SOAP Emergency
  • S
    • Dyspnea for 2 days
    • s/p thoracocentesis on 5/12 700ml
    • Poor intake for 2 days
    • Nausea and vomiting after inake
    • Phx: Ovarian cancer
    • Allergy: NKA
• 2023-05-12 SOAP Hemato-Oncology
  • S: Today explain to patient 40 minutes for chemotherapy. But she still hestitate to receive chemotherapy.
  • P: explain the possibility of chemotherapy to control tumor, but patient still hestitate to receive C/T.
    • F/U weekly
    • refer to ER for chest tapping

[consultation]

• 2023-04-21 Hemato-Oncology
  • Q
    • For ovarian cancer neuadjuvant chemotherapy
    • We have consulted GYN, who suggested neoadjuvant chemotherapy first, followed by debulking surgery and HIPEC.
    • Due to the above reasons, we sincerely need your expertise for the neoadjuvant chemotherapy. Thank you very much!
  • A
    • This 51 year old woman is a case of ovarian cancer with peritoneal carcinomatosis and bilateral pleura effusion. Pleura effusion cell block show pleomorphic tumor cells CK7(+), CK20(-), PAX8(+), WT-1(+), TTF1(-), NAPsin A(-), P40(-), GATA3(-),calretinin(-), and CD56(-), the result consistent with metastatic carcinoma from ovary.
    • Arrange 24 urine CCR, anti HBc, anti HBs, HBsAg, Anti HCV, breast echo and port A insertion. apply Major Disease” C56.9 stageIV.
    • We will arrange chemotherapy (palitaxel + carboplatin ) the next day of port A insertion (Expected to have chemotherapy next Tuesday). Arrange our OPD after discharge.
• 2023-04-20 Obstetrics and Gynecology
  • Q
    • For evaluation of suspected ovarian cystic adenocarcinoma
    • This is a 51-year-old female with no underlying diseases. She presented to our ER with progressive dyspnea for 3 weeks, while CXR showed massive bilateral plerual effusion. Bilateral thoracentesis and right pigtail drainage was performed for symptom relief. Examination of the drainage showed to be exudative in nature.
      • Cancer/Tumor:
        • 4/18 Chest CT: bilateral lower lobes lung edema or pneumonitis and transudative left pleural effusion, due to connective tissue disease? abdominal ascites, cause? due to lesion in pelvic cavity?
        • 4/19 Abdominal CT: 1. Carcinomatosis is suspected. Please correlate with ascites cytology. 2. Cystic adenocarcinoma of the ovary is highly suspected. Please correlate with GYN. sonograph, MRI and CA125.
      • Tumor markers: pending results
      • TB, fungus, infection: pending results
      • Autoimmune: negative
    • Due to the above reasons, we sincerely need your expertise to evaluate the pelvic mass, suspect ovarian cystic adenocarcinoma. Thank you very much!
  • A
    • This is a 51 y/o woman who was hospitalized due to pleural effusion. Image survey with abdominbal CT showed suspected carcinomatosis of which ovarian cystic adenocarcinoma was highly suspected. Tumor markers were checked with the results pending. We were consulted for evaluation.
      • CC: Progressive dyspnea for 3 weeks.
      • ObGyn history: Sex(+), P0, menopaused
      • Sono: Pelvic mass, 101 x 78 mm (multiple papillary, with solid mass: 26 x 25 mm)
    • Impression
      • Huge pelvic mass, malignancy could not be ruled out
    • Suggestion
      • Please pursue the level of tumor markers.
      • Arrange EGD and colonoscopy.
      • Surgical intervention (laparotomy and frozen section) is suggested for diagnostic and therapeutic value. If malignancy is proven intraoperatively, debulking surgery is indicated.
      • Further cancer staging if malignancy is proven.
    • Addendum to consultation response 2023-04-21 14:45:54
      • Highly suspected cystic adenocarcinoma of the ovary with carcinomatosis and malignant plerual effusion, at least cstage IVA
      • Well explained current treatment plan and survival rate:
        • arrange EGD and colonoscopy first
        • consulted GS for port-A insertion and consulted Oncologist for neoadjuvant chemotherapy 3-4 times and followed debulking surgery and HIPEC

[chemotherapy]

• 2023-08-21 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-07-31 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-07-06 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-06-08 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-05-18 - paclitaxel 175mg/m2 135mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-04-25 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 375mg NS 250mL 2hr
  • dexamethasone 4mg 5# PO Q6H at D0 2300 and D1 0500 + dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + NS 250mL

==========

2023-08-21

No medication reconciliation issues were found after reviewing PharmaCloud and HIS5.

2023-05-17

• The patient’s serum albumin level has shown a decrease, potentially due to nausea and vomiting post-ingestion and several days of insufficient nutrition intake. Severe hypoalbuminemia could potentially exacerbate the patient’s pleural effusion. It might be necessary to provide additional nutritional support.
  • 2023-05-12 Albumin 3.1 g/dL
    
  • 2023-04-22 Albumin 3.5 g/dL
• The recommendation is to include antiemetics as part of the premedication protocol for the upcoming dose of the current paclitaxel and carboplatin regimen.

700558953

230821

[MedRec]

• 2021-02-08 SOAP Radiation Oncology Chang YouKang
  • A/P
    • PE, 2021-02-08: Op scar(+) over UOQ. No palpable LAPs over axilla or SCF.
    • Imp: Right breast cancer, Mucinous carcinoma, pT2N0(sn) cM0 s/p BCT & SNB on 2021/01/29.
    • Endocrine therapy: Femara since 2021/02/08.
    • Plan: Adjuvant R/T to Rt breast & scar for 5000cGy/25 fx & 6000cGy/30 fx is suggested. Possible toxicity (radiation dermatitis and pneumonitis) is told. CT simulation on 2021/03/02. Psychosocial support. Diet education.
• 2021-01-21 SOAP General and Gastroenterological Surgery
  • S: s/p CNB (2021-1-13): mucinous carcinoma ==> advise adm for BCT + SLND
  • O:
    • 2021/01/14 PATHO - breast biopsy (no need margin)
      • Breast, right, sono-guided biopsy — Mucinous carcinoma, hypercellular type
      • IHC shows following features:
        • ER (Ab): Positive (> 95%, strong intensity)
        • PR (Ab): Positive (> 95%, strong intensity)
        • HER-2/Neu (Ab): Negative (score= 1)
        • Ki-67: 10%
    • A 3x2.5 cm sl firm mass in rt breast
      • Rt breast ca
      • cT2N0M0 stage 2A
• 2021-01-12 SOAP General and Gastroenterological Surgery
  • S: breast sono: right breast tumor, r/o carcinoma, cT2N0 - BI-RADS 5
    • Chief complaint: A breast lump was noted recently with mastalgia
  • P: CNB

[surgical operation]

• 2023-04-03
  • Operation
    • Excision of intraabdominal malignant tumor: omentectomy
    • Tenckhoff tube insertion
  • Finding
    • Tenckhoff tube: over RLQ
• 2023-04-03
  • Surgery
    • Diagnosis: Right ovarian cancer
    • Surgery: Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)
  • Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder
    • Adnexa:
      • LOV: grossly normal
      • ROV: 8cm tumor
      • Fallopian tube: bilateral grossly normal
    • CDS: invisible due to tumor mass occupied
    • Ascites: ascites (+), adhesion (+)
    • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
    • Omentum: grossly normal
    • Estimated blood loss: 150 mL
    • Blood transfusion: nil
    • Complication: nil
• 2021-01-29
  • Surgery
    • Partial mastectomy and sentinel node(s) biopsy        
  • Finding
    • a 3x2.5x1.5 cm sl firm mass in rt breast    
    • SLN 0/2    
• 2021-01-13
  • Operation
    • Breast tumor biopsy (63010C)
    • Intraoperative sonography (19002B)
  • Finding
    • IOUS: a breast tumor in right side, 8 o’clock / 4 cm location

[chemotherapy]

• 2023-07-31 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr + [docetaxel 30mg/m2 45mg + cisplatin 30mg/m2 45mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-07-06 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr + [docetaxel 30mg/m2 45mg + cisplatin 30mg/m2 45mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-06-12 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-05-22 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-04-28 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 45mg + cisplatin 30mg/m2 50mg + gentamicin 45mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

701158972

230821

[immunochemotherapy]

• 2023-08-07 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)

• 2023-07-19 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)

• 2023-07-05 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-06-28 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)

• 2023-06-21 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-06-14 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-06-07 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-06-07 - trastuzumab 6mg/kg 350mg NS 250mL 90min (Chang YaoRen)

• 2023-02-10 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

• 2023-01-27 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

• 2023-01-12 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

• 2022-12-29 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2022-12-07 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2022-11-16 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2022-10-26 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2022-10-05 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2022-09-14 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2022-08-24 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2022-08-03 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2022-07-13 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2022-06-22 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2022-05-25 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2022-05-04 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2023-04-13 - trastuzumab 6mg/kg 390mg NS 250mL 90min

• 2023-03-23 - trastuzumab 6mg/kg 375mg NS 250mL 90min

• 2022-03-02 - trastuzumab 6mg/kg 360mg NS 250mL 90min

• 2022-02-09 - trastuzumab 6mg/kg 360mg NS 250mL 90min

• 2022-01-19 - trastuzumab 6mg/kg 360mg NS 250mL 90min

• 2021-12-29

• 2021-12-08

• 2021-11-17

• 2021-10-27

• 2021-10-06

• 2021-09-15

• 2021-08-25

• 2021-08-04

• 2021-07-14

• 2021-06-23

• 2021-06-02

• 2021-05-05

• 2021-04-14

• 2021-03-24

• 2021-03-03 - trastuzumab emtansine 230mg NS 250mL 1.5hr

  • betamethasone 8mg + diphenhydramine 30mg + NS 250mL

• 2021-02-10 - trastuzumab emtansine 230mg NS 250mL 1.5hr

  • betamethasone 8mg + diphenhydramine 30mg + NS 250mL

• 2021-01-11

• 2020-12-21

• 2020-11-30

• 2020-11-09

• 2020-10-19

• 2020-09-28

• 2020-09-07

• 2020-08-17

• 2020-07-27

• 2020-07-06

• 2020-06-22

• 2020-06-15

• 2020-06-03

• 2020-05-27

• 2020-05-13

• 2020-05-06

• 2020-04-22

• 2020-04-15

• 2020-04-01 - eribulin 1.4mg/m2 2.4mg NS 50mL 10min

  • betamethasone 8mg + diphenhydramine 30mg + NS 20mL

• 2020-03-25 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + eribulin 1.4mg/m2 2.4mg NS 50mL 10min

  • betamethasone 8mg + NS 250mL

• 2020-03-11 - eribulin 1.4mg/m2 2.4mg NS 50mL 10min

  • betamethasone 8mg + diphenhydramine 30mg + NS 20mL

• 2020-03-04 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr + eribulin 1.4mg/m2 2.4mg NS 50mL 10min

  • betamethasone 8mg + diphenhydramine 30mg + NS 250mL

• 2020-02-10 - trastuzumab 600mg SC 5min

• 2020-01-20 - trastuzumab 600mg SC 5min

==========

2023-08-21

[cachexia]

The patient has lost 10 kg in three months, from 63.2 kg on 2023-05-25 to 52.5 kg on 2023-08-11. To combat this significant weight loss, it’s important to improve the patient’s nutritional intake. In the absence of dysphagia, megestrol can be introduced as an appetite stimulant at a suggested dosage of 200 to 600 mg/day to counteract anorexia.

[oral mucotitis]

For oral mucotitis, the introduction of Nincort Oral Gel (triamcinolone) is recommended to relieve discomfort.

701260169

230821

[MedRec]

• 2023-05-01 ~ 2023-05-03 POMR General and Gastroenterological Surgery
  • Discharge diagnosis
    • Malignant neoplasm of unspecified site of right female breast
    • Right breast invasive carcinoma status post port A insertion on 2023/05/02. pT2N0M0, stage IIA. ECOG:0.
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
  • Present illness
    • Under surgery of right breast simple mastectomy+SLNB on 2023/04/14.
    • Pathology: solid papillary carcinoma with invasion,size 2.7 cm,Gr 2, pT2N0M0, stage IIA.
    • Adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles were suggest.
    • Under the impression of right breast invasive carcinoma, she was admitted for surgery of port A insertion. Arrange 1st adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 on 2023-05-03.
• 2023-04-13 ~ 2023-04-15 POMR General and Gastroenterological Surgery
  • Discharge diagnosis
    • Right breast invasive carcinoma status post simple mastectomy + sentinel lymph node biopsy  on 2023/04/14. cT2N0M0, stage IIA. ECOG:0.
    • Type 2 diabetes mellitus without complications
    • Essential (primary) hypertension
  • CC
    • noted a palpable mass at right breast and stabbing pain over 2 months.
  • Present illness
    • This 40-year-old female patient has past history of hypertension and Type 2 diabetes mellitus over 3 years with regular medicine control. She denied cancer history. She denied any TOCC histories in recent 3 months.
    • She noted a palpable mass at right breast and stabbing pain over 2 months. She came to our OPD for help. Breast sono showed right breast heteregeneous tumor, 10’ region, suggest biopsy. Right breast 9’ region and left 12’ region angulated tumors, suggest close follow up. Core needle biopsy revealed invasive carcinoma, ER: positive (strong,99%), PR: positive (strong,99%), Her2/neu: negative (0), Ki-67 inedex: 40%, p63: negative. CA-153：10.123 U/ml, CEA：2.247 ng/ml. PET and abdomen echo showed no obvious lesion for metastasis. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss. PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at right breast around 4x4 cm without discharge. left breast P scar. The nipple was dimping without exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
    • Under the impression of right breast invasive carcinoma, she was admitted for surgery of simple mastectomy + SLNB.  
  • Course of inpatient treatment
    • After admission, right breast simple mastectomy + SLNB was performed on 2023/04/14. The wound is clean and dry. Under the stable condition, she was discharged today, wound will be follow up in OPD.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
• 2023-04-10 SOAP General and Gastroenterological Surgery
  • O
    • 2023/03/31 PET scan
      • A glucose hypermetabolic lesion in the right breast, compatible with primary breast malignancy.
      • Mild glucose hypermetabolism in two small right axillary lymph nodes, in a small left axillary lymph node and in the right pulmonary hilar region. Inflammatory process is more likely.
      • Glucose hypermetabolism in a focal area in the body of the pancreas.
      • Increased FDG accumulation in both kidneys and colon.
    • Lab
      • 2023/03/31 Anti-HCV (NM) = Negative;
      • 2023/03/31 Anti-HCV Value (NM) = 0.032;
      • 2023/03/31 Anti-HBc (NM) = Negative;
      • 2023/03/31 Anti-HBc Value (NM) = 2.410;
      • 2023/03/31 Anti-HBs (NM) = Positive;
      • 2023/03/31 Anti-HBs value (NM) = 480.000 mIU/mL;
• 2023-03-29 SOAP General and Gastroenterological Surgery
  • S: Rt breast ca proved by CNB on 2023-03-24
  • O
    • 2023/03/24 PATHO - breast biopsy (no need margin)
      • Breast, right, core needle biopsy — Invasive carcinoma of no special type
      • ER: positive (strong,99%), PR: positive (strong,99%), Her2/neu: negative (0), Ki-67 inedex: 40%, p63: negative.
• 2023-03-22 SOAP General and Gastroenterological Surgery
  • S: breast lump
  • O
    • premenopausal
    • menarche 13 y/o
    • G0P0
    • FH of breast ca (-)
    • Hormone(-)
    • A 4 cm elastic firm mass in rt breast
• 2021-05-14 SOAP Metabolism and Endocrinology
  • Prescription x3
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QDAC
    • Ankomin (metformin 500mg) 1# BIDAC
    • Zulitor (pitavastatin 4mg) 1# QNAC
    • Amepiride (glmepiride 2mg) 0.5# QDAC
    • Galvus Met (vidagliptin 50mg, metformin 500mg) 1# BIDAC
• 2021-01-22 SOAP Metabolism and Endocrinology
  • Prescription x3
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
    • Ankomin (metformin 500mg) 2# BIDCC
    • Zulitor (pitavastatin 4mg) 1# QN
• 2020-12-12 SOAP Metabolism and Endocrinology
  • A/P
    • Complete metabolic profiles
    • Diet control
    • Prescribe metformin 500 TID
    • SMBG QDAC at home
    • RTC 2 W later
  • Prescription
    • Ankomin (metformin 500mg) 1# TIDCC

[surgical operation]

• 2023-04-14
  • Surgery: Simple mastectomy and sentinel lymph node biopsy        
  • Finding:
    • a 3x2x2 cm slight firm mass in rt breast
    • SLN 0/1  

[chemotherapy]

• 2023-08-17 - docetaxel 75mg/m2 138mg NS 250mL 1hr (D Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-07-28 - docetaxel 75mg/m2 140mg NS 250mL 1hr (D Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-07-06 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1100mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-06-15 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1100mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-05-25 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1088mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-05-03 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1083mg NS 500mL 1hr (AC(lipo) Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-08-21

The patient underwent 4 rounds of liposome doxorubicin and cyclophosphamide treatment on 2023-05-03, 2023-05-25, 2023-06-15, and 2023-07-06 without any signs of leukopenia.

However, a week following the initial dose of docetaxel on 2023-08-04, leukopenia was detected. Consequently, Granocyte (lenograstim 250ug) was administered the same day.

2023-08-17 WBC 7.32 x10^3/uL <- docetaxel 2023-08-06 WBC 3.47 x10^3/uL
2023-08-04 WBC 1.12 x10^3/uL <- leukopenia
2023-07-28 WBC 4.20 x10^3/uL <- docetaxel 2023-07-06 WBC 4.19 x10^3/uL
2023-06-15 WBC 4.65 x10^3/uL
2023-05-25 WBC 7.70 x10^3/uL
2023-05-10 WBC 7.11 x10^3/uL
2023-04-13 WBC 5.66 x10^3/uL

Docetaxel is associated with a high incidence of leukopenia. (UpToDate: 84% to 99%; grades 3/4: 49%; grade 4: 32% to 44%)

The patient received a second dose of docetaxel on 2023-08-17. Prophylactic G-CSF is scheduled for 2023-08-22 and 2023-08-23. Currently, there’s no indication of newly emerging leukopenia.

701493999

230821

[MedRec]

• 2023-08-15 SOAP Family Medicine Ye JiaZe
  • S: previosu tx at CGMH, elevated Bil
  • P: arrange hospice ward
• 2023-08-15 SOAP Hemato-Oncology He JingLiang
  • S: adenocarcinoma of pancreatic tail with liver mets
  • O: jaundice, T Bili 8.22
  • P: refer to hospice admission

==========

2023-08-21

The patient renewed a repeat prescription for insulin degludec, linagliptin, clopidogrel, doxazosin, bisoprolol, pitavastatin, levothyroxine, and ginkgo biloba extract on 2023-08-04. Some of these medications are not listed in the active medication list. Please verify if the unlisted medications are no longer required.

701494892

230821

[exam findings]

• 2023-07-10 CT
  • PHx: left RCC S/P operation.
  • Findings: CT of chest, abdomen, and pelvis without and with IV contrast enhancement show - Comparison: CT on 2023-04-08.
    • Chest
      • No identified residual pulmonary embolism.
      • Multiple newly-developed nodules up to 0.8cm in bilateral lungs, in favor of lung metastasis
      • A fatty mass with calcified spot about 11.4x9.2x3.7cm at left upper back, in favor of lipoma.
      • Otherwise, the mediastinum is centered and of normal width. There is no lymphadenopathy and there are no perihilar masses. The heart has a normal configuration. Major intrathoracic vessels are unremarkable. No evidence of osteolytic or osteoblastic change of thoracic cage.
    • Abdomen
      • S/P left nephrectomy for RCC; no evidence of local tumor recurrence nor visible regional lymphadenopathy.
      • A newly-developed hypodense lesion with heterogeneous enhancement about 3.4x2.2cm at left adrenal gland, in favor of adrenal metastasis.
      • Faint hypodense lesions up to 2.2x1.8cm in bilateral liver lobes, in favor of liver metastasis.
      • Osteolytic lesion at left pubic inferior ramus, R/O bone metastasis.
      • Compression fracture of L2 vertebra.
      • Small right renal cysts.
      • Right inguinal hernia without bowel loop in the hernia sac.
      • Otherwise, the GB, spleen, pancreas are normal in size and position. The urinary system is not obstructed. The pelvic inlet appears normal, with normal configuration of the iliac wings and iliopsoas muscles.
  • IMPRESSION:
    • S/P left nephrectomy without local tumor recurrence nor visible regional lymphadenopathy.
    • Newly-developed left adrenal, liver, and bilateral lung metastasis as described above.
    • R/O bone metastasis at left pubic inferior ramus.
    • No identified residual pulmonary embolism.
    • A lipoma about 11.4x9.2x3.7cm at left upper back.

[MedRec]

• 2023-08-18 SOAP Emergency
  • Impression: D41.00 Neoplasm of uncertain behavior of unspecified kidney

==========

2023-08-21

There are no medication reconciliation issues identified after reviewing the PharmaCloud database and HIS5 records.

700133802

230818

[exam findings]

• 2023-07-14 KUB
  • Mild dilatation of small intestine at RLQ abdomen is highly suspected.
• 2023-07-12 KUB
  • High grade mechanical small bowel obstruction is suspected. Please correlate with CT.
• 2023-05-19 Cell block cytology
  • bilateral pleural effusion 50cc, brown, turbid — Atypia
  • Smears and cell block show lymphocytes, mesothelial cells, histiocytes and several atypical cells.
• 2023-05-19 Pleural tapping
  • Special Procedure
    • echo-assisted Pleural tapping 16 #-needle Right side 1200 ml serosanguineous
    • echo-assisted Pleural tapping 16 #-needle Right side 1200 ml bloody
  • Echo diagnosis
    • left side small amount of pleural effusion
    • right side moderate amount of pleural effusion, 1200cc bloody fluid was aspirated for analysis.
• 2023-05-18 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
  • Pleura effusion of right and left costal-phrenic angle
• 2023-05-16 CXR
  • Bilateral pleural effusion.
  • Ground glass opacities in bil. lungs.
• 2023-05-10 All-RAS + BRAF mutation
  • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-05 Cell block cytology
  • 35cc orange cloudy ascites — Positive for malignancy, compatible with colonic origin
    
  • The smears and cell block show lymphocytes, reactive mesothelial cells and scant atypical nest which immunocytochemistry shows CDX-2(+) and PAX-8(-). According to clinical information and cytomorphologic findings, it is compatible with metastatic adenocarcinoma with colonic origin. Clinical correlation is advised.
• 2023-05-05 Acites tapping
  • Course: 18G needle was inserted at RLQ under echo guided insertion.
  • Findings: 1800 ml straw to orange color ascites was drained.
• 2023-05-05 ECG
  • Sinus rhythm with Premature supraventricular complexes with aberrant conduction
  • Otherwise normal ECG
• 2023-04-21 Gynecologic ultrasonography
  • Findingws
    • Uterus Position : AVF
      • Size: 96 * 28 mm
    • Endometrium:
      • Thickness: 10.1 mm, Fluid: with fluid
    • Adnexae:
      • ROV: Mass: 72 * 49 mm
      • LOV: Mass: 56 * 42 mm
    • CUL-DE-SAC: with fluid
      
  • IMP:
    • Ascites
    • R/O Bilateral Ovarian mass
• 2023-04-20 SONO - chest
  • Special Procedure
    • echo-assisted Pleural tapping 16 #-needle Right side 1000 ml serosanguineous
  • Echo diagnosis
    • pleural effusion
  • Suggestion:
    • Send pleural effusion about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
• 2023-04-19 ECG
  • Sinus tachycardia
  • Minimal voltage criteria for LVH, may be normal variant
  • Borderline ECG
• 2023-04-14 CT - abdomen
  • Indication: 20220130 CT: D-colon cancer with acute obstruction, pT3N2a cM0, stage IIIB
  • Findings:
    • There is massive ascites and multiple soft tissue masses in the perihepatic space parietal peritoneum and omentum that is c/w carcinomatosis. Please correlate with ascites cytology.
    • There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer.
    • There is mild left side hydroureteronephrosis and mild delayed contrast excretion of left kidney that is c/w obstructive uropathy.
      • The transition zone locates at left M3 ureter but nature?
      • Please correlate with retrograde pyelography.
        
    • There are bilateral Pleura effusion (more severe on right side).
  • Impression:
    • Carcinomatosis is noted. Please correlate with ascites cytology.
    • There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer. Please correlate with CEA and CA125.
• 2023-04-11 Colonoscopy
  • Diagnosis: DS colon s/p OP with uncertain anastomosis region
  • Suggestion: follow CT to evaluation colon condition ( high risk before confirm anastomosis )
• 2022-11-07 CT - abdomen
  • No evidence of recurrent/residual tumor in the study.
• 2022-10-24 CT - brain
  • Clinical information: Cranial CT scans from the vertex to the mid-maxillary level were performed without i.v. contrast injection.
  • Impression:
    • The brain shows age-related cortical atrophy, sulcal space widening, proportionate ventricular dilatation and white matter ischemic change including the periventricular, subcortical and subinsular regions. Right frontal scalp swollen change. There is no intracranial hemorrhage seen.
    • The posterior structures including the brain stem, cerebellum and CP angles look normal. However, the beam-hardening artifact over the skull base may hamper the film reading.
    • Please take notice that non-enhanced CT scan is limited in the detection of acute ischemic infarction (particularly within the first 6 hours), small vascular lesion, neoplasm, infectious/toxic/metabolic disease. Recommend correlate with clinical condition.
• 2022-07-23 CT - abdomen
  • s/p left hemicolectomy. No evidence of recurrent/residual tumor in the study.
• 2022-04-07 CT - abdomen
  • S/P colon operation.
  • Some LNs (up to 1.3cm) at mediastinum.
  • Right minimal pleural effusion.
• 2022-02-17 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Large intestine, descending-sigmoid colon, laparoscopic extensive left hemicolectomy —- Adenocarcinoma, moderately differentiated
      
    • Resection margins, proximal and distal: Free
    • Lymph node, mesocolic, dissection — Positive for adenocarcinoma (6/13)
    • T-colostomy, closure — Confirmed
    • AJCC 8th edition Pathology stage: pT3N2a(if cM0); AJCC stage IIIB
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: laparoscopic extensive left hemicolectomy
    • Specimen site: left descending-sigmoid colon
      
    • Specimen size: 22 cm in length
      
    • Tumor size: 4.5 cm
    • Tumor location: 3 cm away from the closest resection margin
    • Depth of invasion grossly: mesocolic soft tissue
      
    • Mucosa elsewhere: Not remarkable
    • Representative sections and labeled as: A1-8:tumor, A9-10:LNs, B:proximal end, C:distal end, D: T colostomy
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
    • Histology Grade: moderately differentiated
    • Depth of invasion: mesocolic soft tissue
      
    • Angiolymphatic invasion: Present
    • Perineural invasion: Present.
    • Discontinuous extramural tumor extension: Not identified.
      
    • Circumferential (radial) margin of rectum: N/A / Serosal margin status of colon: Uninvolved
    • Lymph node metastasis, mesocolic: Positive (6 / 13)
    • Lymph node metastasis, IMA / SMA: N/A.
    • Extranodal involvement: Present.
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT) - pT3: Tumor invades through the muscularis propria into pericolorectal tissues
      • Regional Lymph Nodes (pN) - pN2a: Four to six regional lymph nodes are positive
      • Distant Metastasis (pM) - N/A
    • Type of polyp in which invasive carcinoma arose: Not identified
      
    • Additional pathologic findings: None identified.
    • TNM descriptors: N/A.
      
    • Tumor regression grading S/P CCRT: N/A.
• 2022-02-15 Colonoscopy
  • C/W colon cancer, with nearly total luminal obstruction, D-S junction
  • S/p T-colon colostomy
• 2022-02-09 Patho - colon biopsy
  • Colon tumor, sigmoid, biopsy — High grade dysplasia at least
  • Microscopically, the sections show a picture of high grade dysplasia at least of colonic mucosal tissue characterized by atypical glands lined by high-grade dysplastic columnar cells, in tubular, fused glandular or cribriform arrangement without obvious desmoplasia due to limited specimen.
  • Immunohistochemistry of CDX2(+), PMS2(+), MLH1(+), MSH2(+) and MSH6(+) for dysplastic cell. According to clinical and radiologic findings, more advanced lesion (adenocarcinoma) should be suspect. Repeat biopsy is advised for further evaluation, if clinically indicated.
• 2022-02-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (66.7 - 24.1) / 66.7 = 63.87%
    • M-mode(Teichholz) = 63.9
  • Conclusion:
    • Thickened AV with no AR
    • Normal MV with mild MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
• 2022-02-08 Spirometry
  • Mild restrictive ventilatory impairment
• 2022-01-30 CT - abdomen
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:IIIB(Stage_value)
• 2022-01-30 ECG
  • Sinus rhythm with Premature supraventricular complexes
  • Left ventricular hypertrophy with repolarization abnormality
  • Abnormal ECG

[consultation]

• 2023-05-09 Hemato-Oncology
  • Q
    • 80 y/o female, a pt of D-colon colon, pT3N2a cM0, stage IIIB wt obstruction wt T loop colostomy s/p laparoscopic extensive L hemicolectomy and closure of T loop colostomy on 2/16 22 by Dr Lv ZongRu. After operation, she was referred to oncology for adjuvant chemotherapy with Oxalip 85mg/m2 + 5-Fu 2800mg/m2 since 2022/04/06 to 2022/10/06. She kept regular follow up at CRS outpatient department and hematology oncology outpatient department.
    • The patient complained about abdominal distention recent. Abdominocentesis for cell block examination on 2023-05-05.
    • The smears and cell block show lymphocytes, reactive mesothelial cells and scant atypical nest which immunocytochemistry shows CDX-2(+) and PAX-8(-). According to clinical information and cytomorphologic findings, it is compatible with metastatic adenocarcinoma with colonic origin.
    • We need your expertise for help her further management for  chemotherapy. Thanks for you help!
  • A
    • This 82-year-old female patient has past history of 1) Hypertension and hyperlipidemia under medical control for 10 years at NTUH. 2) HIVD s/p *2 times at TzuChi Hospital and NTUH 3) Descending-colon cancer, pT3N2acM0 stage IIIB with obstruction post T loop colostomy on 2022/01/30, post laparoscopic extensive left hemicolectomy + closure of T loop colostomy on 2022/03/16 with adjuvant with C/T since 2022/04/06 to 2022/10/06. 4) port-A implantation on 2022/03/28.
    • Follow up abdominal CT 2023-04-14 show 1. There is massive ascites and multiple soft tissue masses in the perihepatic space parietal peritoneum and omentum that is c/w carcinomatosis. 2. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer.
    • Ascites cell block show: Positive for malignancy, compatible with colonic origin CDX-2(+)and PAX-8(-). We are consulted for further evaluation.
      
    • Please arrange exploratory laparotomy as your scheduled 5/10 for tissue and send All-RAS and RAF. Palliative chemotherapy is indicated. We will discuss with patient. Thanks for your consultation.
• 2023-04-21 Obstetrics and Gynecology
  • Q
    • This 80-year-old female patient had past history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension.
    • She suffered from initial presentation of constipation for a long time & abrupt onset of abd pain in Jan 2022. After operation. She kept regular follow up at our OPD. Refollow up abdomen CT showed bilateral pleural effusion. carcinomatosis is noted. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted.
      
    • We cnsultation CM. was suggest f/u chest echo and tapping 1000ml serosangumous pleural effusion at right side on 4/20. Cnsultation Hematologis who suggest we consult GYN for further evaluation. Get any tissue proof (colon cancer recurrent or newly diagnosis GYN cancer…).
    • Therefore, we needs your expert experience for further evaluation. Thaks a lot !!
  • A
    • This 80 y/o female with history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension.
    • She was admitted for abd distention and dyspnea. followed up CT showed bilateral pleural effusion. carcinomatosis is noted. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted. we were consulted for cancer evaluation
    • Lab:
      • CEA 12.36ng/mL, CA 125 ?
      • Right pleura effusion cell block ??
      • TVUS and TAS:
        • Uterus: 96*28mm, EM 10.1mm + fluid
        • RT 72*49 mm
        • LT 56*42 mm
      • Ascites (+)
    • Impression:
      • Ascites
      • R/O Bilateral Ovarian mass, or colon cancer seeding (Krukenber tumor?)
    • Suggestion:
      • Consider CT guide biopsy for tissue proof
      • Consult oncologist for chemotherapy fist
      • Consider arrange tumor team meeding when tissue proof
• 2023-04-21 Hemato-Oncology
  • Q
    • This 80-year-old female patient had past history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension. She suffered from initial presentation of constipation for a long time & abrupt onset of abd pain in Jan 2022.
    • After operation. She kept regular follow up at our OPD. Refollow up abdomen CT showed carcinomatosis is noted. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted.
      
    • Due to abdomen CT showed pleural effusion, I consulted CM, and arranged a chest echo examination at 14:30 this afternoon.
    • We needs your expert experience for further evaluation and treatment. Thaks a lot !!
  • A
    • This 80 year old woman is a case of D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. For suspect carcinomatosis, we are consulted. Abdomen CT showed there are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted.
      
    • Complete tumor marker. Arrange chest echo for right pleura effusion (send cell block). Consult GYN for further evaluation. Get any tissue proof (colon cancer recurrent or newly diagnosis GYN cancer…) Thanks for your consultation.
• 2023-04-20 Chest Medicine
  • Q
    • This 80-year-old female patient had past history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension. she suffered from initial presentation of constipation for a long time & abrupt onset of abd pain in Jan 2022.
    • After operation. She kept regular follow up at our OPD. Refollow up abdomen CT showed bilateral pleura effusion (more severe on right side) and carcinomatosis is noted.
      
    • We needs your expert experience for further evaluation and treatment (cytology). Thaks a lot !!
  • A
    • This 80 y.o female was a case of D-colon adenocarcinoma, pT3N2aM0, stage IIIb, post operation on 111-02-16 and C/T from 111-04 to 111-10. Now, because of Abdominal CT showed bilateral pleural effusion and carcinomatosis, we were consulted for further treatment.
    • Suggestion:
      • Please arrange Chest echo + pleural effusion drainage or pig-tail insertion for right massive pleural effusion (pleural effusion will submitted for cell block exam)
      • If Colon Ca with metastasis confirmed, please consult Hematologist for further treatment

[surgical operation]

• 2022-02-16
  • Surgery
    • Laparoscopic extensive left hemicolectomy + closure of T loop colostomy
  • Finding
    • Tumor in DS colon with adhesion to left side lumbar region peritoneum.
    • LN in IMA root, removed
    • stenosis of rectum,
    • No 29 SDH for anastomosis for cancer
    • hand sew 2 layer for T colostomy
    • moderate stool in colon
    • Tissel 4ml for both 2 anastoomsis
    • No.15 Drain into pelvis
• 2022-01-30
  • Surgery: T loop colostomy        
  • Finding: Dilation of colon 
• 2017-05-10
  • Diagnosis: Lumbar stenosis, L3/4/5
  • PCS code: 83002C
  • Finding
    • Lumbar spondylosis with
      • Hypertrophic changes of ligamentum flavum and facet joints at L3/4 and L4/5 levels with dura compression and bilateral L4 and L5 roots compression. left side more severe.
      • No gross instability noted.

[immunochemotherapy]

• 2023-08-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 165mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
• 2023-07-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 150mg D5W 250mL 90min + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
• 2023-06-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 165mg D5W 250mL 90min + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
• 2023-06-05 - irinotecan 120mg/m2 165mg D5W 250mL 90min + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
• 2023-05-19 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
• 2022-10-06 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4370mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-09-21
• 2022-09-08
• 2022-08-25
• 2022-08-10
• 2022-07-22
• 2022-07-07
• 2022-06-22
• 2022-06-06
• 2022-05-09 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4190mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-04-22 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-04-06 - oxaliplatin 60mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-08-18

No medication reconciliation issues were identified after reviewing PharmaCloud and HIS5 records.

2023-08-04

The repeat prescription issued by NTUH was refilled on 2023-08-01 and includes Norvasc (amlodipine), Aprovel (irbesartan), Lipitor (atorvastatin), and Xanax (alprazolam). These medications are currently being used with no reconciliation issues identified.

2023-07-13

This patient visited NTUH on 2023-06-15 and was prescribed Norvasc (amlodipine), Aprovel (irbesartan), Lipitor (atorvastatin), Xanax (alprazolam) which were refilled at a local pharmacy on 2023-07-03. These drugs are now in the active medication list, no reconciliation issues found.

2023-06-28

Upon examining the PharmaCloud database, it appears that access to this patient’s information is currently unavailable, potentially due to lack of authorization. However, a review of the HIS5 medication records indicates that all valid prescriptions were provided by the Hemato-Oncology department. Hence, no medication reconciliation issues have been found.

700372532

230818

[diagnosis] - 2023-03-15 admission note

• Malignant neoplasm of rectum
• Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema

[past history]

• Type 2 diabetes mellitus and hyperlipidemia for 4-5 years under medications treatment.
• Past operation: left middle finger post traumatic amputation 30+ years ago            

[allergy]

• NKDA     

[family history]

• Father died: AMI
• Mother: diabetes
• There is no family history of cancer, mental diseases or asthma

[exam findings]

• 2023-06-20 CT - abdomen
  • History and indication: ca of colon
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon and liver operation. A patchy density (2.3cm) at RML. Recurrent metastases at right liver operative margin (much regression).
    • Some calcifications in prostate.
    • Tiny gallbladder stones.
    • Degeneration and spondylosis of L-S spine.
    • Atherosclerosis of aorta, iliac and coronary arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P colon and liver operation. A patchy density (2.3cm) at RML. Recurrent metastases at right liver operative margin (much regression).
• 2023-02-13 Microsonography
  • Clinical Diagnosis: IRC and ME os
  • Report: 207/482 um, IRC and ME os
• 2023-02-09 CT - abdomen
  • History and indication: colon cancer with recurrent liver mets S/P op & C/T
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon and liver operation. Right pleural effusion with adjacent lung collapse. Recurrent metastases at right liver operative margin.
    • Some calcifications in prostate.
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • Normal appearance of gallbladder.
    • Patency of portal vein.
    • Degeneration and spondylosis of L-S spine.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac and coronary arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P colon and liver operation. Right pleural effusion with adjacent lung collapse. Recurrent metastases at right liver operative margin.
• 2022-12-27 Patho - pleural/pericardial biopsy
  • Diaphragm, right, partial resection — Adenocarcinoma, moderately differentiated, compatible with metastatic colonic adenocarcinoma of liver with diaphragm invasion
  • The sections show a picture of adenocarcinoma, moderately differentiated, composed of low columnar neoplastic cells arranged in tubular and cribriform patterns with dirty necrosis. The surgical margin is close to tumor. The finding is compatible with metastatic colonic adenocarcinoma of liver with diaphragm invasion.
• 2022-12-27 Patho - liver partial resection
  • PATHOLOGIC DIAGNOSIS
    • Liver, S7, S7 resection — Metastatic colonic adenocarcinoma
      
    • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
  • MACROSCOPIC EXAMINATION
    • Procedures: S7 resection
    • Specimen Size: 11 x 8.0 x 5.0 cm and 120 gm
      
    • Tumor Focality: Solitary
      
    • Tumor Site: S7
      
    • Tumor Size: 3.2 x 3.0 x 2.2 cm
      
    • Large vessel involvement: Not identified
      
    • Non-tumorous part: Not cirrhotic
      
    • Sections are taken and labeled as: A1-A2= tumor + margin, A3-A4= tumor + capsule
  • MICROSCOPIC EXAMINATION
    • Diagnosis: Metastatic colonic adenocarcinoma
      
    • Histologic grade: Moderately differentiated
      
    • Tumor growth pattern: Pushing
      
    • Tumor pseudocapsule: Present
      
    • Tumor necrosis: Moderate (15%)
      
    • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 1.5 cm from resection margin
        
    • Vascular invasion: Not identified
      
    • Perineural invasion: Not identified
      
    • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
    • Non-neoplastic liver parenchyma: Moderate lymphocytic portal inflammation and regeneration of hepatocytes
    • Fatty Change: Absent
• 2022-12-26 ECG
  • Normal sinus rhythm
  • Left ventricular hypertrophy with repolarization abnormality
• 2022-11-24 Whole body PET scan
  • A mild glucose hypermetabolic lesion in the segment 7 of the liver. Liver metastasis of low FDG uptake can not be ruled out. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in a focal area in the right iliac bone. The nature is to be determined. Please follow up other imaging modalities for further evaluation.
  • Mild glucose hypermetabolism in bilateral shoulders and hips. Inflammatory process may show this picture.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2022-11-14 CT - abdomen
  • Indication: Malignant neoplasm of rectum
  • Abdominal CT with and without enhancement revealed:
    • Hepatic tumor at right liver surface with marginal enhancement and central necrosis is found. Hepatic metastasis is considered. In comparison with CT dated on 2022-04-25, the lesion enlarged.
    • Hypervascular hepatic tumor at S5/6 of liver up to 0.8cm in largest dimension. Hemangioma is considered.
    • s/p RAR.
    • The spleen, pancreas, both kidneys and adrenals are intact.
    • There is no evidence of paraarotic LAPs.
  • Imp: colon cancer s/p RAR with liver metastasis, in progression.
• 2022-08-22 SONO - abdomen
  • Findings
    • Normal echogenicity of the liver.
    • Presence of gallbladder stones and polyps.
    • Patency of PV, HVs, IVC and aorta in hepatic portion.
  • Impression:
    • GB stones and polyps.
• 2022-05-30 MRA - brain
  • Acute infarcts in right upper medulla oblongata. Intracranial artherosclerosis.
• 2022-04-25 CT - abdomen
  • S/P colon and liver operation. No evidence of tumor recurrence.
• 2022-01-27 SONO - abdomen
  • Gallbladder stones (up to 0.56cm).
• 2021-11-01 CT - abdomen
  • S/P colon and liver operation. No evidence of tumor recurrence.
• 2021-04-20 Patho - conjunctiva biopsy/pterygium
  • Labeled as “sclera od”, trabeculectomy od — fibrotic tissue
• 2021-04-12 Patho - colorectal polyp
  • Intestine, large, cecum, 120 cm from anal verge, biopsy — tubular adenoma
• 2021-04-09 CT - abdomen
  • Indication: rectal CA, pT3N2aM0, stage IIIB s/p CCRT from 2018-03 to 2018-05 and LAR wt protective ileostomy on 2018/06/07
    • 20180507 CT: hemangioma 0.8 cm in S5
    • 20190708 CT: hemangioma 0.8 cm in S5.
    • 20191230 CT: two metastases 0.7 cm in S7 and 1.3 cm in S6?
    • 20200204 MRI: two metastases in S7 and S6?
    • Metastases confirmed by pathology after resection
  • FINDINGS:
    • There are focal defect in S7 and S6 of the liver that are compatible with metastases S/P surgical enucleation.
      • There is no evidence of tumor recurrence.
    • S/P LAR with autosuture retention over the rectum.
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
    • Others
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidney.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion in the mesentery and omentum.
  • IMP:
    • No evidence of tumor recurrence in the liver.
• 2021-04-09 Colonoscopy
  • The scope reach the cecum under poor colon preparation.
  • Two small and sessile polyp was noted in the cecum size 0.7 cm. (120 cm from anal verge)
• 2020-10-19 CT - abdomen
  • S/P colon and liver operation. No evidence of tumor recurrence.
• 2020-02-25 Patho - liver partial resection
  • PATHOLOGIC DIAGNOSIS:
    • Liver, S7 with partial S6, segmental hepatectomy — Metastatic colorectal adenocarcinoma
      
    • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
      
  • MACROSCOPIC EXAMINATION
    • Procedures: Segmental hepatectomy of S7 with partial S6
      
    • Specimen Size: 12.0 x 7.5 x 5.5 cm and 180 gm
      
    • Tumor Focality: Solitary
      
    • Tumor Site: S6
      
    • Tumor Size: 2.2 x 2.0 x 1.7 cm
      
    • Large vessel involvement: Not identified
      
    • Non-tumorous part: Not cirrhotic
      
    • Sections are taken and labeled as: A1-A4= tumor, A5- A6= non-neoplastic liver
      
  • MICROSCOPIC EXAMINATION
    • Diagnosis: Metastatic colorectal adenoarcinoma
      
    • Histologic grade: Moderately differentiated
      
    • Tumor growth pattern: Infiltrating
      
    • Tumor pseudocapsule:Absent
      
    • Tumor necrosis: Moderate (10%)
      
    • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 0.4 cm
        
    • Vascular invasion: Not identified
      
    • Perineural invasion: Not identified
      
    • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
      
    • Non-neoplastic liver parenchyma: Perivenular congestion, regeneration of hepatocytes, and mild lymphocytic and neutrophil portal inflammation
      
    • IHC: CK7(-), CK20(+) and CDX2(+)
• 2020-02-24 MRI - liver, spleen
  • History and indication: R/I recurrence of liiverr mets.
  • IMP: Progressive enlargement of right liver tumors (S6-7, 1.0cm, 1.7cm), metastases shoulde be ruled out.
• 2019-12-30 CT - abdomen
  • Rectal cancer s/p operation. Right liver hemangioma (8mm). Poor enhancing tumors (6mm, 9mm) in S6-7 of liver suspected metastases.
• 2019-01-21 CT - abdomen
  • Status post LAR with autosuture at the rectum.
  • There is no evidence of tumor recurrence.
• 2018-06-08 Surgical pathology Level VI
  • PATHOLOGIC DIAGNOSIS
    • Rectum, s/p CCRT, laparoscopic assisted LAR and protective colostomy —- Adenocarcinoma, moderately differentiated
    • Resection margins: free
    • Lymph node, mesocolic, s/p CCRT, dissection —- Metastatic adenocarcinoma (4/11) with extranodal extension (1/4).
    • Lymph node, IMA / SMA, dissection — N/A.
    • AJCC 8th edition Pathology stage: ypT2N2a (if cM0); ypStage: IIIB.
    • NOTE: cM might be the same or might be upgraded when additional clinical and image findings are available for evaluation.
  • MACROSCOPIC EXAMINATION
    • Operation procedure: s/p CCRT, laparoscopic assisted LAR and protective colostomy
    • Specimen site: rectum
      
    • Specimen size: 9 cm in length
      
    • Tumor size: 3 x 2 cm
    • Tumor location: 3 cm and 2 cm away from the two resection margins, respectively
    • Depth of invasion grossly: muscularis propria
    • Mucosa elsewhere: free
    • Tissue for sections: A1-4: tumor; A5-6: lymph nodes.
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
    • Histology Grade: moderately differentiated
    • Depth of invasion: muscularis propria
    • Angiolymphatic invasion: Present.
    • Perineural invasion: Not identified.
    • Discontinuous extramural tumor extension: Not identified.
    • Circumferential (radial) margin of rectum: Uninvolved, 5 mm from the margin.
    • Lymph node metastasis, mesocolic: (4/11)
      
    • Lymph node metastasis,, IMA / SMA: N/A.
    • Extranodal involvement: Present.
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT) ypT2: Tumor invades the muscularis propria
      • Regional Lymph Nodes (pN) ypN2a: Four to six regional lymph nodes are positive
      • Distant Metastasis (pM) (if cM0); ypStage: IIIB.
      • NOTE: cM might be the same or might be upgraded when additional clinical and image findings are available for evaluation.
    • Type of polyp in which invasive carcinoma arose: Not identified
    • Additional pathologic findings: None identified.
    • TNM descriptors: y (Post-treatment).
      
    • Tumor regression grading S/P CCRT:
      • Grade 3 (dominant fibrosis outgrowing of 50% of the tumor mass).
• 2018-02-06 Surgical pathology Level IV
  • Clinical diagnosis:
  • Neoplasm of unspecified nature of digestive system;
  • Pathological diagnosis:
    • Rectum, 8 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • MICROSCOPIC DESCRIPTION:
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[consultation]

• 2022-05-30 Neurology
  • Q
    • l’t arm weakness since this morning. unsteady sensation.
    • hx of DM, HTN.
  • A
    • S
      • This 58 y/o man with a Hx of DM, HTN, dyslipidemia, and rectal CA with liver mets, Dx in Jan 2018, s/p CCRT under regular OPD follow-up. He was in ADL independent status.
      • This time, he suffered from acute left side numbness at 2PM on 5/28 while driving with left neck pain. Left limbs weakness was noted on the next day morning on awakending. Due to persisted symptoms, he came to our ER. There was no vomiting, diplopia, choking, slrred speech, convulsion, headache, fever or recent head trauma.
    • O
      • NE
        • GCS: E4V5M6
          
        • VF: no hemianopia
        • light reflex: 3/3 -/+ (cata/cata (right eye glaucoma s/p OP
        • EOM: free
          
        • no nystagmus
        • no facial palsy
          
        • PPS: left face V-I,II,III hypoesthesia (equivocal
      • Muscle power:
        • RUE/LUE: 5/4
        • RLE/LLE: 5/4
      • PPS: left hypoesthesia
      • FNF & HKS: no dysmetria
      • gait: tilt to left
      • NIHSS 000 000 1010 01000 =3
      • Lab Bil 1.17, CEA 5.465
      • brain MRA: Acute infarcts in right upper medulla oblongata
    • Impression
      • Acute infarcts in right upper medulla oblongata
    • Suggestion
      • aspirin 100mg 1# ST and QD
      • clopidogrel 300mg ST and 75 mg QD
      • famotidine 1# ST and BID
      • N/S run 60 ml/hr
      • hold OPD anti-hypertensive medication and control BP < 220/120
      • admit to ward under Dr Xiao’s service
      • closely monitor neurological signs
• 2020-09-10 Ophthalmology
  • Q
    • This 57-year-old man patient is a case of colon cancer with liver metastasis s/p operation. He was admitted for chemotherapy. This time, glaucoma with high intraocular pressure. Now, for follow-up. Thank you.
  • A
    • S: for f/u IOP
    • O
      • OPHx: DMR complicated with NVG s/p several IVILs ou and cryotherapy od and full PRP ou
      • recent IOP, od on 9/7 W1 up to 40 was noted –＞ diamox 1# qid + combigan + xalatan
      • PT: 10/12 mmHg
      • VAcNC: OD 20/200 OS 20/200
      • conj: not injected ou
      • K: cl ou
      • AC:deep/cell trace - 1+ od, deep /clear os
      • c/d: pale disc 0.6-7 od, 0.5 os
    • P:
      • tapper the diamox to 1# bid

[surgical operation]

• 2022-12-26
  • Surgery
    • open S7 resection with rt diaphram partial resection and repair
  • Finding
    • S7 hepatic tumor 3.2 x 3.0 x 2.0 cm with direct invasion to diaphragm
• 2020-07-27
  • Surgery: 0 IVI Lucentis    ou    
  • Finding: retinal edema    ou 
• 2020-02-24
  • Surgery
    • S7 and partial S6 resection
    • laparoscope
  • Finding
    • AN illed define heteroechoic tumor at S7 1.7 cm and 1.5 cm tumor at S6
    • mild adhesion
• 2019-08-16
  • Diagnosis: Exudative senile macular degeneration
  • PCS code: 86201B
• 2019-07-05
  • Diagnosis: Proliferative diabetic retinopathy OU
  • PCS code: 86201B
• 2019-05-24
  • Diagnosis: DME ou
  • PCS code: 86201B
• 2019-04-19
  • Diagnosis: DME ou
  • PCS code: 86201B
• 2018-11-22
  • Diagnosis: Rectal cancer s/p LAR and ileostomy
  • PCS code: 73020C
  • Findings: Loop-ileostomy was taken down and resection with re-anastomosis was achieved using GIA 75/4.8. The procedure was smooth.
• 2018-06-07
  • Diagnosis: Adenocarcinoma of rectum, cT3N2M1 s/p CCRT
  • PCS code: 74205B
  • Finding
    • Rectal cancer s/p CCRT was noted at middle rectum.
    • The laparoscopy procedure was converted to open method due to difficult to apply endo-GIA instrument.
    • The anastomosis was then achieved using SDH-33. Cutting ends are intact and even. Air test is ok.
    • TISSEEL 2ml was used at anastomosis site.
    • Loop-ileostomy was done at LLQ abdomen. A drain in pelvos.
• 2018-02-07
  • Diagnosis: Rectal Ca
  • PCS code: 47080B
  • Findings: We identify the cephaic vein & use cutdown method to insert the Echo Port 7 Fr cathter into it. We also use intra-operative EKG to check its position

[chemoimmunotherapy]

• 2023-08-17 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg IVD + NS 250mL + aprepitant 125mg D1-3
• 2023-07-31 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5100mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg IVD + NS 250mL + aprepitant 125mg D1-3
• 2023-07-10 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5150mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 0.5mg IVD + NS 250mL
• 2023-06-20 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5150mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-05-26 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5125mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-04-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5180mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-04-06 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5170mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-03-15 - irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 735mg NS 250mL 2hr + fluorouracil 2800mg/m2 5155mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-02-24 - irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 729mg NS 250mL 2hr + fluorouracil 2800mg/m2 5100mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-02-09 - irinotecan 160mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2020-09-10 - oxaliplatin 85mg/m2 146mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4810mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2020-08-27 - FOLFOX
• 2020-08-13 - FOLFOX
• 2020-07-30 - FOLFOX
• 2020-07-16 - FOLFOX
• 2020-07-02 - FOLFOX
• 2020-06-18 - FOLFOX
• 2020-05-28 - FOLFOX
• 2020-05-14 - FOLFOX
• 2020-04-30 - FOLFOX

==========

2023-08-18

A 28-day supply of Ulstop (famotidine), Bokey (aspirin), Saline (nicametate), and Vemlidy (tenofovir alafenamide) are refilled on 2023-08-05, all added to the active formulary with no reconciliation issues found.

2023-08-01

Our neurologist prescribed Ulstop (famotidine), Bokey (aspirin), Saline (nicametate citrate) on 2023-07-17, our ophthalmologist prescribed Xalatan (latanoprost), Azarga (brinzolamide, timolol), Alphagan (brimonidine) eye drops on 2023-07-31. These drugs are included in the active medication list without a reconciliation issue.

2023-07-11

[reconciliation]

The prescription of Alphagan (brimonidine tartrate), Azarga (brinzolamide), and Xalatan (latanoprost) eye drops were refilled at a local pharmacy on 2023-06-26, with a valid 28-day duration for his glaucoma diagnosis. However, these drugs are not currently included in the patient’s active medication list. Please check whether these medications are still required for the patient.

2023-06-21

• This patient receives medical services exclusively at our hospital. In addition to hematology and oncology, the patient also sees metabolism and endocrinology for type 2 DM, hyperlipidemia, primary hypertension, constipation; ophthalmology for glaucoma; and neurology for previous stroke.
• The patient received a refillable prescription from Metabolism and Endocrinology on 2023-06-05 for Toujeo (insulin glargine), Through (sennoside), Crestor (rosuvastatin), Kludon (gliclazide), Dobose (acarbose), Olmetec (olmesartan), and Trulicity (dulaglutide). From the ophthalmology department, the patient was prescribed Xalatan (latanoprost), Azarga (brinzolamide, timolol), and Alphagan (brimonidine) on 2023-05-08. The neurology department prescribed Ulstop (famotidine), Bokey (aspirin), and Saline (nicametate) on 2023-04-24.
• All of these medications have been added to the current formulary, except for the eye drops from the ophthalmology department. Please remind the patient to continue using them to prevent his glaucoma from worsening.

2023-04-07

• During this hospitalization, the patient received his first dose of Avastin (bevacizumab) as part of the FOLFIRI chemoimmunotherapy regimen. Although the patient had previously received 3 cycles of FOLFIRI, monitoring for bleeding and thrombosis may still be necessary as these symptoms may be related to the use of bevacizumab.
• The preprandial FS glucose levels on 2023-04-06 and 2023-04-07 morning were 218 and 249, respectively. If the readings exceed 200 for more than two consecutive days, the insulin dose may need to be increased.

2023-03-16

• The patient’s blood sugar level has been well controlled during his current hospitalization.
• He has a history of acute infarcts in the right upper medulla oblongata and was found to have intracranial atherosclerosis on a brain MRA performed on 2022-05-30. On 2023-03-16 at 13:14, his SBP was measured to be 182mmHg. If the patient continues to have persistently high blood pressure, the addition of amlodipine may be considered.

700813390

230818

[exam findings]

• 2023-08-17 Sigmoidoscopy
  • Low rectal cancer involving anal canal and anal sphincter

[MedRec]

• 2023-08-14 SOAP Radiation Oncology Chang YouKang
  • S
    • PH: lung cancer stage Ia s/p OP in NTUH in 2018.
    • BPH s/p OP; C spine s/p OP > 10 yr.
    • No DM; no HTN.
    • Anal pain with some bleeding since 2023/05.
    • Anal fistula s/p admission and OP at HsinChu Mackay Hospital.
  • O
    • CT, 2023/08/11, HsinChu Mackay Hospital: 4-cm tumor over anal canal, small perirectal LAPs, no enlarged bilateral inquinal LAPs; cT3N1M0 at least. No lung, liver, distal LN metastasis.
    • CXR, 2023/08/08: blurred left CP angle.
    • DRE, 2023/08/14: anal canal induration and an ulcerative wound at right lateral to anterior.
    • 2023/08/10, CEA 1.77, CA199 7.77.
    • HsinChu Mackay Hospital Pathology, 2023/08/09 (S2306571): adenocarcinoma (goblet cell adenocarcinoma or signet ring cell ccarcioma with neuroendocrine differentiation)
  • Imp: Low rectal cancer (involving anal canal), cT3N1M0 at least; 83 Y/O.
  • Suggest CCRT then observation (prefered due to very old age), or local excision if good tumor response or APR.
    • RT dose: 5400cGy/30 fractions.
    • CT simulation on 8/17, 14:30.
    • Possible RT side effects are told; diet education.
• 2023-08-14 SOAP Colorectal Surgery Xiao GuangHong
  • S
    • Anal fistula s/p admission and OP at HsinChu Mackay Hospital
    • Post-OP patho: adenocarcinoma
    • PH: lung cancer
  • O
    • CT: TxN0M0
    • DRE: anal canal induration and an ulcerative wound at right lateral to anterior
  • A
    • Suggest CCRT then evaluation of observation (prefered due to very old age) or APR
      
  • P
    • Arrange sigmoidoscopy for R/O colonic lesion

==========

2023-08-18

This patient received a repeat prescription on 2023-06-28 at NTUH HsinChu Branch and refilled it on 2023-07-20 at a local pharmacy for a 28-day supply of Sennapur (sennoside), Betmiga (mirabegron), Xanax (alprazolam), and Eurodin (estazolam). There is no mirabegron included in the active medication list, please confirm if the drug is no longer needed.

701114210

230818

[MedRec]

• 2023-07-25 SOAP Metabolism and Endocrinology Hu YaHui
  • Diagnosis
    • Corticoadrenal insufficiency [E89.6]
    • Malignant neoplasm of rectum [C20]
    • Goiter, unspecified [E04.9]
    • Malignant adrenal gland neoplasm [C74.02]
    • Anemia [D64.9]
  • Prescription x3
    • Docone (dexamethasone 0.5mg) 1# QD
    • Florinef (fludrocortisone 0.1mg) 1# QD
    • Crestor (rosuvastatin 10mg) 1# QD
    • Lipanthyl Supra (fenofibrate 160mg) 1# QD
    • cortisone acetate 25mg 2# PRNBID if headache or fever
• 2023-06-21 ~ 2023-06-29 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • K-RAS wild type Rectum cancer, pT3N0M0 post neoadjuvant with concurrent chemoradiotherapy, status post low anterior resection in 2018-08 WITH recurrence post palliative chemotherapy. Multiple LNs, lung and liver metastases in 2023-04.
    • Secondary malignant neoplasm of right adrenal gland
    • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
  • CC
    • for further management
  • Present illness
    • This 68-year-old male, a pt of rectal adeno CA, cT3N0M0 s/p neoadjuvant CCRT, s/p LAR in Aug 2018 by Dr Xiao GuangHong, s/p post-Op adjuvant Xeloda & R adrenal mets s/p bil adrenectomy in 2020-01 by Dr Cai YaoZhou, s/p post-Op palliative C/T with FOLFIRI / Avastin from April to July 2020 by Dr Liu JunHuang & recurrenec at para-aortic LN mets in 2021-01.
    • KRAS: wild type., s/p 2nd line palliative C/T wt CapeOx x 12 from Feb to Nov 2021 wt Dz in progress at new hepatic tumor, s/p 3rd line palliative C/T wt FOLFIRI / Erbitux IV Q2W x 12 since 12/7 21.
    • L adrenal tumor with rapid increase in size after surgery, Adrenal gland, R, lap.
    • Adrenalectomy (2/21 20) proved mets adenoCA, favoring colorectal origin. Adrenal MRI (1/20 20) showed mets in right adrenal gland is highly suspected. Right adrenaltumor enlargment suspect adrenal mets, suggest LPS adrenalecotmy. Lt adrenalectomyin 06/2019 & Rt adrenalectomy on 2020/02/21.
    • A left para-aortic glucose-hypermetabolic soft tissue lesion, metastasis in a leftpara-aortic lymph node was noted.He was referred to our clinic on 5/25 20 for continuous C/T by Dr Liu JunHuang. #5 chemotherapy with Avastin / FOLFIRI IV Q2W x 8 on 6/8 20, #6 on 6/22 20. #7 on7/6 20. #8 on 7/20 20 (finished).
    • Follow-up abd CT (7/15 20) showed s/p LAR with autosuture retention at the rectum.No evidence of tumor recurrence. CEA: 1.4 (7/15 20), CEA: 1.0 (12/28 20).FCXR & abd sono (9/28 20): negative. Abd CT (1/228 20) revealed rectal CA s/p Op. A LN (1.8cm) at paraaortic region r/o tumor mets. Newly developed para-aortic LNs;biopsy (1/12 21) proved adenocarcinoma. IHC stain: CK20(+), c/w lcolorectal recurrence.
    • We explain to pt about the indication & risk / benefit of 2nd line palliative C/T wt mFOLFOX IV Q2W x 12.
    • Follow-up abd CT (12/28 20) showed rectal CA s/p Op. A LN (1.8cm) at paraaortic region r/o tumor mets.newly developed para-aortic LNs; biopsy (1/12 21) proved adenocarcinoma. IHC stain: CK20(+), c/w colorectal recurrence.
    • 2nd line palliative C/T wt mFOLFOX IV Q2W x 1 on 2/1 21. (DC it due to SE & pt declined it). Due to SE, may shift to CapeOx.will shift to CAPEOX ( Capecitabine 1000mg/m2 PO BID D1~14 Q3W + Oxaliplatin 130mg/m2 ) IV Q3W .
    • 2nd line palliative C/T wt CapeOx ( Capecitabine 700mg/m2 ( 2# ) PO BID D1~14 Q3W + Oxaliplatin 60mg/m2 IV Q3W ) x 6 on 2/23 21, #2 CapeOx ( Capecitabine 1000mg/m2 (3#) + Oxaliplatin 70mg/m2 IV Q3W x 6 on 3/16 21, #3 on 4/6 21, #4 on 4/27 21. #5 on 5/18 21. #6 on 6/30 21. #7 ( Oxalip 100mg/m2 ) on 7/13 21. #8 ( Oxalip 110mg/m2 ) on 8/3 21. #9 ( Oxalip 120mg/m2 ) on 8/24 21. #10 on 9/14 21. #11 ( Oxalip 130mg/m2 ) on 10/5 21. #12 on 11/2 21. ( portable ).Abd CT (5/4 21) (8/4 21) showed s/p R hemicolectomy, post-op at rectum with left paraaortic recurrence, stationary.
    • Abd CT (11/16 21) revealed s/p RAR. L perirenal space metastatic lymphadenopathy, stable. New hepatic tumor at dome. r/o meta.#1A 3rd line palliative C/T wt FOLFIRI / Erbitux IV Q2W x 12 on 12/7 21.Erbitux 400mg/m2 (give 600mg) IVF 2 hr then 250mg/m2 ( give 400mg ) IVF 1 hr QW x8, plus FOLFIRI as 3rd line palliative C/T.
    • RTC 1 wk later on 5/10 22 for #3 4th palliative C/T wt FOLFIRINOX / Erbitux IV Q2W x 12 (the last biochemotherapy on 2022/7/5).
    • Followed CT of abdominal on 2023/5/16 revealed S/P colon operation. Multiple LNs, lung and liver metastases. He was admitted for further management
  • Course of inpatient treatment
    • After admission,CT guide biopsy was administered on 2023/6/23 revealed Metastatic adenocarcinoma, consistent with colorectal primary.
    • Chemotherapy with C1D1 FOLFIRI (dose adjusted to 20% off) was administered on 2023/6/26-28 after fully explaination.
    • Adequate hydration. selfpaid of Emend and PRN Dexamethasone for chemotherapy related emesis.
    • With the relatively stable condition, he was discharged on 2023/06/29 and will OPD follow up later
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H as painkiller
    • loperamide 2mg 1# PRNQ6H if diarrhea
    • Limeson (dexamethasone 4mg) 1# PRNBID as antiemetic
• 2019-08-07 SOAP Metabolism and Endocrinology Hu YaHui
  • Diagnosis
    • Corticoadrenal insufficiency [E89.6]
    • Malignant neoplasm of rectum [C20]
    • Goiter, unspecified [E04.9]
    • Malignant adrenal gland neoplasm [C74.02]
    • Anemia [D64.9]
  • Prescription x3
    • cortisone acetate 25mg 2# PRNBID
    • Compesolon (prednisolone 5mg) 0.5# BID
• 2018-03-29 SOAP Colorectal Surgery Xiao GuangHong
  • S: A case of newly diagnosed rectal cancer at 8cm from AV

==========

2023-08-18

Our endocrinologist issued a repeat prescription for Docone (dexamethasone), Florinef (fludrocortisone), Crestor (rosuvastatin), and Lipanthyl Supra (fenofibrate), all of which are currently in use, with no medication reconciliation problems found.

701450638

230818

[exam findings] (not completed)

• 2023-05-30 Tc-99m MDP bone scan
  • Increased activity in the lower C-spine and lower L-spines. Degenerative change is more likely. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone sacn for further evaluation.
  • Increased activity in the right shoulder, right sternoclavicular junction, bilateral hips and knees, compatible with benign joint lesions.
• 2023-05-19 CT - abdomen
  • 20220906 CT: Sigmoid colon cancer with micro-perforation and attachment to bladder region and liver, lung with distant lymph nodes metastasis, cT4N2M1b, stage: IVB status post Hartmann’s operation on 2022/09/06
  • History: hepatitis B anti-Hbc: positive
  • Findings: Comparison: prior chest CT dated 2023/02/21.
    • S/P LAR with autosuture retention over the rectosigmoid junction.
      • S/P colostomy at left upper pelvis.
    • Prior CT identified several metastases on both hepatic lobes are noted again, mild decreasing in size.
      • However, three liver metastases in S4, S5, and S6/7 are noted again, mild increasing in size.
      • Multiple liver metastases S/P C/T show stable disease.
    • Prior CT identified metastatic lymph node in hepatoduodenal ligament is noted again, stationary.
    • Prior CT identified multiple metastatic nodes in para-aortic space and para-cava space are not noted again that is c/w multiple metastatic nodes S/P C/T show complete response.
    • Prior CT identified a lung metastasis in LLL (Srs:7 Img:5) is noted again, mild decreasing in size.
  • Impression:
    • Multiple liver metastases S/P C/T show stable disease.
• 2023-05-17 Shoulder Rt
  • AP internal and external rotation views of left shoulder show:
    • Rt osteoarthritis of A-C joint
• 2023-04-10 SONO - abdomen
  • Liver parenchymal disease
  • liver tumors, favor metastatic tumors
  • fatty infiltration of pancres(incomplete exam of pancreas)
• 2023-02-21 CT - chest
  • Impression: sigmoid colon cancer with lung, liver, and distant LNs metastases, in regression as compared previous CT on 2022/09/13.
• 2022-09-13 CT - chest
  • Impression: sigmoid colon cancer with lung, liver, and distant LNs metastases, with pleural effusion.
• 2022-09-08 All-RAS + BRAF mutation
  • All-RAS: There was no variant detected in the KRAS/NRAS gene
  • BRAF: There was no variant detected in the BRAF gene
• 2022-09-07 Patho - colon segmental resection for tumor
  • Diagnosis:
    • Intestine, large, sigmoid colon, Hartmann procedure - — moderately differentiated adenocarcinoma
      • — perforation with acute peritonitis
    • Lymph node, regional, dissection
      • — metastatic adenocarcinoma (9/13)
    • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
    • AJCC 8th edition pathology stage: pT4aN2b(cM1c); AJCC stage IVC
  • Gross Description:
    • Procedure: Hartmann procedure    - Tumor Site: Sigmoid colon
    • Tumor Size: 6 x 4 cm.
      
    • Macroscopic Tumor Perforation: Present
      
    • Macroscopic Intactness of Mesorectum (if applicable): Complete
    • Sections are taken and labeled as: A1: bil cut-ends, A2-4: LNs, A5-10: tumor
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension
      • Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Involved
        
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Present
    • Tumor Budding
      • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2):
      • Intermediate score (5-9)
    • Type of Polyp in Which Invasive Carcinoma Arose: Absent
    • Tumor Deposits: Not identified
      • Specify number of deposits: N/A
    • Regional Lymph Nodes
      • Number of Lymph Nodes Involved/Examined: 9/13
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
      • Primary Tumor (pT)
        • pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
      • Regional Lymph Nodes (pN):
        • pN2b: Seven or more regional lymph nodes are positive
      • Distant Metastasis (pM)
        • N/A
    • Additional Pathologic Findings (select all that apply):
      • perforation with acute peritonitis
    • Ancillary Studies: Pending (IHC stain of MSI will be followed.)
      
    • Comment(s)
      • NOTE: There is no peritoneal tissue, adjacent organs or structures for proof of tumor invasion or metastasis.
• 2022-09-06 CT - abdomen
  • Clinical history: 72 y/o male patient with fever for 1 day and abd pain for 1 wk, diarrhea+ for 3 months.
  • With and without contrast enhancement CT of abdomen - whole:
    • Focal thickening wall at the sigmoid colon with ulceration, r/o sigmoid colon cancer.
    • Focal air bubbles around sigmoid colon, proximal to the sigmoid tumor, r/o perforation.
    • There are poor enhancing tumors, up to 6.5cm in S4 liver, r/o liver metastasis.
    • There are multiple enlarged lymph nodes in pericolonic, common iliac and paraaortic regions.
    • Presence of ascites.
    • Left lower lung nodules, r/o lung metastasis.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • Impression:
    • Sigmoid cancer with lymph nodes metastasis, liver and lung metastasis, cstage T4N2M1.
    • Focal air bubbles around sigmoid colon, proximal to the sigmoid tumor, r/o perforation.

[MedRec]

• 2022-09-23 Gastroenterology
  • S
    • Come for NUC prophylaxis for C/T
    • First C/T scheduled on 20221003
  • O
    • PH:
      • OBI (ChatGPT: In a medical context, OBI stands for “Occult Hepatitis B Infection”. Occult Hepatitis B infection is characterized by the presence of hepatitis B virus (HBV) DNA in the liver (with detectable or undetectable HBV DNA in the serum) of individuals testing hepatitis B surface antigen (HBsAg) negative in routine assays.)
      • S-colon cancer with liver mets, s/p operation, under C/T
    • Start NUC prophylaxis. Check HBV DNA/antiHBs in advance
  • Prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
• 2022-09-20 SOAP Hemato-Oncology
  • S: explain to pt & his wife & son about the indication & risk / benefit of palliative C/T wt FOLFIRI / Avastin IV Q2W x 12. (9/20 22).
    • 2022/09/14 HBsAg (NM) = Negative;
    • 2022/09/14 Anti-HBc (NM) = Positive;
    • 2022/09/14 Anti-HCV (NM) = Negative;
    • will consult Dr Xiao ZongXian for anti-HBV Tx for C/T (9/20 22).
    • will consult Dr Chen YanZhi for Port-A installation (9/20 22)
    • will do HBsAg, anti-HBc, anti-HCV
    • will give palliative C/T wt FOLFIRI / Avastin IV Q2W x 12. (9/20 22).
    • Adm on 10/3 22 for #1 palliative C/T wt FOLFIRI / Avastin IV Q2W x 12.
• 2022-09-06 ~ 2022-09-14 POMR Colorectal Surgery
  • Discharge diagnosis
    • Adenocarcinoma of sigmoid colon with microperforation and attachment to bladder region and liver, lung with distant lymph nodes metastasis, cT4N2M1c, stage: IVC status post Hartmann’s operation on 2022/09/06 with lung, liver, and distant LNs metastases, with pleural effusion
    • Malignant neoplasm of sigmoid colon
  • CC
    • abdominal fullness over lower abdomen for a long time this year, assciated requent bowel movement up to 7-8 times per day, acute onset of severe abdominal cramps this morning.
  • Present illness
    • This 72-year-old man denied major systemic disease. This time, he has abdominal fullness over lower abdomen for a long time this year, assciated requent bowel movement up to 7-8 times per day, acute onset of severe abdominal cramps this morning. He was vist our GI OPD for help. Physical Exam show abdomen soft, mass like distention over lower abdomen, tympanic on percussion, dullness on percussion over pelvic region, but marked rebound tenderness over lower abdomen. KUB was performed and revaled stool retention in the bowel. Then,refer to ER for PE signs of peritonitis. At ER, the con’s clear,Vital sign TPR:38.2/110/18 BP:131/79mmHg. Abdomen CT was performed and revealed 1. Sigmoid cancer with lymph nodes metastasis, liver and lung metastasis, cstage T4N2M1, 2. Focal air bubbles around sigmoid colon, proximal to the sigmoid tumor, r/o perforation. CRS was consulted and he underwent oepration of Hartmann’s procedure. Postoperation, he was admission to SICU for further management.
  • Course of inpatient treatment
    • He underwent oepration of Hartmann’s procedure on 2022/09-06. Op finding: 1) micro perforation over sigmoid colon region and attachment to bladder region. 2) much turbid pus intra abdomen. Following the operation, he was transferred to the surgical intensive care unit for further monitoring. At SICU, he was given nothing by mouth with adequate IV fluid supplement and empirical antibiotic treatment with Brosym were prescribed. After well weaning parancter, extubation smoothly on 2022/09/07. She had passed stool with normal bowel movement. Oral intake with clear liquid diet is encouraged. Since the general condition became more stabalized, he was transferrd to ordinary ward for further care on 2022/09/08.
    • We keep antibiotic treatment with Brosym. No fever or chills, leukocytosis improved much. Early activity is encouraged. The wound healing well and no erythema change. He had flatus passage and abdominal wound pain subsided. Drain is clear ascites and removal of JP drain on 2022/09/10. Oral intake program was adjusted and there was no abdominal discomfort after trying oral intake, IV fluid supplement was tapered and discontinued later. Chest CT was done for cancer survey and showed sigmoid colon cancer with lung, liver, and distant LNs metastases, with pleural effusion. His abdominal wound pain had got much better. In stable condition, he was discharged on 2022/09/14 and will receive OPD follow up next week.
  • Prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Curam (amoxicillin 875mg, clavulanic acid 125mg) 1# Q12H
    • Acetal (acetaminophen 500mg) 1# PRNQ6H

[immunochemotherapy]

• 2023-08-17 - Avastin + FOLFIRI
• 2023-07-27 - Avastin + FOLFIRI
• 2023-07-13 - Avastin + FOLFIRI
• 2023-06-26 - Avastin + FOLFIRI
• 2023-04-14 - Avastin + FOLFIRI
• 2023-03-27 - Avastin + FOLFIRI
• 2023-03-10 - Avastin + FOLFIRI
• 2023-02-21 - Avastin + FOLFIRI
• 2023-02-03 - Avastin + FOLFIRI
• 2023-01-06 - Avastin + FOLFIRI
• 2022-12-19 - Avastin + FOLFIRI
• 2022-12-05 - Avastin + FOLFIRI
• 2022-11-21 - Avastin + FOLFIRI
• 2022-11-07 - Avastin + FOLFIRI
• 2022-10-20 - FOLFIRI
• 2022-10-03 - FOLFIRI

==========

2023-08-18

A 28-day supply of Baraclude (entecavir) refilled on 2023-07-25 has been added as a current use item and no medication reconciliation issues found.

2023-07-28

[liver function follow-up]

Observation shows a spike in liver enzymes, which exceeded 200 U/L in early June. Despite a visible decrease, the levels have not yet returned to the normal range. The patient is currently prescribed BaoGan (silymarin). At this time, there does not appear to be a need to change the treatment plan. Please continue to monitor the changes closely.

2023-07-26 S-GPT/ALT 97 U/L
2023-07-13 S-GPT/ALT 155 U/L
2023-07-07 S-GPT/ALT 101 U/L
2023-06-25 S-GPT/ALT 140 U/L
2023-06-21 S-GPT/ALT 156 U/L
2023-06-14 S-GPT/ALT 179 U/L
2023-06-10 S-GPT/ALT 235 U/L
2023-06-09 S-GPT/ALT 217 U/L
2023-04-26 S-GPT/ALT 27 U/L
2023-04-14 S-GPT/ALT 25 U/L

700551138

230817

{serous carcinoma of right fallopian tube with peritoneal and pleural invastion with tumor recurrent, pT3cN1aM1a, stage IVA}

[diagnosis] - 2023-03-30 discharge note

• Right fallopian tube carcinoma, pT3N1aM1a, FIGO stge IVA s/p Debulking surgery + CRS HIPES s/p IP C/T with Taxol/CDDP and Peripheral C/T with Taxol and Carboplatin with pseudomyxoma peritonei with liver and spleen metastases s/p C/T with Avastin/Taxotere/Carboplatin and IO therapy with Keytruda s/p mild progressive disease of pseudomyxoma peritonei with liver and spleen metastases with IO therapy with Q3W Keytruda and C/T with Avastin/Lipo-Dox/Carboplatin
• Essential (primary) hypertension
• Insomnia
• Chronic viral hepatitis B without delta-agent

[past history]

• Hypertension more than 10years with regular medical at our CV OPD
• Goiter post subtotal thyroidectomy at VGH-Taipei 10years ago.

                                                        

[allergy]

• Drug adverse event: never occurred
• Food allergy: never occurred
• Transfusion adverse event: never received transfusion                                                         

[family history]

• Non contributory to the psychiatric disorders.
• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-08-02, -07-26 KUB
  • Fecal material store in the colon.
  • S/P metalic autosuture at the rectosigmoid junction
• 2023-07-18 KUB
  • Radiopaque spots at pelvic region.
  • Presence of ileus.
• 2023-07-18 CXR (erect)
  • Blunted bilateral costophrenic angles.
  • Presence of ileus.
• 2023-06-07 All-RAS + BRAF mutation
  • Tissue Block No: S2019-12133 Fs
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-08 CT - abdomen
  • History and indication: Right fallopian tube cancer s/p OP and C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy and colon operation.
    • Some low attenuations at liver and spleen (up to 1.8cm). Focal thickening of peritoneum.
    • S/P mammoplasty.
    • Absence left thyroid gland. A nodule (7mm) at right thyroid gland.
  • IMP:
    • S/P hysterectomy and colon operation.
    • Some low attenuations at liver and spleen (up to 1.8cm) r/o metastases.
    • Focal thickening of peritoneum r/o tumor seeding.
• 2023-04-17 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (90.5 - 35.0) / 90.5 = 61.33%
    • M-mode (Teichholz) = 61.3
  • Conclusion
    • Normal AV with mild AR
    • Normal MV with mild MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
• 2023-03-29 Foot Lt
  • Fracture of 5th MT base of left foot is highly suspected. please correlate with clinical condition.
  • Osteoporotic change
• 2022-12-02 ECG
  • Sinus bradycardia
  • Moderate voltage criteria for LVH, may be normal variant
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2022-12-02 PET scan
  • Glucose hypermetabolism in multiple focal areas in the right lobe of the liver, in a small focal area in the left lobe of the liver, in two focal areas in the spleen and in a focal area in the anterior aspect of the upper midline abdominal cavity, compatible with multiple metastatic lesions.
  • A glucose hypermetabolic lesion in the posterior aspect of the left upper thigh. The nature is to be determined (a metastatic lesion? inflammation or infection?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the right shoulder and in the esophagus. Inflammation may show this picture.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
• 2022-12-01 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (66 - 20) / 66 = 69.70%
    • M-mode (Teichholz) = 70
  • Concentric LVH with normal LV systolic function.
  • Mild RV hypertrophy with normal RV systolic function.
  • Mild aortic valve sclerosis; mild MR; mild PR.
  • Minimal amount pericardial effusion (<50ml).
  • poor apical echo window
• 2022-11-18 CT - abdomen
  • History: Serous carcinoma of Rt fallopian tube with peritoneal and pleural invasion with tumor recurrent, pT3cN1aM1a; Stage IVA
    • 20220128 CT: Pseudomyxoma peritonei is highly suspected.
    • 20220224 CT guided biopsy: liver metastasis
  • FINDINGS:
    • Prior CT identified lobulatd cystic lesion in Rt subhphrenic space, S8 liver invasion, Rt lower medial perihepatic space with indentation the liver capsule, gastrohepatic ligament, lesser sac, and the medial perisplenic space with indentation the splenic capsule are noted again.
      • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease.
    • S/P hysterectomy
    • S/P LAR with autosuture retention over the rectosigmoid junction.
    • S/P water bag breast implantation, bilateral.
    • There is no focal lesion in both lung and mediastinum.
    • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
    • There is no ascites or lymphadenopathy.
    • There is no bowel wall thickening, and no bowel obstruction.
    • The abdominal aorta and IVC are grossly unremarkable.
      
    • There is no evidence of intrinsic or extrinsic bladder mass.
    • There is no focal lesion in the mesentery.
  • IMP:
    • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease. please correlate with clinical condition.
• 2022-11-18 CXR
  • Scoliosis of the T-spine with convex to right side.
  • Enlargement of cardiac silhouette.
• 2022-10-19 Sonography - right shoulder
  • Findings
    • Thickening and inhomogeneous echogenesity of right supraspinatus tendon. No definite discontinuity.
    • Prominent fluid in subacromial-subdeltoid bursa.
  • Impression
    • Supraspinatus tendinosis and subacromial-subdeltoid bursitis
    • suspected subacromial impingement. Suggest radiography correlation.
• 2022-08-27 CT - abdomen
  • Focal low attenuation at right kidney r/o nephritis.
  • S/P mammoplasty.
• 2022-08-27 CXR
  • Blunted bilateral costophrenic angles.
  • Presence of scoliosis of the T-spine.
• 2022-07-22 CT - abdomen
  • History: Serous carcinoma of Rt fallopian tube with peritoneal and pleural invasion with tumor recurrent, pT3cN1aM1a; Stage IVA
    • 20220128 CT: Pseudomyxoma peritonei is highly suspected.
    • 20220224 CT guided biopsy: liver metastasis
  • FINDINGS:
    • Prior CT identified lobulatd cystic lesion in Rt subhphrenic space, S8 liver invasion, Rt lower medial perihepatic space with indentation the liver capsule, gastrohepatic ligament, lesser sac, and the medial perisplenic space with indentation the splenic capsule are not noted again, except a small cystic lesion in the spleen.
      • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T with near complete response are suspected.
    • S/P hysterectomy
    • S/P LAR with autosuture retention over the rectosigmoid junction.
    • S/P water bag breast implantation, bilateral.
  • IMP:
    • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T with near complete response are suspected. please correlate with clinical condition.
• 2022-04-13 Panendoscopy
  • Reflux esophagitis LA grade A
  • Superficial gastritis
  • Gastric erosions, antrum
• 2022-04-12 CT - abdomen
  • Clinical history: 64 y/o female patient with Serous carcinoma of right fallopian tube with peritoneal and pleural invasion with tumor recurrent, pT3cN1aM1a; Stage IVAFor tumor f/u.
  • Findings
    • Post-op at the colon. S/P hysterectomy.
    • There are subphrenic and subhepatic soft tissue tumors, regression as compare with CT study on 2022-03-02.
    • Wall edema of the cecum.
    • Spleen tumor, 0.97cm.
  • Impression:
    • Post-op at the colon. S/P hysterectomy.
    • Pseudomyxoma peritoneum with liver and spleen involvement, regression as compare with CT study on 2022-03-02.
    • Wall edema of the cecum.
• 2022-04-11 Patho - colon biopsy
  • Transverse colon, biopsy — Nonspecific active colitis
• 2022-04-07 KUB
  • S/P metalic autosuture at the the rectosigmoid junction
• 2022-03-02 CT - abdomen, pelvis
  • Pseudomyxoma peritonei with liver and spleen metastases show stationary.
• 2022-02-24 Needle aspiration cytology - liver
  • Smears show histiocytes and clusters of atypical hyperchromatic papillary tumor. Malignancy is favored.
• 2022-02-23 CT - lung/mediastinum/pleura
  • no lung metastasis. pseudomyxoma peritonei and splenic lesion.
• 2022-01-28 CT - abdomen, pelvis
  • Pseudomyxoma peritonei is highly suspected. Please correlate with aspiration cytology.
• 2021-11-04 SONO - abdomen
  • Right liver cyst (1.75x2.10cm).
• 2021-08-10 CT - abdomen, pelvis
  • s/p LAR and autosuture. No evidence of recurrent/residual tumor in the current study.
• 2021-05-11 SONO - abdomen
  • A hepatic cyst measuring 1.81 cm in S6 is noted.
• 2021-02-09 CT - abdomen, pelvis
  • Post-op at the colon. S/P hysterectomy and oophorectomy.
• 2020-11-19 Whole body PET scan
  • Mild glucose hypermetabolism in a right axillary lymph node. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in bilateral shoulders and in the soft tissues around bilateral hips. Inflammatory process may show this picture.
  • Mildly increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
• 2020-11-13 CT - abdomen, pelvis
  • No Abscess or lymphocele in right pelvic sidewall is noted.
• 2020-09-18 CT - abdomen, pelvis
  • Abscess 3.5 x 2.8 cm in right pelvic sidewall is suspected.
  • The differential diagnosis include lymphocele.
• 2020-09-08 CT - abdomen, pelvis
  • Post op. change of the rectum.
  • Cystic change at right pelvic side wall, stable.
• 2020-05-25 CT - abdomen, pelvis
  • S/P hysterectomy.
  • Some LNs (up to 1.1cm) at bil. inguinal regions.
  • A cystic lesion (3.8cm) at right pelvic cavity.
• 2019-12-24 CT - abdomen, pelvis
  • S/P pigtail catheter drainage, right lower abdomen.
  • S/P CAPD catheter in the pelvic cavity, with focal loculated fulid in pericatheter region.
  • Cystic lesion, 3.8cm in right pelvic cavity, r/o lymphocele.
  • Post-op at the colon.
  • Bilateral pleural effusion with basal atelectasis.
• 2019-07-25 Patho Level VI - sigmoid colon
  • pathologic diagnosis
    • Sigmoid colon, radical proctectomy? — Serous carcinoma, metastatic
      
    • Faciform ligament, excision — Serous carcinoma, metastatic
      
    • Soft tissue over rectum, excision — Serous carcinoma, metastatic
      
    • Lymph nodes, mesocolic, dissection — Metastatic serous carcinoma (4/4)
  • microscopic examination
    • Histology: Serous carcinoma, metastatic
      
    • Histology Grade: High grade
    • Depth of invasion: Subserosal tumor with muscularis propria invasion
    • Angiolymphatic invasion: Present
      
    • Perineural invasion: Not identified
      
    • Lymph node metastasis, mesocolic: Positive (4/4)
    • Faciform ligament: Serous carcinoma, metastatic
      
    • Soft tissue over rectum: Serous carcinoma, metastatic
• 2019-07-25 Patho Level VI - BSO, hysterectomy
  • pathologic diagnosis
    • Fallopian tube, right, BSO — Serous tubal intraepithelial carcinoma and serous carcinoma, consistent with right fallopian tube is primary site
      
    • Ovaries, bilateral, BSO — Involved by serous carcinoma
      
    • Fallopian tube, left, BSO — Involved by serous carcinoma
      
    • Uterus, corpus, total hysterectomy — Involved by serous carcinoma
      
    • Uterus, cervix, total hysterectomy — Free of carcinoma
      
    • Omentume, omentectomy — Involved by serous carcinoma
      
    • Peritoneum, right, excision — Involved by serous carcinoma
      
    • Bladder, biopsy — Involved by serous carcinoma
      
    • Lymph nodes, external iliac, left, PLND — Metastatic serous carcinoma
      
    • Pathologic Stage: pT3cN1aM1a; Stage IVA at least
  • microscopic examination
    • Histologic type: Serous carcinoma
      
    • Histologic grade: High grade
    • Bilateral ovaries involvement: Present
    • Bilateral ovarian surface involvement: Present
    • Right tube involvement: Present
    • Left tube involvement: Present
    • Serous tubal intraepithelial carcinoma in right fallopian tube: Present
    • Uterine serosa involvement: Present
    • Omentum involvement: Present
    • Uterine Cervix: Chronic cervicitis, Nabothain cyst and squamous metaplasia
    • Endometrium involvement: Atrophy
    • Myometrium: Leiomyoma and adenomyopsis
    • Largest Extrapelvic Peritoneal Focus: 5.0 x 3.5 x 2.0 cm
    • Peritoneal/Ascitic Fluid: Malignant (positive for malignancy)
    • Pleural Fluid: Malignant (positive for malignancy)
    • Regional Lymph Nodes: Positive for metastasis
    • Other organs or specimens involvement: Present, specify: Bladder and sigmoid colon (S2019-12175)
    • Additional Pathologic Findings: Brenner tumor in right ovary
    • IHC for tumor cells (S2019-12133FS): WT1(+), PAX8(+), p53(+ aberrant expression), calretinin(-)

[MedRec]

• 2023-07-05 SOAP Psychosomatic Medicine
  • Diagnosis
    • Generalized anxiety disorder [F41.1]
    • Major depressive disorder single episode,unspecified [F32.9]
    • Nonorganic sleep disorder,unspecified [F51.9]
    • Malignant neoplasm of right fallopian tube [C57.01]
  • Prescription
    • Anxiedin (lorazepam 0.5mg) 1# QN
    • Lexapro (escitalopram 10mg) 1# QN
    • Stilnox (zolpidem 10mg) 1# HS
    • Alpraline (alprazolam 0.5mg) 1# PRNQN
• 2023-07-05 SOAP Cardiology
  • P: change CCB to Exforge, F/U blood biochemistry.
  • Prescription
    • Exforge (amlodipine, valsartan) 0.5# QD
    • carvedilol 6.25mg 1# QD
• 2023-05-16 SOAP Hemato-Oncology
  • P: Already mention the slow progression of liver and peritoneum comparing 2023-05 vs 2023-02 vs 2022-11 and 2022-08. -> RTC 4 weeks
• 2023-04-18 SOAP Hemato-Oncology Xia HeXiong
  • P: Admission on 2023-04-18 for heart echo then decide the next 6th Lipo-Dox / Carboplatin -> Becasue patient can not tolerate the C/T AE and LVEF drop from 70 to 61, she would not like to take the 6th dose of Lipo-Dox / Carboplatin.
    • Abd/Pelvis plus Chest CT will be arranged two weeks later (on 2023-05-02).
• 2023-04-17 SOAP Cardiology
  • A/P: Malignant neoplasm of right fallopian tube; Bilateral pleural effusion; HCVD, HLD, B hepatitis
    • A: need to R/O pericardioal effusion w/u for right pleural effusion
    • P: need to keep BB and CCB, 2D and CT of chest are indicated, watch for pancytopenia
• 2023-04-12 SOAP Hemato-Oncology
  • P: Admission on 2023-04-18 for heart echo then decide the next 6th Lipo-Dox / Carboplatin
• 2019-10-24 SOAP Psychosomatic Medicine
  • S
    • 1st time visiting come to my clinical due to insomia, dysphoric mood, anxiety, depression, cannot control emotion and ……..
    • 1st time visiting come alone. She claimed she cannot sleep well for a while.
  • O
    • Psychiatric impression:
      • Neurotic depression
      • Insomnia
    • Present illness:
      • This 61 y/o female suffered from serous carcinoma of right fallopian tube with peritoneal and pleural invasion, pT3cN1aM1a and was admitted to our hospital for chemotherapy. Severe insomnia was told and we were consulted for drug adjustment. Upon visit, the patient was coherent and relevant, cooperative attitude and mild anxiousness. According to herself, she started to have sleep disturbance with middle type insomnia ever since she was informed that she had cancer in 2019-07.
      • However, she didn’t seek psychiatric help due to she believed that the cancer treatment also caused insomnia. She received Alpraline 0.5mg/tab 1# HS, Eurodin 2mg/tab 1# HS, rivotril 0.5mg/tab 1# HS but in vain, and would switch to isolated ward due to she felt sensitivity to the environment at night. She claimed that she had low mood but denied suicidal thoughts or hopelessness sensation, decreased appetite was told. She is hesitate to adjust psychotropics in fear that the medications may cause renal impairment. There were no previous psychiatric history, no substance use history.
    • Suggestion:
      • D/C Eurodin 1# and Alpraline 1# HS
      • Add Mirtapine 1# HS for depressed mood
      • May titrate Rivotril dosage if the patient agrees
      • Arrange OPD follow-up
  • Diagnosis
    • Generalized anxiety disorder [F41.1]
    • Major depressive disorder single episode,unspecified [F32.9]
    • Nonorganic sleep disorder,unspecified [F51.9]
    • Malignant neoplasm of right fallopian tube [C57.01]
  • Prescription
    • Lexapro (escitalopram 10mg) 0.5# QN
    • Rivotril (clonazepam 0.5mg) 0.5# QN
    • Alpraline (alprazolam 0.5mg) 1# PRNQN
    • Eurodin (estazolam 2mg) 1# HS
• 2019-09-19 SOAP Hemato-Oncology
  • O:
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2019-08-01
      • Diagnosis: Tubal cancer
      • Staging: pT3cN1aM1a; at least Stage IVA
      • Treatment: Post-operative chemotherapy is recommended.
    • AE: Hair loss: Grade 2: Total hair loss.
    • 20190910 prescription: Taxol/Carboplatin IP with Taxol/Carboplatin C/T
• 2017-01-03 SOAP Cardiology
  • Diagnosis
    • Other and unspecified angina pectoris [I20.9]
    • HCVD, unspecified, without CHF [I11.9]
    • Mixed hyperlipidemia [E78.2]
    • Cardiac dysrhythmia, unspecified [I49.9]
    • Chest pain, other [R07.89]
    • Generalized anxiety disorder [F41.1]
  • Prescription
    • Algitab (alginic acid, MgCO3, Al(OH)3, 200mg) 1# TID
    • Alpraline (alprazolam 0.5mg) 0.5# HS
    • Pitator (pitavastatin 2mg) 1# QD
    • Syntrend (carvedilol 6.25mg) 1# QD
    • Bokey (aspirin 100mg) 1# QOD

[surgical operation]

• 2019-07-19
  • Debulking surgery (ATH + BSO + cytoreduction + infracolic omentectomy + appendectomy)
  • CRS HIPES

[chemoimmunotherapy]

• 2023-08-02 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-07-13 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-26 - gemcitabine 800mg/m2 1200mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + NS 250mL
• 2023-06-20 - topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-07 - topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-05-23 - topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-03-29 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (2023-04-12 WBC 1.46K/uL) (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-06 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Xia HeXiong)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-10 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-05 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-02 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1
• 2022-08-23 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-07-21 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-06-30 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-06-08 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-05-17 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 400mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-04-26 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 400mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-03-28 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-03-02 - + docetaxel 60mg/m2 90mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr (Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1
• 2020-02-03
• 2019-12-09
• 2019-11-11
• 2019-10-15
• 2019-09-11
• 2019-08-20 - paclitaxel 160mg/m2 240mg 3hr + carboplatin AUC 5 300mg 2hr + [paclitaxel 60mg + cisplatin 60mg] IP

Primary Systemic Therapy Regimens - Primary Therapy for Stage II–IV Disease - Epithelial Ovarian/Fallopian Tube/Primary Peritoneal (Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN guidelines version 5.2022 20220916, OV-C 6 OF 11, p43)

• High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
  • Preferred Regimens
    • Paclitaxel/carboplatin q3weeks
    • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
  • Other Recommended Regimens
    • Paclitaxel weekly/carboplatin weekly
    • Docetaxel/carboplatin
    • Carboplatin/liposomal doxorubicin
    • Paclitaxel weekly/carboplatin q3weeks
  • Useful in Certain Circumstances
    • IP/IV paclitaxel/cisplatin (for optimally debulked stage II–III disease)
    • For carcinosarcoma:
      • Carboplatin/ifosfamide
      • Cisplatin/ifosfamide
      • Paclitaxel/ifosfamide (category 2B)

Acceptable Recurrence Therapies for Epithelial Ovarian (including LCOC)/Fallopian Tube/Primary Peritoneal Cancer (Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN guidelines version 5.2022 20220916, OV-C 9 OF 11, p51)

• Recurrence Therapy for Platinum-Resistant Disease (alphabetical order)
  • Preferred Regimens
    • Cytotoxic Therapy
      • Cyclophosphamide (oral)/bevacizumab
      • Docetaxel
      • Etoposide, oral
      • Gemcitabine
      • Liposomal doxorubicin
      • Liposomal doxorubicin/bevacizumab
      • Paclitaxel (weekly)
      • Paclitaxel (weekly)/bevacizumab
      • Topotecan
      • Topotecan/bevacizumab
    • Targeted Therapy (single agents)
      • Bevacizumab
  • Other Recommended Regimens
    • Cytotoxic Therapy
      • Capecitabine
      • Cyclophosphamide
      • Doxorubicin
      • Ifosfamide
      • Irinotecan
      • Melphalan
      • Oxaliplatin
      • Paclitaxel
      • Paclitaxel, albumin bound
      • Pemetrexed
      • Sorafenib/topotecan
      • Vinorelbine
    • Targeted Therapy (single agents)
      • Niraparib (category 3)
      • Olaparib (category 3)
      • Pazopanib (category 2B)
      • Rucaparib (category 3)
    • Hormone Therapy
      • Aromatase inhibitors (anastrozole, exemestane, letrozole)
      • Leuprolide acetate
      • Megestrol acetate
      • Tamoxifen
  • Useful in Certain Circumstances
    • Immunotherapy
      • Dostarlimab-gxly (for dMMR/MSI-H recurrent or advanced tumors)
      • Pembrolizumab (for patients with MSI-H or dMMR solid tumors, or TMB-H tumors >=10 mutations/megabase)
    • Hormone Therapy
      • Fulvestrant (for low-grade serous carcinoma)
    • Targeted Therapy
      • Entrectinib or larotrectinib (for NTRK gene fusion-positive tumors)
      • Dabrafenib + trametinib (for BRAF V600Epositive tumors)
      • For low-grade serous carcinoma:
        • Trametinib
        • Binimetinib (category 2B)

==========

2023-08-17

This patient received repeat prescriptions from our cardiologist (for Exforge (amlodipine, valsartan) and Hexal (carvedilol)) and our psychiatrist (for Anxiedin (lorazepam), Lexapro (escitalopram), Stilnox (zolpidem), and Alpraline (alprazolam)) on 2023-07-05. These drugs are well included in the active formulary and no reconciliation issues were identified.

2023-07-14

On 2023-07-08, the patient refilled her prescription for Baraclude (entecavir) at a local pharmacy. In addition, on 2023-07-05, our cardiologist wrote a prescription for Exforge (amlodipine, valsartan) and Carvedilol. On the same day, our psychosomatic medicine specialist also prescribed Anxiedin (lorazepam), Lexapro (escitalopram), Stilnox (zolpidem), and Alpraline (alprazolam) for the patient. These medications were appropriately added to the patient’s active medication list with no reconciliation issues identified.

2023-05-23

• According to the PharmaCloud database, it seems that the patient has only received medical care at our hospital for the past three months. No discrepancies or issues have been identified during the medication reconciliation process for this patient upon her current admission.
• The patient has been unable to tolerate the adverse events associated with chemotherapy and her LVEF has decreased from 70% to 61%. Therefore, she decided not to receive the 6th dose of the Lipo-Dox and Carboplatin chemotherapy regimen.
• The patient is currently receiving topotecan, a medication which is reimbursable by the National Health Insurance (NHI) for use as a second-line chemotherapy treatment for ovarian cancer and small cell lung cancer. The eligibility for this is conditional on the first-line treatment including platinum compounds.
• The patient’s body surface area (BSA) is 1.56 m2, based on a height of 157 cm and weight of 56 kg. The administered dose of topotecan is 4mg, which is approximately 2.5mg/m2. The recommended dose of topotecan for ovarian cancer and small cell lung cancer is 1.5 mg/m2/day for five consecutive days every 21 days. Our current regimen administers a more concentrated dose in a single day. This warrants monitoring for potential myelosuppression and other adverse reactions.
• The patient experienced an episode of leukopenia on 2023-04-12, with a WBC count of 1.46K/uL, after the previous regimen of lipo-dox and carboplatin administered on 2023-03-29. However, the patient’s WBC count has since recovered to 3.56K/uL on 2023-05-22, making topotecan administration not contraindicated.
• The patient’s SBP exceeds 200mmHg several times and remains around 190mmHg 2023-05-23 08:33 this morning even she is taking Norvasc (amlodipine 5mg 0.5# QD) and Hexal (carvedilol 6.25mg 1# QD), it might be beneficial to double Norvasc to 1# QD first and monitor if the high SBP being mitigated.

2023-03-30

• Consecutive 3 days of granocyte (lenograstim) is scheduled approximately 1 week after the patient received chemotherapy to prevent them from leukopenia without an issue.

2022-12-02

• Several SBP data points exceeded 200mmHg in this patient while taking the self-care medications Norvasc (amlodipine) and Carvedilol (carvedilol) these two days. In order to mitigate her hypertension, the addition of an ARB, such as valsartan, losartan, might be beneficial.

2022-04-06

• This patient was diagnosed with serous carcinoma of the right fallopian tube with peritoneal and pleural invasion with recurrent tumors, received [paclitaxel + carboplatin] 6 times in the period from 2019-08-20 to 2020-02-03 following debulking surgery on 2019-07-19, now she is on [docetaxel + carboplatin] since 2022-03-02 (plus bevacizumab since 2022-03-28).

701192853

230817

[exam findings]

• 2023-07-04 CT - abdomen
  • Stable condition of rectal cancer.
  • Bronchiectasis at bilateral basal lungs.
  • Grade 5 fatty liver.
  • Hyperplasia of left adrenal gland.
  • Renal cysts (up to 1.1cm).
  • Gallbladder stones (up to 1.2cm).
• 2023-07-04 Sigmoidoscopy
  • rectal cancer s/p TNT, with total regression
• 2023-06-27 MRI - pelvis
  • History and indication: Rectal cancer, cT3N2a M0, stage IIIB
  • IMP:
    • Stable condition of rectal cancer as compared with previous CT study (2023-04-13).
    • Bronchiectasis at bilateral basal lungs.
• 2023-05-08 CXR
  • Peri-bronchial wall thickening of the left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2023-04-13 CT - abdomen
  • Much regression of rectal cancer.
  • Bronchiectasis at bilateral basal lungs.
  • Grade 5 fatty liver. Some calcifications at pancreas.
  • Hyperplasia of left adrenal gland.
  • Renal cysts (up to 1.1cm).
  • Gallbladder stones (up to 1.2cm).
• 2023-03-28 Sigmoidoscopy
  • tumor shrinkage to smaller
  • 5cm above AV, TATAME if need OP
• 2023-03-24 SONO - abdomen
  • Diagnosis:
    • Fatty liver, moderate
    • Suspected GB stones with cholecystopathy
    • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
  • Suggestion:
    • GS OPD f/u
    • Follow liver function test and AFP
    • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
• 2023-03-21 CXR
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2023-01-19 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
  • Gastric erosion, antrum
  • R/O gastric intestinal metaplasia with suspicious ulcer scar, prepyloric antrum, PW site
  • Duodenal ulcer, bulb
• 2023-01-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (125 - 30) / 125 = 76.00%
    • M-mode (Teichholz) = 76
  • Conclusion:
    • Concentric LV hypertrophy with Gr I LV diastolic dysfunction.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis; mild MR; mild TR.
• 2022-12-07 CT - abdomen
  • CC: intermittent bloody stool for times,
    • Constipation with excessive straining (-)
    • 20221206 colonoscopy: middle rectal cancer
  • Indication: CT staging
  • Findings:
    • There is asymmetrical wall thickening at right lateral aspect of the middle rectum, measuring 2.1 cm in wall thickness that is c/w adenocarcinoma (T3).
      • In addition, There are five enlarged node in the perirectal space (N2a).
    • There is mild fatty liver, grade 3.
    • There are stones (< 1.6 cm) and sludge in the gallbladder.
    • There is a homogeneous enhancing lesion measuring 1.6 cm in the pancreatic head that may be neuro-endocrine tumor. Please correlate with CA199, MRI, and EUS.
    • Bronchiectasis in RLL and LLL of the lung are suspected.
    • There are few small ovoid-shaped lymph nodes in paratracheal space that may be benign reactive nodes. Follow up is indicated.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3 (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
• 2022-12-07 Patho - colon biopsy (Y1)
  • DIAGNOSIS: Intestine, large, middle rectum, biopsy — adenocarcinoma
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.

[MedRec]

• 2023-07-07 Colorectal Surgery Lv ZongRu
  • A. rectal adenocarcinoma, cT3N2M0
  • P. rectal cancer s/p TNT with total regression.
    • after discuss with patient, patient want follow sigmoidioscopy + CT ever 3 months and LAR if recurrence, refuse TAMIS first. (TAMIS: Transanal Minimally Invasive Surgery)

[chemotherapy]

• 2023-08-16 FOLFOX
• 2023-07-28 FOLFOX
• 2023-07-12 FOLFOX
• 2023-06-26 FOLFOX
• 2023-06-05 FOLFOX
• 2023-05-08 FOLFOX
• 2023-04-10 FOLFOX
• 2023-03-21 FOLFOX
• 2023-03-03 FOLFOX
• 2023-02-16 FOLFOX
• 2023-01-16 5-FU
• 2023-01-09 5-FU
• 2022-12-30 5-FU
• 2022-12-28 5-FU

==========

2023-08-17

This patient obtained a 28-day refill of aspirin, bisoprolol, fenofibrate, ezetimibe, amlodipine, and atorvastatin from VGHTPE on 2023-08-09. All these medications are actively being used, and there are no discrepancies identified.

2023-07-13

This patient refilled a prescription on 2023-07-03 that was issued by VGHTPE on 2023-05-10 for aspirin, bisoprolol, fenofibrate, ezetimibe, amlodipine and atorvastatin. These drugs are now on the active formulary with no reconciliation issues identified.

700367784

230816

[MedRec]

• 2023-07-25 SOAP Dermatology
  • S: Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching
  • Prescription
    • Mycomb BID TOPI
    • Zalain External Gel Q3D EXT
    • Xyzal (levocetirizine 5mg) 1# HS
• 2023-06-20 ~ 2023-06-21 POMR Hemato-Oncology
  • Course of inpatient treatmnet
    • After admission, he received chemotherapy with Gemcitabine + Nab-Paclitaxel (Gemcitabine 1000mg/m2, Nab-Paclitaxel 100mg/m2) on 2023/06/20 (C1D1) smoothly.
    • Hypertension was treated with Olmetec 20mg/tab # PO QD.
    • For chemotherapy, Vemlidy 25 mg/tab # PO QD was given for Hepatitis B carrier (Anti-HBc and HBsAg showed Reactive).
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/06/21 and OPD followed up later.
• 2023-05-23 ~ 2023-05-24 POMR Gastroenterology
  • Discharge diagnosis
    • Pancreatic neuroendocrine tumor with liver metastasis with recurrent at S8, pT3N0M1a, stage IV status post exploratory adhesivelysis and Radiofrequency Ablation on 2023/03/09. ECOG:1; with liver metastasis with recurrent at S7 status post Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) on 2023/05/24
  • CC
    • for feasibility of EUS guided liver tumor ablation WITH ethanol
  • Present illness
    • This 61 year-old male has the history of
      • Hypertension
      • HBV carrier for 30 years,
      • pancreatic neuroendocrine tumor with liver metastasis status post distal partial pancreatectomy on 2011/09/14; s/p S1, S6, S7 segmentectomy and cholecystectomy on 2015/03/26; radiofrequency tumor ablation on 2015/10/16 & 2015/11/27 & 2016/01/22; s/p S8 partial hepatectomy on 2018/05/07; 4th radiofrequency tumor ablation using real-time virtual sonography on 2021/10/29; Pancreatic neuroendocrine tumor with liver metastasis with recurrent at S8, pT3N0M1a, stage IV status post exploratory adhesivelysis and Radiofrequency Ablation on 2023/03/09. ECOG:1
    • The follow up Liver CT (on 2023/04/22) reported S/P pancreatic operation, splenectomy and liver RFA. A small enhancing nodule (1.1cm) in S7 of liver r/o metastases. There was no fever, chills, nausea, vomiting, poor appetite, abdomen pain, bloody or tarry stool passage, tea color urine. he also denied TOCC history. Under the imprssion of Pancreatic neuroendocrine tumor with liver metastasis, he was admitted to GI ward for feasibility of EUS guided liver tumor ablation by ethanol.    
  • Course of inpatient treatment
    • After admission, we gave the preparation of EUS guided liver tumor ablation by ethanol. which was scheduled on 5/24 and reported EUS findings：Using EUS-UCT 260 showed a 21 mm mixed lesion at the seg 7 of  the left lobe of liver, which was closed to origin of the right hepatic vein.Management：CEH-EUS is performed with Sonozoid 0.6 cc injection and after 17 second, vascular hyperenhancement pattern with central hypoenhancement component is noticed. Ethanol injection cannot be performed due to interference by the right hepatic vein, inferior vena cava, and right atrium in the PATH of PUNCTURE ROUTE. Diagnosis：1. Metastatic hepatic tumor s/p CEH-EUS. Well informed above report, under stable condition, he was discahrged on 5/24 and will return to GS OPD later.
• 2023-03-21 SOAP Hemato-Oncology Xia HeXiong
  • P: Intra-OP RFA on 2023-03-09, CT will be done 2023-04-22. If NED -> Apply sunitinib again.
• 2023-03-08 ~ 2023-03-13 POMR General Surgery
  • Discharge diagnosis
    • Pancreatic neuroendocrine tumor with liver metastasis with recurrent at S8, pT3N0M1a, stage IV status post exploratory adhesivelysis and Radiofrequency Ablation on 2023/03/09. ECOG:1
    • Hypertension
    • Reflux esophagitis Los Angeles classification (LA) Classification grade C
    • Hepatitis B carrier
  • CC
    • Scheduled for radiofrequency ablation therapy.     
  • Present illness
    • This 61 year-old male patient has the histories of Hypertension for 10 years, Poliomyelitis for 40+ years, HBV carrier for 30 years, Reflux esophagitis and esophageal ulcer by panendoscopy on 2022/08/30 and pancreatic neuroendocrine tumor with liver metastasis status post distal partial pancreatectomy on 2011/09/14; s/p S1, S6, S7 segmentectomy and cholecystectomy on 2015/03/26; radiofrequency tumor ablation on 2015/10/16 & 2015/11/27 & 2016/01/22; s/p S8 partial hepatectomy on 2018/05/07; 4th radiofrequency tumor ablation using real-time virtual sonography on 2021/10/29. He is regularly followed up in our GI and hematology clinics. His SBP at home is around 120~130 mmHg.
    • This time, he was found at regular OPD followup that abdominal sono on 2022/12/14 showed a 1.5 cm faint tumor near IVC and two 2.3 and 2.8 cm hyperechoic mass at right ant segment. Abdominal CT on 2023/2/11 showed a 1.3cm recurrent tumor in liver dome, no enlarged lymph nodes in para-aortic and pelvic regions. Due to suspected recurrent liver metastasis of pancreatic neuroendocrine tumor, he was scheduled for further evaluation and treatment.     
  • Course of inpatient treatment
    • After admission, Pre-op evaluation was done. Performed exploratory adhesivelysis and radiofrequency ablation therapy (RFA) and repeated hepaectomy moderated adhesion of stomach and T-colon to liver on 112/02/23 due to a 2.7 x 2.5 x 2.5 cm hyperechoic tumor at S8. The postoperative course ran smoothly with intact neurovascular function. Pain control was maintained. The surgery wound mild oozing discharge, and wound education was performed. His condition remained stable, and the patient was discharged on 2023/03/13. OPD follow up will be arranged on 2023/03/21.       
  • Discharge prescription
    • BaiGan (silymarin) 1# TID
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# QID
    • MgO 250mg 1# TID
• 2023-02-14 SOAP Hemato-Oncology Xia HeXiong
  • P
    • May refer back to Chief Wu for the possibility of surgical resection.
    • If RFA and OP is not feasible, may consider TACE.
• 2022-12-20 SOAP Dermatology
  • S: multiple pruritic erytheamtous papule-vesicles on bil pale-soles for months, acute exacerbated.
  • Prescription
    • Topsym cream (fluocinonide) BID EXT
    • Sinpharderm Cream (urea) BID TOPI
    • Xyzal (levocetirine 5mg) 1# QN
• 2022-11-22 SOAP Hemato-Oncology Xia HeXiong
  • P: Refer to GI Chief Wang on 2022-11-29 for the possible recurrence baed on CT report on 2022-11-19.
• 2022-09-27 SOAP Dermatology
  • Prescription
    • Zalain cream (sertaconazole nitrate) BID TOPI
    • doxycycline 100mg 1# BID
    • Asthan (ketotifen 1mg) 1# BID *
• 2022-09-17, -09-06, -08-30, -08-20, -08-13, -08-02 SOAP Dermatology
  • S
    • Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching
      • multiple painful erythematous papule-nodules on face, trunk and 4-limbs.
      • dyskeratotic nails on bil feet and hands for yrs, scaling(+), itching(+), local painful(+)
    • Erythematous patches on trunk and inguinal area for yrs, ringwarm(+)
    • T unguin was Dx and Tx at LMD for yrs
    • poor response to topical drugs
  • A: Buttock cellulitis (suggestive of funal dermatitis) and right foot
  • P: Conservative medications and antibiotics; topical ointment for skin care.
  • Prescription
    • Zalain cream (sertaconazole nitrate) BID TOPI
    • doxycycline 100mg 1# BID
    • Allegra (fexofenadine 60mg) 1# BID
• 2022-08-02 SOAP Infectious Disease
  • S
    • Erythema swelling of buttock for 1-2 months (hot weather); much improvement after topical ointment and oral nemonoxacin x1 week.
    • History: pancreatic neoplasm status post target therapy.
  • O: Topical ointment with Mycomb and Zinc oxide ointment for symptomatic treatment.
  • A: Buttock cellulitis (suggestive of funal dermatitis) and right foot
  • P: Conservative medications and antibiotics; topical ointment for skin care.
  • Prescription
    • Mycomb BID TOPI
    • Zinc Oxide Oint BID TOPI
• 2022-08-02 Hemato-Oncology Xia HeXiong
  • P
    • Due to Gr 1 H-F-S, refer to demratologist
    • Already suggest Hold sutent if deteriorated H-F-S even visiting Dermatologist on 2022-08-02
• 2022-06-29 SOAP Infectious Disease
  • S: Pain over right post plantar, right lateral foot dermatitis. Underlying pancreas cancer
  • O: right lateral foot dermatitis
  • A: no need for antibiotic
  • P: topical Mycomba for skin dermatitis, right foot
  • Prescription
    • Mycomb BID TOPI
• 2022-05-03 SOAP Infectious Disease
  • S: Erythema swelling of buttock for 4 weeks; much improvement after topical ointment and oral nemonoxacin x1 week.
    • History: pancreatic neoplasm status post target therapy.
  • O: Topical ZnO for skin care.
  • A: Buttock cellulitis
  • P: Conservative medications and antibiotics; topical ointment for skin care.
  • Prescription
    • zinc oxide oint BID TOPI
• 2022-05-03 SOAP Hemato-Oncology Xia HeXiong
  • P: Sunitinib 3# QD (270 - 36 - 39 - 63 - 84 = 48)
  • Prescription
    • Sinpharderm Cream (urea) BID TOPI
    • Sutent (sunitinib 12.5mg) 3# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Actein (acetylcysteine 600mg) 1# BID
• 2022-04-27 SOAP Infectious Disease
  • S: Erythema swelling of buttock for 3 weeks
  • A: Buttock cellulitis
  • P: Conservative medications and antibiotics
  • Prescription
    • Taigexyn (nemonoxacin 250mg) 2# QDAC
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
• 2022-04-27 SOAP Hemato-Oncology Xia HeXiong
  • P: Due to suspect hepes vesicle over anal area, hold sutinib for 1 week until 2022-05-04
  • Prescription
    • Sinpharderm Cream (urea) BID TOPI
• 2022-02-24 SOAP Hemato-Oncology Xia HeXiong
  • P: Sunitinib 3# QD (270 - 36 = 234)
  • Prescription
    • Sutent (sunitinib 12.5mg) 3# QD
    • Sinpharderm Cream (urea) BID TOPI
    • Actein (acetylcysteine 600mg) 1# BID
    • Nincort Oral Gel (triamcinolone) BID TOPI
• 2022-02-08 SOAP Hemato-Oncology Xia HeXiong
  • P: Due to the failure of apply Sandostatin. Apply sunitinib
• 2022-01-11 SOAP Radiation Oncology
  • P: RTC 6M. wait for Sandostadin approval due to recurrent liver mets.
• 2021-12-07 SOAP Hemato-Oncology Xia HeXiong
  • P: Apply Sandostadin LAR or everlimus or sunitinib
• 2017-03-14 SOAP General Surgery
  • S
    • Pancreatic NET with single liver mets
      • s/p RFA on 2015 10/16, 11/27
      • CT 1 m F/U showed viable tumor.
      • suggest op due to failed RFA (tumor below the heart)
    • pancreast tail tumor 2011-09
      • path: Pancreas, tail, distal partial pancreatectomy — Well differentiated endocrine tumor, uncertain behavior, with very close peripheral resection margin (<0.1cm).
        • Spleen, splenectomy — Negative for malignancy
        • Lymph node, peripancreatic, dissection — negative for malignancy (0/9)
        • Lymph node, splenic hilar, dissection — negative for malignancy(0/2)
    • arrange admission for op S7 and 6 resection
      • path: Liver, segment 1, 6, and 7, segmentectomy
        • Endocrine carcinoma from pancreas, metastatic
        • Chronic hepatitis B with focal bridging fibrosis and mild portal inflammation
          • Ishak modified HAI grading: necroinflammatory score: 3
          • Ishak modified staging: fibrosis score: 3 (Maximum 6)
          • Corresponding Metavir stage: fibrosis score: 2 (Maximum 4)
        • mild fatty change (10-20%)
  • Diagnosis
    • Secondary liver malignant neoplasm [C78.7]
    • Malignant pancreas neoplasm, part NOS [C25.9]
    • Neoplasm of unspecified nature of digestive system [D49.0]

701300692

230816

[MedRec]

• 2023-08-01 ~ 2023-08-07 POMR Gastroenterology
  • Discharge diagnosis
    • Para-aortic lymphadenopathy susp lymphoma
    • GB wall thickening cause ?
    • Severe persistent asthma with (acute) exacerbation
    • Allergic rhinitis, unspecified
    • Irritable bowel syndrome without diarrhea
    • Gastro-esophageal reflux disease with esophagitis
  • CC
    • Diarrhea 5-6 times /days for 6 months
  • Present illness
    • This is a 44 year old female patient.She had an underlying disease of
      • asthma
      • allergic rhinitis
      • urticaria after covid viccination
    • Patient reported in recent half year, she sufferd from upper abdominal pain, exacerbated by coughing.And diarrhea 5-6 times /days for 6 months,she also reported about fever at night, and losing 10+ kilograms body weight acompanied with night sweating. Patient was regularly followed up chest, gastroenterology OPD at our hospital.
    • At 2023/07/11 US showed diffuse symmetrical edematous wall thickening of the gallbladder, suspect adenomyomatosis.
    • 2023/07/25 CT result shoed GB adenomyomamatosus and suspect lymphoma.Hepatomegaly and splenomegaly was noted.
    • She also complain about discomfortable after receiving the fourth dose of covid vaccine on 2023/01/13 and urticaria after covid viccination last year.
    • The LAB DATA showed higher total bilirubin 2.89mg/dL.
    • 2023/07/12 CT abdominal showed diffuse symmetrical edematous wall thickening of the gallbladder.
    • Under the impression of gallblader wall thinckening and enlargement of lymphnode, highly suspect adenomyomatosis and lymphoma, the patient was admitted to our ward for further evaluation and management.
  • Course of inpatient treatment
    • After admission, we have arranged EUS for her which was revealed as
      • Hepatic hilum tumor, s/p CH-EUS & EUS/FNB (A)
      • Gallbladder wall thickening, s/p CH-EUS & EUS/FNB (B).
    • We have consulted GS for surgical evaluation and reply as waiting pathology report.
    • PET scan was arranged on 08/07. Under the stable condition, she was arranged discharge and OPD follow up.
• 2023-03-08 SOAP Chest Medicine
  • S
    • post COVID
    • cough intermittent, without scanty sputum, sorethroat(-), chest tightness for weeks, dyspnea, rhinorrhea(-), nasal congestion(-), post nasal dripping(-), acid regurgitation, DOE(+), exercise limitation(+)
    • Past history: Allergic rhinitis, asthma
    • Family history of asthma
    • Smoking(-)
    • Allergic history(-)
    • Traveling history(-)
  • O
    • Throat: hyperemia
    • Tonsil: enlargement
    • Neck LAP:(-)
    • Breathing sound:course, wheezing(+), crackle(-)
    • HS: RHB
    • Abdomen: soft and flat
    • Pitting edema(-)
  • Prescription
    • Symbicort Rapihaler (budesonide, formoterol) 2# BID
    • Ulstrop (famotidine 20mg) 1# BID
    • Xyzal (levocetirizine 5mg) 1# HS
    • Actein (acetylcysteine 600mg) 1# BID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Cough Mixture (platycodon) 10mL HS
    • Acetal (acetaminophen 500mg) 1# TID
• 2022-04-25 SOAP Rheumatology
  • S: 220425 impproved mild, mild elevated Eos, headache at night
  • Prescription
    • Allegra (fexofenadine 60mg) 1# TID
• 2022-04-18 SOAP Rheumatology
  • S: 2022 0418 facial swelling, lip swelling off and on for half an yr, urticaria rash over turnk for 1 month
  • Prescription
    • Allegra (fexofenadine 60mg) 1# TID

701483618

230816

[MedRec]

• 2023-07-18 ~ 2023-07-24 POMR Hemato-Oncology
  • Discharge diagnosis
    • Chronic viral hepatitis B without delta-agent
    • Rectal cancer, 4-cm from anal verge with right levator ani muscle invasion, cT4bN0M0, stage IIC.
    • Chronic viral hepatitis B without delta-agent
  • CC
    • for C1D1 chemoradiotherapy with FOLFOX
  • Present illness
    • This 48-year-old woman, a patinet of rectal cancer cT4bN0M0 stage IIC was diagnosed in July by Dr Xiao GuangHong, suffered from bowel habit change and tenesmus and bloody stool for 2-3 years ago and hemorrhoid during pregnancy was also noted. She visited to our CRS OPD for further evaluation and survey.
    • Image study with abdominal CT (2023/07/02) showed rectal cancer is highly suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for rectal cancer: T4b N0 M0, stage: IIC . Colonfiberscopy (2023/07/08) showed rectal cancer s/p biopsy and pathology of Large intestine, rectum, from anal canal to 4 cm from anal verge, biopsy (2023/07/04) proved adenocarcinoma, moderately differentiated
    • Immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • The tumor marker showed CA-199 = 23.687; CEA = 3.627 and HBsAg(NM) = Positive on 2023/06/30.
    • Radiotherapy of 5040cGy/28 fx started since 2023/7/17 for rectal tumor.
    • Today, she was admitted for CCRT followed by C/T with FOLFOX (C1D1) on 2023/07/18.
  • Course of inpatient treatment
    • After admission, radiotherapy started since 2023-07-17 and chemoradiotherapy with 5FU (400mg/m2) plus Leucovorin (20mg/m2) was given on 7/19-7/21 & 7/24 23, smoothly without obvious side effect. She was discharged on 7/24 23 under stable condition and will follow-up at OPD.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2023-07-11 SOAP Hemato-Oncology
  • O
    • Now on CCRT followed by C/T with FOLFOX, CCRT C1D1 on 2023-07-18 or 19
  • P
    • Prescribe anti-HBV medication before CCRT
• 2023-07-11 SOAP Radiation Oncology
  • O
    • Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-07-11
      • CCRT (TNT) then evaluation the of sphincter preserving surgery or APR.
  • A/P
    • IMP: Rectal cancer, 4-cm from anal verge with right levator ani muscle invasion, cT4bN0M0, stage IIC.
    • Plan: Suggest pre-op CCRT (Favor TNT) then evaluation the possibility of sphincter preserving surgery or APR.
      • RT plan: 5040cGy/28 fx.
      • CT simulation on 7/11; possible treatment toxicity is told; diet education is given.
• 2023-07-08 SOAP Colorectal Surgery
  • S
    • Newly diagnosed rectal cancer - cT4bN0M0 stage IIC
  • A/P
    • Suggest pre-op CCRT (Favor TNT) then evaluation the possibility of sphincter preserving surgery or APR
• 2023-06-29 SOAP Colorectal Surgery
  • S
    • Newly diagnosed rectal cancer
    • Bowel habit change and tenesmus
    • Hemorrhoid during pregnancy
    • Mucoid bloody stool noted
    • F.H: Denied
  • O
    • One mass was noted in the rectum (from anal canal up to 4 cm from anal verge, right posterior lateral)
    • Management: Biopsy

[radiotherapy]

[chemotherapy]

700204091

230815

[exam findings]

• 2023-06-15 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 15 dB HL, LE 21 dB HL
  • Bil WNL
• 2023-05-18 Patho - uterus with or without SO non-neoplastic/prolapse
  • PATHOLOGIC DIAGNOSIS
    • Ovarian tumor, right, frozen (F2023-00229) — Endometrioid carcinoma and endometrioma
      • Fallopain tube, right, ditto — Free of tumor invasion
    • Ovarian cyst, left, debulking surgery — Endometrioma and free of tumor invasion
      • Fallopain tube, left, ditto — Free of tumor invasion
    • Cervix, uterus, debulking surgery — Free of tumor invasion
      • Endometrium, uterus — Free of tumor invasion, proliferative phase
      • Myometrium, uterus — Free of tumor invasion, leiomyomas and adenomyosis
    • Uterosacral area mass, ditto — Endometrioid carcinoma
    • R’t peri-ureter tissue, ditto — Endometrioid carcinoma and endometriosis
    • R’t suspensory (IP), ditto — Free of tumor invasion
    • Omentum, omentectomy — Free of tumor invasion
    • Lymph nodes
      • Lymph node, left iliac, dissection — Free of tumor metastasis (0/5)
      • Lymph node, left obturator, dissection — Free of tumor metastasis (0/10)
      • Lymph node, right iliac, dissection — Free of tumor metastasis (0/11)
      • Lymph node, right obturator, dissection — Free of tumor metastasis (0/25)
      • Lymph node, left paraaortic, dissection — Free of tumor metastasis (0/12)
      • Llymph node, right paraaortic, dissection — Free of tumor metastasis (0/6)
    • Bilateral prametria — Free of tumor invasion
    • AJCC Pathologic staging — pT2bN0, if cM0, stage IIB / FIGO stage IIB
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: frozen sections and debulking surgery
    • Specimen type: uterus and left adnexa, pelvic and paraaortic LNs and omentum
    • Specimen size:
      • Right opened ovarian tumor (frozen): 5.2 x 4.8 cm with blood clot and one papillary tumor 1.2 x 0.7 cm
      • Right fallopian tube: 4.5 cm in length, 0.6 cm in diameter
      • Left ovarian cyst: 3.7 x 2.7 cm
      • Left fallopian tube: 3.7 cm in length, 0.7 cm in diameter
      • Uterus: 11 x 7 x 5 cm in size and 415 gm in weight, multiple myomas, up to 5.8 x 5.3 x 4.4 cm
      • Omentum: 31 x 9 x 0.5 cm
    • Uterosacral area mass: three pieces, up to 1.3 x 0.6 x 0.4 cm
    • R’t peri-ureter tissue: one piece, 3.7 x 2.6 x 2.1 cm
    • R’t suspensory (IP): one piece, 2.8 x 1.8 x 1.3 cm
    • Tumor site: R’t ovary, uterosacral area mass and R’t peri-ureter tissue
    • Tumor appearance: cystic tumor with papillary tumor at R’t ovary
    • Specimen integrity: opened ovarian tumor
    • Lymph node: pelvic and paraaortic LNs
    • Representative sections as A: left iliac LNs, B: left obturator LNs, C: right iliac LNs, D1-D3: right obturator LNs, E: L’t paraaortic LNs, F: R’t paraaortic LNs, G1-G3: uterine corpus, G4-G5: low segment of corpus + cervix, G6-G7: corpus, G8-G9: cervix, G10: endometrium, G11: myoma, G12-G14: adenomyosis, G15-G16: bilateral parametrium, H: right suspensory (IP), I: uterosacral area mass, J: omentum, K: right peri-ureter tissue [Reference: frozen section, F2023-00229 FSA1: R’t ovarian papillary nodule, FSA2: R’t ovarian cyst, A1-A2: R’t ovarian cyst and A3: R’t fallopian tube, B1: L’t fallopian tube, B2-B3: L’t ovarian cyst]
  • MICROSCOPIC EXAMINATION
    • Histologic type: Endometrioid carcinoma, endometrioma and endometriosis
      
    • Histologic grade: Grade 1
    • Contralateral ovary involvement: Absent
    • Tumor side ovarian surface involvement: Absent
    • Contralateral ovary surface involvement: Absent
    • Right tube involvement: Absent
    • Left tube involvement: Absent
    • In situ adenocarcinoma in right ＆/or left fallopian tube: Absent
    • Right adnexa soft tissue involvement: Absent
    • Left adnexa soft tissue involvement: Absent
    • Pelvic soft tissue involvement: Present
    • Uterine serosa involvement: Absent
    • Omentum involvement: Absent
    • Uterine Cervix involvement: Absent, chronic cervicitis with Nabothian cysts
    • Endometrium involvement: Absent
    • Myometrium involvement: Absent, leiomyomas and adenomyosis
    • Appendix involvement: Not received
    • Lymph nodes metastasis: Free of tumor metastasis (0/69) in total number
    • Uterosacral area mass: endometrioid carcinoma
    • R’t peri-ureter tissue: endometrioid carcinoma and endometriosis
    • Immunohistochemistry (F2023-00229 FSA1): PAX-8 (+), vimentin (+), ER (+), WT-1 (-) and P53 (wild type)
    • Ascites cytology: Negative
• 2023-05-17 Frozen Section
  • Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma
• 2023-04-25 Patho - colon biopsy
  • Colorectum, splenic flexure, s/p biopsy removal — Hyperplastic polyp
• 2023-04-25 Patho - stomach biopsy
  • Stomach, AW side of antrum, biopsy — Ulcer, H pylori present
  • Stomach, LC side of prepyloric antrum, biopsy — Ulcer, H pylori NOT present
• 2023-04-24 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A-
  • Gastric ulcers, antrum, s/p biopsy at antrum (AW) and prepyloric antrum (LC)
• 2023-04-24 Colonoscopy
  • Colon polyp, splenic flexure, s/p biopsy removal
  • Diverticulosis, descending colon
  • Internal hemorrhoid
• 2023-04-19 CT - abdomen
  • Findings:
    • There is a homogeneous enhancing mass 6.4 cm in the uterus that is c/w myoma.
    • There is cystic lesion in bilateral adnexa with mild wall thickening but no mural nodule and septum.
      • Cystic adenocarcinoma of the ovary is highly suspected.
      • In addition, there are few small soft tissue nodules in right L3 peri-ureter area that may be tumor seeding (T2b)?
      • The right and left adnexal cystic lesion are measured 6.4 cm and 3.6 cm, respectively. Please correlate with GYN. sonography and CA125.
    • Two renal cyst 4 cm and 1.5 cm in left upper pole is noted.
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:T2b(T_value) N:N0(N_value) M:M0(M_value) STAGE:IIB(Stage_value)
• 2023-04-14 Gynecologic ultrasonography
  • R/O Rt Ovarian mass: 68x49mm (papillary: 16x14mm, no blood flow)
  • Adenomyosis
  • Uterine myoma

[MedRec]

• 2023-06-01 SOAP Hemato-Oncology
  • O

    • Cancer Multidisciplinary Team Meeting Conclusion, Date: 20230525

      Treatment Plan:
      • Postoperative adjuvant chemotherapy (referral to Dr. Xia HeXiong)
      • Provide Ovarian Cancer Treatment Shared Decision-Making (SDM) form and explanation of the condition (including genetic testing and targeted therapy).
  • P
    • Arrange admission for 24hr CCr, audiomtery and C/T with TP
• 2023-05-16 ~ 2023-05-25 POMR Obstetrics and Gynecology
  • Discharge diagnosis
    • Malignant neoplasm of right ovary
    • Leiomyoma of uterus, unspecified
    • Female pelvic peritoneal adhesions (postinfective)
    • Debulking surgery on 20230517
  • CC
    • Irregular menstrual cycles with short intervals.
  • Present illness
    • This is a 47 year old famle, G3P2AA1 (NSD x2, with no severe complications), LMP was 20230416. She had hypertension (under medicine control) and kindey cyst (suggested regular follow up), no surgery history, no known allergens.
    • ACCORDING TO THE PATIENT, SHE HAD IRREGULAR MENSTRUAL CYCLES WITH SHORT INTERVALS SINCE APRIL 2023 (03/27, 04/04 are previous cycles, mild menstrual pain). THEREFORE, SHE WENT TO OB/GYN CLINICS FOR HELP. She was informed elevated CA125 and CA199, then she was introduced to Dr. Huang. AT DR. HUANG OPD, TRANSVAGINAL SONOGRAPHY SHOWED Myoma 6051 / 3020 mm IN SIZE, ROV mass 68*49 mm (papillary:16x14mm,no blood flow).
    • CT was performed on 04/19, the findings are as followed: 1. Uterine myoma 6.4 cm. 2. Cystic lesions in bilateral adnexa.
    • UNDER THE IMPRESSION OF UTERINE MYOMA AND OVARAIN TUMOR, MALIGNANCY CANNOT BE RULE OUT, After the evaluation, the paitent was arranged with LSC myomectomy + BSO on 20230517, she was admitted to our ward day before for the pre-operation preparation.
  • Course of inpatient treatment
    • The patient was admitted on 20230516 due to ovarian tumor. The frozen section initial diagnosis:Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma. She underwent Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy on 20230517. The AJCC Pathologic staging — pT2bN0, if cM0, stage IIB / FIGO stage IIB. The GYN tumor board conference suggest the patient to receive chemotherapy on 20230525. Her postoperative course was uneventful. Self voiding was smooth. She was discharged on 20230525. Her follow up appointment is scheduled on 20230601. Keep intraperitoneal Port for chemotheraphy.      
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • Actein (acetylcysteine 200mg) 1# TID
    • cephalexin 500mg 1# QID
    • MgO 250mg 1# TID

[consultation]

• 2023-07-04 Urology
  • Q
    • for USK evaluation
    • This 47-year-old woman, a patient of Right ovarian endometrioid carcinoma, pT2bN0cM0, FIGO stage IIB s/p Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy), bilateral DBJ insertion and Tenckhoff tube insertion on 2023/05/17 . DBJ was removed on 20230605. We need expertise to evaluate her condition thanks!
  • A
    • we will arrnage USK to evaluate Tx effect after DBJ insertion
• 2023-05-18 Urology
  • Q
    • For on D-J catheterization.
    • This 47-year-old female with ovarin cancer was admitted for Debulking surgery at 20230517.
    • We need your evaluation of her condition for on D-J catheterization.
  • A
    • intrapoerative finding showed tumor attached to right low ureter
    • Bilateral DBJ was inserted
    • tumor was dissected from right low ureter
    • For better healing and stablization after operation, DBJ may be kept for one month til 2023/06/05
    • I had explained to her on 2023/05/18 09:30

[surgical operation]

• 2023-05-17
  • Surgery
    • Operation: Tenckhoff tube insertion
  • Finding
    • Tenckhoff tube over RLQ
  • Procedure
    • Under ETGA, GYN and GU performed operation at first. GS was consulted. Inserted a Tenckhoff tube with exit site over RLQ. Closed the wound with 1# Vicryl and skin staples.
• 2023-05-17
  • Surgery
    • DBJ insertion, bilateral        
  • Finding
    • A 6 Fr 24 cm double-J catheter was inserted to left ureter.
    • A 6 Fr 24 cm double-J catheter was inserted to right ureter.
    • Bladder mucosa seems fair
    • no urin eleakage
    • Pelvic tumor is found medial to low ureter. After dissection, pelvic tumor is dissected from right low ureter as much as possible.
  • Procedure
    • With ETGA, the patient was in lithotomy position. Disinfection and draping the operation field were done as usual methods. Cystoscopy was performed to identify the ureteral orifices. After retrograde insertion of guidewire. A 6 Fr 24 cm double-J catheter was inserted to left ureter. A 6 Fr 24 cm double-J catheter was inserted to right ureter. A 14Fr Foley was inserted. Through open wound by gyn doctor, a firm pelvic tumor is found medial to right low ureter. After fine and blunt dissection, pelvic tumor is dissected from right low ureter as much as possible. The patient stood the procedures well. 
• 2023-05-17
  • Surgery
    • Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma
  • Procedure
    • Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy + )
  • Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: AVFL, with multiple uterine myomas(intramural type, 6x5 / 3x2cm)
      • Some papillary tissue over right uteroscaral ligament, medial to ritght ureter, s/p excision
    • Adnexa:
      • Severe adhesion between bilateral adnexa and posterior uterien wall + cul-de-sac, s/p adhesiolysis
      • LOV cystic mass, 5x4 cm, intraoperative rupture with chocolate-like contents
      • ROV cystic mass, 7x5 cm, intraoperative rupture with papillary tissue and -chocolate-like contents
      • Some papillary lesions was noted over right suspensory ligament and right pelvic lateral wall, s/p excision
    • CDS: severe adhesion
    • Ascites: little, s/p washing cytology
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
    • Omentum: diffuse chocolate spots was noted, suspect related to previous rupture of chocolate cyst; infracolic omentectomy was done.
    • Liver: grossly normal & smooth; Subdiaphragmatic surface: miliary tumor seeding(-)
    • Appendix: grossly normal
    • Previous rupture of chocolate was highly suspected, with diffused chocolate spots over the pelvic wall and and bowel adhesion were noted.
    • After the operation, optimal debulking surgery was achieved; Residual tumor: R0
    • Estimated blood loss: 400ml
    • Blood transfusion: LPRBC 2u
    • Complication: nil
    • 15Fr-Jvac x2 at bilateral Cul-de-sac
    • Antiadhesion agent: interceed x 1 piece

[immunochemotherapy]

• 2023-08-15 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-24 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-03 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-14 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr (adjuvant Avastin 15mg/kg IVD Q3W x 6 + 12~15 for 15mo)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-08-15

The patient received a 28-day refill of rabeprazole on 2023-08-10. While the active medication list does not show any current use of PPIs, Stogamet (cimetidine) is being used. Therefore, there are no medication reconciliation concerns.

2023-07-25

There are no medication reconciliation issues identified after reviewing the PharmaCloud database and HIS5 records.

2023-07-04

• After reviewing the PharmaCloud database, there is no prior prescription that is still valid now from other healthcare providers or other departments in this hospital.
• However, there is no records of Norvasc refilled in the past few weeks, and this drug should be a prescription medicine which can only be ordered by a doc, and this drug has been included as a patient-carried item in the active medication list, please check if the self-carried Norvasc does not pass its expired date.

701186682

230815

[exam findings]

• 2023-07-21 SONO - abdomen
  • Propable liver calcification, right
  • S/p cholecystectomy
  • Suspected fatty infiltration of pancreas
  • Small amount ascites
  • C/w ESRD
• 2023-06-21 Joint soft tissue sonography
  • Finding: Ill-defined anechoic effusion with posterior enhancement and mild compressible just below the OP wound of the axilla site.
  • Impression And Suggestions: Right axilla post-OP wound effusion or serosanguineous mass accumulation.
• 2023-05-31 Tc-99m MDP bone scan
  • A hot spot at a mid-T spine and increased activity at L2-4 spines, the nature is to be determined (post-traumatic reaction, early bone mets or other nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
  • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, elbows, S-I joints, knees, and feet.
• 2023-05-31 Patho - breast mastectomy with regional lymph nodes
  • PATHOLOGIC DIAGNOSIS
    • Breast, right, partial mastectomy — Invasive carcinoma of no special type
    • Resection margin, breast, right, partial mastectomy — Free
    • Lymph nodes, sentinel and non sentinel, right axilla, lymphadenecomy — Negative for malignancy (0/8)
    • AJCC 8 th edition, Pathology stage: pT1cN0(cM0); Anatomic stage IA; Prognostic stage IA
  • MACROSCOPIC EXAMINATION
    • Breast Size: 10.5 x 6.0 x 3.5 cm
    • Skin Size: 5.0 x 1.0 cm
    • Nipple: Not included
    • Tumor Size: 1.8 x 1.4 x 1.2 cm
      
    • Resection Margin: Free, 2.4 cm from the deep margin
    • Lymph node: Sentinel (SLN1 and SLN2), and non-sentinel
    • Representative parts are taken for sections and labeled; A1= 12’ and 6’ margins, A2= 3’ and 9’ margins, A3-A4= skin + tumor, A5= tumor + base margin, B=SLN1, C= SLN2, D= non SLN.
  • MICROSCOPIC EXAMINATION
    • Histo
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 1.8 x 1.4 x 1.2 cm
        
      • Histologic grade (Nottingham histologic score): Grade 2 (score= 6)
      • Skin involvement: Absent
      • Ductal carcinoma in situ: Present with intermediate nuclear grade; Extensive DCIS: Negative
    • Margins: Negative; Closest margin: ＞10 mm from closest lateral margins and 24 mm from deep margin
    • Nodal status: Negative (0/8)
      • number of lymph node examined: 3 (SLN1), 2 (SLN2), 3 (non SLN)
      • number with macrometastases (> 2mm): 0
      • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
      • number with isolated tumor cells (<= 0.2mm and <= 200 cells): 0
    • Treatment Effect: No presurgical neoadjuvant therapy received
    • Lymphovascular invasion: Presnt
    • Perineural invasion: Absent
  • IMMUNOHISTOCHEMICAL STUDY (S2023-09128)
    • ER (Ab): Positive (weak, 10%)
    • PR (Ab): Negative
    • HER-2/Neu (Ab): Negative (score= 1+)
    • Ki-67: 20%
• 2023-05-30 Lymphoscintigraphy
  • Probably a sentinel lymph node at the right axillary region.
• 2023-05-11 Patho 0 breast biopsy (no need margin)
  • Breast, right ( 2 / 3.5), core needle biopsy— Invasive carcinoma of no special type
  • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
  • Immunohistochemical study:
    • ER (Ab): Positive (weak, 10%)
    • PR (Ab): Negative
    • Her-2/neu (Ab): Negative (1+)
    • Ki-67 index: 20%
    • CK5/6: Negative
    • p63: Negative
• 2023-05-08 Mammography (magnification)
  • BI-RADS category 4C, High suspicion for malignancy. Tissue diagnosis is suggested.
• 2023-04-21 Cardiac Catheterization
  • Past Medical History
    • The patient has a history of DM for years with OHA control, HCVD with antiHTN and ESRD with PD since 2022-09.
  • Indication
    • The patient was referred with Refrcatory angina and Th-201 scan (++). The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
  • Approach
    • Percutaneous access was performed through the right radial artery
      
  • Catheters
    • Left coronary angiography was performed using 6Fr JL3.5 catheter and Right coronary angiography was performed using 6Fr JR4 catheter.
  • Procedure
    • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 cc. The patient was treated with Heparin and NTG.
  • Finding Summary
    • Syntax Score = 2
    • Left Main : patent
    • Left Anterior Descending : heavy calcification at P- to M-LAD with mild atherosclerosis at P-LAD
    • Left Circumflex : patent
    • Right Coronary : about 50 % eccentric stenosis at M-RCA
  • In conclusion : CAD, SVD-RCA
  • Recommendation : Medical treatment
• 2023-02-16 Myocardial perfusion SPECT with persantin
  • Probably mild to moderate myocardial ischemia at the apical anterolateral wall and posterior wall and mild myocardial ischemia at the septum and mid anterior wall.
• 2023-02-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (119 - 29.3) / 119 = 75.38%
    • M-mode (Teichholz) = 75.4
  • Conclusion:
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Calcified mitral annulus with mild MR, mild TR and PR
    • AV sclerosis with mild AR
    • No regional wall motion abnormalities

[MedRec]

• 2023-07-27 SOAP Gastroenterology
  • Prescription x3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
• 2023-07-20 ~ 2023-07-21 POMR General and Gastroenterological Surgery
  • Discharge diagnosis
    • Right breast invasive carcinoma, pT1cN0M0 stage IA. ER : Positive (weak, 10%), PR: Negative, Her-2/neu : Negative (1+), Ki-67 index: 20%. ECOG:0.
    • End stage renal disease
    • Type 2 diabetes mellitus
    • Papillary thyroid carcinoma status post left thyroidectomy, pT1aNx pStage I status post radical lateral neck lymph node dissection and right thyroidectomy and re-implant of parathyroid gland on 2020/04/28
    • Hypo-osmolality and hyponatremia
    • Abnormal results of liver function studies
    • Anemia in chronic kidney disease
    • Hypoalbuminemia
    • Hyperbilirubinemia
  • CC
    • for 2nd adjuvant chemotherapy
  • Present illness
    • This 55-year-old post menopausal woman has
      • Hypertension
      • Type 2 Diabetes Mellitus
      • Chronic kidney disease stage 5 status post implantation of continuous ambulatory peritoneal dialysis catheter on 2022/08/01
      • Uterine myoma status post
      • Bilateral thyroid papillary carcinoma, pT1aN0M0, stage I
      • Coronary artery disease with medicine control
      • Gallbladder stones status post.
    • She denied any TOCC histories in recent 3 months.
    • She was diagnosed with right breast cancer then underwent of right partial mastectomy and sentinel lymph node biopsy on 2023/05/30. The finally pathlogy revealed invasive carcinoma, pT1N0M0 stage IA. IHC revealed ER (Ab): Positive, PR (Ab): Negative, HER-2/Neu (Ab): Negative, Ki-67: 20%. Tc-99m MDP whole body bone scan showed no obvious lesion for metastasis.
    • Under the impression of right breast cancer, pT1cN0M0 stage IA, she was admitted to our ward for 2nd adjuvant chemotherapy.
  • Course of inpatient treatment
    • After admission, 5-Fu 1047mg in Saline 100ml, Lipodox 55mg in Saline 250ml and Endoxan 800mg in saline 500ml were administered. There was no special complaint. Under the stable condition, she was discharged today and will be arranged next course adjuvent chemotherapy 3 weeks later.
  • Discharge prescription
    • Emend (aprepitant 125mg) 1# QD
    • Limeson (dexamethasone 4mg) 1# BID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • Through (sennoside 12mg) 2# PRNHS
    • Sinpharderm Cream (urea) BID TOPI
• 2023-07-20 SOAP Cardiology
  • Prescription x3
    • Cardiolol (propranolol 10mg) 1# BID
    • Nirandil (nicorandil 5mg) 1# BID
    • Bokey (aspirin 100mg) 1# QD
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID

[consultation]

• 2023-05-31 Nephrology
  • Q
    • This is a 55 years old female patient. She was under PD in our hospital. This time, she was admitted for surgery of partial mastectomy + SLNB on 2023/05/30. We need your consult for combine care. Thank you so much!!
  • A
    • We will arrange PD for the patient during the course of hospitalization.
    • If you need to remove more or less water, please feel free to contact us.
• 2022-08-16 Urology
  • Q
    • For Tenckhoff catheter insertion.
    • This 54-year-old woman has history hypertenion under medical control for 20 years, diabetes mellitus under medical control for 20 years, chronic kidney disease, stage V, thyroid papillary carcinoma s/p left thyroidectomy and parathyroid hyerplasia s/p parathyroidecotomy of left side.
    • Due to progression renal function failure was noted (01/20, Cr: 4.68 mg/dl => 03/17, Cr: 7.32 mg/dl => 6/07, Cr:9.24 mg/dl => 7/05, Cr:9.71 => 8/16, Cr:14.66mg/dl ). Prepare Tenckhoff catheter insertion was suggested for prepare Peritoneal dialysis. After well explained his condition to the patient and his family, she was admitted for further management.
  • A
    • We will arrange PD tube insertion tomorrow, thank you!

[chemotherapy]

• 2023-08-11 - fluorouracil 600mg/m2 1047mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-07-20 - fluorouracil 600mg/m2 1047mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-06-27 - fluorouracil 600mg/m2 1070mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-08-15

[anemia]

• Recent HGB lab results
  • 2023-08-11 HGB 6.2 g/dL
    
  • 2023-07-31 HGB 5.8 g/dL
    
  • 2023-07-20 HGB 6.8 g/dL
    
  • 2023-07-04 HGB 7.2 g/dL
    
  • 2023-06-26 HGB 8.1 g/dL
• In the table above, the patient received FAC(lipo) on both 2023-07-20 and 2023-08-11. In addition, a blood transfusion was performed on 2023-08-11 (a previous transfusion was performed on 2023-05-30). Following the transfusion, the patient’s HGB (hemoglobin) level is expected to have increased.

[restaging]

On 2023-05-31, a bone scan indicated the need for further monitoring of an active spot in the mid-T spine and heightened activity in the L2-4 spines to ascertain potential bone metastasis. Furthermore, an abdominal sonography on 2023-07-21 showed a slight presence of ascites. If the disease is ultimately confirmed to have metastasized, restaging may be necessary.

2023-07-24

[anemia]

• Recent HGB lab results

  • 2023-07-20 HGB 6.8 g/dL
    
  • 2023-07-04 HGB 7.2 g/dL
    
  • 2023-06-26 HGB 8.1 g/dL
    
  • 2023-06-20 HGB 8.0 g/dL
    
  • 2023-06-01 HGB 8.6 g/dL

• This patient received two cycles of FAC (5FU + LipoDox + Endoxan) on 2023-06-27 and 2023-07-20. Prior to treatment, the hemoglobin (HGB) level remained above 8 g/dL, but after the first cycle, the level decreased to 7.2 g/dL and further decreased to 6.8 g/dL on the day of the second cycle administration.

• Pegylated liposomal doxorubicin is known to be associated with anemia (grade 3: 5%, grade 4: <1%), and anemia is also common in patients receiving cyclophosphamide and/or fluorouracil.

• As the patient has end-stage renal disease (ESRD) with impaired hematopoietic function, appropriate administration of epoetin alfa is required in addition to iron supplementation. In emergency situations or as needed, blood transfusion should still be considered to maintain hemoglobin levels.

700033032

230814

[lab data]

2023-05-19 Anti-HBs 1.62 mIU/mL
2023-05-19 Anti-HCV Nonreactive
2023-05-19 Anti-HCV Value 0.12 S/CO
2023-05-19 HBsAg Reactive
2023-05-19 HBsAg (Value) 3220.93 S/CO
2023-05-19 Anti-HBc Reactive
2023-05-19 Anti-HBc-Value 8.80 S/CO

[exam findings]

• 2023-05-18 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 48 dB HL; LE 41 dB HL.
  • RE mild to severe SNHL.
  • LE mild to severe SNHL.
• 2023-05-17 Tc-99m bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in bilateral clavicles, left scapula, some C-, T- and L-spine, and bilateral femoral shaft, M/3, in whole body bone survey.
  • IMPRESSION: Cancer with multiple bone metastases should be considered. Please correlate with the findings of PET scan.
• 2023-05-16 MRI - brain
  • Indication: esophageal cancer survey
  • MRI of the brain in multiplanar projections, multisequences imaging acquisition without and with IV Gd-DTPA administration shows:
    • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
  • Imp:
    • No brain nodule or metastasis. Mild cortical brain atrophy.
• 2023-05-15 Patho - esophageal biopsy
  • Esophagus, middle, biopsy— severe squamous dysplasia
  • Microscopically, it shows pieces of esophageal mucosal tissues with severe dysplasia of the squamous cellls.
• 2023-05-15 PET scan
  • Glucose hypermetabolic lesions in the lower third of esophagus, compatible with the primary esophageal cancer.
    
  • Glucose hypermetabolism in bilateral mediastinal and bilateral pulmonary hilar lymph nodes, highly suspected cancer with regional and distant lymph nodes metastases.
    
  • Increased FDG uptake in the left upper and lower lungs, in the right lower lung, and in skeleton including bilateral clavicles, scapulae, several C-, T- and L-spine, sacrum, and femurs, highly suspected cancer with lung and bone metastases.
    
  • Lower third of esophageal cancer, cTxN2-3M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-05-15 SONO - abdomen
  • Findings
    • Liver
      • Heterogeneous echotexture. Smooth surface. Blunt liver edge.
      • Some cysts in bilateral lobes of liver, up to 1.08 cm
      • A 0.31 cm hyperechoic lesion with PAS in S7
    • Kidney
      • Cysts in both kidneys: 0.8 cm in RK, 0.59 cm in LK
    • Pancreas
      • Some parts of pancreas blocked by bowel gas, especially
  • Diagnosis
    • Parenchymal liver disease
    • Hepatic cysts
    • Hepatic calcified spot, S7
    • Renal cysts
    • Suspected pancreatic cystic lesion, body
• 2023-05-15 Miniprobe Endoscopic Ultrasound
  • c/w, advanced esophageal cancer, lower esophagus, estimated stage, T3NxMx, with esophageal stenosis
  • Esophageal Lugol voiding area, 30cm below the incisor, s/p biopsy
• 2023-05-10 CT - chest
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-05-09 Patho - esophageal biopsy
  • Diagnosis
    • Esophagus, 35-40 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
    • Esophagus, 33 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
    • Esophagus, 24 cm below incisor, biopsy — Hyperplastic polyp
• 2023-05-06 ECG
  • Sinus tachycardia
  • Low voltage QRS of limb leads
  • Borderline ECG

[MedRec]

• 2023-07-10 SOAP Radiation Oncology
  • A/P
    • RT dose: 5040cGy/28 fractions (6 MV photon) to L/3 tumor & LAPs, 2023/5/26 to 7/05.
    • Cisplatin/5FU: 5/22, 5/29, 6/06, 6/13, 6/27, 7/05.
    • RT Side effect evaluation, 7/10: Radiation dermatitis, grade 0; N/V, grade 1; esophagitis, grade 1; pneumonitis, grade 0.
    • Diagnosis: Esophageal cancer, L/3, squamous cell carcinoma, 33-40cm from incisor, with lumen obstruction (liquid diet now), cT3N0M1, with lung & bone metastasis; hypopharyngeal lesion; ECOG =1
    • s/p CCRT since 2023/5/26 to 7/05.
    • Plan: Diet education is given. BW monitoring. Psychological support. RTC 8/15. Watchout infection sign.
• 2023-06-26 SOAP Radiation Oncology
  • Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-05-23
    • cT3N2M1, stage IVB => CCRT

[consultation]

• 2023-05-11 Thoracic surgery
  • Q
    • This is a 67 year old male with chief complaint of poor appetite, dysphagia. Due to above reason, the patient was admitted to our GI ward for further evaluation and management.
    • Panendoscopy on 2023/05/09 showed a lesion over hypopharynx, three lesions s/p biopsy over esophagus. Pathology of esophageal lesions revealed both specimen A (35-40 cm below incisor) and specimen B (33 cm below incisor) squamous cell carcinoma, moderately differentiated, and specimen C (24 cm below incisor) hyperplastic polyp. Chest CT on 2023/05/10 revealed L/3 esophageal cancer T3N0M0.
    • Now, we need your expertise for surgical intervention survey.
  • A
    • I will take over this case. Thanks for your consultation!!
• 2023-05-11 Radiation Oncology
  • Q
    • This is a 67 year old male with chief complaint of poor appetite, dysphagia. Due to above reason, the patient was admitted to our GI ward for further evaluation and management.
    • Panendoscopy on 2023/05/09 showed a lesion over hypopharynx, three lesions s/p biopsy over esophagus. Pathology of esophageal lesions revealed both specimen A (35-40 cm below incisor) and specimen B (33 cm below incisor) squamous cell carcinoma, moderately differentiated, and specimen C (24 cm below incisor) hyperplastic polyp. Chest CT on 2023/05/10 revealed L/3 esophageal cancer T3N0M0.
    • Now, we need your expertise for CCRT survey.
  • A
    • Diagnosis: Esophageal cancer, L/3, squamous cell carcinoma, 33-40cm from incisor, with lumen obstruction (liquid diet now), cT3N0M0, (bone scan is pending); hypopharyngeal lesion; ECOG =1
    • Plan: Biopsy of hypopharyngeal lesion is suggested to R/O double primary cancer. Jejunostomy and Port A implantation is suggested for nutritional support and further chemotherapy. If only esophageal cancer is proved, pre-operative CCRT to esophageal tumor for 5040cGy/28 fx is suggested for tumor control. Possible radiation toxicity (radiation esophagitis and pneumonitis) is told. Diet education is given. CT simulation will be arranged next week after jejunostomy and Port A implantation are done.
• 2023-05-11 Ear Nose and Throat
  • A1
    • The patent was absent during the visit.
    • According to the image of the EGD, the hypopharyngeal lesion was over posterior pharyngeal wall.
    • Biopsy under nasopharyngoscope is indicated.
    • VS Huang preferred biopsy at his OPD (e.g. next Monday PM). If the patient is already discharged by then, please arrange ENT OPD follow-up.
  • A2 (2023-05-16)
    • the hypopharyngeal lesion can’t be seen by nasopharyngoscopy exam
    • suggest biopsy under PES
• 2023-05-11 Hemato-Oncology
  • A
    • This 67 year old man is a case of newly diagnosis lower third moderately differentiated esophagus squamous cell carcinoma, cT3N0M0, stage II. We are consulted for neoajuvant CCRT.
      • Please arrange EUS and PET scan for complete staging.
      • Consult chest surgeon for further evaluation (1. For esophagus cancer evaluation; 2. arrange port A insertion and consider jejunostomy if difficle oral intake due to dysphagia)
      • Consult radio-oncologist for further evaluation (CCRT)
      • For CCRT, we will give weekly cisplatin (25-30mg/m2 IVD 2hr) with 5FU (1000mg/m2 IVD 24hr). Please arrange 24 urine CCR and auditory test.

[radiotherapy]

[chemotherapy]

• 2023-08-14 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
• 2023-07-05 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
• 2023-06-28 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
• 2023-06-14 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
• 2023-06-07 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
• 2023-05-29 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
• 2023-05-22 - cisplatin 25mg/m2 35mg NS 500mL 3hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL

==========

2023-08-14

No reconciliation issues found after reviewing PharmaCloud and HIS5 records.

2023-05-25

As of 2023-05-19, the patient has tested reactive for Anti-HBc. Baraclude (entecavir 0.5mg) 1# QDAC has been appropriately prescribed. The patient’s vital signs are currently stable and there are no issues with the active prescription.

700162322

230814

[exam findings]

• 2023-07-18 Pure Tone Audiometry, PTA
  • Reliabilty Fair
  • R’t : 16 dB HL, normal to mild SNHL
  • L’t : 11 dB HL, WNL.
• 2023-07-12 CXR
  • Tortous aorta with calcification is noted.
• 2023-07-10 Tc-99m MDP bone scan
  • No strong evidnce of bone metastasis.
  • Suspected benign lesions in both rib cages, nasal bone, some C-, T- and L-spine, sacrum, bilateral shoulders, left elbow, hips, and knees.
• 2023-07-08 MRI - brain
  • No evidence of brain metastasis.
• 2023-07-07 PET
  • The FDG PET findings are compatible with esophageal cancer involving the EG junction with three regional lymph node metastases.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar regions and bilateral shoulders. Inflammatory process may show this picture.
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2023-07-06 Treadmill Exercise Test
  • Diagnosis: Esophageal ca
  • Exam for: Pre-op evaluation
  • Exam records:
    • Ergometer protocol: incrementa
    • Ergometer type: cycle ergometer,work rate:7 watt/min
    • Load time: 10.1 min
    • ΔVO2/ΔWR (Normal>8.6~10.3): 8.6
    • AT: 556 / 1182 = 47
  • Predict
    • MIP :104 -( 0.51 * 64 ) = 71.36
    • MEP :170 -( 0.53 * 64 ) = 136.08
    • Meas
      • MIP :96 / 71.36 )= 135
      • MEP :74 / 136.08 )= 54
    • Cause of stop:
      • CAT: 11341001 = 11
    • Rest BP: 110/70 mmHg
    • Max Exercise: 71 watts
    • Max BP: 179/65 mmHg
    • Max Borg: 5
    • Max leg fatigue: 10
    • Recovery 1st minute HR:104, BP:156/57 mmHg
    • Recovery 3rd minute BP:136/61 mmHg
    • Recovery 5th minute BP:107/61 mmHg
  • Conclustions
    • maximal exercise by RER>1.01
    • normal exercise capacity ( VO2 85%, WR 100%) ( normal value >85%)
    • spirometry: normal (FVC 88%, FEV1 85%)
    • respiratory muscle strength: low ( MIP 96%, MEP 54%)
    • No desaturation below 90%
    • low cardiac response during exercise
    • HR response during exercise: normal slope
    • work efficiency normal
    • anaerobic threshold normal
    • oxygen pulse normal
    • BP response: normal response during exercise
    • EKG: nonspecific findings
    • Health-related quality of life, CAT= 11, chest tightness 3, dyspnea 4
  • suggestion:
    • Treat underlying disease
    • For low cardiac response, suggest patient to intake adequate fluid for keeping adequate preload, suggest to survey cardiac function such as cardiac echo
    • For low respiratory muscle strength, do breathing exercise
• 2023-07-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 23) / 93 = 75.27%
    • M-mode (Teichholz) = 75
  • Conclusion:
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; mild MR; mild to moderate TR; mild PR.
• 2023-07-05 SONO - abdomen
  • Findings: A 4 cm hypoechoic mass near EC junction
  • Diagnosis: C/W esophageal tumor
• 2023-07-04 CT - chest
  • Indication: lower 1/3 esophageal SCC
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Soft tissue mass at dilstal esophagus near EG junction measuring 4.1cm is found. Regional lymph nodes (n＝4) are also noted.
      • Calcified coronary arteries is found.
  • Imp: Esophageal cancer at EG junction with regional lymphadenopathy.
    
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-06-20 Patho - stomach biopsy
  • Stomach, cardia, biopsy —- Moderately differentiated squamous cell carcinoma
  • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests and sheets of tumor cells in infiltrative growth pattern, squamous differentiation and focal dyskeratosis.The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, nuclear pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
• 2023-06-20 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
  • Gastric erosion, prepyloric antrum, LC
  • Gastric tumor, cardia R/O SET with ulcer or cancer, s/p biopsy(A)
  • Gastric polyps, body and fundus, s/p biopsy(B)
• 2023-06-14 Esophagography
  • A polypoid lesion at lower esophagus.
• 2022-07-28 Bone densitometry - Hip
  • Hip BMD performed by DXA revealed: Hip, BMD is 0.562 gms/cm2, about 2.6 SD below the peak bone mass (66%) and 0.5 SD below the mean of age-matched people (92%).
  • IMP: osteoporosis
• 2020-03-25 Patho - esophageal biopsy “distal esophague near EG junction”, biopsy — low grade dysplasia.

[consultation]

• 2023-07-11 Radiation Oncology
  • A
    • This 64-years-old female sufferred from dysphagia for 6 months. She can only eat semisolid or liquid diet. Thus she was brought to our Gastroenterology clinic on 2023/06/06. Upper Gastrointestinal endoscopy revelaed gastric tumor and Gastric polyps. Stomach biopsy was done and the pathology report showed moderately differentiated squamous cell carcinoma. The cancer staging revealed esophago-cardiac junction cancer, staging at least cT3N2M0.  
    • Neoadjuvant CCRT is indicated. CT-simulation will be arranged on 2023/07/17. Plan to deliver 45 Gy/ 25 fx to the esophagus and adjacent lymphatic drainage area. Then boost the EC junction tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 20230719 or 20. Thank you very much.

[radiotherapy]

[chemotherapy]

• 2023-08-14 - cisplatin 75mg/m2 110mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-20 - cisplatin 75mg/m2 110mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-07-20

After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were identified.

700301305

230814

[diagnosis] - 2023-03-22 discharge note

• Peripheral T-cell lymphoma with right palatine tonsil, bilateral nasopharyngeal, cervical and axillary regions, bilateral SCF, ICF, bilateral pulmonary hilar regions and mediastinum , celiac chains, bilateral para-aortic space, common iliac chains, external and internal iliac chains, inguinal and thigh regions.
  • In addition,lower T- and L-spine involvement, Lugano stageIII, IPI Score:3, High-intermediate risk group
• Paroxysmal atrial fibrillation
• Hypertensive heart disease without heart failure
• Chronic viral hepatitis B without delta-agent

[past history] - 2023-04-05 admission note

• Hypertension for 10 years with regular medication control.
• Denied history of DM        

[allergy]

• NKDA         

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.  

[exam findings]

• 2023-08-10 CT - chest
  • Indication: T cell lymphoma, bilateral para-aortic space, common iliac chains, external and internal iliac chains, inguinal and thigh regions, lower T- and L-spine involvement, Lugano stageIII, IPI Score:3, High-intermediate risk group
  • Findings
    • Lungs: no abnormal nodule or mass in the lungs.
      • dependent partail atelectasis over RLL.
    • Chest wall, visible neck, mediastinum and hila: extensive lymphadenopathy in the visceral space and anterior prevascular spaces of mediaastinum, cardiophrenic angles, bilateral axillary and supraclavicular regions.
      • mild calcified plaques of the LAD coronary artery.
    • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
    • Heart: normal in size of cardiac chambers.
    • Pleura: moderate Rt and small Lt effusion, in progression.
    • Visible abdominal-pelvic contents: hyperplasia of left adrenal gland. distended gall bladder with a 5mm stone.
      • many bilateral renal cysts measuaring up to 4.8cm
      • multiple hepatic cysts measuaring up to 17mm
      • unremarkable of the spleen and pancreas,
      • extensive enlarged lymph nodes in retroperitoneum, mesentery root, and bilateral iliac chaind and inguinal regions. mild ascites.
    • Visualized bones:
      • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis. no lytic or blastic destruction.
    • Impression:
      • lymphoma extensive involving both sides of the diaphgram, in progression as compared with CT on 2023/04/05
• 2023-08-09 KUB
  • Spondylosis of the L-spine is noted.
  • Gallstone is highly suspected.
• 2023-08-08 ECG
  • Sinus tachycardia with Premature atrial complexes
  • Left atrial enlargement
• 2023-08-01 Bronchodilator Test
  • Mild restrictive ventilatory impairment
  • Not significant bronchodilator reversibility
• 2023-07-14 CXR
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Enlargement of cardiac silhouette.
• 2023-06-27, -05-29, -05-15 CXR
  • Band-like opacity projecting at RLL of the lung.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Fibrosis projecting at bilateral middle lung is suspected.
• 2023-05-03 24hr ECG
  • Sinus rhythm
  • Occasional isolated apcs
  • Rare apc couplets
  • A few episodes short run atrial tachycardia (longest: 4 beats)
  • A few isolated vpcs
  • No long pause
  • No significant tachyarrhythmia
• 2023-04-25 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, antrum
  • Suggestion
    • PPI use
• 2023-04-17 SONO - chest
  • Echo diagnosis
    • Bilateral pleural effusion, R>L
    • Post tapping at right side, about 520cc seroanguinous
    • Left side minimal pleural effusion
  • Suggestion
    • sent for anlysis and culture, and CXR follow up
• 2023-04-05 CTA - chest
  • CTA of chest revealed:
    • Enlarged LNs at bil. neck, axillary regions, mediastinum, retroperitonum and mesentery.
    • A patchy density (1.7x6.0cm) at RML. Ground glass opacities at bil. lungs. Right pleural effusion.
    • Liver and renal cysts (up to 5.0cm).
    • Gallbladder stone (6mm).
  • IMP:
    • Enlarged LNs at bil. neck, axillary regions, mediastinum, retroperitonum and mesentery.
    • A patchy density (1.7x6.0cm) at RML. Ground glass opacities at bil. lungs. Right pleural effusion.
    • Gallbladder stone (6mm).
• 2023-04-05 CXR
  • Ground glass opacities in bil. lungs.
• 2023-04-03 Bladder Sonography
  • PVR 3.67 mL
• 2023-04-03 Uroflowmetry
  • Q max: fair
  • flow pattern: obstructive
• 2023-03-20 CXR
  • Right pleura effusion.
  • Partial atelectasis in RLL is suspected.
• 2023-03-06 SONO - kidney, urology
  • bilateral renal cyst
• 2023-03-06 Bladder Sonography
  • PVR 3.3 mL
• 2023-02-23 CXR
  • Bilateral pleura effusion.
• 2023-02-22 PET
  • Glucose-hypermetabolism in the right palatine tonsil and above-mentioned lymph node regions (Deauville score 5), highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    
  • Glucose-hypermetabolism in some lower T- and L-spine (Deauville score 4), the nature is to be determined (DJD or lymphoma with involvement of bone marrow), suggesting further investigation.
    
  • T-cell lymphoma with involvement of lymph node regions on both sides of the diaphragm, stage III at least (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-02-21 CT - chest
  • Indication: T cell lymphoma, pending staging
  • MDCT (128-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Lungs: no abnormal nodule or mass in the lungs.
      • dependent partail atelectasis over RLL.
    • Chest wall, visible neck, mediastinum and hila: extensive lymphadenopathy in the visceral space and anterior prevascular spaces of mediaastinum, cardiophrenic angles, bilateral axillary and supraclavicular regions.
      • mild calcified plaques of the LAD coronary artery.
    • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: moderate Rt and small Lt effusion.
    • Visible abdominal-pelvic contents: hyperplasia of left adrenal gland. distended gall bladder with a 5mm stone.
      • many bilateral renal cysts measuaring up to 4.8cm
      • multiple hepatic cysts measuaring up to 17mm
      • unremarkable of the spleen and pancreas,
      • extensive enlarged lymph nodes in retroperitoneum, mesentery root, and bilateral inguinal regions. mild ascites.
      • Extensive atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
    • Visualized bones:
      • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis.
  • Impression:
    • T-cell lymphoma extensive involving both sides of the diaphgram.
• 2023-02-21 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • IHC stains: CD117: <1%; CD34: <1 %; LCA: 10 %; CD3 and CD20: no predominant sub-population. (of the nucleated cells).
  • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
• 2023-02-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (106 - 22) / 106 = 79.25%
    • M-mode (Teichholz) = 78
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild MR, TR
    • Pulmonary hypertension, RV hypertrophy
• 2023-02-14 Patho - soft tissue biopsy/simple excision (non lipoma)
  • Lymph node, right neck, excision — Malignant T-cell lymphoma, consistent with peripheral T-cell lymphoma
  • Section show lymph nodes with diffusely infiltration of medium to large-sized lymphoid cells.
  • The immunohistochemical stains reveal CD3(+), CD20(-), CD4(+), CD8(-), CD10(-), BCL2(+), BCL6(-), Cyclin D1(-), CD30(-), ALK-1(-), CD56(-), Granzyme-B(-), TdT(-), CD21(-), and CK(-). The Ki-67 is about 60%. The results are consistent with peripheral T-cell lymphoma. Please correlate with the clinical presentation and image study.
• 2023-02-07 CT - neck
  • Indication:
    • 2023/02/06 multiple painless neck swelling for 3-4 months (suspect lymphoma)
    • productive cough with mild sputum for 2 months
    • referred from endocrinologist, sonogram revealed multiple neck LAP
  • Pre- and post-contrast CT scans of the head and neck region from skull base to lower neck were performed on a spiral CT scanner and axial, coronal and sagittal images of a slice thickness of 3 mm were reconstructed and show:
    • Numerous enlarged lymph nodes, some with necrotic change, at bilateral levels I-V, supraclavicular fossas and axillary regions and also in superior mediastinum.
    • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
    • Presence of right pleural effusion.
    • No skull base lesion, nor abnormality at visible intracranial regions.
  • IMP:
    • Bilateral cervical lymphadenopathies. R/O TB lymphadenitis. D/D: metasatses, lymphoma.
• 2023-02-06 Nasopharyngoscopy
  • smooth NPx, OPx, HPx
  • fair inf. turbinate, L with clear mucus, NSD to L
• 2023-01-30 SONO - thyroid
  • autoimmune thyroid disease
  • bilateral cervical lymph nodes
• 2022-11-21 Clinical Dementia Rating
  • CDR score: 0.5
• 2022-11-21 Mini-Mental State Examination
  • MMSE score: 24
• 2021-11-22 Clinical Dementia Rating
  • CDR score: 0.5
• 2021-11-22 Mini-Mental State Examination
  • MMSE score: 24

[MedRec]

• 2023-03-06 SOAP Hemato-Oncology
  • Sick sinus syndrome
  • Bradycardia
• 2023-02-20 SOAP Hemato-Oncology
  • Peripheral T cell lymphoma with bil neck enlargement, anr Rt pleural effusion
  • Hypertension
  • History of bradycardia treated by CV
  • Af under anticoagulation
  • Dementia

[consultation]

• 2023-08-11 Radiation Oncology

  • A
    • A: Malignant T-cell lymphoma, consistent with peripheral T-cell lymphoma, Lugano stage III, s/p chemotherapy, with progression.
    • P: Radiotherapy is indicated for this patient with the following indicators: tonsil tumor with easy choking, and dyspnea.
      • Goal: palliation
      • Treatment target and volume: tonsil tumor, peripheral involved, to bilateral involved neck nodal lesions.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the tonsil tumor, peripheral involved, to bilateral involved neck nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-08-14.

• 2023-08-11 Family Medicine

  • Q
    • The 86 y/o has peripheral T-cell lymphoma with right palatine tonsil, bilateral nasopharyngeal, cervical and axillary regions, bilateral SCF, ICF, bilateral pulmonary hilar regions and mediastinum, celiac chains, bilateral para-aortic space, common iliac chains, external and internal iliac chains, inguinal and thigh regions, lower T- and L-spine involvement, Lugano stageIII, IPI Score:3, High-intermediate risk group. Due to disease progress, family asks for hospice assessment. Thanks!
  • A
    • A 86 years old male, case of peripheral T-cell lymphoma.
    • He was admitted for pneumonia but status of lymphoma was in progression.
    • Cons: E4V5M6, ECOG:1-2
    • complained dyspnea and easy chocking
    • Patient could understand hospice and palliative care.
    • We will arrange combine care and follow his condition.
    • Consider hospice ward if agreed with palliative treatment.

• 2023-08-11 Ear Nose Throat

  • Q
    • Due to dysphagia and easy choking, so he need your help use scope for NG insertion. Thanks!
  • A
    • Nasogastric tube was inserted smoothly under nasopharyngoscopy.

• 2023-04-07 Infectious Disease

• 2023-04-07 Chest Medicine

• 2023-04-07 Cardiology

• 2023-02-22 Vascular Surgery

  • A: insertion of port-A will be scheduled on 20230223.

[chemotherapy]

• 2023-07-14 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-06-16 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-05-15 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-03-20 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D2-6 (mCHOP, cyclophosphamide 10% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-02-24 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-08-14

[tube feeding: Detrusitol SR (tolterodine), Valcyte F.C (valganciclovir)]

• Based on the information for Valcyte F.C (valganciclovir), the drug should not be crushed for tube feeding because animal data suggests that valganciclovir has the potential to be carcinogenic in humans. As this hospital does not have access to foscarnet or cidofovir, and ganciclovir shares a similar potential carcinogenic risk, it seems that continuing with Valcyte for tube feeding is the only option at this stage.

• Detrusitol SR (tolterodine) is an extended-release capsule, and crushing it for tube feeding could compromise its prolonged-release properties. This could result in a more pronounced fluctuation in its concentration in the bloodstream, potentially affecting its therapeutic efficacy. All other in-hospital available drugs within the same class as tolterodine, such as Urotrol F.C (propiverine 15mg), Oxbu ER (oxybutynin 5mg), Vesicare F.C (solifenacin 5mg), and Betmiga (mirabegron 50mg), are designed as film-coated or extended-release. It might be beneficial to divide the dosage of Detrusitol into two administrations per day to stabilize the concentration in the bloodstream for tube feeding.

2023-06-16

• The patient had an appointment at a local eye clinic in XinDian on 2023-06-06 for his left eye aqueous misdirection and was prescribed brimonidine tartrate and timolol maleate eye drops, which should last for a duration of 28 days. Although the prescription is not yet expired, these two eye drops are not reflected in the current active medication list. It is suggested to confirm if the related eye condition has been resolved.

2023-05-15

• Patients undergoing treatment with immunosuppressive drugs are at an increased risk of developing Pneumocystis pneumonia (PCP). This risk is particularly heightened in patients who are receiving glucocorticoids in combination with cytotoxic agents such as cyclophosphamide, and in those receiving multiple chemotherapeutic agents, especially during periods of leukopenia. As a measure against PCP, the patient has been prescribed Morcasin (containing trimethoprim 80mg and sulfamethoxazole 400mg, also known as TMP-SMX). Given that the patient doesn’t show signs of renal insufficiency (based on 2023-05-15 lab data), there is no need for a dose adjustment.

• Lab data reveals that the patient’s CMV viral load, which had peaked at 803 IU/mL on 2023-05-02, has now decreased to less than 35 IU/mL as of today, 2023-05-15. Valganciclovir, the active ingredient in Valcyte, is an oral prodrug that is rapidly converted into ganciclovir, a substance instrumental in the treatment and prevention of CMV infections in immunocompromised hosts. The marked decrease in CMV viral load suggests that the prescribed Valcyte is effectively managing the CMV infection.

  • 2023-05-15 CMV viral load assay <35 IU/mL
    
  • 2023-05-02 CMV viral load assay 803 IU/mL
    
  • 2023-04-24 CMV viral load assay 159 IU/mL
    
  • 2023-04-12 CMV viral load assay 141 IU/mL

• As per the PharmaCloud records, all of the patient’s recent medications have been prescribed by our hospital, and no issues related to medication reconciliation have been identified.

2023-04-06

• 2023-04-05 lab data showed elevated CRP, NT-proBNP, hs-Troponin I, D-dimer, as well as hyponatremia, leukopenia and anemia. Liver and kidney functions were normal. Cardiologist has been consulted.

  • 2023-04-05 CRP 8.35 mg/dL
  • 2023-04-05 NT-proBNP 581 pg/mL
  • 2023-04-05 hs-Troponin I 27.6 pg/mL
  • 2023-04-05 D-dimer 1228.12 ng/mL(FEU)
  • 2023-04-05 Na (Sodium) 127 mmol/L
  • 2023-04-05 WBC 2.84 x10^3/uL
  • 2023-04-05 HGB 10.3 g/dL

• Pneumonia with exaggerated dyspnea and hypoxemia was observed on admission; planned chemotherapy is withheld until respiratory symptoms resolve. Brosym (cefoperazone + sulbactam) has been prescribed since the day the patient was admitted.

• Rivaroxaban and amlodipine have been prescribed properly as self-carried items with no medication reconciliation issues.

701008526

230814

[diagnosis]

• recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020-07-02, RFA on 2020-12-11, rcTxN0M1a, stage IVA

[exam findings]

• 2023-06-30 CT - abdomen
  • History: Recurrent rectal cancer with liver metastasis
    
  • Findings:
    • S/P LAR with autosuture retention over the rectum.
      • There is no evidence of tumor recurrence.
    • There is a non-enhancing lesion 2.1 x 1.5 cm in S5 of the liver that is c/w metastasis s/p RFA with complete response.
      • In addition, Prior CT identified a poor enhancing lesion 8 mm in S8 of the liver is noted again, stationary. Follow up is indicated.
      • Prior CT identified few hepatic cysts on left lobe liver, the largest one 1 cm in S4, are noted again, stationary.
    • Bil. renal cysts (up to 2.9cm).
    • S/P posterior instrumentation fixation from L4 To L5.
  • Impression:
    • S/P LAR with autosuture retention over the rectum.
    • There is no evidence of tumor recurrence.
• 2023-06-23 Anoscopy
  • Stool color : normal
  • Rectal mucosa : normal
  • Anal canal : abnormal
  • Impression : DRE/anoscopy: no palpable mass, no blood, mild hemorrhoids
• 2023-06-21 Nasopharyngoscopy
  • Findings
    • vocal cords movement well and symmetric.
    • much whitish sputum in hypopharynx and larynx.
  • Diagnosis/conclusion
    • Swallowing disorder
• 2023-04-28 Nasopharyngoscopy
  • Findings
    • No tumor noted in nasopharynx, oropharynx, hypopharynx and larynx.
    • Injected arytneoids.
  • Diagnosis/conclusion
    • Reflux laryngitis
• 2023-04-27 Tc-99m MDP bone scan
  • In comparison with the previous study on 2021/04/20, the lesions in the L-spines are a little more evident. Degenerative change in a little more severe status may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • No prominent change is noted in other bone lesions.
• 2023-04-07 Anoscopy
  • Stool color : normal
  • Rectal mucosa : normal
  • Anal canal : abnormal
  • Impression : 2022-01-18: DRE: mild blood in finger, no tumor obstruction, mild hemorrhoids
• 2023-03-31 Bladder sonography
  • Report: PVR: 67 ml
• 2023-03-31 Uroflowmetry
  • Q max : low
  • flow pattern : obstructive
• 2023-03-27 CT - abdomen
  • History and indication: Recurrent rectal cancer with liver metastasis
    
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Rectal cancer s/p operation without interval change.
    • Liver tumor s/p RFA.
    • Bil. renal cysts (up to 2.9cm).
    • S/P posterior longitudinal transpedicular screws and rods fixation.
  • IMP:
    • Rectal cancer s/p operation without interval change.
    • Liver tumor s/p RFA without viable tumor.
• 2023-02-19 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-02-16 CT - brain
  • Clinical history: 86 y/o male patient with contusion of scalp, initial encounter: Malignant neoplasm of rectum, Essential (primary) hypertension
    • preliminary impression: Contusion of scalp, initial encounter.
  • Without enhancement CT of brain:
    • Low density lesions in bilateral basal ganglia regions, could be due to infarcts.
    • Widening cerebral sulci, fissure and cisterns due to cerebral atrophy.
    • No intracranial hemorrhage.
    • No midline structure deviation.
    • Normal pneumotization of paranasal sinuses and bilateral mastoid air cells.
    • Calcification of bilateral supraclinoid ICAs and VAs.
  • Impression:
    • Suspected infarcts in bilateral basal ganglia region.
    • Brain atrophy.
• 2022-12-05 CT - abdomen
  • Indication: Recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, (kras 12/13mutated), rcTxN0M1a, stage IVA
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness) Abdominal CT with and without enhancement revealed:
    • s/p RFA at right lobe liver. Several hepatic cysts at both lobes of liver is found. Simple cysts are favored.
    • s/p LAR. Minimal infiltration at presacral space is found. In comparison with CT dated on 2022-08-25, the lesion is stationary.
    • Swelling of the cecum is found. In comparison with CT dated on 2022-08-25, the change is stationary. Suggest correlate with tumor marker.
  • Imp:
    • s/p LAR with residual infiltration at presacral space. Statinary.
    • s/p RFA at right lobe liver. No recurrent/residual tumor in the liver is found.
    • Swelling of cecum. Suggest correlate with tumor marker and follow up.
• 2022-10-18 KUB
  • S/P posterior longitudinal transpedicular screws and rods fixation.
  • Presence of ileus.
  • S/P operation.
  • Compression fracture of L1-3.
• 2022-09-30 Nasopharyngoscopy
  • no obvious bleeder or erosion wound noticed over bilateral nasal cavity, Npx
• 2022-09-06 CT - brain
  • Brain atrophy with bilateral periventricular ischemic/aging white matter change. Atherosclerosis.
• 2022-08-25 CT - abdomen
  • Rectal cancer s/p operation without interval change.
  • Liver tumor s/p RFA without viable tumor.
• 2022-05-20 Colonoscopy
  • Local recurrent cancer at low rectum
  • Colon polyps, A-colon and S-colon
• 2022-05-17 CT - abdomen, pelvis
  • Post-op at the colon, with prominent soft tissue around anastomosis, suggest colonoscopy study.
  • S/P RFA for liver tumor.
  • Duodenal diverticulum.
  • Stationary of right upper pole kidney low density lesion, 1.4cm, suggest follow up.
  • Fibrotic infiltrate in bilateral upper lungs.
• 2022-02-16 Chest PA erect view
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2022-02-14 Chest PA erect view
  • Ground glass opacity in bilateral lower lungs.
• 2022-01-04 CT - whole abdomen, pelvis
  • S/P RFA for liver tumor.
  • Duodenal diverticulum.
  • Stationary of right upper pole kidney low density lesion, 1.4cm, suggest follow up.
  • Fibrotic infiltrate in bilateral upper lungs.
• 2021-10-01 Sigmoidoscopy
  • Diagnosis: local recurrent cancer at low rectum
  • Suggestion: possible R/T or transanal debulking excision
• 2021-09-23 CT - whole abdomen, pelvis
  • Rectal cancer s/p operation without interval change.
  • Liver tumor s/p RFA without viable tumor.
• 2021-04-20 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 20190725, the lesions in the upper L-spines are a little less evident. Compression fracture or severe degenerative change with some resolution may show this picture.
  • The previous hot spots in some right costovertebral junctions are also a litlte less evident. However, please correlate with other imaging modalities for further evaluation.
  • No prominent change is noted in the lesions in the lower L-spines. Post-operative change may show this picture.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and wrists, compatible with benign joint lesions.
• 2021-04-06 CT - whole abdomen, pelvis
  • Post-op at the colon with preirectal fatty infiltrates, stationary.
  • S/P RFA for liver tumor.
  • Suspected complicated right renal cyst.
  • Fibrotic infiltrates in bilateral lung apex and RML.
  • Osteoblastic lesions in the ribs, spine and pelvis, suspected bone metastasis.
• 2021-02-26 Colonoscopy
  • Recurrent rectal tumor found 6cm AAV.
• 2021-01-07 CT - liver, spleen, biliary duct, pancreas
  • Rectal cancer s/p operation without interval change.
  • Liver tumor s/p RFA without viable tumor.
• 2020-11-10 PET scan
  • In comparison with the previous study on 20200622, the previous glucose hypermetabolic lesion in the segment 5 of the liver is less evident. However, the previous glucose hypermetabolic lesion on the rectal wall disappeared and no prominent FDG uptake was noted in the previous glucose hypermetabolic lesion in the segment 4 of the liver.
  • Two mild and small glucose hypermetabolic lesions in the right lower lung field. The nature is to be determined (inflammation? early metastases? other nature?).
  • Glucose hypermetabolism in bilateral pulmonary hilar regions and some mediastinal lymph nodes. Inflammation may show this picture.
  • Increased FDG accumulation in the colon. Physiological FDG accumulation is more likely.
• 2020-10-30 Sigmoidoscopy
  • Previous anastomosis site was no evidence disease (NED).
• 2020-10-07 CT - abdomen, pelvis
  • Metastasis 1.6 x 1.1 cm in S5 of the liver is suspected and it shows stable in size. Please correlate with MRI.
  • Renal cyst with hemorrhage 2 cm at right upper pole shows stable in size.
• 2020-07-03 Patho - colorectal polyp
  • Rectum, transanal excision - Adenocarcinoma, recurrent
• 2020-06-22 PET scan
  • A glucose-hypermetabolic lesion on rectal wall, compatible with the lesion of recurrent rectal cancer as diagnosed histopathologically.
  • Glucose hypermetabolism in the lesion in segment 5 of liver revealed in the previous CT scan, hepatic metastasis may show such a picture.
  • Another glucose-hypermetabolic lesion in segment 4 of liver, nature to be determined (inflammatory lesion, malignancy, or other nature).
  • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change resulting from locoregional inflammation may show such a picture.
  • Rectal cancer with recurrence, rcTxN0M1a, stage IVA (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2020-06-17 CT - abdomen, pelvis
  • Metastasis 1.6 x 1.1 cm in S5 of the liver is suspected.
  • Renal cyst with old hemorrhage 2 cm at right upper pole is suspected.
• 2020-06-15 Patho - colon biopsy
  • Large intestine, rectum, biopsy - Adenocarcinoma, moderately differentiated
• 2020-06-12 Sigmoidoscopy
  • one 2.5cm tumor mass was noted in the low rectum (previous anastomosis, posterior site)
• 2020-01-03 Patho - colon segmental resction for tumor
  • Recto-Sigmoid colon, LAR - Adenocarcinoma
  • Bilateral cutting ends, ditto - Free of tumor invasion
  • Lymph node, dissection - Positive for tumor metastasis (2/12) without extracapsular extension (0/2)
  • AJCC pathologic stage - ypT3N1b(if cM0), stage IIIB
  • IHC: CDX-2(+), MLH1(+), PMS2(+), MSH2(+) and MSH6(+)
• 2019-07-01 CT - liver, spleen, biliary duct
  • Rectal cancer s/p CCRT with regional LAP (T3N2Mx).
  • Segmental wall edema of terminal ileum with adjacent fat stranding and ascites. A poor enhancing lesion (2.4cm) in right kidney.
• 2019-06-08 CT - abdomen
  • Imaging Report Form for Colorectal Carcinoma: T3N2Mx

[consultation]

• 2022-05-19 Colorectal Surgery
  • Q
    • The 85y/o male recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, rcTxN0M1a, stage IVA
      
    • 2022/05/17 f/u CT Impression: Post-op at the colon, with prominent soft tissue around anastomosis, suggest colonoscopy study, so we need ypor help. Thank you.
  • A
    • The 85y/o male recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, rcTxN0M1a, stage IVA, with C/T + target therapy.
    • Impression:
      • Post-op at the colon, with prominent soft tissue around anastomosis, suggest colonoscopy study.
      • S/P RFA for liver tumor.
      • Duodenal diverticulum.
      • Stationary of right upper pole kidney low density lesion, 1.4cm, suggest follow up.
      • Fibrotic infiltrate in bilateral upper lungs.
    • A: Recurrent rectal cancer with liver metastases s/p CCRT and RFA, with disease progression
    • P:
      • Colonoscopy will be performed on this Friday afternoon
      • We would like to follow this patient
• 2022-01-08 Infectious Disease
  • Q
    • The 85 y/o man has recurrent rectum cancer under chemotherapy. Due to fever with chills, we gave Cefepime for infection control at first. The Sphingomonas paucimobilis bacteremia from port-a was noted, but Port-a was removed in 20220106. We need your help for antibiotic assassment. Thanks!
  • A
    • Infections of Sphingomonas paucimobilis include bacteraemia/septicaemia caused by contaminated solutions, e.g. distilled water, and sterile drug solutions.
    • Infections due to S. paucimobilis have not been associated with mortality.
    • The drug of choice may be a fluoroquinolone because of the susceptibility patterns and ease of administration.
    • Levofloxacin in a dose of 500 mg per day, or Finibax in the dose of 500 mg every 8 hours may be used.
• 2021-11-08 Urology
  • Q
    • The 82 y/o man has recurrent rectum cancer stage IV with urinary incontinence, so we need your help for management. Thanks!
  • A
    • This 84yo male has underlying diseases of recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, (kras 12/13mutated), rcTxN0M1a, stage IVA.
    • CC: urinary incontinence was noted for 3 months
    • PI: urgency+, frequency+, IPSS: 22
    • Suggestion:
      • acquire U/A, PSA fisrt
      • arrange UFM, PVR and TURSP
      • may add solifenacin if PVR < 100 ml
• 2021-09-28 Colorectal Surgery
  • Q
    • The 84 y/o man has adenocarcinoma of rectum, cT3N2bM0, IIIC, s/p CCRT with partial response, s/p laparoscopic- LAR and protective ileostomy (2020-01-02), pT3N1bM0(2/12), LVI(+), PNI(-), stage IIIB. Due to few bloody after stool passage for 1-2 weeks, no hemorrhoid or fistula noted, so we need your help for management. Thanks!
  • A
    • The patient was consulted for bloody stool passage in recent 1-2 weeks.
    • 2021-09-23 CT:
      • Rectal cancer s/p operation without interval change.
      • Liver tumor s/p RFA without viable tumor.
    • A:
      • Local recurrent rectal adenocarcinoma with S5 liver metastasis, stage IVa s/p transanal local excision (2020-07-02) and s/p palliative R/T + chemotherapy + target therapy and RFA for liver metastasis
      • Adenocarcinoma of rectum, cT3N2bM0, IIIC, s/p CCRT with partial response, s/p laparoscopic- LAR and protective ileostomy(109-01-02), pT3N1bM0(2/12), LVI(+), PNI(-), stage IIIB, s/p close ileostomy (2020-04-20)
    • P
      • Suggest sigmoidoscopy this Friday afternoon
      • We would like to follow this case
• 2021-08-10 Psychosomatic Medicine, Mental Health
  • Q
    • The 84 y/o man has recurrent rectal cancer stage IVA, is admitted for deep drowsy. In hospital, we hold his sedation as Eurodin, Revotril and Imipramine. Due to delirium at night for days, so we need your help for management.
  • A
    • Psychiatirc impression:
      • acute delirium
    • Psychiatric history:
      • This 84 year-old male patient with history of rectal cancer stage IVA under chemotherapy. He suffered form diarrhea after chemotherapy since last discharge (20210629~20210716). He present weakness, bedridden and persistent diarrhea during late July 2021. This time we was brought to this ER on 20210801 due to general weakness and drowsiness.
      • According to his son, he display consciousness flactuation and disorientation since late July and progressed after this admission. Sleep cycle disturbance. Sundowning syndrome. Self talking and suspect visual hallucination. Upon visit, sleepiness, poor attention lasting, hearing impairment, incoherent and irrelevent speech, disoriented to time and place.
      • 20210809 Given 0.5# Rivotril due to poor sleep, still cannot fall asleep; given 0.5# again, can fall asleep, but becomes drowsy during the day
      • currently hold eurodin, rivotril and imipramine
    • Suggesting:
      • please correct his underlying condition
      • encorage daily activities and prevnet daytime sleep, reorientation to time, person and place
      • DC rivotril and neurontin and avoid BZD use
      • give risperidol 0.5# hs
      • please contact us if any psychiatric problem
• 2021-08-09 Urology
  • Q
    • The 84 y/o man has Adenocarcinoma of rectum, cT3N2bM0, stage IIIC, post operation with CCRT and chemotherapy. Due to frequency urine noted, we gave Harnalige for control since 20210805, but his son complainted of condition without control. The patient urinates every 2-3 hours during the day and every 1-2 hours at night, so we need your help for management. Thanks!
  • A
    • S/O
      • The 84 y/o man
      • Adenocarcinoma of rectum, cT3N2bM0, stage IIIC, post operation with CCRT and chemotherapy
      • Admitted for weakness
      • Due to frequency urine noted,
      • Harnalige for control since 20210805, but his son complainted of condition without control
      • UA: clear
    • P
      • arrange random PVR, if PVR <300 ml, administer Vesicare 1 tab QD
• 2020-11-13 Gastroenterology
  • A
    • 83M
    • PH:
      • Adenocarcinoma of rectum, cT3N2bM0, stage IIIC status post laparoscopic low anterior resection and protective loop-ileostomy on Jan. 02, 2020 status post CCRT, rcTxN0M1a, stage IVA
      • DVT with left IVC filter status post removal IVC filter on Apr. 7, 2020
      • Gallbladder stones with acute cholecystitis post cholecystectomy on Jan. 19, 2020
      • Hypertension for 10+ years under medical treatment
      • Type 2 diabetes mellituss for 10+ years under medical treatment
      • HIVD s/p L3-L5 spine surgery on 2017-12 at Cathay General Hospital
    • CC:
      • Followed up CT on 2020/06/17 and 10/07 revealed “metastasis 1.6 x 1.1 cm in S5 of the liver is suspected” –> adm for solitary liver lesion
    • Due to liver tumor, we are consulted for RFA.
    • S+O
      • No disconfort
      • Conscious: E4V5M6
      • Abdomen: Soft and flat, no tenderness, no rebound tenderness
      • Lab
        • 2020-11-09 AST:17, ALT:37, BUN:24, Cr:0397, T-bil:0.56
        • WBC:4.97, Hb:11.8, PLT:248
    • Impression
      • Liver tumor, S5
    • Suggestion
      • arrange abdominal echo
      • arrnage GI OPD after discharge. We will discuss with the patient about RFA in GI OPD
• 2020-11-12 General and Gastrointestinal Surgery
  • Q
    • This time,he was admitted for clarifying the nature of solitary liver lesion. PET done on 20201110 which revealed In comparison with the previous study on 20200622, the previous glucose hypermetabolic lesion in the segment 5 of the liver is less evident. However, the previous glucose hypermetabolic lesion on the rectal wall disappeared and no prominent FDG uptake was noted in the previous glucose hypermetabolic lesion in the segment 4 of the liver.
    • We need your expertise for op evaluation, thanks
  • A
    • S: a case of rectal cancer with recurrence, rcTxN0M1a, stage IVA. PET found suspected liver METs over S4 & S5, further evaluation is consulted.
    • O: vital signs: stable, no fever
      • abdomen: soft, ovoid, decrease bowel sound, no tenderness, no rebounding pain
      • lab data: see chart
      • CT & PET: suspected liver & lung METS
    • A: rectal cancer with recurrence, rcTxN0M1a, stage IVA.
    • P: Please arrange biopsy of suspected liver tumors for tissue prove
      • If rectal Ca with liver METS diagnosed, surgical intervention is not suitable for him due to high surgical risk (old age, previous DVT, and terminal stage).
      • RFA and RT, or target and immunotherapy is better and suggested.
• 2020-01-18 General and Gastrointestinal Surgery
  • Q
    • PH: adenocarcinoma of rectum, cT3N2bM0, III s/p L-LAR with protective ileostomy (2020-01-02), decreased appetite, abdomen fullness and discomfort and feels weakness
  • A
    • A case of acute RUQ pain for days
    • PE
      • soft abdomen, no muscle guarding
      • positive murphy signs and knocking pain, right
    • lab disclosed neutrophilia over 80%, CRP over 28
    • CT: gall stones with acute cholecystitis
    • Emergency op or drainage is indicated
• 2020-01-18 Colorectal Surgery
  • Q
    • PH: adenocarcinoma of rectum, cT3N2bM0, III s/p L-LAR with protective ileostomy (2020-01-02), decreased appetite, abdomen fullness and discomfort and feels weakness
  • A
    • This 83-year-old with a known history of adenocarcinoma of rectum, cT3N2bM0, III s/p L-LAR with protective ileostomy (2020-01-02) This time, he had decreased appetite, abdomen fullness and discomfort and feels weakness. His laboratory data showed leucocytosis and elevated CRP level. After evaluation, please arrange abdominal CT.
    • PE:
      • Rebounding pain (+) especial right side and RUQ.
      • knocking tederness (-)
      • ileostomy: gas + watery yellowish diarrhea
    • Suggest:
      • please check abdominal CT
      • please consult GS

[surgical operation]

• 2020-12-11 Colon cancer with single liver metastasis s/p RFA (2 sessions) using RVS

• 2020-01-19

  • Surgery: Exp lap with cholecystectomy and drainage
  • Finding
    • black stones with GB wall thickening and pericholecystal abscesses and adhesions
    • one impaction over orifice of cystic duct
    • no liver tumor or cirrhotic change

• 2019-10-22

  • Diagnosis: L3-S1 spondylosis, radiculopathy
  • PCS code: 96005C
  • Finding
    • bilateral L3-4 HIVD, ASD, spinal stenosis, radiculopathy
    • L5-S1 HIVD
    • intraoperative fluoroscopy confirmed needle localization

[radiotherapy]

• 2019-04-18 ~ 2019-05-31: 4500cGy/25fx of the pelvic and 5040cGy/28fx of the rectal tumor area

[chemotherapy]

• 2023-07-17 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 3630mg NS 500mL 46hr (FOLFOX Q2WK, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-06-13
• 2023-05-22
• 2023-04-24
• 2023-03-28
• 2023-02-20 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 3770mg NS 500mL 46hr (FOLFOX Q2WK, ox and 5fu 20% off due to old age)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-01-09 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-12-02 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-11-16 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-10-27 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-10-14 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-08-22 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-08-01 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-07-18 - oxaliplatin 85mg/m2 115mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-06-16 - oxaliplatin 85mg/m2 115mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3790mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-05-23 - oxaliplatin 85mg/m2 115mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3790mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-03-09 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3750mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2021-12-15 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3615mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2021-11-24 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3615mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2021-11-04 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3690mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2021-10-19 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3625mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2021-09-24 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 3675mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-06-29 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-06-02 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-04-21 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-04-07 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-03-22 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 235mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3650mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2021-03-08 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 235mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3650mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-10-06 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 235mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3650mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-09-21 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3720mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-09-07 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3720mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-08-18 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3730mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-08-03 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 535mg 2hr + fluorouracil 2800mg/m2 3750mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
• 2020-07-20 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 535mg 2hr + fluorouracil 2800mg/m2 3750mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD

==========

2023-08-14

[reconciliation]

On 2023-06-23, our cardiologist prescribed Januvia (sitagliptin), Eliquis (apixaban), and Zandip (lercanidipine) for the patient, while on 2023-07-01, our gastroenterologist prescribed Ulstop (famotidine), Gaslan (dimethylpolysiloxane), and Mopride (mosapride citrate). All medications, with the exception of Mopride, are currently on the active medication list. Please determine if the use of Mopride is still necessary.

2023-07-17

This patient just refilled his prescription for Januvia (sitagliptin), Eliquis (apixaban), Zanidip (lercanidipine), Betmiga (mirabegron), Urief (silodosin) on 2023-07-11 at a local pharmacy and these drugs are now added to the active medication list with no reconciliation issues found.

2023-06-12

• According to the PharmaCloud database, the patient has solely been using our hospital for both outpatient and inpatient services over the past three months.
• The patient visited our Neurology and Psychosomatic Medicine OPD on 2023-06-09 for chemotherapy-related polyneuropathy, L spine radiculopathy, suspected mild cognitive impairment, and insomnia. Refillable prescriptions were given for Muaction (tramadol), Kentamin (B1, B6, B12), Trynol (amitriptyline), Neurontin (gabapentin), calcium carbonate, U-Ca (calcitriol), and Alpraline (alprazolam). These drugs are appropriately reflected on the current active medication list. No issues were identified in the medication reconciliation process.

2023-05-22

• A review of PharmaCloud records did not identify any medication reconciliation issues.

• This patient’s chemotherapy-induced polyneuropathy may be more likely due to the oxaliplatin component of the FOLFOX regimen, which was started in Oct 2021. Appropriate measures have been taken, including the addition of Kentamin (B1, B6, B12) and Neurontin (gabapentin) to the patient’s active medication regimen as prescribed by our neurologist.

• The patient’s CEA and CA199 levels have shown similar upward trends in recent months, which may indicate that the disease is becoming more resistant to current treatment. This may require further evaluation and possible adjustments to the future treatment plan.

  • 2023-05-09 CEA (NM) 29.020 ng/ml
    
  • 2023-04-11 CEA (NM) 29.090 ng/ml
    
  • 2023-03-07 CEA (NM) 30.892 ng/ml
    
  • 2023-02-22 CEA (NM) 22.304 ng/ml
    
  • 2023-05-09 CA-199 (NM) 99.780 U/ml
    
  • 2023-04-11 CA-199 (NM) 94.910 U/ml
    
  • 2023-03-07 CA-199 (NM) 91.315 U/ml
    
  • 2023-02-22 CA-199 (NM) 66.824 U/ml

2023-03-27

• CEA and CA199 levels have been consistently above the normal range since Oct 2022.
• The patient is being treated for bilateral L5 and bilateral below wrist numbness caused by chemotherapy-related polyneuropathy and L spine radiculopathy. The treatment plan, including the use of Kentamine (B1 50mg + B6 50mg + B12 500ug), Neurontin (gabapentin), Trynol (amitriptyline), and Muaction (tramadol), has been properly prescribed by our neurologist on 2023-03-24.
• As of now, the patient has had one bowel movement on 2023-03-26 and there are no signs of constipation. Loperamide 2mg PRNQ4H has been prepared in advance if needed.
• Based on the TPR panel, the patient’s underlying conditions of hypertension and diabetes are well controlled.
• There were no medication reconciliation issues identified and there are no issues with the current active prescription.

2023-02-20

• As of now, the patient’s TPR, blood pressure, and blood sugar level remain stable. The lab data 2023-02-19 showed grossly normal readings, except for slightly high BUN and slightly low levels of albumin and calcium.
• The recently prescribed drugs that were disclosed in the NHI PharmaCloud System have been appropriately prescribed during this hospital stay. No medication reconciliation issues have been found in the patient.

2023-01-09

• 2020 ASCO guidelines suggest that clinicians may offer duloxetine to patients with chemotherapy-induced peripheral neuropathy, and 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for treatment of neuropathic pain in this setting. ref: Loprinzi CL, Lacchetti C, Bleeker J, et al. Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325.
• Duloxetine for adult patients with chemotherapy-induced peripheral neuropathy: Oral initial 30 mg once daily for 1 week, then 60 mg once daily. Ref: Smith EM, Pang H, Cirrincione C, et al; Alliance for Clinical Trials in Oncology. Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial. JAMA. 2013;309(13):1359-67. doi:10.1001/jama.2013.2813
• There is Cymbalta (duloxetine 30mg/cap) available in the stock.

2022-12-02

• In this case, the patient had chemotherapy related polyneuropathy and L spine radiculopathy, which was evaluated by our neurologist on 2022-11-14. Neurontin (gabapentin 100mg/cap) 1# BID has been prescribed.
• At this time, vital signs appear to be stable. According to the lab data on 2022-12-01, there was a slight pancytopenia, but overall the results were normal.
• There is no issue with the active prescription.

2022-10-14

• Duloxetine is recommended for the mitigation of chemotherapy-related sensorimotor polyneuropathy (Type of recommendation: evidence based, benefits equal harms; Evidence quality: intermediate; Strength of recommendation: moderate. Ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. Journal of Clinical Oncology 2020 38:28, 3325-3348)
• Duloxetine for chemotherapy-induced peripheral neuropathy (off-label use): Oral initial: 30 mg once daily for 1 week, then 60 mg once daily.

2022-07-18

• Colonoscopy (2022-05-20) showed local recurrent cancer at low rectum.
• CEA levels continue to rise in recent months:
  • 2022-06-24 23.795 ng/mL
  • 2022-06-10 17.995 ng/mL
  • 2022-05-17 14.022 ng/mL
  • 2022-03-18 13.494 ng/mL
    
  • 2022-01-20 8.210 ng/mL
    
  • 2021-12-14 6.908 ng/mL
    
• CA199 exhibits a similar trend to CEA
• Lab data on 2022-07-18 showed generally normal readings except for slight anemia.

2022-05-17

• Lab data on 2022-05-16 showed that liver and kidney function, electrolytes and CBC were generally normal.
• Biomarkers
  • CEA 2022-03-18 13.494 ng/ml <- 2022-01-20 8.210 ng/ml <- 2021-12-14 6.908 ng/ml, increasing
  • CA199 2022-03-18 73.781 U/ml <- 2022-01-20 49.528 U/ml <- 2021-12-14 40.779 U/ml, increasing
• The last CT scan was performed on 2022-01-04, so the image may need to be updated.

2022-01-04

• according to in-hospital database, the patient had mild drug allergy with: Sketa, Warfarin, Dipyridamole, Valaciclovir, Solaxin (chlorzoxazone).

2021-04-28

• O
  • stool Clostridium difficile GDH positive reported on 4/27
• A
  • Clostridioides difficile infection (CDI) is one of the most common nosocomial infections and is an increasingly frequent cause of morbidity and mortality among older adult hospitalized patients.
  • vancomycin, fidaxomicin, metronidazole might work on CDI.
  • according to lab data reported on 4/19, the patient has normal liver and kidney functions, no need to adjust dose for the above antimicrobials.
• Suggestion
  • discontinuation of the inciting antibiotic agent as soon as possible at least in the patient’s room.
  • vancomycin 125mg PO QID for 10 days or fidaxomicin 200mg PO BID for 10 days could be considered.
  • if vancomycin is prescribed, therapeutic drug monitoring for its trough level at 30 minites just before the 5th dose administration is highly recommended.
  • monitor clinical signs for CDI and recheck stool GDH after having administrating of the above antimicrobials for 5 days to evaluate the effect.

701443315

230814

[exam findings]

• 2023-08-11 ECG
  • Normal sinus rhythm
  • Prolonged QT
  • Abnormal ECG
• 2023-07-24 MRI - nasopharynx
  • Indication: Right lower gum squamous cell carcinoma, grade I, cT3N2aM0, stage IVA s/p concurrent chemoradiotherapy to H&N tumors for 7140cGy/34 fractions, start and weekly chemotherapy with TP
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows - Comparison: 2023/04/29, 2022/09/22 HN MRI - prominent motion artifacts were found on most the images
    • Right low gum, bucco-gingival tumor mass, seems invading to mouth floor, seems stationary.
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • Necrotic right IB LAP, seems stationary.
      
    • Presence of soft tissue swelling over bil. neck, post CCRT change favored.
• 2023-07-21 CT - chest
  • Indication:
    • Right upper lung adenocarcinoma, cT3N1M0, stage IIIA s/p weekly chemotherapy with TP (Carboplatin AUC:2 / Docetaxel 35mg/m2) from 2022/12/12 to 2023/02/06, progression for right upper lobe and left upper lobe tumor s/p chemotherapy with GP (Gemzar 800mg/m2, CDDP 60mg/m2) from 2023/05/02 ~
    • Right lower gum squamous cell carcinoma, grade I, cT3N2aM0, stage IVA s/p concurrent chemoradiotherapy to H&N tumors for 7140cGy/34 fractions, start from 2022/12/12 to 2023/2/13 and weekly chemotherapy with TP (Carboplatin AUC:2 / Docetaxel 35mg/m2) from 2022/12/12 to 2023/02/06
  • Chest and Abdominal CT with and without enhancement revealed:
    • Chest:
      • Mass like lesion at right upper lobe measuring 4.87cm and left upper lobe measuring 3.18cm are found. In comparison with CT dated on 2023-02-17, the right upper lobe mass decreased in size but the left upper lobe tumor progressed.
      • Another spiculated mass at right lower lobe measuring 3.67cm and 2.3cm in largest dimension are found. In progression.
      • Bronchiectatic change over right lower lobe and left lower lobe with tree in bud appearance at left lower lobe is found.
      • No evidence of bilateral pleural effusion.
      • Lymphadenopathy at both sides of the mediastinum.
    • Visible abdomen:
      • There is stone at dependent portion of GB. GB stone(s) are noted.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
  • Imp:
    • Right upper lobe mass, in regression.
    • Left upper lobe and right lower lobe mass like lesion. In progression. However, lung meta or recent inflammation should be differentiated.
    • Bilateral lower lung Bronchiectatic changes
• 2023-06-14 CXR
  • Prior plain film identified Patchy opacity of the right upper lung zone is noted. again, decreasing in size. Please correlate with CT.
  • Linear infiltration over left upper lung zone and nodular opacity projecting at right lower lung is noted. please correlate with clinical condition.
  • Atherosclerotic change of aortic arch
  • Spondylosis with scoliosis of the T-spine with convex to right side
• 2023-04-29 MRI - nasopharynx
  • Comparison: 2022/09/22 HN MRI
    • Right low gum, bucco-gingival tumor mass, seems invading to mouth floor.
    • Invasion of right anterior mandible bone, a 4A lesion?
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor, with mild regression.
    • Necrotic right left IB LAP, mild regressed size.
      
    • Presence of soft tissue swelling over bil. neck, post CCRT change favored.
• 2023-02-17 CT - chest
  • History: This 71 years-old man has noted a 3x3 cm growing mass over right level I cervical lymph node since 2022/06. Dysphagia with solid food was also mentioned. The mass was fixed and solid, there was no tenderness, no redness or pus
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Spiculated mass at right upper lobe measuring 5.48cm in largest dimension is found. Another spiuclated lesion at left upper lobe measuring 2.97cm in largest dimension. In comparison with CT dated on 2022-09-24, the right upper lobe mass enlarged and left upper lobe mass is new.
      • No evidence of bilateral pleural effusion.
      • S/p port-A placement with its tip at Superior vena cava.
    • Visible abdomen:
      • There is stone at dependent portion of GB. GB stone(s) are noted.
      • The liver, spleen, pancreas,and adrenals are intact.
      • Left renal stone up to 0.4cm is found.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Right upper lobe and left upper lobe mass, in enlargement.
• 2023-01-27 ALK IHC (EGFR positive needs self-paid)
  • S2022-16336: Negative
• 2022-12-01 CXR
  • Patch density at RUL.
  • Presence of scoliosis of the lumbar spine.
  • A calcified spot at right neck.
• 2022-11-24 PD-L1 IHC
  • Tumor cell (TC) staining assessment: >= 10% and < 50%
  • Percent of PD-L1 expression in tumor cells (TC): 10%
• 2022-11-24 PD-L1 22C3
  • Tumor Proportion Score (TPS) assessment: >= 1% and < 50%
  • Tumor Proportion Score (TPS) : 10%
• 2022-11-24 PD-L1 SP142
  • Result
    • Tumor cell (TC) staining assessment: TC category: TC >= 1% and < 5%
    • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
  • Note:
    • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
    • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2022-11-22 Pure tone audiometry
  • Reliability FAIR
  • Average RE 65 dB HL; LE 60 dB HL.
  • R’t moderate to severe MHL. (BC masking dilemma)
  • L’t mild to severe MHL.
    • Note: There are three kinds of hearing loss.
      • Conductive Hearing Loss (CHL) happens when there is a problem with the outer or middle ear that blocks sound from traveling to your inner ear. Often this is caused by wax build-up, fluid in the ears, a perforated eardrum, or damage to the bones in your ears.
      • Sensorineural Hearing Loss (SHL) happens when there is a problem in the inner ear that prevents sound from traveling to the cochlea or the auditory nerve. This can be caused by trauma, aging, disease, or being exposed to loud noise.
      • Mixed Hearing Loss (MHL) is a combination of both.
• 2022-10-05, -10-03, -10-02, -09-29, -09-26, -09-20 CXR
  • One mass lesion over RUL.
  • Tortuosity of the aorta with atherosclerotic change.
  • Degenerative change of T-L spines with marginal osteophytes.
  • Scoliosis of the T-L spine.
• 2022-10-05 Bronchodilator Test
  • moderate obstructive impairment; non-significant bronchodilator response.
• 2022-10-04 Patho - bronchus biopsy
  • Lung, RUL, bronchoscopic biopsy — mild chronic inflammation
• 2022-10-04 Bronchoscopy
  • Abnormal Endobronchial tumor over RUL
• 2022-10-03 Tc-99m MDP whole body bone scan
  • Increased activity in the right aspect of mandible, the nature is to be determined (oral cancer with adjcent bone involvement, dental problem or other nature ?), suggesting investigation.
  • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral shoulders, elbows, hips, femurs, and knees.
• 2022-10-03 MRI - brain
  • Old insults in right frontal lobe. Cerebral small vessel disease. Mild general brain atrophy. A small enhancing nodule (5 mm) at left frontal base, may be due to confluent cortical veins. Suggest follow-up.
• 2022-10-03 ROS1 FISH
  • ROS1 fluorescent-in-situ hybridization report - rearrangement of ROS1 gene is NOT detected. Patient with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
• 2022-10-03 EGFR mutation
  • No mutation was detected at exon 18, 19, 20, 21 of EGFR gene in this specimen.
• 2022-09-26 Patho - lung transbronchial biopsy
  • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated
  • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
• 2022-09-24 CT - chest
  • Indication
    • 71 y/o man with RUL tumor for many years, stroke 5 years ago without hemiplegiaRight lower gum squamous cell carcinoma, grade I
  • Findings
    • Chest:
      • Mass like lesion at right upper lobe up to 6.9cm with attachement with interlobar fissure is found.
      • Some lymph nodes are found at right hilar region.
    • Visible abdomen:
      • Left renal stone is found.
  • Imp: Right upper lobe lung cancer with right hilar lymphadenopathy is favored.
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2022-09-23 Whole body PET scan
  • Glucose hypermetabolism in the right lower gum with possible invasion to adjcent mandible and mouth floor, compatible with primary malignancy involving these regions.
  • Glucose hypermetabolism in a right neck level I lymph node and a right neck level IV lymph node, compatible with metastatic lymph nodes.
  • Glucose hypermetabolism in a large focal area in the upper lobe of right lung. Primary lung malignancy should be wached out. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2022-09-22 MRI - nasopharynx
  • Imaging Report Form for Oral Cavity Carcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2022-09-21 SONO - abdomen
  • Diagnosis
    • Parenchymal liver disease
    • Gallbladder stone and sludge
    • Gallbladder wall thicking, suspected cholecystopathy
    • suspected Calcified spot, right kidney
  • Suggestion
    • Regular ultrasound follow up
• 2022-09-21 Panendoscopy
  • Diagnosis
    • Reflux esophagitis, LA B
    • Superficial gastritis and erosions, whole stomach, s/p CLO test
  • Suggestion
    • Please pursue CLO test
    • No evidence of esophageal lesion

[consultation]

• 2022-10-06 Hemato-Oncology
  • Q
    • Consultation for evaluation and treatment advice for right lower gum squamous cell carcinoma, grade I
    • This 71 year-old man, has lung tumor and stroke 5 years ago with right eye nearly blindness. He denied any other systemic disease or surgical history. 3 months ago he noted a 3x3 cm growing mass over right level I cervical lymph node. Dysphagia with solid food was also mentioned. The mass was fixed and solid, there was no tenderness, no redness or pus secretion. Irregular palpable lesion over right lower gum was noticed. There was no bleeding or pus. The patient denied drooling, pain, choking, decreased appetite or body weight loss. Biopsy of right lower gum was done in 804 Hospital and showed squamous cell carcinoma, grade I, well differentiated. This time he is admitted for tumor survey.
    • MRI showed one 2.5x2.5 cm well-shaped homogenous nodule over right lower gum. There was no finding of metastasis or lymphadenopathy over opposite side of neck. PET will be done today.
    • Under the impression of right lower gum , our tentative plan will be either operation or CCRT. Therefore we need your advice for his further treatment. Thank you very much! We appreciate your help.
  • A
    • Impression:
      • Right lower gum, squamous cell carcinoma, grade I, well differentiated
      • Right upper lung mass
      • Stroke 5 years ago with right eye blindness
      • Superficial gastritis and erosion
    • Suggestion:
      • Pending PET data. May consider check EGFR
      • Arrange chest CT (+/-contrast) for right upper lung mass evaluation. And then CT guide biopsy if available
• 2022-09-29 Infectious Disease
  • Q
    • This 71 year-old man, has lung tumor and stroke 5 years ago with right eye nearly blindness. He denied any other systemic disease or surgical history. 3 months ago he noted a 3x3 cm growing mass over right level I cervical lymph node. Dysphagia with solid food was also mentioned. The patient came to our ENT OPD for help, after examination, right lower gum cancer was impressed. He was admitted for cancer work up. After a series of examination right lower gum, squamous cell carcinoma, grade I was diagnosed.
    • Since his left lung nodule persist for a logn time, radio-oncologist suggest for further lung CT and CT guide biopsy for rule out malignancy.
    • The patient underwent lung CT on 20220924 which revealed right upper lung cancer, cT3N1M0. We arrange CT guide biopsy on 20220926. After CT guide biopsy, room air SPO2:88~90%. We recheck CXR today showed right lung pneumothorax. Right chest pig-tail was placed on 20220926.
    • According to his serum lab data revealed RPR/VDRL: reactive 1:2. We request your consultation for further treatment.
  • A
    • The Lab data discloses the information, I suggest my opinions as follows:
      • RPR (1:2x) with negative TPHA: false positive for syphilis.
      • RPR (1:2x) with elevated TPHA, not exceeding 1:320, follow-up (RPR and TPHA) 1 month apart; pre-emptive treatment with single dose Retarpen 2.4 MU IM may be considered.
      • RPR (1:2x) with TPHA exceeding exceeding 1:320, follow-up 3 months apart.
    • Suggestion: Check TPHA
• 2022-09-23 Radiation Oncology
  • A
    • Impression: Rt right lower gum cancer with Rt level I LAP metastasis, WD SqCC, cT2N2M0 at least, with synchronous lung cancer, RUL; ECOG =1.
    • Plan: Chest CT and CT-guided biopsy of RUL tumor for staging and tissue proof of RUL tumor. I will follow up him with his son next Tuesday after reports of MRI and PET scan, and clinical staging are available.
• 2022-09-23 Oral and Maxillofacial Surgery
  • Q
    • MRI showed one 2.5x2.5 cm well-shaped homogenous nodule over right lower gum. There was no finding of metastasis or lymphadenopathy over opposite side of neck. PET will be done today.
    • Under the impression of right lower gum, our tentative plan will be either operation or CCRT. Therefore we need your expertise to evaluate the condition of his teeth before radiotherapy. Thank you very much! We appreciate your help.
  • A
    • this 71-year-old man came for dental evaluation before radiotherapy.
    • O:
      • Residual root of tooth #17, #46
      • Severe peridontitis of tooth #18, #24, #41, #44, #45
      • Poor oral hygiene is noted.
    • A:
      • Residual root of tooth #17, #46
      • Severe peridontitis of tooth #18, #24, #41, #44, #45
    • P:
      • take panoramic X-ray film to check
      • explain the findings and treatment plan to the patient
      • suggest extraction of tooth #17, 18, #24, #41, #44, #45, #46
      • tooth extraction would be arranged on 2022/09/26 and 2022/09/29
      • please prescribe Amoxicillin 250mg 2# PO Q8H 2 days before tooth extraction

[chemoimmunotherapy]

• 2023-07-25 - gemcitabine 800mg/m2 1000mg NS 100mL 30min D1 + cisplatin 60mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) (gencitabine + cisplatin, Q3W, NSCLC)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-05 - gemcitabine 800mg/m2 1000mg NS 100mL 30min D1 + cisplatin 60mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) (gencitabine + cisplatin, Q3W, NSCLC)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-07 - gemcitabine 800mg/m2 1000mg NS 100mL 30min
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-05-31 - gemcitabine 800mg/m2 1000mg NS 100mL 30min D1 + cisplatin 60mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) (gencitabine + cisplatin, Q3W, NSCLC)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-10 - gemcitabine 800mg/m2 1000mg NS 100mL 30min
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-05-02 - gemcitabine 800mg/m2 1000mg NS 100mL 30min
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-02-06 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 110mg NS 500mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-06 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 110mg NS 500mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-14 - docetaxel 25mg/m2 40mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-04 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-28 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-21 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-12 - carboplatin AUC 2 120mg NS 500mL 2hr D1 + docetaxel 25mg/m2 35mg D5W 100mL 1hr D2 (reverse sequence?)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1 + NS 250mL D1-2 + aprepitant 125mg PO D1-3

==========

2023-08-14

• According to the PharmaCloud database, the patient only visited our hemato-oncology and radiation oncology departments in the last 3 months, no reconciliation issues were identified.

2022-12-13

• The patient admitted to receive carboplatin/docetaxel treatment for the first time to treat his right lower gum squamous cell carcinoma.
• In the lab results of 2022-12-12, no extreme abnormalities were observed.
• In previous lab analyses of lung adenocarcinoma, EGFR mutation or ROS1 rearrangement was not detected, and PD-L1 TPS and TC were 10%. (no ALK results available yet)
• Patients with NSCLC who are positive for PD-L1 and negative for actionable molecular biomarkers might benefit from atezolizumab treatment. The NHI covers atezolizumab under certain conditions.
• Except for a higher SBP of 156mmHg (2022-12-12 20:30), all vital signs were stable. There is no issue with the active prescription.

700515575

230811

[exam findings]

• 2023-08-04 CT - chest
  • Indication: Malignant neoplasm of liver, primary, unspecified as to type
  • Findings:
    • Low density lesions are found at both lobes of thyroid measuring 2.8cm in largest dimension.
    • Enlarged lymph nodes are found at hepatic hilar region. In comparison with CT dated on 2023-06-23, these lymph nodes enlarged slightly.
    • s/p op. over S4/5 of liver.
    • Bilateral renal cysts up to 5.2cm is found.
  • Imp:
    • Hepatic hilar lymphadenopathy, slightly enlarged.
    • No evidence of pulmonary meta.
    • Thyroid nodules. Suggest sonography.
• 2023-07-20 Patho - liver biopsy needle/wedge
  • Lymph node, hepatoduodenal ligament, EUS-guided FNA/B — Metastatic poorly differentiated carcinoma
  • The sections show a picture of metastatic poorly differentiated carcinoma, composed of nests of pleomorphic polygonal neoplastic cells, arranged in solid pattern with moderate inflammatory cell infiltrate, embedded in fibrous stroma.
  • IHC, tumor cells reveal: CK7(-), CK20(-), Hepa-1(-) and Arginase-1(-). Neither hepatocytic nor cholangiocytic differentiation can be found.
• 2023-06-23 CT - abdomen
  • Hx
    • 20221018 CT: liver tumor 7cm in S4 shows contrast enhancement in arterial phase and contrast washout at late phase, r/o HCC.
    • 20221121 Liver, S4-5, segmentectomy: HCC, pT2Nx; Stage II at least
      
  • Findings:
    • S/P S4-5 segmentectomy of the liver and cholecystectomy.
      • Biloma 2.5 x 2 cm in S5 liver bed is noted.
    • There are several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size.
      • Metastatic nodes are highly suspected.
      • The differential diagnosis includes reactive nodes and lymphoma.
      • please correlate with clinical condition and PET scan.
      • In addition, there is one enlarged node 1.4 x 0.8 cm in left para-aortic space.
    • There are several renal cysts on both kidney and the largest one measuring 5.7 cm in size at left lower pole.
    • Abdominal aorta shows atherosclerosis and aneurysm 3.8 cm.
    • S/P hysterectomy
    • There is a diverticulum measuring 4 cm in the medial aspect of duodenum 2nd portion, near the ampulla of Vater area. Please correlate with clinical condition.
    • Hyperplasia of left adrenal gland is noted.
    • There is mild irregular contour of the left lobe liver that may be early cirrhosis.
  • Impression:
    • There are several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size.
    • Metastatic nodes are highly suspected.
    • The differential diagnosis includes reactive nodes and lymphoma.
    • please correlate with clinical condition and PET scan.
• 2022-11-21 Patho - liver partial resection
  • PATHOLOGIC DIAGNOSIS:
    • Liver, S4-5, laparoscopic segmentectomy — Hepatocellular carcinoma
      
    • Pathologic Staging: pT2Nx; Stage II at least
      
  • MACROSCOPIC EXAMINATION
    • Specimen Type: S4-5 laparoscopic segmentectomy
    • Specimen Size: 10.2 x 8.1 x 4.0 cm; Weight: 162.5 gm
      
    • Focality: Solitary, well-defined, yellow and tan mass, 1.4 cm away from the nearest resection margin
      
    • Tumor Size: 7.0 x 6.0 x 3.5 cm
      
    • Satellite nodules: None
    • Tumor necrosis: Present
      
    • Venous (Large Vessel) Invasion: Absent
      
    • Non-tumor Liver Tissue: Cirrhotic
    • Representative parts are taken for section and labeled as: A1= tumor + margin, A2-A4= tumor, A5= non-tumor
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Hepatocellular carcinoma, mixed trabecular and pseudoglandular patterns
    • Histologic Grade: Poorly differentiated (G3)
    • Tumor Growth Pattern: Mass-forming
      
    • Tumor Necrosis: Present (<10%)
    • Tumor Extension: Tumor confined to hepatic parenchyma
      
    • Large Vessel Invasion: Not identified
      
    • Small Vessel Invasion: Present
      
    • Perineural Invasion: Not identified
      
    • Margins
      • Parenchymal Margin: Free, 1.6 cm from closest margin
        
      • Hepatic Capsule: Involved by invasive carcinoma
    • Pathologic Staging (pTNM): Stage II at least (pT2Nx)
      
    • Additional Pathologic Findings: Marked intratumoral neutrophils and chronic inflammatory cells infiltration
    • Hepatitis (specify type): Non-B and non-C
    • Ishak Modified HAI Grading: Score=4 (interphase hepatitis=1/4, confluent necrosis=0/6, focal necrosis=1/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
      
    • Ishak Staging: F6 (Corresponding Metavir F4, cirrhosis)
    • Fatty change: Minimal (1%)
    • IHC: CK7(+ for pseudoglandular component), CK20(-), Hepa-1(+), Arginase-1(+)
• 2022-10-25 Bronchodilator Test
  • mild restrictive impairment; non-significant bronchodilator response
• 2022-10-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 29) / 111 = 73.87%
    • M-mode (Teichholz) = 74
• 2022-10-18 CT - abdomen
  • Clinical history: 83 y/o female patient with RUQ for 2 weeks, symptoms improving now, No fever. aggravated when breath?.
  • With and without contrast enhancement CT: ABD — liver, spleen, biliary duct, pancreas
    • There is liver tumor, 7cm in S4 with mild enhancement and some washout at late phase, with abdominal wall abutting, r/o atypical HCC, cholangiocarcinoma or mixed type.
    • Bilateral renal cysts, up to 4.7cm.
    • Presence of duodenal diverticulum.
    • Aneurysmal dilatation of abdominal aorta.
    • Bulging contour at left adrenal gland, r/o adrenal hyperplasia.
  • Impression:
    • Liver tumor (S4) with abdominal wall abutting, r/o atypical HCC, cholangiocarcinoma or mixed type.
    • Bilateral renal cysts.
    • Duodenal diverticulum.
    • Aneurysmal dilatation of abdominal aorta.
    • R/O left adrenal hyperplasia.
  • Post-OP:
    • Liver, S4-5, laparoscopic segmentectomy — Hepatocellular carcinoma, Pathologic Staging: pT2Nx; Stage II at least
  • Imaging Report Form for Hepatocellular Carcinoma
    • Impression (Imaging stage) : T:T1b(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)

[MedRec]

• 2023-08-10 SOAP Radiation Oncology

  • O: RT (2023-08-09 ~): at 360cGy/2 fractions of the metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.

• 2023-08-02 SOAP Hemato-Oncology Xia HeXiong

  • P: Port-A and admission for CCRT with CDDP or 5-FU

• 2023-07-27 SOAP Hemato-Oncology Gao WeiYao

  • O
    • 2023/07/20 PATHO - Liver biopsy needle/wedge
      • IHC, tumor cells reveal: CK7(-), CK20(-), Hepa-1(-) and Arginase-1(-). Neither hepatocytic nor cholangiocytic differentiation can be found.
  • P
    • Recommend to be checked with PET for searching with possible primary origin.

• 2023-07-27 SOAP Radiation Oncology

  • O
    • Cytology (N2023-02815, 2023-07-21): EUS guide NA/B of liver: posiitve for malignancy; see description. The differential diagnoses include but not limited to cholangiocarcinoma or hepatocellular carcinoma with the former favored.
      
    • Pathology (S2023-14355, 2023-07-24): Lymph node, hepatoduodenal ligament, EUS-guided FNA/B — Metastatic poorly differentiated carcinoma.
  • A:
    • Hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least), s/p laparotomy S4-5 partial resection & cholecystectomy, with metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.
  • P:
    • Radiotherapy is indicated for this patient with the following indicators: metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.
    • Goal: palliation
    • Treatment target and volume: metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 4500cGy/25 fractions of the metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.
      
    • The treatment planning of radiotherapy will be started at 1030, 2023-08-01.

• 2023-07-19 ~ 2023-07-20 POMR Gastroenterology

  • Discharge diagnosis
    • Hepatocellular carcinoma, s/p partial resection and cholecystectomy in 2022/11, r/o hepatoduodenal ligment LN metastases, s/p endoscopic ultrasound biopsy on 2023/07/20
  • CC
    • For scheduled endoscopic ultrasound and fine needle biopsy for lymph nodes enlargement
  • Present illness
    • This 85 y/o female patient had the following underlying diseases,
      • Type 2 diabetes mellitus,
      • Hypertension and
      • Hepatocellular carcinoma,s/p S4/5 partial resection, PT2Nx stage II and cholecystectomy on 2022/11/21
    • She was regular followed up at our GI OPD follow-up. The 2023/06/21 CT showed several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size and one enlarged node 1.4 x 0.8 cm in left para-aortic space. Metastatic nodes are highly suspected. She denied body weight loss or poor appetite or abdominal discomfort. The aFP level was not elevated (3.3).
    • Under suspicious hepatocellular carcinoma lymph node metastases, she was admitted for endoscopic ultrasound and fine needle biopsy for lymph nodes enlargement.
  • Course of inpatient treatment
    • She was admitted for EUS + biopsy for suspicious HCC lymph nodes metastases. The EUS + biopsy was performed on 7/20 and showed Multipe hypoechoic lesions with hypoechoic component noted at hilum near the pancrea; Largest one was about 35 mm.
    • Mild ascites was noted. s/p lymph node biopsy.
    • The pathology report was pending.
    • There was no obvious abdominal pain after the procedure, she then was arranged todischarge on 7/20 and GI/GS OPD follow-up.

• 2023-07-04 SOAP Hemato-Oncology Gao WeiYao

  • S: For evaluation due to several enlarged nodes in the hepatoduodenal ligament and partaaortic space with NORMAL AFP

• 2023-07-04 SOAP Radiation Oncology

  • S: For evaluation due to several enlarged nodes in the hepatoduodenal ligament and partaaortic space.
    • PI: Hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least), s/p laparotomy S4-5 partial resection & cholecystectomy (on 2022-11-21), with suspicious metastatic nodes in the hepatoduodenal ligament and partaaortic space.
    • Family history: (-)
    • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
    • Personal Hx: DM (+); HTN (+)
    • Allergy (+)
    • Previous RT Hx: (-)
  • O:
    • O: ECOG: 0
    • PE: neck and bil SCF: neg.
    • Operation (2022-11-21): Laparotomy S4-5 partial resection & cholecystectomy
    • Pathology (S2022-20594, 2022-11-23):
      • Liver, S4-5, laparoscopic segmentectomy — Hepatocellular carcinoma.
      • Pathologic Staging: pT2Nx; Stage II at least
        
    • Abd sono (2023-3-24):
      • S/P surgical resection of S4 liver.
      • S/P cholecystectomy.
      • There is a hypoechoic lesion 3.55 x 2.87 cm in the peripancreatic neck area that may be enlarged node.
      • Abdominal aortic aneurysm 3.4 x 3.7 cm (width x depth).
      • Several renal cysts on both kidneys.
      • Otherwise, no significant abnormal finding is noted.
    • CT scan of abdomen (2023-6-23):
      • There are several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size. Metastatic nodes are highly suspected. The differential diagnosis includes reactive nodes and lymphoma. please correlate with clinical condition and PET scan.
    • Lab data
      • 2023/06/23 AFP = 3.3 ng/mL;
  • A:
    • Hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least), s/p laparotomy S4-5 partial resection & cholecystectomy, with suspicious metastatic nodes in the hepatoduodenal ligament and partaaortic space.
  • P:
    • Refer to medical oncology for further evaluation the nature of suspicious nodal lesions.
    • RTC: 2 weeks.

• 2023-06-21 SOAP Cardiology

  • Prescription
    • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# PRNQD
    • Eurodin (estazolam 2mg) 1# HS
    • Concor (bisoprolol 5mg) 0.5# QD
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD

• 2023-06-20 SOAP Metabolism and Endocrinology

  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertention, unspecified [I10]
    • Heart failure,unspecified [I50.9],
  • Prescription x2
    • Tulip (atorvastatin 20mg) 0.5# QD
    • Glimet (glimepiride 2mg, metformin 500mg) 0.5# QD
    • Dibose (acarbose 100mg) 1# QD
    • Trajenta (linagliptin 5mg) 1# QD

[consultation]

• 2023-08-10 Psychosomatic Medicine
  • Q
    • Cancer inpatients with suicidal thoughts score >= 2.
  • A
    • Psychiatric impression:
      • Adjustment disorder, with depressive and anxious mood.
    • Clinical course:
      • This is a 84 y/o female who lives with her family. She was admitted today for preparing chemotherapy for hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least).
      • According to the patient, she has right upper abdominal discomfort about 2 months ago, and after a serial of examination, hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least) was impressed, and she is receiving treatment now, underwent radiotherapy and now preparing for chemotherapy. She also mentioned about stressfulness feeling and worry about her husband because he suffered from COVID infection, worrisome behaviors, and fell down in recent 1 month.
      • In recent 1 month, she has dysphoric mood, less happy feeling , decrease appetite, sometimes insomia (difficulty falling asleep, shallow sleep), intermittent death thoughs (The patient mentioned that about a month ago, when her husband was less stable, she would think about leaving and giving up. Currently, her husband’s condition has improved, and she doesn’t have those thoughts of wanting to die as much. However, she still feels distressed due to dealing with health issues like the tumor.)
      • MSE: kempt, sitting at her bedside, concious clear, frowning, worry, low mood, polite and social smile, fluent speech, appropriate tone and volume
    • Suggestion:
      • Acute intervention, supportive psychotherapy
      • Suggest Mirtazapine (30mg) 0.5# HS with Eurodin (2mg) 0.5-1# HSPRN if insomnia

[radiotherapy]

[chemotherapy]

==========

2023-08-11

[reconciliation]

A repeat prescription was issued by our cardiologist on 2023-06-21 and was refilled on 2023-08-06 for Algitab (alginic acid, MgCO3, Al(OH)3), Eurodin (estazolam), Concor (bisoprolol), and Sevikar (amlodipine 5mg, olmesartan 20mg). All of these refilled drugs, except for Algitab, have been included in the formulary. Please confirm whether Algitab is still necessary for the patient.

[FDG-PET/CT in detecting cancers with unknown primary site depends on histological subtype]

On 2023-07-20, the pathologic analysis results of the liver biopsy needle/wedge did not reveal any evidence of hepatocytic or cholangiocytic differentiation based on ICH staining. Therefore, the primary origin of the condition remains unidentified. An article titled “The usefulness of FDG-PET/CT in detecting and managing cancers with unknown primary site depends on histological subtype. Sci Rep. 2021;11(1):17732. Published 2021 Sep 6” highlighted the following key points:

• The study evaluated the usefulness of FDG-PET/CT for detecting primary tumors and guiding treatment in 64 patients with cancers of unknown primary site (CUP).
• PET/CT detected the primary tumor in 44% of patients overall. Detection rate was lower for squamous cell carcinoma (SCC) at 10% vs 50% for non-SCC tumors.
• PET/CT detection did not differ by age, SUVmax, or sites of metastases between groups. However, SCC patients had fewer metastatic lesions than non-SCC.

In light of this, the use of PET could be an optional tool to help identify the origin of the biopsy liver lesion.

700551627

230811

[exam findings]

• 2023-06-23 Pure Tone Audiometry, PTA
  • Reliabilty Fair
  • R’t : 31 dB HL, normal to moderate SNHL
  • L’t : 35 dB HL, mild to moderate SNHL.
• 2023-06-05 Bladder Sonography
  • PVR: 26 mL
• 2023-06-22 CXR
  • Interstitial pattern at LLL.
• 2023-05-23 Patho - vaginal biopsy
  • Vagina, vaginectomy — Adenocarcinoma, recurrent
  • The secvtions show a picture of adenocarcinoma (tumor size: 0.3 x 0.3 cm), composed of low columnar to cuboidal neoplastic cells, arranged in glandular and papillary patterns, floating in mucin pool. The surgical margin is free of carcinoma. The distance of tumor from closest margin about 3 mm.
• 2023-05-03 CT - chest
  • Indication: AIS of lung Vagina adenocarcinoma s/p OP and R/T. R/O recurrence
  • Comparison was made with previous CT dated on 2022
    • Lungs: surgical staple lines and coarse reticular and subsegmental opacities at both lower lobes, s/p wedge-resection.
      • a 11mm lung cyst at RLL too.
      • normal appearance of both upper lobes and RML.
    • Mediastinum and hila: no enlarged LN or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion.
    • Vessels: normal appearance of thoracic aorta.
    • Central pulmonary arteries: dilated trunk (3.4cm in caliber)
    • Heart: normal in size of cardiac chambers.
    • Pleura: minimal effusion and thickening, both sides.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents: a poor enhancing nodule (1.5cm) at liver dome, S8, r/o a hemangioma
      • normal appearance of gall bladder. unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
    • Visualized bones: compression fracture of L1 vertebral body
  • Impression:
    • post op change in both lower lobes of the lungs.
    • no new lung nodule (s). pulmonary hypertension, cause?
• 2023-05-02 CT - abdomen
  • History and indication: Malignant neoplasm of vagina
  • IMP:
    • S/P hysterectomy. R/O recurrent tumor (2.3cm) at vaginal stump with urinary bladder invasion.
    • A poor enhancing nodule (1.5cm) at liver dome r/o hemangioma.
• 2023-04-12 Pap Smear
  • Atypical glandular cells favor neoplasm
• 2023-03-07 CT - abdomen
  • Clinical history: 53 y/o female patient with liver lesion and pathological report and follow up the deisease condition and report. LMP 8/3/20 HPV : + (type 18) pap : abnormal (2020). LEEP in 2016 NTUH, LSC LAVH+BSO (SlLS) on 20200907.
    • post laparotomy operation visit. for checking wound. Vaginal Ca s/p OP.
  • With and without contrast enhancement CT of abdomen–whole:
    • S/P hysterectomy. There is rim enhanced lesion, 1.6cm in the vaginal stump, with urinary bladder involvement, r/o recurrent tumor.
    • Liver tumor, 1.5cm in S8, prior MRI study showed hemangioma. Suggest follow up.
    • Ventral herniation (lower abdomen).
  • Impression:
    • S/P hysterectomy. Rim enhanced lesion in the vaginal stump, with urinary bladder involvement, r/o recurrent tumor.
    • Liver tumor, r/o hemangioma.
    • Post-op at bilateral lower lungs.
• 2023-01-09 CXR
  • Cardiomegaly is noted.
  • Some fibrotic change at left lower lobe is found.
  • Osteopenia of the bony structure is noted.
• 2022-12-09 CT - abdomen
  • history: 52 y/o female patient with Vaginal cancer s/p OP
    • 20220914 lung nodule in RLL and LLL, favor metastases?
    • 20220921 Lung, RLL, VATS wedge: Non-necrotizing granulomatous inflammation
      
    • 20221116 Lung, LLL, VATS wedge: adenocarcinoma in situ.
  • Findings:
    • Prior CT identified two poor enhancing mass 1.5 cm in S8 and 0.4 cm in S5/6 of the liver are noted again, stationary that are c/w hemangiomas after correlate with prior MRI.
    • There are soft tissue lesion with curvelinear calcification in RLL and LLL of the lung that are c/w prior VATS procedure.
  • Impression:
    • Two hemangioma in S8 and S5/8 show stationary.
• 2022-11-16 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, left, lower lobe, wedge resection —- Adenocarcinoma in situ
    • Lymph node, left, group No.9, lymphadenectomy —- Negative for malignancy (0/2) —- Non-necrotizing granulomatous inflammation
      
    • AJCC 8th edition pTNM Pathology stage: pTisN0
  • MACROSCOPIC EXAMINATION:
    • Specimen:
      • F2022-00544: Lung, size: 5.7 x 4.2 x 1.1 cm
      • S2022-20247: Lymph nodes, a bottle, group 9, maximal size: 0.5 x 0.2 cm
    • Tumor Site: Periphery
    • Tumor Size: Solitary: 0.2 x 0.2 x 0.2 cm
    • Gross tumor patterns: Well defined
    • A granuloma measuring 0.3 x 0.2 x 0.2 cm is seen.
    • Tissue for sections:
      • F2022-00544: Representative sections are taken and labeled as: FsA1: granuloma; FsA2: tumor, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: resection margin; X2: lung; X3-4: lung, near tumor.
      • S2022-20247: All for section in a cassette.
        
  • Microscopic Description
    • Tumor Focality: Single tumor
    • Histologic Type (select all that apply): Adenocarcinoma in situ (AIS), nonmucinous; The immunohistochemical stain of TTF-1 is positive.
      
    • Histologic Grade: Not applicable
    • Spread Through Air Spaces (STAS): Not identified
    • Visceral Pleura Invasion: Not identified
    • Lymphovascular Invasion (select all that apply): Not identified
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 0.5 cm
      • Specify closest margin: wedge resection margin
    • Treatment Effect: No known presurgical therapy
    • Regional Lymph Nodes: group 9: 0/2
    • Extranodal Extension: Not identified
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pTis (AIS): Adenocarcinoma in situ (AIS): adenocarcinoma with pure lepidic pattern, ≤3 cm in greatest dimension
        • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
    • Additional Pathologic Findings (select all that apply)
      • Non-necrotizing granulomatous is seen in the lung parenchyma and lymph nodes. The PAS and AFB special stains are negative.
• 2022-11-01 Patho - cervix biopsy
  • Uterus, cervix, biopsy — high-grade glandular dysplasia
  • Microscopically,it shows high-grade glandular dysplasia characterized by papillary hyperplasia of atypical glands lined by high-grade atypical cells with nuclear hyperchromaisa and pleomorphism,coarse chromatin and occasional mitotic figures.
  • Immunohistochemical stain reveals ap16(+) and Ki-67 (+) at dysplastic cells.
• 2022-09-22 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right lower lobe, VATS wedge — Non-necrotizing granulomatous inflammation
      
    • Lymph node, LN 7, right, LND — Non-necrotizing granulomatous inflammation
      
  • MICROSCOPIC EXAMINATION:
    • The section of both “RLL nodule” and “LN7” show a picture of non-necrotizing granulomatous inflammation, composed of granulomas with aggregates of tightly clustered epitheloid histiocytes with giant cells. Necrosis is not present. Neither T.B. bacilli nor fungi can be identified in the acid fast and PAS stains.
• 2022-08-10 Pap Smear
  • Atypical glandular cells favor neoplasm
• 2022-05-16 CT - abdomen
  • S/P hysterectomy.
  • A poor enhancing nodule (1.5cm) at liver dome r/o hemangioma.
• 2022-02-14 MRI - liver, spleen
  • R/O hemangiomas (up to 1.3cm) at S6-8 of liver. Right liver cyst (0.3cm).
• 2022-01-04 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Moderate fatty change, compatible with non-alcoholic fatty liver disease (NAFLD)
    
  • The sections show liver tissue with mild portal inflammation, subtle piecemeal necrosis, mild lobular inflammation, few hepatic ballooning, a poorly formed granuloma, and moderate steatosis (50%). Periportal fibrosis and bridging fibrosis can be identified. There is no evidence of malignancy in the sections examined.
    
  • The grading and staging for NAFLD as follows:
    • Grading: Score = 4 (steatosis = 2/3, ballooning = 1/2, lobular inflammation = 1/3)
      
    • Staging: 3 (Bridging fibrosis)
• 2021-12-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (65 - 17) / 65 = 73.85%
    • M-mode (Teichholz) = 73.8
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Concentric LVH, grade 1 LV diastolic dysfunction
    • Trivial MR, mild TR and PR
• 2021-12-27 Cystography
  • The bladder capacity is about 200cc.
  • No evidence of contrast medium leakage.
• 2021-12-21 Patho - vaginal biopsy
  • PATHOLOGIC DIAGNOSIS
    • Vagina, resection — Adenocarcinoma, HPV-associated
      
    • Pathologic Stage (AJCC 8th ed.): pT1aNx, stage IA if cMo; FIGO stage I
      
  • MICROSCOPIC EXAMINATION
    • Procedure: Vaginal resection
      
    • Tumor Site: Vagina, not otherwise specified
      
    • Tumor Size: 0.8 x 0.6 cm
      
    • Histologic Type: Adenocarcinoma, HPV-associated
      
    • Histologic Grade: G2, moderately differentiated
      
    • Tumor Extension: Involves muscular wall (pT1a)
      
    • Lymphovascular Invasion: Not identified
      
    • Margins: All margins negative for invasive carcinoma
      • Distance of closest margin at least 4 mm
        
    • Regional Lymph Nodes: No lymph nodes submitted (pNx)
      
    • Distant Metastasis: Not applicable
    • Additional Findings: Adenocarcinoma in situ
      
    • IHC: CK7(+), CK20(-), CDX2(focal+), and p16(+)

[MedRec]

• 2023-06-21 ~ 2023-06-24 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Adenocarcinoma, HPV-associated, of the vgaina, pT1aNx, stage IA( if cMo); FIGO stage I status post Exision of vaginal lesion on 2021/12/20, recurrent tumor (2.3cm) at vaginal stump with urinary bladder invasion, s/p vaginal stump mass + partial vaginectomy on 2023/05/22, s/p chemotherapy with Paclitaxel plus carboplatin from 2023/06/23
    • Malignant neoplasm of vagina
    • Type 2 diabetes mellitus without complications
    • Chronic viral hepatitis B without delta-agent
  • CC
    • for prepare chemotherapy
  • Present illness
    • This is a 53-year-old, G6P2AA4 (C/S X 2) woman with underlying medical history of:
      • Cervix biopsy with report CIN3 and Condyloma at right vagina-s/p Loop electrosurgical excision procedure (LEEP) at NTUH on 2005.
      • s/p tracheletomy with report CIN2 recurrence and right side vgina biopsy report VAIN1 at NTUH on 2006.
      • Uterus, cervix, biopsy report LSIL at NTUH on 2009.
      • Recurrent abnormal findings of pap smear; HPV 18 (+) - Cervix biopsy with report: moderate glandular dysplasia, s/p Laparoscopic assisted vaginal hysterectomy + bilateral salpingo-oophorectomy on 2020/09/07 - 2021/10 Vaginal cuff smear: atypical glandular cells, favor neoplasm, s/p vaginal cuff biopsy: high grade glandular dysplasia, s/p Exision of vaginal lesion on 2021/12/20, with pathology report:(Cervical cancer), Adenocarcinoma, HPV-associated, pT1aNxcM0; FIGO stage I, s/p radiotherapy (2022/1/21~3/22); with recurrence.
      • Hemangiomas (up to 1.3cm) at S6-8 of liver.
      • Carcinoma in situ of lung over left lower lobe, s/p video-assisted thoracoscopic surgery left lower lobe lung wedge resection and lymph node sampling on 2022-11-16, under OPD followup.
      • Non necrotizing granulomas in the lungs, under OPD followup.
      • Type II diabetes mellitus, on oral hypoglycemic agent.
    • She has had regular follow-ups at Taipei Tzu Chi Hospital after LAVH + BSO since 2020, and for the above diseases. Abdomen + pelvis CT was performed as needed, in which liver dome and lund nodule were noticed and metastases of cervical cancer had been ruled out via examinations and pathology test. She reported no vaginal bleeding. Occasional vaginal discharge and palpitations were noted.
    • During the recent GYN OPD followup on 2023/03/24, elevated tumor marker CEA level (CEA = 5.23 ng/mL) was detected. Cystoscopy was performed for cancer surverys, and no urethra or bladder invasion was noted. Abdomen + pelvis CT was arranged on 2023/05/02 with impression of 1) S/P hysterectomy.R/O recurrent tumor (2.3cm) at vaginal stump with urinary bladder invasion; 2) A poor enhancing nodule (1.5cm) at liver dome r/o hemangioma. Under the impression of cervical cancer with recurrence, excision of vaginal stump mass + partial vaginectomy, which were performed on 2023/05/22. Severe adhesion between vagina and posterior bladder wall was noted during the operation and bladder ruptured intraoperatively during adhesiolysis, received bladder repair. This time, she was admitted for the prepare chemotherapy and further management.
  • Course of inpatient treatment
    • After admission, collect 24hrs CCr. on 2023/04/04 showed 66.4mL/min, and arranged audiometry on 2023/06/23 showed R’t : 31 dB HL, normal to moderate SNHL、L’t : 35 dB HL, mild to moderate SNHL. Dorison 5#(20mg) po and Cimetidine 1# po before chemotherapy with Taxol 12 hrs on 2023/06/22 at 23:00 and before chemotherapy with Taxol 6 hrs on 2023/06/23 at 05:00, she received chemotherapy with paclitaxel (175mg/m2, self paid) plus carboplatin (AUC:6, sflf paid) on 2023/06/23 (C1) smoothly. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. Type 2 diabetes mellitus was treated with Kludone MR 60mg/tab 1# PO QDAC and Forxiga 10mg/tab 1# PO QDAC control. For chemotherapy, Vemlidy 25 mg/tab 1# PO QD was given for Anti-HBc reactive. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/06/24 and OPD followed up later.
  • Discharge prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
• 2023-05-20 ~ 2023-05-25 POMR Obstetrics and Gynecology Huang SiCheng
  • Course of inpatient treatment
    • She was arranged to admit for excision of vaginal stump mass + partial vaginectomy, which were performed on 20230522. Severe adhesion between vagina and posterior bladder wall was noted during the operation and bladder ruptured intraoperatively during adhesiolysis. We consulted urologist for bladder repair.The perforation lesion was repaired with 3-0 vicryl with watertight closure technique. There was no leak after normal saline leak test for 200 ml. Cystoscopy showed intact trigone and bilateral DBJ in situ. We were suggested to keep her foley 1 week after the operation for further observation. Her postoperative course was uneventful. Abdominal wound was clear without discharge and healing was well. Under patient’s requirement, she was discharged on 2023/05/25 with foley and double-J catheterization. Her OPD follow-up appointment is scheduled on 2023/05/30. Cystoscopy will be arranged then.
• 2021-12-30 SOAP Hemato-Oncology Xia HeXiong
  • Conclusion of Multidisciplinary Cancer Team Meeting, Meeting Date: 2021-12-30
    • Liver biopsy (2021/12/9 Abd CT: r/o liver meta)
    • Postoperative Radiotherapy.

[surgical operation]

• 2023-05-22 Cystorrhaphy + cystoscopic exam
  • Finding:
    • A 3 cm laceration wound at posterior wall, just near the previous vaginal wall
    • No N/S leak after 200 ml infusion to bladder
  • Procedure:
    • We took over from GYN doctor. Identify the perforation site of urinary bladder. Repair with 3-o vicryl with watertight closure technique. There was no leak after normal saline leak test for 200 ml. Cystoscopy showed intact trigone and bilateral DBJ in situ. The GYN doctor took over for the further surgery.
• 2023-05-22 Excision of vaginal stump mass + partial vaginectomy
  • Finding:
    • Moderate adhesion of pelvic wall and sigmoid colon. Little ascites s/p washing cytology.
    • Vaginal lesion with papillary tissue at 9 ~12 oclock direction, 2x1cm, s/p excision
    • Severe adhesion between vagina and posterior bladder wall, bladder rupture intraoperatively, s/p repair by urologist.
    • Estimated blood loss: 300ml
    • Blood transfusion: nil
    • Complication: nil
  • Procedure:
    • Put patient on the lithotomy position.
    • Skin disinfection with betadine.
    • Supraumbilical midline vertical skin incision was done
    • Open the abdominal wall layer by layer.
    • Apply auto-retractor and pack up the intestine to expose the pelvic cavity.
    • Pelvic adhesiolysis was done.
    • Severe adhesion between vagina and posterior bladder wall, bladder rupture intraoperatively, s/p repair by urologist.
    • Excision of vaginal lesion and partial vaginectomy were performed smoothly to remove the lesion with safe margin.
    • Close the wound with 2-0 Vicryl.
    • Severe adhesion between vagina and posterior bladder wall, bladder rupture with a 3x2 cm hole intraoperatively, s/p repair by urologist.
    • Checking bleeding and hemostasis.
    • Two 15fr J-VAC were placed in the bilateral CDS
    • Reperitonealization and close the abdominal wall layer by layer.
    • Approximation of skin with 4-0 Vicryl.
• 2023-05-22 cystoscopy examination and bilateral double J stenting   - Finding:
  • mass compression of bladder neck from external side
  • No gross tumor noted in bladder
  • Procedure:
    • Under endotracheal general general anesthesia, the patient was in lithotomy position. Disinfection and draping the operation field were done as usual methods. Cystoscopy was performed to examinate bladder and identify bil UO. After retrograde insertion of guidewire, 6 Fr 24 cm double-J catheters were inserted at each side.
    • A 14 Fr Foley catheter was indwelled. The patient stood the procedures 

[chemotherapy]

• 2023-07-18 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-21 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-08-11

[reconciliation]

A refill for a 28-day quantity of Omeprotect (omeprazole) and Dulcolax (bisacodyl) was recently completed on 2023-08-05, but these medications are currently not listed in the active medication records. Kindly assess whether these drugs are no longer required for the patient.

2023-07-19

[reconciliation]

On 2023-07-08, the patient just refilled a 28-day supply of Omeprotect (omeprazole) and Dulcolax (bisacodyl), and on 2023-07-10 refilled a 30-day supply of Anxoken (metformin), Kludone (gliclazide), and Forxiga (dapagliflozin). However, metformin is currently absent from the active medication list, and a serum glucose level of 341mg/dL was recorded on 2023-07-19 at 16:16. It is advisable to determine if the omission of metformin is deliberate or due to the scheduling of a CT scan.

700768893

230811

[exam findings]

• 2023-08-02, -08-01 CXR
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-07-29 KUB
  • Calcifications in the pelvic cavity, could be due to phleboliths.
• 2023-07-29 ECG
  • Sinus tachycardia
  • Right atrial enlargement
  • Nonspecific ST abnormality
• 2023-07-13 EGD
  • Gastric cancer, borrmann type IV
  • Reflux esophagitis LA Classification grade A
• 2023-06-05 CT - abdomen
  • Indication: Gastric cancer s/p C/T
  • Abdominal CT with and without enhancement revealed:
    • Diffuse gastric wall thickening at antrum is found. In comparison with CT dated on 2023-01-11, the lesion is stationary.
    • The GB is well distended without soft tissue lesion
    • There is no evidence of destructive bone lesion.
    • Dilated IHDs and CBD is found.
    • s/p enterostomy with its orifice at RLQ.
    • The urinary bladder is partially distended without evidence of abnormal soft tissue lesion.
    • No evidence of abnormal soft tissue mass at pelvic cavity.
    • No definite inguinal or pelvic sidewall LAP
    • The spleen, pancreas, both kidneys and adrenals are intact.
  • Imp:
    • Diffuse gastric wall thickening, stable.
    • Dilated IHDs and CBD. Suggest close observation.
• 2023-02-10 Lower GI Series (colon filling study)
  • Filling LGI series show
    • No evidence of abnormal filling defect along the course from rectum into descending colon.
    • Increased intestinal gas is found.
    • There is no evidence of destructive bone lesion.
• 2023-02-06 CXR
  • Blunted left costophrenic angle.
• 2023-02-06 ECG
  • Normal sinus rhythm
  • Low voltage QRS
• 2023-02-06 Flow volume loop
  • moderate restrictive impairment
• 2023-02-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (54 - 16) / 54 = 70.37%
    • M-mode (Teichholz) = 69
  • Adequate LV systolic function with normal resting wall motion
  • Trivial MR and trivial TR
  • Preserved RV systolic function
• 2023-01-13 Patho - doudenum biopsy
  • Labeled as “duodenum, SDA”, biopsy (B)— benign duodenal tissue with marked chronic inflammation and mild to moderate dilatation of lymphatics.
• 2023-01-13 Patho - stomach biopsy
  • Stomach, GC, biopsy — Adenocarcinoma.
  • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and isolated neoplastic signet ring-like cells.
  • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0). CD68 (-).
• 2023-01-11 CT - abdomen
  • History:
    • 20220927 CT：Pneumoperitoneum. Swelling and wall thickening of the terminal ileum and ascending colon.
    • Emergent S/P right hemicolectomy and terminal ileostomy: A-colon perforation, Compatible with diverticulitis with perforation and suppurative peritonitis
  • Indication: weight loss
  • Impression:
    • There is dilatation of IHDs, CHD, CBD, and pacreatic duct.
      • Please correlate with serum alk-p and bilirubin level.
    • There is edematous wall thickening of the distal esophagus, stomach, and duodenum. Please correlate with gastroscopy.
    • Adhesion bands induce mechanical high grade small bowel obstruction is highly suspected.
      • please correlate with clinical condition.
    • There is edematous wall thickening of the transverse-and descending colon. Please correlate with colonoscopy to R/O ulcerative colitis or Crohn disease.
• 2023-01-10 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
• 2023-01-10 SONO - abdomen
  • Gallbladder sludge
  • CBD dilatation and IHD dilatation
• 2022-12-26 Patho - stomach biopsy
  • Stomach, unspecified site, biopsy — Non-atrophic chronic gastritis, Helicobacter Pylori: NOT present
• 2022-12-23 Esophagogastroduodenoscopy, EGD
  • Giant folds of stomach with poor distention upon air inflation, r/o inflitrated type malignancy, s/p CLO test and biopsy
  • Reflux esophagitis LA Classification grade A
• 2022-10-14 CXR
  • Focal sclerotic change of left humerus.
  • Blunted bilateral costophrenic angles.
• 2022-10-12 CXR
  • Bilateral pleural effusion.
  • Ground glass opacity in bilateral lower lungs.
  • Some calcifications at left humerus.
• 2022-10-10 CXR
  • Ground glass opacity in RLL.
  • Patch density at LLL.
  • Focal sclerotic change at left humeral head.
• 2022-10-04 CTA - chest
  • Indication: pulmonary embolism
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Status post endotracheal tube placement.
      • Consolidation over both lower lungs with bilateral pleural effusion is found.
      • Increased pulmonary vasculature is found.
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • There is no evidence of mediastinal LAP
      • Patent airway is found.
    • Visible abdomen:
      • Moderate ascites at abdominal cavity is found mostly around pancreas is found. Please exclude the possibility of pancreatitis.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • Minimal infiltration at mesentery is found.
      • Suggest clinical correlation
  • Imp:
    • No evidence of pulmonary embolism nor aortic dissection is found.
    • Increased pulmonary vasculature is found.
    • BIlateral pleural effusion and consolidation over bilateral lower lungs.
    • Moderate ascites at abdominal cavity is found mostly around pancreas is found. Please exclude the possibility of pancreatitis.
• 2022-09-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (92 - 38) / 92 = 58.70%
    • M-mode (Teichholz) = 58.5
  • Normal chamber size
  • Adequate LV and RV systolic function
  • Mild MR and TR , trivial AR
  • No regional wall motion abnormalities
• 2022-09-29 SONO - chest
  • Bilateral thorax: small amount pleural effusion; thoracocentesis was not performed due to high risk of complications.
• 2022-09-27 Patho - colon resection (non tumor)
  • PATHOLOGIC DIAGNOSIS
    • Ascending colon, right hemicolectomy — Compatible with diverticulitis with perforation and suppurative peritonitis
  • MACROSCOPIC EXAMINATION
    • Operation procedure: Right hemicolectomy
      
    • Specimen site: Right colon
      
    • Specimen size: 25 cm (ascending colon), 8 cm (ileum), and 7 cm (appendix) in length, respectively
      
    • Grossly, the surface of intestine is coated by fibrinous exudate. There is a subtle diverticulum with a perforated hole in ascending colon is present. The appendix is congested. The ileum is unremarkable.
    • Representative parts are taken for section and labeled: A1= ascending colon with perforation, A2-A4= colon + pericolic soft tissue, A5-A6= appendix
  • MICROSCOPIC EXAMINATION
    • The sections of ascending colon show a picture compatible with diverticulitis with perforation, composed of diverticulum with transmural necrosis, moderate neutrophil infiltration, subserosal fibrosis, granulation tissue, and acute serositis. Suppurative peritonitios with bacterial colonies and abscess formation are present.
    • The sections of appendix show mucosal hyperplasia and periappendicitis.
    • The sectiobns of ileum show acute serositis.
• 2022-09-27 CXR
  • Ground glass opacity in bilateral lower lungs.
• 2022-09-27 CTA - chest
  • Clinical history: 60y/o female patient with sudden low abdominal pain since 2 hours ago, epigastric pain for half month.
  • With and without contrast enhancement CT: CTA, Chest
    • Presence of ascites and pneumoperitoneum.
    • Swelling/thickening at terminal ileum.
    • Enlarged mesentery lymph nodes in right lower abdomen.
    • No abnormal fluid accumulation in the mediastinum and pleural space.
  • Impression:
    • Pneumoperitoneum with ascites, suspected hallow organ perforation.
    • Swelling/thickening at terminal ileum.
• 2022-09-27 ECG
  • Sinus rhythm with ventricular premate complexes
  • Nonspecific ST abnormality
  • Prolonged QT

[MedRec]

• 2023-07-25 SOAP Hemato-Oncology
  • Taking “Astragalus Root” (huang2qi2) since the beginning of chemotherapy
• 2023-07-18 SOAP Hemato-Oncology
  • P: Changing regimen from FLOT to FOLFOX

[consultation]

• 2023-02-23 Hemato-Oncology
  • Q
    • Gastric cancer for neoadjuvant chemotherapy
    • This 60 y/o female with past history of ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27.
    • However, poor intake, poor appetite with body weight loss was still persisted after operation.
    • Further UGI scope was performed which revealed enlarged Gastric folds prob Scirrhous s/p biopsy. Pathology showed adenocarcinoma. IHC stains: CK highlights neoplastic cells. Her2/neu: negative. (score=0). CD68 (-).
    • She was admitted to our ward for nutrition support first then further oepration was performed on 2023/02/20. Operation finding showded severe intraperitoneal adhesion (frozen peritoneal), huge gastric ca with possibly peritoneal spread. We discussion with her family then further chemotherapy will be consider first. We need your help for further managememt for chemotherapy. Port-A insertion will be arrange on 2023/02/22 PM. Thanks for your time!!
  • A
    • This 60 year old woman is a case of previously untreated, unresectable, non-HER2-positive gastric cancer with possibly peritoneal spread (pending pathology result). She had history of ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27. We are consulted for further treatment.
    • Please check PD-L1, HbsAg, AntiHbc, Anti HCV. Please arrange port A insertion. And arrange chest CT+/-contrast for complete staging.
    • Chemotherapy +/- immunotherapy is indicated in this patient. Arrange our OPD after discharge. Thanks for your consultation.
• 2023-02-06 Anesthesiology
  • Q
    • CVC insertion for nutrition with TPN
    • This 60 y/o female was a case of 1) Ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27. 2) Gastric cancer.
    • This time, she sufferred from poor appetite with vomit then BW weight loss was noted in recent months. We need your help for CVC insertion with nutrition support. Thanks for your time!!
  • A
    • Procedure
      • After positioning via Trendelenburg position,head rotated, elevated shoulder, the skin was sterilized and anesthetized with 2% lidocaine 2 m.l..
      • The right IJV was difficult to cannulated.
      • We performed 7 fr CVC insertion to left internal jugular vein with ultrasound-guided under Seldinger technique
      • The pt tolerant the procedure well.
      • There was no sign of hematoma, pneumothorax, infection after the procedure.
    • The recommandation is as followed:
      • Please check chest roentgenography for localization.
      • Change IV set QD if TPN used or Q4D if general fliud.
      • Change OP site at least every week. IF loosening or blood accumulation please change it ASAP.
      • We do not recommand routinely change the CVC unless there are some infectious signs.
• 2022-10-19 Cardiac surgery
  • Q
    • For further evaluation of D-dimer elevation, deep vein thrombosis ???
    • This 60 y/o female suffered from sudden low abdominal pain for hours, and epigastric pain for half month.
      • CT: Pneumoperitoneum with ascites.
      • Ascending colon diverticulitis with perforation was diagnosed. Operation of Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27.
      • During hospitalization. D-dimer elevation was noted and Clexane 30mg SC QD was give since 2022/10/14. Bilateral legs no distention, and freely movable.
      • D-dimer
        • 2022-09-30 05:58 2100.45 ng/mL(FEU)
          
        • 2022-10-04 12:28 > 10000.00 ng/mL(FEU)
        • 2022-10-09 07:50 7286.88 ng/mL(FEU)
          
        • 2022-10-10 05:17 6349.13 ng/mL(FEU)
          
        • 2022-10-12 05:09 8695.92 ng/mL(FEU)
          
        • 2022-10-14 07:28 9250.27 ng/mL(FEU)
          
        • 2022-10-19 07:42 8570.57 ng/mL(FEU)
          
    • So we consult you for further evaluation and management of blood D-dimer elevation the problem. (is it possible to swift oral medication?).
  • A
    • This 60 y/o female, history reviewed as above and herself examined, consulted for elevated D-dimer under clexane therapy
      • Chest CTA 2022/10/04 no pulmonary embolism
      • PE both limb soft, without tender swelling, already off-bed ambulation, dyspnea (-)
    • Recommendation
      • no clinical evidence of significant DVT
      • may arrange duplex PRG (lower limbs sonography for peripheral vessel) to exclude DVT possibility, then DC clexance accordingly
• 2022-10-07 Thoracic Medicine
  • Q
    • for Left pleural effusion.
    • This 60 y/o female had history of gastric ulcer. Under the impression of sigmoid colon with perforation, fecal peritonitis + necrosis of omentum and septic shock s/p emergent Hartman procedure on 2022/09/27. CXR showed Left pleural effusion on 2022/10/07. We need your help for treatment assessment (chest echo?? tapping??). Thank you so much!!!
  • A
    • Series image showed progressive bilateral pleural effuison, Left side > right side.
    • severe hypoalbuminemia : <1.9 —> 2.3 —> 2.3
    • 20221004 CT showed: peritonitis with ascites, reactive bilateral pleural effusion
    • Suggestion:
      • Please take the permit. We will arrange chest echo for chest tapping +/- 14Fr. pig-tail catheter insertion for her.
      • Change antibiotics to Unasym or consult infection to adjust antobiotics use
      • Albumin replacement to keep Albumin level = 3.5 at least
      • Lasix for remove third space edema
      • thanks and f/u prn.
• 2022-09-27 Thoracic Medicine
  • Q
    • This 60 y/o female had history of gastric ulcer. According to her family’s history, she had got lower abdominal pain since last night. Epigastric pain had been noted for half month. At ER, dyspnea with chest pain and cold sweating were also noted. Vital signs showed BP 115/67mmHg, HR 93bpm, BT 36.9’C, RR 18. Lab data revealed: WBC 13K, CRP 1.0, Troponin within normal range, no elevated Bilirubin or Lipase. CT showed: Pneumoperitoneum with ascites, r/o hallow organ perforation and swelling terminal ileum. Brosym was prescribed and operation was arranged. Resection of A colon with ileostomy was perforemed. Under the impression of Pneumoperitoneum with ascites due to A colon perforation, she was admitted to our ICU for further care.
    • Consult purpose: decrease saturation with Bilateral pleural effusion, r/o lung compartment syndrome. consider Bronchoscopy?
  • A
    • S: short of breath
    • O:
      • 20220929 bed-side chest sono: bilateral small amount pleural effusion
      • 20220929 CRP=37, WBC=27.5K
      • 20220927 albumin < 1.5
      • 20220927 BW=63.1 Kg –> 20220929 BW=66.5Kg
      • 20220928 CXR: bilateral lung consolidation
      • 20220929 breath sound: clear
    • A:
      • ARDS, moderate to severe degree; favor secondary to intra-abdmonial infection
      • pneumoperitoneum s/p operation
    • P:
      • Bronchoscopy was relatively contra-indicated due to high oxygen demand [FiO2=100% on 20220929 PM3:00]. Bronchoscopy probably causes desaturation during and after the procedure.
      • arrange cardiac echo and check serum D-dimer and NT-proBNP for suspected pulmonary embolism and congestive heart failure
      • follow up ABG/CXR QD
      • prone position was relatively contra-indicated due to septic shock status and large surgical wound over anterior abdominal wall
      • check serum Aspergillus Ag, serum cryptococcus Ag, serum Mycoplasma IgM, serum Chlamydia IgM, and urine legionella Ag, urine streptococcus Ag for pathogen survey
      • check sputum TBPCR, TB culture, acid-fast stain and aerobic culture for pathogen survey
• 2022-09-27 General and DigestiveSurgery
  • A
    • P,E showed regid abdomen, with muscle guarding
    • diffuse local tenderness and knocking pain, right
    • Lab and CT showed neumoperitoneum , in favor of PPU
    • Emergency op is indicated

[chemotherapy]

• 2023-08-09 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-06-27 - (FLOT)
• 2023-06-13 - (FLOT)
• 2023-05-30 - (FLOT)
• 2023-05-16 - (FLOT)
• 2023-04-25 - (FLOT)
• 2023-04-11 - (FLOT)
• 2023-03-23 - (FLOT)
• 2023-02-24 - docetaxel 35mg/m2 50mg D5W 160mL 1hr + oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 200mg/m2 270mg NS 250mL 2hr + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (FLOT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-08-11

[Astragalus Root]

The patient has been consistently using Astragalus Root since starting chemotherapy (2023-07-25 Onc Opd). To assess whether Astragalus Root might impact the effectiveness of chemotherapy, a literature search was conducted, and a relevant article was found: “Meta-Analysis of Astragalus-Containing Traditional Chinese Medicine Combined With Chemotherapy for Colorectal Cancer: Efficacy and Safety to Tumor Response. Front Oncol. 2019;9:749. Published 2019 Aug 13. doi:10.3389/fonc.2019.00749”

Here is a summary of the key points from the research article:

• The article is a meta-analysis evaluating the efficacy and safety of combining Astragalus-containing traditional Chinese medicine (TCM) with chemotherapy for treating colorectal cancer, compared to chemotherapy alone.
• 22 randomized controlled trials with a total of 1409 patients were included. Trials used various oral, injected or external TCM preparations containing Astragalus.
• The meta-analysis found combining Astragalus-based TCM with chemotherapy significantly improved tumor response rate and quality of life compared to chemotherapy alone.
• Combination therapy also reduced chemotherapy side effects including myelosuppression, nausea/vomiting, diarrhea and neurotoxicity.
• No significant differences were found between groups for liver or kidney dysfunction side effects.
• Limitations include generally low quality of included trials and all Chinese studies, reducing applicability. More rigorous research is needed.
• Overall, the meta-analysis suggests Astragalus-containing TCM combined with chemotherapy may have benefits for colorectal cancer, but further high-quality studies are warranted.

Based on the findings of this study, there is currently no evidence to suggest that the patient should discontinue the use of Astragalus Root.

2023-03-20

• Leukopenia was observed on 2023-03-08, approximately 2 weeks after the patient received her first cycle of FLOT regimen chemotherapy, which started on 2023-02-24. The patient then received Granocyte (lenograstim 250ug) for three consecutive days (since 2023-03-08) and has not experienced any further episodes of leukopenia.

  • 2023-03-15 WBC 9.76 x10^3/uL
    
  • 2023-03-08 WBC 1.76 x10^3/uL
    
  • 2023-02-23 WBC 5.75 x10^3/uL
    
  • 2023-02-21 WBC 6.51 x10^3/uL

• According to a study, preoperative FLOT chemotherapy appears to be safe and feasible for the treatment of resectable locally advanced gastric cancer. The FLOT regimen used in the study consisted of docetaxel (60 mg/m2), oxaliplatin (85 mg/m2), leucovorin (200 mg/m2), and 5-fluorouracil (2,600 mg/m2 as a 24 hr infusion). The study suggests that FLOT may be more effective in reducing morbidity and improving overall survival compared to initial surgery followed by chemotherapy. The patient received a reduced version of the FLOT regimen, which includes docetaxel 35mg/m2, oxaliplatin 75mg/m2, leucovorin 200mg/m2, and fluorouracil 2600mg/m2. (ref: Docetaxel, oxaliplatin, leucovorin, and 5-fluorouracil (FLOT) as preoperative and postoperative chemotherapy compared with surgery followed by chemotherapy for patients with locally advanced gastric cancer: a propensity score-based analysis. Cancer Manag Res. 2019;11:3009-3020. Published 2019 Apr 10. doi:10.2147/CMAR.S200883).

• The dose used in this patient was lower than what is recommended in our in-hospital “Prescription Collection of Chemotherapy for Gastric Cancer” protocol (dated 2022-06-21). The protocol recommends a dose of docetaxel 50 mg/m2 IV D1, oxaliplatin 85 mg/m2 IV D1, and 5-FU 1200 mg/m2 IV continuous infusion (over 24 hours daily) on D1 and D2.

• There is no need to adjust the dosage at this time. It is recommended to continue monitoring the patient’s blood cell counts to evaluate the response after the second cycle of treatment.

700796645

230811

[exam findings]

• 2023-03-28 Patho - uterus (with or without SO) neoplastic
  • PATHOLOGIC DIAGNOSIS
    • Uterus, endometrium, total hysterectomy — Carcinosarcoma with heterologous element
    • Ovaries and fallopian tubes, bilateral, BSO — No remarkable change
    • Lymph nodes, pelvic and para-aortic, bilateral, BPLND+PALND— Negative for malignancy (0/51)
    • AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II
  • MACROSCOPIC EXAMINATION
    • Procedure: total hysterectomy + BSO + omentectomy + BPLND + bilateral para-aortic LN dissection
    • Specimen Size: 20.5 x 12.0 x 8.0 cm(uterus), 3.0 x 2.0 x 2.0 cm (Lt ovary), 4.5 x 1.0 cm (Lt tube), 3.0 x 2.0 x 2.0 cm (Rt ovary), 4.5 x 1.0 cm (Rt tube), and 24 x 12 x 2.0 cm (omentum)
    • Specimen Integrity: Intact
    • Tumor Site: Endometrium
    • Tumor Size: 19.5 x 10.5 cm
    • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para=aortic, and right para-aortic. Representative parts are taken for section and labeled as: A1-A2= left iliac LNs, B= left obturator LNs,C1-C2= right iliac LNs, D1-D3= right obturator LNs, E= left para-aortic LNs, F= right para-aortic LNs, G1-G2= left ovary and fallopian tube, G3-G4= right ovary and fallopian tube, G5-G13= uterine corpus, G14-G15= cerivx, H1-H2= omentum.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Carcinosarcoma with heterologous (chondrosarcomatous) component
    • Histologic Grade: High-grade
    • Depth of tumor invasion: Tumor invading > 1/2 of the myometrium
    • Uterine Serosal Involvement: Not identified
    • Cervical Stromal Involvement: Present
    • Other Tissue/Organ Involvement: Not identified
    • Peritoneal/Ascitic Fluid: Negative
    • Margins: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin: 0.1 cm from parametrium
    • Lymphvascular Invasion: Present
    • Regional Lymph Nodes: All lymph nodes negative for tumor cells (0/51)
      • number of lymph node examined: 16 (left iliac), 4 (left obturator), 7 (right iliac), 13 (right obturator), 5 (left para-aortic), 6 (right para-aortic)
      • number with metastases > 2 mm: 0
      • number with metastases > 0.2 mm and up to 2 mm or less: 0
      • number with isolated tumor cells (<= 0.2mm): 0
    • Pathologic Stage
      • Primary Tumor: pT2 (tumor invading the stroma of the cervix)
      • Regional Lymph Nodes: pN0 (no regional lymph node metastasis
      • Distant Metastasis: cM0
    • FIGO Stage: Stage II
    • AdditionalPathologic Findings
      • Cervix: Chronic cervicitis with Nabothian cyst
      • Myometrium: Leiomyoma
      • Ovary, right: No remarkable change
      • Ovary, left: No remarkable change
      • Fallopian tubes, blateral: No remarkable change
      • Omentum: Free of carcinoma
• 2023-03-24 CT - chest
  • Minimal interstitial change at Right lower lobe and left lower lobe
  • Calcified coronary arteries is found.
  • Right upper lobe tiny nodule. 0.2cm, meta is less likely but follow up is suggested.
• 2023-03-20 MRI - pelvis
  • Clinical history: 68 y/o male patient with Vagina, excisional biopsy — Carcinosarcoma.
  • With and without contrast enhancement MRI: Pelvis
    • Diffuse soft tissue tumors(up to 10cm) in the uterine cacvity, involving more than half of myometrium, focal soft tissue in the uterine cervical region.
    • Focal soft tissue tumor in border of left uterine surface, r/o adnexal or parametrium invasion.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE: IIIB_(Stage_value)
• 2023-03-17 Gynecologic ultrasonography
  • Findings
    • Uterus Position : AVF
      • Size: 104 x 88 mm
    • Endometrium:
      • Thickness: 71.8 mm
    • Adnexae:
    • CUL-DE-SAC: with fluid
      
    • Other: Bilateral adnexae free
  • IMP: R/O EM:71.8mm (RI:0.51), or Uterus mass?
• 2023-03-10 Patho - vaginal biopsy
  • Vagina, excisional biopsy — Carcinosarcoma
  • The sections show a picture of carcinosarcoma, composed of both malignant epithelial and mesenchymal components. The epithelial component arranged in glandular and solid patterns. The sarcomatous components composed of fascicles of spindle-shaped neoplastic cells with focal hyalinized stroma and focal chondroid differentiation. Surface ulcer, moderate inflammatory cells infiltrate, and granulation tissue are present. The surgical margin is involved by tumor.
  • IHC: CK (+ for epithelial component), Vimentin (+ for both epithelial and mesencymal components), PAX8 (+), ER (-), PR (+) and Napsin A (-).

[consultation]

• 2023-05-18 Radiation Oncology
  • Q
    • The patient is an 68-year-old female with a history of 1. hypothyroidism s/p medical control, 2. hyperlipidemia s/p medical control, 3. Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy), stage pT2N0cM0; stage II; FIGO stage II.
      
    • This time, she suffered from fever with chillness since 2023/05/03, last chemotherapy on 2023/05/02, until symptoms worsen, so she was brought to our ER for help. Associated symptoms included poor appetite, frequent urination, fever with chillness. Denied painful urination, cough or URI symptoms and abdominal pain. At ER he conscious level is E4V5M6, vital sign BP:121/69; PR:112; BT:38; RR:18. Physical examination showed abdominal OP scar clear, breathing sound clear. Lab data showed Sediment-WBC >=100 /HPF; Bacteria = 3+ /HPF; Creatinine = 2.51 mg/dL; CRP = 36.8 mg/dL; WBC = 13.14 x10^3/uL. Under the tentative diagnosis of Urinary tract infection. So, she was admitted to our ward for further evaluation and management.
    • For radiotherapy, we need your further evaluation and management.
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: Recovery from urinary tract infection.
      • PI: Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy) on 2023-03-27, stage AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II.
      • Chemotherapy: since 2023-05-02
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM(-); HTN(-)
      • Allergy(-)
    • O:
      • ECOG: 0
      • PE: neck and bil SCF: neg; abdomen: surgical scars.
      • CXR (2023-03-03): No active lung lesion. No cardiomegaly. Thoracic spondylosis.
      • MRI of pelvis (2023-03-20): Diffuse soft tissue tumor in the uterine cavity, with focal soft tissuse tumor in left uterine border, r/o parametrial/adnexal invasion. Clinical biopsy vaginal carcinosarcoma, cstage T3bN0M0.
      • Operation (2023-03-27): Staging surgery (Total hysterectomy + bilateral salpingo - oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy)
      • Ascites (2023-01154, 2023-03-29): neg.
      • Pathology (S2023-05755, 2023-03-30): 1. Uterus, endometrium, total hysterectomy — Carcinosarcoma with heterologous element. 2. Ovaries and fallopian tubes, bilateral, BSO — No remarkable change. 3. Lymph nodes, pelvic and para-aortic, bilateral, BPLND + PALND — Negative for malignancy (0/51). 4. AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II. Lymphvascular Invasion: Present.
      • RT (2023-04-28 ~): at 900cGy/5 fractions (10MV photon) of the pelvic area.
    • A: Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo - oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy), stage AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II.
    • P: The patient interrupted radiotherapy after 2023-05-05 due to urinary tract infection. Because she already recovery from that, radiotherapy can be continued.
• 2023-05-12 Neurology
  • Q
    • The patient is a 68-year-old female with a history of 1. hypothyroidism s/p medical control, 2. hyperlipidemia s/p medical control, 3. Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy), stage pT2N0cM0; stage II; FIGO stage II.
    • She presented with chronic migraine for many years, under treatment (ponstan) at LMD, but renal function has worsened. For chronic migraine, we need your further evaluation and management.
  • A
    • If renal function is poor, consider using the following (all are PRN, used only when having a headache):
      • acetaminophen
      • ultracet/tramadol
      • ergotamine/caffeine: limited to one a day, not recommended for those with cardiovascular disease
      • imigran: limited to 50mg a day, no more than twice a week, at most 8 tablets a month
    • You can use (choose one from 1, 2) in combination with (choose one from 3, 4)
    • The patient has used inderol 10mg qd as a prophylactic for migraines in the past (June 2019 neurology clinic), and the effect was good, it can be tried again.

[chemotherapy]

• 2023-07-17 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-2
• 2023-06-20 - carboplatin AUC 2 150mg D5W 2hr (weekly CDDP changed to carboplatin, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2023-06-13 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-06 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-30 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-22 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-02 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-08-11

Our endocrinologist wrote a repeat prescription for Eltroxin (levothyroxine) on 2023-08-01 and the drug is included in the formulary with no reconciliation issue identified.

2023-07-18

[reconciliation]

The patient was seen by our urologist on 2023-07-12 who prescribed Cero (cefaclor 250mg) 2# TID and Celebrex (celecoxib 200mg) 1# QD for a period of 7 days to treat suspected UTI infection or catheter-related discomfort. These medications are not currently on the active medication list, so it’s advisable to confirm resolution of these symptoms.

701081046

230811

[diagnosis] - 2023-05-02 admission note

• Diffuse large B-cell lymphoma, stage II, IPI score: 2 s/p R-miCHOP from 2023/03/31
• Type 2 diabetes mellitus with other specified complication
• Chronic viral hepatitis B without delta-agent
• Hyperlipidemia, unspecified
• Cerebral atherosclerosis
• Hypothyroidism, unspecified
• Essential (primary) hypertension

[past history]

Medical history: - Hypertension under Losa & hydro control for more than ten years - Type 2 diabetes mellitus under Dibose and Trajenta contro for two months - Hypothyrodism without medical control for over three years. - Hyperlipidemia with Zulitor F.C 4mg 0.5# po QD - Cerebral atherosclerosis with Plavix F.C 75mg 1# po QD

Surgical history: - Left knee osteoarthritis status post left total knee replacement on 2016. - Gastric perforation status post Billroth II for many years.

[allergy]

• NKDA         

[family history]

• There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

• 2023-06-05 Nasopharyngoscopy
  • smooth nasopharynx, oropharynx and hypopharynx.
• 2023-03-31 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2023-03-30 KUB
  • Fecal material store in the colon.
  • Spondylosis of the L-spine is noted.
• 2023-03-29 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • The trachea shows right lateral deviation in thoracic inlet level that may be intrathoracic goiter. Please correlate with clinical condition or CT.
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2023-03-29 PET
  • Glucose hypermetabolism lesions in the left thyroid bed (Deauville score 5), compatible with diffuse large B-cell lymphoma.
    
  • Glucose hypermetabolism lesions in the left neck, SCF, and ICF lymph nodes (Deauville score 5), in the right neck and SCF, and right mediastinal lymph nodes (Deauville score 5), highly suspected lymphoma with involvement of lymph node regions on the same side of the diaphragm.
    
  • Increased FDG uptake in bilateral pulmonary hilar lymph nodes (Deauville score 3), probably reactive nodes.
    
  • Diffuse large B-cell lymphoma, stage II (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2023-03-28 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • Section shows piece(s) of bone marrow with 30% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • IHC stains: CD3: <2%; CD20: <2 %. (of the nucleated cells).
• 2023-03-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 25) / 87 = 71.26%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Trivial MR, TR
• 2023-03-17 Patho - thyroid total/lobe
  • PATHOLOGIC DIAGNOSIS
    • Lymph node, VI, excision — Compatible with diffuse large B-cell lymphoma with a T-cell/histiocyte rich pattern
    • Thyroid, left, subtotal thyroidectomy — Compatible with diffuse large B-cell lymphoma with a T-cell/histiocyte rich pattern and Hashimoto thyroiditis
  • MACROSCOPIC EXAMINATION
    • The specimen submitted in three parts. Part (1) consists of a piece of tan-gray and firm soft tissue, labeled LN VI, measuring 2.0 x 1.5 x 0.8 cm. All for section as: “A”. (2) a piece of tan-gray and firm soft tissue, labeled left thyroid, measuring 3.5 x 2.5 x 1.4 cm. All for section in two cassettes as: B1-B2. (3) a piece of pink-white and firm tissue, received for frozen section, measuring 1.0 x 0.9 x 0.4 cm. All for paraffin section as: F2023-00108.
  • MICROSCOPIC EXAMINATION
    • The sections of all three parts show following features:
      • Specimen: Left thyroid and lymph node VI
      • Procedure: Excision and subtotal thyroidectomy
      • Tumor site: Thyroid and lymph node
      • Histologic type: Compatible with diffuse large B-cell lymphoma with a T-cell/histiocyte rich B-cell lymphoma pattern, composed of mixed proliferation of small lymphocytes, histiocytes, and scattered large transformed atypical cells and Hodgkin/Reed-Sternberg-like cells. Focal geographic necrosis is present. The thryoid tissue also shows Hashimoto thyroiditis with fibrosis. IHC, anaplastic carcinoma is unlikely.
      • Immunophenotyping for large transformed atypical cells and Hodgkin/Reed-Sternberg-like cells: CK(-), CAM5.2(-), PAX8(-), TTF1(-), CD3(+ background small lymphoid cells), CD20(+), PAX5(few cells +), CD68(abudant background histiocytes+), CD15(-), CD30(+), Ki67= 40%
• 2023-03-17 Frozen Section - thyroid
  • Thyroid, left, frozen section — The sections show necrosis, sclerosis, and scattered large atypical cells with inflammatory background. The finding favor lymphoma, and Hodgkin lymphoma should be considered
• 2023-03-16 CXR
  • Cardiomegaly and tortuosity of the thoracic aorta.
  • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
  • Degenerative joint disease of T-spine with marginal osteophytes.
  • Right-side deviation of the trachea.
• 2023-03-09 CT - chest
  • Indication: Hodgkin lymphoma of neck. Please perfrom from neck, chest to Abd/Pelvis. Thanks.
  • Chest and Abdominal CT with and without enhancement revealed:
    • Chest:
      • Huge left thyroid mass up to 5.89cm in largest dimension is found with tracheal deviation to right side is found.
      • Small lymph nodes are found at bilateral paratracheal region.
      • Calcified coronary arteries is found.
      • No evidence of bilateral pleural effusion.
      • Increased pulmonary vasculature is found.
    • Visible abdomen:
      • Dilated CBD with soft tissue nodule at distal CBD is suspected. suggest MRCP.
      • Infrarenal aortic aneurysm with mural thrombosis is found up to 2.8cm in largest dimension.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • The GB is well distended without soft tissue lesion
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Huge left thyroid mass up to 5.89cm with tracheal deviation.
    • Distal CBD nodule. Nature? Suggest MRCP
• 2023-02-20 Patho - lymphnode biopsy
  • Lymph node, left neck, core needle biopsy — Scatter atypical large B cells, suspicious for Hodgkin lymphoma
  • Microscopically, the sections shows a picture of scatter atypical large B cells with prominent nucleoli surrounded by small lymphocytes and has background of reactive CD4(+) T cells in focal area.
  • Immunohistochemistry shows CD15(-), CD30(+), CD3(-), CD20(+, focal), Bcl-6(+, scatter), PAX-5(+, scatter), CD4(+, reactive T cell), CK(-) and TTF-1(-) for atypical lymphoid cells. According to above histopathologic findings, it is suspicious for Hodgkin lymphoma due to limited specimen. More adequate specimen is need for further evaluation.
• 2023-02-07 CT - neck
  • Indication: left neck swelling for months
  • Pre- and post-contrast CT scans of the head and neck region from skull base to lower neck were performed on a spiral CT scanner and axial, coronal and sagittal images of a slice thickness of 3 mm were reconstructed and show:
    • A huge hypodense mass with heterogenous enhancement involving left thyroid lobe, about 94 mm x 58 mm x 59 mm, causing mass effect on surrounding structures (esophagus, trachea, great vessels and msucles) and protruding to superior mediastinum.
    • No enlarged lymph noe.
    • Calcification foci and non-enhacning artheroma along major arteries at neck, indicating artherosclerosis.
    • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
    • Post-oepration change at both lens.
  • IMP; Left thyroid tumor (94 mm, 58 mm x 59 mm). Malignancy should be first considered until proved otherwise.
• 2023-02-01 Nasopharyngoscopy
  • smooth NPx, oropharynx, hypopharynx
  • laryngeal edema with mild narrowed airway
• 2022-11-02 Flow Volume Loop
  • mild restrictive impairment
• 2022-09-23 Hearing Test
  • Tymp RE Type C, LE type A
  • ART reduced and absent
  • PTA:
    • Reliability FAIR
    • Average RE 59 dB HL, LE 65 dB HL
    • RE moderate to profound SNHL
    • LE mild to profound SNHL
• 2022-08-26 Hearing Test
  • Reliabilty Fair
  • PTA
    • R’t : 53 dB HL
    • L’t : 60 dB HL
    • Bil moderate to severe SNHL
  • Tymp
    • R’t : Type C
    • L’t : Type A
  • ART
    • Bil absent.
• 2022-07-29 Hearing Test
  • Reliabilty Fair
  • PTA
    • R’t : 54 dB HL
    • L’t : 61 dB HL
    • Bil moderate to severe SNHL.
• 2022-07-05 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (73 - 16) / 73 = 78.08%
    • M-mode (Teichholz) = 78
  • Conclusion:
    • Septal hypertrophy with Gr II LV diastolic dysfunction and impaired RV relaxation; severely dilated LA.
    • Normal LV and RV systolic function.
    • Prominent mitral annulus calcification with trivial MR; mild aortic valve sclerosis.
    • Dilated proximal ascending aorta (36mm); mild aortic root calcification.
• 2022-07-07 Neurosonology
  • Moderate to severe atheromatous lesions in right BIF with diameter reduction in 54.5%, area reduction in 48.7%.
    • Moderate atheromatous lesions in left ICA with diameter reduction in 43.6%. Mild to moderate atheromatous lesions
    • in right ICA, left BIF, left distal CCA and left mid CCA.
  • Normal PSV in bilateral ICA and CCA. Normal ICA/CCA PS ratio bilaterally
  • Adequate total VA flow (150) may suggest no evidence of VBI
• 2022-07-01 ENT Hearing Test
  • Tymp bil type A
  • ART bil absent
  • PTA:
    • Reliability FAIR
    • Average RE 60 dB HL, LE 64 dB HL
    • bil moderate to severe SNHL
• 2022-06-21 MRA - brain
  • The MRA study shows moderate to severe arteriosclerosis of the neck and intracranial vessels with irregular outline and mild multiple focal stenoses but without complete occlusion.
  • Imp:
    • Right frontal-temporal brain contusions.
    • Bilateral convexity SDHs
    • Brain atrophy
    • Diffuse arteriosclerosis.
• 2022-06-20 CXR
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
  • mild enlarged cardiac silhoutte due to prominent pericardial fat/ prominent cardiophrenic angle mediastinal fat pad
  • Coronary arterial calcification (left anterior descending artery) indicating CAD
  • Clean lung fields based on plain image
  • Displacement of the tracheal axis to right at thoracic inlet due to enlarged thyroid gland
• 2022-06-14 CTA - chest
  • favor small airways disease.
  • extensive 3V-CAD and thyroid goiter

[consultation]

• 2023-03-28 General and Digestive Surgery
  • Q
    • This 88 year-old woman had history of hypertension, type 2 diabetes mellitus, and hypothyrodism under medical control for over ten years.
    • Her operation history of
      • Left knee osteoarthritis status post left total knee replacement on 2016.2
      • Gastric perforation status post Billroth II for many years.
    • According to herself and medical record, she had a mass at left neck for more than 3 years ago. She felt tumor enlarging, worsen with pain and mild shortness of breath for days. She went to LMD for help, the symptoms not improved after LMD treatment. She came ENT OPD for further evaluation. At physical examination, a huge mass over left lower neck about 5x5 cm, non-movable and non-tender. Neck sonography showd a huge mass at left thyroid with trachea deviation to right side. FNA pathology showed negative. Neck CT showed left thyroid tumor about 94 mm x 58 mm x 59 mm. Malignancy should be first considered. Sono-guide biopsy of enlarged lymph nodes and left thyroid tumor, which pathology releaed unsatisfactory-thyroid, suspicious for Hodgkin lymphoma-lymph nodes. Thus, left subtotal thyroidectomy and excision of central neck LAP was performed, and pathologic report of Lymph node at VI which was compatible with diffuse large B-cell lymphoma with a T-cell/histiocyte rich pattern.
    • We strongly nned your experise for port-A insertion for chemotherapy. Thnak you very much.
  • A
    • we will arrange op tomorrow

[MedRec]

• 2023-04-12 SOAP Hemato-Oncology
  • Multidisciplinary Cancer Team Meeting Conclusion (2023-04-03)
    • Diffuse large B-cell lymphoma stage Ⅱ
    • IPI
    • Tx: R-miniCHOP (old age).
  • Now on R-miniCHOP, C1D1 on 2023-03-31
    • AE: Gr 3 Leukopenia
• 2023-03-21 SOAP Hemato-Oncology
  • P: Arrange admission for BM Study, PET, Heart Echo, Port-A, then C/T
• 2023-03-08 SOAP Metabolism & Endocrinology
  • A: Theoretically, lymphoma and a thyroid mass are two distinct issues. It’s suggested that the lymphoma be treated first, then reassess whether thyroid surgery is necessary. In the event it is a thyroid lymphoma, chemotherapy and/or radiotherapy could also potentially shrink the mass.
• 2022-08-11 SOAP Chest Medicine
  • PHx: small airway disease, COVID, HTN
  • Diagnosis
    • Mild intermittent asthma, uncomplicated
    • Post COVID-19 condition,unspecified
    • Dizziness and giddiness
    • Essential (primary) hypertension
    • history of Hypothyroidism
• 2022-07-01 SOAP Cardiology
  • Prescription
    • Concor (bisoprolol 5mg) 0.5# QD 28D
    • Coxine (isosorbide-5-mononitrate 20mg) 0.5# BID 28D
• 2022-07-01 SOAP Cardiology
  • S: refer from chest OPD; systolic murumur at aortic area; CTA: 3V CAD; formerly followed up at chest OPD

[chemoimmunotherapy]

• 2023-05-02 - rituximab 375mg/m2 540mg NS 500mL 12hr + cyclophosphamide 400mg/m2 550mg NS 250mL 30min + vincristine 1mg NS 50mL 10min + doxorubicin 25mg/m2 35mg NS 50mL 24hr + prednisolone 40mg/m2 60mg D1-5
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO + aprepitant 125mg PO D1-3
• 2023-03-31 - rituximab 375mg/m2 540mg NS 500mL 12hr + cyclophosphamide 400mg/m2 550mg NS 250mL 30min + vincristine 1mg NS 50mL 10min + doxorubicin 25mg/m2 35mg NS 50mL 24hr + prednisolone 40mg/m2 60mg D1-5
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO + aprepitant 125mg PO D1-3

Revised Edition of Hematologic Oncology Chemotherapy Drug Prescription (in hospital regimen collection, version 2022-07-04)

• Non-Hodgkin’s lymphoma (NHL) - First-Line for Diffuse large B-cell lymphoma - R-CHOP
  • Rituximab 375 mg/m2 IV - Several schedules, e.g. on day 1 of each cycle of CHOP chemotherapy, or given on day 3 of each cycle of therapy, or 7+3 days before cycle 1 and cycle 2 days before cycles 3, 5 and 7.
  • Cyclophosphamide 750 mg/m2 IV D1
  • Doxrubicin 50 mg/m2 IV D1
  • Vincristine 1.4 mg/m2 (max. 2mg) IV D1
  • Prednisone 60 mg/m2 PO D1-5
  • To be repeated every 3 weeks, 6-8 cycles
  • References: Br.J Cacer 1995;71:326-330

Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP21) for non-Hodgkin lymphoma 2023-06-06 https://www.uptodate.com/contents/image?imageKey=ONC%2F63586&topicKey=HEME%2F4729

• Cycle length: 21 days.

• Regimen

  • Rituximab
    • 375 mg/m2 IV
    • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. For subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count ≥5000/microL.
    • Day 1
  • Cyclophosphamide
    • 750 mg/m2 IV
    • Dilute in 250 mL NS or D5W and administer over 30 minutes.
    • Day 1
  • Doxorubicin
    • 50 mg/m2 IV
    • Dilute in 50 mL NS or D5W and administer over three to five minutes.
    • Day 1
  • Vincristine
    • 1.4 mg/m2 IV (max dose 2 mg)
    • Dilute in 50 mL NS or D5W and administer over 15 to 20 minutes.
    • Day 1
  • Prednisone
    • 100 mg orally
    • Administer 30 minutes prior to chemotherapy on day 1, then every 24 hours on days 2 to 5.
    • Days 1 to 5

• Pretreatment considerations:

  • Hydration
    • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day) and void frequently to reduce risk of hemorrhagic cystitis.
  • Emesis risk
    • MODERATE (30 to 90% risk of emesis).
  • Prophylaxis for infusion reactions
    • Premedicate with acetaminophen and diphenhydramine, with or without an H2 blocker, 30 minutes prior to at least the first and second infusions of rituximab.
  • Vesicant/irritant properties
    • Doxorubicin and vincristine are vesicants; avoid extravasation.
  • Infection prophylaxis
    • The risk of febrile neutropenia with this regimen is 10 to 20%; primary prophylaxis with hematopoietic growth factors should be considered on an individual basis, particularly for high-risk patients such as those with preexisting neutropenia, advanced disease, poor performance status, or patients age 65 years or older.
  • Dose adjustment for baseline liver or renal dysfunction
    • Adjustment of initial cyclophosphamide, doxorubicin, and vincristine doses may be needed for preexisting liver dysfunction. In addition, dose adjustment of cyclophosphamide may be required for renal dysfunction.
  • Hepatitis screening
    • Patients should be screened for hepatitis B and C virus prior to starting rituximab, and if positive, considered for antiviral prophylaxis.
  • Cardiac screening
    • LVEF should be evaluated prior to initiation of therapy. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation. Infusion times and schedule may be adjusted to decrease the risk of cardiotoxicity in individuals at high risk for its development.
  • Neurotoxicity
    • Vincristine may cause constipation, and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine.

• Monitoring parameters:

  • CBC with differential and platelet count weekly during treatment.
  • Assess basic metabolic panel (creatinine and electrolytes) and liver function prior to each subsequent treatment cycle.
  • LVEF should be evaluated periodically based on LVEF at initiation of therapy and cumulative dose of doxorubicin.
  • Carriers of hepatitis B or C should be monitored for clinical and laboratory signs of active infection during and following completion of therapy. Rituximab should be discontinued if reactivation occurs.

• Suggested dose modifications for toxicity:

  • Myelotoxicity
    • Treatment should be delayed until ANC is >1500/microL and platelet count is >100,000/microL. If a patient develops grade 4 (ANC <500/microL) neutropenia or febrile neutropenia with any cycle, G-CSF support is added to the regimen for subsequent cycles. If grade 4 neutropenia or febrile neutropenia occurs despite G-CSF support, or if the patient develops grade 3 (25,000 to 50,000/microL) or 4 (<25,000/microL) thrombocytopenia with any cycle, the doses of cyclophosphamide and doxorubicin should be decreased by 50% for subsequent cycles.
  • Neuropathy
    • Dose adjustment of vincristine may be necessary if the severity of neuropathy persists or worsens. No specific guidelines are available for dose adjustments.

Older patients with DLBCL generally have a worse prognosis compared to younger patients due, in part, to more comorbid conditions and lower treatment tolerance. 2023-06-06 https://www.uptodate.com/contents/initial-treatment-of-advanced-stage-diffuse-large-b-cell-lymphoma

• For patients >80 years with adequate heart, kidney, and liver function and for patients 60 to 80 years with modest impairments, we generally treat with R-mini-CHOP to reduce adverse effects (AE) associated with more intensive regimens.
  • Pretreatment evaluation
    • For older patients, a comprehensive geriatric assessment can aid assessment of comorbid conditions and functional status and facilitate formulation of an appropriate, individualized treatment plan. Special considerations for the use of chemotherapy in older patients are discussed separately.
  • Treatment
    • Our preferred approach for older adults who are unable to tolerate standard doses of R-CHOP-21 is treatment with
      • R-mini-CHOP (rituximab 375 mg/m2, cyclophosphamide 400 mg/m2, doxorubicin 25 mg/m2, vincristine 1 mg on day 1 of each cycle, 40 mg/m2 prednisone on days 1 to 5).
    • A pre-treatment phase of a systemic steroid, with or without rituximab, may improve the patient’s performance status (PS) and facilitate treatment with R-mini-CHOP.
    • Frail patients who require symptom palliation but cannot tolerate R-mini-CHOP may benefit from a systemic steroid (with or without rituximab) or single chemotherapeutic agents.

==========

2023-08-11

Our endocrinologist wrote a repeat prescription for Zulitor (pitavastatin), Trajenta (linagliptin 5mg) and Dibose (acarbose 100mg) on 2023-08-02 and the drugs are included in the formulary with no reconciliation issue identified.

2023-06-30

On 2023-06-08, our neurologist issued a refillable prescription for Plavix (clopidogrel) and diphenidol, and on 2023-06-23, our otolaryngologist prescribed Strocain (oxethazaine polymigel), Acetal (acetaminophen), and cephalexin. Apart from diphenidol, which is no longer necessary due to the resolution of vertigo, all other validly prescribed drugs mentioned have been incorporated into the active medication list without any reconciliation issues.

2023-06-06

• This patient visited local medical doctor on 2023-05-26, 2023-05-28, 2023-05-29, 2023-05-30, 2023-06-01, 2023-06-04 for her myositis, functional dyspepsia, acute upper respiratory infection, and prescribed acetaminophen, diazepam, loratadine and opium derivatives. for each a short 3-day valid prescription. These symptoms are generally covered in current medical problem list and managed with corresponding same or similar therapeutic class medications. No medication reconciliation issues identified.

• Given that this patient has been diagnosed with myositis and dyspepsia that have persisted for months according to the PharmaCloud database, it’s plausible that these could be indicative of statin-induced muscle side effects. Clinical experience suggests that a change in dosing frequency, such as alternate day dosing, may improve statin tolerability in patients experiencing adverse effects such as myalgia. This strategy is particularly beneficial for patients who cannot tolerate daily statin therapy. In addition, alternate-day statin therapy is also considered a cost-effective method to improve drug utilization (Ref: Efficacy and Safety of Alternate-Day Versus Daily Dosing of Statins: a Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther. 2017;31(4):419-431). Considering the information from these studies and the fact that the laboratory data indicate an improvement in the patient’s hyperlipidemia, it is recommended that the administration of Zulitor be changed from 0.5# QD to 0.5# QOD.

  • 2023-05-16 LDL-C 102 mg/dL
    
  • 2023-04-25 LDL-C 135 mg/dL
    
  • 2023-01-04 LDL-C 167 mg/dL
    
  • 2023-04-25 Cholesterol total 217 mg/dL
    
  • 2023-01-04 Cholesterol total 239 mg/dL

2023-05-03

• Due to the patient’s advanced age, R-miniCHOP (a dose-reduced version of R-CHOP with reduced amounts of cyclophosphamide and vincristine) was selected as treatment starting on 2023-03-31. One episode of leukopenia was observed (1.56K/uL on 2023-04-12) and was alleviated with two consecutive days of Granocyte (lenograstim) administration. Please monitor for recurrence of leukopenia after this 2nd dose of R-miniCHOP.

• Beta-2 microglobulin (b2M) is a major histocompatibility complex (MHC) class I molecule found on the surface of nearly all nucleated cells in the body. Cells with a high turnover rate, such as immune cells and cancer cells, tend to produce and express higher levels of b2M on their surface. In non-Hodgkin’s lymphoma, cancer cells may also have elevated levels of b2M. The elevated levels of b2M observed around the trough of leukopenia may indicate the destruction of cancerous B cells.

  • 2023-04-26 B2-Microglobulin 2899 ng/mL
    
  • 2023-04-13 B2-Microglobulin 4166 ng/mL
    
  • 2023-03-28 B2-Microglobulin 2946 ng/mL
    
  • 2023-03-08 B2-Microglobulin 2438 ng/mL

• Lab data showed that levels above the ULN are associated with type 2 diabetes and hyperlipidemia. Dibose (acarbose), Trajenta (linagliptin) and Zulitor (pitavastatin) are currently appropriately prescribed.

  • 2023-04-25 HbA1c 7.6 %
    
  • 2023-04-25 Glucose(AC) 127 mg/dL
    
  • 2023-04-25 Cholesterol total 217 mg/dL
    
  • 2023-04-25 LDL-C 135 mg/dL
    
  • 2023-04-25 Triglyceride (TG) 172 mg/dL

• The patient’s cerebral atherosclerosis is treated with Plavix (clopidogrel) and her hepatitis B is treated with Baraclude (entecavir) without an issue.

• Hypothyroidism is listed as a diagnosis for the patient, but there is no corresponding medication prescribed currently. The serum free T4 level on 2023-03-17 was 0.57 ng/dL, which is slightly below the normal range. It is recommended to reevaluate the patient’s condition and consider prescribing appropriate medication, such as levothyroxine, if necessary to manage her hypothyroidism.

2023-03-27

[drug identification]

The three requested drugs have been identified as follows:

• Sodicon: contains dextromethorphan 15mg
• Losa & Hydro: contains losartan 50mg and hydrochlorothiazide 12.5mg
• Acetal: contains acetaminophen 500mg

An in-hospital porter will be sent to deliver these medications to the patient’s ward.

701306367

230811

[exam findings]

• 2023-08-01 Neck soft tissue
  • Placement of nasogastric tube and tracheostomy.
  • Straightening alignment of cervical spine.
  • Degenerative change of the spine with marginal spur formation.
• 2023-08-01 CXR
  • Normal heart size with tortuous aorta.
  • Placement of tracheostomy and nasogastric tube.
  • Multiple right ribs fracture, old.
  • Fibrocalcified nodules at RUL.
  • Bilateral clear costophrenic angles.
  • L2 compression fracture status post vertebroplasty.
• 2023-07-27 CXR
  • Tortuosity of the aorta with atherosclerotic change.
  • Fibrocalcified change over right apical lung, may be old TB.
  • Old fracture of multiple ribs.
  • S/P tracheostomy.
  • S/P N-G tube insertion.
• 2023-07-20 Tc-99m MDP bone scan
  • Increased activity in the lower C-spine and L2-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Some faint hot spots in bilaterla rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral hips, knees, right ankle and right foot, compatible with benign joint lesions.
• 2023-07-19 CT - neck
  • Right tongue squamous cell carcinoma, moderately differentiated, for cancer work up
  • With and Without contrast Neck CT showed
    • The neck airway was unremarkable.
    • heterogeneous enhancing tumors in the oral cavity, oropharynx and bilateral hypopharynx.
    • multipe necrotic lymph nodes in the left carotid space, riht submandibular space and right posterior cervical space
    • The major salivary glands were unremarkable.
    • The skull base and C-spine alignment were unremarkable
  • IMP: extensive tumors in the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck.
• 2023-07-18 EGD
  • Suboptimal study due to poor intolerance
  • Reflux esophagitis LA Classification grade C
  • Esophageal mucosal lesion, EC junction, s/p biopsy
  • Hiatal hernia
  • Superficial gastritis
  • Gastric erosions, antrum
• 2023-07-10 Patho - tongue biopsy
  • Tongue tumor, R’t, biopsy — Squamous cell carcinoma, moderately differentiated
  • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated of the tongue tumor tissue characterized by solid tumor nests infiltration with keratin formation, hemorrhage and necrosis.
  • Immunohistochemistry shows CK(+), P40(+), P16(-) and HPV(-) for tumor.
• 2023-07-08 Embolization (TAE) - neuro
  • The procedure was performed under general anaesthesia via right femoral artery approach with a Fr#8 angiocatheter sheath and guiding catheter.
  • Bilateral carotid angiograms reveal tumor stains over oropharyngeal space, supplied by bilateral lingual artery. .
  • Transarterial embolization of the tumor was then performed by infusion of particles (Embospheres).
  • Post embolization bilateral carotid angiograms show total embolization of this tumor.
• 2023-07-08 Carotid angiography bilat.
  • Tumor stains over oropharyngeal space, supplied by bilateral lingual artery.
• 2023-07-08 Aortography - thoracic
  • Type II aortic arch.
  • No critical stenosis of bilateral proximal carotid and vertebral arteries.
  • The whole procedure was smoothly done without apparent immediate complication and the patient stood it well under local anesthesia.
• 2023-07-08 CT, CTA - brain
  • Presence of huge lobulated mass lesion over oropharyngeal space, mainly at posterior tongue, with invasion of anterior part of the tongue and the epiglottis. Large necrotic area of this tumor. The tumor was mainly supplied by bilateral lingual arteries.
  • Several necrotic nodes over left-side of the neck.
  • S/P tracheostomy.
• 2023-04-11 Patho - doudenum biopsy
  • Duodenum, bulb, GC/PW, biopsy — Brunner’s gland hyperplasia
• 2023-04-11 EGD
  • Reflux esophagitis LA Classification grade C
  • Duodenal polyps, bulb, s/p biopsy
  • Hiatal hernia
  • Superficial gastritis
• 2023-04-03 EEG
  • This EEG were composed by continuous diffuse theta wave with 5-6 Hz, 10-20 uv in bilateral hemisphere with left side more severe. There were no obvious photic driving response.
  • This EEG suggest moderate diffuse cortical dysfunction left side more severe. Advise clinical correlation.
• 2023-03-30 CT - brain
  • Small amount of chronic subdural effusions along right convexity. Minimal amount of acute SDH over right temporal fossa.
  • Traumatic head injury with right frontal scalp and face swollen change.
  • Depressed left hemicranium with thickening dura. Compressed left cerebral hemisphere with large area of old infarction.
  • S/P V-P shunt insertion.

[MedRec]

• 2023-08-08 SOAP Hemato-Oncology
  • P: Arrange admission for CCRT with weekly CDDP
• 2023-08-04 SOAP Radiation Oncology
  • S: Diagnosis: extensive tumors in the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck. cT4aN2cM0 at least.
  • O: 2023/07/27~ RT to the oral cavity and bil. neck lymphatic drainage area: 12 Gy/ 6 fx.
  • P: Plan to deliver 50 Gy/ 25 fx to the oral cavity, oropharynx, and bil. neck lymphatic drainage area. Then boost the gross tumor and LAPs to 70 Gy/ 35 fx.
• 2023-07-08 ~ 2023-08-28 POMR Ear Nose Throat
  • Discharge diagnosis
    • Malignant neoplasm of overlapping sites of tongue, stage IV
    • Oropharyngeal tumor bleeding with hypovolemic shock
    • Hemoptysis
    • Acute hypoxemic respiratory failure post intubation
  • CC
    • cough with much blood sputum today, and poor intake fo 2 days
  • Present illness
    • This 51-year-old man has past history of 1.) old CVA with right weakness, 2.)　alcoholism　3.)　Traumatic brain injurys/p craniectomy 4.) Epilepsy 5.) s/p abdomen operation (colon).
    • According to statement of his ex-wife, he suffered from cough with much blood sputum today, and poor intake fo 2 days. He was brough to our hospital for help. At ER, Con’s:E4V5M6, TPR:37.1/112/18, BP:94/55mmHg; SpO2:99%, sudden massive blood from oral and desaturation, bradycardia, hypotension were noted, s/p Bosmin injection, difficult oral endotrachea tube installation, emergency tracheostomy with ventilator support was performed at ER. Laboratory studies showed leukocytosis, increase of segment, Imbalance electrolyte as hyperkalemia, hyponatremia. The chest film disclosed Fibrocalcified change over RUL.
    • Due to massive oral bleeding, so we arrange brain CT, which revealed 1. Presence of huge lobulated mass lesion over oropharyngeal space, mainly at posterior tongue, with invasion of anterior part of the tongue and the epiglottis. Large necrotic area of this tumor. The tumor was mainly supplied by bilateral lingual arteries. 2. Several necrotic nodes over left-side of the neck. Angiography was arranged and embolization was done. Empirical antibiotics, IV fluid challenge, and blood transfusion for hypovolemic shock were given. Under the impression of 1.) Acute hypoxemic respiratory failure post intubation 2.) oropharyngeal tumor bleeding with hypovolemic shock, he was admitted to MICU for further treatment.
    • He did not received vaccice included covid-19 and Influenza
  • Course of inpatient treatment
    • MICU 7/08-7/17
      • After admitted to MICU, on cricothyrotomy with ventilator support. Arrange tracheostomy on 7/9. Unstable hemodynamics under IVF hydration and levophed titration infusion.
      • Empiric antibiotic with tapimycin Tapimycin (7/8-) and Targocid (7/9-7/11) for infection treat. Give MgSO4, KCL IVD, Ca. gluconate and high P diet were given for correct imbalance electrolyte.
      • Transamin IV and Bosmin inhalation were given for hemoptysis. AEDs with dilantin IV shift to oral form and ativan PRN IVD for seizure control. Contact ENT for biopsy of right tongue tumor: Squamous cell carcinoma. Try T-mask overnight since 7/15 for weaning ventilator. He wil transfer to ENT ward for further care.
    • ENT ward 7/17-7/28
      • Under relative stable condition, we remove foley catheter and shift tracheostomy to shiley 6 # smoothly on 7/18.
      • Cancer work up was arranged, which revealed tongue tumor with extensive invasion the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck. Operation was not indicated due to massive invasion. Radiotherapy will be arranged from 7/27, and he will be discharged under relative stable condition.
  • Discharge prescription
    • Zalain Cream (sertaconazole nitrate 2%) BID TOPI
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
    • Phenytoin (diphenylhydantoin 100mg) 1# TID
    • Ulstop (famotidine 20mg) 1# BID
    • Parmason Gargle Soln (chlorhexidine) BID GAR
    • Acetal (acetaminophen 500mg) 1# PRNQ6H
• 2023-03-31 ~ 2023-04-12 POMR Infectious Disease
  • Discharge diagnosis
    • Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction
    • Hypostatic pneumonia, unspecified organism
    • Contusion of unspecified part of head, initial encounter
    • Contusion of eyeball and orbital tissues, right eye, initial encounter
    • Altered mental status, unspecified
    • Unspecified adrenocortical insufficiency
    • Gastritis, unspecified, without bleeding
    • Gastro-esophageal reflux disease with esophagitis
  • CC
    • Drowsy conscious and poor appetite in recent three days.
  • Present illness
    • This is a 51 year-old male patient, who has underlying histories of alcoholism, Left TBI s/p craniectomy, s/p abd op (colon), is admitted for drowsy conscious and poor appetite in recent three days.
    • According to his ex-wife, he suffered from drowsy conscious and poor appetite after fall down with hit the head before three days ago. He also accompanying symptoms of headache, right eye swelling and ecchymosis.There is no TOCC or trauma hisory. He had no previous allergy to food or drug. There is no URI or UTI symptom in recent days.
    • He was brought to our ED for help.
    • At ED, vital signs showed tachycardia (BP:129/88; HR:104; BT:35.5; RR:18). PE showed ecchymosis, swelling, local heat, painful and tenderness over right eye, sclera congestion, pupils has light reflex. Laboratory data showed leukocytosis (13200/uL), elevated Hb (Hb:18.1 g/dl), CRP (7.06mg/dL), glucose (Glu:190 mg/dl), and normal liver and renal function. Blood gas (vein) showed respiratory acidosis with metabolic compensation. Urinalysis showed elevated urobilinogen (8 mg/dl), bilirubin (1+), no pyuria. CXR showed clear both lung field. Brain CT revealed small amount of chronic subdural effusions along right convexity. Minimal amount of acute SDH over right temporal fossa.
    • Under the impression of hypostatic pneumonia, dehydration, SDH, he is admitted to the Infection ward for evaluation and management on 2023-03-31.    
  • Course of inpatient treatment
    • During the hospital stay, we use parenteral cefuroxime for empirical treatment of hyposttaic pneumonia. Consciousness was monitor due to post head injury. Raise the head of the bed up 30 degree. Neurology consulted for treatment of SDH and headache. This EEG suggest moderate diffuse cortical dysfunction left side more severe. The adequate fluid hydration due to dehydration. The Foley catheter indwelling is for monitor and record urine amount. Oncology was consulted for suspect polycythemia. Patient received JAK2, BCR ABL, therapeutic phlebotomy (maintain the hematocrit < 45 percent) and bone marrow aspiration and biopsy.
    • Patient’s ex-wife complained of no stool passage above three days and abdominal distension. KUB revealed stool impaction. Laxative, antiflatulent were given. Hiccup is noted, we also addition prokinetic treatment. Patient’s ex-wife complained of dark green stool noted, stool is submitted for stool OB. We also give recheck Hb level and adrenal function survey. No bacterial growth on blood culture is noted. Mild decreased ACTH is noted, adrenocortical insufficiency was considered.
    • We give addition systemic steroid. Panendoscopy was arrange due to anemia and stool OB 4+. Panendoscopy revealed Reflux esophagitis LA Classification grade C
    • Duodenal polyps, bulb, s/p biopsy. Hiatal hernia. Superficial gastritis. PPI was given after panendoscopy examination. Voiding is smooth after removal foley catheter. No bacterial growth on blood culture is noted. Laboratory examinaiton revealed improve. No more fever occurs. Conscious clear. Respiratory pattern is smooth. Under stable condition, he is discharged on April 12, 2023.
  • Discharge prescription
    • cortisone acetate 25mg 0.5# QD
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Mopride (mosapride citrate 5mg) 1# TID
    • Through (sennoside 12mg) 1# HS
• 2021-07-27 SOAP Neurosurgery
  • S
    • Wedge compression fracture, L2 post vertebroplasty on 2021/07/16
    • Postoperatively, his symptom has been relieved.
  • P
    • Porlia infusion
  • Prescription
    • Prolia (denosumab 60mg) ST SC
• 2021-07-15 ~ 2021-07-16 POMR Neurosurgery
  • Discharge diagnosis
    • Wedge compression fracture, L2 post vertebroplasty on 2021/07/16
  • CC
    • Lower back pain for 3 weeks
  • Present illness
    • This is a 49 year-old male with alcoholism, Left TBI s/p craniectomy, s/p abd op (colon).
    • This time he was suffered from lower back pain after fell down when work since 6/28. The pain became worse so he came to our NS OPD for help on 7/5.
    • At OPD, PE showed MP RUE 3 RLE 3, LUE 4 LLE, SLRT -/- Lasguest test(+). L-spine X-ray showed L2 compresion fracture. MRI of L spine revealed: L2 subacute compression fracture. After discussion with the patient, surgery would be arranged.
    • Under the impression of L2 compression fracture, he was admitted for further management.
  • Course of inpatient treatment
    • After admission, we did pre-OP prepare. L2 body bone cement augmentation was arranged on 7/16. The patient’s condition and vital sign was stable after the surgery and his symptoms was mild improved. After assessment, he will discharge on 7/16 and OPD follow up.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# QID
    • Sindine Aq Soln (povidone iodine) QD EXT for L-spine wound

[consultation]

• 2023-07-24 Dermatology
  • Q
    • Itching papule over peri-inguinal region was noticed for days. We need your expertise for further evaluation and treatment.
  • A
    • This patient suffered from erytehamtous patches on L’t thigh for days.
    • Imp: Tinea corprois
    • Suggestion:
      • Mycomb * 2 tubes/bid
      • Zalain cream * 2 tubes/bid
• 2023-07-21 Hemato-Oncology
  • Q
    • Operation may not be indicated due to masive tumor invasion. We need your expertise for concurrent or induction chemotherapy arrangement.
    • The patient’s caregiver is his ex-wife, and they have a 14-year-old underage daughter together.
  • A
    • This 51 year old man is a case of Tongue base squamous cell carcinoma, moderately differentiated, p16(-), HPV (-) with tumor bleeding, status post angiography embolization on 2023/07/08, status post tracheostomy on 2023/07/09.
    • Neck CT revealed tumor invasion over oral cavity, oropharynx and hypopharynx with necrotic LAP in the bilateral neck. We are consulted for CCRT. Please arrange port A insertion.
    • Check Anti HBc, HBsAg, Anti HCV. Arrange 24 urine CCR. Please arrange our OPD after discharge.
• 2023-07-21 Radiation Oncology
  • A
    • This time, he was admitted to our ward for oropharyngeal tumor bleeding. Biopsy over tongue revealed squamous cell carcinoma, moderately differentiated, p16(-), HPV (-). Neck CT revealed tumor invasion over oral cavity, oropharynx and hypopharynx with necrotic LAP in the bilateral neck.
    • CCRT is indicated. CT-simulation will be arranged on 7/24. Plan to deliver 50 Gy/ 25 fx to the oral cavity, oropharynx, and bil. neck lymphatic drainage area. Then boost the gross tumor and LAPs to 70 Gy/ 35 fx. RT will start around 7/27. Thank you very much.
• 2023-07-19 Oral and Maxillofacial Surgery
  • Q
    • tongue cancer patient, for oral cavity evaluation
    • This is a 51-year old man with past history
      • Old cerebrovascular accident with right side weakness
      • Alcoholism　
      • Traumatic brain injury status post left craniectomy more than 20 years ago
      • Epilepsy under phenytoin
      • Unknown colon lesion status post operation
    • This time, he was admitted to our ward for massive tumor bleeding. Emergent tracheostomy with tongue tumor biopsy was perfromed smoothly, and pathology report showed moderately differentiated squamous cell carcinoma. As part of cancer evaluation, we need your expertise for oral cavity evaluation.
  • A
    • After examing the intraoral condition, poor oral hygiene and multiple deep caries were noticed.
    • As the patient is unwilling to open his mouth and refuse to accept further dental evaulation.
    • Extraction of hopeless teeth might be difficult.
• 2023-07-08 Ear Nose Throat
  • A1
    • If massive bleeding occurs again, you can pack the mouth with Bosmin gauze (4x4 unfolded gauze pieces tied together in a string).
  • A2 Supplementary Consultation Response: 2023-07-08 21:02:07
    • The procedure performed this time was a cricothyrotomy (non-tracheostomy procedure), and tracheostomy surgery will be needed in the coming days.
• 2023-04-05 Hemato-Oncology
  • Q
    • This 51 y/o man admitted due to hypostatic pneumonia. History of smoking and trauma s/p V-P shunt. Hb:18.1 g/dl, suspect polycythemia. So we need your help for further suggestion. Thanks.
  • A
    • Please check JAK-2, BCR ABL, and arrange theraputic phlebotomy (maintain the hematocrit ＜45 percent).
    • Bone marrow aspiration and biopsy is indicated. Thanks for your consultation.
• 2021-06-29 Neurosurgery
  • Q
    • CC: fell down 3 days ago? and low back pain and generalized weakness; decreased appetite; slurred speech as usual (according to the ex-wife)
    • PH: alcoholism, Left TBI s/p craniectomy on 1995, s/p abd op (colon?)
    • Allergy: denied
  • A
    • The patient had lower back pain and general weakness.
      • Recent Hx of chest trauma: undetectable
      • CT scan of the abdomen showed old fracture of right lower ribs with chronic pleural change.
      • Patient hand no chest pain and dyspnea
    • Suggestion:
      • OPD FU for CS condtion
      • Consult NS
• 2021-06-29 Neurosurgery
  • Q
    • CC: fell down 3 days ago? and low back pain and generalized weakness; decreased appetite; slurred speech as usual (according to the ex-wife)
    • PH: alcoholism, Left TBI s/p craniectomy on 1995, s/p abd op (colon?)
    • Allergy: denied
  • A
    • This patient suffered from back pain after a fall 3 days ago. At ER, his L spine films showed L2 compression fracture. Conservative therapy, including back brace, is suggested. OPD f/u is advised.

[radiotherapy]

[chemotherapy]

==========

2023-08-11

[reconciliation]

The patient obtained a 28-day refill of the repeat prescription for Dilantin Kapseals (phenytoin) for his “absence epileptic syndrome, not intractable, with status epilepticus” from Taipei City Hospital on 2023-08-04. However, the patient is currently not taking phenytoin (according to the active medication list). It is recommended to assess whether the patient’s neurological symptoms persist and to determine the continued necessity of the drug.

700048952

230810

[exam findings]

• 2019-08-16 Colon fiberscopy
  • A sessile 0.8cm polyp at proximal T-colon and biopsy removal was done. Previous rectal cancer (10cm AAV) s/p CCRT was seen.
• 2019-07-03 CTA - pelvis
  • CT on 2018/12/21: cT3N2M1, paraaortic LN (+) potentially resectable
  • Findings Comparison: prior CT dated 2019/03/28.
    • Prior CT identified enhanceing focal wall thickening in the rectum about 1.2 cm in wall thickness is noted again, decreasing in size to 1 cm in the current CT that is c/w rectal cancer S/P C/T with partial response.
    • Prior CT identified enlarged node 0.88 cm in left common iliac chain is noted again, stable in size.
      • It is compatible with metastatic node S/P C/T with partial response.
    • There are several renal cysts on both kidney and the largest one is measured about 3.1 cm in size at the right upper pole.
    • A small hepatic cyst 4 mm in S2/3 shows stable in size.
    • A gallstone 7 mm also shows stable in size.
  • Impression:
    • Rectal cancer and metastatic node in left common iliac chain S/P C/T show partial response. please correlate with clinical condition.
• 2019-03-28 Sigmoidfiberscopy
  • Rectal cancer at 80 cm from AV s/p CCRT with significant tumor regression
• 2019-03-28 CT - abdomen
  • Much regression of rectal cancer. Decreased size of non-regional LNs.
  • Renal cysts (up to 2.8cm).
  • Gall stone (7mm).
• 2018-12-26 MRI - pelvis
  • History and indication: Rectal cancer
  • With and without contrast MRI of upper abdomen revealed:
    • Wall thickening of rectum (1.6cm in thickness) with regional and non-regional LAP.
    • Renal cysts (up to 3.2cm).
  • Impression:
    • Rectal cancer with LNs metastases.
• 2018-12-21 CT - abdomen
  • Clinical history: 59 y/o male patient with newly diagnosed rectal cancer at 8 cm from AV.
  • With and without contrast enhancement CT, ABD — Liver, Spleen, Biliary duct:
    • Thickening wall at rectum, r/o rectal malignancy.
    • Unremarkable change of the liver, spleen, pancreas and both kidneys.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
  • Impression:
    • Rectal cancer with perirectal involvement and lymph nodes in pelvic cavity and paraaortic region, cstage T3N2M1.
    • GB stone.
    • Renal cysts.
• 2012-12-14 SONO - hepatobiliary
  • Sonography of hepatobiliary system revealed:
    • Increased echogenicity of the liver. A hypoechoic nodule (1.12x1.50cm) at S5 of liver.
    • Gallbladder stone (0.87cm).
    • Patency of PV, HVs, IVC and aorta in hepatic portion.
    • Normal appearance of spleen.
    • No evidence of pleural effusion.
    • Right renal cyst (2.34x2.69cm). Left renal cyst (1.08x1.17cm).
  • IMP:
    • Mild fatty liver. A hypoechoic nodule (1.12x1.50cm) at S5 of liver.
    • Gallbladder stone (0.87cm). Bil. renal cysts.
• 2018-12-04 Surgical pathology Level IV
  • Rectum, 8 cm above anal verge, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[MedRec]

• 2023-07-10 SOAP Colorectal Surgery

• 2020-06-16 SOAP Metabolism and Endocrinology

  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension , malignant [I10]
    • Gouty arthropathy [M10.00]
    • Mixed hyperlipidemia [E78.2]
    • Obesity, unspecified [E66.09]
    • Malignant neoplasm of rectum [C20] *
  • Prescription
    • repaglinide 1mg 2# TIDAC15
    • Blopress (candesartan 8mg) 1# QD
    • Dibose (acarbose 100mg) 1# TIDAC
    • Tresiba FlexTouch (insulin degludec) 56 unit QN SC
    • Victoza (liraglutide) 1.8mg QDAC SC
    • Zulitor (pitavastatin 4mg) 1# QN

• 2018-12-04 SOAP Colorectal Surgery

  • S
    • A case of newly diagnosed rectal cancer at 8 cm from AV

• 2018-11-05 SOAP Colorectal Surgery

  • S
    • The patient received physical check up and was positive for FOBT.
    • Family hx of colon cancer (-)
    • Systemic disease/ Past history: Type 2 DM since 2007, HCVD
    • Op history: back lipoma s/p op
    • FOBT(+) noted on routine health exam / colon cancer screening
    • Small caliber stool
      
    • Anal discomfort and bloody stool
    • Ocupation: Driver
    • Anal fresh bleeding off and on and noted again these days

• 2017-03-06 SOAP Metabolism and Endocrinology

  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension , malignant [I10]
    • Gouty arthropathy [M10.00]
    • Mixed hyperlipidemia [E78.2]
    • Obesity, unspecified [E66.09]
  • Prescription
    • Levemir FlexPen (insulin detemir) 24 unit HS SC
    • Victoza (liraglutide) 1.8mg QDAC SC
    • NovoNorm (repaglinide 1mg) 2# TIDAC
    • Preterax (perindopril 2mg, indapamide 0.625mg) 1# BIDAC
    • Uformin (metformin 500mg) 1# TIDCC

[chemotherapy]

• 2020-05-20 - irinotecan 150mg/m2 270mg D5W 100mL 2hr
  • dexamethasone 6mg + granisetron 3mg + NS 500mL + atropine 0.3mg
• 2020-05-06 - oxaliplatin 85mg/m2 150mg D5W 150mL 2hr
  • dexamethasone 6mg + granisetron 3mg + NS 250mL
• 2020-04-17 - oxaliplatin 85mg/m2 150mg D5W 150mL 2hr
  • dexamethasone 6mg + granisetron 3mg + NS 250mL

==========

2023-08-10

On 2023-08-01, this patient obtained a 28-day supply of metformin, repaglinide, bisoprolol, olmesartan, and pitavastatin from Cheng Hsin General Hospital. It is noted that GLP-1 agonist (such as semaglutide) and HMG-CoA reductase inhibitor (like pitavastatin) are not currently listed in the active medication profile. It is advisable to closely observe the patient’s blood lipid and blood sugar levels to determine whether these medications or similar drugs within the same therapeutic class are necessary for his ongoing treatment.

701177392

230810

[lab data]

2023-08-10 Anti-β2-glycoprotein-I Ab 0.6 U/mL
2023-08-10 Anti-cardiolopin IgG 0.7 GPL-U/mL
2023-08-10 Anti-cardiolipin IgM 1.3 MPL-U/mL

2023-08-08 CEA (NM) 89.031 ng/ml

2023-08-07 HBsAg Nonreactive
2023-08-07 HBsAg (Value) 0.36 S/CO
2023-08-07 Anti-HBc Reactive
2023-08-07 Anti-HBc-Value 6.47 S/CO
2023-08-07 Anti-HCV Nonreactive
2023-08-07 Anti-HCV Value 0.09 S/CO

2023-08-07 CEA 96.78 ng/mL
2023-08-07 CA199 29.24 U/mL

2023-08-07 D-dimer > 10000.00 ng/mL(FEU)
2023-08-07 PT 11.1 sec
2023-08-07 INR 1.08
2023-08-07 APTT 25.7 sec
2023-08-07 Fibrinogen(quantita) 364.4 mg/dL

2023-08-04 Alkaline phosphatase 931 U/L

[exam findings]

• 2023-08-09 T- and L-spine AP + Lat.
  • Osteolytic lesion in L3 and L4 vertebral body is noted that may be bony metastasis. Please correlate with CT.
• 2023-08-09 Pelvis & Bilat. Hip Lat
  • An ill-defined osteopenic defect in right ilium is highly suspected.
• 2023-08-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 26) / 81 = 67.90%
    • M-mode (Teichholz) = 68
  • Conclusion:
    • Normal LV filling pressure; impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; trivial tricuspid regurgitation.
    • Possible mild pulmonary hypertension (the estimated systolic PA pressure 43 mmHg).
• 2023-08-09 Venous Ultrasound
  • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
  • Spontaneous signal:
    • Right:
      • CFV: N
      • SFV: N
      • PV: T
      • PTV: N
      • SV: N
    • Left:
      • CFV: N
      • SFV: N
      • PV: T
      • PTV: N
      • SV: N
  • Respiratory changes:
    • Right:
      • CFV: N
      • SFV: N
      • PV: T
      • PTV: N
      • SV: N
    • Left:
      • CFV: N
      • SFV: N
      • PV: T
      • PTV: N
      • SV: N
  • Cough response:
    • Right:
      • CFV: N
      • SFV: N
      • PV: T
      • PTV: N
      • SV: N
    • Left:
      • CFV: N
      • SFV: N
      • PV: T
      • PTV: N
      • SV: N
  • Compression study:
    • Right:
      • CFV: N
      • SFV: N
      • PV: T
      • PTV: N
      • SV: N
    • Left:
      • CFV: N
      • SFV: N
      • PV: T
      • PTV: N
      • SV: N
  • Report: Thrombus at R’t, L’t PV
    • Varicose vein : None
      
    • Right side:
      • SVC: 13.9 mmHg ; 15.5 mmHg ;
      • MVO/SVC: 85 % ; 79 % ;
      • Average MVO/SVC: 82.00 %
    • Left side:
      • SVC: 12.3 mmHg ; 17.0 mmHg ;
      • MVO/SVC: 92 % ; 76 % ;
      • Average MVO/SVC: 84.00 %
  • Conclusion:
    • Subacute DVT, thrombus involved both popliteal vein with total occlusion
• 2023-08-08 Tc-99m MDP bone scan
  • The scintigraphic findings suggest multiple bone metastases.
• 2023-08-08 Patho - lymphnode biopsy
  • Lymph node, axillary, right, sono-guided biopsy — Metastatic adenocarcinoma, lung origin
  • The sections show a picture of metastatic pulmonary adenocarcinoma, poorly differentiated, composed of lymphoid tissue with nests, cords, and signle large polygonal neoplastic cells with abundant eosiophilic cytoplasm, arranged in solid, papillary and subtle acinar patterns.
  • IHC - the tumor cells show: TTF1(+), GATA3(-), and PAX8(-).
• 2023-08-05 CT - chest
  • MRI at Cardinal Catholic: suspected tumors over spine with elevated alkaline phosphatase and CEA. Significant weight loss was noted.
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Lymphadenopathy at right axillary, both sides of the mediastinum and
      • Cystic lesion at right upper lobe measuring 1.98cm in largest dimension. Cystic lung cancer is highly suspected.
      • Right and left pulmonary embolism is found. Suggest urgent treatment.
      • No evidence of bilateral pleural effusion.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
      • Non-specific bowel gas at abdominal cavity is found.
  • Imp:
    • Right upper lobe cystic tumor. 1.98cm, r/o cystic lung cancer with bone meta, right axillary and mediastinal lymphadenopathy.
    • Bilateral pulmonary embolism. Suggest further, urgent treatment.
  • Imaging Report Form for Lung Carcinom
    • Impression (Imaging stage): T:T1(T_value) N:N3(N_value) M:M1(M_value) STAGE:____(Stage_value)

[MedRec]

• 2023-08-04 SOAP Hemato-Oncology Gao WeiYao
  • S: She experienced back pain since this March 2023 and she visited Cardinal Catholic hospital ortho and later she was transferred hematologic oncologic divsion at the same hospital.
  • A: BW 59, significant weight loss 11 kg within one month
    • MRI from other hospital revealed suspected spine tumor which might be related to her back pain.

700329331

230809

[lab data]

2023-07-26 Anti-HBc Reactive
2023-07-26 Anti-HBc-Value 6.35 S/CO
2023-07-26 Anti-HBs 7.41 mIU/mL
2023-07-26 Anti-HCV Nonreactive
2023-07-26 Anti-HCV Value 0.23 S/CO
2023-07-26 HBsAg Nonreactive
2023-07-26 HBsAg (Value) 0.26 S/CO

[exam findings]

• 2023-08-04 MRI - pelvis
  • CC: Bloody stools for 2-3 months. BW loss 6-7 Kg/half year
    • 20230705 colonoscopy: One hemi-circular tumor with ulceration and friability was noted at 10cm AAV, and the scope was unable to pass the lumen. Biopsy was done. pathology: adenocarcinoma.
    • 20230718 CT: rectal cancer with suspicious uterus invasion
  • Indication: Rectal cancer, MRI to R/O uterus invasion.
  • Findings:
    • There is segmental circumferential wall thickening at the upper rectum, measuring 5.5 cm in size, with suggestive intussusception from the sigmoid colon invagination into the rectum that is c/w Adenocarcinoma (T3).
      • In addition, the fat plane between the rectal cancer and uterine cervix area is still clear.
      • Rectal cancer with uterine cervix invasion is less likely.
    • There are seven enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w metastatic nodes (N2b).
    • There are few cystic lesions in the uterine cervix area, the largest one 1 cm, that are c/w Nabothian cysts.
    • There are two hypodense nodule 1.4 cm and 0.7 cm in the uterine myometrium on T2WI that are c/w myoma.
    • There is no cystic lesion in left adnexa.
  • IMP:
    • Rectal cancer is noted.
    • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for colon cancer: T3 N2b M0, stage: IIIC
• 2023-07-18 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Thickening wall at rectosigmoid colon, r/o colon malignancy.
    • Presence of pericolonic lymph nodes, r/o lymph nodes metastasis.
    • Cystic lesion, 1.5cm in left adnexa, r/o left ovarian cyst.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M0(M_value) STAGE: IIIB_(Stage_value)
  • Impression:
    • Rectosigmoid cancer with regional lymph nodes, cstage T3N2M0.
    • R/O left ovarian cyst.
• 2023-07-06 Patho - colon biopsy
  • Colorectum, rectum 10 cm above anal verge, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[MedRec]

• 2023-07-25 SOAP Radiation Oncology
  • RT planning: 5040cGy/28 fx (pre-operative) to rectosigmoid cancer and LAPs. CT simulation on 8/01 13:30. Possible GI/GU toxicity and menopause are told to her and her husband. Diet education (BW loss 6-7 kg in half yr).
• 2023-07-25 SOAP Hemato-Oncology
  • P
    • Simulation on 2023-08-01
    • Admission for 5-FU/LV
• 2023-07-22 SOAP Colorectal Surgery
  • S
    • A case of newly diagnosed rectal cancer
    • Poor appetite
    • BWloss 6-7 Kg in half year
  • A/P
    • Suggest TNT then OP
• 2023-07-17 SOAP Gastroenterology
  • O: 2023/07/06 PATHO-Colon biopsy - Colorectum, rectum 10 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1
• 2017-03-02 SOAP Cardiology
  • Diagnosis
    • Pure hypercholesterolemia [E78.0]
    • Essential (primary) hypertension [I10]
  • Prescription
    • Hyzaar (losartan 100mg, hydrochlorothiazide 12.5mg) 0.5# QD
    • Norvasc (amlodipine 5mg) 1# QD
    • Tulip (atorvastatin 20mg) 0.5# QD

700335852

230809

[lab data]

2023-08-03 RPR/VDRL Nonreactive
2023-08-03 HBsAg Nonreactive
2023-08-03 HBsAg (Value) 0.31 S/CO
2023-08-03 Anti-HCV Nonreactive
2023-08-03 Anti-HCV Value 0.11 S/CO
2023-08-03 HIV Ab-EIA Nonreactive
2023-08-03 Anti-HIV Value 0.09 S/CO
2023-08-03 Anti-HBc Nonreactive
2023-08-03 Anti-HBc-Value 0.11 S/CO

[exam findings]

• 2023-08-07 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • Section shows piece(s) of bone marrow with 30% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
• 2023-08-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (146 - 32) / 146 = 78.08%
    • LVEF (%) = 78
    • M-mode (Teichholz) = 78
  • Conclusion:
    • Dilated LV; normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 2.
    • Normal RV systolic function.
    • Aortic valve sclerosis with mild AS (AVA (Doppler) = 1.79 cm² ,Mean aortic pressure gradient = 9 mmHg); moderate MR; mild TR; mild PR.
    • Marked sinus bradycardia during exam.
• 2023-08-04 PET scan
  • The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on the same side of the diaphragm and involving multiple bone or bone marrow as mentioned above (stage IV).
• 2023-08-02 MRI - nasopharynx
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:3(T_value) N:3(N_value) M:____(M_value) STAGE:____(Stage_value)
• 2023-07-25 Aspiration Cytology - thyroid
  • Left neck mass — Positive for malignant tumor, in favor of lymphoma
    • NOTE: Correlation with biopsy result and clinical findings is recommended.
      
  • Smears show non-cohesive high-grade tumor cells with large hyperchromatic nuclei, irregular nuclear contour, mitotic activity, variable-sized nucloeli and scanty cytoplasm.
• 2023-07-25 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasopharynx, left, biopsy — Diffuse large B-cell lymphoma, non-GCB type
    
  • Section shows several pieces of respiratory epithelium lined tissue with infiltration of large lymphoid cells.
  • The immunohistochemical stains show CD3(-), CD20(+), CD56(-), CK(-), CD10(-), BCL2(+), BCL6(-), Cyclin D1(-), C-MYC(+), and MUM1(+). The Ki-67 is > 90%.
• 2023-07-25 SONO - head and neck soft tissue
  • Clinical Impression/Intent: left neck level II mass
  • Sonographic Impression: left neck level II confluent LAP, R/O malignancy
  • Diagnosis: left neck level II confluent LAP, R/O malignancy, s/p FNA

[MedRec]

• 2023-04-16 SOAP Metabolism and Endocrinology
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular [E08.319]
    • Mixed hyperlipidemia [E78.2]
    • Essential hypertention, unspecified [I10]
    • Chronic kidney disease, stage 3 (moderate) [N18.3]
    • Nontoxic multinodular goiter [E04.2]
    • Hepatitis [K75.81]
  • Prescription
    • Crestor (rosuvastatin 10mg) 1# QW1357
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
    • Trajenta (linagliptin 5mg) 1# QD
    • Uformin (metformin 500mg) 1# TIDCC
• 2017-03-14 SOAP Cardiology
  • Diagnosis:
    • HCVD, unspecified, without CHF [I11.9]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Dyslipidemia ; other and unspecified hyperlipidemia [E78.4]
  • Prescription
    • Eurodin (estazolam 2mg) 1# HS
    • Eazide (trichlormethiazide 2mg) 1# QD
    • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
• 2017-03-14 SOAP Metabolism and Endocrinology
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Mixed hyperlipidemia [E78.2]
    • Essential hypertention, unspecified [I10]
    • Nontoxic multinodular goiter [E04.2]
    • Arterial embolism and thrombosis of lower extremity [I74.4]
  • Prescription
    • Trajenta (linagliptin 5mg) 1# QD
    • Glucobay (acarbose 100mg) 0.5# TIDAC
    • Robestar (rosuvastatin 10mg) 1# QD
    • Uformin (metformin 500mg) 1# TIDCC
• 2017-03-14 SOAP Nephrology
  • Diagnosis: Renal failure, unspecified, uremia NOS [N19]

==========

2023-08-09

No recent lab results for LDH or beta-2-microglobulin were found in HIS5. If needed, initiate testing to establish a baseline prior to treatment.

700360174

230809

[lab data]

2023-07-14 Anti-HBc Reactive
2023-07-14 Anti-HBc-Value 7.77 S/CO
2023-07-14 Anti-HBs 437.04 mIU/mL
2023-07-14 HBsAg Nonreactive
2023-07-14 HBsAg (Value) 0.26 S/CO

[exam findings]

• 2023-07-06 PercutaneousTransluminal Angioplasty, PTA
  • Past Medical History
    • The patient has a history of CAD s/p PCI and thoracic aorta aneurysm.
  • Indication
    • The patient was referred with marked swelling of left arm and left forearm. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
  • Approach
    • Percutaneous access was performed through the av shunt fistula where a 8F sheath was inserted.
  • Procedure
    • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 40cc. The patient was treated with dormicum (Dosage=2.5 mg).
  • Finding Summary
    • Left Radio cephalic AVF, left innominate vein : 81% stenosis. AV fistula.
  • Intervention Summary
    • Left Radio cephalic AVF, draining left innominate vein, Pre-DS = 81%
    • MLD/RVD=4.5/23.5 mm → 20.3/22.6 mm, Post-DS = 10%.
    • Guide Wire: Terumo Radifocus 0.035 150cm.
    • Balloon: Bard ATLAS. 16.0 X 40 mm. Pressure: 10 atmospheres.
  • In conclusion :
    • S/P PTA for left radiocephalic AVF, draining left innominate vein, successful, from 81% to 10% residual stenosis
  • Recommendation :
    • PTA Intervention Treatment: Antegrade
• 2023-07-04 Patho - colon biopsy
  • Large intestine, lower rectum, 3-5 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2023-07-03 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with adjacent fat stranding and regional LAP.
    • Absence of left thyroid gland. Enlargement of right thyroid gland with nodules (up to 9mm).
    • Some LNs at mediastinum, axillary regions.
    • Left adrenal nodule (2.5cm).
    • Enlargement of prostate.
    • Bil. renal cysts (up to 3.1cm). Tiny calcifications in both kidneys.
    • Normal appearance of liver, spleen, pancreas.
    • Tiny gallbladder stones.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • Some calcifications at bilateral lungs.
  • Addendum Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2023-02-22 CTA - chest
  • Indication: aortic root dilatation hx, acute pul. edema, r/o aortic disseciton
  • With and without contrast enhancement CT of chest shows:
    • No intimal flap, nor intramural hematoma of aorta. Dilatation of aortic root, 5.0cm.
    • No filling defect of pulmonary artery.
    • Suspect stenosis of coronary artery, left anterior descending artery (Srs:8;Img:62).
    • No definite lung consolidation.
    • Small mediastinal lymph nodes.
    • No pleural lesion.
    • Polycystic kidney disease.
    • No bony destructive lesion on these images.
  • Impression
    • No CT-evidence of aortic dissection or pulmonary embolism
    • Aortic root dilatation
    • Suspect coronary artery stenosis, LAD

[MedRec]

• 2023-07-20 SOAP Radiation Oncology
  • P: Admission for infusional or oral 5-FU (UFUR)
  • Prescription
    • Vemlidy (tenofovir alafenamide 25mg) 1# QW135 (after dialysis on QW1,3,5)
• 2023-07-14 SOAP Radiation Oncology
  • Plan: CT-simulation will be arranged on 7/18. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 7/20 or 21.
• 2023-07-13 SOAP Hemato-Oncology
  • O: Will decide what regimen
  • A: Now on HD on W1, 3, 5, Noon time
• 2023-07-13 SOAP Colorectal Surgery
  • A/P:
    • Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-07-11
      • CCRT (TNT) then OP
• 2023-07-03 ~ 2023-07-05 POMR Colorectal Surgery
  • Discharge diagnosis
    • Rectal cancer with bleeding, cT4aN2aM0, STAGE:IIIC
    • End stage renal disease
    • Chronic ischemic heart disease, unspecified
    • Chronic systolic (congestive) heart failure
    • Thoracic aortic aneurysm (50 mm)
    • Enlargement of prostate
    • Left adrenal nodule
    • Pure hypercholesterolemia
  • CC
    • Bloody stool for 1 day
  • Present illness
    • This is a 70-year-old male with underlying history of ESRD QW135, CHF, and CAD s/p stent placement. He was admitted this time due to bloody stool for 1 day.
    • He was in his usual status of health until 1 days ago at midnight, when he started to defecate blood clot about 300ml. Then during hemodialysis, another episode of bloody stool was noted, therefore he was sent directly to our ER. After arrival at our ER, no bloody stool was noted. He was currently taking Bokey due to CAD s/p stent status. He denied history of peptic ulcer disease, HBV, HCV infection history,dizziness, abdominal pain, chest tightness or pain.
    • At ER, T/P/R: 36.6/107/18. BP:153/93mmHg. Con’s:E4V5M6. SpO2:95%. PE showed pink conjunctiva, no abdominal tenderness. Lab data showed hyperkalemia, BUN/Cr 107/10.1, WBC 9.34. Sigmoidoscopy showed several 0.2-0.3 cm IIa polyps at sigmoid colon. An ulcerative tumor was noted at lower rectum about 3-5 cm above anal verge, and Internal hemorrhoid. Abdominal CT showed rectal wall thickening r/o tumor. Under the impression of rectal ulcerative tumor bleeding, he was admitted for supportive treatment.
  • Course of inpatient treatment
    • After admission, abdominal CT showed rectal wall thickening r/o tumor. Sigmoidoscopy showed several 0.2-0.3 cm IIa polyps at sigmoid colon. An ulcerative tumor was noted at lower rectum about 3-5 cm above anal verge, and Internal hemorrhoid. The patient had no bloody stool after admission. Due to stable condition, and the patient requested for AV shunt occlusion management, the patient was discharged on 2023/7/5. Regular OPD f/u is arranged. Subsequent chemotherapy may be arranged after definite staging could be done after pathology report.
• 2023-05-10 SOAP Cardiology
  • A: In stationary condition now, no subjective complaints, asked for drug refill, acceptable BP control, keep on current medications
  • Prescription
    • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QD
    • Bokey (aspirin 100mg) 1# QD
    • Coxine (isosorbide-5-mononistrate 20mg) 1# BID
    • Nebilet (nebivolol 5mg) 0.5# BID
• 2017-09-14 SOAP Cardiology
  • S: A case of chronic GN with ESRD under regular hemodialysis since 2013, QW1,3,5 night
  • Diagnosis
    • Chronic ischemic heart disease, unspecified [I25.9]
    • Chronic systolic (congestive) heart failure [I50.22]
    • End stage renal disease [N18.6]
    • Dependence on renal dialysis [Z99.2]
    • Pure hypercholesterolemia [E78.0]
  • Prescription
    • Vytorin (ezetimibe 10mg, simvastatin 20mg) 0.5 HS
    • Plavix (clopidogrel 75mg) 1# QD
    • Hexal (carvedilol 25mg) 0.5# QD
    • Bokey (aspirin 100mg) 1# QD
• 2017-01-06 SOAP Nephrology
  • S: ESRD on HD 3
  • O: regular HD 3
  • Diagnosis: Chronic renal failure [N18.6]
• 2017-01-04 SOAP Nephrology
  • S: ESRD on HD 2
  • O: regular HD 2
  • Diagnosis: Chronic renal failure [N18.6]
• 2017-01-02 SOAP Nephrology
  • S: ESRD on HD 1
  • O: regular HD 1
  • Diagnosis: Chronic renal failure [N18.6]

[radiotherapy]

[chemotherapy]

• 2023-08-02 - [fluorouracil 400mg/m2 700mg NS 100mL 10min + leucovorin 20mg/m2 35mg NS 100mL 10min] D1,3-6 (CCRT)

==========

2023-08-09

[optimal dosage adjustment of metoclopramide for intermittent hemodialysis patients]

Metoclopramide is not effectively removed during dialysis. Therefore, it is advisable to administer approximately one-third (or less) of the standard total daily dose for patients undergoing intermittent (three times weekly) hemodialysis. ref: Metoclopramide kinetics in patients with impaired renal function and clearance by hemodialysis. Clin Pharmacol Ther. 1985;37(3):284-289. doi:10.1038/clpt.1985.41

700648329

230809

[exam findings]

• 2023-08-08 Tc-99m MDP bone scan
  • Increased activity in the lower T-spines and L3-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in biateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2023-08-07 PET
  • Increased FDG uptake in the left breast, compatible with the primary breast cancer.
    
  • Increased FDG uptake in the left mid- and high-axillary lymph nodes, highly suspected breast cancer with regional lymph nodes metastases.
  • Increased FDG uptake in multiple lobes of bilateral lungs and in both lobes of the liver, highly suspected cancer with distant metastases.
    
  • Left breast cancer, cTxN3aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-08-04 Patho - breast biopsy
  • DIAGNOSIS: Breast, left, biopsy — ductal carcinoma in situ, intermediate-grade
  • Microscopically, section shows intermediate-grade ductal carcinoma in situ characterized by a proliferation of atypical ductal epithelial cells with central necrosis of comedo-type. The tumor cells exhibit round to oval nuclei, nuclear pleomorphism, hyperchromasia and increased N/C ratio.
    
  • Immunohistochemical stain reveals
    • ER: negative
    • PR: negative
    • Her2/neu: positive(3+)
    • CK5/6: negative
    • p63: positive for myoepithelium.
• 2023-08-04 SONO - breast
  • Left breast malignancy with axillary lymph nodes metastasis.
    
  • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
• 2023-08-03 CXR
  • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-06-20 CT - abdomen
  • History and indication: abdominal pain
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Left breast tumor (5.4cm).
    • Multiple lung and liver tumors.
    • Right renal stone (3mm).
  • IMP:
    • Left breast cancer with lung and liver metastases.

[MedRec]

• 2023-08-02 SOAP Hemato-Oncology Xia HeXiong
  • P: Arrange admission for biops. Consult GS for breast biopsy or sono-guided biopsy and lab.
• 2023-06-23 SOAP Hemato-Oncology He JingLiang
  • S
    • multiple liver and lung mets
    • ca of breast is considered
    • suggest breast biopsy

==========

2023-08-09

2023-08-04 breast biopsy pathology IHC revealed: ER (-), PR (-), Her2/neu (3+), CK5/6 (-), p63 (+ for myoepithelium).

NHI coverage for pertuzumab is applicable under the following conditions: 1. Pertuzumab, in combination with trastuzumab and docetaxel, is used to treat patients with HER2-positive (IHC3+ or FISH+) metastatic breast cancer who have not previously received treatment with anti-HER2 therapy or chemotherapy for metastasis. 2. Prior approval is required for usage, and after approval, efficacy assessment data must be provided every 18 weeks for re-application. If the disease worsens, re-application should not be pursued. The maximum coverage duration for each patient is limited to 18 months.

If doxorubicin is intended for use, it is advisable to conduct a pre-treatment 2D transthoracic echocardiography to establish the baseline heart function.

701011695

230809

{not completed}

[past history]

• Hypertension in 2009 with Diovan F.C 160mg 1# po QD control.
• Bladder diverticulum s/p open repair 20 years ago.    
• Left inguinal hernia s/p LESS TEP repair on 2019/07/31.
• Bladder small cell neuroendocrine carcinoma and invasive urothelial carcinoma, high-grade, cT1N0M0, stage I s/p transurethral resection of bladder tumor on 110/12/01; s/p chemotherapy with etoposide + cisplatin for 4 times from 2022/01/12~2022/03/22.

[family history]

• There is no family history of cancer.
• Father and Mother: Hypertension. 

[exam findings]

• 2023-07-03 CT - abdomen
  • Indication
    • Small cell neuroendocrine carcinoma and UC of bladder, cT1N0M0, s/p neoadjuvant Etoposide and cisplatin (4), s/p RARC with neobladder reconstruction on 2022/04/11, ypT1N0 (0/25) M0 with lung metastasis s/p VATS RUL, RML, RLL wedge resection + LND on 2023/03/17 and chemotherapy with EP (Etoposide 80mg/m2 x3 days / Cisplatin 25mg/m2 x3 days) on 2023/04/20~ check from pelvis to chest, please 3Q
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • S/p port-A placement with its tip at Superior vena cava.
      • s/p right upper lobe,
      • Tiny nodule at right lower lobe measuring 0.2cm is found. Some perifissural nodule at right lower lobe measuring 0.3cm is also noted. still other comet tail like nodule at left lingula lobe up to 0.4cm, right upper lobe tup to 0.2cm, 0.6cm and left upper lobe measuring 0.23cm are found. In comparison with CT dated on 2023-02-04, the lesions are statianry.
    • Visible abdomen:
      • s/p ileoneobladder.
      • s/p cholecystectomy.
  • Imp:
    • s/p cystectomy and ileoneobladder.
    • Recurrent/residual tumor at both lung fields. Stationary.
• 2023-06-08, -05-09, -05-02 CXR
  • S/P port-A implantation.
  • There is multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
• 2023-04-18 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 25 dB HL, LE 25 dB HL
  • bil normal to mild SNHL
• 2023-04-11 CXR
  • Port-A catheter inserted into cavo-atrial junction via right subclavian vein.
  • elevation of Rt hemidiaphragm
  • Multiple nodules of variable sizes in both lungs due to metastases
  • a Rt minor fissure loculated effusion 44mm?
• 2023-03-17 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right, upper lobe, wedge resection —- small cell neuroendocrine carcinoma, in favor of metastatic
    • Lung, right, middle lobe, wedge resection —- small cell neuroendocrine carcinoma, in favor of metastatic
    • Lung, right, lower lobe, wedge resection —- small cell neuroendocrine carcinoma, in favor of metastatic
    • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
    • Lymph node, right, group No.10, lymphadenectomy —- Negative for malignancy (0/1)
    • Lymph node, right, group No.11, lymphadenectomy —- Negative for malignancy (0/2)
• 2023-02-14 CT guide biopsy
  • RUL nodule, s/p CT-buided biopsy
• 2023-02-04 CT - chest
  • Indication: Urinary bladder with lung mets
  • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • S/p port-A placement with its tip at Superior vena cava.
      • Diffuse nodular lesions scattered at both lungs are found. Lung meta is considered. In comparison with CT dated on 2022-01-09, the lesions are enlarged in size and numbers.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Hepatic cysts at both lobes of liver is found.
      • s/p cholecystectomy.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp: Bilateral lung meta. In progression.
• 2023-02-02 CT - abdomen
  • History and indication: Bladder tumor
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P urinary bladder operation.
    • Some nodules at bil. lungs.
    • Liver and renal cysts (up to 3.5cm).
    • Normal appearance of spleen, pancreas, adrenals.
    • S/P cholecystectomy.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
  • IMP:
    • S/P urinary bladder operation.
    • Some nodules at bil. lungs suspected metastases.
• 2022-11-09, -08-17 CT - abdomen
  • History: small cell neuroendocrine carcinoma and UC of bladder, cT1N0M0, s/p neoadjuvant Etoposide and cisplatin (4), s/p Robotic-assisted radical cystoprostatectomy (RARC) with neobladder reconstruction on 2022-04-11, ypT1N0(0/25)M0
  • Indication: FU
  • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • S/P radical cystoprostatectomy with neobladder reconstruction
    • Liver and renal cysts (up to 3.3cm).
    • S/P cholecystectomy.
    • Others
      • There is no focal abnormality in the biliary system, pancreas, and spleen.
        
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • S/P radical cystoprostatectomy with neobladder reconstruction
      • There is no evidence of tumor recurrence.
    • Detailed findings, please see description.
• 2022-08-18, -05-26 Uroflowmetry
  • Q max: low
  • Flow pattern: obstructive
• 2022-08-18 Bladder Sonography
  • PVR 1.59mL (post-void residual)
• 2022-05-26 Bladder Sonography
  • PVR 1mL (post-void residual)
• 2022-05-26 SONO - urology
  • Miction pain, treated outside in 2020-09, and 2021-02, s/p diverticulectomy, open 20 years ago. nocturia 3/n, SUI(+), wound: well - Diagnosis:
    • Right hydronephrosis
    • Bilateral renal stones
    • Left renal stone
• 2022-04-20 Cystography
  • Cystography via foley catheter administration revealed:
    • The bladder capacity is about 100cc.
    • No evidence of contrast medium leakage.
• 2022-04-12 Patho - urinary bladder partial/total resection
  • PATHOLOGIC DIAGNOSIS:
    • Urinary bladder, Robotic-assisted radical cystoprostatectomy (s/p TURBT) — infiltrating urothelial carcinoma, high-grade
    • Prostate, RARC (s/p TURP) — Non-invasive papillary urothelial carcinoma, high-grade (at prostatic urethra) — Free of apex margin
    • Seminal vesicles, bilateral, RARC — Negative for malignancy
    • Ureter cuff end, right, RARC — low-grade urothelial dysplasia
    • Ureter cuff end, left, RARC — Negative for malignancy
      
    • Lymph node, left iliac, dissection — Negative for malignancy (0/1)
    • Lymph node, right iliac, dissection — Negative for malignancy (0/3)
    • Lymph node, left obturator, dissection — Negative for malignancy (0/9)
    • Lymph node, right obturator, dissection — Negative for malignancy (0/12)
    • AJCC 8th edition Pathology stage: pT1N0(if cM0); AJCC pathologic stage I
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: Robotic-assisted radical cystoprostatectomy
    • Specimen size:
      • Urinary bladder: (12) x (8) x (5) cm
      • Prostate: (4.8) x (3.5) x (3.2) cm
      • Tumor size: 0.5 cm
      • Tumor site: Posterior wall
      • Sections are taken and labeled as: F2022-153FSC: right cuff end, F2022-153FSD: left cuff end, A1-11: prostate, A12: bil seminal vesicles, A13-20: bladder, B: left iliac LN, C: right iliac LN, D1-2: left obturator LN, E1-2: right obturator LN
  • MICROSCOPIC EXAMINATION (for urinary bladder):
    • Histological type
      • Urothelial: Papillary urothelial carcinoma, invasive
    • Histological grade: High grade
    • Pathological staging (pTNM, AJCC 8th edition):
      • TNM Descriptors: (required only if applicable) (select all that apply)
        • m (multiple primary tumors)
        • r (recurrent)
        • y (posttreatment)
      • Primary tumor (pT): pT1: Tumor invades lamina propria (subepithelial connective tissue)
      • Regional lymph nodes (pN): pN0: No lymph node metastasis
      • Distant metastasis (pM): N/A
    • Section margins:
      • Involved by noninvasive low-grade urothelial carcinoma/ urothelial dysplasia, site:right ureter curr end
    • Explanatory note:
      • Immunohistochemical stain for prostate: AMACR(-), 34BE12(+) and GATA3(+).
• 2022-04-11 Frozen Section
  • Left ureter cuff end, frozen section — Negative for malignancy
  • Right ureter cuff end, frozen section — High-grade dysplasia
  • Right ureter cuff end, frozen section — Low-grade dysplasia
  • Left ureter cuff end, frozen section — Negative for malignancy
• 2022-03-23 CT - abdomen
  • History and indication: Bladder tumor
  • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is diffuse wall thickening of the urinary bladder and few calcifications within the wall that is c/w urothelial cell carcinoma. Please correlate with cystoscopy.
    • Liver and renal cysts (up to 3.8cm).
    • S/P cholecystectomy.
  • Impression:
    • There is diffuse wall thickening of the urinary bladder and few calcifications within the wall that is c/w urothelial cell carcinoma. Please correlate with cystoscopy.
• 2022-03-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (90 - 14) / 90 = 84.44%
    • M-mode (Teichholz) = 84.2
  • Dilated LA - Adequate LV, RV systolic function with normal wall motion
  • LV hypertrophy, Impaired LV relaxation
  • Mild MR, TR, AR, PR
• 2022-02-09 Spirometry
  • Normal spirometry
• 2021-12-21 MRI - prostate
  • With and without enhancement MRI: Prostate
  • Findings
    • Mucosal thickening at lower portion of urinary bladder and near urinary bladder orifice. suspected urinary bladder tumors.
    • Relative wall thickening at right urinary bladder wall.
    • Outpouching lesion in right aspect of urinary bladder, suggesting urinary bladder diverticulum.
    • Non-enhancing tumors in the liver, 4.1cm in S8 and 2.6cm in S2, suspected liver cysts.
    • Non-enhancing tumors in bilateral kidneys, up to 1.97cm in left kidney, suspected renal cysts.
    • No enlarged lymph node in the pelvic cavity and paraaortic region.
    • No ascites.
  • Impression:
    • Mucosal thickening at lower portion of urinary bladder and near urinary bladder orifice. suspected urinary bladder tumors.
    • Relative wall thickening at right urinary bladder wall.
    • Urinary bladder diverticulum.
    • LIver and renal cysts.
• 2021-12-07 Tc-99m MDP whole body bone scan with SPECT
  • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the lower C-spine, some L-spines, bilateral shoulders, hips and knees in whole body survey.
  • IMPRESSION:
    • Mildly increased activity in the lower C-spine and some L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
• 2021-12-02 CT - abdomen
  • History and indication: Bladder tumor
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of urinary bladder with adjacent fat stranding and regional LAP. S/P foley catheter indwelling.
    • Liver and renal cysts (up to 3.5cm).
    • Normal appearance of spleen, pancreas, adrenals.
    • S/P cholecystectomy.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • No abnormal density at bilateral basal lungs.
  • Addendum Imaging Report Form for Urinary Bladder Carcinoma
    • Impression (Imaging stage) : T:T4b(T_value) N:N2(N_value) M:M0(M_value) STAGE:IVA(Stage_value)
• 2021-12-01 Patho - prostate TUR
  • Prostate, TUR-P biopsy — Small cell neuroendocrine carcinoma and invasive urothelial carcinoma, high-grade
    
  • The sections show a picture of small cell neuroendocrine carcinoma, composed of sheets of poorly differentiated tumor cells seperated by scant stroma. The neoplastic cells have small to intermediate-sized, round to oval nuclei and high N/C ratio. Mitosis are numerous.
    • IHC shows: CD56(+), synaptophysin(+), and PSA(-).
      
  • The overlying urothelium shows invasive urothelial carcinoma, high-grade. Tumor cell invades subepithelial connective tissue.
    • IHC, these tumor cells reveal: CK5/6(focal+), GATA3(+).
• 2021-12-01 Patho - urinary bladder TUR
  • Urianry bladder, TURBT — Invasive papillary urothelial carcinoma, high-grade
    
  • The sections show following features:
    • Histologic type: Papillary urothelial carcinoma, invasive
      
    • Histologic grade: High-grade
      
    • Tumor configuration: Papillary
      
    • Muscularis propria: Present
      
    • Lymphovascular invasion: Not identified
      
    • Microscopic tumor extension: Tumor invades subepithelial connective tissue
• 2021-11-13 Uroflowmetry
  • Q max: fair
  • flow pattern: obstructive
• 2021-11-13 Bladder Sonography
  • PVR 107mL (post-void residual)
• 2021-04-30 Bone densitometry - hip
  • Hip BMD performed by DXA revealed:
    • Left hip, BMD is 0.616 gms/cm2, about 2.1 SD below the peak bone mass (72%) and 1.2 SD below the mean of age-matched people (83%).
  • Impression
    • Osteopenia
• 2021-04-30 SONO - abdomen
  • Diagnosis
    • Liver cyst, S2 and S7
    • Liver hemangioma, S6
    • post cholecystectomy
    • Renal stone, right
    • Renal cyst, left
    • Dilated pelvis of left kidney
    • pancreatic body and tail masked by gas.
  • Suggestion
    • ultrasound follow up
    • visit urology if symptoms revealed.
• 2021-04-10 Bladder Sonography
  • PVR 148mL (post-void residual)
• 2021-04-10 Uroflowmetry
  • Q max: fair
  • flow pattern: obstructive

[MedRec]

• 2023-05-02 SOAP Hemato-Oncology
  • O
    • Cancer Treatment Radiotherapy/Targeted Therapy Side Effect Assessment (2023-05-02)
      • Sensory abnormalities: G1: Asymptomatic; loss of DTR (Deep Tendon Reflex) or abnormal skin sensation.
        • Management of sensory abnormalities: Observation.
      • White blood cell reduction: G1: 3000 - 4000/mm3
        • Management of white blood cell reduction: Observation.
• 2023-03-30 SOAP Hemato-Oncology
  • P: Admission for 24 hours CCr, Audiometry and EP
• 2023-03-30 SOAP Thoracic Surgery
  • A: small cell neuroendocrine carcinoma, metastatic.
  • P: refer back to Onco. Dr. Xia for adjuvant therapy.
• 2023-02-23 SOAP Thoracic Surgery
  • A/P: arrange admission on 3/16; 3/17 VATS RML, RLL wedge, for tissue proof.
• 2023-02-09 SOAP Hemato-Oncology
  • A/P: Admission for CT-guided biopsy (Already discuss with radiologist Dr. Chang)
• 2023-02-02 SOAP Hemato-Oncology
  • A/P
    • Arrange Chest CT
    • May consider Biopsy after Chest
    • Then discuss the appropriate regimen of treatment
• 2022-04-28 SOAP Urology
  • O
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-04-25
      • Subsequent imaging follow-up, focusing on chest imaging.
    • 2022-01-12 ~ 2022-03 - neoadjuvant Etopside, cisplatin (4) - AE: nasuea, vomiting, hicccup
• 2022-01-25 SOAP Urology
  • O
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-01-03
      • The patient is considering cystectomy and may need to undergo urethrectomy again.
    • Cancer Multidisciplinary Team Meeting Conclusion> Meeting Date: 2021-12-20
      • Recommend neoadjuvant chemotherapy + radical cystectomy
      • Prostate cancer workup (Lung CT, prostate MRI, PSA) for double cancer.

[surgical operation]

• 2023-03-17
  • Surgery
    • VATS RUL, RML, RLL wedge resection + LND.
  • Finding
    • Multiple lung nodules over RUL, RML and RLL, size range from 1.2cm to 0.5cm.
    • One 24 Fr. straight chest tube was inserted via right 8th ICS.
• 2022-04-11
  • Surgery
    • Robotic-assisted radical cystoprostatectomy with neobladder reconstruction.  
  • Finding
    • Bladder tumor over dome.
    • severe adhesion over anterior bladder wall
    • blood loss: 1000ml (urine included)
    • console time: 300 mins    
• 2021-12-01
  • Surgery
    • TUR-BT
    • TUR prostate biopsy
    • EC of bladder diverticulum
  • Finding
    • Mild kissing prostate appearance
    • Papillary uneven prostate mucosa over bilateral lobes, right side dominate
    • Papillary bladder tumors over BN 4-5 o’clock
    • Papillary bladder tumors over right posterolateral wall to bladder dome, large amount
    • Large diverticulum over right side lateral wall
    • Papillary tumors in diverticulum
    • Perfrom EC after tumor resection
    • Clear urine output from bilateral UO
    • Bilateral UO and ES remained intact after the procedure

[chemotherapy]

• 2023-08-08 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
• 2023-07-19 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
• 2023-06-29 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
• 2023-06-08 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
• 2023-05-16 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
• 2023-04-20 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
• 2022-03-22 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
• 2022-03-01 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
• 2022-02-08 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
• 2022-01-12 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3

==========

2023-08-09

The patient recently renewed his repeat prescription for Diovan (valsartan) for a 28-day supply on 2023-08-07. This medication has been added to the active list of medications without an identified reconciliation problem.

2023-06-30

According to the PharmaCloud database, this patient regularly refills his prescription for Diovan (valsartan) to treat his primary hypertension. This medication was correctly added to the active formulary and no issues were identified during the medication reconciliation process.

2023-06-09

According to PharmaCloud data, this patient has only sought medical treatment at our hospital. No issues with medication reconciliation were identified.

The latest lab data, collected on 2023-06-06, shows largely normal results and readings from the TPR panel are stable. There are no issues with the current prescription.

2023-05-17

The patient’s prostate cancer was pathologically confirmed as small cell neuroendocrine carcinoma on 2021-12-01. Given the histologic characteristics of small cell components, the regimens used for small cell lung cancer (SCLC) are considered preferable. Therefore, the patient received both cisplatin (25mg/m2) and etoposide (100mg/m2) on days 1 to 3 for 4 cycles in the first quarter of 2022. The same regimen was restarted (etoposide at 80mg/m2) on 2023-04-20 due to a lung wedge biopsy performed on 2023-03-17 that indicated metastatic small cell neuroendocrine carcinoma. The treatment is currently ongoing.

There were no notable abnormalities found in the TPR panel and lab data from 2023-05-16. In addition, no medication reconciliation issues were identified.

701101946

230809

[lab data]

2023-07-22 Anti-HBc Reactive
2023-07-22 Anti-HBc-Value 4.23 S/CO
2023-07-22 Anti-HCV Nonreactive
2023-07-22 Anti-HCV Value 0.13 S/CO
2023-07-22 Anti-HBs 5.84 mIU/mL
2023-07-22 HBsAg Nonreactive
2023-07-22 HBsAg (Value) 0.49 S/CO

[exam findings]

• 2023-08-07 CXR
  • RUL lobar consolidation with occuded lobar bronchus and involving the hilum
  • there is pulmonary fibrosis at lower lung and LUL
  • moderate enlarged cardiac silhoutte due prominent cardiophrenic angle mediastinal fat pad / supine position
  • Port-A catheter inserted into RA via left subclavian vein.
• 2023-07-28 PET
  • Glucose hypermetabolism in a focal area in the upper lobe of right lung with invasion to the right pulmonary hilar region and adjacent right aspect of the mediastinumm, compatible with metastatic neuroendocrine carcinoma involving these regions.
  • Mild glucose hypermetabolism in the left shoulder. Inflammatory process may show this picture.
  • Mild glucose hypermetabolism in some focal areas in the mandible. Dental problem is more likely.
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureter. Physiological FDG accumulation may show this picture. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2023-07-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (103 - 42.2) / 103 = 59.03%
    • M-mode(Teichholz) = 59
  • Conclusion:
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR, mild MR, TR and PR
    • No regional wall motion abnormalities
    • One nodule lesion with diamter about 1.27x1.1 cm at RA cavity
• 2023-07-27 BronchoDilator Test
  • Diagnosis: Lung cancer
  • Conclusion: POOR PERFORMANCE
    • mild obstructive ventilatory impairment without significant reversibility, combine restrictive
• 2023-07-26 24hr ECG
  • Baseline was sinus rhythm
  • A few isolated VPCs / VPC couplet
  • A few isolated APCs / APC couplets (with some blocked APC)
  • 9 episodes of short-run At, max 4 beats
  • No long pause
• 2023-07-26 Tc-99m MDP bone scan
  • Two hot spots at the lower T- and upper L-spine, the nature is to be determined (severe DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, mandible, some upper T-spine, sacrum, right sternoclavicular junction, bilateral shoulders, left elbow, S-I joints, hips, and left knee.
• 2023-07-26 Neurosonology
  • Mild (to moderate) atheromatous lesions in R middle to distal CCA and L ICA; mild atheromatous lesions in L middle CCA to CCA bifurcation, R CCA bifurcation and R ICA
  • Smaller caliber with decreased flow in R cervical VA, possible R VA hypoplasia.
  • Normal extracranial carotid and L vertebral arterial flows.
• 2023-07-25 MRI - brain
  • Multifocal areas of acute ischemic cortical infarct over both frontal, parietal & occipital lobes and left temporal lobe. Also multiple embolic infarcts over both corona radiata.
  • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
  • No evidence of brain metastasis.
• 2023-07-24 Patho - pleural/pericardial biopsy
  • Lung, right, CT-guide biopsy — metastatic neuroendocrine carcinoma
    
  • Sections show nests of pleomorphic tumor cells infiltrating in a fibrotic stroma with focal tumor necrosis.
  • The immunohistochemical stains reveal CK7(focal +) , CK20(-), Synaptophysin(focal +), TTF-1(-), Napsin A(-), and p40(-). The results are consistent with metastatic neuroendocrine carcinoma.
• 2021-07-16 CT - abdomen
  • S/P total gastrectomy and partial resection of S7 of the liver. There is no evidence of tumor recurrence.
• 2017-11-01 Surgical pathology level VI
  • PATHOLOGIC DIAGNOSIS
    • Stomach, cardia, radical total gastrectomy with frozen section for margin (S2017-17868) —- Neuroendocrine carcinoma, grade 3.
      • IHC stains: synaptophysin (+), chromogranin A (-), NSE (-), S-100 protein (-), CD56 (-), Ki-67: 80%. (on S17-17911A4)
    • Margin: free
    • Lymph node, LN1-2-3, LN4, LN5-6, LN7-8-9, LN 10-11, LN12, D2 dissection — Metastatic neuroendocrine carcinoma (2/27 = serosal surface LN: (1/2), LN 1-2-3: (1/9), LN4: (0/1), LN5-6: (0/1), LN 7-8-9: (0/11), LN 10-11: (0/2), LN12: (0/1).
    • Pathology stage: pT3N1 (cMx); pStage: IIB.
      • IHC stain: (S17-17753 biopsy specimen): Her2/neu: (-).
  • MACROSCOPIC EXAMINATION
    • Specimen type: radical total gastrectomy with frozen section for margin
    • Specimen size: Greater curvature: 20 cm, Lesser curvature: 15 cm
    • Number of lesions: 1
    • Tumor site: cardial region, greater curvature side
    • Tumor size: 6 x 6 cm.
    • Tumor configuration: For advanced cancer (Borrmann’s classification)
      • Type III ulcerated and infiltrating.
    • Tissue for sections: S2017-17898FS: Esophageal end margin; S2017-17911A1: distal margin; A2-5: tumor with serosal surface; B: omentum; C1-3: LN1-2-3, D: LN4, E1-2: LN5-6, F1-2: LN7-8-9, G1-2: LN 10-11, H: LN12.
  • MICROSCOPIC EXAMINATION
    • Histologic type: Neuroendocrine carcinoma
    • Histologic grade: Grade 3
    • Depth of tumor invasion: serosal adipose tissue.
    • Lymph node
      • Lymph node as designated NO. positive / NO. total
      • 2/27 = serosal surface LN: (1/2), LN 1-2-3: (1/9), LN4: (0/1), LN5-6: (0/1), LN 7-8-9: (0/11), LN 10-11: (0/2), LN12: (0/1).
    • Pathology Staging: pT3N1 (cMx); pStage: IIB.
      • Tumor invasion: T3 Tumor penetrates subserosal connective tissue without invasion of visceral
      • Lymph node status: N1 Metastasis in 1 to 2 regional lymph nodes
    • Margins
      • Proximal Margin: Free, 5 mm from the margin
      • Distal Margin: Free, 9.5 cm from the margin
      • Circumferential (Adventitial) Margin: Free, 0.2 cm from the margin
    • Additional pathologic findings:
      • Mitotic count: 10 mitoses/10HPFs. Ki-67: 80%.
      • IHC stains: synaptophysin (+), chromogranin A (-), NSE (-), S-100 protein (-), CD56 (-), (on S17-17911A4)
• 2017-10-30 Surgical pathology level IV
  • Stomach, fundus, biopsy — Adenocarcinoma.
  • Section shows fragments of gastric tissue infiltrated by irregular glands.
  • IHC stain of cytokeratin (CK) highlights irregular neoplastic glands. Her2/neu: (-).

[MedRec]

• 2023-07-21 SOAP Gastroenterology Zhao YouCheng
  • Diagnosis: Gastric cacner [C16.9]
  • Prescription x3
    • Nexium (esomeprazole 40mg) 1# QN
    • B-Red (hydroxocobalamin 1mg) 1# ST IM
    • Foliromin (ferrous sodium citrate 50mg) 1# QD
    • Allegra (fexofenadine 60mg) 1# QN
    • Stogamet (cimetidine 300mg) 1# QN
• 2018-08-30 SOAP Rheumatology
  • Diagnosis
    • Gouty arthropathy [M10.00]
    • Malignant neoplasm of stomach, unspecified [C16.9]
  • Prescription x2
    • Feburic (febuxostat 80mg) 1# QD
    • Paran (acetaminophen 500mg) 1# PRNBID
    • Compesolon (prednisolone 5mg) 1# PRNBID
    • colchichine 0.5mg 1# QD
• 2017-12-18 SOAP Rheumatology
  • Diagnosis
    • Gouty arthropathy [M10.00]
    • Malignant neoplasm of stomach, unspecified [C16.9]
  • Prescription x2
    • Mopik (meloxicam 7.5mg) 1# PRNQD
    • Euricon (benzbromarone 50mg) 1# QD
• 2017-11-20 SOAP Hemato-Oncology Gao WeiYao
  • Diagnosis
    • Malignant neoplasm of stomach, unspecified [C16.9]
    • Drug-induced gout, right ankle and foot [M10.271]
    • Iron deficiency anemia, unspecified [D50.9]
    • Acute nasopharyngitis [common cold] [J00]
  • Prescription
    • Foliromin (sodium ferrous citrate 50mg) 1# BID
• 2017-10-27 SOAP Gastroenterology Zhao YouCheng
  • Diagnosis: Gastric cacner [C16.9]

[consultation]

• 2023-08-04 Hemato-Oncology
  • A
    • This 79 year old man is a case of Gastric cancer, neuroendocrine carcinoma, grade 3, pT3N1 cM0 s/p radical total gastrectomy on 2017/10/31 with liver metastasis s/p S7 segmental hepatectomy on 2018/4/12 s/p C/T with EP, shift to carboplatin plus irinotecan regimen since 2018/05/14 with RUL metastasis; ECOG = 2. We are consulted for further treatment.
    • We will take over this case. Please book 11A (fisrt) or 10B. Thanks for your consultation.
• 2023-07-31 Radiation Oncology
  • A
    • Diagnosis: Gastric cancer, neuroendocrine carcinoma, grade 3, pT3N1 cM0 s/p radical total gastrectomy on 2017/10/31 with liver metastasis s/p S7 segmental hepatectomy on 2018/4/12 s/p C/T with EP, shift to carboplatin plus irinotecan regimen since 2018/05/14 with RUL metastasis; ECOG =2.
    • Plan: Palliative RT to RUL tumor for 4900cGy/14 fx is suggested for tumor control. CT simulation is arranged on July 31 15:30. Possible toxicity is told; diet education is given. Treatment will be started 2-3 days later.
• 2023-07-26 Neurology
  • Q
    • For brain MRI showed Multifocal areas of acute ischemic cortical infarct over both frontal, parietal & occipital lobes and left temporal lobe. Also multiple embolic infarcts over both corona radiata.
    • This is 79 years-old male has had history of gouty. And he was diagnosed with gastric neuroendocrine carcinoma s/p radical total gastrectomy on 2017/10/31. The surgery pathology reports Neuroendocrine carcinoma, grade 3, pT3N1(2/27)(cMx); pStage: IIB, Free Margin, 9.5cm, KI-67: 80%.
    • This time, Cough for days, Fall down on 2023-07-16. COVID-19 virus infection on 2023-07-17. Had a CT scan done in Kinmen, suspected lung cancer, further examination recommended (case details available in the cloud). Poor appetite and Body weight loss (don’t remember how many kilograms) were noted. He came to our GI OPD refer to CM OPD, CXR and CT showed right upper lung collapse and tumor obstruction.
    • Admission from ER. At ER, Vital sign: TPR: 36.3/63/18, BP: 119/56mmHg, Conscious clear, GCS: E4V5M6, SpO2: 97%, Laboratory: Covid-19 PCR: Not Detected, No leukocytosis. D-dimer: 838.28 ng/mL(FEU).
    • Under the impression of right upper lung collapse and tumor obstruction, suspect lung cancer, he was admitted for lung cancer survey.
  • A
    • According to the patient and his wife’s statement, he denied focal weakness, slurred speech, easy choking, blurred vision or other symptoms except generalized weakness.
    • NE E4V5M6 relatively cachexia
      • CNs: intact
      • MP symmetric and weak MP 3
      • sensation: intact for touch
      • FNF/HNS: no dysmetria
    • brain MRI on 7/25: Multifocal areas of acute ischemic cortical infarct over both frontal, parietal & occipital lobes and left temporal lobe. Also multiple embolic infarcts over both corona radiata.
    • impression: embolic stroke, suspect cardiogenic etiology, r/o Trousseau syndrome
    • suggestion:
      • please do heart echography, 24H holter EKG and CPA/TCD for embolic stroke survey; be cautious of infectious endocarditis
      • use DOAC if no contraindication and Af or Trousseau syndrome was confirmed
      • neurology OPD follow-up after discharge if indicated.
    • Contact me if any questions and thank you for consultation.

[surgical operation]

• 2018-04-12
  • Diagnosis: Gastric neuroendocrine tumor, pstage IIB with liver metastasis, S7
  • PCS code: 75003B
  • Finding
    • A 2.5x1.5 cm tumor over S7 noted from intra-op Sono. No daughter nodule. no vein thrombosis.
    • Two nodules over R`t abdominal wall peritoneum and biopsy was done.
    • Severe peritoneal adhesion due to previous total gastrectomy & D2 LN dissection. We lysis all of them with electrocautery.
• 2017-10-31
  • Diagnosis: Gastric cardial Ca, cT2N0M0
  • PCS code: 72032A
  • Finding
    • 7x7 cm gatric tumor over gastric cardial region, greater curvature side with suspect serosal invasion
    • Preigastric lymph nodes (area 3, 7, 8, 9, 10, 11, & 12) enlargement were noted and D2 lymph node dissection was done.
    • Proximal cutting end about 2 cm and frozen section was free
    • Blood loss about 300 ml

==========

2023-08-09

[prophylactic antiviral therapy prior to immunosuppressive agent use]

The patient’s hepatitis B serology results indicate that he is immune due to natural infection, with negative HBsAg, positive anti-HBc, and positive anti-HBs. However, he remains vulnerable to reactivation if exposed to immunosuppressive agents.

Given this situation, if the treatment plan involves immunosuppressive agents, it is advisable to consider prophylactic antiviral therapy. Possible options include prescribing either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD. This preventive approach can effectively lower the risk of potential HBV reactivation induced by the immunosuppressive effects of the treatment.

ref: Pharmacy FAQ - Hepatitis B reactivation and screening. http://www.bccancer.bc.ca/pharmacy-site/Documents/Pharmacy%20FAQs/Pharmacy-FAQ-Hepatitis-B.pdf

701489999

230809

[lab data]

2023-07-31 Anti-HBc (NM) Positive
2023-07-31 Anti-HBc Value (NM) 0.636
2023-07-31 Anti-HBs (NM) Positive
2023-07-31 Anti-HBs value (NM) 677.000 mIU/mL
2023-07-31 Anti-HCV (NM) Negative
2023-07-31 Anti-HCV Value (NM) 0.043
2023-07-25 HBsAg (NM) Negative
2023-07-25 HBsAg Value (NM) 0.418

2023-07-25 CA-199 (NM) 354.780 U/ml
2023-07-25 CEA (NM) 31.940 ng/ml

[exam findings]

• 2023-07-21 CT - abdomen
  • CC: Dark red bloody stool passage off and on and noted again these days, Mucoid bloody stool passage
    • 20230720 colonoscopy: One mass in the sigmoid colon, 15 cm AAV, R/O malignancy
  • Findings:
    • There is segmental irregular wall thickening of the rectosigmoid junction, measuring 5 cm in size that is c/w adenocarcinoma (T3).
    • There are four enlarged nodes in the adjacent mesocolon (N2a).
    • There are two poor enhancing masses 3.7 cm in S4 and 2 cm in S7 of the liver that are c/w metastases (M1a).
    • There are several mild poor enhancing masses in the uterus that are c/w myomas. Please correlate with GYN. sonography.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
• 2023-07-21 Patho - colorectal polyp
  • DIAGNOSIS: Intestine, large, rectosigmoid junction, 15 cm from anal verge, biopsy — adenocarcinoma
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2023-07-20 Colonoscopy
  • Diagnosis:
    • Siogmoid polyp s/p polypectomy
    • Rectosigmoid cancer s/p biopsy
    • Severe melanosis coli
    • Large mixed hemorrhoids

[MedRec]

• 2023-08-07 SOAP Nutrition Consultation
  • S
    • Occupation: Homemaker
    • Dietary Habits:
      • Breakfast (6-7 AM): Meal replacement (Shou Mei Li) with or without a slice of thick toast (butter spread) / Boiled egg
      • Morning Snack: 1 can of Ensure (consistently consumed daily)
      • Lunch: Half a bowl of porridge + 2 and a half pieces of tilapia fish + 2/3 portion of greens
      • Afternoon Snack: 1 Kiwi
      • Dinner: Same as lunch
    • Exercise: Light jogging once a day, for 40 minutes including warm-up
    • Fluid Intake: 1500-2000 ml
  • A
    • Anthropometry:
      • BMI kg/m2: normal / over weight / obesity
      • Current energy intake: adequate / inadequate
      • Nutrition problem:
        • Ensure 1-2
  • P
    • Goal: BS control
    • Education topic: DM diet principle, 6 Food Groups and food groups contain CHO, eating-out principles, Food exchange list, protein restricted diet education,Balance diet
    • Meal planning: kcal
      • Cereal : ex/d
      • Meat/Bean-choose low fat protein (soy products, egg): ex/d
      • Green vegetable: ex/d
      • Fruits: ex/d
      • Low fat milk: ex/d
      • Oil: ex/d
      • Increase physical activity: 3 times/ week, 30 min/time
      • Decrease alcohol: ex/d →
      • SMBG with diet recoard
• 2023-07-27 SOAP Hemato-Oncology
  • P
    • CCRT with FOLFOX and followed by FOLFOX with or wtihout bevacizumab and cetuximab (need further discussion with family).
    • Admission for CCRT with FOLFOX
• 2023-07-27 SOAP Radiation Oncology
  • P
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectosigmoid tumor bed area.
    • The treatment planning of radiotherapy will be started at 1030, 2023-08-02.
• 2023-07-27 SOAP Colorectal Surgery
  • A/P
    • Suggest pre-op chemotherapy + target therapy then colectomy + hepatectomy
    • Arrange MRI for differential uterine invasion; T4b ? or T3 ?
    • Refer to Radiotherapy for reducing size, better resectability

700710186

230808

[exam findings]

• 2023-07-13 Pure Tone Audiometry, PTA
  • Reliability FAIR to POOR (tinnitus+, inconsistent response)
  • Average RE 24 dB HL; LE 65 dB HL.
  • RE normal to moderately severe SNHL.
  • LE mild to severe mixed type HL.
• 2023-06-23 Tc-99m MDP bone scan
  • Increased activity in the skull base. Malignancy with local bony involvement may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in a middle T-spine. The nature is to be determined (degenerative change? other nature?). Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the lower L-spine. Degenerative change may show this picture.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2023-06-21 MRI - nasopharynx
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:4(T_value) N:3(N_value) M:0(M_value) STAGE:IVA(Stage_value)
  • Findings
    • The left nasopharyngeal tumor involving left side of clivus, longus colli muscle, foramen ovale, foramen lacerum, and cavernous sinus, and encasing left ICA.
    • White matter edema in left anterior temporal lobe also noted.
    • Enlarged lymph nodes at both sides of the neck, also at left parotid gland and right paratracheal region.
• 2023-06-13 Patho - nasopharyngeal/oropharyngeal
  • DIAGNOSIS:
    • Nasopharynx, left, biopsy — Non-keratinizing nasopharyngeal carcinoma, undifferentiated
  • GROSS DESCRIPTION:
    • Specimen submitted in formalin consists of several pieces of tan, irregular tissue measuring up to 0.3 x 0.2 x 0.1 cm. All for section in one cassette.
  • MICROSCOPIC DESCRIPTION:
    • Section shows several pieces of nonkeratinzing squamous cell carcinoma.
    • The immunohistochemical stains reveal CK(+) and p40(+).
  • MICROSCOPIC EXAMINATION:
    • Histologic Type (select all that apply): Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B)
    • Treatment Effect (applicable to carcinomas treated with neoadjuvant therapy): patient not received
    • Additional Pathologic Findings (select all that apply): None identified
    • Ancillary Studies: not applicable
    • Clinical History (select all that apply): Neoadjuvant therapy: No
• 2023-06-15 Nasopharyngoscopy
  • left NP tumor, with extension to lateral pharyngeal wall
  • easily touch bleeding, biopsy done

[MedRec]

• 2023-06-19 ~ 2023-06-24 POMR Ear Nose Throat
  • Discharge diagnosis
    • Malignant neoplasm of nasopharynx T4N3M0, STAGE:IVA
  • CC
    • Blood-tinged rhinorrhea and headache for 2 months
  • Present illness
    • This is a 68-year-old woman with underlying hypertension, hyperlipidemia and diabetes mellitus under medication control for over 2 years. She had noticed blood-tinged rhinorrhea and left headache for 2 month. Left tinnitus, left neck pain and left face numbness were noted too, no body weight loss.
    • She visited LoTung PohAi Hospital for help, left nasopharyngeal lesion was noted and suggested biopsy. Denied drinking, cigarette and betel nuts. Therefore, she came to our ENT OPD for second opinion. Fiberscopic exam showed left nasopharyngeal tumor, with extension to lateral pharyngeal wall. Left otitis media with effusion and left neck mass about 8cm, can’t movable, tenderness. Biopsy of the tumor was done, and the pathology report non-keratinizing nasopharyngeal carcinoma, undifferentiated. Admission for further examination was suggested, and she agreed after thorough consideration. Therefore, under the impression of nasopharyngeal cancer, she was admitted for cancer work-up.   
  • Course of inpatient treatment
    • After admission, serial tests were arranged for tumor staging work up. Nasopharyngeal MRI showed nasopharyngeal carcinoma T4N3M0, STAGE IVA. Abdominal sonography showed gall stone. Whole body bone scan showed increased activity in the skull base. Malignancy with local bony involvement may show this picture. Under relative stable condition, the patient was dishcarged with OPD follow up.
  • Discharge prescription
    • OxyNorm (oxycodone 5mg) 1# Q6H 7D

[chemotherapy]

• 2023-08-07 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + carboplatin AUC 4 300mg NS 250mL D2 + fluorouracil 1000mg/m2 1200mg NS 500mL D2-5 (TPF Q3W)
  • dexamethasone 4mg D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4 + NS 250mL D1-4
• 2023-07-14 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + carboplatin AUC 4 300mg NS 250mL D2 + fluorouracil 1000mg/m2 1200mg NS 500mL D2-5 (TPF Q3W)
  • dexamethasone 4mg D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4 + NS 250mL D1-4

==========

2023-08-08

No medication reconciliation issues were found after reviewing PharmaCloud and HIS5.

700948807

230808

[exam findings]

• 2023-06-07, -03-22 CXR
  • Atherosclerotic change of aortic arch
  • S/P metalic autosuture at right upper lung with lung volume decrease.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-03-15 All-RAS + BRAF mutation
  • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-02-23 CXR
  • s/p right chest tube in place, its tip directed medially, projecting over 6th intercostal space
  • atelectasis of RUL
• 2023-02-21 Patho - lung total/lobe/segmental
  • PATHOLOGIC DIAGNOSIS
    • Lung, RUL, VATS RS2 segmentectomy — Metastatic adenocarcinoma, colorectal origin
    • Lymph node, LN 7, right, dissection — Negative for malignancy ( 0 / 3 )
    • Lymph node, LN 11, right, dissection — Negative for malignancy ( 0 / 6 )
    • Lymph node, LN 12, right, dissection — Negative for malignancy ( 0 / 4 )
    • AJCC 8th edition pathology stage (for colon cancer): pTxN0M1a; AJCC stage IVA
  • MACROSCOPIC EXAMINATION
    • Surgical Procedure(s): VATS RS2 segmentectomy
    • Specimen Type:
      • Location: Right upper lobe
      • Lymph node dissection: yes (specify): LN7, LN 11, LN 12
    • Specimen Integrity: intact
      
    • Specimen Size: Greatest dimensions: 10x 5 x 2.5 cm
    • Tumor Site: Right upper lobe
    • Tumor number: Multiple (Number:2 )
    • Tumor Size: Greatest dimension: 0.6 cm and 0.2 cm, respectively
    • Gross tumor patterns:poorly defined
    • Gross Tumor Extension (specify) : Not identified
    • All for sections are taken and labeled as: F2023-70FS:tumor, F2023-70A1:tumor, F2023-70A2-13”RUL, A:LN7, B:LN11, C:LN 12
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Metastatic adenocarcinoma, colorectal origin
      
    • Histologic Grade: G2: Moderately differentiated
    • Microscopic Tumor Extension: not identified
    • Margins: Margins free, Distance from closest margin: 2 cm
    • Visceral Pleura Invasion: not identified
    • Lymph-Vascular Invasion: present
      
    • Perineural Invasion: not identified
      
    • Regional lymph Nodes:
      • Number examined: 13
      • Number involved: 0
    • Ancillary Studies: IHC stain — CK20(+), TTF-1(-), Napsin A(-), CK7(-)
• 2023-02-19 CXR
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • Blunting of left costophrenic angle due to pleural thickening
  • a small nodular opacity over medial RUL
  • extensive increased opacity over Lt and Rt lower lung zonesdue to breast shadows
  • partial atelectasis with bronchiectasis of inferior lingular segment
• 2023-02-09 SONO - abdomen
  • Propable liver cyst, left
  • Suspected fatty infiltration of pancreas
• 2023-02-07 CT - chest
  • a well-defined RUL solid nodule, increase in size (from 6mm to 8mm), and statonary of bronchiectasis and bronchiolitis at lingula, and several subpleural reticular opacities at LLL as compared with previous CT on 2022/11/03.
• 2022-11-09 Barium Enema
  • Double contrast study of LGI series revealed:
    • The contrast medium passage from anus to terminal ileum smoothly without obstruction.
    • S/P operation.
    • Colonic diverticula.
  • IMP: S/P operation. Colonic diverticula.
• 2022-11-03 CT - abdomen
  • History and indication: Colon cancer at splenic flexure
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Colon cancer s/p operation.
    • A nodule (6mm) at RUL.
    • Duodenal diverticulum.
    • Increased density of bil. breast.
    • Liver and renal cysts (up to 1.6cm).
    • Atherosclerosis of aorta, iliac arteries.
    • Disc space narrowing at L4/5.
  • IMP:
    • Colon cancer s/p operation.
    • A nodule (6mm) at RUL.
• 2022-05-05 SONO - abdomen
  • Diagnosis:
    • Propable liver cyst,left
    • Suspected fatty infiltration of pancreas
    • Propable left renal cyst
  • Suggestion:
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2021-11-04 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Large intestine, splenic flexure colon, SILS left hemicolectomy —- Adenocarcinoma, moderately differentiated
    • Resection margins: free
    • Lymph node, mesocolic, dissection — Negative for malignancy (0/12)
    • Lymph node, IMA / SMA, dissection —- N/A.
    • Pathology stage: pT3N0(if cM0); AJCC stage IIA
  • MACROSCOPIC EXAMINATION
    • Operation procedure: SILS left hemicolectomy
    • Specimen site:splenic flexure colon
    • Specimen size: colon: 15 cm in length
    • Tumor size: 2.5 cm
    • Tumor location: 3.5cm away from the closest resection margin
    • Depth of invasion grossly: perirectal soft tissue
    • Mucosa elsewhere: Not remarkable
    • Representative sections and labeled: A1-2:bilateral margins, A3-6:LNs, A7-10:tumor
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
    • Histology Grade: moderately differentiated
    • Depth of invasion: pericolorectal tissue
    • Angiolymphatic invasion: Present
• 2021-11-01 CT - chest
  • LLL curvilinear opacity (11 mm), focal atelectasis or a primary nodule, no lung metastasis, suggest f/u CT at 6 to 12 months later.
  • lingular bronchiectasis.
• 2021-11-01 SONO - abdomen
  • Liver cyst.
  • Hypoechoic nodule, 0.98x0.81cm in right lobe liver. Suggest follow up.
  • Right renal cyst.
• 2021-10-28 ECG
  • Sinus bradycardia
  • Low voltage QRS of limb leads
  • Borderline ECG
• 2021-10-20 CT - abdomen
  • History: diarrhea and abdominal pain for 3 ms. blood in stool (+). stool 3-4/day. cramp (+). fullness esp post meal. 2021/10/13 colonoscopy: One huge ulcerative tumor at just proximal to splenic flexure colon
  • Indication: colon cancer, splenic flexture, CT for staging
  • Findings:
    • There is soft tissue mass measuring 2 cm in the splenic flexure colon that is compatible with adenocarcinoma.
      • In addition, there are two lymph nodes in the adjacent mesocolon that may be metastatic nodes.
    • There is an ill-defined small poor enhancing nodule 5 mm in S8 of the liver that may be flow artifact, cyst or tumor. Please correlate with sonography.
    • A hepatic cyst measuring 1.6 cm in S2 is noted.
    • Two renal cysts 0.8 cm and 1 cm in left upper pole are noted.
      
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
• 2021-10-14 Patho - colorectal polyp
  • Colon tumor, 45-42 cm from anal verge, biopsy — Adenocarcinoma
    
  • Microscopically, the sections show a picture of adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with focal necrosis and desmoplasia.
  • Immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
• 2021-10-13 Colonoscopy
  • Colon polyp, A-colon, s/p biopsy removal (A)
  • Highly suspect colon cancer, just proximal to splenic flexure(occupied 45 to 42cm from AV), s/p biopsy (B)
  • Colon polyp, S-colon, s/p hot snare polypectomy (C)
  • Internal hemorrhoid

[MedRec]

• 2022-02-10 SOAP Colorectal Surgery
  • 20220210 UFT discotinue due to general malaise and poor appetite

[surgical operation]

• 2023-02-20
  • Surgery
    • VATS RS2 segmentectomy + LND.
  • Finding
    • One nodular lesion was noted over RS2 of RUL, size about 1.5cm in diameter.
    • Frozen section: adenocarcinoma.
    • One 20 Fr. straight chest tube was inserted via right 5th ICS.
• 2021-11-03
  • Surgery
    • SILS left hemicolectomy        
  • Finding
    • splenic flexure tumor, T3N1bMx Stage: IIIB
    • Anastomosis by GIA 75/4.8mm *2

[immunochemotherapy]

• 2023-06-26 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-21 - irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-30 - irinotecan 120mg/m2 180mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2021-11-22 ~ 2021-12-27, 2022-02-07 ~ 2022-06-09 - UFT (tegafur 100mg, uracil 224mg) 2# BID

==========

2023-08-08

Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf

• Dipeptiven should be mixed with a compatible amino acid carrier solution or an amino acid containing infusion regimen prior to administration. Patients with total enteral nutrition Dipeptiven is continuously infused over 20-24 hours per day.

2023-06-27

• Based on the information in the PharmaCloud database, our hospital has been the exclusive provider of all necessary medical services and medications for this patient for the past three months. All current medications have been prescribed by our hemato-oncology department. Therefore, no medication reconciliation issues have been identified.

• The recent lab results indicate a decreasing trend in the patient’s CEA level, potentially suggesting that the current regimen of FOLFIRI plus Avastin is effective. On the other hand, the gradually increasing CA199 level could imply a condition related to the pancreas, which aligns with the abdomen sonography conducted on 2023-02-09 suggesting suspected fatty infiltration of the pancreas? The latest lab results from 2023-06-26 showed normal readings in CBC, electrolytes, and renal and liver functions. The dosage of irinotecan in the FOLFIRI regimen has been increased to a regular dose (180mg/m2) during this hospitalization. No adjustments to the medication dosage are currently required.

  • 2023-06-16 CEA 2.54 ng/mL
    
  • 2023-05-05 CEA 3.14 ng/mL
    
  • 2021-10-20 CEA 10.61 ng/mL
    
  • 2023-06-16 CA199 109.70 U/mL
    
  • 2023-05-05 CA199 91.76 U/mL

701016342

230808

[MedRec]

• 2023-08-07 DutyNote
  • Problem List
    • left breast invasive ductal carcinoma cT2N1 stage IIB at least
    • left multiple rib fructure and hemothorax status oist left video-assisted thoracoscopic surgery evacuation of hematoma on 112/7/3
    • acute to subacute multiple embolic storke over bilateral frontal parietal, temproal and left occipital lobe suspect related to tumor embolic.
    • type 2 diabetes mellitus
    • hypertension
  • Course of treatment
    • This 71-year-old female, a patient had history of hypertension & stroke of left pontine/right caudate infracts in 2013. This time, fall down was noted for 1-2 weeks and visited to WanFang hospital for evaluation and CXR showed rib fructure. Owing to sudden onest of dyspnea and chest discoomfort was developed and came to WanFang hospital ER again and left multiple rib fructure and hemothorax status oist left video-assisted thoracoscopic surgery evacuation of hematoma on 2023/07/03. suspected aphasia was noted on 2023/07/08 and brain CT showed acute to subacute multiple embolic storke over bilateral frontal parietal, temproal and left occipital lobe suspect related to tumor embolic. Elevated CEA &CA-199 level was noted during storke survey thrtrgore vaginal ultrasound was done and no specific finding was noted.
    • Breast sono revealed highly suspected breast cancer at left 2.5 with left axillary lymphadenopathy. Breast biopsy proved microscopically incasive ductal carcinoma with ER (+) , PgR(+) , Her2: negative (1+) and Ki-67 with 5-10%positive nuclei. Owing to disease progression noted and for further treatment by her family and she was transferred to our hospital on 2023/08/07.
• 2023-11-20 ~ 2013-11-29 Discharge Note
  • CC
    • Right limbs weakness for about 2 days
  • Present illness
    • This 63 y/o female patient is a case of right OA knee and patella fracture s/p op. Before this episode, she could walk with a regular cane but with right leg weakness. This time, she seemed to suffer from right side limbs weakness for about 2 days. She became unable to walk this morning and was brought to our ER for help. Neurological examination revealed right central facial palsy, mild dysarthria and right muscle power UE = 4+; LE = 4+. Brain CT was performed and no ICH. Under the impression of left hemisphere ischemic stroke, she was advised to admission for further evaluate and management.
  • Course of inpatient treatment
    • After admission, adequated hydration and antiplatlet were given. TCD/CCD was done and showed minimal atherosclerosis in bilateral CCA and right BIF; mild atheromatous lesions in left proximal CCA. Brain MRA was done and revealed an acute infarct in left pons. An old infarct in right caudate nuscleus. Cardiac echo was done and showed mild MR and TR; trivial AR. Rehab. dept was consulted and rehab. program was started smoothly. General skin itching but no rash was found, so we check autoimmune profile and showed normal. So CTM and sinbaby was given. Bilateral leg pain was controlled by Scanol. Under stable condition, she was discharged and OPD follow up was arranged.

==========

2023-08-08

Concor (bisoprolol) and Nexium (esomeprazole) should be prepared by the simple suspension method before tube feeding.

The simple suspension method refers to the process of placing tablets and capsules in warm water for a period of time and gently shaking them to promote disintegration and suspension of the medication, rather than grinding them into powder for tube feeding.

701170059

230808

[exam findings]

• 2023-08-12 KUB and lateral views of lumbar spine:
  • S/P posterior instrumental fixation with TPS-rod fixation and posterolateral fusion and anterior fusion with cage at L2-S1 levels
  • No loosening of TPs
  • S/P decompressive laminectomy of L2-L5
• 2023-08-08 SONO - nephrology
  • Bilateral chronic change of both kidneys.
  • Bilateral renal cysts.
  • Thickened bladder wall with irregular border, cause?.
• 2023-08-07 CT - abdomen
  • Patchy consolidation over LLL. Increased infiltration over both lower lungs. May be active infection.
  • Left pleural effusion.
  • Markedly distended urinary bladder. Mild bilateral hydroureteronephrosis.
  • Bilateral perirenal fatty strandings.
  • S/P posterior instrumentation of L2-S1 vertebrae.
• 2023-08-07 CT - brain
  • The brain shows age-related cortical atrophy, sulcal space widening, proportionate ventricular dilatation and white matter ischemic change including the periventricular, subcortical and subinsular regions. Old lacuna infarct over left internal capsule. There is no intracranial hemorrhage seen.
  • The posterior structures including the brain stem, cerebellum and CP angles look normal. However, the beam-hardening artifact over the skull base may hamper the film reading.
  • Please take notice that non-enhanced CT scan is limited in the detection of acute ischemic infarction (particularly within the first 6 hours), small vascular lesion, neoplasm, infectious/toxic/metabolic disease. Recommend correlate with clinical condition.
• 2023-08-07 CXR
  • Cardiomegaly and tortuosity of the thoracic aorta.
  • Widening of the mediastinum.
  • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
  • Left pleural effusion.
  • Degenerative joint disease of T-spine with marginal osteophytes.
• 2023-07-03, -06-29 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Interstitial and alveolar infiltrates involving predominantly the mid-and lower-lung fields, and pleura effusions are seen. Acute pulmonary edema is highly suspected.
• 2023-06-24 ECG
  • Sinus rhythm with Premature atrial complexes
  • T wave abnormality, consider anterior ischemia
• 2023-06-23 SONO - abdomen
  • Fatty liver, moderate
  • Parenchymal liver disease
  • cholecystopahty: improved.
  • Renal cyst, right
  • Renal stone, right
  • Ascites, moderate
• 2023-06-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (113 - 44.1) / 113 = 60.97%
    • M-mode (Teichholz) = 61.0
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Moderate MR, mild AR and TR
    • Dilated LA, IVC and aortic root; thick IVS and LVPW
    • Moderate pulmonary hypertension
    • Premature beats and suspected short-run atrial arrhythmia during the exam, HR 79-117bpm
• 2023-06-16 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
• 2023-06-16 SONO - abdomen
  • Diagnosis:
    • Fatty liver, moderate
    • suspicious, acute cholecystitis
    • Ascites, mild
    • Parenchymal renal disease, bilateral
    • Renal cyst, right
    • r/o, Renal stone, left
    • pancreatic tail masked by gas.
  • Suggestion:
    • consult GS surgeon.
• 2020-03-20 MRI - L-spine
  • History
    • 20200318 Residual pain over sacrum.
    • 20200219 Numbness for 2 days. Residual pain.
    • 20200204 For SIJ RF
    • 20191218 Bilateral SIJ pain, VAS 7.
    • 20190403 SIJ pain improved 50%, acceptable. Still right L5 radicular pain and numbness.
    • 20190319 For IPM
    • 20190313 Pain relieved for one day. VAS 10.
    • 20190227 L-spine s/p PD + PI + PF x 4 time, last op one month ago. Bilateral buttock pain, VAS 9. CAD s/p stent. Plvix use. Numbness over right lateral leg.
  • Non-contrast MRI of lumbar spine, including sagittal T2W FSE, sagittal T1W, coronal STIR, axial T2W and axial T1W images (3 mm thickness in sagitta images and 4 mm thickness in the other images) reveals:
    • Scoliosis of L-spine.
    • S/P posterior decompression and TPSs at L2-3-4-5-S1.
    • General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral mild neuroforaminal narrowing at L2-3-4-5-S1, esp right side at L2-3 (with midl retrolisthesis).
    • No intramedullary lesion.
    • Diffuse infiltrative T2-hyperintensity in the atrophic muscles of lower back, indicating myositis.
    • Several T2-hyperintence cysts in both kidneys, with the largest one about 15 mm.
• 2019-03-13 KUB + L-spine Lat.
  • KUB and lateral views of lumbar spine show:
    • S/P posterior instrumental fixation with TPS-rod fixation and posterolateral fusion and anterior fusion with cage at L2-S1 levels
    • No loosening of TPs
    • S/P decompressive laminectomy of L2-L5

[MedRec]

• 2023-07-06 MultiTeam - Oncology Psychology
  • Referral Date: 2023-06-28
  • Reason for Referral: Disease stress event: Psychophysiological stress reactions caused by physical illness or decisions about what kind of treatment to accept. Emotional distress: anxiety, fear, depression, anger; shyness, shock, etc. Social/interpersonal/communication difficulties: Conflicts or communication difficulties with family, colleagues, friends, medical staff, other patients.
  • Conclusion:
    • S
      • Visited on 2023/07/04, cared for by a caregiver, the patient was sleeping deeply. The patient’s wife mentioned that her husband would cough at night, couldn’t sleep well, had deep phlegm that couldn’t be suctioned out. The caregiver encouraged the patient to try coughing it out himself. The patient’s wife said that tying up his hands at night makes him even more unable to sleep. Once he falls asleep, it’s fine. The pain originally was only in the stomach, now it’s in the back and all over the body. When changing patches, he needs an extra half a shot for pain relief. Moreover, when he feels pain, it’s acute, very painful, not a gradual pain. If it’s a little pain, he wouldn’t say he needs an injection. When he was first admitted to the hospital, it was too painful, he even cursed himself and his daughter, because it was too painful and he was confused.
      • Now he’s more lucid, even jokes around with everyone, unlike the initial confusion. (Speaking softly) “Sometimes he says he’s in so much pain, it would be better to die”, now the doctor helps him relieve the pain, prescribed four kidney medications, thanks for the concern.
    • O
      • Prostate cancer (bone metastasis), colon cancer (post-surgery 2022-07) treated in another hospital, 2023/06/01-15 melena, discovered gastritis, internal hemorrhoids, abnormal liver function, thickened gallbladder wall at Taipei Mackay Hospital, transferred to our hospital for further treatment on 2023/06/16, 2023/06/28 confused consciousness, aggressive behavior, emotional and communication issues were referred by the NP, 2023/06/30 family meeting, 2023/07/03 occupational safety room, social worker concern.
    • I
      • Caring for the family’s care expectations.
    • AP
      • After care from multiple parties, the family expressed apology. They still have relatively strong opinions on care (suctioning, restraint, pain relief, etc.). It is recommended to communicate in a coordinate way and enhance prognostic awareness. Counselor Psychologist Huang XiaoFang
  • Reply by: Huang XiaoFang
  • Reply date: 2023-07-05 18:34
• 2023-07-04 MultiTeam - Social Services
  • Referral Date: 2023-06-30
  • Reason for Referral: The patient and family members have emotional distress issues during hospitalization
  • Case Status: Not Open
  • Reason for not opening the case : 2023-07-03 Consultation with the patient’s wife:
  • Family situation:
    • The patient is 70 years old, married with three daughters.
    • The patient usually lives with his wife in Shulin District.
    • The eldest daughter is married and lives in Taipei, and sometimes can work remotely due to her job nature; the second daughter is unmarried, lives in Linkou District, runs her own business, and has flexible working hours; the youngest daughter is unmarried and lives in Neihu District.
  • Assessment and Treatment:
    • During the patient’s hospitalization, the caregiver and the patient’s wife were by his side to care for him. Due to the patient’s weakness, a conversation was held with his wife. Concerned about the patient’s condition during hospitalization, his wife expressed that the patient was in discomfort and sometimes confused when he was first admitted. The wife mentioned that last week, the patient had difficulty coughing up phlegm, the primary nurse suggested suctioning, but the patient didn’t want to be suctioned. The primary nurse then said, “If you don’t get the phlegm suctioned, (coughing like this) is expected.” The patient was displeased when he heard this, and his wife was also somewhat dissatisfied.
      • The wife stated that she asked the primary nurse whether it was the doctor’s recommendation to suction, but the primary nurse did not give a straightforward answer, which led to an argument that day. However, the team was informed and intervened, the wife said that it was mainly due to a misunderstanding in communication, and the patient was cursing people randomly due to his confusion at the time. The family has since apologized to the nursing staff, the wife stated that there were no issues with the care provided by the nursing staff afterwards, the patient is now more lucid, and there have been no more incidents of cursing people randomly. Therefore, there have been no issues with the care in recent days.
    • It was also understood during the consultation that there is a nurse caring for the patient during the hospitalization period. The patient’s wife, eldest daughter, and second daughter also take turns coming to the hospital to accompany him. Considering that the patient has out-of-pocket and other derivative expenses, the social worker was concerned about the family’s financial burden. The wife indicated that the family is financially secure and able to cover the additional expenses during hospitalization. The main issue currently is the patient’s back pain and other multiple sites of pain, sometimes the pain relief is not very effective, so the team is asked to pay attention to the patient’s pain.
    • The head nurse was informed of the above matters, and it was also learned from the head nurse and the primary nurse that the patient and his family’s attitudes have been more amicable recently, and there are currently no derivative issues with the care.
    • This referral provides the above treatment, and it is understood from the consultation that the patient and his family members currently have no derivative emotional distress issues, and the main concern is the patient’s pain, asking the team to pay attention. If there are further needs for social worker assistance in the future, they can be informed again, thank you.
  • Reply by: Luo Yuquan
  • Reply date: 2023-07-03

[consultation]

• 2023-06-29 Dermatology
  • Q
    • This is a 70-year-old man with past history of:
      • Transverse colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH
      • Prostate cancer with multiple osseous metastases
      • CAD s/p PCI DES x2 at RP, under clopidogrel/Nicorandil
      • HFDEF (2022/04 LVEF:58%)
      • Adrenal insufficiency Hypoaldosteronism Hypotonic hyponatremia, r/o Al
      • Normocytic anemia, related to colon cancer
      • Hypertension Benign prostate hyperplasia.
    • Patient bedridden.
    • For skin itchy, we need your further evaluation and management.
  • A
    • The patient had sufferred from generalized itchy skin over trunk and limbs.
      
    • Under the impression of xerotic dermattiis
    • The following sugeetion:
      • CB strong 3 tube mix-up with Sinphraderm 1 tube. After evenly mixing with baby oil or lotion, apply it to the dry areas of the body.
      • consider Xyzal 1# HS po use and Orolsin 1#PRNTID po use for itchy control.
• 2023-06-24 Rehabilitation
  • Q
    • For general weakness, rehabilitation plan, we need your further evaluation and management.
  • A
    • Due to deconditioning, we were consulted for bedside PT rehabilitation programs.
    • Assessment
      • Malignant neoplasm of prostate
    • Plan
      • His wife and the patient declined rehab training currently
• 2023-06-23 Gastroenterology
  • Q
    • The patient is an 70-year-old male with a history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent x2, Adrenal insufficiency. He presented with intermittent bloody stool for 4 days sent to MMH.
    • For cholecystitis, liver function raised, we need your further evaluation and management.
  • A
    • 70M.
      • The clinical history and medical records were reviewed.
      • He was hospitalized 2023/6/1-6/16 with admission diagnosis of GI bleeding.
      • The definite etiology of bleeding was uncertain, but may be colon ulcer according to the endoscopy.
      • He received a protracted antibiotic treatment course in the hospitalization, including Flumarin plus metronidazole (6/5-6/10), ertapenem (6/10-6/14) and fluconazole (6/3-6/15).
      • He developed RUQ pain and tenderness with an acute cholestatic hepatitis in days before his transfer to our hospital.
    • S+O:
      • Drinking alcohol (-)
      • Raw food consumption (-)
      • Nausea (-), Vomiting (-)
      • Diarrhea (-)
      • Taking other medications not from this hospital (-)
    • PE: mild tenderness over RUQ region
    • Lab:
      • in MMH
        • 2023/06/02 AST 18 ALT 16 TBI 0.5
        • 2023/06/13 AST 405 ALT 391 ALP 451 GGT 1494 Lipae 33 TBI 2.0 DBI 1.7
        • 2023/06/15 AST 654 ALT 672 TBI 3.8 DBI 2.6
      • in TTCH

        • 2023/06/16 AST 237 ALT 441 ALP 430 GGT 1489 TBI 2.97 DBI 1.74; WBC 9.65 Seg 94.8% CRP 1.2 PCT 0.36

        • 2023/06/23 AST 68 ALT 127 ALP 239 GGT 993 TBI 5.64 DBI 3.43 PT 11.5 NH3 51

        • 2023/06/17 HBsAg-/AntiHBs+/AntiHCV-

        • 2023/06/23 TSH 0.053 (low), T3 0.67 (low) FT4 1.27; cortisol 17.74

      • in MMH
        • 2023/06/15 CT scan: marked edematous change of GB, but no evident gallstone or CBD stone, no biliary tract dilatation
      • in TTCH
        • 2023/06/16 Abd echo: moderate fatty liver, marked GB wall thickening with non-disteded GB, no biliary tract dilatation, mild ascites
        • 2023/06/23 Abd echo: moderate fatty liver, improved GB wall thickening, no biliary tract dilatation, moderate ascites
    • Impression:
      • Cholecystopathy or cholecystitis (non-calculous)
      • Acute cholestatic hepatitis or cholangitis, more likely to be intrahepatic cholestasis, but extrahepatic cause (such as microlithiasis of CBD) could not be ruled out
        • possible etiology of intrahepatic cholestas is included: atypical viral hepatitis, DILI (e.g. fluconazole or other antibiotic), sepsis, TPN, autoimmune liver disease (less likely)
      • Abnormal thryoid function, r/o sick euthyroid syndrome
    • Suggestion:
      • Treat acute disease per your expertise
      • No indication of biliary drainage since there was NO sign of biliary obstruction
      • Watch out for the hepatic decompensation for the progression of ascites and jaundice
      • May try empirical treament of Urso in dose of 1-2# TID
      • Consider EUS or MRCP to rule out microlithiasis of CBD
      • Screen viral hepatitis, such as HAV, EBV, CMV. May survey HEV (by CDC) if the other viral infeciton is excluded
      • Consider diagnostic paracentesis for the ascites
      • Avoid hepatic toxic agent and simplify medication if possible
      • Regularly follow up liver and biliary enzymes, bilirubin, PT
      • If the diagnosis remains inconclusive after these studies, consider to survey autoimmune profile, including: ANA. SMA, AMA, IgG4
      • Monitor liver function. If the above examinations and treatments do not yield results or improvements, please contact us.
• 2023-06-23 Cardiology
  • Q
    • For HF history, liver function raised, R/O HF related, we need your further evaluation and management.
  • A1
    • 70 year-old male had the history of HF, CAD s/p stent(?), DM, T-colon cancer s/p left hemicolectomy at other hospital.
      • CXR 20230616 cardiomegaly
      • ECG 20230616 sinus tachycardia
    • O
      • LAB
        • 20230623 TSH 0.053, FT4 1.27 T3 0.67 cortisol 17.7 A1c6.3% chol 147 TG182 LDL99
        • Hb13.3 WBC8800 PLT112k ALT 441–201-127 Cre0.63 K2.8 albumin3.7 CRP4.8
      • Echocardiogram 20230623
        • Findings
          • AO(mm) = 38
          • LA(mm) = 47
          • IVS(mm) = 14.8-14.3
          • LVPW(mm) = 13.9-14.8
          • LVEDD(mm) = 49.1
          • LVESD(mm) = 33.0
          • TAPSE(mm) = 18.5
          • LVEF(%) =M-mode(Teichholz) = 61.0
          • TR: mild ; Max pressure gradient = 49 mmHg
          • Mitral E/A = 124 / 81.4 cm/s (E/A ratio = 1.52) ;
          • IVC size 21.4 mm with inspiratory collapse < 50%
        • Conclusion:
          • Adequate LV systolic function with no regional wall motion abnormality at resting state
          • Moderate MR, mild AR and TR
          • Dilated LA, IVC and aortic root; thick IVS and LVPW
          • Moderate pulmonary hypertension
          • Premature beats and suspected short-run atrial arrhythmia during the exam, HR 79-117bpm
    • liver echo-20230616
      • Fatty liver, moderate
      • suspicious, acute cholecystitis
      • Ascites, mild
      • Parenchymal renal disease, bilateral
      • Renal cyst, right
      • r/o, Renal stone, left
      • pancreatic tail masked by gas.
    • Impression
      • Moderate MR
      • suspected arrhythmia
      • abnormal liver biochemistry, related to fatty liver? congestive liver?
    • Suggestion
      • Holter ECG for atrial arrhythmia evaluation
      • resume medications as bisoprolol, valsartan, antiplatelet, OADs, furosemide and spironolactone
      • Monitor fluid status and titrate diiuretic dose, monitor potassium level
  • A2 2023-06-23 20:36:51
    • 6/23 NTproBNP 22334 A1c6.3%
    • Heart failure with preserved EF
  • A3 2023-07-11 14:22:49
    • lowest body weight on 7/1
    • more clear lung field by CXR of 7/3 than 6/29 and 7/10
    • Suggestion
      • may increase concor dose for HR control
      • may add digoxin 0.5# qd for HF
• 2023-06-23 Infectious Disease
  • A
    • Consultation of Mepem antibiotic
      • There is no medical record about underlying disease and indication of Mepem antibiotic
      • Normal white count, negative serum PCT level, CRP level 4.9 on 2023-06-19, 4 days ago.
      • Patient has received one-week Flumarin for possible cholecystitis since 2023-06-16, the day of admission.
      • Higher bilirubin level noted today, that Flumarin is replaced by Mepem today.
      • Mepem seems not absolutely necessary at the present time.
    • Suggestion:
      • Recheck serum CRP level.
      • Use Brosym to replace Mepem.
• 2023-06-21 Metabolism and Endocrinology
  • Q
    • The patient is an 70-year-old male with a history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent x2, Adrenal insufficiency. He presented with intermittent bloody stool for 4 days sent to MMH.
    • For Adrenal insufficiency history, we need your further evaluation and management.
  • A
    • This 70-year-old male, with past history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent x2, Adrenal insufficiency, was admitted due to bloody stool. We were consulted for adrenal insufficiency.
    • O:
      • Lab
        • 2023-06-19 S-GOT/AST 32 U/L
          
        • 2023-06-19 S-GPT/ALT 201 U/L
          
        • 2023-06-19 BUN 31 mg/dL
          
        • 2023-06-19 Creatinine 0.74 mg/dL
          
        • 2023-06-16 Na (Sodium) 141 mmol/L
          
        • 2023-06-16 K(Potassium) 3.8 mmol/L
          
      • SBP: 122-163
      • HR: 77-111
      • F/S: 377/239/284
    • A:
      • Adrenal insufficiency history
      • DM
    • Suggestions:
      • Keep Cortisone 1# BID at present
      • If vital signs unstable, IV hydrocortisone is indicate
      • Check ACTH/cortisol 8am, HbA1C, Cho, TG and LDL
      • After new data available, call me to interpret
• 2023-06-17 Gastroenterology & General Surgery
  • Q
    • The patient is an 70-year-old male with a history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent*2, Adrenal insufficiency. He presented with intermittent bloody stool for 4 days sent to MMH.
    • 2023/06/10 CT showed
      • Compared with last CT on 2022/07/08, no CT evidence of local recurrence at previous operation region at colon loop & mild shrinkage of prostate gland and bilateral seminal vesicles
      • Neurogenic bladder
      • Suspicious for congestive heart failure; Please correlate with cardiac sonography findings.
    • 2023/06/16 Abdominal echo showed
      • Fatty liver, moderate
      • suspicious, acute cholecystitis
      • Ascites, mild
      • Parenchymal renal disease, bilateral
      • Renal cyst, right
      • r/o, Renal stone, left
      • pancreatic tail masked by gas.
    • above all, we need your further evaluation and management.
  • A
    • we were consulted for suspect cholecystitis and abnormal liver function test
    • lab data:
      • jaundice and AST/ALT improved (comparing the data on 6/15 and 6/16)
    • impression
      • abnormal LFT, suspect passing tiny CBD stones with cholangitis related
      • cholecystitis
    • suggest
      • keep flumarin use
      • try water today, may try clear liquid diet tomorrow
      • f/u lab data next w1

[treatment]

• 2023-07-07 ~ undergoing - Xtandi (enzalutamide 40mg) 4# QDAC

• 2023-07-10 - Zoladex Depot (goserelin 3.6mg) SC ST

• 2023-05-09 - Firmagon (degarelix 80mg) at Taipei Mackey Hospital

• 2023-04-11 - Firmagon (degarelix 80mg) at Taipei Mackey Hospital

• 2023-05-09 - Xgeva (denosumab)

• 2023-04-11 - Xgeva (denosumab)

==========

2023-08-08

[Brosym 1000mg Q12H for patients with CrCl < 15mL/min]

Patient: Male, 70 years old, weighing 52kg, with a creatinine level of 3.58mg/dL, resulting in a creatinine clearance (CrCl) of 14mL/min.

According to the Sanford Guide, the recommended maximum dose of sulbactam for patients with a CrCl < 15mL/min is 500mg every 12 hours. Therefore, the appropriate dose for this patient would be Brosym 1000mg every 12 hours.

2023-07-12

[to increase the dose of long-acting insulin]

Considering that fasting blood glucose levels from 2023-07-10 to 2023-07-12 are still on the high side, ranging around 200mg/dL to 300mg/dL, even with the current insulin regimen of Apidra (insulin glulisine) 3 units TIDAC and Tresiba (insulin degludec) 6 units HS for days, it is recommended to increase the dosage of Tresiba from 6 units to 7 units and continue monitoring blood glucose levels to determine if further adjustments are necessary.

[bilirubin level follow-up]

The patient’s bilirubin levels have remained stable over the past two weeks.

• 2023-07-10 Bilirubin total 1.62 mg/dL
  
• 2023-07-07 Bilirubin total 1.59 mg/dL
  
• 2023-07-03 Bilirubin total 1.84 mg/dL
  
• 2023-06-29 Bilirubin total 1.71 mg/dL
  
• 2023-07-10 Bilirubin direct 0.53 mg/dL
  
• 2023-07-07 Bilirubin direct 0.75 mg/dL
  
• 2023-07-03 Bilirubin direct 0.67 mg/dL
  
• 2023-06-29 Bilirubin direct 0.78 mg/dL

Upon reviewing the drugs in the patient’s active medication list, there is no clear evidence suggesting a need to adjust the dosages based on the current state of the patient’s liver function.

2023-07-10

[bedside visit]

I visited the patient around 09:15 on 2023-07-10. He was lying in bed with his eyes closed, and his wife and a caregiver were present in the room. The patient didn’t respond when I conversed with his wife and the caregiver.

The patient’s caregiver mentioned that the patient’s feet were cold, so she placed a warm water bag near his feet to try to provide warmth. The patient’s wife reported that the patient had begun to sweat profusely on his head the previous night (without night sweats from the body), had not slept all night, and had a poor appetite, eating only a small amount.

Upon asking about the patient’s pain, bowel movements, and breathing, the caregiver indicated that the patient’s stools were regular, but his urine output was reduced due to concerns about pulmonary edema and fluid retention leading to reduced fluid intake. The patient continues to experience occasional shortness of breath and expresses discomfort, but there has been no significant increase in the intensity or duration of pain.

[Zoladex (goserelin)]

There is no dosage adjustment necessary for Zoladex (goserelin) in kidney impairement and/or hepatic impairment patients.

NHI provides coverage for the use of Gn-RH analogs, such as goserelin, exclusively for conditions like prostate cancer, central precocious puberty, endometriosis, and breast cancer in pre-menopausal (or peri-menopausal) cases. This patient should meet the criteria for coverage.

2023-07-06

[bedside visit: breathing smoother]

I visited the patient on 2023-07-06 at approximately 10:30. The patient was in bed, using an oxygen mask with his eyes closed, and his wife and daughter were in the room with him. I noticed that the patient’s breathing did not seem rapid. I asked his wife and daughter about the patient’s condition, and his daughter replied that the patient’s breathing seemed smoother than it had been in the past few days and that there were no specific problems at the moment. When I asked if they had any questions about the medication or wanted to understand more, they indicated that they did not have any at this time.

[patient education: enzalutamide]

The patient agreed to use Xtandi (enzalutamide). I prepared an information sheet about enzalutamide, highlighting points the patient should be aware of, as well as potential side effects of the medication. At approximately 14:10 on 2023-07-06, I visited the patient, who was resting in the room with his daughter and caregiver. I gently woke the patient’s daughter and gave her the highlighted sheet. I also gave her the contact information for the pharmacy window and encouraged her to call if she had any questions about the medication.

2023-06-30

[Minutes of the Multidisciplinary Team Meeting and Patient Family Meeting]

Today, on 2023-06-30 at around 11:45, Dr. Hsia gathered the patient’s daughter and the patient’s wife’s brother, and explained the current status of the patient’s condition using medical images. Then, from 12:15 to 13:15, a multidisciplinary team meeting and family meeting was held in the ward conference room. The meeting was chaired by Dr. Hsia and included members such as the nurse practitioner, the head nurse of the ward, the charge nurse, the social worker, and myself as the pharmacist. The the patient’s family representatives included the patient’s daughter and the patient’s wife’s brother. Dr. Hsia first clarified several key observations and considerations about the patient’s current condition. I presented the rationale behind the selection of anti-androgen agents, taking into account the expected changes in liver function. In addition, each of the nursing professionals also expressed their own perspectives.

Going forward, the pharmacy will continue to collaborate with the entire team in the management of this patient.

[bedside visit]

I visited the patient around 13:15 on 2023-06-30. The patient was using an oxygen mask, and his wife was standing by his bed. I asked about the patient’s current condition, and his wife indicated that he still had difficulty breathing, but he no longer coughed up blood. Upon checking the patient’s feet, I did not find any signs of lower limb edema.

2023-06-29

[Rationale for the Selection of Anti-Androgen Agents in Patients with Potential Hepatic Impairment]

We currently have three anti-androgen medications in stock: Casodex (bicalutamide 50mg), Xtandi (enzalutamide 40mg), and Nubeqa (darolutamide 300mg), with the last one is a temporary purchase item and thus limited its use for certain patients.

Considering the patient’s normal AST and ALT levels along with elevated bilirubin (direct 0.78mg/dL, total 1.71mg/dL) as of 2023-05-29, the patient’s liver function should be taken into account when prescribing these drugs.

• Bicalutamide:
  • For hepatic impairment at treatment initiation: No dosage adjustment is necessary for mild, moderate, or severe impairment. However, caution is advised for patients with moderate to severe impairment as clearance may be delayed in severe impairment (based on a limited number of patients).
  • For hepatic impairment during treatment: If ALT rises above twice the upper limit of normal or jaundice develops, the treatment should be discontinued immediately.
• Enzalutamide:
  • For mild, moderate, or severe impairment (Child-Pugh class A, B, or C): No dosage adjustment necessary. Nevertheless, an increased drug half-life has been observed in patients with severe hepatic impairment.
• Darolutamide:
  • For mild impairment (Child-Pugh class A): No dosage adjustment necessary.
  • For moderate impairment (Child-Pugh class B): The dose should be reduced to 300 mg twice daily.
  • For severe impairment (Child-Pugh class C): There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).

In conclusion, enzalutamide appears to be least affected by liver function and could be a reasonable choice if the patient’s liver function is not expected to recover in the short term.

2023-06-19

• The PharmaCloud database does not disclose any data for this patient, which could be due to the patient not having granting access.

• In the past 3 years, there have been no records of outpatient or inpatient services for this patient at our hospital prior to this hospitalization. Consequently, no medication reconciliation issues have been detected.

• Since the patient’s admission, fasting blood glucose levels have consistently ranged between 200 and 300 mg/dL, even with the administration of regular insulin 2 units PRNQ6H. To better manage these elevated blood sugar levels, it is advisable to increase the insulin dose to 3 units just before each meal. This approach trys to prevent blood glucose levels from exceeding 200 mg/dL. Continue to monitor blood glucose readings to assess the effectiveness of this adjustment and determine if further changes are needed.

• The fasting serum glucose levels since this hospitalization were between 200 and 300 mg/dL even under regular insulin 2 units PRNQ6H. It is recommended to increase the dose to 3 unit right before each prandial to keep the blood sugar level at least not exceed 200mg/dL and keep monitoring the readings to decide if furthur adjustment necessary.

701481418

230808

[lab data]

• 2023-07-14 BM Chromosome Analysis
  • Chromosome Analysis:
    • Tissue Examined: Bone marrow
    • Staining Method: G-Banding
    • Colony number: NA
    • Bands level: 500
    • Chromosome Counts:
      • 45-(2)、46-(17)、47-()、Other-(1) Total-(20)
    • Karyotype: 46,XX[16]
  • Interpretation:
    • Analysis of this bone marrow sample shows a female having 46,XX[16] karyotype. There was no significant clonal chromosomal abnormality detected. However, from 20 cells analyzed, four cells with abnormal karyotypes [44,XX,-14,-21; 45,XX,-11; 45,XX,-22 and 46,XX,t(2;7)(q11.2;q11.2), respectively] were observed. No clinical significance can be ascribed to these non-clonal findings at the present time.
  • Note:
    • ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

[exam findings]

• 2023-06-26 Patho - bone marrow biopsy
  • Bone marrow, biopsy — No evidence of lymphoma involvement
  • The sections show normocellular marrow (35%). M/E ratio = 4:1. The myeloid cells show good maturation with mild neutrophilia. The megakaryocytes are normal in number and morphology. No lymphoid aggregates can be found.
  • IHC, there is no evidence of lymphoma involvement in CD3 and CD20 immunostains. Suggest further bone marrow smear evaluation and clinic correlation.
• 2023-06-19 CT - chest
  • Indication: Diffuse large B-Lymphoma
  • Comparison was made with abdominal CT on 2023/05/02
    • Lungs: partial relaxation atelectasis of LLL and lingula.
      • band subsegmental atelectasis at RML and basal segments of RLL.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels:
      • mild calcified plaques of the LAD coronary artery.
      • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch.
      • Central pulmonary arteries: mild dilated trunk (3.4cm) and right (2.8cm) pulmonary artery.
    • Heart: normal size of cardiac chambers.
    • Pleura: moderate Lt-sided effusion.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents: marked splenomegaly with extensive poorly enhanced masses. abnormal masses in the pancreatic tail
      • extensive lymphadenopathy at the para-aortic, splenic hilum, retroperitoneum (peripancreatic region), and pelvic (bilateral iliac chains).
      • mild Lt hydronephrosis and delayed parenchymal enhancement due to compression at U-P junction lymphadenopahty.
      • unremarkable of the liver, GB, spleen, both adrenal glands
  • Impression:
    • no lymphadenopathy in the chest but moderate Lt pleural effusion.
    • intra-abdominal extensive lymphadenopathy with splenic and pancreatic involvement, in progression increase in size as compared with the previous abdominal CT on 2023/05/02
• 2023-06-16 PET
  • Findings: There was increased FDG uptake in multiple lymph node regions in the abdomen and pelvis and in multiple focal areas in the spleen.
  • IMPRESSION: The FDG PET findings are compatible with lymphoma involving the spleen and involving multiple lymph node regions below the diaphragm as mentioned above.
• 2023-06-02 Patho - peritoneum biopsy
  • Lymph node, para-aortic and left iliac, CT-guide biopsy — Diffuse large B-cell lymphoma, non-GCB type
  • Section shows cores of lymphoid and fibrous tissue with infiltration of large pleomorphic lymphoid cells.
  • The immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(-), BCL6(+), MUM-1(+), Cyclin D1(-), cMYC(-), and BCL2(+). The Ki-67 is about 90%.
• 2023-05-09 Gynecologic ultrasonography
  • Uterine myoma
  • R/O Lt Ovarian mass
  • EM: 11.2mm (+fluid)
• 2023-05-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (127 - 33) / 127 = 74.02%
    • LVEF (%) = 74
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Dilated LV; normal LV systolic function with normal wall motion.
    • LV posterior wall thickeing, dilated LA; impaired LV relaxation.
    • Normal RV systolic function.
    • Aortic valve sclerosis with no AS and AR; mild MR; mild TR; mild PR.
    • Possible mild pulmonary hypertension, estimated PASP: 37 mmHg.
• 2023-05-03 Embolization (TAE) - ABD for tumor
  • TAE of spleen via right common femoral artery puncture using Seldinger technique revealed:
    • Under local anesthesia, a 5 Fr arterial sheath was inserted into right common femoral artery smoothly.
    • Selective angiography of the splenic artery revealed splenomegaly with inhomogeneous vascularity. No definite contrast extravasation.
    • Proximal embolization with gelfoam pieces was performed. A decreased parenchymal vascularity after embolization.
    • No procedure-related complication during this procedure.
  • Impression
    • s/p proximal emobilization of left splenic artery
    • A Fr.5 arterial sheath was placed in right femoral artery. Please remove it in 3 days.
• 2023-05-02 CT - abdomen
  • Indication: left abdominal pain, no vomit, no tarry stool. no trauma. hx of HTN; Med: Bisoprolol, Amlodipine , Olmesartan; NKA
  • With and without contrast enhancement CT of abdomen shows:
    • Enlargement of spleen. Several poor enhancing lesions in spleen.
    • Hyperdense fluid in perisplenic and pelvic regions.
    • Soft tissue mass in para-aortic and left iliac artery regions.
    • A cystic lesion, with wall enhancement, 4.5x5.1cm, in left adnexa.
    • A hyperdense stone in distal CBD.
    • No bony destructive lesion on these images.
  • Impression
    • Splenomegaly and splenic mass lesions
    • Para-aortic and left iliac lymphadenopathy
    • Left ovarian cystic mass
    • The differential diagnosis includes, but is not limited to ovarian ca with lymph node and spleen metastasis
    • Suggest further evaluation

[MedRec]

• 2023-07-06 SOAP Hemato-Oncology Xia HeXiong
  • O
    • Conclusion of Multidisciplinary Cancer Team Meeting, Meeting Date: 2023-07-03
      • DLBCL (Diffuse Large B-Cell Lymphoma), stage IV
      • R-COP treatment plan (Start with COP x1, then add R, turning into R-COP x5).
    • Now on R-COP +/- H, C1D1 on 2023-06-27
• 2023-06-13 SOAP Hemato-Oncology Xia HeXiong
  • O
    • 2023/06/02 PATHO-peritoneum biopsy
      • Diffuse large B-cell lymphoma, non-GCB type
    • Lab
      • 2023/06/03 B2-Microglobulin = 4325 ng/mL;
      • 2023/06/02 LDH = 709 U/L;
      • 2023/06/02 Uric Acid = 9.0 mg/dL;
• 2023-05-18 SOAP Hemato-Oncology Xia HeXiong
  • A/P
    • CT:
      • Splenomegaly and splenic mass lesions, Favor lymphoma.
      • Para-aortic and left iliac lymphadenopathy
      • Left ovarian cystic mass
    • Suggestion:
      • antibiotic treatment
      • tumor biopsy for cancer survey
      • pain control
    • Arrange admission for CT-guided biopsy and check Beta2-microglobulin

[immunochemotherapy]

• 2023-08-07 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
• 2023-07-17 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
• 2023-06-27 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4

==========

2023-08-08

According to the PharmaCloud database, the patient’s medical care has exclusively been provided by our hospital in the recent 3 months. Consequently, no discrepancies in medication reconciliation have been detected.

2023-07-18

Based on the PharmaCloud database, the patient has only received medical services from our hospital for the past three months. As a result, no medication reconciliation issues have been identified.

701488243

230808

[exam findings]

• 2023-08-1 CT - brain
  • No ICH. Left frontal inner skull destruction, metastasis?
• 2023-07-10 Patho - breast biopsy
  • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains: ER (+, 100%, strong intensity), PR(+, 10%, intermediate intensity), Her2/neu: negative(score= 1+), Ki-67(<10 %), E-cadherin (+). An addendum report of the result of Her2/neu DISH will be followed.
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
• 2023-07-08 MRI - breast
  • Clinical history: 61 y/o female patient with malignancy with bone mets.
  • With and without enhancement MRI of breast (axial T1, T1FS, sagittal T2, T2FS, axial and sagittal T1FS contrast, dynamic study):
    • S/P bilateral breast augmentation.
    • R/O diffuse siliconomas in bilateral breasts.
    • There are irregular tumors (6.7x3.1cm) with enhancemant in left breast, with skin involvement, r/o malignancy.
    • Left axillary lymph nodes, r/o lymph nodes metastasis.
    • Right pleural effusion.
    • R/O bone metastasis.
  • Impression:
    • S/P bilateral breast mammoplasty.
    • Left breast malignancy with skin invasion and axillary lymph nodes metastasis, bone metastasis.
    • Right pleural effusion.
      
    • BI-RADS: Category 6-proven malignancy
• 2023-07-05 PET
  • Increased FDG uptake in the left breast and left axillary lymph nodes, highly suspected left breast cancer with regional lymph nodes metastases.
    
  • Increased FDG uptake in the left pulmonary hilar lymph nodes, in the right lower lung, and in the right cervical lymph nodes, the nature is to be determined, suggesting investigation.
    
  • Increased FDG uptake in skeleton including the skull, spines, sacrum, bilateral pelvic bones, sternum, both rib cages, clavicles, scapulae, humeri, and femurs, highly suspected multiple bone metastases.
  • Left breast cancer, cTxN2aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-06-30 SONO - breast
  • diagnosis
    • Bil. fibroadenomas and cysts as described
    • S/P bil. mammoplasty
    • Diffuse subcutaneous tissue thickening of left breast r/o malignancy
  • BI-RADS:
    • 4c. suspicious abnormality, biopsy should be considered (high suspicion for malignancy: 50-95%)
• 2023-06-29 CT - chest
  • Indication: suspected left breast cancer with lung and ribs mets
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • s/p breast augmentation.
      • Minimal soft tissue mass enhancement at left breast is found. The possiblity of neoplasm should be suspected.
      • Very tiny nodular lesion are found at both lung fields.
      • Diffuse blastic change at whole bony structure is found. Breast cancer with bone meta is considered.
      • Enarged lymph node at left hilar region and left axillary lymphadenopathy is found.
      • Mild right pleural effusion is found.
    • Visible abdomen:
      • Hepatic cysts at both lobes of liver up to 3.67cm in largest dimension. Simple cysts are considered.
  • Imp:
    • s/p breast augmentation with left breast cancer, axillary lymphadenopathy, lung meta and diffuse bone meta.
• 2023-06-26 Tc-99m MDP bone scan
  • Highly suspected malignancy (lung, breast, or other site ?) with multiple bone metastases, suggesting chest CT and breast sono for further investigation.

[MedRec]

• 2023-07-17 POMR General and Gastroenterological Surgery
  • Prescription
    • BioCal chewable tablets (tribasic calcium phosphate and cholecalciferol 1203mg 330IU) 1# BID
    • Femara (letrozole 2.5mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Zobonic (zoledronic acid 4mg) NS 100mL ST IVD
• 2023-07-05 POMR Nuclear Medicine
  • A: highly suspected breast cancer with multiple bone mets
  • P: indication for PET for further staging
• 2023-07-03 POMR General and Gastroenterological Surgery
  • O
    • a 8x7x2.5 sl firm mass with skin invasion over lt breast
    • a 1.5 cm sl firn lt axilla LN
    • a 2 cm firm rt neck LN
• 2023-06-29 POMR Nuclear Medicine
  • A: right shoulder pain, highly suspected malignancy (breast, lung or other site ?) with bone mets
  • P: breast sono and chest CT for investigation
• 2023-06-26 POMR Nuclear Medicine
  • S
    • right shoulder pain for months, suspected bone mets
    • PI: history taking from patient herself and medical recod keeping of JingMei Hospital
      • had a trauma history, right shoulder pain developed since then. Shoulder MRI, however, showed suspected malignancy with bone mets at JingMei Hospital
      • was referred to our hospital for bone scan for investigation
    • Allergy history: nil
    • TOCC history within 2 weeks: NP
  • P
    • bone scan for investigation

[consultation]

• 2023-08-01 Dermatology
  • Q
    • This 61-year-old female patient of left breast invasive carcinoma with multiple lymph nodes and bone metastasis, she was admitted due to car accident. However, erytheamtous plaques on scalp was noted for a while. We need your help for assessment. Thank you so much!!
  • A
    • This patient suffered from erytheamtous plaques on scalp for yrs. Hair loss(+)
    • Imp: Alopecia
    • Suggestion:
      • Doxyxlin 1 /Bid
      • Mycomb x 4 tubes/bid
• 2023-07-20 Radiation Oncology
  • A
    • Diagnosis: Left breast cancer with LN, bone metastasis, cT4N3M1 under CDK4/6 inhibitor Ibrance since 2023/7/20; ECOG 1.
    • Plan: R/T to right humerus for 3000cGy/10 fx is suggested for pain control. CT simulation is arranged on July 24 09:30 and possible RT toxicity is told.

==========

2023-08-08

Bicytopenia (reduced WBC and PLT) developed in late July, and Femera (letrozole) was initiated on 2023-07-17 (ongoing using). While there is a temporal relationship between the introduction of letrozole and bicytopenia, the incidence of such adverse reactions with this medication is not high based on the literature. During this period, the patient also underwent radiation therapy (at least one day on 2023-07-24). It is known that bone marrow cells are sensitive to radiation therapy, and as a result, we cannot rule out the possibility that radiotherapy is contributing to the development of leukopenia and thrombocytopenia.

2023-08-07 WBC 1.83 x10^3/uL
2023-07-31 WBC 2.33 x10^3/uL
2023-07-03 WBC 6.85 x10^3/uL

2023-08-07 PLT 29 10^3/uL
2023-07-31 PLT 79 10^3/uL
2023-07-03 PLT 134 *10^3/uL

700201636

230807

[exam findings]

• 2023-06-26, -06-19, -06-01, -05-29, -05-25, 05-22, -04-19 Body fluid cytology - ascites
  • Negative
• 2023-05-22 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 10 dB HL; LE 21 dB HL
  • R’t WNL.
  • L’t normal to mild CHL.
• 2023-04-20 Patho - soft tissue biopsy/simple excision (non lipoma)
  • PATHOLOGIC DIAGNOSIS
    • Lesser omentum, excision — Metastatic serous carcinoma
    • Soft tissue, abdominal wall #1 and #2, excision — Foreign body granuloma
    • Soft tissue, LUQ, excision — Foreign body granuloma
  • MACROSCOPIC EXAMINATION
    • The specimen is submitted in four parts. Part (1) consists of six pieces of gray-white and firm soft tissue, labeled “abdominal wall tumor #2”, measuring up to 3.0 x 2.5 x 0.5 cm. All for section as: A1-A4. Part (2) consists of a piece of soft tissue, received for frozen section, labeled “abdominal wall tumor #1”, measuring 5.5 x 2.9 x 0.5 cm. On section, an white and firm nodule is noted, measuring 2.5 x 1.0 x 0.4 cm. Representative parts are taken for section as: F2023-00178 and FSA1. Part (3) consists of a piece of pinkish white soft tissue, received for frozen section, labeled “lesser omentum tumor”, measuring 1.2 x 1.0 x 0.3 cm. All for section as: F2023-00178FSB-ink green. Part (4) consists of a piece of soft tissue, received for frozen section, labeled “LUQ tumor”, measuring 1.0 x 0.9 x 0.3 cm. All for section as: F2023-00178FSB without ink.
  • MICROSCOPIC EXAMINATION
    • The sections of “lesser omentum tumor” show a picture of metastatic serous carcinoma, composed of pleomorphic polygonal tumor cells, arranged in solid and papillary patterns. The sections of “abdominal wall tumor #1 and #2” and “LUQ tumor” show a picture of foreign body granuloma, composed of foreign material surrounded by histiocytes and foreign body type giant cells.
• 2023-04-17 SONO - abdomen
  • mild fatty liver
  • fatty infiltration of pancreas
• 2023-03-08 Gynecologic Ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2023-02-08 PET
  • The left subphrenic lesion shown on the previous abdomen CT reveals increased FDG uptake, highly suspected tumor seeding.
    
  • Increased FDG uptake in bilateral pulmonary hilar regions, probably reactive nodes.
    
  • Increased FDG uptake in bilateral palatine tonsils, probably chronic inflammation/infection process.
    
  • Increased FDG uptake in the lower abdomen and left pelvis, probably physiological uptake of FDG in the colon. However, tumor seeding should be excluded.
    
  • Left ovarian cancer s/p treatment with highly suspected tumor seeding in the left subphrenic region, by this F-18 FDG PET scan.
• 2023-01-31 CT - abdomen
  • History and indication: ovary cancer with peritonal seeding
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. S/P Port-A infusion catheter insertion. A nodule at left subphrenic region.
    • A calcified spot (3.7cm) at S6 of liver.
  • IMP: S/P hysterectomy. A nodule at left subphrenic region r/o tumor seeding.
• 2022-09-17 Gynecologic Ultrasonography
  • Bilateral adnexae: free
  • ATH
  • No obvious uterine or ovarian lesion
• 2022-08-10 CT - abdomen
  • History: Ovarian CA. pT3bN0Mx; FIGO stage IIIB, s/p debulking surgery on 8/26 19 by Dr Zhen LunNa, s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Jan 2020 & recurrence wt peritoneal seeding in Jan 2021, s/p debulking wt HIPEC on 3/24 21 by Dr Li ZhaoShu,
  • Impression: S/P hysterectomy. There is no evidence of tumor recurrence.
• 2022-02-17 CT - abdomen
  • History and indication: ovary cancer with peritonal seeding
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. S/P Port-A infusion catheter insertion.
    • A calcified spot (3.7cm) at S6 of liver.
  • IMP: S/P hysterectomy. No evidence of tumor recurrence.
• 2021-10-06 CT - abdomen
  • History and Indication: Recurrent Ovarian CA.
  • Impression:
    • S/P hysterectomy
    • Prior CT identified several soft tissue nodules (up to 0.8cm) in the omentum of left upper abdomen are not noted again, that is compatible with tumor seeding S/P C/T show complete response.
• 2021-03-25 Patho - soft tissue biopsy/simple excision (non lipoma)
  • DIAGNOSIS:
    • Soft tissue , greater omentum, left, cytoreductive surgery — High-grade serous carcinoma, recurrent
      
    • Soft tissue , omentum, frozen biopsy — foreign body suture granuloma
      
    • Description: Microscopically, the sections show high grade serous carcinoma composed of irregular branching and highly cellular of neoplastic papillae and solid sheets of tumor cells with small papillary clusters spearated by hyaline fibrous stroma. Section FSA shows a foreign body suture granuloma.
      
    • Immunohistochemical stain reveals PAX8(+), CK7(+), CK20(-), WT-1(+).
• 2021-02-23 SONO - abdomen
  • Diagnosis: ovarian cancer s/p OP
  • Suggestion: further laparoscopy and maybe CRS
• 2021-02-06 Gynecologic Ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2021-01-30 CT - abdomen
  • Clinical history: 49 y/o female patient with Ovarian CA s/p Op ＆ C/T.
  • With and without contrast enhancement CT of abdomen–whole:
    • S/P hysterectomy and oophorectomy.
    • There are soft tissue nodules (up to 0.8cm) in mensentery of left upper abdomen
  • Impression:
    • S/P hysterectomy and oophorectomy.
    • Soft tissue nodules in LUQ, r/o peritoneal carcinomatosis.
• 2020-08-12 Gynecologic Ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2020-08-01 CT - abdomen
  • S/P hysterectomy. No evidence of tumor recurrence.
• 2020-04-08 Gynecologic Ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2020-02-15 CT - abdomen
  • S/P hysterectomy. No evidence of tumor recurrence.
• 2019-12-25 Gynecologic Ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2019-08-27 Surgical Pathology Level VI
  • PATHOLOGIC DIAGNOSIS
    • Ovary, left, debulking surgery — High-grade serous carcinoma
      • Fallopian tube, left, ditto — Free from tumor invasion
    • Ovary, right, ditto — High-grade serous carcinoma
      • Fallopian tube, right, ditto — Free from tumor invasion
    • Cervix, uterus, ATH — Free of tumor invasion
      • Endometrium — Hyperplasia with nuclear atypia and free of tumor invasion
      • Myometrium — Free of tumor invasion
    • Omentum, omentectomy — High-grade serous carcinoma
    • Appendix, appendectomy — Involved by tumor in muscular wall
    • Soft tissue, “tumor”, excision — Carcinoma
    • Lymph nodes
      • Lymph node, R’t pelvic 1, dissection — Free of tumor metastasis (0/14)
      • Lymph node, R’t pelvic 2, ditto — Free of tumor metastasis (0/1)
      • Lymph node, L’t pelvic 3, ditto — Free of tumor metastasis (0/6)
      • Lymph node, L’t pelvic 4, ditto — Fat tissue only
    • AJCC Pathologic staging: pT3bN0Mx; FIGO stage IIIB at least
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: ATH, BSO, pelvic tumor excision, omentectomy, appendectomy, lymph node dissection
    • Specimen type: Uterus, bilateral adnexa, pelvic tumor, omentum, appendix & 4 bottles of lymph nodes
    • Specimen size:
      • R’t ovary: 2.2 x 1.4 x 1.3 cm
      • R’t fallopian tube: 4 x 0.7 x 0.6 cm
      • L’t ovary: 3.3 x 1.7 x 1.1 cm
      • L’t fallopian tube: 4 x 1.2 x 1.1 with paratubal cyst, 1.2 cm in diameter
      • Uterus: 9.1 x 6.2 x 5 cm in size and 125 gm in weight
      • Cervix: Nobothian cysts
      • Endometrium: thickness, 0.7 cm
      • Myometrium: No significant change
    • “Tumor” soft tissue: one small piece, 3.2 x 2.3 x 0.9 cm in size
    • Omentum: one piece, 17.5 x 6.3 x 3.3 cm in size
    • Appendix: 3.7 x 0.7 x 0.7 cm in size
    • Tumor site: bilateral ovary and peri-adnexal soft tissue
    • Tumor size: a few foci, up to 1.0 x 0.4 cm in dimension
      
    • Tumor appearance: Papillary and solid
      
    • Specimen integrity: Intact
    • Lymph nodes: R’t pelvic 1 (5 gm), R’t pelvic 2 (0.2 gm), L’t pelvic 3 (2 gm) and L’t pelvic 4 (0.2 gm)
    • Representative sections as: A1: R’t ovary, A2-A3: R’t F-tube, A4-A7: L’t ovary + F-tube, A8-A15: endometrium, myometrium, endocervix and cervix, A16: endometrium + myometrium, B1-B4: omentum, C: appendix, D: “tumor” soft tissue, E1-E2: R’t PLN1, F: R’t PLN2, G: L’t PLN3 and H: L’t PLN4
  • MICROSCOPIC EXAMINATION
    • Histologic type: High-grade serous carcinoma [IHC stains: CK7(+), WT-1(+), PAX-8(+), P53(+, 100%), ER(+)]
    • Histologic grade: High grade
    • Contralateral ovary involvement: Present
    • Tumor side ovarian surface involvement: Present
    • Contralateral ovary surface involvement: Present
    • Right tube involvement: Absent
    • Left tube involvement: Absent
    • In situ adenocarcinoma in right &/or left fallopian tube: Absent
    • Right adnexa soft tissue involvement: Present
    • Left adnexa soft tissue involvement: Present
    • Pelvic soft tissue involvement: Present (“tumor”)
    • Uterine serosa involvement: Absent
    • Omentum involvement: Present
    • Uterine Cervix involvement: Absent. chronic cervicitis with Nabothian cyst
    • Endometrium involvement: Absent. Hyperplasia with nuclear atypia
    • Myometrium involvement: Absent
    • Appendix: Involved by tumor
    • Lymph nodes metastasis: Free of tumor metastasis, total number: 0/21
• 2019-08-10 Gynecologic Ultrasonography
  • Suspected RT ovarian mass

[chemotherapy]

• 2023-07-10 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

  • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4

• 2023-05-29 - paclitaxel 60mg/m2 90mg NS 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-06-16 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

  • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4

• 2023-05-29 - paclitaxel 60mg/m2 90mg NS 250mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

• 2023-05-22 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

  • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4

• 2023-04-19 - [liposome doxorubicin 30mg/m2 50mg D5W 100mL + carboplatin AUC 5 675mg NS 250mL] 90min IP (HIPEC)

• 2022-07-25 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-07-01 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-06-10 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-05-17 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-04-21 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-03-31 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-03-11 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-02-16 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-01-26 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2022-01-05 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2021-12-15 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2021-11-24 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2021-10-04 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2021-09-10 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-08-18 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-07-29 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-07-02 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-05-31 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-04-27 - docetaxel 60mg/m2 95mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2021-03-23 - [liposome doxorubicin 30mg/m2 40mg D5W 100mL + carboplatin AUC 5 600mg NS 250mL] 90min IP (LipoDox dose reduced)

• 2020-01-14 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + acetaminophen 500mg PO + granisetron 2mg + NS 250mL

==========

2023-08-07

Based on the records from the PharmaCloud and HIS5, the patient exclusively utilizes healthcare services at the hemato-oncology department in our hospital. As a result, no medication reconciliation discrepancies have been detected.

2023-07-11

According to the PharmaCloud database, the patient only receives medical services from our hospital. Therefore, there are no identified medication reconciliation issues.

2023-06-19

• The PharmaCloud database reveals that all medical needs of this patient have been met at our hospital in the last three months. Consequently, no medication reconciliation issues have been identified.

• The patient’s serum potassium level was slightly low at 3.3mmol/L as of 2023-06-16, and it has been trending downwards. It might be helpful to recommend that the patient consume more potassium-rich foods.

  • 2023-06-16 K(Potassium) 3.3 mmol/L
    
  • 2023-06-07 K(Potassium) 3.7 mmol/L
    
  • 2023-05-29 K(Potassium) 3.9 mmol/L

701280715

230807

{rectal cancer with LNs, lung, sacrum, sacroiliac joints mets, stage IV}

[lab data]

2023-07-19 HBsAg (NM) Negative
2023-07-19 HBsAg Value (NM) 0.420
2023-07-19 Anti-HBs (NM) Negative
2023-07-19 Anti-HBs value (NM) <2.000 mIU/mL
2023-07-19 Anti-HBc (NM) Negative
2023-07-19 Anti-HBc Value (NM) 2.190

2021-06-02 KRAS 12/13 Sample No S2021-6919
2021-06-02 KRAS 12/13 mutation detected
2021-06-02 NRAS/KRAS Sample No S2021-6919
2021-06-02 NRAS/KRAS mutation Not detected

2021-05-14 HBsAg Nonreactive
2021-05-14 HBsAg (Value) 0.34 S/CO
2021-05-14 Anti-HBc Nonreactive
2021-05-14 Anti-HBc-Value 0.44 S/CO
2021-05-14 Anti-HCV Nonreactive
2021-05-14 Anti-HCV Value 0.06 S/CO

[exam finding]

• 2023-07-19 CT - chest
  • Impression: rectal cancer with lung metastases, sligthly in regression as compared with CT on 2023/2/7
• 2023-06-21 MRI - L-spine
  • Indication: Pain over sacral region and bil SI joint area for 2 yrs
  • Without- and with-contrast MRI of lumbar spine, including sagittal T2W FSE, sagittal T1W, coronal STIR, axial T2W and axial T1W images (3 mm thickness for sagittal images and 4 mm thickness for the others) reveals:
    • Wedge-shaped deformity, fracture lines, T1-hypointensity, mottled T2-hyperintensity and heterogeneous enhancement involving L4 vertebral body, associating with left paraspinal soft tissue mass (mainly T1-hypointensity, mild T2-hyperintensity and faint peripheral enhancement). D/D: compression fracture with spondylitis and left paraspinal abscess, metastases (less likely).
    • Mild general bulging disc at L1-2-3-4-5-S1.
    • No intramedullary lesion.
  • IMP: L4 vertebral body facture with left paraspinal lesion. D/D: compression fracture with spondylitis/left paraspinal abscess; metastases (less likely).
• 2023-06-13 L-spine AP + Lat. (including sacrum)
  • Compression fracture of L4 vertebral body.
  • S/P metalic stent in the rectum.
• 2023-05-15 CT - abdomen
  • Imp:
    • Rectal cancer s/p stent placement. Stable in the local region.
    • Lymphadenopathy at right pelvic side wall. Stationary.
    • Bilateral lung meta. In regression.
    • Compression fracture. L4.
• 2023-02-07 CT - chest
  • Impression: rectal cancer with pelvic LNs metastasis and lung metastases, in progression as compared with CT on 2022/12/07
• 2022-12-07 CT - chest
  • Impression: rectal cancer with pelvic LNs metastasis and stationary of lung metastases as compared with CT on 2022/08/30
• 2022-11-28 Tc-99m MDP bone scan
  • Increased activity at bilaterl S-I joints comes to more evident and some new lesions of increased activity in some T-spine are noted compred with the previous study on 2022-04-28; the nature is to be determined (severe DJD, bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
  • Suspected benign lesions in bilateral rib cages, some L-spine, bilateral sternoclavicular junctions, shoulders, and hips.
• 2022-10-05 CT - abdomen
  • Impression:
    • Rectal cancer with bowel obstruction.
    • Lymph nodes metastasis and multiple lung metastasis.
• 2022-10-05 Sigmoidoscopy
  • Findings:
    • Colonoscopy and Seld-expandable metalic stent (SEMS. 12cm, uncovered stent) was inserted smoothly
    • Stool passage was noted immediately after stent placement
  • Diagnosis:
    • Rectal cancer obstruction s/p SEMS
  • Suggestion:
    • Elective colectomy
  • Complication:
    • No immediate complication
• 2022-08-30 CT - chest
  • Impression: rectal cancer with progressive lung metastases compared with CT on 2022/05/28
• 2022-07-10 CXR
  • There are few nodular opacity projecting in both lung that are c/w metastases.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
• 2022-05-28 CT - abdomen, pelvis
  • Findings
    • Mild progression of rectal cancer with LNs and lung metastases.
    • Right renal cyst (1.4cm).
  • IMP:
    • Mild progression of rectal cancer with LNs and lung metastases.
• 2022-04-28 Tc-99m MDP whole body bone scan
  • Mildly increased activity in some L-spines. Degenerative change may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Probably benign joint lesions in bilateral sternoclavicular junctions, shoulders, hips, and knees.
• 2022-03-08 Chest PA erect view
  • There are few nodular opacity projecting in both lung that are c/w metastases.
• 2022-02-21 CT - abdomen, pelvis
  • Mild progression of rectal cancer with LNs and lung metastases.
• 2021-12-21 Chest PA erect view
  • There are few nodular opacity projecting in both lung that are c/w metastases.
• 2021-11-18 CT - abdomen, pelvis
  • Mild regression of rectal cancer with LNs and lung metastases.
• 2021-08-10 CT - abdomen, pelvis
  • Rectal malignancy with lymph nodes and lung metastasis, regression.
• 2021-05-06 Chest PA eract view
  • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
• 2021-05-05 Tc-99m MDP whole body bone scan
  • Markedly increased tracer uptake in the sacrum and bilateral S-I joints, the nature is to be determined, suggesting further investigation and follow-up with bone scan in 3 months for further evaluation.
  • Probably benign lesions in both rib cages, bilateral sternoclavicular junctions, shoulders, hips, and knees.
• 2021-05-03 Patho - colon biopsy
  • Rectum, 5 cm above anal verge, biopsy — Adenocarcinoma.
  • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
    
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
• 2021-05-03 CT - abdomen, pelvis
  • Impression (Imaging stage): T4aN2bM1a, stage IVA
• 2021-05-03 Chest PA erect view
  • Multiple nodules at bil. lungs.
• 2021-05-03 Colonoscopy
  • Diagnosis: Rectal ulcerative lesion, s/p biopsy, suspected malignancy.
  • Suggestion: F/U pathology report; suggest admission for more evaluation and management.

[MedRec]

• 2023-06-30 SOAP Neurology
  • Prescription
    • Arcoxia (etoricoxib 60mg) 1# PRNQD
    • Neurontin (gabapentin 100mg) 1# PRNBID

[chemoimmunotherapy]

• 2023-08-07 - irinotecan 180mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2800mg/m2 4535mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2023-07-24 - irinotecan 180mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2800mg/m2 4535mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2023-07-10 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2023-06-26 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2023-06-13 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2023-05-30 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2023-05-12 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2023-04-21 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2023-04-03 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2023-03-09 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2023-02-21 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2022-09-19 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2022-09-01 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2022-08-14 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2022-08-01 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

• 2022-07-11 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

• 2022-06-27 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 157mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

• 2022-06-06 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 336mg 1.5hr + leucovorin 400mg/m2 748mg 2hr + fluorouracil 2800mg/m2 5235mg 46hr

• 2022-05-19 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5190mg 46hr

• 2022-04-29 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5190mg 46hr

• 2022-04-15 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5130mg 46hr

• 2022-03-23 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 347mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr

• 2022-03-09 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 347mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr

• 2022-02-22 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 348mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr

• 2022-02-08 - irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

• 2022-01-18 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

• 2022-01-04 - bevacizumab 5mg/kg 380mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

• 2021-06-29 ~ 2022-01-18 - FOLFIRI + bevacizumab

• 2021-05-13 ~ 2021-06-11 - FOLFIRI

==========

2023-08-07

[anemia]

Since 2023-02, the patient has been receiving FOLFIRI regimen. On 2023-08-06, there was an episode of grade 3 anemia (HGB < 8 g/dL) (another grade 3 anemia was recorded on 2023-04-03 with a HGB level of 7.6g/dL). To address the anemia, blood transfusions were administered on 2023-03-14, 2023-04-03, 2023-05-12, and 2023-08-06.

Starting from 2023-04-03, the dose of Irinotecan was reduced to 60% (300mg -> 180mg -> 175mg).

2023-07-25

According to the PharmaCloud database, this patient has only received his medical needs from our hospital in the past 3 months, no medication reconciliation issues identified.

2022-06-07

• This is a stage IV rectal cancer patient with a LN and lung mets (EGFR+, pMMR, mutated KRAS codon 12/13) who is currently being treated with FOLFIRI plus ramucirumab.
• The presence of KRAS mutations have been identified as predictors of resistance to anti-EGFR therapy in patients with mCRC. PFS was significantly improved with ramucirumab (currently used) compared to placebo in the RAS mutation subgroup (P=0.021) ( https://pubmed.ncbi.nlm.nih.gov/30339194/ )
• The imaging studies revealed regression (2021-11-18 CT) followed by mild progression (2022-02-21 CT, 2022-04-28 bone scan, 2022-05-28 CT) with CEA (2022-05-10 7.474 ng/mL) and CA199 (2022-05-10 38.630 U/ml) remaining elevated.
• As the effect of the current treatment is still being observed, [trifluridine + tipiracil] might be an option if the results do not meet expectations (the drug is covered by national health insurance).
• The patient had primary hypertension and his BP readings have been around 150/100 since this hospital stay under Sevikar (amlodipine 5mg plus olmesartan 20mg) 1# PO QD. If the high pressure does not go down and becomes symptomatic, then increasing the dose of Sevikar could be an option. (Maximum daily dose: amlodipine 10 mg, olmesartan 40 mg).

2022-04-18

• This is a patient with stage IV rectal cancer with a LN and lung metastasis being treated with FOLFIRI since 2021-05-13.
• Earlier tests indicated that EGFR(+), MMR-proficient, and mutated KRAS codon 12/13.
• CT images revealed first regression (2021-11-18) and then progression (2022-02-21). Bevacizumab was added from 2021-06-29 to 2022-01-18, then ramucirumab was added from 20202-22-22.
• Lab readings were generally normal (2022-04-15), however CEA (2022-04-01) and CA199 (2022-04-08) remained elevated.
• Current updated treatment effect is still being observed, and if the results are not as expected, then [trifluridine + tipiracil] might be an option (the drug is covered by national health insurance).
• Besides analgesics, non-pharmacological interventions that can control pain over a longer period of time might also be considered. The following interventions are available to treat metastatic bone cancer pain (not exhaustive, reference: https://pubmed.ncbi.nlm.nih.gov/31140913/):
  • Epidural and selective nerve root block
  • Radiofrequency ablation and cryoablation
  • Vertebral augmentation
  • Intrathecal drug delivery
  • Spinal cord stimulation
  • Dorsal root ganglion stimulation

220607

[assessment]

• This is a stage IV rectal cancer patient with a LN and lung mets (EGFR+, pMMR, mutated KRAS codon 12/13) who is currently being treated with FOLFIRI plus ramucirumab.
• The presence of KRAS mutations have been identified as predictors of resistance to anti-EGFR therapy in patients with mCRC. PFS was significantly improved with ramucirumab (currently used) compared to placebo in the RAS mutation subgroup (P=0.021) ( https://pubmed.ncbi.nlm.nih.gov/30339194/ )
• The imaging studies revealed regression (2021-11-18 CT) followed by mild progression (2022-02-21 CT, 2022-04-28 bone scan, 2022-05-28 CT) with CEA (2022-05-10 7.474 ng/mL) and CA199 (2022-05-10 38.630 U/ml) remaining elevated.
• As the effect of the current treatment is still being observed, [trifluridine + tipiracil] might be an option if the results do not meet expectations (the drug is covered by national health insurance).
• The patient had primary hypertension and his BP readings have been around 150/100 since this hospital stay under Sevikar (amlodipine 5mg plus olmesartan 20mg) 1# PO QD. If the high pressure does not go down and becomes symptomatic, then increasing the dose of Sevikar could be an option. (Maximum daily dose: amlodipine 10 mg, olmesartan 40 mg).

220418

[assessment]

• This is a patient with stage IV rectal cancer with a LN and lung metastasis being treated with FOLFIRI since 2021-05-13.
• Earlier tests indicated that EGFR(+), MMR-proficient, and mutated KRAS codon 12/13.
• CT images revealed first regression (2021-11-18) and then progression (2022-02-21). Bevacizumab was added from 2021-06-29 to 2022-01-18, then ramucirumab was added from 20202-22-22.
• Lab readings were generally normal (2022-04-15), however CEA (2022-04-01) and CA199 (2022-04-08) remained elevated.
• Current updated treatment effect is still being observed, and if the results are not as expected, then [trifluridine + tipiracil] might be an option (the drug is covered by national health insurance).
• Besides analgesics, non-pharmacological interventions that can control pain over a longer period of time might also be considered. The following interventions are available to treat metastatic bone cancer pain (not exhaustive, reference: https://pubmed.ncbi.nlm.nih.gov/31140913/):
  • Epidural and selective nerve root block
  • Radiofrequency ablation and cryoablation
  • Vertebral augmentation
  • Intrathecal drug delivery
  • Spinal cord stimulation
  • Dorsal root ganglion stimulation

700301189

230804

[exam findings]

• 2023-03-28, -03-27, -03-24, -03-22 CXR
  • Pneumo-mediastinum is highly suspected.
  • Left Pleura effusion is noted.
  • Focal pneumothorax at right CP angle.
  • Subcutaneous emphysematous change over bilateral lower neck, bilateral axillary and right lateral chest wall.
  • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
  • S/P pigtail catheter implantation at right CP angle with focal pneumothorax.
• 2023-03-22 SONO - chest
  • Pleural effusion, moderate, right
  • Atelectasis, RLL
  • Organized pleurae, left
• 2023-03-21 CT - chest
  • Comparison was made with previous CT dated on 2022/08/26
    • Lungs: multiple randomly distributed pulmonary nodules of varying sizes, consistent with metastatic lesions.
      • dependental partial relaxation atelectasis of RLL.
      • massive Rt and moderate Lt, bilateral pleural effusions, with parietal pleural thickening.
      • multiple subleural bulla lung cyst in bilateral apical lungs
    • Mediastinum and hila: no enlarged LN or mass.
    • Aorta: normal caliber of thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal-pelvic contents: hypodense lesions in pancreatic tail up to 19mm.
      • several small hepatic cysts.
      • unremarkable of the spleen, GB, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
      • no obvious bowel wall thickening of colon and rectum based on CT images.
      • extensive spondylosis and degenerative spinal canal and lateral recesses stenosis at L4-S1 levels.
  • Impression:
    • bilateral pulmonary metastases and exudative pleural effusion, in progression and new pancreatic tail tumors (metastases d/d primary cancer) as compared with previous CT study on 2022/08/26
• 2023-03-21 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Septal infarct, age undetermined
• 2022-09-23 Patho - lung transbronchial biopsy
  • Lung, right, CT-guide biopsy—adenocarcinoma, moderately differentiated, metastatic, consistent with colorectal origin
  • Sections show neoplastic cribriform glandular cells infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal CK7(-), CK20(+), TTF-1(-), and CDX2(+). The results are consistent with metastatic colorectal adenocarcinoma.
• 2022-08-26 CT - chest
  • Bilateral lung meta. Stable
  • Consolidation over left lower lobe, please monitor superimposed pneumonitis.
• 2022-05-13 CT - chest
  • Multiple lung meta with necrotic or solid nodular appearance. In progression.
  • Small lymph nodes are found in the mediastinum.
• 2022-04-06 CXR
  • Multiple nodules at RLL.
• 2022-01-07 CT - abdomen
  • There is no evidence of wall thickening in the rectum. Please correlate with colonoscopy.
• 2022-01-07 Colonoscopy
  • Previous surgical scar at low rectum was found. No recurrent.
• 2020-12-04 CT - abdomen
  • There is no evidence of wall thickening in the rectum. Please correlate with colonoscopy.
• 2020-12-04 Colonoscopy
  • No definite mucosal lesion was seen from rectum to cecum. Previous surgical scar at low rectum was seen without recurrent evidence
• 2019-12-10 CT - abdomen
  • Clinical history: 73 y/o male patient with
    • 2019-04-08: He had been to KFSYSCC for second opinion, but they suggest him to receive surgery at our hospital, he refused APR, thus, transanal local excisin + CCRT is first choice
    • 2019-05-03: adenocarcinoma of low rectum s∕p transanal local excision (2019-04-15), pT2NxM0, stage I, at least, G2, LVI(-), PNI(+), left margin involved (+)
    • 2019-06-14: for CEA report (suggest CTC), s∕p 22th R∕T, refuse chemotherapy, anal pain, 2019-07-19: finished R/T, no discomfort, refuse C/T
    • 2019-11-01: no discomfort, for follow-up programs.
  • With and without contrast enhancement CT of abdomen - whole:
    • Small gallbladder stone.
    • Liver cysts, up to 0.8cm in left lobe.
    • Unremarkable change of the spleen, pancreas and both kidneys.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
  • Impression:
    • Clnical lower rectal cancer s/p, suggest follow up.
    • Small gallbladder stone.
    • Liver cysts.
• 2019-04-16 CT - abdomen
  • There are few small gas bubbles in the perirectal space, near anal verge. please correlate with clinical condition.
  • Few tiny gallstones are suspected.
• 2019-04-16 Surgical pathology Level IV
  • PATHOLOGIC DIAGNOSIS
    • Large intestine, rectum, transanal local excision —- Adenocarcinoma, moderately differentiated
      
    • Resection margins: involved, left
      
    • Lymph node, mesocolic, dissection —- Not received
    • Lymph node, IMA / SMA, dissection —- Not received
    • AJCC 8th edition Pathology stage: pStage I, pT2Nx(if cM0)
  • MACROSCOPIC EXAMINATION
    • Operation procedure: transanal local excision
    • Specimen site: rectum
      
    • Specimen size: 2.8 x 1.7 x 1.4 cm
      
    • Tumor size: 1.5 x 1.0 cm
    • Tumor location: anterior: 0.3 cm; right: 0.4 cm; posterior: 0.6 cm; left: involved; deep: 0.8 cm
    • Depth of invasion grossly: muscularis propria
    • Mucosa elsewhere: congestion
    • Two separated tissue fragments measuring up to 2.0 x 0.7 x 0.5 cm are found.
    • All for section and labeled as: A1-2: cross section from right (green) to left (blue); A3: anterior; A4: posterior; A5: separated tissue fragments.
  • MICROSCOPIC EXAMINATION
    • Histology: adenocarcinoma; The immunohistochemical stains reveal CK(+) and CD56(-).
    • Histology Grade: moderately differentiated
    • Depth of invasion: muscularis propria
    • Angiolymphatic invasion: Not identified.
      
    • Perineural invasion: Present.
      
    • Discontinuous extramural tumor extension: Not identified.
      
    • Circumferential (radial) margin of rectum: Uninvolved, 8 mm from the margin,
    • Lymph node metastasis, mesocolic: not received
      
    • Lymph node metastasis, IMA / SMA: not received
      
    • Extranodal involvement: not received
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT): pT2:Tumor invades the muscularis propria
      • Regional Lymph Nodes (pN): Nx
      • Distant Metastasis (pM): if cM0
    • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
    • Additional pathologic findings: S2019-3459: IHC stain— PMS2(+), EGFR(+), MSH-2(+), MSH-6(+), MLH-1(+)
    • TNM descriptors: unknown
      
    • Tumor regression grading S/P CCRT: patient not received
• 2019-04-15 ECG
  • Normal sinus rhythm with sinus arrhythmia
  • ST abnormality, possible digitalis effect
  • Abnormal ECG
• 2019-03-28 CT - abdomen
  • Imaging Report Form for Colorectal Carcinoma
    • TxN0Mx

[consultation]

• 2023-03-27 Thoracic Surgery
  • Q
    • This is a 77 years old male with adenocarcinoma of low rectum s/p transanal local excision in 2019 with lungs metastases, stage IVa.
    • Complained about shortness of breath for 15+ days, exertional dyspnea. He came to ER on 2023/03/21, and was admitted on 2023/03/22.
    • Pig tail was inserted on 2023/03/22 for pleural effusion, output:1400 on 2023/03/22.
    • However, patient complained about exertional coughing/pain in the evenging, CXR showed focal pneumothorax. at 23:38 on 2023/03/22.
    • Symptom improved with rest. Educated about emptying air from the bag to the patient and caretaker.
    • Subcutaneuos emphesema was observed on 2023/03/24 over right lower neck and right axillary and right lateral chest wall.
    • After discussing with our VS, he suggested to put local compression over the pig tail insertion spot due to relatively asymptomatic manifestation.
    • Patient tolerated the situation well excpet exertional shortness of breath, until 2023/03/26 evening when he complained about enlarged area of subcutaneuos emphysema
    • LPS 18cm H2O was connected to pig tail on 2023/03/26, 22:57
    • His SpO2 remained 94-99%, stable TPR.
    • We would like to consult your expertise, thank you!
  • A1
    • S
      • This 77 y.o male was a case of Rectal Ca, Adenocarcinoma, post OP in 2019 with lung metastasis, stage IVa now. This time, he was admitted due to progressive dyspnea and bilateral pleural effusion noted on CXR on 2023-03-21. Chest echo + right pig-tail insertion for effusion drainage was done on 2023-03-22. Unfortunately, little subcutaneous emphysema and right focal pneumothorax was noted since 2023-03-24 by CXR. This condition not improvement after conservative treatment and LPS 18cm H2O. Follow up CXR on 2023-03-27 showed prograssive right subcutaneous emphysema and we were consulted for further treatment.
    • O
      • 2023-03-27 CXR: bilateral subcutaneous emphysema, pneumomediastinum, left CP angle blunting due to pleural effusion and right pig-tail in position.
    • Suggestion
      • keep right pig-tail drainage with LPS 15-20cm H2O, if necessary, may try two bottle drainage system
      • please consult Chest surgeon to evaluate his subcutaneous emphysema condition and the indication of surgical treatment or not
  • A2
    • may replace pigtail with chest tube. Bigger calibre would offer adequate chest drainage to release patient’s subcutaneous emphysema.

[SOAP]

• 2022-08-19 Colorectal Surgery
  • A
    • adenocarcinoma of low rectum s/p transanal local excision (2019-04-15), pT2NxM0, stage I, at least, G2, LVI(-), PNI(+), left margin involved (+), s/p R/T
  • P
    • APR is refused, so arrange CCRT (R/T + UFUR by patient choice, BUT he refuse chemotherapy!)
    • F/U CEA + CXR (2022-07), CT (2022-12), colonoscopy (2022-12)
    • 2022-08-19 he did not receive CT-gioded biopsy for lung lesions (personal reason), re-check chest CT

[surgical operation]

• 2019-04-15
  • Diagnosis: Adenocarcinoma of low rectum, cT1N0M0
  • PCS code: 74211B - Extensive excision of sacrococcygealrectal villous adenoma or malignacy
  • Finding
    • A 1.5cm tumor was identified at 3-5cm above anal verge of anterior aspect of low rectum.
    • Friable tumor pieces was pelling off after putting anal retractor.
    • Full-thickness local rectal excision was performed as possible to gain a safe margin.
    • Normal saline irrigation and hemostasis was done. Blood loss was about 10-20ml.
    • The wound was closed with 4/0 vicryl.
• 2017-10-12
  • Diagnosis: back tumor
  • PCS code: 62011C - Excision of skin or subcutaneous tumor (Except face) - 2 to 4 cm
  • Finding: back tumor 3cm, x1
  • Procedure: Under LA, the tumor was excised. The wound was closed with 3-0 viryl and 4-0 Nylon.

[immunochemotherapy]

• 2023-08-02 - Avastin + FOLFIRI
• 2023-07-12 - Avastin + FOLFIRI
• 2023-06-23 - Avastin + FOLFIRI
• 2023-06-02 - Avastin + FOLFIRI
• 2023-05-05 - FOLFIRI
• 2023-04-07 - FOLFIRI

==========

2023-08-04

The recently refilled repeat prescription for Vemlidy (tenofovir alafenamide) on 2023-07-05 is being utilized without any reconciliation issues detected.

2023-03-29

On 2023-03-24, a Port-A was inserted for the patient who previously refused chemotherapy.

All the oral/inhaled medications in the active prescription are appropriate for his respiratory symptoms, including Sodicon (dextromethorphan), Butanyl (terbutaline), and Ipratran (ipratropium bromide).

700573987

230804

[exam findings]

• 2023-06-20 CXR
  • Solitary pulmonary nodule at right lung.
  • Presence of radiopaque gallbladder stones.
• 2023-06-13 SONO - abdomen
  • GB stone, multiple
• 2023-05-24 Patho - lymph node region resction
  • DIAGNOSIS:
    • Lymph node, level II, right, modified radical neck dissection — Positive for moderately differentiated squamous cell carcinoma ( 1 / 7 )
    • Lymph node, level Ia, midline, modified radical neck dissection — Negative for malignancy ( 0 / 2 )
    • Lymph node, level Ib, right, modified radical neck dissection — Negative for malignancy ( 0 / 4 )
    • Lymph node, level III, right, modified radical neck dissection — Positive for moderately differentiated squamous cell carcinoma. ( 1 / 5 )
    • Lymph node, level IV, right, modified radical neck dissection — Positive for moderately differentiated squamous cell carcinoma. ( 1 / 9 )
    • Lymph node, level Va, right, modified radical neck dissection — Negative for malignancy ( 0 / 1 )
    • Lymph node, level Vb, right, modified radical neck dissection — Negative for malignancy ( 0 / 3 )
    • Salivary gland, submandibular, right, modified radical neck dissection — Negative for malignancy
    • Skin, neck,level II, right, modified radical neck dissection — Negative for malignancy
  • MICROSCOPIC EXAMINATION
    • Neck Lymph Nodes: Positive for moderately differentiated squamous cell carcinoma (see above)
      • Size (greatest dimension) of the largest positive lymph node: 5 cm
      • Extranodal extension: Absent
    • Submandibular gland, right: Negative for malignancy
    • Skin, level II, right neck: Negative for malignancy
• 2023-04-28 Patho - tonsil and/or adenoid
  • DIAGNOSIS:
    • Nasopharyngeal lesion, right, biopsy— Lymphoid hyperplasia
    • Nasopharyngeal lesion, left, biopsy— Lymphoid hyperplasia
    • Tongue base, right, laryngomicrosurgery — Lymphoid hyperplasia
    • Tonsil, right, tonsillectomy— Lymphoid hyperplasia
  • Microscopically, sections A, B, C and D shows bland tissues with lymphoid hyperplasia. There are no evidence of malignancy.
  • Immunohistochemical stain reveals CK (-).
• 2023-04-19 PET scan
  • Increased FDG uptake in the right oropharynx, highly suspected the primary oral malignancy, suggesting biopsy for investigation.
    
  • Increased FDG uptake in lymph nodes of the right neck region, compatible with metastatic lymph nodes.
    
  • Mildly increased FDG uptake in 2 lesions in the right lower lung, the nature is to be determined (chronic inflammation process, benign/malignant neoplasm, or other nature ?), suggesting further investigation and follow-up.
  • Increased FDG uptake in bilateral pulmonary hilar regions, probably physiological uptake of FDG.
    
  • Right oropharyngeal cancer, cTxN1M0, by this F-18 FDG PET scan.
• 2023-04-12 Patho - lymphonode biopsy
  • Lymph node, neck, right, excision — Non-keratinizing squamous cell carcinoma, metastatic
  • The sections show a picture of metastatic non-keratinizing squamous cell carcinoma, poorly differentiated, composed of lymphoid tissue with nests of large neoplastic cells with oval nuclei, arranged in solid pattern. Keratin formation is absent.
  • IHC, tumor cells reveal: CK7(-), CK20(-), p40(+) and p16(-).
  • EBER in situ hybridization — Negative
• 2023-04-06 CT - neck
  • Indication: the R’t neck mass get enlarged progressively in recent 6 months
  • Finding:
    • Enlarged lymph nodes at right level II (46 mm) and level III (15 mm), both with heterogeneous enhancement. Mass effect on right submandibular gland and internal jugular vein also noted.
    • Calcification along aortic arch.
  • IMP:
    • Enlarged lymph nodes at right level II and III.
    • D/D: lymphoma, reactive lympadenitis.
• 2023-02-07 CT - abdomen
  • A nodule (1.9cm) at RLL.
  • Gallbladder and distal CBD stones (2-4mm).
  • Colonic diverticula.
• 2022-08-02 CT - chest
  • Finding: a dense calcified nodule (13mm) and adjacent 3mm calcification at superior segment and a lobulated soft-tisue nodule with two tiny eccentric calcification (18mm) with surrounding interlobular septal thickening at posterobasal segment of RLL. Multiple subleural bullae in bilateral apical lungs
  • Impression:
    • two granulomas up to 13mm and a calcified nodule (18mm) in RLL of lung, stationary as compared with CT on 2016/07/05.
    • multiple subleural bullae in bilateral apical lungs
• 2020-08-06 CT - brain
  • Mild cortical brain atrophy.
• 2018-02-23 CT - brain
  • No intracranial abnormality
• 2017-08-05 SNCV, MNCV
  • Comments
    • Normal motor and sensory conduction studies of the arms and legs.
    • Normal F-wave latencies followed all sampling nerve stimulations.
    • Normal H-reflex study in both legs..
  • Conclusion
    • This is a normal NCV study.

[surgical operation]

• 2023-05-24
  • Surgery
    • Modified radical neck dissection, right
  • Finding
    • Enlarged indurated lymphadenopathy over right level II, III
    • Right SCM (upper part partially removed with level II LN), IJV, SAN preserved
• 2023-04-27
  • Surgery
    • Nasopharyngeal biopsy, bilateral    
    • Laryngomicrosurgery        
    • Right tonsillectomy        
  • Finding
    • Granular surface over upper pole of right tonsils  
• 2023-04-12
  • Surgery
    • Excision        
  • Finding
    • A 4 cm hard tumor over R’t lateral neck and we excise part of it for biopsy

[MedRec]

• 2023-05-04 SOAP Hemato-Oncology Gao WeiYiao
  • P: ENT Dr Hwang will perfomed to receive operation first followed by CCRT
• 2023-05-04 SOAP Ear Nose Throat Huang TongCuan
  • A/P
    • right neck metastatic SCC
    • s/p Right tonsillectomy, biopsy of right base lesion and bi nasopharynx on 2023/04/27, no primary lesion found
    • cTxN2aM0 >>> explanation about treatment option:
      • Op + post-op RT or CCRT
      • CCRT
• 2023-04-25 SOAP Ear Nose Throat Huang TongCuan
  • A/P: right neck metastatic cancer >>> arrange admission for endoscope exam + biopsy (NP, tongue base) + tonsillectomy
• 2017-08-01 SOAP Neurology
  • S
    • P’t suffered from bilateral hands and feet numbness for 2~3 months. Left side dominent, worse when sit.
  • O
    • E4V5M6
    • Normal cranial nerve sign
    • MP: Full
    • Sensation: distal hyperalgesia
    • DTR: bilateral ankle +
  • A
    • Polyneuropathy [G62.9]
  • Prescription
    • Euclidan (nicametate citrate 50mg) 1# BID

[radiotherapy]

[chemotherapy]

• 2023-07-25 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL
• 2023-07-18 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL
• 2023-07-07 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL
• 2023-06-30 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL

==========

2023-08-04

The package insert for Dicetel (pinaverium bromide) advises against oral ingestion or chewing. It is recommended to swallow the medication with a large glass of water during meals to prevent contact with the esophageal mucosa (risk of esophageal injury) and not be taken while lying down or before bedtime. This indicates that tube feeding is not recommended.

700617345

230804

(not completed)

[surgical operation]

• 2023-04-06
  • Surgery
    • Operation
      • Port-A (47080B)
      • Fluoroscopy (32026C)        
  • Finding
    • Insertion via right subclavian vein.
    • Port: Polysite, 3007, 7Fr,
    • Fluorosopy: catheter tip in SVC above RA
• 2023-03-29
  • Surgery
    • Diagnosis: Endometrial cancer
    • Surgery: Staging surgery
  • Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder
    • Bilateral adnexa: grossly normal
    • CDS: mild adhesion (+), ascites (+)
    • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
    • Omentum: grossly normal
    • Estimated blood loss: 300 mL
    • Blood transfusion: nil
    • Complication: nil
  • Procedure
    • Put the patient on the lithotomy position
    • Vaginal douching, insert Foley catheter, skin disinfection with beta-iodine, and skin draping.
    • Make midline vertical skin incision and open the abdominal wall layer by layer.
    • Serous ascites, send for cytology
    • Apply auto-retractor and pack up the intestine to expose the uterus.
    • Clamp, ligate and cut left round ligament
    • Clamp, cut andligate left infundibulo-pelvic ligament
    • Repeat step 6-7 at the right side.
    • Dissect the densely adherent posterior leaf of broad ligaments overlying the uterosacral ligaments bilaterally.
    • Dissect and reflect the bladder downwards and off the uterus.
    • Clamp, cut andligate the ascending branches of uterine arteries bilaterally at the level of isthmus of cervix.
    • Clamp, cut and ligate the paracervical vessels along lateral borders of cervix step by step downwards bilaterally till the level of lateral vaginal fornix.
    • Cut the uterus and grasp the vaginal stump
    • Suture the bilateral angles of vaginal stump with 1-0 Vicryl
    • Suture the vaginal stump with 1-0 Vicryl
    • Step by step clamp, cut and ligate the omentum.
    • Irrigate the pelvic cavity with normal salin.
    • Check bleeding and hemostasis.
    • Insert J-VAC X 2 at the cul-de-sac.
    • Close the abdomen layer by layer.
    • Skin approximation.
• 2023-03-16
  • Surgery
    • Diagnosis: R/O endometrial hyperplasia
    • Surgery: Fractional dilatation and curettage        
  • Finding
    • Uterus: Anteversion, 7 cm.
    • Scanty endocervical and some endometrial tissue were curetted out.
    • Mild laceration wound at 4 o’clock of the hymen.
    • Estimated blood loss:5 mL, Blood transfusion: nil, complication: nil.        
  • Procedure
    • Put the patient on lithotomy position.
    • Douching, skin disinfection and skin draping as usual.
    • Sounding: Anteversion, 7 cm.
    • Cervical dilatation to Hegar No. 7.
    • Curette the endocervical canal and uterine cavity.
    • Check bleeding.
    • Pack one piece of Bosmin gauze in the vagina to compress the hymen laceration wound.

[radiotherapy]

• 2023-05-04 ~ 2023-06-16 - 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.

[chemotherapy]

• 2023-08-03 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-14 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-08 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-01 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-25 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-18 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-11 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-04 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-08-04

[reconciliation]

This patient recently refilled a 30-day prescription on 2023-07-24, provided by Taipei Veterans General Hospital, for rufinamide, lamotrigine, topiramate, lacosamide, perampanel, and clobazam to manage her “localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus.” However, these medications are not currently in use. Please verify if there is no longer a need for these drugs.

2023-07-14

[leukopenia]

The organization of WBC level changes is as follows, where * represents WBC < 3K/uL, ** represents WBC < 2K/uL. Leukopenia, which occurred in late May and worsened in mid-June, is more likely the result of the cumulative effects of multiple CCRTs when considering the treatment timeline. After each dose of Granocyte (lenograstim 250ug) administered on 2023-06-29 and 2023-07-01, leukopenia is currently no longer present.

2023-07-13 WBC 5.96 x10^3/uL 2023-07-06 WBC 4.03 x10^3/uL
2023-06-29 WBC 1.64 x10^3/uL ** Granocyte (lenograstim 250ug) 06/29, 07/01 2023-06-15 WBC 1.59 x10^3/uL ** concurrent CDDP 06/08 2023-06-07 WBC 2.05 x10^3/uL * concurrent CDDP 06/01 2023-05-31 WBC 2.02 x10^3/uL *
2023-05-24 WBC 2.22 x10^3/uL * concurrent CDDP 05/18, 05/25 2023-05-17 WBC 3.21 x10^3/uL concurrent CDDP 05/11 2023-05-10 WBC 3.47 x10^3/uL concurrent CDDP 05/04 2023-05-02 WBC 5.00 x10^3/uL
2023-03-30 WBC 10.44 x10^3/uL
2023-03-28 WBC 3.01 x10^3/uL
2023-03-08 WBC 3.31 x10^3/uL
2021-07-12 WBC 3.97 x10^3/uL

[paclitaxel administered, leukopenia needs to be monitored in the coming weeks]

• It is worth noting for the future that the paclitaxel, which we started administering today on 2023-07-14, is also expected to cause bone marrow suppression. Among these, neutropenia is the main dose-limiting hematologic toxicity of paclitaxel. Severe, grade 4 neutropenia and febrile neutropenia have been reported. Neutrophil nadir is generally rapidly reversible. The onset is intermediate, with neutrophil nadir typically occurring at a median of 11 days. Risk factors include higher doses, longer duration of infusion, and extent of prior cytotoxic chemotherapy.
• In addition to paclitaxel, cisplatin is also being used simultaneously. The latter causes leukopenia (25% to 30%; nadir: Day 18 to 23; recovery: By day 39; dose-related).
• Therefore, it is suggested to closely monitor the patient over the next few weeks.

700902773

230804

[MedRec]

• 2023-07-03 Metabolism and Endocrinology
  • Prescription x3
    • Eltroxin (levothyroxine 50ug) 2# QDAC
• 2023-06-26 Orthopedics
  • Prescription x3
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# BID
    • Neurontin (gabapentin 100mg) 1# HS
    • Toricam (piroxicam) ASORDER TOPI
• 2023-05-25 Cardiology
  • Diagnosis
    • Atrial fibrillation [I48.0]
    • Sick sinus syndrome [I49.5]
    • Presence of cardiac pacemaker [Z95.0]
    • Conduction disorder, unspecified [I45.9]
    • Chronic renal failure [N18.6]
    • Unspecified hypothyrodism [E03.9]
    • Anemia, unspecified [D64.9]
  • Prescription x3
    • Cordarone (amiodarone 200mg) 0.5# QD
    • Ulstop (famotidine 20mg) 1# QD
    • midorine 2.5mg 2# PRNTID
• 2022-07-31 ~ 2022-08-04 POMR Hemato-Oncology Gao WeiYao
  • Discharge diagnosis
    • Urothelial carcinoma, low grade, papillary type, of the right renal pelvis, s/p NU, cystectomy, hysterectomy, urethrectomy, with local recurrence (vaginal metastases) .
    • End stage renal disease under hemodialysis on QW 246 (clinic)
    • Paroxysmal atrial fibrillation
    • Sick sinus syndrome
    • Presence of cardiac pacemaker
    • Hypothyroidism, unspecified
  • CC
    • for CCRT
  • Present illness
    • The 73-year-old woman has histories of
      • ESRD on regular hemodialysis QW246 since 2016.
      • Thyroid goiter s/p partial thyroidectomy under Thyroxin control for 20+ years.
      • Left ureteral urothelial carcinoma, high grade, pT2N0cM0, status post anterior pelvic exenteration and left nephroureterectomy on 2016/08/31
      • Bladder urothelial carcinoma, high grade, pT1N0cM0, status post radical cystectomy on 2016/08/31
      • Urothelial carcinoma over the right renal pelvis, left upper ureter, bladder and urethra s/p bilateral neprhectomy, cystectomy, abdominal total hysterectomy with bilateral salpingo-oophorectomy and urethrectomy on 2014/11/05
      • Sick sinus syndrome pacemaker implantation on 2017/4/19
    • In 2022/06 she had suffered from bloody stool. She had visited CRS OPD and colonoscopy showed extra-rectal tumor with external compression. She was referred to GYN OPD. DRE test found extra-rectal large solid tumor at anterior. PV exam found ulcerative mass at posterior vaginal wall. Malignancy was highly suspected. GYN echo showed one 48x39mm mass. Cervical biopsy was done and showed malignancy with urothelial origin. Urothelial cell carcinoma with vaginal metastasis was diagnosed.
    • Under the impression of urothelial cell carcinoma with vaginal metastasis, radiotherapy was suggested. The patient agreed to undergo the therapy. Therefore she was admitted on 2022/7/31 for further evaluation and radiotherapy localization was scheduled on 2022/8/3.
  • Course of inpatient treatment
    • After admission, she received LPRBC 2u and EPO for anemia. Nephro was consulted and arranged HD qw 246. Chemotherapy as C1 Gemzar (200mg/m2) during RT- RT positioning on 2022/8/4. Under the stable condition, she can be discharged on 2022/08/04. OPD follow up is arranged.

[chemotherapy]

• 2022-09-14 - gemcitabine 200mg/m2 280mg NS 100mL (after hemodialysis) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-08-31 - gemcitabine 200mg/m2 280mg NS 100mL (after hemodialysis) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-08-12 - gemcitabine 200mg/m2 282mg NS 100mL (after hemodialysis) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-08-02 - gemcitabine 200mg/m2 282mg NS 100mL (after hemodialysis) (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2023-08-04

All repeat prescriptions from our endocrinologist, orthopedist, and cardiologist were added to the active medication list, with the exception of midorine. During this hospitalization, there is no evidence of symptomatic orthostatic hypotension in the HIS5 records, so no reconciliation issues were identified.

701073389

230804

[diagnosis] - 20230114 discharge note

• Pancreatic head cancer, stage III, with common bile duct obstructive jaundice, status post Endoscopic Retrograde Biliary Drainage revision
• Duodenal ulcer compared with tumor invasion
• Hypokalemia
• Chronic viral hepatitis B without delta-agent
• Type 2 diabetes mellitus without complications
• Inferior wall myocardial infarction with cardiogenic shock, status post Percutaneous transluminal coronary angioplasty with stent on 2012/05/25

[past history]

• HBeAg(-) HBV carrier
• Inferior wall myocardial infarction with cardiogenic shock, post primary PCI & stent for RCA on 2012/05/25
• DM    
• Pancreatic head cancer with obstructive jaundice and duodenal invasion, status post Contrast harmonic echo-endoscopic ultrasound guided fine needle biopsy, stage III.

[exam findings]

• 2023-06-24 CT - abdomen
  • Pancreatic head cancer (3.7*2.7cm), in regression
  • s/p biliary stents
  • Liver hypodensity; DDx: fatty liver, hepatitis
• 2023-05-04 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • No bloody material nor coffee ground material during this examination
    • Gastric mucosa swelling, antrum, PW site
    • C/W pancreatic cancer with duodenal involving
    • Duodenal orifices, ampulla and periampulla, need to r/o pancreatic cancer involving duodenal causing perforation
    • Duodenal plastic stent inplace
    • Superficial gastritis
    • Deformed antrum
  • Suggestion
    • PPI use
• 2023-04-29 Embolization (TAE) - abdomen
  • Embolization of gastroduodenal artery via right femoral artery puncture revealed:
    • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
    • No definite active bleeding during the celiac axis and SMA injections.
    • Prevention emobilization of gastroduodenal artery was periformed with 2 coils. Nearly total obliteration of gastroduodenal artery after embolization.
    • No procedure related complication.
  • Impression
    • c/w TAE of gastroduodenal artery
    • A Fr.5 sheath was placed in right common femoral artery. Please remove it in 3 days.
• 2023-04-29 Esophagogastroduodenoscopy, EGD
  • Duodenum
    • One 3mm clean base ulcer with pigmentation was found at SDA. Active oozing, suspect the previous ulcer(2022/12/15), near the major papilla was noted, due to unable to tolerate, hemostasis is not done.
  • Diagnosis
    • Incomplete study due to much blood and intolerace
    • Duodenal oozing lesion, suspicious previous ulcer, 2nd portion
    • Duodenal ulcer, Forrest classification IIc, SDA, AW
  • Suggestion
    • Arrange TAE for hemostasis
    • Admission to ICU and then repeat EGD in the future
    • High dose PPI and NPO
• 2023-03-13 CT - abdomen
  • Indication: Pancreatic head cancer, stage III, with common bile duct obstructive jaundice, status post Endoscopic Retrograde Biliary Drainage revision
  • Abdominal CT with and without enhancement revealed:
    • Cystic lesion at pancreatic head measuring 5.7cm in largest dimension obliterating CBD and causing dilated biliary tree is found. In comparison with CT dated on 2022-11-30, the tumor size is stationary.
    • Marked fatty liver is found.
    • s/p biliary tree stent placement.
    • The GB is well distended without soft tissue lesion
    • No evidence of abnormal soft tissue mass at pelvic cavity.
    • No definite inguinal or pelvic sidewall LAP
    • The urinary bladder is well distended without soft tissue lesion.
    • Scoliotic alignment of the thoracolumbar spine is noted.
  • Imp:
    • Cystic lesion at pancreatic head measuring 5.7cm in largest dimension obliterating CBD and causing dilated biliary tree is found. In comparison with CT dated on 2022-11-30, the tumor size is stationary.
• 2023-03-09 CXR
  • Atherosclerotic change of aortic arch
  • Scoliosis of the T-spine with convex to right side.
• 2023-01-12 Endoscopic Retrograde CholangioPancreatography, ERCP
  • Indication
    • pancreatic head cancer post ERBD, malfunction of ERBD
  • Diagnosis
    • Pancreatic head cancer with CBD obstructive jaundice, post ERBD revision
    • Duodenal ulcer, c/w, tumor invasion.
  • Suggestion
    • On diet tonight
    • f/u Hb, serum AST/ALT, T-bil, lipase on the next morning
• 2023-01-11 Abdomen - standing (diaphragm)
  • S/P CBD stenting.
• 2023-01-11, 2022-12-26 CXR
  • Presence of scoliosis of the T-L spine.
• 2022-12-30 Whole body PET scan
  • There was inhomogenously increased FDG uptake in the region about the pancreatic head (SUVmax early: 7.43, delay: 6.38) and there was increased FDG uptake in the left shoulder joint (SUVmax early: 8.51, delay: 5.94). Besides, there was increased FDG accumulation in the colon, both kidneys and right ureter.
  • IMPRESSION:
    • Inhomogenously increased FDG uptake in the region about the pancreatic head, compatible with primary pancreatic malignancy. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in the left shoulder joint, compatible with active arthritis.
    • Increased FDG accumulation in the colon, both kidneys and right ureter. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2022-12-23 SONO - abdomen
  • Liver tumor, S6 and S7, suspicious Liver hemangioma
  • Fatty liver, mild
  • post ERBD.
  • Dilated left IHD.
• 2022-12-16 T-tube cholangiography
  • Cholangiography via PTCD catheter administration revealed:
    • Patency of the catheter.
    • Poor drainage function of CBD stent.
• 2022-12-16 Patho - duodenum biopsy
  • Labeled as “duodenum, major papilla (A)”, biopsy — adenocarcinoma.
    • IHC stains: CA19-9 (+), CK19 (+), CK7 (+), CK 20 (focal +), Ki-67 (60-70%)
  • Labeled as “duodenum, postbulb (B)”, biopsy — adenocarcinoma.
    • IHC stains: CA19-9 (+), CK19 (+), CK7 (+), CK 20 (focal +), Ki-67 (60-70%)
• 2022-12-16 Patho - pancreas biopsy
  • Labeled as “Pancreas”, EUS biopsy — adenocarcinoma.
    • IHC stains: CA19-9 (+), CK19 (+), CK7 (+), CK 20 (focal +), Ki-67 (60-70%)
• 2022-12-15 Endoscopic Retrograde CholangioPancreatography, ERCP
  • Indication
    • pancreatic head cancer with obstructive jaundice
  • Diagnosis
    • pancreatic head cancer with obstructive jaundice, s/p EST, CBD dilatation + ERBD
    • duodenal ulcer, suspicious tumor invasion, s/p biopsy(A) at major papilla, biopsy(B) at postbulb
    • post PTCD
  • Suggestion
    • On NPO except water tonight
    • f/u Hb, serum AST/ALT, T-bil, lipase on the next morning
    • PPI Rx
• 2022-12-15 Endoscopic Ultrasonography, EUSDiagnosis：
  • Diagnosis: Pancreatic head cancer with obstructive jaundice and duodenal invasion, s/p CHE-EUS-FNB
  • Suggestion: pursue pathology.
• 2022-12-13 MRI - pancreas
  • Pancreatic head tumor (5.4cm).
  • S/P PTCD. Some nodules in liver.
  • Bil. pleural effusion with adjacent lung collapse.
• 2022-12-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (138 - 48) / 138 = 65.22%
    • M-mode (Teichholz) = 65
  • Borderline dilated LA and LV; Adequate LV systolic function with normal resting wall motion
  • Trivial MR and trivial TR
  • LV diastolic dysfunction, Gr 1
  • Preserved RV systolic function
• 2022-12-08 Visceral Angiography 2 vessels
  • DSA of celiac trunk, SMA and common hepatic artery via right common femoral artery puncture revealed:
    • S/P PTCD.
    • Liver cirrhosis.
    • Patency of hepatic arteryies and portal vein. No evidence of active bleeding.
    • No procedure-related complication during the whole procedure.
  • IMP: No evidence of active bleeding.
• 2022-12-08 Percutaneous Transhepatic Cholangial Drainage, PTCD (drainage)
  • Dilatation of the biliary tree (by CT images).
  • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
  • No procedure-related complication during the whole procedure.
• 2022-11-30 CT - abdomen
  • Findings:
    • There is a well-defined hypodense mass at the pancreatic head, measuring 6 cm in size (the largest dimension), causing dilatation of bile ducts and pancreatic duct. During contrast-enhanced dynamic study, this mass shows poor enhancement in arterial phase and portal venous phase images, and mild enhancement in delayed phase images.
      • Adenocarcinoma of the pancreatic head is highly suspected.
      • The differential diagnosis include acinar cell carcinoma.
      • In addition, There is loss of normal fat plane between the pancreatic head mass and superior mesenteric vein that may be tumor direct invasion superior mesenteric vein (T4).
    • There are several ill-defined mild enhancing lesions in both hepatic lobes at arterial phase images. However, all lesions are not identified (isodensity) in portal venous phase and delayed phase images. The largest one 2.4 x 1.2 cm in S7 of the liver.
      • Pseudolesions (flow artifacts) are highly suspected.
      • The differential diagnosis include metastases.
      • Please correlate with sonography and MRI.
    • A renal cyst measuring 1 cm in left middle pole is noted.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T4 (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:III(Stage_value)
• 2021-05-11, -02-23 CXR
  • There is scoliosis of the T-spine with convex to right side.
  • Atherosclerotic change of aortic arch
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura thickening or effusion?
• 2020-03-04 Treadmill exercise test (BRUCE protocol)
  • The patient exercised according to the BRUCE for 08:00 min:s, achieving a work level of max METS: 10.1. The resting heart rate of 96 bpm rose to a maximal heart rate of 169 bpm. This value represents 107 % of the maximal, age-predicted heart rate. The resting blood pressure of 145/71 mmHg, rose to a maximum blood pressure of 201/61 mmHg. The exercise test was stopped due to Target heart rate maximal, Dyspnea, Fatigue.
  • Conclusion:
    • Resting ECG: normal
      
    • Arrhythmia: Nil
    • No significant ST-T change during exercise and recovery phases.
  • Impressions
    • Negative for myocardial ischemia
• 2022-12-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 35) / 93 = 62.37%
    • M-mode (Teichholz) = 63
  • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
  • Subendocardial scarring of inferior and inferoseptum with preserved wall motion and normal LV systolic function.
  • Normal RV systolic function.
  • Mild AV sclerosis; trivial MR.
  • Sinus tachycardia.
• 2017-01-07 SONO - Nephrology
  • Finding:
    • Size Shape
      • R’t :10.69 cm, smooth
      • L’t :10.87 cm, smooth
    • Cortex
      • R’t :Echogenicity: normal; Thickness: normal
      • L’t :Echogenicity: normal; Thickness: normal
    • Pyramid:
      • R’t : visible
      • L’t : visible
    • Sinus
      • Not Dilated
    • Cyst
      • None
    • Stone
      • None
    • Mass
      • None
  • Interpretation:
    • No signficant abnormality from echography for both kidneys.

[consultation]

• 2022-12-20 Radiation Oncology
  • Diagnosis: Pancreatic head cancer, adenocarcinoma, cT4N1M0 at least, with obstructive jaundice on 2022/12/08, s/p ERCP + ERBD / EUS-FNB on 2022/12/15; severe BW loss; ECOG =1.
  • Plan: Pre-operative CCRT to pancreatic head tumor & regional LAPs for 5040cGy/28 fx is suggested for locoregional tumor control. Possible treatment toxicity is told. CT simulation is arranged on 2022/12/21. Psychological support & diet education is given to him and his daughter. Please consult dietician for diet education, medical oncologist for systemic chemotherapy and surgeon for PortA implantation.

[MedRec]

• 2023-07-25 SOAP General and Gastroenterological Surgery
  • Prescription x3
    • Protase (pancrelipase 280mg) 1# TIDCC
• 2023-06-06 SOAP Cardiology
  • Prescription x3
    • Plavix (clopidogrel 75mg) 1# QD
    • carvedilol 6.25mg 1# BID
    • Cabudan (captopril 25mg) 1# QD
    • Alpraline (alprazolam 0.5mg) 1# HS
• 2023-05-17 SOAP Gastroenterology
  • Prescription x3
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Genurso (ursodeoxycholic acid 100mg) 1# BID
    • BaoGan (silymarin 150mg) 1# TID
    • Dexilant (dexlansoprazole 60mg) 1# QD
• 2023-01-03 SOAP Hemato-Oncology
  • O:
    • Cancer Multidisciplinary Team Meeting Conclusion, meeting date: 20230103
      • Neoadjuvant C/T -> OP.
  • S
    • will give pre-Op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 12.
    • RTC 1 wk later on 20230109 for LFT & arrange adm for #1 pre-Op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 12.

[radiotherapy]

• 2023-01-27 ~ 2023-02-20 - 5040cGy/28 fractions (15 MV photon) to pancreatic tumor/LAPs

[chemotherapy]

• 2023-08-02

• 2023-07-11

• 2023-06-23 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 2800mg 3500mg NS 500mL 46hr (FOLFIRINOX, Iri 90%, 5FU 80%)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-05-31 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg NS 500mL 2hr + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 2800mg 4320mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-04-07 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 235mg NS 500mL 2hr + leucovorin 400mg/m2 625mg NS 500mL 2hr + fluorouracil 2800mg 4375mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-03-09 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 235mg NS 500mL 2hr + leucovorin 400mg/m2 625mg NS 500mL 2hr + fluorouracil 2800mg 4385mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• 2023-02-13 - fluorouracil 225mg/m2 340mg NS 500mL 24hr D1-5 (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

• 2023-02-06 - fluorouracil 225mg/m2 340mg NS 500mL 24hr D1-5 (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

==========

2023-08-04

All repeat prescriptions issued by our gastroenterologist on 2023-05-17, cardiologist on 2023-06-06, and general surgeon on 2023-07-25 have been consistently refilled. These medications have been added to the active medication list, and no reconciliation issues have been identified.

2023-06-26

• Based on the PharmaCloud database, it appears that our hospital has been exclusively providing all necessary medical services and medications for this patient in the past few months. As such, we’ve found no issues regarding medication reconciliation.

2023-03-10

• The 2023-03-09 lab results indicate elevated levels of AST, ALT, direct bilirubin readings, and hypoalbuminemia. Plasbumin (human albumin) and BaoGan (silymarin) have been prescribed properly.
• As this is the patient’s first time receiving FOLFIRINOX, he is are undergoing a modified regimen, which involves a lower dose of oxaliplatin (reduced from 85mg/m2 to 70mg/m2) and irinotecan (reduced from 180mg/m2 to 150mg/m2), and the 5-FU bolus dose is skipped, with the same dose added to the 5-FU infusion.
• The active prescription does not appear to be an issue.

2023-02-09

• Cancer Multispecialty Team Meeting on 2023-01-03 concluded: Neoadjuvant C/T (CCRT) then op. For the time being, the patient is receiving CCRT.
• There has been a weight loss of 3kg in the past month for the patient (54.4kg 2022-12-07 -> 51kg 2023-02-07). The addition of some appetizers, such as megestrol, might be beneficial.
• The patient has a history of DM. As all data points of fasting blood sugar level during this hospital stay exceeded 110 mg/dL, metformin 500mg BID could be added, since the patient’s renal function appears to be in good working order.
• Other underlying conditions caused by HBV and cardiovascular disease are managed with corresponding medications appropriately.

701168936

230804

[MedRec]

• 2023-07-11 ~ 2023-08-02 POMR Family Medicine
  • Discharge diagnosis
    • hepatocellular carcinoma, cT4N0M1 with multiple metastases on both lungs status post C1 selfpaid of Avastin plus Tecentriq on 2023/6/27
    • Type 2 diabetes mellitus without complications
  • CC
    • dyspnea with chest pain for two days.
  • Present illness
    • This 74 year old female has history of 1) Diabetes Mellitus 2) hepatocellular carcinoma, cT4N0M1 with multiple metastases on both lungs status post C1 selfpaid of Avastin plus Tecentriq on 2023/6/27
    • This time she had suffered from dyspnea with chest pain for two days.Therefore,she was brought to our ER for help. There were no fever,no abdominal pain or tarry stool. At ER, her vital sign was BP:181/104mmHg;HR:114bpm; BT:37.4 ℃; RR:28 bpm; SpO2:86%. Physical examination showed pitting edema 4+. Laboratory test revealed leukocytosis(WBC 10.1k/ul),elevated CRP level(14.4 mg/dL),hypoalbuminemia(2.9 g/dL ),hyperbililubinemia(2.25 mg/dL),hyponatriemia(122 mmol/L).Chest film disclosed Nodular lesions in both lung fields,lung metastasis.Empiric antibiotics with Brosym was prescribed.
    • Under the impression of hepatocellular carcinoma, cT4N0M1 with multiple metastases on both lungs status post C1 selfpaid of Avastin plus Tecentriq on 2023/6/27 with acute respiratory failure, she was admitted to our ward for further management
  • Course of inpatient treatment
    • After admission, selfpaid of Albumin 100mg QD with diuretic was prescribed from 7/12-. Methyprednisolone 40mg Q12H IVD for dyspnea relief. Empiric antibiotics with Brosym 4g Q12H from 7/11, blood culture was negative. Patient refused the NG tube insertion. Followed chest film on 7/13 disclosed multiple nodular opacity projecting in both lung that are c/w metastases. Desaturation was noted during Bipap used. Hospice was also consulted and DNR had signed after we explained the current condition, but not all of family agree hospice care and some families hesitated to continue active treatment. Thus, respiratory failure was noted under RT weaning as NRM or V-M, Finally, all family members agreed transfer to hospice ward on 2023/8/2.
    • After transferred to hospice ward, the patient showed drowsy consciousness with nearly air-huger breathing pattern, and we had informed the family on the patient’s clinical condition. The family had agreed on discontinuing IV fluid and adding PRN Morphine for the patient’s dyspnea. The patient’s condition continued downhill, and she expired at 17:46 on 2023-08-02.
• 2023-06-20 ~ 2023-06-30 POMR Hemato-Oncology
  • Discharge diagnosis
    • Malignant neoplasm of liver, primary, unspecified as to type, AFP positive hepatocellular carcinoma, stage IV
    • Secondary malignant neoplasm of unspecified lung. multiple lung metastases from AFP positive hepatocellular carcinoma
    • Type 2 diabetes mellitus without complications
  • CC
    • for CT guide biopsy
  • Present illness
    • This 74 y/o with underlying disease of type 2 DM was admitted for CT guide biopsy.
    • She was found to have multiple lung tumor with elevated AFP 1210 via CT at local clinic. She had Falling down injury over Rt shoulder. She had mild dyspnea after walking. Leg edema 2+ was noted. Lab data showed 2023/06/12 S-GOT/AST = 91 U/L; Bilirubin direct = 0.30 mg/dL; HGB = 9.4 g/dL.
    • Under the impression of multiple lung tumor with elevated AFP 1210 via CT, she was admitted to our ward for further treatment adn evaluation.
  • Course of inpatient treatment
    • After admission, CT-guide biopsy was done and revealed Consistent with metastatic hepatocellular carcinoma. ABD contrast CT showed HCC, cT4N0M1 with multiple metastases on both lungs. Pitting edema was noted, laxis 1# QD (06/23-27) was given > 1# BID (06/27- ). Heart echo was arranged. Heart echo: Preserved LV and RV systolic function. She started avastin (06/27)+ tecentriq (06/27).
    • On 06/28, we DC forxiga and pioglitazone on 06/28 for pitting edema.
    • Under stable condition, she was discharged with OPD follow up.
  • Discharge prescription
    • Apidra (insulin glulisine) 3 unit TIDAC
    • Tresiba FlexTouch (insulin degludec) 6 unit HS
    • Allegra (fexofenadine 60mg) 1# BID
    • Diovan (valsartan 160mg) 0.5# QD
    • Foliromin (ferrous sodium citrate 50mg) 1# QD
    • Januvia (sitagliptin 100mg) 1# QD
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H if pain
    • Ulstop (famotidine 20mg) 1# BID
    • Uretropic (furosemide 40mg) 0.5# QD hold if SBP < 120

700021224

230802

[exam findings]

• 2023-06-24 CT - abdomen
  • Indication: Combined hepatocellular and cholangiocarcinoma of the liver, s/p S2/3 hepatectomy (2021-08-18, NTUH), with left subhepatic region and retroperitoneum recurrence and lung metastasis, stage IV
  • With and without contrast enhancement CT of abdomen shows:
    • s/p left lobe hepatectomy. A cyst, 0.8cm, in S7 of liver.
    • Mild regression of nodules along celiac axis.
    • Regression of LUL nodule.
  • Impression
    • Hepatocellular and cholangiocarcinoma of liver, s/p operation
    • Lung metastsis, in regression
    • Retroperitoneal recurrence, mild in regression
• 2023-03-01 CT - chest
  • Indication: HCC with lung mets
  • Comparison was made with previous CT dated on 2022/11/05
    • Lungs: significant regression of a subsegmwental opacity at lingula as compared with previous CT. no nodule and minimal dependent atelectasis at LLL.
    • Pleura: minimal Lt-sided effusion.
    • Visible abdominal-pelvic contents:
      • mild dilatation of CHD and CBD
      • regression of presumbed metastatic LAP at retroperitoneum, around the pancreatic head.
      • wall thickening at antral part of stomach?.
      • Lt renal cyst measuring 1.5cm. unremarkable of both adrenal glands. diffuse wall thickening of the U-bladder.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • Lingular nodule, significant in regression.
    • retroperitoneal LAP, in regression. chronic cystitis.
• 2022-12-26 KUB
  • Spondylosis with scoliosis of the T-and L-spine with convex to right side.
  • Wedge deformity at left lateral aspect of T12 vertebral body is noted. Please correlate with clinical symptom and history.
  • S/P clips projecting at right lobe liver?
• 2022-11-10 CXR
  • A nodular opacity projecting in the left middle lung is noted that may be metastasis suspected. Please correlate with CT.
  • Wedge deformity at left lateral aspect of T12 vertebral body is noted. Please correlate with clinical condition.
• 2022-11-10 Patho - peritoneum biopsy
  • Lung, LUL, Ct-guide biopsy — poorly differentiated carcinoma, suggestive of metastatic hepatocellular carcinoma
  • Sections show sheets of pleomorphic tumor cells infiltrating in a fibrotic stroma with focal tumor necrosis.
  • The immunohistochemical stains reveal CK(focal +), CK7(focal +), CK20(-), a-fetoprotein(focal +), Hepatocyte(-), Arginase(-), TTF-1(-), p40(-), and CD56(-). The resitulin special stain reveals trabecular growth pattern. The results are suggestive of metastatic hepatocellular carcinoma. Please correlate with the clinical presentation.
• 2022-11-07 PET
  • Glucose hypermetabolic lesions in the gastrohepatic space, left subhepatic region, and right subhepatic region, highly suspected recurrent tumor with celiac chain lymph nodes metastases, suggesting biopsy for further investigation.
  • Glucose hypermetabolic lesions in the left upper lung with pleura involvement, highly suspected another primary or secondary lung cancer. Please correlate with the findings of pathological examination.
    
  • Glucose hypermetabolic lesions in bilateral pulmonary hilar and mediastinal regions, the nature is to be determined (cancer with regional or distant lymph nodes mets, reactive nodes or other nature ?), suggesting biopsy for investigation.
    
  • Increased FDG accumulation in the colon, probably physiological uptake of FDG.
    
  • Malignant neoplasm of liver s/p treatment with tumor recurrence in the gastrohepatic space, left subhepatic and right subhepatic regions; another primary or secondary lung cancer in the left upper lung, by this F-18-FDG PET/CT scan.
• 2022-11-05 CT - chest
  • History and indication: Malignant neoplasm of liver
  • With and without-contrast CT of chest revealed:
    • S/P liver and spleen operation. Soft tissue tumors (up to 4.4cm) at left subhepatic region and retroperitoneum. Right liver cyst (1.0cm).
    • A soft tissue nodule (2.3cm) at LUQ r/o accessory spleen.
    • A patchy density (2.7cm) at LUL. A tiny nodule (1.8cm) at LLL.
    • R/O left renal cyst (1.5cm).
  • IMP:
    • S/P liver and spleen operation. Soft tissue tumors (up to 4.4cm) at left subhepatic region and retroperitoneum.
    • A patchy density (2.7cm) at LUL. A tiny nodule (1.8cm) at LLL.
• 2021-03-25 ENT Hearing Test
  • PTA:
    • Reliability FAIR
    • Average R’t 81 dB HL; L’t 91 dB HL
    • R’t moderately severe to profound mixed type HL.
    • L’t severe to profound mixed type HL.
    • (masking dilemma)
  • Tymp: R’t type A; L’t type C.
  • ART: Bil ipsi absent. (contra line malfunctioned, test not done)
  • Functional gain
    • RE: 10-35 dB.
    • LE: 20-45 dB.

[MedRec]

• 2023-03-20 SOAP Hemato-Oncology
  • Owing to Leukopenia (WBC: 4890, seg:20, ANC:987) was notd and hold C/T on 3/20 23 .
• 2022-11-24 ~ 2022-11-27 POMR Hemato-Oncology
  • Discharge diagnosis
    • Liver cell carcinoma
    • hepatocellular carcinoma, stage IVB
    • viral hepatitis B of anti-Hbc positive
  • Prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC 7D
    • Promeran (metoclopramide 3.84mg) 1# TIDAC 7D
• 2022-11-21 SOAP Hemato-Oncology
  • S
    • explain to pt & his brother & sister about the indication & risk / benefit of palliative C/T wt FOLFOX4 plus Pembrolizumab (self paid) or Atezolizumab / Avastin ( self-paid).
      
    • Pt cannot afford expensive Atezo / Avastin, but accepted FOLFOX4 plus pembrolizumab (11/21 22).
    • will give FOLFOX4 plus Pembrolizumab IV Q2W x 4 then do chest CT for response evaluation (11/21 22).
    • Adm on 11/21 22 for #1 FOLFOX4 plus Pembrolizumab ( self-paid ) IV Q2W x 4.
• 2022-11-08 SOAP Hemato-Oncology
  • A
    • combined hepatocellular & cholangiocarcinoma s/p Op x 2 in 2018 & 2021 at NTUH, was noted to have recurrence in retroperitoneal lesion & lung mets.

[consultation]

• 2023-05-30 Dermatology
  • Q
    • for skin itchy, small bubble noted for one week.
    • This 69-year-old female, a pt of combined hepatocellular & cholangiocarcinoma s/p Op x 2 in 2018 & 2021 at NTUH, recurrence at lung mets & retroperitoneal LNs mets Dx in Nov 2022.
    • Today, he was admitted for #8 FOLFOX4 plus Pembrolizumab (self-paid) IV Q2W x 4 on 5/30 23. 
    • He complaints skin itchy, small bubble noted for one week, so we need your help for evaluation, thanks a lot!!
  • A
    • The patient had sufferred from dry scaling texture witherythematous papules on the trunk.
      
    • Under the impression of xerotic dermatitis. r/o follculitis development.
    • The following sugeetion:
      • First, use lotion broadly, then Mycomb cream 1 tube topical bid use for crust and itchy erythematous lesions.
      • consdier add Topysm cream 1 tube topical bid PRN use over residual itchy papules.

[chemoimmunotherapy]

• 2023-08-01 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-07-13 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-06-21 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 310mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 620mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 935mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-05-30 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 315mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 630mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 945mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-24 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-29 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-27 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4; reduced Oxa hereafter)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-08 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 85mg/m2 130mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-05 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 85mg/m2 130mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-15 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 85mg/m2 130mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-24 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4; reduced Oxa)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-05-31

• Pembrolizumab is associated with a variety of dermatologic toxicities. These can include immune-mediated rashes, severe conditions like Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN; some cases can be fatal), exfoliative dermatitis, and bullous pemphigoid. Among the spectrum of immune-related adverse events (irAEs) linked to pembrolizumab, skin-related effects like skin rash, pruritus, and vitiligo are the most common and typically occur earliest. However, rarer rashes such as lichenoid eruption (e.g., lichenoid dermatitis), psoriasis flare (e.g., plaque), and bullous disorders including bullous pemphigoid, SJS, and TEN warrant special attention due to their severity and potential life-threatening consequences.

• The exact mechanism underlying these skin-related side effects is not well-understood. It is thought to possibly involve the blockade of a common antigen present both on tumor cells and the dermo-epidermal junction, or other layers of the skin.

• The onset of these dermatologic toxicities can vary, but they often appear within the first 3 to 4 weeks of therapy and may affect patients with any type of tumor. They have also been reported to occur later in the course of treatment. The median time to onset for Sjogren syndrome-like symptoms is 70 days. For most patients, dermatologic toxicity is the first irAE experienced.

• Considering the first administration of pembrolizumab was on 2022-11-01, approximately six months ago, it would be worth considering whether the skin symptoms might have developed earlier in the treatment course. According to recent outpatient records, there have been no reports of skin-related adverse events. This might warrant further investigation.

• I visited the patient around 14:00 on 2023-05-31, the patient was with his wife by his side. It is confirmed that the skin symptoms appeared about a week ago, limited to the back near the waist, with a few scattered spots of broken skin due to scratching, which showed signs of subsiding after the use of dermatological medication. The patient believes it is caused by rubbing too hard during a bath, while his wife suspects it was caused by contact with moldy wood shavings when he was sawing wood. It was suggested that the skin symptom had little to do with pembrolizumab.

• In addition, a rash occurred during the 7th chemotherapy administration (started on 2023-04-24). It was treated with a reliever and by reducing the infusion rate. During this (8th) chemotherapy session, the infusion rate was reduced as soon as the patient felt itchy. No adverse skin reactions were observed during the visit, and the management was appropriate.

700128348

230802

[diagnosis]

• Malignant neoplasm of endometrium

[past history]

• Localized swelling, mass and lump, neck, pathology: metastatic endometrioid carcinoma,status post left selective neck dissection and left axillary mass excision on 2022/12/27
• Endometrial adenocarcinoma, Grade 2, stage pT1aN0M0, FIGO stage: IA, status post staging surgery on 2019-12-25 and postoperative radiotherapy, status post
• Gastric adenocacinoma, pT3N0M0, status post total gastrectomy with Roux-en-Y gastrojejunostomy in 2016/07 chemotherapy and immunotherapy at Far Eastern Memorial Hospital
• Insomnia
• Lumbar spine stenosis status post vertebroplasty

[allergy]

• NKDA     

[family history]

• There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

• 2023-02-24 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Compression fracture of L1 S/P vertebroplasty T12, L1, and L2.
• 2023-01-12 Gynecologic ultrasonography
  • Bilateral adnexae:free
  • ATH
  • IMP: No obvious uterine or ovarian lesion
• 2022-12-27 Patho - lymph node region resection
  • Diagnosis:
    • Lymph node, level II ＆ amp level, left selective neck dissection— metastatic endometrioid carcinoma ( 2 / 2 )
    • Lymph node, level Vb LAPs, left selective neck dissection— metastatic endometrioid carcinoma ( 1 / 1 )
    • Lymph node, supraclavicular fossa, left selective neck dissection— metastatic endometrioid carcinoma ( 1 / 2 )
    • Lymph node, axillary LAPs, excision— metastatic endometrioid carcinoma ( 1 / 5 )
    • AJCC 8th edition pathology stage: pM1; FGO stage IVB, C:supraclavicular fossa, D1-4:
  • Gross description:
    • The specimen submitted consists of 1 tissue fragment measuring 1.5x 1.3x 1 cm in size, fixed in formalin. Grossly, it is brownish and elastic.
    • The specimen submitted consists of 1 tissue fragment measuring 3.5x 2.5x 2cm in size, fixed in formalin. Grossly, it is brownish and elastic.
    • The specimen submitted consists of 1 tissue fragment measuring 1.5x 1x 1cm in size, fixed in formalin. Grossly, it is brownish and elastic.
    • The specimen submitted consists of 1 tissue fragment measuring 3.3x 2.5x 2cm in size, fixed in formalin. Grossly, it is brownish and elastic.
    • Sections are taken and labeled as: A:level II & amp level, B1-4:Vb LAPs, C:supraclavicular fossa, D1-4: axillary LAPs
  • Microscopic Description:
    • Lymph Nodes:
      • Level II & amp level: metastatic endometrioid carcinoma ( 2 / 2 )
      • Level Vb LAPs, left: metastatic endometrioid carcinoma ( 1 / 1 )
      • Supraclavicular fossa, left metastatic endometrioid carcinoma ( 1 / 2 )
      • Axillary LAPs, left — metastatic endometrioid carcinoma ( 1 / 5 )
    • Ancillary Studies: IHC stain — ER(+), vimentin (+), CD56(-), CDX-2(-), CK20(-).
• 2022-12-23 Whole body PET scan
  • Prominent glucose hypermetabolism in a left neck level II lymph node, a left neck level V lymph node, a left supraclavicular lymph node, a left infraclavicular lymph node and some left axillary lymph nodes. Multiple metastatic lymph nodes may show this picture.
  • Mild to moderate glucose hypermetabolism in some mediastinal lymph nodes and bilateral pulmonary hilar lymph nodes. Inflammatory process is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Increased FDG accumulation in the colon, bilateral kidneys and ureters. Physiological FDG accumulation may show this picture.
• 2022-12-13 CT - neck
  • One micro-lobulated mass lesion (2.8cm) over left supraclavicular fossa. Suggest tissue proof to rule out malignant node.
  • Another round node (7mm) over left level V of neck. Highly suspect malignant node.
• 2022-11-16 CT (Far Eastern Memorial Hospital)
  • Imp: bil lung tiny nodules, suspect peritoneal seeding
  • compared to previous 2022-07-29
    • Status post operation for endometrial cancer
    • Status post total gastrectomy with Roux-en-Y gastrojejunostomy for gastric adenocarcinoma (pathology: pT3N0). No obvious local recurrence
    • Status post left neck metastatic mass excision
    • Enlarged soft tissue mass at left axilla and left neck base, in favor of metastasis, decreased in size
    • Multiple tiny nodules in bilateral lungs, in favor of lung metastasis s/p treatment, decreased in number & size
    • Mild enlarged heart size
    • compatible with liver metastasis s/p treatment, with residual one in left hepatic lobe, decreased in number & size
    • Prominent right renal pelvis- Status post splenectomy
    • Unremarkable gall bladder, pancreas and adrenal glands
    • Mild mesentery fat stranding and suspected mesenteric nodule, peritoneal seeding can not be excluded, no significant interval change - Small lymph nodes at abdominal paraaortic region
    • Mild ascites in the pelvis
    • Status post vertebroplasty at T12
• 2020-12-02 CT - abdomen
  • History and Indication:
    • 2019-12-23 CT: Hydrometra with mural soft tissue nodule. R/O Endometrial cancer
    • 2019-12-25 Uterus endometrioid adenocarcinoma, Grade 2, pT1aNO, FIGO stage: IA
  • Findings:
    • S/P hysterectomy
    • S/P vertebroplasty of T12, L1, and L2 vertebral body.
    • S/P total gastrectomy and splenectomy.
    • There are several hepatic cysts in both lobes and the largest one is measured about 2.3 x 1.6 cm in size at S6.
    • Hyperplasia of left adrenal gland is noted.
  • Impression:
    • S/P hysterectomy.
    • There is no evidence of tumor recurrence.
• 2020-12-01 Patho - vaginal biopsy
  • Labeled as “vaginal stump”, biopsy — adenocarcinoma.
  • Section shows adenocarcinoma with papillary like structure, morphologically similar to focal areas of previous tumor (S2019-22417).
  • IHC stains: vimentin (+), WT-1 (-), p16 (+), ER: (+, strong intensity 100%), PR (+ intermedoate, intensity 70%),compatible with endometrial origin. CK20 (-): dis-favor gastrointestinal origin.
• 2019-12-25 Surgical pathology Level VI
  • Clinical diagnosis: Postmenopausal bleeding;
  • PATHOLOGIC DIAGNOSIS:
    • Uterus, endometrium, staging surgery — endometrioid adenocarcinoma, Grade 2 — pTNM: pT1aNO , FIGO stage: IA
    • Uterus, myometrium, staging surgery — involved by endometrioid adenocarcinoma (< 1/2 thickness) — adenomyosis
    • Uterus, cervix, staging surgery — negative for malignancy — free of lower cervical margin
    • Fallopian tube, right, staging surgery — negative for malignancy
      
    • Fallopian tube, left, staging surgery — negative for malignancy
      
    • Ovary, right, staging surgery — negative for malignancy
      
    • Ovary, left, staging surgery — negative for malignancy
    • Lymph node, left external iliac, dissection — negative for malignancy ( 0 / 4 )
    • Lymph node, left obturator, dissection — negative for malignancy ( 0 / 2 )
    • Lymph node, right external iliac, dissection — negative for malignancy ( 0 / 4 )
    • Lymph node, right obturator, dissection — negative for malignancy ( 0 / 3 )
    • Lymph node, left para-aortic, dissection — negative for malignancy ( 0 / 2 )
    • Lymph node, right para-aortic, dissection — negative for malignancy ( 0 / 7 )
    • Pathology stage:pTNM: pT1aNO, FIGO stage: IA
  • MICROSCOPIC EXAMINATION
    • Histology type: endometrioid adenocarcinoma
    • Histology grade: grade 2
      
    • Depth of invasion: Tumor invades less than one-half of myometrium (2 mm)
      
    • Lymphovascular invasion: absent
    • The cervical stroma involvement: absent
    • Resection margins of the cervix (or vagina): free (3.5 cm)
    • Additional pathologic findings:
      • Endometrial hyperplasia: present
      • (squamous) metaplasia: absent
      • adenomyosis: present
    • Bilateral adnexa: free of tumor
      
    • Lymph node metastasis
      • Group as specified No. Positive / No. Total
      • Left iliac ( 0 / 4 )
      • Left obturator ( 0 / 2 )
      • Right iliac ( 0 / 4 )
      • Right obturator ( 0 / 3 )
      • Left para-aortic ( 0 / 2 )
      • Right para-aortic ( 0 / 7 )
    • Immunohistochemical stain reveals CK7(+), PAX-5(-), CDX-2(-), vimentin(focal+), CK20(-).
• 2019-12-16 Gynecologic ultrasonography
  • IMP: Suspected endometrial hyperplasia (with Papillar)

[MedRec]

• 2022-12-30 MultiTeam - Social Services Referral
  • Referral Date: 2022-12-26
  • Reason for Referral: Others - Inpatient with a brief health scale score ≥ 10 points
  • Handling Status: Not opened for case management
  • Reason for Not Opening: Referral Reason: BSRS=10
    • The patient lives with her husband, who is the primary caregiver. They have three daughters and one son, all of whom are married. The family support system is still good, and there is sufficient financial support.
    • The patient was admitted for tumor resection surgery and experienced preoperative anxiety and difficulty falling asleep.
    • On 2022/12/27, a postoperative reassessment was conducted, and the BSRS score was 0.
    • If there are any further needs during the course of treatment, please do not hesitate to contact the social worker. Thank you!
  • Responder: Wu FangQian
  • Response Date: 2022-12-30
• 2022-12-29 MultiTeam - Psychological Oncology Referral
  • Referral Date: 2022-12-26
  • Reason for Referral: Others - Cancer inpatient with a brief health scale score ≥ 10 points
  • Conclusion:
    • (Summary) Visited on 12/28 with the patient’s husband accompanying. The patient expressed feeling anxious before the surgery, but now that the surgery is done, she feels settled. Before being hospitalized, she was still busy preparing Christmas gifts and had a total of twenty to thirty people, including her grandchildren. They played a game of picking gifts from a grid to find out what they got. Since childhood, she has been putting candy in stockings for the children, and they used to run a grocery store, making Christmas lively every year. She was admitted to the hospital the day after Christmas but didn’t let her son and daughter know in order not to worry them. Her son is in the engineering field, and she didn’t want to distract him. This hospitalization has been manageable because her husband is here, and they even brought the tea set from home to have afternoon tea together every day. “Being in her seventies, she is content and takes things lightly.”
    • (Objective) 7 years ago, she had gastric cancer surgery. In 2019 Dec, she had stage IA endometrial cancer, followed by IVRT post-surgery. In 2020 Dec, there was a recurrence, and she received treatment at another hospital. She has had a lump in her left neck and armpit for nearly a year, and recent biopsies confirmed malignancy. She underwent surgery on 12/27. Her BSRS score is 10 (moderate), and she has been intermittently visiting the Psychiatry Department since 2017 for panic disorder and mild depression.
    • (Intervention) Focus on post-surgery emotional status and family support.
    • (Action Plan) All presented aspects are positive, focusing on post-surgery and holiday matters. There was no mention of psychiatric symptoms or family conflicts. Continue monitoring based on the BSRS score. Counseling Psychologist Huang XiaoFang
  • Responder: Huang XiaoFang
  • Response Date: 2022-12-28 17:21
• 2017-01-17 SOAP Psychosomatic Medicine
  • S
    • come alone.
    • easily affect by noise. anxiety, rumination were told. education to use ear plug.
    • Whenever the patient’s husband coughs loudly at night, she becomes anxious and experiences chest tightness. It is advised to teach the patient to use earplugs.
    • Without taking medication, the patient easily becomes irritable and starts verbally abusing others.
    • The patient is constantly worried about the heavy dosage of her medications. She is afraid to take sleeping pills and keeps asking when she can stop taking the medications.
  • O
    • CGI: 3
    • Reeducative individual psychotherapy for drug information and compliance:
    • The patient has intermittent poor complaince because of overworring about drug adverse effect and addiction possibility. We educate the patient to understand the mechanism of drug effect and possible side effets. Also, we ensure that the medications are not addictive if taking it regularly everyday.
  • Diagnosis
    • Neurotic depression [F34.1]
    • Panic disorder [F41.0]
    • Nonorganic sleep disorder,unspecified [F51.9]
  • Prescription x3
    • Seroxat (paroxetine 12.5mg) 1# HS
    • Seroxat (paroxetine 12.5mg) 1# PRNHS
    • Eurodin (estazolam 2mg) 0.5# PRNHS

[consultation]

• 2023-02-23 General and Digestive Surgery
  • Q: this is a 71-year-old female with history of Endometrioid adenocarcinoma, Grade 2, of the uterine endometrium, stage pT1aN0(cM0) , FIGO stage: IA, s/p staging surgery (BSO + omentectomy + ATH + retroperitoneal lymphadenectomy), and s/p radiotherapy, with vaginal stump recurrence (2020-12), with multiple lymph nodes metastases, s/p operation (Selective neck dissection, left. Excision of left axillary conflulent LNs, left, 2022-12-27 ). The patient said ever received immunotherapy at Far Eastern Memorial Hospital. She was admitted for chemotherapy, so port-A is suggested.
  • A: we will arrange port-A implantation tomorrow

[surgical operation]

• 2022-12-27
  • Surgery
    • Selective neck dissection, left
    • Excision of left axillary conflulent LNs, left
  • Finding
    • Endometrial adenoca s/p OP in 2019 and RT
    • Gastric adenoca s/p total gastrectomy with Roux-en-Y gastrojejunostomy (pT3N0) later at Far Eastern Memorial Hospital
  • LN metastasis was suspected and told by GYN but Rx poor (chemotherapy and immunotherapy) Immunotherapy (NT 11W*4 times) at Far Eastern Memorial Hospital in vain (origin from which ca? no definite pathologic report)

[radiotherapy]

• 2023-02-22 ~ undergoing - 4000cGy/20 fractions of the left neck to left axilla area.
• 2020-01-30 ~ 2020-02-20 - 2800cGy/7 fractions via IVRT to vaginal cuff mucosa surface.

[chemoimmunotherapy]

• 2023-08-01 - paclitaxel 175mg/m2 200mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2023-05-30 - paclitaxel 175mg/m2 235mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2023-03-23 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2023-02-24 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL

==========

2023-08-02

This patient refilled Eurodin (estazolam) and Lexapro (escitalopram) on 2023-07-10 issued by our psychosomatic medicine department and these drugs have been included in the active medication list without a reconciliation issue found.

2023-03-24

• Laboratory results from 2023-03-24 showed that the patient’s liver and kidney function, albumin and electrolyte levels were grossly normal, with the exception of slightly lower blood cell counts. However, the levels are still within an acceptable range to continue chemotherapy.
• The patient was not found to need to reconcile her medications.

701139535

230802

[exam findings]

• 2023-05-18 CXR
  • Tortous aorta with calcification is noted.
  • s/p sternotomy with metalic wire fixation of the sternum.
  • s/p op. over right lung.
• 2023-05-04 ECG
  • Possible Left atrial enlargement
  • Inferior infarct, age undetermined
  • Nonspecific T wave abnormality
• 2023-04-24, -04-21 CXR
  • s/p right chest tube in place, its tip directed superiorly projecting over 3rd intercostal space
  • multifocal consolidation in Rt lung s/p wedge-resection at RUL and RLL
• 2023-04-24 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right, upper lobe, wedge resection — Adenocarcinoma x 2, metastatic, consistent with colorectal origin
    • Lymph node, right, group No.11, lymphadenectomy — Negative for malignancy (0/2)
  • MACROSCOPIC EXAMINATION:
    • Specimen: Lung, 2 pieces of wedge resection; specimen A1: size: 6.0 x 3.0 x 3.0 cm, 22 g; specimen A2: 5.5 x 4.5 x 3.0 cm, 19 g.
      • Lymph nodes, a bottle, group 11; maximal size: 1.3 x 0.7 cm
    • Tumor Site: Periphery
    • Tumor Size: specimen A1: Solitary: 1.7 x 1.5 x 1.5 cm; specimen A2: 1.8 x 1.6 x 1.5 cm
    • Gross tumor patterns: poorly defined
      
    • Tissue for sections:
      • A1: resection margin, specimen A1; A2: lung, non-tumor, specimen A1; A3-4: tumor, specimen A1; A5: resection margin, specimen A2; A6: lung, non-tumor, specimen A2; A7-8: tumor, specimen A2; B: lymph node, group 11.
  • Microscopic Description
    • Tumor Focality: Separate tumor nodules of same histopathologic type in same lobe
    • Histologic Type (select all that apply) : Metastatic adenocarcinoma with abundant extravasated mucin, mucinous adenocarcinoma is favored; The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-), The results are consistent with colorectal origin
      
    • Histologic Grade: G2: Moderately differentiated
    • Spread Through Air Spaces (STAS): Not identified
    • Visceral Pleura Invasion: Not identified
    • Lymphovascular Invasion (select all that apply): Present, Lymphatic
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): specimen A1: 0.3 cm; specimen A2: 0.3 cm
      • Specify closest margin: wedge resection margin
    • Regional Lymph Nodes: group 11: 0/2
    • Extranodal Extension: Not identified
    • Additional Pathologic Findings (select all that apply): None identified
• 2023-04-21 ECG
  • Sinus rhythm with occasional Premature ventricular complexes or aberrant conduction
  • Possible Left atrial enlargement
  • Inferior infarct , age undetermined
  • Abnormal ECG
• 2023-04-21 CXR
  • two nodular opacities (up to 20mm, lobular borders) over RUL
  • a tiny granuloma at lateral RLL
  • s/p prior median sternotomy with wires fixation s/p CABG
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
  • mild enlarged cardiac silhoutte due to dilated cardiac chamber (LVD) and prominent cardiophrenic angle mediastinal fat pad
  • Coronary arterial calcification (left circumflex artery, left anterior descending artery) indicating CAD
  • s/p prior median sternotomy with wires fixation
• 2023-03-23 CT - chest
  • Indication: for R’t lung nodules and sternum f/u
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Nodular lesions with central calcification scattered at both lungs up to 1.6cm is found at right upper lobe. Lung meta is considered first but other possibiity cannot be excluded.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • s/p sternotomy with metalic wire fixation of the sternum.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Polycystic change at both lobes of liver are found.
      • There is no ascites accumulation at abdominal cavity.
      • There is no evidence of destructive bone lesion.
  • Imp: Nodular lesions with central calcification at both lungs. Lung meta is favored. Suggest check tumor marker such as CEA or others.
• 2023-02-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (136 - 40.3) / 136 = 70.37%
    • M-mode (Teichholz) = 70.4
    • 2D (M-simpson) = 56.1
  • Conclusion:
    • Thickened AV with trivial AR
    • Calcification of posterior MV leaflet, mild MR
    • Concentric LVH, mildly dilated LV
    • Preserved LV and RV systolic function
    • Hypokinesia of basal to mid inferior wall
    • Mild PR, mild TR, normal IVC size
    • Dilated LA
• 2022-12-29 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • s/p sternotomy with metalic wire fixation of the sternum.
  • Nodular lesion at right upper lobe and right central lung field is found.
  • Clear bilateral costophrenic angle is noticed.
• 2022-12-29 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Inferior infarct, age undetermined
  • Abnormal ECG
• 2022-04-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (186 - 76) / 186 = 59.14%
    • 2D (M-simpson) = 59
  • Conclusion:
    • Dilated LA, LV
    • Adequate LV, RV systolic function with normal wall motion
    • Concentric LV hypertrophy, Impaired LV relaxation
    • Mild AR
    • Calcified aortic valve and mitral annulus, No significant AS, MS
• 2021-10-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (144 - 42) / 144 = 70.83%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Dilated LV with hypokinesia of inferior wall, posterior wall; preserved LV and RV systolic function.
    • Septal and RV hypertrophy with indeterminated LV filling pressure and impaired RV relaxation.
    • Aortic valve sclerosis with trivial AR; marked mitral annulus calcification with mild MR; mild PR.
    • Dilated aortic root and proximal ascending aorta (39mm) with prominent calcification.
    • Minimal pericardial effusion (< 50ml); some R’t pleural effusion.
• 2021-09-24 CT - chest
  • Indication: CAD 3VD for CABG preoperative evaluation
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Calcified coronary arteries is found.
      • Mild pericardial effusion is found.
      • Tiny nodualr lesion at right upper lobe up to 0.3cm, and 0.17cm, left upper lobe about 0.24cm is found.
      • Several calcified dots at both lungs is found.
      • Minimal atelectatic change over left lower lung is found.
    • Visible abdomen:
      • s/p LAR.
      • Diffuse cystic change at liver and both kidneys are found. Polycystic kidney is considered.
      • The spleen, pancreas, both adrenals are intact.
  • Imp:
    • Nodular lesions at right upper lobe and left upper lobe, please exclude the possiblity of lung meta.
    • Polycystic liver and kidneys.
    • Calcified coronary arteries is found.
• 2021-09-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (142 - 88) / 142 = 38.03%
    • M-mode (Teichholz) = 37
    • 2D (M-simpson) = 30
  • Conclusion:
    • Dilated LA and LV; moderate to severely abnormal LV systolic function with inferoposterior wall hypokinesia
    • Septal hypertrophy
    • Mild MR, mild AR and trivial TR
    • Moderate pericardiac effusion without cardiac tamponade sign
    • Preserved RV systolic function
• 2021-09-22 Cardiac Catheterization
  • Exam: CATH
    
  • Diagnosis: MI, CAD with TVD
  • Past Medical History
    • The patient has a history of ESRD under H/D and Hypertension.
  • Indication
    • The patient was referred with NSTEMI. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
  • Approach
    • Percutaneous access was performed through the right radial artery where a 6F sheath was inserted.
  • Catheters
    • Left coronary angiography was performed using 6Fr JL3.5 catheter and right coronary angiography was performed using 6Fr JR4 catheter.
  • Procedure
    • Percutaneous 18020A-Cath one side
    • Percutaneous 18022A-CAG
    • Percutaneous 33076A-PTCA 1 Vessel
    • The patient was taken to the cardiac catheterization laboratory. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 120cc. The patient was treated with Heparin (Dosage=7000) and NTG (Dosage=200).
  • Activated Clotting Time and BP
    • The measurement data of ACT was 257 S (ACT 1).
  • Finding Summary
    • LAD-D2 : 90-99 % stenosis, Type: C, TIMI: (1)
    • Syntax Score = 32.5
    • Suggest OP : Wait discussion stage PCI or CABG
    • Euro Score = 9.52%
    • In conclusion : CAD with TVD
    • Recommendation : PCI for DB2 for possible thombotic occlusion
    • Left Main :
      • Calcification
    • Left Anterior Descending :
      • Calcification, proximal part 70-80% stenosis, distal part 60-70% stenosis; DB1 90-99% stenosis, DB2 haziness with TIMI 1 flow (thrombus?)
    • Left Circumflex :
      • Calcification, middle part CTO with collaterals from bridging collaterals
    • Right Coronary :
      • Calcification, middle part 70-80% stenosis, distal part 80-90% stenosis with collaterals from LCA
  • Intervention Summary
    • LAD-D1
    • MLD/RVD=0/2.5 mm
      
    • Guiding catheter: Medtronic Luncher 6F EBU3.5.
    • Guide Wire: Asahi Fielder FC wire.
    • Balloon: OrbusNeich Sapphine. 1.0 X 10 mm. Pressure: 10-16 atmospheres. Note: ruptured at 16 atm.
    • A workhorse soft-tip wire could not cross the DB2 lesion, which suggested it as a chronic obstruction. A 1.0mm SC balloon was tried to dilate the proximal part of DB2 but failed.
    • In conclusion : CAD with TVD
    • Recommendation : CABG first, or PCI/medical therapy if the patient refused the surgery.
• 2018-08-06 SONO - hepatobiliary
  • Sonography of hepatobiliary system revealed:
    • Diffuse anechoic nodules in the liver and bilateral kidneys, r/o polycystic renal and liver disease.
      
    • Normal appearance of gall bladder without stone.
    • Patency of PV, HVs, IVC and aorta in hepatic portion.
  • Impression:
    • Diffuse anechoic nodules in the liver and both kidneys, r/o polycystic renal and liver disease.

[MedRec]

• 2023-05-16 SOAP Hemato-Oncology
  • S
    • Metaastatic adenocarcinoma over right upper lobe, status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21.
    • Multiple lung nodules status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21
    • End stage renal disease
    • 2023-05-16 adenocarcinoma of rectum with multiple lung mets
    • explain the clinical utcome to patient and her daugther. suggest C/T with FOLFIRI. apply Avastin

[consultation]

• 2023-08-01 Nephrology
  • Q
    • The patient is a 68 y/o male with the history of Polycystic kidney under HD QW135 for 9+ years, Hypertension for 9 years ago, Colon cancer s/p operation for 4 year at NTUH. Hyperlipidemia, Non-ST elevation myocardial infarction, 3-vessel disease, post coronary artery bypass graft s/p CABG x 4 in 2021/10/29, Metastatic adenocarcinoma over right upper lobe, status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21 and Multiple lung nodules status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21. The RUL lung wedge resection pathology showed adenocarcinoma x 2, metastatic, consistent with colorectal origin. The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-).
    • This time, he was admitted to our ward for chemotherapy. We need your expertise to arrange hemodialysis. Thanks a lot!
  • A
    • We will arrange hemodialysis QW135 for the patient during the course of hospitalization.
    • Please prescribe EPO 5000 IU QW if Hb < 11.

[immunochemotherapy]

• 2023-08-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 2300mg NS 500mL 46hr (FOLFIRI 70% x 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-07-11 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2300mg NS 500mL 46hr (FOLFIRI 70% x 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-06-23 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2500mg NS 500mL 46hr (FOLFIRI 30% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
• 2023-05-25 - bevacizumab 5mg/kg 200mg NS 100mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-05-24 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2500mg NS 500mL 46hr (FOLFIRI 30% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg SC + NS 250mL

==========

2023-08-02

• The patient recently obtained a 28-day supply of hydralazine on 2023-07-31. In stead of hydralazine, the active medication list includes carvedilol and Caduet (amlodipine, atorvastatin), no reconciliation issues found with these medications.

[hemodialysis]

• Hemodialysis QW135 is arranged for the patient during the course of hospitalization on 2023-08-01 by our nephrologist and EPO 5000 IU QW is suggested if Hb < 11.

• It is advisable to administer Vemlidy (tenofovir alafenamide) and famotidine after the dialysis session has been completed.

[hypertension]

Despite the patient’s current medication regimen of beta-blocker carvedilol and calcium channel blocker amlodipine, the hypertension readings remain elevated. Therefore, it may be worth considering the addition of an angiotensin-receptor blocker, such as valsartan, to better manage the patient’s hypertension.

2023-06-26

• Given that the patient is regularly receiving recombinant epoetin beta 2000IU every two or three days at a local clinic, it is likely that these treatments align with the dialysis schedule for his ESRD. Therefore, if the duration of hospital stay is anticipated to exceed the usual interval between dialysis sessions, there might be a need to arrange for in-hospital dialysis. Additionally, the administration of recombinant epoetin beta would need to be organized in accordance with this plan.
• If Vemlidy (tenofovir alafenamide) is to be given on the same day as dialysis, it should be given after the dialysis is completed.

2023-05-25

• The patient is currently taking Vemlidy (tenofovir alafenamide 25mg) once daily for his HBV condition. For patients undergoing intermittent hemodialysis (thrice weekly), Vemlidy does not require dosage adjustment. If the dose is scheduled on a dialysis day, it should be administered after the dialysis.

• If the treatment is switched to Baraclude (entecavir), dosage adjustments are needed for patients on intermittent hemodialysis (thrice weekly). Although entecavir is not significantly dialyzed (13%), it is recommended to administer 10% of the usual indication-specific dose daily. Alternatively, the usual indication-specific dose can be administered every 7 days. Similar to Vemlidy, if the dose falls on a dialysis day, it should be administered after hemodialysis.

• There appears to be no issue with the current anti-HBV medication listed in the active prescription for the patient.

• For patients on intermittent hemodialysis (thrice weekly), the dosage adjustments for famotidine are as follows: If the usual dose is 10 mg twice daily, use 10 mg every other day; if the usual dose is 20 mg once daily, use 10 mg every other day; and if the usual dose is 20 mg twice daily, use 10 mg once daily or 20 mg every other day. No supplemental dose is necessary, and it should be administered after hemodialysis on dialysis days.

• The current prescription of Ulstop (famotidine) at 10mg QD appears to be appropriate and doesn’t pose any issues.

2023-05-24

• According to the PharmaCloud database, it appears that the patient regularly visits a local physician (LMD) to refill his prescription for epoetin beta for anemia associated with end-stage renal disease (ESRD). However, this medication is not currently on the patient’s active medication list in our records. Therefore, it would be prudent to verify the patient’s continued use of epoetin beta and consider adding it to the active medication list to ensure proper medication reconciliation.

• It is about to apply the FOLFIRI plus Avastin to the patient on hemodialysis.

  • In patients with renal impairment and a glomerular filtration rate (GFR) less than 10 mL/minute, it is recommended to start irinotecan therapy at 50% to 66% of the initial dose and increase the dose if well tolerated. However, caution should be exercised in patients with impaired renal function.
  • In patients on hemodialysis, irinotecan may be started at 50% to 66% of the initial dose and increased if tolerated, although this is not usually recommended by the manufacturer. Alternatively, the weekly dose could be reduced from 125 mg/m2 to 50 mg/m2 and administered either after hemodialysis or on nondialysis days. This approach allows for better control of potential accumulation of the drug in the body due to impaired renal function.

• Fluorouracil is typically administered at a standard dose to patients undergoing hemodialysis without the need for dose adjustment. However, it is generally given after the hemodialysis session on dialysis days to prevent potential drug removal during the procedure.

• This patient also has coronary artery disease 3-vessel disease status post coronary artery bypass graft on 2021-10-29. Fluorouracil has been associated with cardiotoxicity, as reported in postmarketing studies. Manifestations of cardiotoxicity may include angina, myocardial infarction/ischemia, arrhythmia, and heart failure. The risk factors for this toxicity include continuous infusion administration (as opposed to intravenous bolus) and pre-existing coronary artery disease. The American Heart Association recognizes fluorouracil as an agent that may cause reversible direct myocardial toxicity or exacerbate underlying myocardial dysfunction. Therefore, if a patient has previously experienced cardiotoxicity related to fluorouracil, the risks of resuming treatment with this drug have not been well established and must be carefully weighed against the potential benefits. Given these risks, it is recommended to monitor the patient’s cardiovascular status closely during the course of treatment with fluorouracil.

• As with bevacizumab, no dose adjustment is required for any degree of renal impairment. However, cardiovascular toxicity, GI toxicity (perforation or fistula), thromboembolic events should be observed.

700610703

230801

==========

2023-08-01

[fluconazole dosing for HD patients]

For patients undergoing intermittent (thrice weekly) hemodialysis, whether intravenous or oral fluconazole is used, the dosing should be administered three times a week after each dialysis session. No dosage adjustment is required for indication-specific loading/initial or maintenance doses recommended in the adult dosing section. However, it is important to administer maintenance doses only three times per week on dialysis days after the dialysis session.

701453309

230801

[lab data]

• 2023-01-27 HBsAg(nuclear medicine) Negative
  
• 2023-01-27 HBsAg Value(nuclear medicine) 0.395
  
• 2022-10-07 Anti-HBc Reactive
  
• 2022-10-07 Anti-HBc-Value 4.33 S/CO
  
• 2022-10-07 Anti-HBs 66.52 mIU/mL
  
• 2022-10-07 HBsAg(quantitative) Nonreactive
  
• 2022-10-07 HBsAg Value(quantitative) 0.00 IU/mL
  
• 2022-10-07 Anti-HCV Nonreactive
  
• 2022-10-07 Anti-HCV Value 0.09 S/CO
  
• 2022-10-04 HBsAg(nuclear medicine) Negative
  
• 2022-10-04 HBsAg Value(nuclear medicine) 0.415

[exam findings]

• 2023-05-05 CT - abdomen
  • History: Bloody stool passage
    • 20220929 Low rectal cancer at right lateral from dentate line up to 4 cm above dentate line, T3N1aM1a, STAGE: IVA s/p chemoradiotherapy from 2022/10/17 to 2022/11/23
  • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
  • Findings: Comparison: prior CT dated 2022/09/30.
    • Prior CT identified two metastatic nodes in right internal iliac chain are noted again, stationary.
      • Prior CT identified one metastatic node in left posterior perirectal space is noted again, marked decreasing in size.
    • Prior CT identified wall thickening at right lateral aspect of the rectum is noted again, stationary.
    • Multiple gallstones are noted.
    • S/P hysterectomy.
  • IMP:
    • Prior CT identified two metastatic nodes in right internal iliac chain are noted again, stationary.
    • Prior CT identified one metastatic node in left posterior perirectal space is noted again, marked decreasing in size.
• 2023-02-02 Colonoscopy
  • Rectal cancer s/p CCRT
  • Significant tumor regression
• 2023-02-02 MRI - pelvis
  • Indication: Adenocarcinoma of low rectal with right interal iliac LNs metastasis, cT3N1aM1a, stage IVA s/p chemoradiotherapy from 2022/10/17 to 2022/11/23 (R/T from 2022/10/17 to 2022/11/23 to the pelvis for 45 Gy/ 25 fr, The rectal tumor and LAPs for 48.6 Gy/ 27 fr)
  • Findings: Comparison: prior CT dated 2022/09/30.
    • Prior CT identified two metastatic nodes in right interal iliac chain and one metastatic node in left posterior perirectal space are noted again, stationary.
    • Prior CT identified wall thickening at right lateral aspect of the rectum is noted again, stationary.
• 2023-01-26 CT - abdomen
  • History and indication: low rectal cancer
  • IMP: Mild regression of rectal cancer and metastatic LAP.
• 2023-01-26 CXR
  • Clear both lung field.
• 2022-10-14 CXR
  • Solitary pulmonary nodule at RLL.
• 2022-09-30 CT - abdomen
  • History: Bloody stool passage
    • 20220929 Low rectal cancer at right lateral from dentate line up to 4 cm above dentate line
  • Findings:
    • There is wall thickening at right lateral aspect of the low rectum, measuring 1.5 cm in wall thickness that is c/w adenocarcinoma (T3).
      • In addition, There is a lymph node measuring 1 cm in left lateral posterior aspect of the perirectal space that is c/w metastatic node (N1a).
      • There are two enlarged nodes 0.7 cm and 1.1 cm in right interal iliac chain that may be non-regional nodal metastases (M1a).
      • Please correlate with MRI.
    • Multiple gallstones are noted.
    • S/P hysterectomy.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3 (T_value) N:N1a (N_value) M:M1a (M_value) STAGE:IVA(Stage_value)
• 2022-09-30 Patho - colorectal polyp
  • Low rectal tumor, biopsy — Adenocarcinoma
  • Microscopically, the sections show a picture of adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with desmoplasia and focal necrosis.
  • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
• 2022-09-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (85.8 - 22.1) / 85.8 = 74.24%
    • M-mode (Teichholz) = 74
  • Normal chamber size
  • Adequate LV and RV systolic function
  • Mild to moderate MR, mild TR and PR , trivial AR
  • No regional wall motion abnormalities

[MedRec]

• 2023-04-06 SOAP Colorectal Surgery
  • A
    • The patient request NO surgery and keep follow up due to very old age
• 2023-02-09 SOAP Colorectal Surgery
  • A
    • RT finished on 2022-11-23
    • Much regression of the tumor and suggest keep chemotherapy for disease control
    • Althogh the tumor is smaller but still fixed with the sphincter, Surgery may assosciated with a permanent colostomy, palliative CCRT and observation is another good choice for this patient.
• 2023-01-19 SOAP Hemato-Oncology
  • Re-evaluation by 2023-01-26, OP in 2023-02
• 2022-12-08 SOAP Hemato-Oncology
  • A/P: Consider FOLFOX (Minor) or biweekly HDFL (Major)
• 2022-11-04 SOAP Radiation Oncology
  • Suggest CCRT then re-evaluation the cancer
  • Refer to GS for Port-A insertion
  • Arrange admission for CCRT with 5-FU on 2022-10-17
  • Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx.
• 2022-10-06 SOAP Hemato-Oncology
  • A/P
    • Suggest CCRT then re-evaluation the cancer
      • Refer to GS for Port-A insertion
      • Arrange admission for CCRT with 5-FU on 2022-10-17

[chemoimmunotherapy]

• 2023-07-31 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-28 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-31 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-05 - (FOLFOX)
• 2023-04-14 - (FOLFOX)
• 2023-03-20 - (FOLFOX)
• 2023-03-01 - (FOLFOX)
• 2023-01-30 - oxaliplatin 75mg/m2 115mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg/m2 3500mg 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3
• 2022-12-30 - oxaliplatin 75mg/m2 115mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg/m2 3500mg 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3
• 2022-12-15 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg/m2 3500mg 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3
• 2022-11-11 - fluorouracil 225mg/m2 340mg 10min D1-D5 (CCRT)
  • dexamethasone 4mg D1-5
• 2022-10-20 - fluorouracil 225mg/m2 340mg 10min D1-D5 (CCRT)
  • dexamethasone 4mg D1-5

==========

2023-08-01

The patient recently renewed her repeat prescription for Diovan (valsartan) to manage her primary hypertension at a local pharmacy on 2023-07-19. This medication is currently listed in the active formulary, and no reconciliation issues have been identified.

The most recent medical image was scaned on 2023-05-05 (abdomen CT). An update may be beneficial to reassess the current disease status.

2023-06-29

• The patient regularly refills her prescription for Diovan (valsartan) for primary hypertension at a local pharmacy. This medication was accurately added to the active formulary and no reconciliation issues were identified.
• It’s worth noting that the patient had prescriptions filled for respiratory medications for COVID-19, acute nasopharyngitis, and acute bronchitis on 2023-06-06, 2023-06-15, and 2023-06-21, respectively. These prescriptions were for short-term use and are no longer valid. Please continue to monitor for persistent respiratory symptoms.

2023-06-01

• The patient consistently renews her Diovan (valsartan) prescription for her primary hypertension at a neighborhood pharmacy. This medication has been correctly added to the active medication list and there were no conflicts discovered during the medication reconciliation procedure.

2023-01-31

• CT 2023-01-26 showed partial response.
• The HBsAg retest result for 2023-01-27 was still negative after a period of approximately three months.

2022-11-14

• Since late Sep 2022, all four serum bilirubin data points (direct and total) have exceeded the upper limit of normal range, and there were multiple gallstones being found on CT in September 2022. When there is no longer a concern about diarrhea, Dicetel (pinaverium bromide 100mg 1# BID) may provide relief from symptoms associated with functional disorders of the biliary tract.
• The patient has one bowel movement a day, blood pressure within acceptable ranges, and the underlying conditions remain stable.
• The active prescription is not subject to any issues.

700052492

230731

[exam findings]

• 2023-07-11 Nasopharyngoscopy
  • much saliva over right pyriform sinus. invisible vocal cord
• 2023-05-12 MRI - brachial plexus
  • Indication: right upper limb weakness
  • Without- and with-contrast MRI of brachial plexuses, focusing on right side, with axial, sagittal and coronal T1WI and T2WI using 3 mm - 5 mm thickness reveal:
    • Severe progressive enlargement of the enhancing soft tissue mass at right lower neck, involving carotid space, paravertebral space (C4-T1 levels), and extending along brachial plexus, as compared with MRI on 20221214. Progressive recurrence is considered.
    • S/P disc prosthesis at C3-4-5-6-7.
    • No enlarged lymph node.
    • Scoliosis of C-spine.
  • IMP: C/W Tumor recurrence at right lower neck, involving carotid and paravertebral space and brachial plexus. Severe progression as compared with MRI on 20221214.
• 2023-03-29 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in bilateral rib cages, lower C-spine, lower L-spine, bilateral shoulders, right femoral shaft, D/3, and left knee.
• 2023-03-14 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right, middle lobe, wedge resection —- Metastatic squamous cell carcinoma
    • Lymph node, right, group No.7, lymphadenectomy —- Negative for malignancy (0/16)
    • Pleura, right, excision —- Metastatic squamous cell carcinoma
  • MACROSCOPIC EXAMINATION:
    • Specimen: Lung, size: 6.0 x 3.2 x 2.4 cm, 14 g
      • Lymph nodes, a bottle, group 7, maximal size: 1.3 x 0.7 cm
    • Tumor Site: Periphery
    • Tumor Size: Solitary: 3.0 x 2.7 x 1.8 cm
    • Gross tumor patterns: poorly defined, Pleural retraction
    • A piece of pleural nodule, measuring 1.0 x 1.0 x 0.5 cm, is received
    • Tissue for sections: A1: resection margin; A2: lung; A3-5: tumor; B: lymph node, group 7; C: pleural nodule.
  • Microscopic Description
    • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes
    • Histologic Type (select all that apply): Consistent with metastatic squamous cell carcinoma, keratinizing
      
    • Histologic Grade: G2: Moderately differentiated
    • Spread Through Air Spaces (STAS): Not identified
    • Visceral Pleura Invasion: Present (PL1)
    • Lymphovascular Invasion (select all that apply): Present, Lymphatic, Arterial, Venous
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 0.3 cm
      • Specify closest margin: resection margin
    • Treatment Effect: No known presurgical therapy
    • Regional Lymph Nodes: group 7: 0/16
    • Extranodal Extension: Not identified
    • Additional Pathologic Findings: The pleural nodule reveals metastatic squamous cell carcinoma.
• 2023-03-14 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right, upper lobe, wedge resection — Metastatic squamous cell carcinoma,
  • MACROSCOPIC EXAMINATION:
    • Specimen: Lung, size: 6.0 x 5.8 x 3.0 cm, 38 g
    • Tumor Site: Periphery
    • Tumor Size: Solitary: 2.2 x 2.0 x 1.5 cm
    • Gross tumor patterns: poorly defined
      
    • Several pleural fibrotic nodules, measuring up to 0.5 x 0.4 x 0.2 cm, are seen.
    • Tissue for sections: A1: resection margin; A2: lung; A3: bronchus; A4-6: tumor; A7: pleural fibrosis.
  • Microscopic Description
    • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes
    • Histologic Type (select all that apply): Consistent with metastatic squamous cell carcinoma, keratinizing
      
    • Histologic Grade: G2: Moderately differentiated
    • Spread Through Air Spaces (STAS): Not identified
    • Visceral Pleura Invasion: Not identified
    • Lymphovascular Invasion (select all that apply): Not identified
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 0.3 cm
      • Specify closest margin: resection margin
    • Treatment Effect: No known presurgical therapy
    • Additional Pathologic Findings: Several pleural fibrotic nodules are seen.
• 2022-07-19 MRI - larynx
  • The current study was compared to the prior one obtained on 2021/08/23.
  • Progressive effacement of right pyriform sinus with mucosal thickening. Suggest clinical correlation and tissue proof.
  • Diffuse softt issue swelling at AE folds and retropharyngeal wall.
  • Paranasal sinusitis.
• 2022-05-17 Tc-99m MDP bone scan
  • In comparison with the previous study on 2020/7/31, the lesions in the lower C-spine and L4-5 spines are a little more evident. The nature is to be determined (degenerative change in a little more severe status? other nature?). Please correlate with other imaging modalities for further evaluation.
  • Some new faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders and left knee. Benign joint lesions such as arthritis are more likely.
• 2022-02-22 Patho - lymph node region resection
  • PATHOLOGIC DIAGNOSIS
    • Lymph nodes, level III-IV, right, neck LN dissection — Metastatic squamous cell carcinoma (1/7)
    • Lymph nodes, level II, right, neck LN dissection — Negative for malignancy (0/4)
    • Soft tissue, level IV, biopsy for frozen section — Metastatic squamous cell carcinoma
  • MACROSCOPIC EXAMINATION
    • Surgical Procedure(s): Right neck LN dissection
    • Specimen Type: Right neck lymph node dissection, including level II and level III-IV
      • Representative parts ae taken for section as: S2022-02835A= level II lymph nodes, B1-B2= level III-IV lymph nodes.
    • Specimen received for frozen section: two pieces of pink gray soft tissue, labeled level IV, measuring up to 0.9 x 0.5 x 0.3 cm. All for section as: F2022-00064.
  • MICROSCOPIC EXAMINATION
    • Number of lymph nodes involved: 1 (level III-IV)
    • Number of lymph nodes examined: 4 (level II), 7 (level III-IV)
    • Size of largest metastatic deposit: 2.2 cm
    • Extranodal extension: Present
    • The sections of frozen section specimen also show metastatic squamous cell carcinoma (not identified in frozen section slide), composed a few neoplastic cells in fibrous stroma. No lymphoid tissue can be found.
    • IHC, the neoplastic cells reveal: CK(+) and P40(+).
• 2021-03-09 MRI - larynx
  • Intervally increased soft tissue in the supraglottic, post-cricoid region, combined with edema likely
  • Severe narrowed supaglottic airway.
• 2020-07-31 Patho - larynx biopsy
  • Labeled as “postcricoid tumor”, biopsy — squamous cell carcinoma.
    
  • IHC stains: p16 (-), p40 (+).

[MedRec]

• 2020-07-29 ~ 2020-07-31 POMR Ear Nose Throat
  • Discharge diagnosis
    • C13.0 Post-cricoid tumor, suspect malignant status post laryngomicrosurgery and esophagoscopy on 2020-07-31
    • Gastro-esophageal reflux disease with esophagitis, LA Classification grade A
    • Essential (primary) hypertension
    • Carrier of viral hepatitis B
  • CC
    • Sorethroat and cough for 1 year
  • Present illness
    • This 48-year-old man is a hepatitis B carrier who has history of GERD and hypertension without medication control. He has smoking for 30 years with alcohol drinking. He suffered from sorethroat and cough for 1 year. Regurgitation was also complained. He treated at local clinic but in vain. He then visited our ENT OPD for help. At OPD, fiberscope found post-cricoid tumor. Under the suspect of malignancy, we suggest him admission for tumor survey and LMS biopsy.
  • Course of inpatient treatment
    • After admission, tumor survey were arranged. MRI was done on 7/29 which revealed submucosal tumor at posterior hypopharyneal wall. D/D: inflammatory/infectious mass, malignancy. UGI/PES was done on 7/30 which revealed erosive esophagitis LA Classification grade A. The patient underwent larygomicrosurgery and esophagoscopy on 2020/7/31. Post-operation, there was no active oral bleeding but throat pain with cough were noted. Clindamycin and paran were added for symptoms relief. Bone scan was done on 7/31 which revealed no strong evidence of bone metastasis. Under relatviely stable condition, the patient was discharged with medication and OPD follow-up. 
  • Discharge prescription
    • Lindacin (clindamycin 150mg) 2# QID
    • Lactam (acetaminophen 500mg) 1# QID
    • Nexium (esomeprazole 40mg) 1# QDAC

[surgical operation]

• 2023-03-13
  • Surgery
    • VATS RUL and RML wedge + LN sampling.
  • Finding
    • One tumor was noted over the apex of RUL, another nodular lesion was noted over RML, size about 2.0cm in diameter.
    • One 24 Fr. straight chest tube was inserted via right 8th ICS.

[chemotherapy]

• 2023-07-03 - (PF, Q4W)

• 2023-06-05

• 2023-05-08

• 2023-04-09

• 2022-04-26 - (cisplatin, QW)

• 2022-04-19

• 2022-04-12

• 2022-04-08

• 2022-03-29

• 2022-03-22

• 2020-10-20 - (cisplatin, QW)

• 2020-10-13

• 2020-10-06

• 2020-09-29

• 2020-09-22

• 2020-09-15

==========

2023-07-31

The patient just refilled Ultracet (tramadol, acetaminophen) and Lyrica (pregabalin) for his aalignant neoplasm of hypopharynx at a local pharmacy on 2023-07-27. In current active medication list, there were Tramacet, Lyrica and Durogesic (fentanyl) prescribed, no reconciliation issues identified.

700308626

230731

[exam findings]

• 2023-07-29 CT - abdomen
  • Clinical history: 59 y/o female patient with RLQ (VAS 4-7). Hx of samll intestine GIST with liver and spleen metastasis.
  • With and without contrast enhancement CT of abdomen–whole:
    • Mutiple low density liver tumors in both lobes of liver(up to 2.5cm), r/o liver metastasis.
    • Multiple soft tissue tumors (up to 11.4cm) in right subphrenic region and right lower abdomen, r/o metastasis.
    • R/O tumor invasion of right kidney.
    • Unremarkable change of the spleen, pancreas and left kidney.
    • No enlarged lymph node in the paraaortic region.
    • Presence of ascites.
  • Impression:
    • Clnical history of small bowel GIST.
    • Liver metastasis, multiple peritoneal metastasis (mainly in right) and ascites, with invasion of right kidney.
• 2019-01-30 SONO - abdomen
  • CC: right upper to middle abdominal pain
  • Findings
    • Liver: The liver parenchyma is homogenous. A heterogenous mixed echoic lesion with hypoechoic rim: size 4.7cm, at right lobe: metastatic tumor or primary liver tumor both considered.
    • Gallbladder and bile ducts: some gallstones: size up to 0.6-0.7cm
    • Others: a mixed echoic lesion in right abdomen, adjacent to right kidney and liver, size about 6.3cm
  • Diagnosis
    • liver tumor: cause to be considered
    • gallstones
    • suspect intra-abdominal tumor or focal inflammation in right abdomen
  • Suggestion
    • suggest admission for treatment and emergent CT scan: but patient hesitated: she requested for the second opinion at TMUH, suggest go to ER of TMUH, suggest her go to ER directly because of acute abdominal pain
• 2018-09-19 Mammography
  • Screening Digital mammography of both breasts with MLO and CC views:
  • Old mammographic study: 2012-7-17 (BIRADS 0)
    • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
    • There are benign calcifications in bilateral breasts.
    • Bilateral axillary lymph nodes.
  • Impression: Dense breast.
    • Benign calcifications in bilateral breasts.
  • BI-RADS: Category 2

[MedRec]

• 2023-07-18 SOAP Hemato-Oncology Xia HeXiong
  • S
    • Hx of Jejunal GIST s/p LPS excision of intestial tumor and resection of inerinal tumor on 2015-02-10, pT3N0M0, Stage II
      • s/p imatinib from 2015-03 to 2019-03
      • s/p liver mets -> RFA x 4 on 2020-04-21
      • s/p intra-abdominal recurrence GIST, LPS tumor eccision on 2020-05-12
      • s/p LIver mets and LPS S6/7 hepatectomy and peritoneal nodule resection on 2021-05-28
      • s/p liver and peritoneal mets, then sunitinib 3# from 2023-03-27 to 2023-07-14
  • O
    • CT in 2023-07: Disease in progression
    • s/p imatinib and sunitinib -> PD
  • P
    • Apply regorafenib
• 2019-01-30 SOAP Gastroenterology
  • S
    • RUQ to RMQ pain for 3-4 days
    • dull pain with fullness sensation. without vomiting.
    • nausea (-)
    • fever yesterday, the day before yesterday
    • explained high CRP: we’ve suggested admission for thorough exam, IV antibiotic, close observation.
    • patient denied pregnancy
    • constipation sometimes. denied tarry/bloody stool; denied dysuria
    • we’ve informed the patient and family: if symptoms recur or aggravate: should back to OPD or ER immediately
    • suggest admission for treatment and emergent CT scan but patient and her family hesitated: they requested to go to TMUH. Direct referral to the Emergency Department has been recommended.
  • O
    • history of small bowel GIST post surgery in TMUH. Last follow-up (TMUH) 6 months ago
    • abd echo on 1/30 PM
    • PE abd soft tenderness at RUQ to RMQ area. no muscle guarding; no rebound pain.
  • Diagnosis
    • right upper quadrant pain [R10.11]
    • small bowel GIST post surgery [C17.9]

==========

2023-07-31

[medication reconciliation]

The patient was prescribed famotidine, cyanocobalamin, and betamethasone on 2023-07-28 for a 7-day duration at JingMei Hospital to address her malignant neoplasm of the small intestine. However, these medications are currently not included in the active medication list. It is advised to review whether they are still necessary for the patient’s current condition.

700357530

230731

[exam findings]

• 2023-06-10 Bladder sonography
  • PVR: 44.2 ml
• 2023-06-10 Urology SONO - kidney
  • CC:
    • Bladder lymphoma s/p TUR-BT, pathology proven lymphoma
    • repeat TUR-BT revealed bladder lymphoma,
    • Under C/T for lymphoma
  • Diagnosis:
    • Grossly normal, bilateral kidneys
• 2023-05-30 CT - abdomen
  • Clinical history: 81 y/o male patient with Triple diffuse arge B cell lymphoma with urinary bladder wall,gastric wall, distal descending colon, and sigmoid colon, left upper neck, bilateral pulmonary hila, and right lower paratracheal area, involvement, Lugano stage I.
  • With and without contrast enhancement CT of abdomen - whole:
    • Liver cysts, up to 5.5cm in S2 liver.
      
    • Aneurysmal dilatation of distal abdominal aorta.
  • Impression:
    • Clinical urinary bladder diffuse arge B cell lymphoma. Suggest follow up.
    • Liver cysts.
    • Aneurysmal dilatation of distal abdominal aorta.
• 2023-05-01, -04-06, -02-15 CXR
  • Enlargement of cardiac silhouette.
• 2023-03-18 Bladder sonography
  • PVR: 32.3 ml
• 2023-02-17 Patho - colorectal polyp
  • Colorectum, cecum, s/p cold snare polypectomy (A) — Hyperplastic polyp
  • Colorectum, transverse colon, 55cm AAV, s/p cold snare polypectomy (B) — Hyperplastic polyp
  • Colorectum, transverse colon, 50cm AAV s/p cold snare polypectomy (C) — Tubular adenoma with low grade dysplasia
  • Colorectum, descending colon, s/p biopsy removal (D) — Tubular adenoma with low grade dysplasia
• 2023-02-17 Patho - stomach biopsy
  • Stomach, angle, s/p biopsy (A) — Chronic gastritis with intestinal metaplasia, H pylori NOT present
  • Stomach, GC site of middle body, s/p biopsy (B) — Ulcer, H pylori and candida present
• 2023-02-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (101 - 27) / 101 = 73.27%
    • LVEF(%) = 73
    • M-mode (Teichholz) = 73
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 2.
    • Normal RV systolic function.
    • Mild AR; mild MR; mild TR; mild PR.
• 2023-02-13 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — No evidence of lymphoma involvement
  • The sections show normocellular marrow (25%). M/E ratio = 3:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology. No lymphoid aggregates can be found. No increased blasts in CD34 and CD117 immunostains. Scattered CD3+ small T lymphocytes, and CD20+ and/or CD79a+ small B-cells in interstitium can be identified. There is no evidence of large B-cell lymphoma involvement in the sections examined. Suggest further bone marrow smear evaluation and clinic correlation.
• 2023-02-11 Bladder sonography
  • PVR: 83.2 ml
• 2023-02-07 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
• 2022-08-04 CT - abdomen
  • History and indication: Bladder cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P foley catheter indwelling. Collapse of urinary bladder with wall thickening. Fat stranding with some air in periventricular region r/o rupture. Several LNs at pelvic cavity.
    • Some tiny nodules at bil. lungs r/o metastases.
    • Liver cysts (up to 5.1cm).
    • Mild dilatation of infrarenal abdominal aorta (3.7cm).
    • Atherosclerosis of aorta, iliac arteries.
  • Imaging Report Form for Urinary Bladder Carcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:N2(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
• 2022-08-03 PD-L1 (SP142)
  • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • Tumor type: Mixed high grade urothelial carcinoma and diffuse large B cell lymhpoma
    • Tumor location: urinary bladder
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark ULTRA
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: [V]Pass, [ ]Fail
    • Adequate tumor cells present (>=50 viable tumor cells): [V] Yes, [ ] No
  • Result:
    • Tumor cell (TC) staining assessment:
      • TC category:TC < 1%
      • Percentage of PD-L1 expressing tumor cells (%TC): <1%
    • Tumor-infiltrating immune cell (IC) staining assessment:
      • IC category: IC >=1% and <5%
      • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): <5%
  • Note:
    • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
    • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2022-08-03 PD-L1 IHC
  • PD-L1 Immunostaining Result
    • Tissue blocks/unstained slides received labeled as: S2022-12650A1
    • Testing assay: 28-8 pharmDx Assay (Agilent/Dako)
    • Control slide result: [V]Pass
    • Adequate tumor cells present (>= 100 viable tumor cells): [V]Pass
  • Result:
    • Tumor cell (TC) staining assessment: TC < 1%
    • Percent of PD-L1 expression in tumor cells (TC): 0%
• 2022-08-03 PD-L1 22C3
  • PD-L1 Immunostaining Result
    • Tissue blocks/unstained slides received labeled as: S2022-12650A1
    • Testing assay: 22C3 pharmDx Assay (Agilent/Dako)
    • Control slide result: [V]Pass
    • Adequate tumor cells present (>= 100 viable tumor cells): [V]Pass
  • Result:
    • Combined Positive Score (CPS) assessment: CPS >= 10
    • Combined Positive Score (CPS): 15
• 2022-08-03 Patho - urinary bladder TUR
  • PATHOLOGIC DIAGNOSIS
    • Tumor, urianry bladder, TURBT — Mixed invasive papillary urothelial carcinoma, high-grade and diffuse large B cell lymphoma
    • Muscularis propria — Free of tumor invasion
  • MICROSCOPIC EXAMINATION
    • Histologic type: Mixed invasive papillary urothelial carcinoma and diffuse large B cell lymphoma
      
    • Histologic grade: High grade
      
    • Tumor configuration: Papillary
      
    • Muscularis propria: Present and free
      
    • Lymphovascular invasion: Not identified
      
    • Microscopic tumor extension: Tumor invades subepithelial connective tissue
      
    • Immunohistochemistry:
      • Urothelial carcinoma: CK7(+), CK20(+, scatter), GATA-3(+), CD3(-) and CD20(-)
      • Malignant lymphoma: CD20(+), CD3(-), CD10(-), CD30(-), Bcl-2(+), Bcl-6(+), C-MYC(+, 60-70%), MUM-1(+) and Ki-97:>90%
• 2022-08-02 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
• 2022-08-02 CXR
  • Incrased density in right lower lung, suggest chest CT for further study.
  • Plate atelectasis in left lower lung.
• 2022-07-07 Transrectal Ultrasound of Prostate - TRUS-P
  • CC
    • 2022/07/07 recurred hematuria with blood clot
    • 2022/06/16 keep Tx
    • 2022/03/24 nocturia (several times at learly beginning and improved after SLEEP PILLS)
    • 2021/12/30 for report and improved hematuria now
    • 2021/12/20 gross hematuria with blood and visited ER
    • 2021/12/02 urinary burning sensation
    • low abd discomfort on foley at ER, no AUR?
    • hematuria now
    • nocturia 4-5 with voiding difficulty for a while
    • BPH on med at Cathay H and Sutien for 1 year
    • BIH s/p op 10 years ago here
  • Diagnosis:
    • Benign prostatic hyperplasia

[consultation]

• 2021-11-17 Urology
  • Q
    • for acute urine retension with hematuria
    • He was admitted due to # CAD s/p Robotic CABG x1 on 2021/11/12. Suddent AUR s/p foley insertion. We need your help for further care.
    • Hx of enlarged prostate with lower urinary tract symptoms status post transurethral resection of the prostate on 2020/07/29
  • A
    • This 80yo male received CABG on 2021-11-12.
      • Aspirin +
      • AUR was noted this morning and a 18 Fr. 2-way Foley was inserted.
      • Gross hematuria was noted after Foley. Blood clots (+)
      • active ozzing now (+), manual irrigation: some littile blodd clots
    • Plan:
      • continuous irrigation
      • if Foley obstructed, then consider manual irrigation and 22 Fr. 3-way Foley
• 2021-10-24 Cardiology
  • Q
    • Suspected cardiac chest pain/chest discomfort with cold sweats
      • noted since 9AM today, lasting for around half an hour
      • feeling better now
      • chronic cough also noted
      • no fever
      • deny chest/abdomen/back pain
      • 2021/09/23 2nd dose Moderna
    • PH: HTN; BPH s/p op ; chronic insomnia
    • NKA
  • A
    • SUFFERED from PSVT a few months before.
      • This time, came for different symptom and chest tightnes spontaneous resolved
      • At ER, his ECG showed sinus rhythm and gradual trop-I elevation noted.
      • Bedside echo: normal LV wall motion
    • Suggestion:
      • could be and not excluded NSTEMI
      • recommended empirical DAPT (Aspirin / Plavix) and Q8H trop-I follow up

[immunochemotherapy]

• 2023-07-03 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
  • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-05-29 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
  • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-05-02 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
  • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-04-06 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
  • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-03-13 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
  • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-02-20 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
  • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
• 2022-08-04 - mitomycin-C 30mg/m2 30mg BI 1hr

==========

2023-07-31

On 2023-06-10, our urologist wrote a 3-time refill prescription (valid for 84 days) for Harnalidge (tamsulosin) and Betmiga (mirabegron). Additionally, on 2023-06-12, our cardiac surgeon issued a 3-time repeat prescription (also valid for 84 days) for Blopress (candesartan), Bokey (aspirin), Concor (bisoprolol), Eurodin (estazolam), and Crestor (rosuvastatin). These medications have been included in the active medication list, and no reconciliation issues have been identified.

2023-07-03

In accordance with the PharmaCloud database, this patient has only been a patient of our hospital for the last 3 months. In addition to our hemato-oncology department, our urologist prescribed Harnalidge (tamsulosin) and Betmiga (mirabegron) on 2023-06-10. In addition, our cardiac surgeon prescribed Blopress (candesartan), Bokey (aspirin), Concor (bisoprolol), Eurodin (estazolam), and Crestor (rosuvastatin) on 2023-06-12. These medications have been accurately added to the list of active medications and no discrepancies have been identified in the reconciliation.

701486100

230731

[lab data]

2023-06-27 Anti-HBc Reactive
2023-06-27 Anti-HBc-Value 1.04 S/CO
2023-06-27 Anti-HCV Nonreactive
2023-06-27 Anti-HCV Value 0.10 S/CO
2023-06-27 Anti-HBs 229.48 mIU/mL
2023-06-27 HBsAg Nonreactive
2023-06-27 HBsAg (Value) 0.32 S/CO

[MedRec]

• 2023-07-17 SOAP Hemato-Oncology Xia HeXiong
  • S
    • << GS-US-570-6015 (IRB No: 11-FS-150) ICF Process >>
      • The subject has been provided the informed consent form (GS-US-570-6015_site 17413_Main ICF V6.1.1_02May2023_Chinese) and were fully explained the content of the informed consent form on 2023/07/14 by investigator and study Coordinator. The subject had enough time to ask all questions regarding the study. The subject brought the consent form back to consider whether to participate.
      • The subject understood the (GS-US-570-6015_site 17413_Main ICF V6.1.1_02May2023_Chinese) and signed on 2023/07/17. A copy of the signed informed consent form was provided to the subject.
      • GS-US-570-6015_Emergency Medical Support and Subject Card_v2.0_04May2022_ZH-TW has dispensed to subject on 2023/07/17 by PI/SC.
  • O
    • 2023.07.17
      • Subject No.: 17413101_initial: BLS
      • Ethnicity: Not Hispanic or Latino
      • Race: Asian
      • Country: TAIWAN
      • Never use alcohol
      • Never use tobacco
      • BH : 156.1 cm / BW : 71.9 Kg
      • Vital signs (assessed in a seated position after resting): 35.9’C/72/20 BP: 119/70 mmHg at 09:44 AM
      • Physical Examination:
        • Head, eyes, ears, nose and throat - Normal, specify
          
        • Cardiovascular - Normal, specify
        • Dermatological - Normal, specify
          
        • Musculoskeletal - Normal, specify
          
        • Respiratory - Normal, specify
          
        • Gastrointestinal - Intermittent diarrhea and abdominal distention
          
        • Neurological system - Normal, specify
          
      • ECOG Performance Status: 0
      • Childbearing Potential: NA, menopause around 52 years.
      • Collect 12-lead ECG at 09:41 AM
      • Collect central Hematology & Coagulation & Chemistry &
      • Endocrine function and basal cortisol & Hepatitis serology & HIV serology at 08:53 AM
      • Collect U/A at 09:50 AM
  • P
    • 2023.07.17
      • Anticipate to arrange the freshly cut unstained FFPE slides on 2023.07.17.
      • Arrange Neck & Chest & Abd & Pelvis CT on 2023.07.21.
    • Actein for prevention of contrast-induced nephropathy.
  • Prescription
    • Actein Effervescent (acetylcysteine 600mg) 1# BID 4D, use 2 days before CT from 2023-07-19 to 2023-07-22
• 2023-07-12 SOAP Hemato-Oncology Xia HeXiong
  • S: CRC with multiple LNs mets s/p OP and C/T
  • O: 2023/06/27 HGB = 8.3 g/dL
  • P: Blood transfusion with pRBC
  • Prescription
    • Benamine (diphenhydramine 30mg/amp) ST IVD before blood transfusion
    • furosemide 20mg ST IVD after 2U pRBC
    • NS 500mL ST IVD for drug and blood transfusion
    • Hepac Lock Flush 100 USP units/mL 10mL ST IRRI
• 2023-06-27 ~ 2023-06-28 POMR Hemato-Oncology Xia HeXiong
  • Discharge diagnosis
    • Rectosigmoid colon ca with para-aortic LAP CT3N2bM1a, stage IVA s/p LPS LAR on 2020-03-31, pT3N2bM1a, stage IVA (21/22), EGFR positive, KRAS: wild type, s/p FOLFIRI & A-FOLFOX 
    • Right upper lobe lung adenocarcinoma pT1bN0M0, stage IA2
    • Essential (primary) hypertension
    • Type 2 diabetes mellitus without complications
    • Chronic diarrhea
    • Chronic viral hepatitis B without delta-agent
  • CC
    • for CT guide biopsy of left plevis LNs
  • Present illness
    • The 64 years-old woman has past history of
      • Beta-Thalassemia: IVS-2nt 654 (C to T), heterozygous
      • Hypertension. Thyroid ca post-thyroidectomy in 2017
      • Rectosigmoid colon cancer with para-aortic LAP CT3N2bM1a, stage IVA s/p LPS LAR on 109-3-31, pT3N2bM1a, stage IVA (21/22), EGFR positive, KRAS: wild type (2020), s/p FOLFIRI & A-FOLFOX
      • Right upper lobe lung adenocarcinoma pT1bN0M0, stage IA2
    • In the beginning, she suffered from bloody stool for 1 years on 2020/03, visited to FuRen University Hospital, colonoscopy was done showed Rectosigmoid colon tumor, s/p biopsy showed tubulovillous adenocarcinoma with high grade dysplasia at least. Chest to pelvic CT was done on 2020/03/28 showed CRC cT3N26M1a (para-A LN) stage IVA, s/p laparoscopic LAR: mod-differentiated LN (21/22) pT3N2bMx on 2020/03/31. She received chemotherapy with FOLFIRI x 8 (no avastin ?) from 2020/04/22 ~ 08/20. 2020/11/10 CEA / Ca-199 4.45 / 14.4. CT guide biopsy was done on 2020/11/12 showed adenocarcinoma, CK7, TTF-1(+), (-)CK20 & CDX2, c/w primary lung adenocarcinoma.
    • Follow up bone scan on 2020/12/09 showed focal uptake in ant aspec of Lt 4th rib. Chest to abd CT was done on 2021/01/25 showed post OP change of RUL no liver mets. PET was done on 2021/03/15 showed PD in left lower neck & mediastinal, paraaortic to elvic LN, rTON2M1a. Bone scan was done on 2021/03/17 showed 1. No apparently interval changes in areas mentioned above, benign natures could be considered first. Follow up Colonoscopy on 2021/11/15 showed polyps, and the Pathology showed adenocarcinoma, Hyperplastic. CT image was folloe up on 2022/02/08 showed LAP in PD. Then, she received capecitabine, C1D1 on 2021/11/06 ~. Denied TOCC history in recent three months. Accroding to the CT image at Taipei Medical University Hospital on 2023/05, report showed progression of pelvis LNs was found. This time, she admitted to our ONC ward for CT guide biopsy of left pelvis LNs on 2023/06/27.

[consultation]

• 2023-06-28 Diagnostic Radiology
  • Q
    • The patient is an 64-year-old female with a history of colon cancer s/p in 2020 (TMUH), HTN, DM, Lung adenocarcinoma s/p in 2021 (TMUH), Thyroid cancer s/p in 2016 (XiYuan Hospital), Lymphoma of the left neck.
    • For CT guide biopsy of pelvis LNs, we need your further evaluation and management. Thanks a lot!!!
  • A
    • Dear Dr.: According to the clinical condition and imaging findings, biopsy is indicated.

==========

2023-07-31

[prophylactic antiviral therapy prior to immunosuppressive agent use]

The patient’s hepatitis B serology results were as follows: HBsAg (-), anti-HBc (+), anti-HBs (+), indicating that she is immune due to natural infection but remains at risk for reactivation if exposed to immunosuppressive agents.

• 2023-06-27 Anti-HBc Reactive
  
• 2023-06-27 Anti-HBc-Value 1.04 S/CO
  
• 2023-06-27 Anti-HBs 229.48 mIU/mL
  
• 2023-06-27 HBsAg Nonreactive
  
• 2023-06-27 HBsAg (Value) 0.32 S/CO

Given this information, if immunosuppressive agents are part of the treatment plan, it is recommended that prophylactic antiviral therapy be considered. Options include either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD. This preventive measure can help reduce the risk of possible reactivation of HBV infection due to the immunosuppressive effects of treatment.

• ref: Pharmacy FAQ - Hepatitis B reactivation and screening. http://www.bccancer.bc.ca/pharmacy-site/Documents/Pharmacy%20FAQs/Pharmacy-FAQ-Hepatitis-B.pdf

700061972

230728

[exam findings]

• 2023-07-17 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Abnormal ECG
• 2023-06-23 Patho - oral cancer (wide excision + lymph node)
  • PATHOLOGIC DIAGNOSIS
    • Tumor, left tongue, wide excision — Squamous cell carcinoma
    • Resection margins — Free of tumor invasion
      • Deep margin, left, frozen section (F2023-00293) — Free of tumor invasion
    • Lymph nodes
      • Lymph node, bilateral level Ia, dissection — Free of tumor metastasis (0/6)
      • Lymph node, left level Ib, ditto — Free of tumor metastasis (0/1)
      • Lymph node, left level III, ditto — Free of tumor metastasis (0/3)
      • Lymph node, left level IIa+III, ditto — Free of tumor metastasis (0/3)
        
    • Salivary gland, left level Ib — Free of tumor invasion
      
    • AJCC Pathologic staging — pT3N0, if cM0, stage III
  • MACROSCOPIC EXAMINATION
    • Surgical Procedure(s): wide excision
    • Specimen Type:
      • Main location: tongue
      • Other part(s) included: N/A
      • Lymph node dissection: Yes
    • Specimen Integrity: Intact
    • Specimen Size: 5 x 3.9 x 2.3 cm
    • Tumor Site: left tongue
    • Tumor Focality: solitary
    • Tumor Size: 2.2 x 2.1 cm
      • Tumor thickness: 1.3 cm
    • Mucosal Surface: elevated tumor
    • Gross Tumor Extension (specify) : 1.3 cm in depth
    • Salivary gland at level Ib: 3.7 x 2.8 x 1.7 cm
    • Representative sections as follows: A: bilateral level Ia LN, B1: left level Ib LN, B2: salivary gland at level Ib, C:left level III LN, D: left level IIa+III LN, E1, E3 and E5: tumor + anterior margin + base, E2, E4 and E6: tumor + posterior margin, E7: tumor + medial margin, E8:-E10: tumor + lateral margin [Reference: Frozen section: F2023-00293FS left deep margin, one small piece of muscle tissue measured 1.1 x 0.9 x 0.3 cm in size]
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Squamous cell carcinoma
    • Histologic Grade: G2, moderately differentiated
    • Microscopic Tumor Extension: 1.3 cm in depth
    • Margins: Free, 0.6 cm from base, 0.7 cm from anterior, 2.0 cm from posterior, 0.5 cm from medial and 0.4 cm from lateral margin
    • Lymph-Vascular Space Invasion: Not identified
    • Perineural Invasion: Present
    • Neck Lymph Nodes: free of tumor metastasis (0/13) in total number
• 2023-06-21 ECG
  • Sinus rhythm with 1st degree A-V block
  • Inferior infarct, age undetermined
  • Poor wave progression
  • Abnormal ECG
• 2023-06-12 Nasopharyngoscopy
  • smooth NPx, OPx, HPx
  • fair inf. turbinate, with clear mucus
  • 3 cm protruding mass with ulcer over left posterior tongue, with suture
• 2023-05-26 Tc-99m MDP bone scan
  • Mildly increased activity in the middle C-spine and lower L-spines. Degenerative change may show this picture.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture. Please correlate with other clinical findings for further evaluation.
  • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, hips, right knee and right foot, compatible with benign joint lesions.
• 2023-05-24 Patho - tongue biopsy
  • Labeled as “left dorsal tongue”, incisional biopsy — squamous cell carcinoma.
  • IHC stain: p16 (-).
• 2023-05-23 MRI - nasopharynx
  • Findings: Left dorsal ventral tongue tumor mass, extending to right, up to 31mm, seems with extrinsic muscle invasion (likely the styloglossus).
  • IMP: Left tongue CA, T4aN0M0 stage IVA.
  • Oralcavity - Impression (Imaging stage) : T:4A N:0 M:0 STAGE:IVA

[MedRec]

• 2023-06-21 ~ 2023-07-11 POMR Ear Nose Throat
  • Course of inpatient treatment
    • ENT ward 6/21-23
      • After admission, pre-operative evaluation was done. We also consulted plastic surgeon for free flap reconstruction. Operation was perforemed on 6/23, and he was tranferred to intensive care unit after operation.
    • ICU 6/23-24
      • During SICU, under Pain control with Fentanyl titration, Tracheostoym with ventilator support. After when patient conscious recover to clear, try weaning ventilator to T-mask use it well. Today, try on EN feeding with NG diet 1000 kcal/day, due to stable hemodynamic condition and pulmonary condition, we arrange transfer this patietn to ENT ward for care.
    • ENT ward 6/24-7/11
      • We removed foley catheter and femoral CVC smoothly on 6/27, and shifted antibiotics from Cefmetazole IVD to Cefaclor PO from 6/30. We removed JP drain and shifted tracheostomy from low pressure to shiley on 7/03, and removed suture over left neck surgical wound on 7/04. Under stable condition, he will be discharged on 7/10, and outpatient depatment following up will be arranged then.
  • Discharge prescription
    • Biomycin Ointment (neomycin, tyrothricin) QD TOPI
    • Parmason Gargle Solution (chlorhexidine) TID GAR
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
    • Through (sennoside 12mg) 2# HS
    • MgO 250mg 1# Q6H
    • Cero (cefaclor monohydrate 250mg) 2# Q8H
• 2023-05-22 ~ 2023-05-27 POMR Oral and Maxillofacial Surgery
  • Discharge diagnosis
    • squamous cell carcinoma of the left posterior tongue (near lingual tonsil) (cT4aN0M0, MRI images)
    • infection of the tongue
    • Old cerebrovascular accident with left hemiparesis
    • Parkinson’s disease
    • Hypertensive heart disease without heart failure
    • Enlarged prostate with lower urinary tract symptoms
    • Paroxysmal atrial fibrillation
    • Primary insomnia
    • Unspecified kidney failure
    • Parenchymal liver disease
    • Splenomegaly
    • Gout, unspecified
  • CC
    • I had A painful red lump at my left tongue for few weeks.
  • Present illness
    • According to his statement, this 56-year-old male patient had history of the left tongue cancer after operation and oral chemotherapy for 20+ years in ShinKong Hospital. He did not go to ShinKong Hospital for regular opd follow-up. lately, he noted a mass lesion at his left tongue for few weeks. He visited to our Oral and Maxillofacial Surgery clinic on 2023/05/16, where an ulcerative, red malignant lesion at the left posterior tongue (near lingual tonsil) was noted. His panoramic film showed no bone destruction by tumor but periodontal bone loss. Because a malignancy tongue lesion was highly suspected, we had to do a biopsy for him. Unfortunately, trismus and posterior location of this malignant lesion were noted. After we explained his treatment plans to the patinet, he was admitted for tumor survey and further surgical management.
  • Course of inpatient treatment
    • During the hospitalized time, he underwent nasopharynx MRI examinaton on 05/23, which shows tumor size over 4cm with DOI over 10mm. No regional nodal metastasis was noted. Then the biopsy of left tongue under general anesthesia was performed on 2023/05/24. Empirical antibiotic agent with cefazolin were prescribed. Along with algesic agent for surgical wound pain control. Mouth care and mouth gargling with Parmason solution Q3H and PRN was educated.
    • Because his general condition was acceptable after the operation. After his abdomen sona on 05/25 and whole body bone scan on 05/26 were done and showed no tumor metastasis. He was discharged on 2023/05/26.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ4H
• 2023-05-18 SOAP Urology
  • Diagnosis
    • Enlarged prostate with lower urinary tract symptoms [N40.1]
  • Prescription
    • Anxiedin (lorazepam 0.5mg) 1# HS
    • Doxaben XL (doxazosin 4mg) 1# QD
    • Betmiga (mirabegron 50mg) 1# QD
  • ChatGPT
    • Doxazosin and Mirabegron can be coadministered in the management of urinary symptoms, particularly in the context of conditions like benign prostatic hyperplasia (BPH) and overactive bladder (OAB).
    • Doxazosin is an alpha-1 adrenergic receptor blocker used to relax the smooth muscles of the prostate and bladder neck, which can improve urine flow and decrease symptoms of BPH. It can also be used in hypertension as it relaxes blood vessels.
    • Mirabegron is a beta-3 adrenergic receptor agonist used to treat overactive bladder (OAB) symptoms. It works by relaxing the detrusor muscle during the storage phase of the bladder fill-void cycle, leading to increased bladder capacity.
• 2019-07-25 SOAP Urology
  • Prescription
    • Doxaben XL (doxazosin 4mg) 1# QD
• 2019-06-17 SOAP Urology
  • Diagnosis
    • Enlarged prostate with lower urinary tract symptoms [N40.1]
  • Prescription
    • Harnalidge (tamsulosin 0.4mg) 1# HS
• 2019-05-25 SOAP Orthopedics
  • Prescription x3
    • Arcoxia (etoricoxib 60mg) 1# QD
• 2019-04-22 SOAP Orthopedics
  • S: left toe pain during walking
  • O: mild swelling and ecchymosis, imflammatory sign+
  • Prescription
    • Celebrex (celecoxib 200mg) 1# QD
    • colchicine 0.5mg 1# QD
• 2017-10-24 SOAP Neurology
  • Diagnosis
    • Nontraumatic intracerebral hemorrhage in hemisphere, subcortical [I61.0]
    • Parkinsonism [G21.4]
  • Prescription x3
    • Madopar (levodopa, benserazide; 250mg) 0.5# QID
• 2017-01-18 SOAP Cardiology
  • Diagnosis
    • HCVD, unspecified, without CHF [I11.9]
    • Unspecified late effect of cerebrovascular disease [I69.90]
    • Peristent disorder of initiating or maintaining sleep [F51.01]
    • Gout, unspecified [M10.9]
    • Mixed hyperlipidemia [E78.2]
  • Prescription x3
    • Modipanol (flunitrazepam 1mg) 1# HS
    • Ancogen (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNBID
    • Through (sennosides 12mg) 2# HS
    • Bokey (aspirin 100mg) 1# QD
    • Pitator (pitavastatin 2mg) 1# QN
    • Blopress (candesartan 8mg) 1# QD
    • Euricon (benzbromarone 50mg) 1# QD
    • Adalatoros (nifedipine 30mg) 1# QD

[consultation]

• 2023-07-07 Oral and Maxillofacial Surgery
  • A
    • we are consulted prior to postoperative radiotherapy
    • poorly-fitted bridge of right lower tooth was pulled out along with previous cancer ablation surgery.
    • the rest of the dentition was in acceptable condition

[surgical operation]

• 2023-06-23
  • Surgery
    • resurface of mucosal defect of left oral base with tongue flap
  • Finding
    • missing at least left 3/5 of the tongue and most of its inner muscles
    • 9cm X 5cm mucosal defect over left oral base and tongue base
    • Although free flap was palnned, the tongue flap was thought to be OK to fill the intra-oral defect; so the remaining part of the tongue after cancer ablasion was used to form a flap.
    • a 10F JP drain was placed over left-anterior neck fro post operative drainage
  • Procedure
    • after cancer ablasion, re-drape the patient
    • design, elevation, and transposition of the flap
    • suture inset of the flap
    • placement of the JP drain
    • closure and dressing of the wound of the neck
• 2023-06-23
  • Surgery
    • Composite resection of oral cancer, left
    • Glossectomy, near-total
    • Selective neck dissection, left (level Ia, Ib, IIa, III)
    • Tracheotomy
  • Finding
    • MRI = tongue cancer, left, cT4aN0
    • floor-of-mouth in communication with neck, left posterolateral (mylohoid and digastric muscle were meticulously preserved since no gross invasion of cancer could be identified)
    • left lingual nerve, CN 12, sacrifice
    • left lingual artery ligated
    • right lingual artery ligated
    • frozen section (deep margin)= free from tumor
    • carotid bifurcation, IJV, superior thyroid artery exposed after dissection
    • enlarged LN over L level IIa
    • poor oral hygiene with caries (foul smell), yet all the teeth were not loose
• 2023-05-24
  • Surgery
    • Soft tissue biopsy (92067C * 1)
    • Complicated tooth extraction of #47 (92014C * 1)
    • Removal of casting crown of #45 (90007C * 1)
  • Finding
    • An ulcerative malignant-like lesion on the left posterior tongue
    • Underbridge deep caries of #47

==========

2023-07-28

[reconciliation]

Our hospital is the only medical provider for this patient according to the PharmaCloud database, no medication reconciliation issues identified.

[tube feeding]

Betmiga (mirabegron) is a long acting formulation, it is not recommended to crush or halve for tube feeding. As the effect of mirabegron 50mg is approximately equivalent to that of propiverine 30mg, it is recommended to switch to Urotrol (propiverine 15mg), 1# BID for tube feeding. Doxaben XL (doxazosin) is a sustained-release formulation. It is suggested to consider switching to Urief (silodosin) as an alternative to Doxaben.

700062834

230728

[diagnosis] - 2023-04-06 admission note

• Double hit, diffuse large B cell lymphoma, non-germinal center type with right oropharynx involving and mediastinal lymphadenopathy, stage II, Lugano stage II, IPI score:2 s/p chemotherapy with R-CHOP from 2023/03/17
• Insomnia, unspecified
• Chronic viral hepatitis B without delta-agent
• Hypothyroidism, unspecified

[past history]

• Hypothyroidism history without drug control
• DM(-), HTN(-)   

[allergy]

• NKDA     

[family history]

There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

• 2023-07-06 CT - chest
  • Indication: Double hit, diffuse large B cell lymphoma, non-germinal center type with right oropharynx involving and mediastinal lymphadenopathy, stage II, Lugano stage II, IPI score:2 s/p chemotherapy with R-CHOP from 2023/03/17~
  • Chest CT with and without IV contrast ehnancement shows:
    • Lower neck :
      • Regression of the lymphadenopathy at right neck is found.
      • Patent airway is found.
    • Chest:
      • Small lymph nodes are found at paratracheal region. In comparison with CT dated on 2023-03-10, the lesions are stationary.
      • The lung fields are clear.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
      • Non-specific bowel gas at abdominal cavity is found.
  • Imp:
    • Marked regression of right neck lymphadenopathy.
    • No residual lymphadenopathy at right neck is found.
    • Small lymph nodes at mediastinum. Stable.
• 2023-03-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (110 - 32) / 110 = 70.91%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Normal LV filling pressure.
    • Normal LV and RV systolic function
    • Mild aortic valve sclerosis; trivial MR
• 2023-03-15 CXR
  • Spondylosis of the T-spine
• 2023-03-14 PET scan
  • The FDG PET findings are compatible with lymphoma involving the right nasopharynx, soft palate, right oropharynx and in a large confluent area with some small adjacent focal areas in the right parotid region and right neck level II to V regions.
  • Mildly increased FDG uptake in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation is more likely.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2023-03-10 CT - chest
  • oropharyngeal lymphoma, for cancer work up
  • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Visible neck
      • Huge necrotic soft tissue mass at right neck with extension into oral cavity measuring 10.3cm is found.
    • Chest:
      • Mild centrilobular Emphysematous change over both lungs is found.
      • Lymphadenopathy at bilateral paratracheal and AP window is found.
        • ChatGPT: AP window in CXR stands for “anterior-posterior window”, which is an area seen on the front to back view of a chest X-ray. It refers to the space between the aortic arch and the left pulmonary artery, which can be obscured by structures such as the trachea or mediastinal lymph nodes. Abnormalities in the AP window can indicate the presence of tumors, enlarged lymph nodes or other pathologies.
      • Patent airway is found.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
      • Suggest clinical correlation
  • Imp:
    • Extensive right neck mass with mediastinal lymphadenopathy.
    • Mild COPD.
• 2023-03-09 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • IHC stains: CD3 <5% and CD20: <5% and no predoimnant subpopulation. (of the nucleated cells).
• 2023-03-09 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2023-03-01 Patho - nasopharyngeal/oropharyngeal biopsy
  • Labeled as “right oropharynx”, biopsy — B cell lymphoma.
  • Section shows soft tissue with diffuse infiltration of paternless round blue neoplastic cells.
  • IHC stains: CK (-), CD3 and CD20: a predominant B cell sub-population. Bcl-2 (+), bcl-6 (+, >30%), MUM-1 (+, >30%), c-myc (-), CD10(-), Ki-67: 90%, cyclin-D1 (-), CD23 (-), a pattern of diffuse large B cell lymphoma, non-germinal center type.
• 2023-02-27 Nasopharyngoscopy
  • Findings
    • smooth NPx; boggy inf. turbinate with clear mucus
    • smooth bulging over right lateral pharyngeal wall; granular tumor at right soft palate, right anterior and posterior
    • pillar, right tonsillar fossa; biopsy from right tonsilar fossa done; right RMT smooth bulging
  • Diagnosis/Conclusion
    • right oropharyngeal tumor, favor malignancy, biopsy done

[consultation]

• 2023-03-10 Hemato-Oncology
  • Q
    • for transferred for lymphoma evaluation
    • This is a 57-year-old man with past history of hypothyroidism.
    • This time, he was admitted to our ward for right neck mass and right oropharyngeal tumor. Pathology report for oropharyngeal lesion revealed B cell lymphoma. We need your expertise for further examination suggestion and possible taking over.
  • A
    • This 57 year old man is a case of B cell lymphoma, pending IHC stain. Initial presentation was progressive painless right neck mass for 2 months, accompanying with right side otalgia and lumping throat. He has underline of hypothyroidism under levothyroxine treatment. We are consulted for lymphoma treatment.
    • Please arrange PET CT scan, CT scan of neck extending chest, abdomen to pelvis and bone marrow for complete staging. Transfer to 11A on Dr Xia service.

[chemoimmunotherapy]

• 2023-07-27 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
• 2023-07-07 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
• 2023-06-09 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
• 2023-05-08 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
• 2023-04-07 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
• 2023-03-17 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3

==========

2023-07-28

Based on the PharmaCloud database, we see that the patient has only visited our hemato-oncology department in the last 3 months. As a result, no medication reconciliation issues are identified for this admission.

2023-06-09

• A leucopenia episode occurred on 2023-05-18, just ten days following the initiation of the 3rd cycle of the R-CHOP regimen on 2023-05-08. The patient was treated with Granocyte (lenograstim 250ug) for 3 consecutive days starting on 2023-05-18. Since then, no further instances of leucopenia have been detected.
  • 2023-06-09 WBC 5.23 x10^3/uL
    
  • 2023-05-25 WBC 7.25 x10^3/uL
    
  • 2023-05-18 WBC 1.33 x10^3/uL
    
  • 2023-05-08 WBC 5.66 x10^3/uL
    
  • 2023-04-25 WBC 9.45 x10^3/uL
    
  • 2023-04-20 WBC 5.48 x10^3/uL
• The risk of febrile neutropenia with R-CHOP regimen is 10 to 20%; primary prophylaxis with hematopoietic growth factors might be considered on an individual basis, particularly for high-risk patients such as those with preexisting neutropenia, advanced disease, poor performance status, or patients age 65 years or older.

2023-04-10

• Leucopenia was observed on 2023-03-28, the 11th day since the start of the first R-CHOP regimen on 2023-03-17. Granocyte (lenograstim) was administered for 3 consecutive days starting on the observed day. The patient’s WBC count should be closely monitored 1 to 2 weeks after the start of the second dose, which was administered on 2023-04-07.
  • 2023-04-06 WBC 12.36 x10^3/uL
    
  • 2023-03-28 WBC 1.09 x10^3/uL
    
  • 2023-03-20 WBC 7.21 x10^3/uL
    
  • 2023-03-18 WBC 6.23 x10^3/uL
    
  • 2023-03-16 WBC 9.96 x10^3/uL
    
  • 2023-03-13 WBC 10.03 x10^3/uL
    
  • 2023-03-08 WBC 10.82 x10^3/uL
• Rapid weight loss
  • The patient has recently experienced rapid weight loss, from 50.6 kg on 2023-03-09 to 46.3 kg on 2023-04-06. To address this issue, it is recommended that the patient’s nutritional intake be increased. If there is no dysphagia, megestrol can be used as an appetite stimulant at a dose of 200 to 600 mg/day to alleviate anorexia.
• Constipation
  • Based on the TPR panel indicating no bowel movement for three consecutive days (2023-04-06 to 2023-04-08), it is recommended to rule out the possibility of ileus.
  • For functional constipation or fecal impaction
    • Suppositories:
      • For treatment of defecatory dysfunction, we favor an initial trial of suppositories (glycerin or bisacodyl) since suppositories can be effective in liquifying stool and thereby overcoming obstructive defecation.
    • Disimpaction:
      • Patients with a fecal impaction (a solid immobile bulk of stool in the rectum) should initially be disimpacted starting with manual fragmentation if necessary. After this is accomplished, an enema with mineral oil will help to soften the stool and provide lubrication.
      • If disimpaction is unsuccessful or only partially successful, we may order a water-soluble contrast enema (Gastrografin or Hypaque) administered under fluoroscopy to assure absence of any obstruction and to eliminate more proximal impactions. Occasionally, fractionation of impacted stool beyond the reach of the finger must be accomplished using flexible or rigid sigmoidoscopy with instrumentation. The colon must then be thoroughly evacuated. This can be accomplished with daily warm water enemas for up to three days, or by drinking a balanced electrolyte solution containing polyethylene glycol (PEG) until cleansing is complete.

700601390

230728

[exam findings]

• 2023-05-19 CT - abdomen
  • 20230313 ATH + BSO + omentectomy + BPLND + vaginectomy.
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left: Endometroid carcinoma, FIGO grade 3
      • Endometrium, uterus: Endometroid carcinoma, FIGO grade 2
      • Lymph nodes, pelvic and para-aortic: Negative for malignancy (0/78)
      • Pathology stage: pT1c2N0; stage IC (ovary); and stage IA (endometrium)
  • Findings:
    • There are three kissing cystic lesions in left lateral pelvis and one cystic lesion in right lateral pelvis that may be lymphocele.
    • There is mild fatty stranding of the mesentery at the pelvis.
    • S/P hysterectomy
    • S/P catheter insertion from right upper pelvic wall and the tip located at the dependent portion of the lower pelvis for HIPAC. please correlate with clinical history.
      
  • Impression:
    • There are three kissing cystic lesions in left lateral pelvis and one cystic lesion in right lateral pelvis that may be lymphocele.
    • There is mild fatty stranding of the mesentery at the pelvis.
    • Follow up is indicated.
• 2023-03-14 Patho - uterus (with or without SO) neoplastic
  • PATHOLOGIC DIAGNOSIS
    • Ovary, left, staging surgery — Endometroid carcinoma, FIGO grade 3
    • Endometrium, uterus, staging surgery — Endometroid carcinoma, FIGO grade 2
    • Lymph nodes, pelvic and para-aortic, bilateral, BPLND — Negative for malignancy (0/78)
    • AJCC 8 th edition, Pathology stage: pT1c2N0; stage IC (ovary); and stage IA (endometrium)
  • MACROSCOPIC EXAMINATION
    • Procedure: ATH + BSO + infracolic omentectomy + BPLND + para-aortic LN dissection + vaginectomy
    • Specimen Size: 7.5 x 4.6 x 2.4 cm (Lt ovary, received for frozen section), 5.5 x 0.6 cm (Lt tube), 3.2 x 2.5 x 2.2 cm (Rt ovary), 6.0 x 0.9 cm (Rt tube), 12.0 x 8.0 x 5.0 cm (uterus), 6.0 x 4.0 x 3.0 cm (vagina), 28 x 12 x 3.0 cm (omentum)
    • Specimen Integrity
      • Right ovary: Capsule intact
      • Left ovary: Capsule not intact
      • Right fallopian tube: Serosa intact
      • Left fallopian tube: Serosa intact
    • Tumor Site: Left ovary and endometrium
    • Ovarian Surface Involvement: Present
    • Fallopian tube Surface Involvement: Absent
    • Tumor Size: 7.5 x 4.6 x 2.4 cm (Lt ovary), diffuse thickening, up to 0.9 cm in thickness (endometrium)
    • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, right para-aortic and left para-aortic
    • Representative parts are taken for section and labeled as: F2023-00098FS and A2-A5= left ovary, A1= left fallopian tube. S2023-04575 A= left iliac LNs, B1-B2= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E= left para-aortic, F= right para-aortic LNs, G1-G6= cervix, G7-G12= endocervix, G12-G27= uterine endometrium, G20= corpus, G29= right ovary, G30= right fallopian tube, H1-H4= vagina, I1-I2= omentum.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Synchronous endometroid carcinoma of ovary and endometrium
    • Histologic grade: Grade 3 (ovary) and grade 2 (endometrium)
    • Implants: Not identified
    • Other Tissue/Organ Involvement: Not identified
    • Peritoneal Fluid: Negative
    • Regional Lymph Nodes: All lymph nodes negative for tumor cells (0/78)
    • Pathologic Stage
      • Primary Tumor: pT1c2 (ovary, tumor ruptured) and pT1a (endometrium, tumor limit to endometrium)
      • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
      • Distant Metastasis: Not applicable
    • FIGO Stage: Stage IC (ovary) and Stage IA (endometrium)
    • Lymphovascular invasion: Absent
    • Perineural invasion: Absent
    • Additional Pathologic Findings:
      • Cervix: Chronic cervicitis with Nabothian cysts and squamous metaplasia
      • Endometrium: Endometroid carcinoma
      • Myometrium: Leiomyoma
      • Ovary, right: Compatible with steroid cell tumor NOS (1.0 x 0.5 cm)
      • Fallopian tubes, bilateral: No remarkable change
      • Vagina: Chronic vaginitis
      • Omentum: No remarkable chang
    • IHC for ovarian tumor: ER(+), PR(+), WT1(-), Napsin A(-), p53 (aberrant exprssion)
• 2023-03-13 Patho - stomach biopsy
  • Stomach, GC/AW site of low body (A), biopsy — Hyperplastic polyp
  • Labeled as “esophagus, 30cm below the insicor”, s/p biopsy(B) — papilloma
• 2023-03-09 MRI - pelvis
  • Clinical history: 41 y/o female patient with Uterus, cervix, polypectomy — Adenocarcinoma.
  • With and without contrast enhancement MRI: Pelvis
    • There is cystic tumor, 6cm in left adnexa, with internal soft tissue, r/o left ovarian malignancy.
    • Diffuse endometrial thickening, hyperplasia or malignancy?
    • Focal tubular lesion in the endocervical region, protrusion from uterine body.
    • Unremarkable change of the liver, spleen, pancreas and both kidneys.
    • No enlarged lymph node in the paraaortic region.
    • Presence of ascites.
    • Nodularity at peritoneum, r/o carcinomatosis.
  • Impression:
    • Left ovarian cystic tumor, r/o ovarian malignancy.
    • Nodularity at peritoneum, r/o carcinomatosis.
    • Diffuse endometrial thickening, hyperplasia or malignancy, suggest further study.
    • Focal tubular lesion in the endocervical region, protrusion from uterine body. Nature?
    • Ascites.
      
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T: T1a_(T_value) N: N0(N_value) M:M0(M_value) STAGE:IA__(Stage_value)
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:T1c(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ic____(Stage_value)
• 2023-03-08 PET
  • Increased FDG uptake in the left ovary, highly suspected the primary ovarian cancer, suggesting biopsy for further investigation.
  • Increased FDG uptake in the uterus, compatible with the pathological findings of adenocarcinoma of uterus.
  • Increased FDG uptake in the in the posterior wall of upper hypopharynx, probably chronic inflammation process or other nature. Please also correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    
  • Left ovarian cancer, cTxN0M0, by this F-18 FDG PET scan.
• 2023-03-06 CT - abdomen
  • Clinical history: 41 y/o female patient with Polyp of cervix uteri
  • With and without contrast enhancement CT of abdomen - whole:
    • There is cystic tumor, 5.7cm in left adnexa, with internal hyperdensity and septum, r/o left ovarian malignancy. DDx: endometrioma.
    • Unremarkable change of the liver, spleen, pancreas and both kidneys.
    • No enlarged lymph node in the paraaortic region.
    • Presence of ascites. Mild nodularity and loculated ascites in left upper abdomen. Reative or carcinomatosis?
  • If proven ovarian malignancy:
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T1c(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ic (Stage_value)
• 2023-03-02 Patho - cervix/endometrial polyp
  • Uterus, cervix, polypectomy — Adenocarcinoma
    • NOTE: Please check endometrium or ovary for the possibility of tumor origin.
      
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with invasive growth pattern and areas of necrosis. The tumor cells display hyperchromatic nuclei, pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • Immunohistochemical stain reveals vimentin (+), p53: abberrant-type (strong diffuse positive, 90%), ER: positive (moderate, 90%), P40(-), p16 ( patchy strong focal+, 30%).
• 2023-03-01 Gynecologic ultrasonography
  • Cul-De-Sac: with fluid
  • LT: fluid
  • IMP: Suspected Lt Ovarian mass (47 x 32 mm)

[SOAP]

• 2023-03-28 Hemato-Oncology
  • Arrange admission for 24 hours CCr, audiometry, Chest CT, then IP C/T and systemic C/T

[surgical operation]

• 2023-03-13
  • Operation
    • Excision of intraabdominal malignant tumor, omentectomy
    • Tenckhoff tube insertion
  • Finding
    • Moderate ascites with positive cytology
    • Tenckhoff tube: over RLQ
• 2023-03-13
  • Surgery
    • Diagnosis:
      • Left ovarian tumor, r/o malignancy.
      • Pelvis MRI on 2023/03/09 showed:
        • Left ovarian cystic tumor, r/o ovarian malignancy.
        • Nodularity at peritoneum, r/o carcinomatosis.
        • Diffuse endometrial thickening, hyperplasia or malignancy, suggest further study..
        • Focal tubular lesion in the endocervical region, protrusion from uterine body.
        • Ascites.
  • Operation:
    • Debulking surgery (ATH + BSO + BPLND + paraaortic lymphadectomy + infracolic omentectomy + vaginectomy)
  • Frozen:
    • Left ovary with malignancy.
  • Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size,
    • Adnexa:
      • LOV: 6x5x3 cm , capsule not intact with mass protruding out
      • ROV: 3x2x2 cm , capsule intact , smooth surface.
      • Fallopian tube: bilateral grossly normal
    • CDS: ascites+
    • Ascites: yellowish and clear , about 550 ml
    • Bilateral pelvic and paraaortic lymph nodes: normal(+), enlarged(+), indurated(-)
    • Omentum: grossly normal, no variablesized nodules, infracolic omentectomy was done by GS surgeon.
    • Liver: grossly normal & smooth
      • Subdiaphragmatic surface: miliary tumorseeding(-).
    • Appendix: grosslt normal.
    • After the operation, Optimal debulking surgery was achieved.
    • Residue tumor: R0
    • Estimated blood loss: 200 ml
    • Blood transfusion: nil
    • Complication: nil

[chemotherapy]

• 2023-07-27 - paclitaxel 175mg/m2 240mg D5W 250mL 3hr + cisplatin 75mg/m2 110mg NS 500mL 24hr + NS 1000mL 24hr (Y-sited cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-07-07 - paclitaxel 175mg/m2 240mg D5W 250mL 3hr + cisplatin 75mg/m2 110mg NS 500mL 24hr + NS 1000mL 24hr (Y-sited cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-13 - paclitaxel 175mg/m2 240mg D5W 250mL 3hr + cisplatin 75mg/m2 110mg NS 500mL 24hr + NS 1000mL 24hr (Y-sited cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-25 - paclitaxel 135mg/m2 200mg NS 250mL 24hr D1 + cisplatin 75mg/m2 110mg NS 500mL IP 1hr D2
  • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D2
• 2023-04-11 - paclitaxel 60mg/m2 90mg NS 250mL 1hr (previous D8)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2023-04-05 - paclitaxel 135mg/m2 200mg NS 250mL 24hr D1 + cisplatin 75mg/m2 110mg NS 500mL IP 1hr D2
  • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D2

==========

2023-07-28

Based on the PharmaCloud database, we see that the patient has only visited our hospital. No medication reconciliation issues are identified for this admission after reviewing HIS5 records..

On 2023-07-26, the serum magnesium level was measured at 1.5mg/dL, indicating a low value. As a result, it is advised to add magnesium supplementation for the patient.

2023-04-06

• This patient, who is a nurse on our staff, was diagnosed with endometroid carcinoma pathology stage pT1c2N0 stage IC (ovary) and stage IA (endometrium). She underwent surgical operation ATH + BSO + infracolic omentectomy + BPLND + para-aortic LN dissection + vaginectomy on 2023-03-13. Currently, she has been admitted for her first cycle of chemotherapy, which includes paclitaxel 135mg/m2 200mg IV on day 1 (yesterday) and cisplatin 75mg/m2 110mg IP on day 2 (today).
• As of the latest lab data on 2023-04-04, her values are grossly normal except for elevated D-dimer (3137ng/mL FEU) and U-Cr 24hr (1185mg/kg/24hr), which do not contraindicate the planned chemotherapy.
• To date, there have been no apparent side effects from the patient’s chemotherapy according to the nursing notes.

700736980

230728

{Neuroendocrine carcinoma}

[exam findings]

• 2023-06-07 All-RAS + BRAF mutation
  • Tissue Block No: S2023-03264
  • RESULTS：
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-03 MRI - pelvis
  • With and without enhancement MRI: Pelvis
    • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. with progression .
    • No significant nodule in the liver.
    • Enlarged lymph nodes in left obturator, bilateral internal iliac regions, perirectal regions, could be due to metastatic lymph node.
      
    • No ascites.
    • Non-enhancing nodules in bilateral kidneys (up to 2cm in left kidney), r/o renal cysts.
  • Impression:
    • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Pelvic lymph nodes metastasis. With progression.
    • R/O bilateral renal cysts.
• 2023-04-25 CT - chest
  • Indication: Malignant poorly differentiated neuroendocrine tumors of prostate with lung mets
  • Comparison was made with previous CT dated on 2023/02/02
    • Lungs:
      • no interval change of a small subpleural solid nodule (7mm) at RLL-S9, a subpleural nodule (3mm) at LLL, and two subpleural solid nodules (up to 4mm) at RML as compared with CT on 2023/02/02.
      • a new solid nodule at Rt apical lung (7mm)
      • minimal subpleural fibrosis at both lower lobes and RML.
      • mild subpleural paraseptal emphysema at both apical lung regions.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels:
      • mild calcified plaques of the LAD and right coronary arteries.
    • Aorta: normal caliber of thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal-pelvic contents:
      • progressive in size of infiltrative prostate tumor with adjacent organs invasion and Lt pelvic side metastatic LAP compared with previous abd. CT (2022/06/17) and MRI (2022/10/26).
      • many hepatic and renal cysts (up to 2.0cm)
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression: prostate with regional organs involvement and pelvic metastatic LAP and lung metastases.
• 2023-03-21 SONO - nephrology
  • Chronic renal parenchymal disease, mild to moderate degree
  • Bilateral renal cysts
• 2023-03-07 ENT Hearing Test
  • Tymp: Bil type A.
  • PTA
    • Reliability FAIR
    • Average RE 29 dB HL; LE 31 dB HL.
    • RE normal to moderate SNHL.
    • LE normal to moderately severe SNHL.
• 2023-02-02 MRI - pelvis
  • With and without enhancement MRI: Pelvis
    • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. with partial response.
    • Non-enhancing nodules in bilateral kidneys (up to 2cm in left kidney), r/o renal cysts.
  • Impression:
    • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. With partial response.
    • R/O bilateral renal cysts.
• 2023-02-02 CT - chest
  • Indication: Malignant poorly differentiated neuroendocrine tumors of prostate s/p C/T
  • Imp: No evidence of recurrent/residual tumor in the study.
• 2022-10-26 CT - chest
  • Indication: Prostate NEC with rectal invasion s/p C/T
  • Comparison was made with previous CT dated on 2022/06/17
    • Lungs:
      • no interval change of a small subpleural solid nodule (7mm) at RLL-S9, a subpleural nodule (3mm) at LLL, and two subpleural solid nodules (up to 4mm) at RML as compared with previous CT on 2022/06/17.
      • minimal subpleural fibrosis at both lower lobes.
      • mild subpleural paraseptal emphysema at both apical lung regions.
    • Vessels:
      • mild calcified plaques of the LAD and right coronary arteries.
    • Visible abdominal-pelvic contents:
      • many hepatic and renal cysts (up to 2.0cm)
    • Visualized bones:
      • marginal spurs of multiple vertebrae due to spondylosis.
  • Impression: four small lung nodules up to 7mm, stationary, some may be intrapulmonary LNs.
• 2022-10-26 MRI - pelvis
  • Clinical history: 61 y/o male patient with Prostate NEC with rectal invasion s/p C/T.
  • With and without enhancement MRI: Pelvis
    • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Stationary.
    • Non-enhancing nodules in bilateral kidneys (up to 1.7cm in right kidney), r/o renal cysts.
  • Impression:
    • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Stationary.
    • R/O bilateral renal cysts.
• 2022-09-06 SONO - nephrology
  • Chronic renal parenchymal disease, mild degree
  • Bilateral renal cysts
• 2022-06-17 CT - abdomen, pelvis
  • Findings
    • Prior CT identifed a well-defined heterogeneous mass in between the rectum and prostage, measuring 9 cm in size, is noted again, marked decreasing in size that is c/w neuro-endocrine carcinoma S/P C/T with partial response.
    • Prior CT identified a soft tissue nodule at RLL of the lung measuring 7 x 4 mm at lung window setting is noted again, stationary. Follow up is indicated.
    • Liver and renal cysts (up to 2.0 cm).
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, and spleen.
  • Impression
    • Neuroendocrine carcinoma with rectum and prostate invasion S/P C/T shows partial response.
• 2022-04-08 MRI - brain
  • No evidence of intracranial lesion.
• 2022-03-11 Pure Tone Audiometry, PTA
  • PTA
  • Reliability FAIR
  • Average RE 30 dB HL; LE 36 dB HL.
  • R’t normal to moderate SNHL.
  • L’t normal to moderately severe SNHL.
• 2022-03-01 Patho - prostate needle biopsy
  • “pelvic tumor/peri-prostatic tumor, 9 cm with possible prostatic and recal invasion”, needle biopsy — neuroendocrine tumor.
  • IHC stains:
    • CD56 (+): neuroendocrine origin,
    • CK7 (- to equivocal), CK20 (-): dis-favor rectal adenocarcinoma,
    • vimentin (-): dis-favor sarcoma,
    • CD3 (-), CD20 (-): non-lymphoma,
    • PSA (-): non-prostatic origin.
    • Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma.
• 2022-02-24 Transrectal Ultrasound of Prostate, TRUS-P
  • huge pelvic mass with suspected prostate invasion
• 2022-02-24 Sigmoidoscopy
  • A hard, portuding lesion with intact mucosa was noted at rectum, anterior wall.
• 2022-02-21 CT - abdomen, pelvis
  • A heterogeneous enhancing tumor (9cm) at pelvic cavity with rectum and prostate invasion suspected malignancy.
  • A nodule (4mm) at RLL.

[MedRec]

• 2023-07-12 ~ 2023-07-16 POMR Hemato-Oncology
  • Discharge diagnosis
    • Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy with Etoposide/Carboplatin from 2022/03/14 to 2022/08/09 for 6 cycles with extracapsular, seminal vesicle and left pelvic side wall invasion and pelvic lymph nodes metastases s/p chemotherapy with Topotecan (1.5mg/m2) from 2023/05/12~    
    • Chronic viral hepatitis B without delta-agent
    • Gout, unspecified
    • Chronic kidney disease, stage 2 (mild)
    • Essential (primary) hypertension
  • CC
    • For further anti-cancer management
  • Present illness
    • This 62-year-old man patient suffered from anal protruding mass with pain and bleeding in 2022/02. The abdominal CT scan on 2022-02-21 showed a heterogeneous enhancing tumor (9cm) at pelvic cavity with rectum and prostate invasion, in addition with a suspicious metastatic nodule (4mm) at RLL. The sigmoidoscopy on 2022-02-24 showed the possibility of external compression, rectum and mixed hemorrhoid.
    • The TRUS biopsy for pelvic tumor was done on 2022-03-01 and the report of biopsy showed IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma, IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma.
    • Port-A catheter insertion was done on 2022-03-11. Chemotherapy with EP (Etoposide 80mg x3 days, Carboplatin AUC:6) on 2022/03/14(C1). 2022/04/08(C2), 2022/05/16(C3), 2022/06/14(C4), 2022/07/06(C5), 2022/08/09(C6). Brain MRI on 2022/04/08 showed no evidence of intracranial lesion. The follow-up abdominal CT scan on 2022-06-17 showed neuroendocrine carcinoma with rectum and prostate invasion S/P C/T shows partial response. Then he was treated with oral etoposide.
    • The follow-up Chest CT on 2023-04-25 showed prostate with regional organs involvement and pelvic metastatic LAP and lung metastases. Pelvis MRI on 2023-05-03 showed 1. Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Pelvic lymph nodes metastasis. With progression. 2. R/O bilateral renal cysts. He received chemotherapy with Topotecan (1.5mg/m2, D1~D5) (self pay) on 2023/05/12(C1), 2023/06/06(C2), 2023/06/28(C3). Taken altogether, his disease was in progression. Now, he was admitted to ward for palliative chemotherapy with Topotecan (C4) (reduce Topotecan dose (total dose 1.8mg) for prevention thrombocytopenia after chemotherapy) on 2023-07-12.
  • Course of inpatient treatment
    • After admitted, Palliative chemotherapy with Topotecan (C4) (reduce Topotecan dose (total dose 1.8mg) for prevention thrombocytopenia after chemotherapy) on 2023-07-12 ~ 2023-07-16.
    • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC. Chronic kidney disease, stage 2 (mild) (Cr.:1.26mg/dL, BUN:27mg/dL) with NS 500ml IVF BID and Pentop 1# po QD. Gout with Feburic 80mg 0.5# po QD. Hypertension with Concor 5mg/tab 1# PO QD.
    • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/07/16 and OPD followed up later.
  • Discharge prescription
    • Febric (febuxostat 80mg) 0.5# QD
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Acetal (acetaminophen 500mg) 1# PRNQ6H for fever, BT > 38’C or bone pain after G-CSF
    • Granocyte (lenograstim 250ug) QD SC on 2023/07/20, 2023/07/21, 2023/07/22
• 2023-06-13 SOAP Nephrology
  • S: UPCR < 0.1 -> 1.71 -> 1.43
  • Prescription x3
    • Pentop (pentoxifylline 400mg) 1# QD
• 2022-11-01 SOAP Nephrology
  • S: UPCR < 0.1
    • ChatGPT:
      • In the medical context, UPCR stands for Urine Protein to Creatinine Ratio. This is a test often used to estimate the amount of protein being excreted in the urine, and to assess and monitor kidney function.
      • Proteinuria (protein in the urine) is a common finding in many renal diseases. Creatinine, on the other hand, is a waste product that’s typically excreted at a constant rate.
      • The ratio of protein to creatinine can provide a good estimate of protein excretion over 24 hours without needing a 24-hour urine collection. High levels of protein in the urine, indicated by a high UPCR, can be a sign of kidney disease.
  • Prescription x2
    • Pentop (pentoxifylline 400mg) 1# QD
• 2022-10-04 SOAP Nephrology
  • S: Cr 1.89, add Trental (pentoxifylline) and follow up one month
  • Prescription
    • Pentop (pentoxifylline 400mg) 1# QD
• 2022-09-06 SOAP Nephrology
  • S
    • CKD for follow up
    • r/o carboplatin associated kidney injury, suggest follow up at regular interval
  • A/P
    • Admission for C/T EP on 2022-07-06. Using carboplatin due to impaired renal function
    • NEC, Stage IV

[consultation]

• 2022-05-10 Oral and Maxillofacial Surgery
  • Q
    • The 61y/o male has neuroendocrine carcinoma under chemotherapy. He has toothache at the second to last molar on the lower right. He took amoxicillin for 2-3 days, but in vain, so we need your help for management. Thanks!
  • A
    • Dear doctor, this is a 61-year-old male iwth neuroendocrine carcinoma and was admitted for chemotherapy.
    • He complained of biting pain recently and we are therefore consulted
    • After examiantion (radiologic study), fractured root of right lower first molar was noted
    • Assessment:
      • Tooth fractureo of #46
    • Plan:
      • Explain the findings to the patient and his family members
      • Premedication (Continue using the current inpatient antibiotic, Augmentin.)
      • Arrange extraction of tooth 46 on Thursday (05/12) in the morning.

[chemoimmunotherapy]

• 2023-07-27 - topotecan 1.5mg/m2 1.8mg NS 60mL 30min D1-5
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
• 2023-07-12 - topotecan 1.5mg/m2 1.8mg NS 60mL 30min D1-5 (even lower topotecan)
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
• 2023-06-28 - topotecan 1.5mg/m2 2.0mg NS 60mL 30min D1-2 + topotecan 1.5mg/m2 1.8mg NS 60mL 30min D3-5 (reduce dose for prevention thrombocytopenia after chemotherapy)
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
• 2023-06-06 - topotecan 1.5mg/m2 2.0mg NS 60mL 30min D1-5 (lower topotecan)
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
• 2023-05-12 - topotecan 1.5mg/m2 2.5mg NS 80mL 30min D1-5
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
• 2022-08-09 - etoposide 80mg/m2 140mg 1hr D1-3 + carboplatin AUC 6 450mg 2hr D1
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-07-06 - etoposide 80mg/m2 140mg 1hr D1-3 + carboplatin AUC 6 450mg 2hr D1
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-06-14 - etoposide 80mg/m2 137mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-05-16 - etoposide 80mg/m2 140mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-04-07 - etoposide 80mg/m2 139mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-03-14 - etoposide 80mg/m2 140mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

[reconciliation]

On 2023-07-07, the patient renewed prescriptions for bisoprolol and valsartan. Currently, only bisoprolol is listed as an active medication, and valsartan has not been included. As the patient’s blood pressure has consistently remained within the normal range during this hospital stay, there may not be an immediate need to reintroduce valsartan. Nevertheless, it is crucial to continue monitoring the patient’s blood pressure to assess if any further adjustments to the medication regimen are necessary.

[renal function follow-up]

This month (July), compared to previous months, the serum creatinine has returned to the normal range, and currently, no medications require renal dosage adjustment.

[thrombocytopenia]

Since starting topotecan on 2023-05-12, the patient has experienced several episodes of thrombocytopenia. Blood transfusions were administered on 2023-06-14, 2023-06-28, and 2023-07-27 in response to these events. In addition, the dosage of topotecan was sequentially reduced from 2.5 mg to 2.0 mg and then to 1.8 mg. Despite these measures, thrombocytopenia has been observed to date, but no PLT less than 50K/uL has been observed.

2023-07-25 PLT 90 10^3/uL
2023-07-11 PLT 94 10^3/uL
2023-06-28 PLT 474 10^3/uL
2023-06-20 PLT 89 10^3/uL
2023-06-12 PLT 390 10^3/uL
2023-06-01 PLT 95 10^3/uL
2023-05-25 PLT 15 10^3/uL
2023-05-10 PLT 283 10^3/uL
2023-04-27 PLT 244 *10^3/uL

2023-07-13

[reconciliation]

The patient recently renewed his prescriptions for bisoprolol and valsartan on 2023-07-07. Currently, only bisoprolol is incorporated into the active medication list, while valsartan has been left out. Given that the patient’s blood pressure measurements have consistently fallen within the normal spectrum during this hospital stay, reintroduction of valsartan may not be mandatory at this point. However, it remains important to continually monitor the patient’s blood pressure to establish whether further alterations in his medication regimen are warranted.

2023-06-29

[reconciliation]

• This patient regularly renews his prescriptions for Biso (bisoprolol) and Dafiro (valsartan, amlodipine) for his primary hypertension at a local pharmacy. Currently, the patient is only prescribed Concor (bisoprolol), with valsartan and amlodipine excluded. As the patient’s blood pressure readings have remained within the normal range during this hospitalization, it may not be necessary to reintroduce valsartan and amlodipine at this time. However, it is prudent to continue to monitor the patient’s blood pressure to determine if further adjustments to his medication regimen are necessary.

[thrombocytopenia]

• This patient initiated topotecan therapy on 2023-05-12, with two additional cycles administered on 2023-06-06 and 2023-06-28. The platelet levels are compiled in the following table, where “*” represents PLT < 100K/uL and “**” represents PLT < 50K/uL.

  • 2023-06-28 PLT 474 x10^3/uL
  • 2023-06-20 PLT 89 x10^3/uL *
  • 2023-06-12 PLT 390 x10^3/uL
  • 2023-06-01 PLT 95 x10^3/uL *
  • 2023-05-25 PLT 15 x10^3/uL **
  • 2023-05-10 PLT 283 x10^3/uL

• Intravenous Topotecan is linked with a considerable incidence of thrombocytopenia. As per UpToDate, Grade 4 thrombocytopenia occurs in 27% to 29% of patients. The lowest point (nadir) typically occurs around day 15, and the duration of the thrombocytopenia typically lasts for 3 to 5 days.

• The dose of topotecan was reduced from 2.5g to 2.0g starting from the second cycle and was further reduced to 1.8g for the last three days of the five-day administration period. This was a strategy intended to prevent further thrombocytopenia in the patient. In addition, blood transfusions were conducted on 2023-06-14 and 2023-06-28 to alleviate the impact of this side effect.

• Currently, the patient’s platelet count (PLT) is slightly above the ULN. Although there are no current signs of thrombocytopenia, it remains critical for the healthcare team to regularly monitor the patient’s CBC as is standard procedure.

2023-06-07

[reconciliation]

• This patient recently visited a local clinic on 2023-06-05 for acute tonsillitis and was prescribed cimetidine, acetaminophen, fenoterol, glycyrrhiza extract, and cetirizine. In addition, he was prescribed mefenamic acid and cresolsulfonate for his acute upper respiratory tract infection on 2023-06-01, with each prescription having a short duration of only 3 days. Since there are no related symptoms listed in the admission note or current medical problem list, there appear to be no medication reconciliation issues for these conditions.
• In addition, the patient’s prescription for bisoprolol and valsartan for hypertension management was refilled on 2023-04-28 at a local pharmacy. Currently, valsartan is not listed on the active medication list, but according to the TPR panel, the patient had no record of elevated blood pressure during this hospitalization. Therefore, there is no evidence that the current regimen of Concor (bisoprolol 5 mg) 1# PO is inappropriate.

[assessment]

• As the patient’s renal function is compromised, with a Cockcroft-Gault formula calculated CrCl of 44 mL/min, a review of the need of adjustment to the topotecan dose should be considered.
  • 2023-06-01 Creatinine 1.51 mg/dL
    
  • 2023-06-01 eGFR 50.02
    
  • 2023-06-01 BUN 39 mg/dL
• Suggestions for modifying topotecan dosage:
  • Manufacturer’s labeling (calculate CrCl with Cockcroft-Gault method using ideal body weight): CrCl >= 40 mL/minute: No dosage adjustment necessary.
  • Kintzel 1995: CrCl 46 to 60 mL/minute: Administer 80% of usual dose.
  • O’Reilly 1996b: CrCl >= 40 mL/minute: No dosage adjustment necessary in minimally pretreated patients; however, due to an increased potential for dose-limiting toxicities, reduce the dose from 1.5 mg/m2 to 1 mg/m2 in heavily pretreated patients.
• The dose of Topotecan given this time has been decreased by 20% from the 1.5mg/m2 administered on 2023-05-12. The current dosage appears to be without issue.

2022-08-10

• 2022-08-09 blood creatinine 1.66 mg/dL => CrCl 40 mL/min
• Etoposide for patients with CrCl 15 to 50 mL/minute: Administer 75% of normal dose.
• Entecavir for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours.

700787059

230728

[exam findings]

• 2023-06-29 CT - abdomen
  • History and indication:
    • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I s/p CCRT and chemotherapy with FOLFOX, s/p Low AR + loop ileostomy and Right hemicolectomy and chemotherapy with FOLFOX
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon operation. Some nodules at bil. lungs.
    • A poor enhancing lesion (2.5cm) at liver dome.
    • Renal cysts (up to 3.6cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • S/P colon operation. Some nodules at bil. lungs.
    • A poor enhancing lesion (2.5cm) at liver dome.
• 2023-06-24 CXR
  • Cardiomegaly is noted.
  • S/p port-A placement with its tip at Superior vena cava.
  • Tortous aorta with calcification is noted.
  • Faint aveolar opacity over left upper lobe is found.
  • Emphysematous change over both lungs.
• 2023-06-21 Joint soft tissue sonography
  • Left shoulder supraspinatus calcific tendinopathy
• 2023-06-16 Shoulder Lt
  • Normal bone alignment
  • moderate decreased left shoulder joint space
  • moderate left subacromial spur formation.
  • a nodular lesion in the left upper lung field
• 2023-04-04, -03-21, -03-17, -03-14 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • Old fracture of right clavicle shows mild angulation deformity but good union.
• 2023-03-27 Ga-67 Whole body inflammation scan with SPECT
  • The whole-body gallium-67 inflammation scan with SPECT was performed at the 24th and 48th hour after injecting 6 mCi of Ga-67 to the patient. The images showed increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hilar regions and in the posterior aspect of bilateral lower lung fields and in both kidneys.
  • IMPRESSION:
    • Increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hilar regions and in the posterior aspect of bilateral lower lung fields. Infection/inflammation involving these regions should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mildly increased radiotracer uptake in both kidneys. The nature is to be determined (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
• 2023-03-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (97.3 - 25.3) / 97.3 = 74.00%
    • M-mode (Teichholz) = 74.0
  • Conclusion:
    • Thickened AV with no AR
    • Thickened MV with mild MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Normal LV wall motion
    • No PR, trivial TR, normal IVC size
• 2023-03-11 CTA - chest
  • Findings
    • Bil. pleural effusion with adjacent lung collapse. Ground glass opacities at bil. lungs.
    • S/P operation. Minimal ascites.
    • Renal cysts (up to 3.6cm).
    • S/P Port-A infusion catheter insertion.
  • IMP
    • Bil. pleural effusion with adjacent lung collapse. Ground glass opacities at bil. lungs.
• 2023-03-11 ECG
  • Sinus tachycardia
  • Left bundle branch block
• 2023-03-10 KUB
  • Presence of ileus.
  • Degeneration and spondylosis of L-S spine.
• 2023-02-16 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Tumor, ascending colon, R’t hemicolectomy (s/p CCRT) — Mucinous adenocarcinoma
    • Resection margins, bilateral, ditto — Free of tumor invasion
    • Lymph node, mesocolic, dissection — Free of tumor metastasis (0/18)
    • Appendix — Free of tumor invasion
    • AJCC pathologic stage — ypT3N0, if cM0, stage IIA
  • MACROSCOPIC EXAMINATION
    • Operation procedure: R’t hemicolectomy
    • Specimen site: Ascending colon, terminal ileum and appendix
    • Specimen size: (a) A-colon: 27.7 cm in length, up to 8.4 cm in circumference, (b) Terminal ileum: 2.3 cm in length, 2.3 cm in diameter and (c) Appendix: 2.2 cm in length, 0.7 cm in diameter
    • Tumor size: 4.7 x 3.8 cm
    • Tumor location: ascending colon, 14.8 and 9 cm away from bilateral resection margins
    • Tumor appearance: protruding mass
    • Depth of invasion grossly: pericolonic fat
    • Representative sections as follows: A1: ileum + colonic resection margin, A2: appendix, A3-A6: tumor, A7-A10: lymph nodes
  • MICROSCOPIC EXAMINATION
    • Histology: mucinous adenocarcinoma
    • Histology Grade: G2, moderately differentiated
      
    • Depth of invasion: pericolonic fat
    • Angiolymphatic invasion: not identified
    • Perineural invasion: not identified
    • Discontinuous extramural tumor extension: not present
    • Circumferential (radial) margin of rectosigmoid: not involved
    • Lymph node metastasis, mesocolic: free of tumor metastasis (0/18)
    • Lymph node metastasis, IMA / SMA: N/A
    • Extranodal involvement: N/A
    • Pathological TNM Stage: ypT3N0
    • Type of polyp in which invasive carcinoma arose: N/A
    • Additional pathologic findings: mucin production
    • TNM descriptors: Y
    • Tumor regression grading S/P CCRT: grade 5
• 2023-02-16 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Tumor, rectum, laparoscopic LAR (s/p CCRT) — Adenocarcinoma
    • Resection margins, ditto — Free of tumor invasion
    • Lymph nodes, mesocolic, dissection — Tumor metastasis (1/6)
    • AJCC pathologic stage — ypT4aN1a, if cM0, stage IIIB
  • MACROSCOPIC EXAMINATION
    • Operation procedure: laparoscopic LAR
    • Specimen site: rectum
    • Specimen size: 7.7 cm in length, 3.1 cm in diameter
    • Tumor size: 1.5 x 1.3 cm with perforated hole 2.6 x 0.9 cm
    • Tumor location: 4.5 cm and 0.5 cm away from bilateral resection margins
    • Tumor appearance: subserosal nodule and perforated hole
    • Depth of invasion grossly: visceral peritoneum
    • Proximal margin: 3.2 x 1.2 x 0.9 cm
    • Distal margin: 1.8 x 1.3 x 0.9 cm
      
    • Representative sections as follows: A1-A3: perforated hole (ink) + subserosal tumor, A4-A6: perforated hole (ink) + mucosa, A7-A9: LNs, B: Proximal margin and C: distal margin
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
    • Histology Grade: G2, moderately differentiated
      
    • Depth of invasion: visceral peritoneum (<0.1 cm from serosa layer)
    • Angiolymphatic invasion: present
    • Perineural invasion: present
    • Discontinuous extramural tumor extension: absent
    • Circumferential (radial) margin of rectosigmoid: not involved
    • Lymph node metastasis, mesocolic: Tumor metastasis (1/6)
    • Lymph node metastasis, IMA / SMA: N/A
    • Extranodal involvement: not involved (0/1)
    • Pathological TNM Stage: ypT4aN1a
    • Type of polyp in which invasive carcinoma arose: N/A
    • TNM descriptors: Y
      
    • Tumor regression grading S/P CCRT: G3
• 2023-02-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 34) / 105 = 67.62%
    • M-mode (Teichholz) = 68
  • Conclusion
    • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Prominent posterior mitral annulus calcification with mild MR; mild aortic valve sclerosis .
    • Mild aortic root calcification with sessile atheromas.
• 2023-01-31 Sigmoidoscopy
  • Rectal cancer s/p CCRT , significant tumor regression
• 2023-01-26 CT - abdomen
  • History and indication:
    • Locally advanced rectal cancer with large pelvic LNs A-colon cancer with intussusception (no obstruction sign) –> Suggest pre-op CCRT for better resectability and local control, 20221205 RT finish
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Much regression of rectal and A-colon cancer and metastatic LAP. A tiny nodule at RML.
    • Renal cysts (up to 3.6cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • Much regression of rectal and A-colon cancer and metastatic LAP. A tiny nodule at RML.
• 2022-10-28 All-RAS + BRAF mutations assay
  • All-RAS mutations assay
    • Detection range
      • KRAS codon 12, 13, 59, 61, 117, 146
      • NRAS codon 12, 13, 59, 61, 117, 146
    • Results
      • Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • Interpretation
      • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • BRAF mutations assay
    • Detection range
      • BRAF codon 600
    • Results
      • There was no variant detected in the BRAF gene.
    • Interpretation
      • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
• 2022-10-24 CXR
  • Ground glass opacity in RLL.
• 2022-10-17 CT
  • Indication: synchronous rectal cancer and A-colon cancer
  • Findings
    • Chest:
      • Small lymph nodes are found at both sides of the mediastinum.
      • No evidence of bilateral pleural effusion.
      • Calcified coronary arteries is found.
      • The lung fields are clear.
      • No pleural effusion is found.
    • Visible abdomen:
      • DIffuse wall thickening at rectum about 4.2cm in length with regional lymphadenopathy is found. Rectal cancer is considered. Regional lymphadenopathy is found.
      • Annular lesion at ascending colon near hepatic flexure about 3cm is found. suspected colon cancer with intussusception.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • Non-specific bowel gas at abdominal cavity is found.
      • There is no evidence of destructive bone lesion.
      • No definite inguinal or pelvic sidewall LAP
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • Suggest clinical correlation
  • IMp:
    • Rectal cancer with regional lymphadenopathy, T4N2M0
    • Ascending colon cancer. T2N0M0.
• 2022-10-17 ECG
  • Normal sinus rhythm
  • Left axis deviation
• 2022-10-06 Patho - colorectal polyp
  • Colorectum, ascending colon, biopsy — Adenocarcinoma.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
• 2022-10-06 Patho - colorectal polyp
  • Colorectum, rectum about 11 cm above anal verge, biopsy — Adenocarcinoma.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
• 2022-10-06 Colonoscopy
  • Colon cancer, rectum, s/p biopsy
  • Colon polyp, sigmoid colon, s/p polypecotmy + cliping
  • Colon polyp, descending colon, s/p polypectomy + cliping
  • Colon cancer, ascending colon, s/p biopsy
  • Internal hemorrhoid

[MedRec]

• 2023-05-16 SOAP Metabolism and Endocrinology
  • Diagnosis
    • NIDDM with unspecified complication, not stated as uncontrolled [E11.8]
    • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
  • Prescription
    • Glimet (glimepiride 2mg, metformin 500mg) 0.5# BID
    • Trajenta (linogliptin 5mg) 1# QL
• 2023-03-11 POMR Cardiology
  • Discharge diagnosis
    • Severe sepsis with septic shock
    • Bacteremia with Serratia marcescens on 2023/03/11 and pan-drug resistant (PDR) Klebsiella pneumoniae on 2023/03/22
    • Port A catheter infection with pan-drug resistant (PDR) Klebsiella pneumoniae (by tip culture on 2023/03/24), status post removal on 2023/03/24
    • Urinary tract infection with urosepsis by urine culture grewed Enterobacter cloacae complex on 2023/03/11
    • Non-ST elevation myocardial infarction, favor Type 2 myocardial infarction by infection related
    • Type 2 diabetes mellitus
    • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 112/02/14
    • Iron deficiency anemia
    • Gastrointestinal (GI) bleeding (stool occult blood 1+)
    • Hypokalemia, resolved
    • Hypomagnesemia, resolved
    • Hypocalcemia, improving
    • Constipation
  • CC: fever and chillness at 20230311 night
  • Present illness
    • This 79 y/o male patient has the past history of
      • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 2023/02/14
      • Type 2 diabetes mellitus with OHA control
      • Postoperative Ileus
    • the patient regular follow up at our OPD and just admitted at our proctology service from 2023/02/14 to 2023/03/09 for his adenocarcinoma of the rectum operation.
    • According to the statement of the patient’s families and ER medical record. This time, the patient suffered from fever and chillness at 22:00, so he was sent to our ER on 20230310. At MER, his GCS was E4V5M6 and vital signs showed BP:149/76 mmHg; HR:120 BPM; BT:38.4’C; RR:20 BPM; SpO2:95%. Covid-19 rapid test showed negative. The patient complained upper back pain at 00:05. However, consciousness changed to GCS:E4V1M4 at 00:22 combined with cold sweating, air hunger and blood pressure couldn’t measure, so bosmin 1mg iv stat was given.
      • The laboratory disclosed increased in cardiac enzyme Troponin I:46.8->3918.7->14527.3pg/mL, CK:163ng/mL, D-dimer:7591.06ng/mL, Lactic acid:4.8mmol/L, CPR:1.15mg/dl, band:5.0%, urine analysis (NIT:2+, WBC:>=100 and bacteria:3+) and ABG showed hypoxia (PO2:31.7, SpO2:63.7%). CXR revealed presence of ileus. The first EKG showed sinus tachycardia, the secondary EKG (post Bosmin) showed ST depression in V4~V6, suspect AMI and the third and fourth EKG restored to normal sinus rhythm. Arranged chest CTA disclosed bilateral pleural effusion with adjacent lung collapse, ground glass opacities at bilateral lungs. Cardiology was consulted and who suggested that the subsequent ECG change is associated with bosmin effect, which will lead to transient vasoconstriction, not true MI. Also, KUB revealed presence of ileus and degeneration and spondylosis of L-S spine. Under the impression of Urinary tract infection with urosepsis, NSTEMI, he was admitted to MICU for further evaluation and management on 2023/03/11.
  • Course of inpatient treatment
    • After admitted to MICU, we administered empirical antibiotic with IV Cravit (03/11~03/15) according to his previous (2023/03/01) urine culture grew Enterobacter cloacae complex for infection control and IV hydration for favor poor intake with dehydration and septic shock status, DAPT with Bokey and plavix for AMI and PPI with Nexium for prevent stress ulcer.
      • Echocardiography was done on 03/13 disclosed LVEF: 74%, 1.Thickened AV with no AR; 2.Thickened MV with mild MR; 3.Normal LV chamber size and wall thickness; 4. Preserved LV and RV systolic function; 5.Normal LV wall motion; 6. No PR, trivial TR, normal IVC size. Later, hypokalemia and hypomagnesemia were found, thus 0.298%KCL in NaCL and MgSO4 were given. The blood culture x 2 set grew Serratia marcescens and urine culture grew Enterobacter cloacae complex, single dose of tapimycin was used first on 3/13 and INF was consulted to adjust antibiotic for his infection control. Hb drop from 9.5 to 7.7 g/dl was also found, LPRBC transfusion was given to correct anemia. His condition was relative stable, he was transferred to cardiology general ward for further care on 03/14.
    • At ordinary ward, his consciousness was alert but weakness and vital signs were stable, no dyspnea or chest discomfort was complained, respiratory pattern smooth under nasal cannula support. Cravit was changed to Tapimycin (03/13, 03/15) for his bacteremia with Serratia marcescens and UTI with Enterobacter cloacae complex. Continue to use other current medication to control the underlying disease and closely monitor his vital signs and clinical symptoms.
      • The INF recommend antibiotic treatment with Tienam or Mepem for S. marcescens bacteremia and E. cloacae UTI for 7 to 10 days, thus Tapimycin was shifted to Tienam used on 03/16. We also arrange thallium scan for CAD survey and stool OB, ion profiles examination for his anemia surveyed. Then stool OB was 1+ and iron profiles reported Fe 19 ug/dL, TIBC 272 ug/dL, UIBC 253 ug/dL, so we kept Nexium used and added Foliromin F.C. 50mg/tablet (Sodium Ferrous Citrate). The thallium scan was done on 2023/03/17, and reported probably mild myocardial ischemia at the inferoapical wall and inferolateral wall. Medical treatment was prescribed first.
    • Another episode of fever with chills developed at 23:21 on 03/21, Cravit was added. Gallium whole body inflammation scan was arranged for fever survey. The tracking initial blood culture on 03/22 report GNB. Tienam plus Cravit was changed to Doripenem (03/23~03/26) after contacting the infection doctor. Due to recurrent bacteremia, suspected to be related port-A infection, we consulted with a general surgeon, and port-A was removed on 03/24 with the signed consent of the family.
      • The 2023/03/22 blood culture officially reported as PDR-Klebsiella pneumonia, so Doripenem was changed to Tygacil plus UFO (fosfomycin) after contacting the infectious department. Later, port-A TIP culture on 03/24 also grew PDR-Klebsiella pneumonia. All Abx was shifted to Zavicefta since 03/28 by ID suggestion. Gallium inflammation scan on 2023/03/29 reported increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hailer regions and in the posterior aspect of bilateral lower lung fields. Infection/inflammation involving these regions should be watched out. We followed his blood culture results after 3 days of Zavicefta treatment (03/31) and results are pending.
      • During 7-day treatment course of Zavicefta, he had no fever or other infection signs. On 4/4, lab data were all within acceptable range. Blood culture on 3/31 also showed negative findings. Under the stable hemodynamic status, he was discharged on 4/6.
• 2023-01-03 SOAP Hemato-Oncology
  • S: 2022-11-14 RAS G12D
• 2022-12-14 Radiation Oncology
  • O
    • RT (2022-10-27 ~ 2022-12-05): 4500cGy/25 fractions (15MV photon) of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.
• 2022-11-24 Radiation Oncology
  • A/P
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-10-25
      • CCRT (Concurrent Chemoradiotherapy) first, then surgery.
      • For the liver nodule, it is suggested to evaluate with abdominal sonography for staging purposes.
• 2022-10-28 POMR Hemato-Oncology
  • Discharge diagnosis
    • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I
    • Malignant neoplasm of rectum
    • Type 2 diabetes mellitus with unspecified complications
    • Unspecified viral hepatitis B without hepatic coma
    • Other constipation
  • Present illness
    • This time, he admitted for concurrent chemoradiotherapy with 5-Fu on 2022/10/28 and 2022/10/31-2022/11/03 (5 days).
  • Course of inpatient treatment
    • After admission, CCRT with 5-Fu (225mg/m2 -> 350mg) x 5days on 2022/10/28, stop 2022/10/31-2022/11/03 treatment, change to FOLFOX regimen (Oxalip 85mg/m2 -> 110mg, Leucovorin 400mg/m2 -> 600mg, 5-Fu 2400mg/m2 -> 3700mg) from 2022/10/31 (well treatment for two site tumor), and explain to family (wife and son) and patient.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Type 2 diabetes mellitus with Monitor blood sugar QDAC
      • Glimet F.C 2mg/500mg/tab 1# PO BID.
      • Viral hepatitis B (Anti-HBc (+)) with Baraclude 0.5mg/tab 1# PO QDAC.
      • Constipation (suspect EMEND related, next cycle DC) with Bisacodyl supp 10mg/pill 2 supp RECT ST on 2022/11/02, Through 12mg/tab 1# PO HS, no stool passage add to 2# for MBD.
    • He can tolerance chemotherapy. The patient was discharged on 2022/11/03 under stable condition. ONC OPD follow up was advised.
• 2022-10-20 SOAP Radiation Oncology
  • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
• 2022-10-20 SOAP Colorectal Surgery
  • A
    • Locally advanced rectal cancer with large pelvic LNs
    • A-colon cancer with intussusception (no obstruction sign)
  • P
    • Suggest pre-op CCRT for better resectability and local control
• 2017-01-07 SOAP Metabolism
  • Diagnosis
    • NIDDM with unspecified complication, not stated as uncontrolled [E11.8]
    • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
  • Prescription
    • Pitator (pitavastatin 2mg) 1# QD
    • Glimet (glimepiride 2mg, metformin 500mg) 0.5# TID

[consultation]

• 2023-03-15 Infectious Disease
  • Q
    • for Serratia bacteremia
    • This 79 y/o male patient has the past history of
      • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 2023/02/14
      • Type 2 diabetes mellitus with OHA control
      • Postoperative Ileus
    • This time,the impression of
      • Urinary tract infection with urosepsis (20230301 urine culutre yeild Enterobacter cloacae complex)
      • NSTEMI
      • Syncope, suspect dehydration related
    • He was admitted to MICU for further evaluation and management on 2023-03-11. We gave empirical antibiotic with Cravit (since 20230311) used. His Blood culture (20230311) yeild serratia marcescens. We really need your experience for treatment suggestion, thanks!!!
  • A
    • Hx review as mentioned above and Lab data check
    • Suggestion:
      • Recommend antibiotic Rx with Tienam or Mepem for S. marcescens bacteremia and E. cloacae UTI for 7 to 10 D
      • Repeat B/C
      • Monitor CRP
• 2023-03-11 Cardiology
  • A
    • This patient presented with sepsis syndrome in advanced colon C, not acute coronary syndrom
      • The CXR didnot show medistianl wideing, the aortic dissection is less likely
      • The subsequent ECG change is associated with bosmin effect, which will lead to transient vasoconstriction
      • not true MI
    • please treat underlying diseae, maintain optimal Bp
      • f/u echocardiography for wall motin assessment
• 2023-03-07 Dermatology
  • Q
    • For bilateral perianal skin rash
    • This is a 79-year-old male with past history of synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy.
      • He went through low anterior resection, loop ileostomy and right hemicolectomy on 20230215.   
      • During the surgery, advanced rectal cancer s/p CCRT , tumor dense invasion/adhesion to anterior pelvic wall, LN enlarged Narropw pelvis was found.
      • After surgery, ileus was noted and NG decompression was applied. Now NG has been removed.
    • However, he experienced bilateral multiple perianal rash for 2 days.
      • The rash was painless but pruritus.
      • No vesicles were noted.
      • Mycomb was applied for now.
    • We need your expertise for further evaluation. Thank you so much for your help.
  • A
    • The patient had sufferred from annular lesions with peripheral active borders on the bilateral thigh and genital area.
      
    • Under the impression of tinea cruris et intertrigo eczema.
    • The following suggetion:
      • Exelderm cream 1 tube topical QN use over large area of lesions after body clean and Mycomb cream 1 tube topical PRN Bid use over regional erythema itchy area.
        
      • keep body dry, clean and avoid further friction or compression.

[radiotherapy]

• 2022-10-27 ~ 2022-12-05 - 4500cGy/25 fractions (15MV photon) of the pelvic, and 4680cGy/26 fractions of the rectal tumor bed area. (20221201 OPD)

[chemoimmunotherapy]

• 2023-05-12 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-04-21 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-01-06 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-12-21 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-07 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-25 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-14 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-31 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-28 - fluorouracil 225mg/m2 350mg NS 250mL 10min D1-5 (CCRT)
  • [dexamethason 4mg + NS 250mL] D1-5

==========

2023-07-28

Glimet (glimepiride, metformin) and Trajenta (linagliptin) were refilled on 2023-07-05 as a repeat prescription prescribed by our endocrinologist on 2023-05-16. Both medications have been added to the active medication list without any identified issues.

At 20:14 on 2023-07-27, there was a spike in blood glucose to 269 mg/dL. If this elevation persists, it may require re-evaluation and possible modification of the antidiabetic treatment plan.

There appears to be an upward trend in liver enzyme levels. Given this situation, the addition of BaoGan (silymarin) could be considered as an optional measure if there are no other specific concerns.

2023-07-25 S-GPT/ALT 73 U/L
2023-07-13 S-GPT/ALT 50 U/L
2023-07-13 S-GPT/ALT 51 U/L
2023-06-28 S-GPT/ALT 31 U/L
2023-06-15 S-GPT/ALT 28 U/L

2023-07-25 S-GOT/AST 49 U/L
2023-07-13 S-GOT/AST 34 U/L
2023-07-13 S-GOT/AST 33 U/L
2023-06-28 S-GOT/AST 26 U/L
2023-06-15 S-GOT/AST 27 U/L

2023-06-29

• According to the PharmaCloud database, our hospital has been the sole provider of the patient’s medical services for the past three months. On 2023-06-24, our Thoracic Department issued a 7-day prescription for Curam (amoxicillin, clavulanic acid), Actein (acetylcysteine), Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), and MgO. Due to changes in the patient’s condition, Curam and MgO are not currently on the active formulary, indicating that these medications may no longer be needed. Therefore, no evidence of medication reconciliation discrepancies was identified.

700193556

230727

[diagnosis] - 2023-04-18 admission note

• Malignant neoplasm of retroperitoneum
• Retroperitoneum extraskeletal Ewing sarcoma, s/p tumor resection 2022/11/18, pT2N0M0, Stage IIIA
• Chronic viral hepatitis B without delta-agent
• Hypertension
• Anxiety disorder, unspecified
• Generalized anxiety disorder
• Dysthymic disorder

[past history] - 2023-04-18 admission note

• Hypertension,under medication control
• s/p LM on 2018-07
• Dysthymic disorder,under medication control
• s/p hernia operation
• s/p uterine myoma operation
• TAE, open radical nephrectomy,partial intestine resection were performed on 2022/11/17, 11/18

            

[allergy]

Demerol 50 mg/1 mL/amp (Meperidine):anaphylactic shock

[family history]

Father:DM No cancer, CVA, CAD history in her family

[exam findings]

• 2023-04-12 MRA - abdomen
  • History
    • 20221107 CT: A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis. R/O liposarcoma
    • 20221121 PATHO - Kidney total resection
      • Retroperitoneum, tumor excision — Compatible with extraskeletal Ewing sarcoma/primitive neuroectodermal tumor (PNET)
      • Kidney, left, radical nephrectomy — Focal infarction and free of tumor involvement
        
      • Pathologic stage: pT2N0G2; Stage IIIA if cM0
      • refer to oncology and RT
        
  • Findings:
    • S/P left nephrectomy.
    • There are several hepatic cysts in both lobes and the largest one 1.8 cm in size at S3.
    • Two gallstones (up to 1.3 cm) are noted.
    • Tiny renal cysts on right kidney.
    • There is no focal abnormality in the biliary system, pancreas, spleen.
      
    • There is no evidence of ascites or lymphadenopathy.
      
    • The abdominal aorta and IVC are grossly unremarkable.
      
  • IMP:
    • S/P left nephrectomy.
    • There is no evidence of tumor recurrence.
• 2023-03-15 SONO - nephrology
  • Chronic change with right small sized kidney.
  • Abscent of left kidney.
• 2023-02-20 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 24) / 78 = 69.23%
    • M-mode (Teichholz) = 68
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
• 2022-12-10 SONO - Joint soft tissue
  • Finding:
    • Focal engorgement and non-compressible to probe of left cephalic vein
    • Hyperechoic lesion was noted within left cephalic vein; however, partial flow was still noted
  • Impression And Suggestions:
    • Suspected left cephalic vein thrombosis
• 2022-11-21 Patho - kidney partial/total resection
  • PATHOLOGIC DIAGNOSIS
    • Retroperitoneum, tumor excision — Compatible with extraskeletal Ewing sarcoma/primitive neuroectodermal tumor(PNET)
    • Kidney, left, radical nephrectomy — Focal infarction and free of tumor involvement
      
    • Pathologic stage: pT2N0G2; Stage IIIA if cM0
      
  • MACROSCOPIC EXAMINATION
    • Procedure: Radical nephrectomy + retroperitoneal tumor excision
    • SpecimenSize: 16.5 x 12.3 x 5.6 cm and 590 gm, including left kidney: 9.5 x 5.9 x 4.8 cm and Gerota fascia: 2.5 cm in thickness
    • Tumor Site: Retroperitoneum
    • Tumor Size: 7.0 x 6.2 x 4.5 cm
    • Gross Tumor Pattern: Well circumscribed, dark brown and hemorrhagic mass
    • Representative parts are taken for section and labeled: A1= margins, A3-A10= tumor, A11= Retroperitoneal soft tissue, A12= kidney.
  • MICROSCOPIC EXAMINATION
    • Histologic type: Compatible with extraskeletal Ewing sarcoma/PNET
      
    • Mitotic rate: 5/10 high power fields
      
    • Necrosis: Present (5%)
    • Histologic Grade (FNCLCC): Grade 2
      • Tumor Differentiation: Score=3
      • Mitosis Count: Score=1 (0 to 9 mitosis per 10 HPF)
      • Necrosis: Score=1 (<50%)
    • Margins: Free; Distance of sarcoma from closest margin: 0.1 cm
      
    • Lymphvascular invasion: Present
      • Renal artery invasion: Present
        
    • Pathologic staging
      • Primary tumor: pT2 (tumor > 5 cm and <=10 cm)
        
      • Regional lymph nodes: Negative (0/4 regional LN) (Number of involved/Number of examined)
      • Distant metastasis: Not applicable
    • IHC: Cytokeratin(-), LCA(-), S100(-), CD56(focal+), Synaptophysin(-), and CD99(strong and diffuse membrane staining)
    • Kidney: Free of tumor with mild interstitial nephritis and focal infarction
• 2022-11-21 Patho - small intestine resection for tumore
  • Small intestine, jejunum, segmental resection – Heterotopic pancreas
  • The sections show a picture of heterotopic pancreas, composed of nests of admixture of pancreatic acini, ducts and islets in submucosa and mascularis propria. The adjacent small intestine shows mild acute serositis.
• 2022-11-17 Embolization (TAE) - abdomen
  • TAE of left renal artery via right common femoral artery puncture using Seldinger technique revealed:
    • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
    • Under local anesthesia, a 4 Fr arterial sheath was inserted into right common femoral artery smoothly.
    • The RH-catheter was inserted into left renal artery.
    • No definite tumor stain.
    • TAE of left renal artery was performed using 10mg some gelfoam pieces.
    • No procedure-related complication during the whole procedure. Thanks for your further care.
• 2022-11-16 CXR
  • Intimal calcification of thoracic aorta.
• 2022-11-07 CTA - abdomen
  • History and indication: left retroperitoneal massfor evaluation and surgery
  • With and without contrast CT of abdomen-pelvis revealed:
    • A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
    • Colonic diverticula.
    • Grade 4 fatty liver with left liver cyst (1.8cm).
    • Tiny renal cysts.
    • Normal appearance of spleen, pancreas, adrenals.
    • Gallbladder stones (up to 1.3cm).
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral basal lungs.
  • IMP:
    • A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
• 2022-10-31 Whole body PET scan
  • The left retroperitoneal tumor shown on the previous abdomen MRI reveals mildly increased FDG uptake; the nature is to be determined (liposarcoma or others ?), suggesting biopsy for further investigation.
    
  • Glucose hypermetabolic lesions in the esophagus, D/3 and bilateral palatine tonsils, probably chronic inflammation process, suggesting follow-up.
    
  • Glucose hypermetabolism in level II lymph nodes of bilateral cervical regions, probably reactive nodes.
  • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    
  • No other focal area of abnormal increased FDG uptake from head to bilateral thigh regions.
• 2022-10-29 Gynecologic ultrasonography
  • Uterus Position: AVF
    • Size: 69 x 33 mm
  • Endometrium
    • Thickness: 4.0 mm
  • Cul-De-Sac: No fluid
  • Bilateral adnexae: free
  • IMP: EM 4.0 mm
• 2022-10-13 Myocardial perfusion SPECT with treadmill
  • The Tc-99m MIBI stress myocardial perfusion SPECT performed after stress revealed mildly decreased perfusion of radioactivity to the apex of LV. The Tc-99m MIBI rest myocardial perfusion SPECT revealed reperfusion of radioactivity to the defect. The stress and rest LVEFs were 90% and 90%, respectively. The cine wall motion study revealed synchronized contraction of LV.
  • IMPRESSION:
    • Probably mild myocardial ischemia at the apex of LV.
    • Normal performance of global LV cardiac function.
• 2022-10-13 CT - low dose for lung cancer screening, without contrast
  • Low dose spiral CT of the chest without contrast enhancement for screening of lung tumor showed:
    • Lungs: Paraspinal fibrotic change at right lower lobe is found.
      • Minimal wedge shaped infiltration at left lower lobe, r/o recent inflammation.
  • IMP: Right lower lobe paraspinal fibrosis. Suspected focal fibrosis at left lower lobe
• 2022-10-13 MRI - cerebrovascular
  • Without-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial FLAIR images and axial DWI), cerebral TOF MRA revealed:
    • Mild brain atrophic change. Mild periventricular white matter small vessel disease.
      
    • Tortuosity of intracranial and extracranial arteries in MRA studies (including bilateral subclavian arteries, CCAs, ICAs, ECAs, MCAs, ACAs, PCAs and VAs and BA).
  • IMP: Mild Brain atrophy. Mild periventricular white matter small vessel disease. Mild arteriosclerosis with vessel tortuosity.
• 2022-10-13 MRI - upper abdomen with and without contrast
  • Imaging study of upper abdomen for health examination revealed:
    • Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, suspected liposarcoma or others.
    • Hepatic cyst at left lobe liver up to 2.1cm is found.
  • IMP:
    • Retroperitoneal tumor at left side, 7.3cm, r/o liposarcoma. Suggest further treatment.
• 2022-04-16 Gynecologic ultrasonography
  • Uterus Position: AVF
    • Size: 58 x 35 mm
  • Endometrium
    • Thickness: 3.2 mm
  • Cul-De-Sac: No fluid
  • Bilateral adnexae: free
  • IMP: EM 3.2 mm
• 2020-08-08 Gynecologic ultrasonography
  • Uterus Position: AVF
    • Size: 55 x 33 mm
  • Endometrium
    • Thickness: 4.3 mm
  • Cul-De-Sac: No fluid
  • Bilateral adnexae: free
  • IMP: EM 4.3 mm

[MedRec]

• 2023-02-17 ~ 2023-02-21 POMR Hemato-Oncology
  • Discharge diagnosis
    • Malignant neoplasm of retroperitoneum
    • Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0
    • Positve of anti-HBc
    • Anxiety
  • Present illness
    • This is a 59-year-old female with past history of
      • Hypertension, under medication control
      • s/p LM on 2018-07
      • Dysthymic disorder, under medication control
      • s/p hernia operation
      • s/p uterine myoma operation
    • According to the patient,left kidney tumor was noted after examination. She came to our uro OPD for further examination. MRI showed Retroperitoneal tumor at left side, 7.3cm, r/o liposarcoma.Surgery was suggested.
      • 2022/10/31 PET scan showed 1. The left retroperitoneal tumor shown on the previous abdomen MRI reveals mildly increased FDG uptake; the nature is to be determined (liposarcoma or others ?) 2. Glucose hypermetabolic lesions in the esophagus, D/3 and bilateral palatine tonsils, probably chronic inflammation process, suggesting follow-up. 3. Glucose hypermetabolism in level II lymph nodes of bilateral cervical regions, probably reactive nodes. 4. Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
      • 2022/11/07 Abdomen CTA showed a heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
      • 2022/11/17 Abd TAE was done and smooth.
      • 2022/12/26 Focal engorgement and non-compressible to probe of left cephalic vein showed suspected left cephalic vein thrombosis.
    • RT to the preOP tumor bed (Lt kidney region): 36 Gy/ 18 fx since 2022/12/14-2023/01/22.
    • Under the impression of Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0, so she was admission for adjuvant C/T on 2023/02/17.
  • Course of inpatient treatment
    • After admission, she received Baraclude 0.5mg/tab (Entecavir) 1# qdac for postive og anti-HBc. Anxiety improves after session with psychologist before chemotherapy. Regimen Q3W as alternating between team A and B every three weeks for approximately 17 times.
      • Team A = Vincristin 2mg (D1) 10 mins + Adriamycin 37.5mg/m2 (D1-D2) 15 mins + Endoxan 1200mg/m2 (D1) 1 hour on 2023/2/20-2/21.
      • Team B = IFx 1800mg/m2 (D1-D5) drip 1 hour + VP-16 100mg/m2 (D1-D5) drip 1-2 hrs (next time).
    • Under the stable condition without GI tract problem, so she can be discharge on 2023/02/21. OPD follow up is arranged.
• 2023-01-19 SOAP Hemato-Oncology
  • O: s/p adjuvnat R/T with 44 Gy/ 22 fx to the pre-OP tumor bed, from 2202-12-13 or -14 to 2023-01-12
• 2022-12-22 SOAP Hemato-Oncology
  • A/P
    • Strategy: Adjuvant R/T followed by adjuvant C/T
    • Already suggest discuss with her psychiatrist for the phobia of C/T
• 2022-12-06 SOAP Radiation Oncology
  • Plan: Adjuvant RT then adjuvant C/T is suggested. CT-simulation will be arranged on 2022/12/08. Plan to deliver 44~45 Gy/ 22~25 fx to the preOP tumor bed. RT will start around 12/12 or 13.

[consultation]

• 2023-03-15 Nephrology
  • Q
    • This is a 59-year-old female with past history of
      • Hypertension, under medication control
      • s/p LM on 2018-07
      • Dysthymic disorder, under medication control
      • s/p hernia operation
      • s/p uterine myoma operation.
    • Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0, she received adjuvant chemotherapy on 2023/02/20-21(C1).
      • Regimen Q3W as alternating between team A and B every three weeks for approximately 17 times.
        • Team A = Vincristin 2mg (D1) 10mins + Adriamycin 37.5mg/m2 (D1-D2) 15mins + Endoxan 1200mg/m2 (D1) 1hour on 2023/2/20-2/21.
        • Team B = IFx 1800mg/m2 (D1-D5) drip 1hour + VP-16 100mg/m2 (D1-D5) drip 1-2hrs (next time).
    • This time, she suffered from poor intake for 2 weeks. Blood analysis showed Impaired renal function (BUN/Cr: 39/2.19 mg/dl and hyperkalemia: 5.2 mmol/L)
    • For acute kidney injury, favor dehydration due to poor intake related, we need your further evaluation and management.
  • A
    • This 59-year-old madam with a history of retroperitoneum sarcoma, s/p operation, pT2N0G2; Stage IIIA if cM0, received adjuvant chemotherapy (Vincristine, Adrimycin, Endoxan) on 2023/2/20-21(C1). I’m consulted for impaired renal function. The patient stated her appetite was decreasing after last hospitalization, but she tried to drink water around 2000ml per day and she ate fish, eggs and mild with salty flavor recently. She has started taking Entecavir and Chinese herbal medicine recently. She denied use of medications from other hospital, LMD or pharmacy. She also did not use of NSAIDs recently. There’s no fever, chills, diarrhea, decreasing urine output, or obvious body weight loss. Renal echo on 2023/03/15 shows no evidence of hydronephrosis of right kidney.
    • Impression: AKI, dehydration? Medication (Chinese herbal medicine or entecavir)?
    • Suggestion:
      • Hydration with saline based intravenous fluid, such as D5S or NS and follow up her renal function. You could also follow up serum calcium next time while checking the laboratory data.
      • Check urinalysis.
      • May temporarily discontinuation of Chinese herbal medicine if renal funcition dose not improve or even worse.
    • Thank you for your consultation. I’ll follow up this patient.
• 2022-11-24 Cardiology
  • Q
    • For hypertension control
    • This is a 59-year-old female with past history of
      • Hypertension, under Norvasc 1# QD, Cardiolol 1# QD (previously PRNQD), Atanaal PRNQ8H, control
      • s/p LM on 2018-07
      • Dysthymic disorder
      • s/p hernia operation
      • s/p uterine myoma operation
    • This time she was admitted for TAE (2022/11/17) and open radical nephrectomy (2022/11/18).
    • In recent 4 days,her BP control was not good,highest up to 180-190.
    • She suffered from stomache distension, GERD-like sensation,nausea, vomitting in recent three days. Pantoprazole and imperan was prescribed
    • 2022/11/21: Creatinine: 1.37, eGFR: 41.94, CrCl 48, height: 158cm, weight: 72.4kg
    • We consult for your further evaluation and management, thank you!
  • A
    • I was consulted for poor BP control
    • O
      • Formerly controoled with Norvasc 1# QD and inderal 1# QD
      • Lab
        • 2022-11-21 BUN 8 mg/dL
          
        • 2022-11-21 Creatinine 1.37 mg/dL
          
        • 2022-11-19 BUN 26 mg/dL
          
        • 2022-11-19 Creatinine 1.94 mg/dL
          
      • EKG: NSR
      • CXR: normal heart size
    • Impression:
      • Hypertension, poor contorl
    • Sugggestion:
      • The causes of poor control of BP during admission, including insomnia, pain, NS hydration, abdomen distension and any other discomfort, if present such problem, please correct it.
      • May uptitrate Norvasc to 1# BID PO
      • if high BP > 150/90 mmHg still, may add Carvedilol (6.25) 1# BID PO
• 2022-11-22 Psychosomatic medicine
  • Q
    • For post-op anxiety evaluation and medication adjustment.
    • This is a 59-year-old female with past history of
      • Hypertension,under medication control
      • s/p LM on 2018-07
    • She had regular follow up in our psy OPD before, and was diagnosed with dysthymic disorder, and GAD.
    • Medication Zoloft 1# QD and Eurudin 0.5# HS was used now.
    • This time,under the impression of left kidney tumor, suspected liposarcoma, she was admitted to our ward for scheduled TAE (2022/11/17), open radical nephrectomy and resection of segmental of small intestine (2022/11/18).
    • After operation, she complained about having nightmare during these days. She was abnormally sensitive to pain and very scared, even scared of nurses.
    • She is in a very anxious mood. We consulted for your further evaluation and management, thank you!
  • A
    • This 59 y/o married woman, now still work as an administrative staff, has been followed up in our PSY OPD since 2020/07 for low and anxious mood, anhedonia, insomnia, psychomotor retardation, muscle tension, distracted attention, fatigue, guilty feeling or inattention, suicidal and negative thinking for more than 6 months. Stressor: the passing of her mother at that time. After regularly took meds in our PSY OPD, her mood symptoms improved, but still has decreased sleep lasting: only sleeping for 3 hours, because she didn’t want to rely on sleeping pills, she took only half a tablet of Eurodin.
    • In recent few days, she developed low and anxious, even agitated mood, hypervigilance, decreased frustration tolerance, phobic and avoidant behaviors, guilty feelings, worthlessness feelings, grief reaction, suicidal ideation, rumination of the past events, following the stressors: her father passed away recently, she has to be hospitalized and can’t participate in the funeral arrangements, experienced sudden pain during TAE and was shocked by the doctor’s reaction, felt terrible because she was too scared and it took three attempts to complete the examination, felt extremely nervous and scared about undergoing invasive treatments, cried when the TAE area hurt, and thought about jumping off a building at that time.
    • She also had transient VH following the procedure, seeing ice cream and SpongeBob. (ChatGPT: In the context of psychology or psychotherapy, “VH” typically stands for “vividness of mental imagery” or “vividness of hallucinations.”)
    • MSE: tearfulness, low and anxious mood, distressful feelings, anticipatory anxiety about the following procedure: removing stitches.
    • IMP:
      • Adjustment reaction with anxious and fearfulness mood
      • r/o Persisted depressive disorder
      • Generalized anxiety disorder
    • Suggestion:
      • Carthasis and mental support, discuss the coping skill.
      • Keep Zoloft and Eurodin. Anxiedin 0.5mg 1# BID. Alprazolam 0.5mg 1# PRNQ8H if anxious or before procedure.
      • Arrange PSY OPD follow up.
• 2022-11-18 Diagnostic Radiology
  • Q
    • This is a 59-year-old female with past history of
      • Dysthymic disorder
      • s/p hernia operation
      • s/p uterine myoma operation
    • This time she was admitted for TAE and open radical nephrectomy.
    • 2022/10/13 MRI: Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, r/o liposarcoma or others
    • 2022/11/07 CTA: Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, r/o liposarcoma, suspect Psoas muscle invsion and renal vessel invasion.
    • We consulted for left kidney and Tumor TAE,thank you !
  • A
    • According to the clinical history and imaging findings, TAE is indicated.

[chemotherapy]

• 2023-07-26 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
• 2023-07-06 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 1650mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 120mg NS 500mL 2hr] D1-3 (less ifosfamide)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
• 2023-06-19 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
• 2023-05-24 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 2000mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 130mg NS 500mL 2hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
• 2023-04-18 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
• 2023-03-20 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 2000mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 130mg NS 500mL 2hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
• 2023-02-20 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophosphamide 1200mg/m2 2000mg NS 500mL D1
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Granocyte (lenograstim 250ug) CGRAN01

• 2023-04-23 3# 2023-04-18 IPD
• 2023-03-28 3# 2023-03-28 OPD
• 2023-03-27 3# 2023-03-14 IPD
• 2023-03-25 2# 2023-03-25 EPD
• 2023-03-24 2# 2023-03-14 IPD
• 2023-03-14 1# 2023-03-14 IPD
• 2023-03-07 2# 2023-03-07 OPD
• 2023-03-01 3# 2023-03-01 OPD

WBC

• 2023-04-11 WBC 6.19 x10^3/uL 2023-04-23 G-CSF x3
• 2023-03-28 WBC 1.93 x10^3/uL * 2023-03-28 G-CSF x3
• 2023-03-23 WBC 2.23 x10^3/uL * 2023-03-24 G-CSF x2, 2023-03-25 G-CSF x2, 2023-03-27 G-CSF x3
  
• 2023-03-20 WBC 12.17 x10^3/uL 2023-03-20 ifosfamide + etoposide
• 2023-03-19 WBC 28.21 x10^3/uL
  
• 2023-03-17 WBC 1.99 x10^3/uL *
  
• 2023-03-14 WBC 3.29 x10^3/uL 2023-03-14 G-CSF x1
  
• 2023-03-07 WBC 2.41 x10^3/uL * 2023-03-07 G-CSF x2
  
• 2023-03-01 WBC 0.35 x10^3/uL * 2023-03-01 G-CSF x3
• 2023-02-17 WBC 3.17 x10^3/uL 2023-02-20 vincristine + doxorubicin + cyclophosphamide
  
• 2023-01-19 WBC 3.65 x10^3/uL

VDC/IE (vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide) - Bone Cancer - Version 3.2023 - 2023-04-04 - https://www.nccn.org/professionals/physician_gls/pdf/bone.pdf - BONE-B, 2 OF 6, p27

• ref
  • Addition of ifosfamide and etoposide to standard chemotherapy for Ewing’s sarcoma and primitive neuroectodermal tumor of bone. N Engl J Med 2003;348:694-701.
  • Randomized controlled trial of interval compressed chemotherapy for the treatment of localized Ewing sarcoma: A report from the Children’s Oncology Group. J Clin Oncol 2012;30:4148-4154.

Treatment for Localized Disease, Neoadjuvant chemotherapy - Treatment of Ewing sarcoma - 2023-06-20 - https://www.uptodate.com/contents/treatment-of-ewing-sarcoma

• Interval-compressed VDC/IE
  • For patients age <18 years with localized ES, we recommend interval-compressed therapy with alternating cycles of vincristine/doxorubicin/cyclophosphamide (VDC) and ifosfamide/etoposide (VDC/IE) given every two weeks with hematopoietic growth factor support, rather than every three weeks without growth factor support.

Interval compressed chemotherapy for Ewing sarcoma - 2023-06-20 - https://www.uptodate.com/contents/image?topicKey=ONC%2F7740&imageKey=ONC%2F110260

• ref
  • Protocol supplement from: Womer RB, West DC, Krailo MD, et al. Randomized controlled trial of interval-compressed chemotherapy for the treatment of localized Ewing sarcoma: a report from the Children’s Oncology Group. J Clin Oncol 2012; 30:4148. Available at: http://ascopubs.org/doi/suppl/10.1200/jco.2011.41.5703/suppl_file/Protocol_JCO.2011.41.5703.pdf (Accessed on November 29, 2016).
• Induction chemotherapy
  • Regimen A
    • Timing
      • Weeks 1, 5, and 9
    • Drug
      • Vincristine
        • 2 mg/m2 (maximum 2 mg)
        • IV over 1 minute
        • day 1
      • Doxorubicin
        • 37.5 mg/m2
        • IV over 1 to 15 minutes
        • days 1 and 2
      • Cyclophosphamide
        • 1200 mg/m2
        • IV over 30 to 60 minutes
        • day 1, with mesna
      • Filgrastim
        • 5 mcg/kg per day (maximum 300 mcg)
        • starting day 3
          • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
  • Regimen B
    • Timing
      • Weeks 3, 7, and 11
    • Drug
      • Ifosfamide
        • 1800 mg/m2
        • IV over 1 hour
        • days 1 to 5, with mesna
      • Etoposide
        • 100 mg/m2
        • IV over 1 to 2 hours
        • days 1 to 5
      • Filgrastim
        • 5 mcg/kg per day (maximum 300 mcg)
        • starting day 6
          • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
• Consolidation chemotherapy (Local therapy between weeks 13 and 15. Surgery at week 13, if it is planned. Start of RT delayed to week 15 if surgery also undertaken.)
  • Regimen A
    • Timing
      • Surgery alone - Weeks 15 and 19
      • RT alone - Weeks 13 (with the start of RT) and 25
      • Surgery and RT - Weeks 15 (with the start of RT) and 27
    • Drug
      • Vincristine
        • 2 mg/m2 (maximum 2 mg)
        • IV over 1 minute
        • day 1
      • Doxorubicin
        • 37.5 mg/m2
        • IV over 1 to 15 minutes
        • days 1 and 2
      • Cyclophosphamide
        • 1200 mg/m2
        • IV over 30 to 60 minutes
        • day 1, with mesna
      • Filgrastim
        • 5 mcg/kg per day (maximum 300 mcg)
        • starting day 3
          • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
  • Regimen B
    • Timing
      • Surgery alone - Weeks 17, 21, 25, and 29
      • RT alone - Weeks 15, 19, 23, and 27
      • Surgery and RT - Weeks 17, 21, 25, and 29
    • Drug
      • Ifosfamide
        • 1800 mg/m2
        • IV over 1 hour
        • days 1 to 5, with mesna
      • Etoposide
        • 100 mg/m2
        • IV over 1 to 2 hours
        • days 1 to 5
      • Filgrastim
        • 5 mcg/kg per day (maximum 300 mcg)
        • starting day 6
          • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
  • Regimen C
    • Timing
      • Surgery alone - Weeks 23 and 27
      • RT alone - Weeks 17 and 21
      • Surgery and RT - Weeks 19 and 23
    • Drug
      • Vincristine
        • 2 mg/m2 (maximum 2 mg)
        • IV over 1 minute
        • day 1
      • Cyclophosphamide
        • 1200 mg/m2
        • IV over 30 to 60 minutes
        • day 1, with mesna
      • Filgrastim
        • 5 mcg/kg per day (maximum 300 mcg)
        • starting day 3
          • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.

==========

2023-07-27

Upon review of the PharmaCloud database and hospital HIS5 records, no medication reconciliation issues were identified.

[leukopenia and anemia]

The administration of the alternating chemotherapy regimen of VDC/IE and the nadir of WBC (< 1K/uL) and HGB (< 9g/dL) are as follows. It seems that the trough of WBC occurs around the 10th day after the administration of VDC, indicating a stronger correlation with VDC in terms of timing than with IE. As for HGB, the changes are not as dramatic as for WBC, but it can be confirmed that during the patient’s receipt of the VDC/IE regimen, the overall HGB level shows a decreasing trend. In addition, it’s worth mentioning that the patient received several transfusions and G-CSF during the treatment period, which are also factors influencing WBC and HGB.

2023-07-26 VDC regimen 2023-07-12 HGB 7.9 g/dL 2023-07-06 IE regimen 2023-06-28 WBC 0.16 x10^3/uL 2023-06-28 HGB 8.1 g/dL 2023-06-19 VDC regimen 2023-06-01 HGB 8.6 g/dL 2023-05-24 IE regimen 2023-04-27 WBC 0.33 x10^3/uL 2023-04-18 VDC regimen 2023-03-20 IE regimen 2023-03-17 HGB 8.7 g/dL 2023-03-01 WBC 0.35 x10^3/uL 2023-02-20 VDC regimen

2023-06-20

• Based on the PharmaCloud database, all of this patient’s medical requirements have been addressed at our hospital over the past three months. Therefore, we have not identified any issues related to medication reconciliation.
• The patient is currently undergoing an alternating chemotherapy regimen of VDC/IE, and has been admitted for her 3rd round of VDC treatment during this hospitalization. Although no instances of hemorrhagic cystitis have been reported after the first two doses of cyclophosphamide, the protocol of the source trial for this treatment (http://ascopubs.org/doi/suppl/10.1200/jco.2011.41.5703/suppl_file/Protocol_JCO.2011.41.5703.pdf) specifically mandates the use of mesna with cyclophosphamide and ifosfamide (see page 11). If the decision is made to continue administering cyclophosphamide without mesna, it would be prudent to increase the patient’s hydration and strongly encourage frequent voiding.

2023-04-19

• To prevent potential neutropenia, granulocyte colony-stimulating factor (G-CSF) is prescribed prophylactically.
• This patient primarily seeks medical care at our hospital, and no medication reconciliation issues have been found for the time being.

700415083

230727

[exam findings]

• 2023-07-04 SONO - abdomen
  • Findings
    • Liver: Fine echotexture. Several hyperechoic lesions up to 9.6 cm in GB. A 1.2 cm anechoic lesion at S8
    • Portal vein: Echogenic lesion in right portal vein.
    • Pancreas: Part of head and part of tail masked
    • Others: Bilateral plerual effusion was noted
  • Diagnosis:
    • Hepatoma with right portal vein thrombosis
    • Pleural effusion, bilateral
• 2023-07-02 CT - abdomen
  • Indication: Epigatric pain and back pain since yesterday. Mild cold sweating. No N/V, no tarry stool, no fever, no cough, no sputum, no SOB, no chest pain, no dysuria
  • With and without contrast enhancement CT of abdomen shows:
    • Multiple HCCs, s/p TACE. Uneven surface and left lobe hypertrophy of liver, suggestive of liver cirrhosis. Patent portal vein.
    • Swelling of pancreas with fluid density in retroperitoneum.
  • Impression
    • HCCs, s/p TACE
    • Suspect acute pancreatitis, grade D. Suggest clinical correlation.
• 2023-07-02 ER SONO
  • fluid collection in abdomen: mild over spleno-renal fossa
  • heterogenous mass over bilateral lobe of liver
• 2023-06-30 CT - abdomen
  • history: Right HCC, cT4N0M0 stage IIIB, post TACE on 2023/03/21 and 1st immunotherapy and Target therapy (Tecentriq + Avastin) on 2023/03/23.
  • Findings:
    • There are multiple poor enhancing masses on both hepatic lobes at portal venous phase images that are c/w multiple HCCs.
    • There are multiple hyperdense lesions in both hepatic lobes that are c/w HCCs S/P TACE with lipiodol retention.
    • There is filling defect at right superior portal vein that is c/w tumor thrombosis.
    • There is mild ascites.
  • Impression:
    • Multiple HCCs on both hepatic lobes show stable disease.
    • Tumor thrombosis in right superior segment portal vein.
• 2023-06-13 Embolization (TAE) - abdomen for tumor
  • TACE of RIGHT HCCs via right common femoral artery puncture using Seldinger technique revealed:
    • Presence of liver cirrhosis.
    • Hypervascular tumors at both hepatic lobes with multifeeders. TACE was performed using 10mg adriblastina plus 10 cc lipiodol. Decreased the blood flow of the feeding arteries using some gelfoam pieces also performed.
  • IMP: Bil. HCCs s/p right TACE.
• 2023-05-22 Embolization (TAE) - abdomen for tumor
  • TACE of left HCCs via right common femoral artery puncture using Seldinger technique revealed:
    • Presence of liver cirrhosis.
    • Hypervascular tumors at bil. hepatic lobes with multifeeders. TACE of left HCCs was performed using 10mg adriblastina plus 7 cc lipiodol via microcatheter. Decreased the blood flow of the feeding arteries using some gelfoam pieces also performed.
  • IMP: Bil. HCCs s/p left TACE.
• 2023-05-17 CT - abdomen
  • CC: LUQ pain and fever up to 38’C since last night
  • Past history:
    • right HCC, cT4N0M0 stage IIIB, post Transcatheter arterial chemoembolization on 2023/03/21 and 1st immunotherapy and Target therapy with Tecentriq + Avastin on 2023/03/23.
    • hepatitis B carrier with regular medication control with Entecavir since 2023/03/23.
  • Findings:
    • There are multiple poor enhancing masses on both hepatic lobes at portal venous phase images that are c/w multiple HCCs.
    • There are hyperdense lesions in the superior segment of right lobe liver that are c/w HCCs S/P TACE with lipiodol retention.
    • There is filling defect at right superior portal vein that is c/w tumor thrombosis.
    • There is mild ascites.
  • Impression:
    • Multiple HCCs on both hepatic lobes.
    • Tumor thrombosis in right superior segment portal vein.
• 2023-03-23 Tc-99m MDP bone scan
  • Increased activity in the right aspect of mandible. Dental problem may show this picture. Please correlate with other clinical findings for further evaluation.
  • Some faint hot spots in the right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, right elbow, bilateral hips and knees, compatible with benign joint lesions.
• 2023-03-23 Esophagogastroduodenoscopy, EGD
  • Gastric ulcers and erosions, antrum, s/p biopsy
  • Shallow duodenal ulcers, bulb
  • Superficial gastritis
• 2023-03-21 Embolization (TAE) - abdomen for tumor
  • TACE of RIGHT HCCs via right common femoral artery puncture using Seldinger technique revealed:
    • Presence of liver cirrhosis.
    • The RH-catheter was inserted into distal branch of right hepatic artery.
    • Hypervascular tumors at both hepatic lobes (up to 10.6cm) with multifeeders. TACE was performed using 10mg adriblastina plus 10 cc lipiodol. Decreased the blood flow of the feeding arteries using some gelfoam pieces also performed.
  • IMP: Bil. HCCs s/p right TACE.

[MedRec]

• 2023-07-20 SOAP Dermatology
  • S
    • severe itchy papules and plaques erupition over trunk after medication.
    • HBV carrier.
    • compesolon 0.5# initally up to 2# QD
  • O
    • urticaria/angioedema type
    • maculopapular type
    • urticaria-purpura type
      
    • erythema multiforme SJS/TEM
    • fixed drug eruption or AGEP rapid onset type
    • drug hypersensitivity syndrome as DRESS
    • lichenoid chronic progressive type
    • Suspect related medication: mopride. morbilliform drug eruption.
  • Plan:
    • education about drug side effec and explain
    • Strongly suggested OPD f/u
  • Prescription
    • Compesolon (prednisolone 5mg) 2# QD
    • Xyzal (levocetirizine 5mg) 1# BID
    • Asthan (ketotifen 1mg) 1# BID
    • Pilan (cyproheptadine 4mg) 1# HS
    • Topsym Cream (fluocinonide 0.05%) BID EXT
• 2023-03-20 ~ 2023-03-25 POMR General and Gastroenterological Surgery
  • Discharge diagnosis
    • Hepatocellular carcinoma, cT4N0M0 stage IIIB, status post Transcatheter arterial chemoembolization on 2023/03/21; 1st immunotherapy and Target therapy with Tecentriq + Avastin on 2023/03/23. BCLC:B, ECOG:0
    • Carrier of viral hepatitis B
    • Gastric ulcer
    • Duodenal ulcer
  • CC
    • RUQ pain after chest contussion during work for 2 weeks since 1 month ago
  • Present illness
    • This 40 y/o male with past history of hepatitis B carrier without regular control. This time, he sufferred from RUQ pain after chest contussion during work for 2 weeks. The pain with aggravated if deep breathing, hiccup. He ever visited to CM OPD on 2023/02/14 for follow up and CXR with no evidence of rib fracture. Analgesic agent was given but in vain. However, sever right upper quadrant pain was noted on 2023/03/17 then he visited to ChangGung hospital for help. Abdomen CT was performed and showed multiple liver tumors at both lobes, the largest one > 10.2 cm in S7/8 encasing the right hepatic vein, firstly consider HCC (T4N0), DDx: liver metastasis from other primary cancer. Admission was sugested but patient refused. Due to persised of RUQ pain, he came to our ER for help. Pain control was given, GS was consuted who suggested TACE first. Under impressed of HCC, he was admitted to our ward for TACE management.
  • Course of inpatient treatment
    • After admission, we consulted Diagnostic Radiology for arranging TACE. The procedure was performed on 2023/03/21 uneventfully. He tolerated the treatment well. After bedrest for 8 hours, no significant oozing was found over TACE wound. He also decided to received immunotherapy+target therapy with tecentriq + Avastin after well discussion on 2023/03/23. The medication was applied and no significant discomfort was complained of. UGI scope was also performed before immunoteherapy which showed gastric and duodenal ulcer. We keep PPI with nexium treatment for GU. On the other side, HBV DNA showed 1090IU/mL, then Baraclude (self-pay) for HBV control since 2023/03/23. Under a relative stable condition, he was discharged and OPD will be arranged.
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Nexiuum (esomeprazole 40mg) 1# QDAC
    • Celebrex (celecoxib 200mg) 1# Q12H
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
    • Smecta (dioctahedral simeclite 3mg) 1# PRNTIDAC
    • loperamide 2mg 1# PRNQ12H
    • Naproxen (naproxen 250mg) 1# PRNQ12H
• 2023-02-21 SOAP Chest Medicine
  • S/O: chest contussion during work for 2 weeks, aggravated if deep breathing, hiccup, no dyspnea, no cough,
  • A/P: s/s Tx, arrange CXR
  • Prescription
    • Gaslan (dimethylpolysiloxane 40mg) 1# TID
    • Keto (ketorolac 10mg) 1# Q6H
    • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# Q6H

[immunochemotherapy]

• 2023-06-14 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 500mg NS 100mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-05-23 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 500mg NS 100mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-04-21 - nivolumab 3mg/kg 160mg NS 100mL 1hr
  • none
• 2023-03-23 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 500mg NS 100mL 1hr
  • none

==========

2023-07-27

[reconciliation]

Our dermatologist prescribed a 7-day course of Compesolon (prednisolone), Xyzal (levocetirizine), Asthan (ketotifen), Pilan (cyproheptadine), and Topsym Cream (fluocinonide) for the patient’s severe itchy papules and plaques eruption over the trunk on 2023-07-20. However, these drugs are not currently included in the list of active medications. It is advisable to check whether the skin symptoms have improved before continuing or adjusting the treatment plan.

701251392

230727

[lab data]

2023-07-19 HSV 1 IgM Negative NTU
2023-07-19 HSV 1 IgM Value 1.52 NTU
2023-07-19 HSV 2 IgM Negative NTU
2023-07-19 HSV 2 IgM Value 1.37 NTU
2023-07-19 HLA A-high 11:01
2023-07-19 HLA A-high 33:03
2023-07-19 HLA B-high 38:02
2023-07-19 HLA B-high 39:01
2023-07-19 HLA C-high 07:02
2023-07-19 HLA C-high -

2023-07-19 HLA DRB1-high rsolution 2023-07-19 HLA DQ-high 03:03
2023-07-19 HLA DQ-high 05:02

2023-07-19 HLA DRB1-high rsolution 2023-07-19 HLA DR-high 09:01
2023-07-19 HLA DR-high 14:54

[exam findings]

• 2023-06-23 SONO - abdomen
  • Liver cyst, S6
  • Gallbladder adenomyomatosis
  • Gall stones
  • Renal stone, left kidney
  • Renal cyst, left kidney
• 2023-05-26 Patho - spleen
  • Spleen, laparoscopic splenectomy — N/K T cell lymphoma.
  • Sections show multiple pieces of splenic tissue with prominent white pulps and markedly dilated congested sinuses.
  • IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
• 2023-05-25 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — residual N/K T cell lymphoma.
  • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There are rare minute lymphoid aggregates (< 1mm in sizes).
  • IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
• 2023-05-23 PET
  • Glucose hypermetabolism in two focal areas in the spleen. The nature is to be determined (lymphoma? other nature?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the right anterior upper chest wall and bilateral pulmonary hilar regions. Inflammatory process is more likely.
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2023-05-17 CT - abdomen
  • CC: intermittent fever for 3 days, general malaise, mild dysuria, no cough, no SOB
  • History: Mature T/NK-cell lymphomas
  • Findings:
    • There is splenomegaly and the greatest cranial-caudal dimension measuring about 13 cm in size.
    • A hepatic cyst 1 cm in S5/6 is suspected. Please correlate with sonography.
    • The gallbladder shows small contracted with diffuse symmetrical mild wall thickening that may be adenomyomatosis?
      • In addition, three gallstones in the neck are noted.
    • Two renal stone 1 cm and 0.8 cm in left lower pole are noted.
    • There is nodular osteopenic defect in left lateral aspect of L3 vertebral body with fat density. Lipoma is highly suspected. please correlate with clinical condition and MRI.
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5. There is end plate sclerotic change of L3-4.
    • Transitional vertebra of L5-S1, left side.
      
  • Impression:
    • Splenomegaly is noted. please correlate with clinical condition.
    • Lipoma in left lateral aspect of L3 vertebral body is suspected. please correlate with clinical condition and MRI.
• 2023-05-03, 2022-11-07 MRI - nasopharynx
  • IMP: No neck LAP, stationary.
• 2022-03-08 MRI - nasopharynx
  • Swollen change of hypopharyngeal space with mucosal thickening.
  • The bilateral parotid and submandibular glands enhance as before. It is consistent with post-radiation inflammation.
• 2021-11-16 MRI - nasopharynx
  • History of NK lymphoma of nasopharynx
  • IMP: small LNs in bil. level I-II spaces, stationary.
• 2021-07-02 MRI - nasopharynx
  • Indication: History of nasal NK T cell lymphoma, post chemotherapy and RT. For evaluate tumor status.
  • Impression:
    • Edematous change of bilateral aryepiglottic folds.
    • Regression of the Waldeyer’s ring masses.
    • No enlarged cervical lymphadenopathy.
• 2021-03-29 CT - neck
  • History of NK-T cell lymphoma over oropharynx with mediastinal LN metastases. Follow up lymphoma status
  • IMP: no neck LAP
• 2021-02-18 Neck Soft Tissue
  • Disc space narrowing with marginal osteophyte formation of C3-4 and C4-5.
• 2020-12-24 CT - chest
  • Imp:
    • Regression of mediastinal lymphadenopathy
    • Consolidation over B6 of left lower lobe, previous infection
    • Gallstones and GB polyp(?) Suggest correlate with sonography.
• 2020-10-02 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (71.7 - 16.6) / 71.7 = 76.85%
    • M-mode (Teichholz) = 76.8
  • Conclusion:
    • Concentric LVH.
    • Normal RV & LV systolic function. No regional wall motion abnormalities.
    • Impaired LV relaxation.
    • Aortic valve sclerosis, with mild aortic regurgitation.
    • Mild mitral regurgitation.
    • Mild tricuspid regurgitation.
    • Mild pulmonic regurgitation.
    • Small pericardial effusion.
• 2020-09-24 CT - chest
  • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
  • Small lymph nodes are found at bilateral pulmonary hilar and paratracheal region is found.
  • There is bilateral minimal pleural effusion.
  • Diffuse interstitial change at both lungs is found.
  • Splenomegaly is found.
  • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thickening
• 2020-09-22 CXR
  • Tortuosity of thoracic aorta with Atherosclerotic change of aortic arch and Cardiomegaly
  • Spondylosis with scoliosis of the T-spine with convex to right side
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process. The differential diagnosis include pulmonary edema?
• 2020-09-22 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy
    
  • Sections show 30-40 % cellularity. The M/E ratio is about 3/1 - 4/1. Megakaryocytes are found about 2-9/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells. The immunohistochemical stains of CD3, CD20, and CD56 show no infiltrative lymphoma.
• 2020-09-21 PET
  • Glucose hypermetabolism in nasopharyngeal wall, Waldeyer’s ring, and right piriform sinus, and bilateral cervical lymph nodes, compatible with lymphoma involving lymphatic sites on the same side of diaphragm with extralymphatic extension.
  • Some glucose-hypermetabolic lesions of ground-glass opacity in upper lobe of left lung and middle lobe of right lung, pulmonary infection/inflammation may show such a picture but malignancy cannot be excluded. Please keep follow up with imaging modalities and, if feasible, correlate with histopathological studies for further evaluation.
  • Lymphoma, c-stage IIE (Lugano classification), by this F-18-FDG PET/CT scan.
• 2020-09-14 Patho - nasopharyngeal/oropharyngeal biopsy
  • Labeled as “Post. oropharyngeal wall grnulation tissue, r/o killer cell lymphoma?”, biopsy — Lymphoma.
  • Section shows bland squamous mucosa lined tissue with marked necrotic and diffusely infiltration of atypical round blue cells.
    
  • IHC stains: CD56 (strong +), CD3 and CD20: equivocal; CD4 and CD8 : more CD4 than CD8. CK (equivocal, probalby background). Features compatible with N/K T cell lymphoma.
• 2020-09-04 CT - neck
  • IMP: Lesions at right nasopharynx, left palatine tonsil and right pyriform sinus with bilateral lymph nodes. D/D: multiple malignancies, infectious processes.

[MedRec]

• 2023-06-18 ~ 2023-07-01 POMR Hemato-Oncology
  • Discharge diagnosis
    • Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites stage IV post chemotherapy with relapse over spleen and bone marrow post splenectomy
    • Urinary tract infection, site not specified
  • CC
    • fever and weakness since 2 days ago.
  • Present illness
    • This 64 year old female who denied any systemic disease. Neck CT on 2020/09/03 revealed lesions at right nasopharynx, left palatine tonsil and right pyriform sinus with bilateral lymph nodes. Nasopharyngoscopy local biopsy was done on 2020/09/14, the pathological report proved N/K T cell lymphoma. PET was performed on 2020/09/21 which revealed 1. Glucose hypermetabolism in nasopharyngeal wall, Waldeyer’s ring, and right piriform sinus, and bilateral cervical lymph nodes, compatible with lymphoma involving lymphatic sites on the same side of diaphragm with extralymphatic extension. 2. Some glucose-hypermetabolic lesions of ground-glass opacity in upper lobe of left lung and middle lobe of right lung, pulmonary infection/inflammation may show such a picture but malignancy cannot be excluded. Please keep follow up with imaging modalities and, if feasible, correlate with histopathological studies for further evaluation. 3. Lymphoma, c-stage IIE (Lugano classification). Bone marrow done on 2020-09-21 which revealed Negative for malignancy. Port-A insertion was done on 20200922. CT of chest on 20200924 which revealed small lymph nodes are found in the mediastinum. Diffuse interstitial change at both lungs. Gallstones. Bronchoscopy was performed on 20200925 for distal airway sampling to r/o TB, lymphoma with lung involvement, PJP infection, aspergillosus or other pathogen, PFT test to evaluate small airway dysfunction. RT was started from 2020/10/02 at 1000cGy/5 fractions (6MV photon) of the pharyngeal tumor, peripheral, to bilateral neck nodal area. PJP DNA was reported positive on 2020/10/05, thus Infection was consulted. They suggest Baktar 2# Q8H for PJP infection control and augmented with Cravit 750mg IV QD for two week.
    • Under the diagnosis of Right oropharyngeal N/K T cell lymphoma, stage IIE
    • Chemotherapy as weekly Cisplatin (30) x 3 weeks, then followed by VIPD x3 (every 3 weeks)
    • She received CCRT with Cisplatin since 2020/09 - 2020/11.
    • C1 VIPD on 2020/11/27 to C4 VIPD on 2021/02/18.
    • Followed MRI was performed on 2023/05/03 and report showed no neck LAP.
    • Bone marrow was done for pancytopenia on 2023/05/25.
    • Bone marrow pathoolgy (2023/05/25) showed residual N/K T cell lymphoma. IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
    • PET showed glucose hypermetabolism in two focal areas in the spleen. GS was consulted for pancytopenia and splenomegaly surgical intervention assessment.
    • Spleen, laparoscopic splenectomy pahtology (2023/05/26) showed: N/K T cell lymphoma. IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
    • Due to impression of splenic lesions and splenomegaly with progressed pancytopenia and leukopenia. She received Pneumococcal Vaccine 13 and GCF on 2023/05/25. She received laparoscopic splenectomy on 2023/05/26, and was transferred to GS service care on 2023/05/26.
    • 2023-05-17 ABD CT: Two renal stone 1 cm and 0.8 cm in left lower pole are noted.
    • This time, she has fever with chills and limbs soreness for 2 days, so she was brought to our ED for help pn 2023/06/18 afternoon. She denied abdominal pain or dysuria condition, but sometimes has dry cough. At ED, the lab data showed normal WBC, CRP just 2. No evidence of UTI or pneumonia. Under the impression of fever suspect virus or tumor related, so she was admitted.
  • Course of inpatient treatment
    • After admission, antibiotic was given. Tapimycin (06/18- ) > Sintrix (06/19- ) > Doripemem (06/21- ). Sintrix changed to doripenem was based on U/C. N/S: 500 BID + nako no.5 500 QD were given for hydration. Panadol was given for fever control.
    • Lab data showed WBC: 6.9 (06/18) > 4.4 (06/23), CRP: 2.2 > 1.9 (06/23). Abd echo: no hydronephrosis, Hyperechoic lesion was noted in the left kidney Size 0.9 cm. Blood culture showed no growth on 06/24.
    • On 06/26, U/A showed WBC: 0 (06/26), RBC: 0 (06/26).
    • On 06/27, fever up to 37.8c. WBC showed 6.9 (06/18) > 4.4 (06/23) > 5k (06/27). PCT showed 0.07.
    • We changed to brosym on 06/28. Urine culture on 06/26 showed no growth.
    • Under stable condtion, she was discharged with OPD follow up.
  • Prescription
    • Cinolone (ciprofloxacin 250mg) 2# BIDAC
    • Acetal (acetaminophen 500mg) 1# Q6H
    • Eurodin (estazolam 2mg) 0.5# HS
    • Axcel (acyclovir) QD TOPI for buttock herpes zoster

[chemotherapy]

• 2023-07-19 - L-asparaginase 6000unit/m2 9540unit IM 1min

• 2023-07-10 - methotrexate 4600mg NS 250mL 24hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2021-02-18

• 2021-01-14

• 2020-12-21

• 2020-11-27

• 2020-11-13

• 2020-10-06

• 2020-09-29

==========

2023-07-31

[deterioration in liver function; acetaminophen, Stronger Neo Minophagen C Injection]

In recent days, the patient has shown a significant increase in bilirubin and liver enzymes. After reviewing the drugs listed in the active medication, entecavir, furosemide, and acetaminophen are found to be associated with these symptoms according to the medication database. Since the VAS (visual analogue scale) has been recorded as 0 since 2023-07-29, it might be worth considering discontinuing acetaminophen. Additionally, please note that the Stronger Neo Minophagen C Injection will expire by the morning of 2023-08-01. If it is still required, please extend its use accordingly.

2023-07-31 Bilirubin total 14.51 mg/dL ** 2023-07-27 Bilirubin total 2.44 mg/dL *
2023-07-26 Bilirubin total 1.02 mg/dL
2023-07-24 Bilirubin total 0.70 mg/dL
2023-07-21 Bilirubin total 0.49 mg/dL
2023-07-19 Bilirubin total 0.51 mg/dL
2023-07-17 Bilirubin total 0.52 mg/dL
2023-07-15 Bilirubin total 0.59 mg/dL
2023-07-14 Bilirubin total 0.68 mg/dL
2023-06-27 Bilirubin total 0.31 mg/dL

2023-07-31 S-GPT/ALT 655 U/L 2023-07-27 S-GPT/ALT 309 U/L 2023-07-26 S-GPT/ALT 219 U/L 2023-07-24 S-GPT/ALT 161 U/L 2023-07-21 S-GPT/ALT 180 U/L 2023-07-19 S-GPT/ALT 162 U/L 2023-07-17 S-GPT/ALT 278 U/L 2023-07-15 S-GPT/ALT 541 U/L 2023-07-14 S-GPT/ALT 638 U/L 2023-07-13 S-GPT/ALT 412 U/L 2023-07-09 S-GPT/ALT 137 U/L 2023-06-27 S-GPT/ALT 63 U/L 2023-06-23 S-GPT/ALT 62 U/L 2023-06-18 S-GPT/ALT 46 U/L 2023-06-05 S-GPT/ALT 31 U/L 2023-06-03 S-GPT/ALT 26 U/L

2023-07-27

[No specific preparation is described for Stronger Neo-Minophagen C Injection]

to primary nurse: After checking the Micromedex database, there is no available data on the compatibility of glycyrrhizinate monoammonium, the main ingredient in Stronger Neo-Minophagen C Injection. Additionally, the package insert for this medication does not provide specific instructions regarding the preparation prior to injection administration.

2023-07-19

[teicoplanin 600mg from Q3D to QOD]

2023-07-19 Cre 1.47mg/dL, 57.5kg => CrCl 35mL/min. According to the Sanford Guide, teicoplanin in patients with CrCl 30 to 80, for complicated skin/soft tissue, pneumonia, complicated UTI: 6mg/kg QOD and for bone and joint infections, endocarditis: 12mg/kg QOD. It is recommended to increase the frequency from Q3D to QOD.

[leukopenia]

An episode of leukopenia was observed on 2023-07-19, 9 days after administration of 4600 mg MTX on 2023-07-10. The label for MTX includes a boxed warning regarding potential bone marrow, liver, lung, skin, and kidney toxicity, and patients should be monitored closely for such effects. Given the timing and characteristics of MTX, it cannot be ruled out that the leukopenia episode was due to MTX.

• 2023-07-19 WBC 1.47 x10^3/uL
  
• 2023-07-17 WBC 4.58 x10^3/uL
  
• 2023-07-15 WBC 11.08 x10^3/uL
  
• 2023-07-14 WBC 14.72 x10^3/uL
  
• 2023-07-13 WBC 16.11 x10^3/uL
  
• 2023-07-09 WBC 11.29 x10^3/uL

According to NHI reimbursement guidelines, short-acting G-CSF (e.g., filgrastim, lenograstim) may be used for patients with hematologic malignancies receiving intravenous chemotherapy, provided the patient meets this condition.

2023-07-14

[MTX level follow-up. Leucovorin might begin 24 hr after the start of MTX]

Methotrexate 4600mg was administered on 2023-07-10, and leucovorin 150mg Q3H has been started since 2023-07-13. Follow-up methotrexate level has shown significant decrease and is now less than 10 umol/L.

• 2023-07-14 Methotrexate 9.927 umol/L
  
• 2023-07-13 Methotrexate 39.609 umol/L
  
• 2023-07-13 Methotrexate 65.124 umol/L

It is recommended that rescue treatment following high-dose methotrexate starts with an initial dosage of around 15 mg (~10 mg/m2). This should begin 24 hours after the start of the methotrexate infusion and the treatment should continue Q6H for doses, until the MTX level drops below 0.05 micromolar.

The patient is adequately hydrated with normal saline and the urine is alkalinized with Rolikan (sodium bicarbonate).

[bedside visit]

I visited the patient at around 16:00 today. She mentioned that her throat was a bit sore, which could be due to mucositis. The addition of Nincort Oral Gel (triamcinolone acetonide) might help in relieving her symptoms.

[Covorin demand confirmation]

Today, during the UD (Unit Dose) vehicle preparing, it was discovered that the demand for Covorin (leucovorin 50mg) is 72 amps. At 13:25, I made a call to Dr. Wang QiQi to confirm the chief resident physician’s decision on the medication quantity.

701432045

230727

[diagnosis] - 2023-03-13 admission note

• Malignant neoplasm of stomach, unspecified
• Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
• Type 2 diabetes mellitus without complications
• Thyrotoxicosis, unspecified without thyrotoxic crisis or storm
• Insomnia, unspecified

[past history]

• The patient had type 2 diabetes mellitus and thyrotoxicosis under medicatiosn control.
• history of operation: nil
• Denied recent traveling history
• Blood transfusion history: NIL
• Regular medications：
  • Amepiride 2mg/tab (Glimepiride) 0.5 tab QDAC
  • Cardiolol 10mg/tab (Propranolol) 1 tab TID
  • Methimazole 5 mg/tab (Methimazole) 1 tab TID
  • Uformin 500mg/tab (Metformin) 1 tab BIDCC             

[family history]

• Mother: type 2 diabetes hypertension
• Sisiters: breast cancer and skin cancer

[lab data]

• 2022-08-11 TSH receptor Ab 40 %
  
• 2022-08-11 Free T4 (nuclear medicine) 1.926 ng/dl
  
• 2022-08-11 TSH (nuclear medicine) <0.04 uIU/ml
  
• 2022-07-08 RPR/VDRL Nonreactive
  
• 2022-07-08 T3 3.85 ng/mL
  
• 2022-07-08 TSH <0.005 uIU/mL
  
• 2022-07-08 Free-T4 4.60 ng/dL
  
• 2022-07-08 Free PSA 0.655 ng/mL
  
• 2022-07-08 free PSA/PSA 45.631 %
  
• 2022-07-08 Anti-HAV IgG Nonreactive
  
• 2022-07-08 Anti-HAV IgG Value 0.20 S/CO
  
• 2022-07-08 Anti-HBc Reactive
  
• 2022-07-08 Anti-HBc-Value 7.80 S/CO
  
• 2022-07-08 Anti-HBs 0.99 mIU/mL
  
• 2022-07-08 HBsAg Reactive
  
• 2022-07-08 HBsAg (Value) 4.68 S/CO
  
• 2022-07-08 HIV Ab-EIA Nonreactive
  
• 2022-07-08 Anti-HIV Value 0.09 S/CO
  
• 2022-07-08 Anti-HCV Nonreactive
  
• 2022-07-08 Anti-HCV Value 0.31 S/CO
  
• 2022-07-08 HbA1c 8.4 %

[exam findings]

• 2023-05-12 CT - abdomen
  • History: gastric cancer, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC
  • Findings: Comparison prior CT dated 2021/09/23. There is no significant interval change.
    • Prior CT identified four metastases on both hepatic lobes are noted again, mild increasing in size that is c/w liver metastases S/P C/T with stable disease.
      • A hepatic cyst measuring 0.9 cm in S2/3 is noted.
    • There are few enlarged nodes in hepatoduodenal ligament and celiac trunk area. Metastatic nodes are highly suspected.
    • S/P subtotal gastrectomy and S/P cholecystectomy.
    • Prior CT identified focal cystic lesion 3.6 cm (the largest dimension) in between the residual stomach and pancreatic tail is noted again, mild decreasing in size to 3.2 cm.
  • Impression:
    • Four metastases on both hepatic lobe S/P C/T show stable disease.
    • There are few enlarged nodes in hepatoduodenal ligament and celiac trunk area. Metastatic nodes are highly suspected.
• 2023-02-25 CT - chest
  • Indication: gastric cancer, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC
  • IMP
    • No evidence of pulmonary meta in the study.
    • s/p nearly total gastrectomy.
    • Loculated fluid like accumulation anterior to the pancreatic tail is found measuring 3.5cm in largest dimension. Meta? Post op. change?
• 2023-02-24 CT - abdomen
  • History: gastric cancer, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC
  • Findings:
    • There are four well-defined poor enhancing lesions 1.7 cm in S2, 0.8 cm in S8 (near IVC), 0.4 cm in S5, and 1 cm in S6 of the liver that may be metastases. Please correlate with MRI.
    • A hepatic cyst measuring 0.9 cm in S2/3 is noted.
    • S/P subtotal gastrectomy
    • There is focal cystic lesion 3.6 cm (the largest dimension) in between the residual stomach and pancreatic tail that may be focal seroma or abscess?
  • Impression:
    • Four metastases on both hepatic lobes are highly suspected.
• 2022-09-27 Tc-99m MDP whole body bone scan with SPECT
  • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed some hot or faint hot spots in the anterior aspect of bilateral rib cages and increased activity in the lower L-spines, left humeral shaft, bilateral shoulders, left sternoclavicular junction and bilateral hips in whole body survey.
  • IMPRESSION:
    • Mildly increased activity in the lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some hot or faint hot spots in the anterior aspect of bilateral rib cages and mildly increased activity in the left humeral shaft. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, left sternoclavicular junction and bilateral hips, compatible with benign joint lesions.
• 2022-08-12 Patho - stomach subtotal/total (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Stomach, subtotal gastrectomy — Adenocarcinoma
    • Margin, frozen section — Free of tumor invasion
    • Margins, subtotal gastrectomy — Free of tumor invasion
    • Lymph nodes, LN 1, ditto — Free of tumor metastasis (0/3)
    • Lymph nodes, LN 3, ditto — Tumor metastasis (3/9) with extracapsular extension (3/3)
    • Lymph nodes, LN 4, ditto — Free of tumor metastasis (0/11)
    • Lymph nodes, LN 5, ditto — Free of tumor metastasis (0/1)
    • Lymph nodes, LN 6, ditto — Fat tissue only
    • Lymph nodes, LN 12c, ditto — Free of tumor metastasis (0/1)
    • Lymph nodes, LN 14, ditto — Free of tumor metastasis (0/8)
    • Lymph nodes, LN 7,8,9,11p,12a, ditto — Tumor metastasis (1/7) with extracapsular extension (0/1)
    • Omentum, omentectomy — Free of tumor invasion
    • Gallbladder, cholecystectomy — Free, chronic cholecystitis
    • AJCC Pathologic staging — pT4aN2, if cM0, stage IIIA
  • MACROSCOPIC EXAMINATION
    • Specimen type: Stomach, lymph nodes, gallbladder and omentum
    • Specimen size: (a) Stomach: GC: 20.5 cm; LC: 6.8 cm, (b) Omentum: 35 x 19 x 4 cm
    • Number of lesions: Solitary
    • Tumor site: angle
    • Tumor size: 3.6 cm
    • Tumor configuration: ulcerative mass
    • Gallbladder: 5.6 x 3.3 x 1.6 cm
    • Representative sections as follows: A: LN 1, B1-B3: LN 3, C: LN 4, D: LN 5, E: LN 6, F: LN 12c, G1-G2: LN 14, H1-H2: LN 7,8,9,11p,12a, I1-I2: bilateral resection margins, I3-I8: tumor + serosa, I9: non-tumor stomach, J1-J2: omentum, K: gallbladder [Reference: F2022-00375 FS: cutting end, one small piece measured 9.7 x 0.5 cm with staples]
  • MICROSCOPIC EXAMINATION
    • Histologic type: Adenocarcinoma
    • Histologic grade: Grade 3, poorly differentiated
    • Depth of tumor invasion: serosa layer
    • Lymph nodes: Tumor metastasis (4/40) with extracapsular extension (3/4) in total number
    • Omentum: free of tumor invasion
    • AJCC Pathologic Staging: pT4aN2, stage IIIA
    • Bilateral Margins: Free, 2.8 and 3.6 cm away from bilateral margins
    • Additional pathologic findings: focal tumor necrosis, focal micropapillary pattern and mild intestinal metaplasia
    • Perineural invasion: Present
    • Lymphovascular space invasion: Present
    • Immunohistochemical stains: CK(+) and HER2(equivocal, Dako score 2+)
    • Gallbladder: chronic cholecystitis with one reactive lymph node. No stone
• 2022-08-09 CT - abdomen
  • History and indication: gastric cancer
  • Findings
    • A tumor (3.6cm) at gastric body, LC, with reginal LAP.
    • Left liver cyst (0.9cm).
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • Normal appearance of gallbladder.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral basal lungs.
  • IMP: Gastric body cancer (3.6cm, LC) with regional LAP.
• 2022-08-08 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Borderline ECG
• 2022-08-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (132 - 41) / 132 = 68.94%
    • M-mode (Teichholz) = 69
  • Normal LV filling pressure.
  • Normal LV and RV systolic function.
  • Mild aortic valve sclerosis
• 2022-07-21 Thyroid Ultrasound
  • Autoimmune thyroid disease
• 2022-07-19 CT - abdomen
  • Clinical history: 56 y/o male patient with An big A2 ulcer was noted at angle. Biopsy x4 was done. DIAGNOSIS: Stomach, antgle, biopsy — Adenocarcinoma.
  • Findings
    • Thickening wall at gastric body, c/w gastric malignancy.
    • There are enlarged lymph nodes in perigastric region, could be due to metastatic lymph nodes.
    • Suspected liver cyst, 0.9cm in S2.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
    • Bilateral lower lung cysts.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE: III (Stage_value)
• 2022-07-08 Patho - colorectal polyp
  • Colon, 10 cm above anal verge, cold snare polypectomy (B) — Hyperplastic polyp
  • Section shows fragment(s) of polypoid colonic mucosal tissue with crowded benign hyperplastic mucinous glands.
• 2022-07-08 Patho - colorectal polyp
  • Colon, 25 cm above anal verge, polypectomy (A) — Tubular adenoma with low grade dysplasia
  • Section shows fragment(s) of polypoid colonic mucosal tissue with proliferative tubular mucinous glands lined by cells containing hyperchromatic, elongated nuclei with low grade dysplasia.
• 2022-07-08 Patho - stomach biopsy
  • Stomach, antgle, biopsy — Adenocarcinoma.
  • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
• 2022-07-08 CT - chest
  • Low dose spiral CT of the chest without contrast enhancement for screening of lung tumor showed:
    • Lungs:Pneumatocele at both lungs up to 1.75cm in largest dimension.
    • Unremarkable in the mediastinum and hilars.
    • Unremarkable of the pleura.
    • Unremarkable of the chest wall.
    • Unremarkable of the supraclavicular fossa.
    • Visible bones: Unremarkable.
    • Calcified coronary arteries is found.
    • Enlarged lymph nodes are found at gastric pericardial region. r/o gastric tumor related.
  • IMP:
    • No definite nodular lesion at both lungs.
    • Calcified coronary arteries is found.
    • Perigastric lymphadenopathy, suspected gastric tumor related.
• 2022-07-08 Panendoscopy
  • Superficial gastritis, antrum s/p CLO test
  • GU, large, angle s/p biopsy suspected malignancy

[consultation]

• 2022-12-13 Dermatology
  • Q
    • for skin itchy, skin rash at back and upper limbs after chemotherapy.
    • This 56-year-old male, a pt of gastric CA, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC on 20220812 by Dr Wu, suffered from initial presentation of progressive weight loss of 80kg to 65kg in 3 months & CEG in July 2022 showed a big A2 ulcer at angle. Biopsy proved CA.
    • Today, he was admitted for #2 post-Op adjuvant C/T with mFOLFOX IV Q2W x 12 on 20221213. He complatins skin itchy, skin rash at back and upper limbs after chemotherapy, so we need your help, thanks a lot!!
  • A
    • The patient had sufferred from cancer s/p chemotherapy. diffuse ithcy red papules with keratosis and fine pusutles was noted.
      
    • Under the impression of xerotic dermatitis and lichen pilaris et secondary inflammation episode.
    • The following sugeetion:
      • for itchy reddish papules and fine pustules lesion, Mycomb cream 2 tube topical PRN bid use.
        
      • for follculiar kertosis and xerosis, Sinphraderm cream 1 tube topical QN use.
        
• 2022-08-19 Radiation Oncology
  • Q
    • For CCRT
    • This 56-year-old male is a case of type 2 diabetes mellitus and thyrotoxicosis under medicatiosn control. According for his statement, he noted of weight loss for 20 kg and mild poor appetite in 2 months. Then he came to our hospital for health examination on 2022/07/08. UGI scope was showed erythmatus change of gastric mucosa was found at antrum. An big A2 ulcer was noted at angle. Biopsy was done. Final pathology showed adenocarcinoma. Abdomen CT also revealed gastric malignancy with lymph nodes metastasis, cstage T3N2M0. On the same health examination, type 2 diabetes mellitus and thyrotoxicosis was also noted. So medications was keep control first. Due to gastric cancer, he referred to GS OPD for further management. Tumor marker of CEA:2.095 ng/ml; CA-199:173.175 U/ml on 20220711. After diabetes and thyrotoxicosis under medications control, his body wight was improved and stable in 65kg. He denied fever, chills dizzness, poor appetite, nausea, vomiting, or tarry stool passage in recently.
    • This time, he was admitted to our ward for further evaluate and management. He underwent subtotal gastrectomy + HIPEC on 20220811. Post operative course smoothly, fair oral intake. The pathology showed adenocarcinoma, pT4aN2M0, stage IIIA. We need your expertise for further radiotherapy evaluation. Thanks for your times.
  • A
    • A: Adenocarcinoma of the stomach, AJCC Pathologic staging — pT4aN2(cM0), stage IIIA, s/p distal subtotal gastrectomy with D2 LN dissection. HIPEC with Oxaliplatinum, laparoscope staging, and small bowel serosa repair; laparoscope.
    • P: Postoperative CCRT is indicated for this patient with the following indicators: stage pT4aN2(cM0).
      • Goal: curative
      • Treatment target and volume: gastric to regional lymphatic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the gastric to regional lymphatic area
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his girl friend. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-09-15.

[MedRec]

• 2023-03-08 SOAP Hemato-Oncology
  • O: 2023/02/24 CT ABD: Four metastases on both hepatic lobes are highly suspected.
  • P: Suggest to change regimens to Doctaxel + 5-FU and pembo (100 mg) q2w
• 2022-09-06 SOAP Hemato-Oncology
  • S: Will give post-Op adjuvant C/T wt mFOLFOX IV Q2W x 6 then post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-Op adjuvant C/T wt mFOLFOX IV Q2W x 6.

[surgical operation]

• 2022-08-20
  • Surgery
    • small bowel serosa repair
    • laparoscope
  • Finding
    • small bowel serosa tear with bleeding+
    • intraabd blood 450cc
    • left inguinal hernia indirect type
• 2022-08-11
  • Surgery
    • distal subtotal gastrectomy with D2 LN dissection
    • HIPEC with Oxaliplatinum 300 mg for 60 mins at 42 C
    • laparoscope staging
  • Finding
    • laparoscope staging: distal gastric tumor with serosa involve
    • no peritoneal seeding
    • obvious LN at lesser curvature

[radiotherapy]

• 2022-09-28 ~ 2022-11-02 - 4500cGy/25 fractions of the gastric to regional lymphatic area.

[chemoimmunotherapy]

• 2023-07-26 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 65mg NS 200mL 4hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 1000mg/m2 1640mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 65mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-06-30 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 65mg NS 200mL 4hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 400mg/m2 670mg NS 100mL 10min + fluorouracil 1000mg/m2 1650mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 65mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-06-06 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 65mg NS 200mL 4hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 400mg/m2 675mg NS 100mL 10min + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr He JingLiang)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-05-08 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 60mg NS 200mL 4hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 100mL 10min + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr Wan XiangLin)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-04-06 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 60mg NS 200mL 4hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 400mg/m2 680mg NS 100mL 10min + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr Wan XiangLin)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-03-13 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 60mg NS 200mL 4hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 100mL 10min + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr Wan XiangLin)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-02-22 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 685mg NS 250mL 2hr + fluorouracil 2800mg/m2 4825mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2800mg/m2 4750mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-29 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-13 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4720mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-24 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-10-31 - fluorouracil 225mg/m2 360mg NS 500mL 24hr D1-D3 (adjuvant CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-10-24 - fluorouracil 225mg/m2 360mg NS 500mL 24hr D1-D5 (adjuvant CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-10-17 - fluorouracil 225mg/m2 360mg NS 500mL 24hr D1-D5 (adjuvant CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-10-14 - fluorouracil 225mg/m2 360mg NS 500mL 24hr (adjuvant CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-08-11 - oxaliplatin 300mg/m2 525mg IP 1hr (HIPEC)

[note]

Chemotherapy regimens for advanced esophagogastric cancer: Docetaxel, cisplatin, and fluorouracil (DCF) 2023-07-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F73324

• Cycle length: 21 days.
• Drug
  • Docetaxel
    • 75 mg/m2 IV
    • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
    • Day 1
  • Cisplatin
    • 75 mg/m2 IV
    • Dilute in 250 mL NS and administer over 60 minutes. Do not administer with aluminum needles or IV sets.
    • Day 1
  • Fluorouracil (FU)
    • 750 mg/m2 per day IV
    • Dilute in 500 to 1000 mL D5W and administer as a continuous infusion over 24 hours. For use in an ambulatory infusion pump. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose can be diluted in 100 to 150 mL NS.
    • Days 1 through 5

Chemotherapy regimens for locally advanced, potentially resectable gastric or gastro-esophageal junction adenocarcinoma: Perioperative docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT4) 2023-03-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F120512

• Cycle length: 14 days.
• Duration of therapy: In the original trial, preoperative FLOT was given every 14 days for 4 cycles. Following surgery, postoperative FLOT was given every 14 days for 4 cycles.
• Drug
  • Docetaxel
    • 50 mg/m2 IV
    • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
    • Day 1
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (oxaliplatin and leucovorin can be administered concurrently in separate bags using a Y-connector).
    • Day 1
  • Leucovorin
    • 200 mg/m2 IV
    • Dilute in 250 mL D5W and administer over two hours concurrent with oxaliplatin.
    • Day 1
  • Fluorouracil (FU)
    • 2600 mg/m2 IV
    • Dilute in 500 to 1000 mL D5W and administer over 24 hours (begin immediately after completion of leucovorin infusion). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose can be diluted in 100 to 150 mL NS or D5W.
    • Day 1

ref: Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019;393(10184):1948-1957. doi:10.1016/S0140-6736(18)32557-1

==========

2023-07-27

This patient receives all medical care exclusively at our hospital and has appointments with both the hematology-oncology and endocrinology and metabolism departments. Medications prescribed by the endocrinology and metabolism department, including Cardiolol (propranolol), Galvus Met (vildagliptin, metformin), and methimazole, were correctly documented on the active medication list. As a result, no medication reconciliation issues were identified.

2023-07-03

• This patient is treated exclusively at our hospital and has appointments with both the Hematology-oncology and Endocrinology and Metabolism departments. The medications prescribed by the endocrinology and metabolism department, which include Cardiolol (propranolol), Galvus Met (vildagliptin, metformin), and methimazole, were all accurately entered into the active medication list. As a result, no discrepancies were found during the medication reconciliation process.

2023-06-07

• This patient is treated only at our hospital. In addition to visits to the hematology-oncology service, he also visits the endocrinology and metabolism service. Medications prescribed by the latter department, including Cardiolol (propranolol), Galvus Met (vildagliptin, metformin), and methimazole, are all appropriately included in the active medication list, with no medication reconciliation issues identified.

2023-05-09

• Given that the most recent CT scan was conducted in February 2023 and three months have since elapsed, it may be prudent to schedule a new CT scan to obtain updated imaging.
• The patient’s fasting blood glucose levels during this hospital stay were recorded approximately 150mg/dL. Including Dibose (acarbose 100mg/tab) 1# TIDCC could potentially improve glucose regulation.

2023-03-14

• CT scans conducted in late Feb indicated the possible presence of metastases in the liver as well as loculated fluid-like accumulation near the pancreatic tail. As a result, the FOLFOX regimen was replaced by a new treatment regimen consisting of pembrolizumab, docetaxel, leucovorin, fluorouracil, and cisplatin. This new regimen was first administered during the patient’s current hospital stay.
• The patient’s vital signs in the TPR panel have remained stable, and the lab data from 2023-03-14 showed grossly normal results. The patient’s underlying conditions of hyperglycemia and thyrotoxicosis are being managed with corresponding medications, and hydroxocobalamin is being administered to prevent vitamin B12 deficiency after gastrectomy. No medication reconciliation issues were found.

2022-12-14

• The IHC HER2 result was equivocal (Dako score 2+), and there was no HER2 FISH or PD-L1 result available yet. Trastuzumab or its biosimilar should be added to first-line chemotherapy for HER2 overexpression positive adenocarcinoma.
• The underlying conditions are treated with corresponding medications without an issue.

700145771

230726

[lab data]

2023-07-18 CA-199 (NM) 52.608 U/ml
2023-07-04 CA-199 (NM) 38.491 U/ml
2023-06-09 CA-199 (NM) 39.33 U/ml
2022-05-26 CA-199 53.04 U/mL

2023-06-09 HBsAg (NM) Negative
2023-06-09 HBsAg Value (NM) 0.373
2023-06-09 Anti-HCV (NM) Negative
2023-06-09 Anti-HCV Value (NM) 0.042
2023-06-09 Anti-HBc (NM) Positive
2023-06-09 Anti-HBc Value (NM) 0.009
2023-06-09 Anti-HBs (NM) Negative
2023-06-09 Anti-HBs value (NM) 4.06 mIU/mL

2022-05-26 HBsAg Nonreactive
2022-05-26 HBsAg (Value) 0.63 S/CO
2022-05-26 Anti-HCV Nonreactive
2022-05-26 Anti-HCV Value 0.08 S/CO

[exam findings]

• 2023-07-11 CT - abdomen
  • Clinical history: 85 y/o female patient with cholangiocarcinoma post CCRT (xeloda) at ShinKuan hospital and received CCRT there. But progression was noted 3 months after CCRT.
  • With and without contrast enhancement CT of abdomen - whole:
    • Focal IHD dilatation in left lateral segment of liver.
    • Ill-defined low density lesion, 5.2cm in S2 liver with adjacent vascular compression, r/o cholangiocarcinoma with progression.
    • Enlarged lymph nodes in upper abdomen, r/o metastatic lymph node.
    • Small liver cyst, 4.2cm in S6.
    • Outpouching lesions in the sigmoid colon, suggesting sigmoid colon diverticula.
    • Left renal cyst, 0.9cm.
    • L1 and L2 compression fractures.
  • Impression:
    • Cholangiocarcionoma with IHD dilatations and lymph nodes metastasis. Progression.
      
    • Sigmoid colon diverticula.
    • Liver and left renal cysts.
    • L1 and L2 compression fractures.
• 2023-06-16 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
• 2023-06-16 ECG
  • Normal sinus rhythm
  • T wave abnormality, consider lateral ischemia
  • Abnormal ECG
• 2023-04-17 Microsonography
  • clinical diagnosis: end stage glaucoma ou
  • Report: OCT-D x/72, x/2.14, x/0.86
    • CRT: 209/286 um, high myopia change ou
• 2022-12-13 L-spine AP + Lat. (including sacrum)
  • L1, L2, L3 compression fracture.
  • Grade 1 spondylolisthesis at L5-S1 level.
  • Degenerative change of the spine with marginal spur formation.
  • Osteopenia of visible bones.
• 2022-11-14 Hip BMD performed by DXA
  • Finding: Left hip, BMD is 0.477 gms/cm2, about 3.4 SD below the peak bone mass (56%) and 0.2 SD below the mean of age-matched people (97%).
  • Impression: Osteoporosis
• 2022-05-26 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
  • ST & T wave abnormality, consider lateral ischemia
  • Prolonged QT
• 2022-05-25 CT - abdomen
  • Clinical history: 84 y/o female patient with low back pain, lower abdominal distension, dysuria, bilateral lower limb edema.
  • With and without contrast enhancement CT of abdomen - whole:
    • Focal IHD dilatation in left lateral segment of liver.
    • Ill-defined low density lesion, 5cm in S2 liver, r/o cholangiocarcinoma.
    • Small liver cyst, 4.2cm in S6.
    • Outpouching lesions in the sigmoid colon, suggesting sigmoid colon diverticula.
    • Left renal cyst, 0.9cm.
    • Right pleural effusion with basal lung collapse.
    • L1 and L3 compression fractures.
    • Gr I spondylolisthesis at L5-S1.
  • Impression:
    • Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver. R/O cholangiocarcinoma, suggest further study.
    • Sigmoid colon diverticula.
    • Liver and left renal cysts.
    • Right pleural effusion with basal lung collapse.
    • L1 and L3 compression fractures. Gr I spondylolisthesis at L5-S1.
• 2022-05-25 CXR
  • Mild bunting of costophrenic angle, both sides.
  • Cardiomegaly.
  • Intimal calcification of thoracic aorta.
  • L1 compression fraccture.
  • Narrowing of right shoulder joint.
• 2022-05-25 KUB
  • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
  • Non-specific bowel gas pattern.
  • Clear margin of bilateral psoas muscles.
  • Lumbar spondylosis.
  • L2 and L4 compression fractures.
  • Osteoporosis of the bones.

[MedRec]

• 2023-07-26 POMR ProgressNote
  • The patient requested to self-administer her own medication, adjusting it based on her daily condition. She expressed doubts about receiving medications from nurses. The nurse practitioner informed her about the safety of administering medication through the nursing team, but the patient was unable to accept it. Therefore, the patient’s outpatient medication was canceled.
• 2023-06-23 SOAP Hemato-Oncology
  • A: She requested self-paid Xeloda as before duringt her preparation for vertioplasty by ortho doctors
  • Prescription
    • Xeloda (capecitabine 500mg) 2# BID
• 2023-06-20 SOAP Hemato-Oncology
  • A: She preferred to be treated for her back first and hold the chemotherapy according to her decision.
• 2023-06-16 ~ 2023-06-16 POMR Hemato-Oncology
  • Discharge diagnosis
    • cholangiocarcinoma post CCRT (xeloda) at ShinKuan hospital
  • CC
    • for port-A insertion and further treatment
  • Present illness
    • This 84 years old female with history of
      • HTN
      • Chronic ischemic heart disease
      • Cerebral artherosclerosis
      • cholangiocarcinoma post CCRT (Xeloda) at ShinKuan hospital
      • COVID-19 test (+). Confirmed on 2022-05-17, and discharged on 2022-05-20.
    • According to her daughter, CT at ShinKuan hospital told progression. This time,she was admitted for port-A insertion and further treatment.
  • Course of inpatient treatment
    • After admission, labortaory test revealed fair CBC level. plan to receive port-A insertion on 2023-06-21 but patient requsted for against medical advice discharge due to the next bed had influenza-A on 2023/06/16. OPD follow up was arranged
• 2023-06-02 SOAP Hemato-Oncology Gao WeiYao
  • S: A documented cholangiocarcinoma post CCRT (Xeloda) at ShinKuan hospital and received CCRT there. But progression was noted 3 months after CCRT.
  • P: Ask her and her daughter to bring back the patho report and CT imaging.
• 2022-12-13 SOAP Orthopedics
  • A
    • spinal orthosis
    • prolia 1st dose since 2022/12/13
    • warm packing
    • add density
  • Prescription
    • Arcoxia (etoricoxib 60mg) 1# QD
    • Prolia (denosumab 60mg) SC
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# BID
• 2022-05-25 ~ 2022-06-04 POMR Gastroenterology
  • Discharge diagnosis
    • COVID-19, virus identified
    • Urinary tract infection (Urine culture grew PDR-Chryseobacter indologene)
    • Left lobe liver tumor with focal intrahepatic bile duct dilatation in left lateral segment of liver. Rule out cholangiocarcinoma
    • Sigmoid colon diverticula
    • Right pleural effusion with basal lung collapse
    • Edema, unspecified
    • Hypo-osmolality and hyponatremia
    • Hypokalemia
    • Lumbar spondylosis
    • Lumbar 2 and Lumbar 4 compression fractures
    • Liver cysts
    • Left renal cysts
    • Chronic ischemic heart disease, unspecified
  • CC
    • abdomen distension and pitting edema for few days
  • Present illness
    • This 84 years old female with history of
      • HTN
      • Chronic ischemic heart disease
      • Cerebral artherosclerosis
    • She just discharged from our Hospital, due to COVID-19 test(+). Confirmed on 2022-05-17, and discharged on 2022-05-20.
    • This time, she was suffered from abdomen distension and pitting edema for few days, the s/s was progressive. She was sent to our ER for help. At MER, physical examination revealed acute on chronic ill-looking, the CXR showed Mild bunting of costophrenic angle, both sides, Cardiomegaly. Abd CT was performed and revealed Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver, R/O cholangiocarcinoma, suggest further study. Lab data revealed elevated CRP 9.90mg/dL. Under the impression of Left lobe liver tumor R/O cholangiocarcinoma. She was admitted to our ward for further evaluation and treatment.
  • Course of inpatient treatment
    • After admission, adquat IV fluid support, IV Lasix empirical antibtioic were both given. We Well informed current condition of liver tumor R/O cholangiocarcinoma to herself and her son and suggested tissue proof later. They understand and wait for their answer. Nephrologist was consulted for hyponatremia. WE Checked HBsAg, anti-HCV, AFP, CEA, Ca19-9, ALP and rGT st and arrange abdomen echo. However, her SARS-CoV-2 RT-PCR reported Positive today and after we contact our infection control unit, suggested COVID-19 ward for isolation and for further management.
    • After isolation ward, keep current treatment and antibiotic with Brosym 4gm ivd (20220526~20220601) was perscribed. Diuretics with lasix was given for lower limbs edema. Intravenous infusion with 3% NaCL was given for one day for hyponatremia, then shift 0.9% NaCL 500ml/day. Follow-UP lab, revealed hypokalemia, Radi-K po was given (20220530 - 20220604). Due to COVID-19 CT value > 30, she was transfer to GI ward for further management. After transferring to ordinary ward, we kept the medical treatment. WE SUGGESTED LIVER BIOPSY AND DUPLEX STUDY FOR HER LEFT LEG EDEMA. FAMILY WISH EARLY DISCHARGE. Under stable condition, she was discharged on 2022/06/04 and GI OPD follow-up was arranged later.
  • Discharge prescription
    • Through (sennoside 12mg) 2# HS
    • Uretropic (furosemide 40mg) 0.5# QD
    • Alpraline (alprazolam 0.5mg) 1# HS
• 2017-07-18 SOAP Ophthalmology
  • Diagnosis
    • Tear film insufficiency, unspecified [H04.123]
    • Lens replaced by other means [Z96.1]
    • Exotropia, unspecified [H50.10]
  • Prescription x3
    • Vidisic Gel (carbomer) QID OU
    • tetracycline BID OD
    • Sinomin (sulfamethoxazole) QID OU
• 2017-03-09 SOAP Neurology
  • Diagnosis
    • Chronic ischemic heart disease, unspecified [I25.9]
    • Cerebral atherosclerosis [I67.2]
    • Arteriosclerotic dementia, uncomplicated [F01.50]
    • Displacement of lumbar intervertebral disc without myelopathy [M51.27]
  • Prescription x3
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Syntam (piracetam 1200mg) 1# BID
    • Schnin (ginkgo biloba 9.6mg) 1# BID
    • Rivotril (clonazepam 0.5mg) 1# HS

[consultation]

• 2022-05-26 Nephrology
  • Q
    • This 84 y/o female with history of 1) HTN 2) Chronic ischemic heart disease, just discharge from our Hospital, due to COVID-19 test(+). This time, she was suffered from low back pain and pitting edema for few days, the s/s was progressive. She was sent to our ER for help. At MER, physical examination revealed acute on chronic ill-looking, the CXR showed Mild bunting of costophrenic angle, both sides, Cardiomegaly. Abd CT was performed and revealed Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver. R/O cholangiocarcinoma, suggest further study. Lab data revealed elevated CRP 9.90mg/dL. Under the impression of Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver, R/O cholangiocarcinoma. She was admitted to our ward for further evaluation and treatment.
    • we need your expertis for hyponatremia
  • A
    • Consult for hyponatremia
    • Lab data :
      • WBC: 10.83, Hb: 14.8,Plt: 155
      • Na: 131(5/17) -> 123, K: 3.3, CRP: 9.9, NTproBNP: 446
      • BUN: 19, cre: 0.57
      • Lipase: 45, T bil: 0.79, albumin: 3.6, gucose: 108
      • HBV (-), HCV (-), ALKP: 75 ,r GT: 68
      • AFP: 4.0, CEA: 3.3, CA199: 53.04
      • U/A: light yellow, clear, SG: 1.008, PH: 7.0, Nit: -, glu: -, pro: -, OB: -, RBC: 3-5, WBC: 0-5, Cast: 0, bacteria :-
      • CXR: cardiomegaly and bilateral costophrenic angle bunting and slight pulmonaty congestion
      • KUB: L2-L4 compression fracture
      • CT abdomen: Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver. R/O cholangiocarcinoma
      • PE: EDEMA 2-3+
      • Current medication : lasix 20mg IV QD
    • Impression:
      • Hyponatremia cause to be determined
    • Suggestion :
      • Check plasma osmolality, urine osmolarity, Ur Na, Ur K, Ur cre, Ur Cl, Fe uric acid
      • Check lipid profile, total protein
      • Check thyroid function and ACTH, cortisol
      • Please arrange cardiac echo to rule out heart failure
      • Follow up Na, K,
      • Thank you very much for your consultation.

==========

2023-07-26

[medication reconciliation]

This patient just refilled Betmiga (mirabegron) on 2023-07-10 for her urinary incontinence for a 28-day valid duration at Far Eastern Hospital, this drug is not included in the active medication list, please confirm if this drug is not necessary for the patient’s current condition.

[poor medication compliance, non-adherence to medication regimen]

The 2023-07-26 progress note states, “The patient requested to self-administer her medications, adjusting them based on her daily condition. She expressed concern about receiving medications from nurses. The nurse practitioner educated her about the safety of medication administration by the nursing team, but the patient was unable to accept it. As a result, the patient’s outpatient medication was discontinued”.

On 2023-07-26, I visited the patient and her caregiver at approximately 11:00 am to address the concerns raised in the progress note regarding the patient’s medication compliance.

The patient said she is a member of TzuChi and was diagnosed with suspected cholangiocarcinoma in 2022-05 and subsequently treated at ShinKong Hospital. During the visit, I found that the patient tends to be selective in taking prescribed medications, believing that certain medications are more effective and should be taken more, while she perceives little efficacy from other prescribed medications. In addition, the patient mentioned that she does not always take her prescribed painkiller.

I have tried to help the patient understand the importance of adhering to the prescribed medication regimen. However, it appears that the patient still holds strong personal beliefs regarding medication, which may lead to inaccurate assessments of treatment effectiveness.

Regarding the issue of low sodium levels, I advised the patient to increase her salt intake, the patient attributed this to the caregiver’s cooking, as she felt that the meals were not seasoned enough. However, upon further discussion with the nurses, the caregiver mentioned that she already added an adequate amount of salt to the meals.

700185130

230725

{not completed}

[exam findings]

• 2023-07-05 CT - abdomen
  • History:
    • Pancreatic cancer with tumor necrosis, portal vein thrombosis, invasion to left kidney, T4NxM1, stage IV, status post transabdominal pancreatic biopsy on 2023/04/11 s/p EP from 2023/04/27
    • 20230411 US-guided biopsy: Neuroendocrine carcinoma, large cell type
  • Findings:
    • Prior CT identified a large heterogeneous poor enhancing tumor with central tumor necrosis (10.0cm in the largest dimension) at the pancreatic body and tail is noted again, stationary that is c/w neuro-endocrine carcinoma of the pancreas S/P C/T with stable disease.
      • Prior CT identified tumor thrombosis in the trifurcation of the splenic vein, superior mesenteric vein, and portal vein is noted again, stationary.
      • In addition, there is small size of the splenic artery and non-visualization of the splenic vein that is c/w tumor encasement.
    • There is splenomegaly (the greatest cranial-caudal dimension measuring 13 cm in size).
    • There is ascites in the pelvis.
  • Impression:
    • Neuro-endocrine carcinoma of the pancreatic body and tail S/P C/T shows stable disease.
• 2023-07-02 CT - brain
  • Indication: con’s change
  • Impression: No definite abnormality in this study
• 2023-07-01 ECG
  • Sinus bradycardia
  • Lateral infarct, age undetermined
• 2023-06-13 ECG
  • Sinus rhythm with short PR
• 2023-06-09 All-RAS + BRAF mutation
  • Tissue Block No: S2023-06855
  • RESULTS：
  • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-04-26 ENT Hearing Test
  • Reliabilty Fair
  • PTA
  • R’t : >120 dB HL, profound HL
  • L’t : 93 dB HL, severe to profound SNHL.
• 2023-04-12 Patho - pancreas biopsy
  • Pancreas, sono-guided biopsy — Neuroendocrine carcinoma, large cell type
  • The sections show neuroendocrine carcinoma, large cell type, composed of large pleomorphic neoplastic cells with moderate amount eosinophilic cytoplasm, arranged in solid pattern. Tumor necrosis is present.
  • IHC, tumor cells reveal: CK(+), CK7(+), CD56(focal +), Synaptophysin(+), Trypsin(-/+) and Ki67=70%.
• 2023-04-11 Sono-guided pancreatic tumor biopsy
  • Findings: A large heterogeneous isoechoic tumor with anechoic component at pancreatic neck and body.
• 2023-04-08 MRI - pancreas
  • History and indication: abdominal pain
  • With and without contrast MRI of abdomen with MRCP reconstruction revealed:
    • A large poor enhancing tumor (8.8x10.0cm) at LUQ with splenic artery, vein, stomach, left adrenal, adjacent bowel and spleen invasion. Proximal portal vein thrombosis with collateral circulation.
    • Normal appearance of liver and kidneys.
    • No ascites, nor enlarged lymph node.
    • No abnormal signal intensity in bilateral basal lungs.
  • IMP:
    • In favor of pancreatic tumor as described.
• 2023-04-07 SONO - abdomen
  • Diagnosis
    • Pancreatic tumor, with tumor necrosis, PVT, invasion to left kidney.
    • Splenomegaly, mild
  • Suggestion
    • consider trans-abdominal biopsy.
• 2023-03-25 CT - abdomen
  • History and indication: Hematochezia / Melena
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A large poor enhancing tumor (8.1x10.0cm) at LUQ r/o pancreatic tumor. Splenic artery and vein invasion and proximal portal vein thrombosis with collateral circulation was noted. Stomach, left adrenal, adjacent bowel and spleen invasion should be ruled out.
    • Small amout ascites. Some LNs at upper abdomen.
  • IMP:
    • Suspected pancreatic tumor with splenic artery/ vein/ portal vein/ stomach/ left adrenal gland/ adjacent bowel loop and splenic invasion.

[consultation]

• 2023-06-09 Obstetrics and Gynecology
  • Q
    • This is a 43-year-old female with history of Pancreatic cancer with tumor necrosis, portal vein thrombosis, invasion to left kidney, T4NxM1, stage IV, status post transabdominal pancreatic biopsy on 2023/04/11, s/p Etoposide plus Cisplatin form 2023/04/27, this time, she was admitted for chemotherapy.  
    • For menstrual pain was noted, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • We consulted for menstrual pain
    • OBGYN:
      • P2 (NSD*2)
      • LMP 06/06
    • Lab:
      • WBC 3660, Hb 10.7, PLT 178000, BCS WNL
      • CEA 2.09, CA199 9.14, CA125 49.3
    • PV:
      • moderate amount of red discharge
      • no lifting pain
      • smooth cervix
    • TVUS and TAS:
      • Uterus 108*40mm, EM 14.8mm
      • ROV 2418mm, LOV 2317mm
      • ascites+
    • Impression:
      • EM 14.8mm
    • Suggestion:
      • current no GYN lesion noted
      • NSAID for pain control
      • GYN OPD f/u for menstrual cycle
• 2023-04-13 Hemato-Oncology
  • A -This 43 year old woman is a case of pancreatic tumor with splenic artery/ vein/ portal vein/ stomach/ left adrenal gland/ adjacent bowel loop and splenic invasion s/p Transabdominal pancreatic biopsy was done on 20230411. We are consulted for further evaluation.
    • May check LDH, HBsAg, Anti-HBc, Anti-HBs, Anti-HCV. Pending pathology result. Arrange our OPD after discharge.
• 2023-04-12 General and Gastroenterological Surgery
  • Q
    • This 43 years old woman denied any systmic underlying disease, hearing-impaired person.
    • This time, she has abdominal pain since 2023-03-15 (thought it was menstrual pain) but pain sensation no improve so she came to our ED for hlep on 2023-03-19, ecchymosis around the navel was also noted, suggest abdominal CT examination but reufsed and AAD. Still intermittent abdominal pain and mass lesion over left abdominal, back stool passage for one weeks, so she came to ED and arrange PES was done on 2023-03-24, report showed Gastric huge mass lesion, upper body, suspect external compression, no ulcer or active bleeding noted. The Abdominal CT was done on 2023-03-25 and revealeding R/O pancreatic tumor with splenic artery/ vein/ portal vein/ stomach/ left adrenal gland/ adjacent bowel loop and splenic invasion. There was no fever, productive cough, abdominal pain is intermittent, The tarry stool was improved after medication, but syncope while riding a motorcycle yesterday. TOCC history was unremarkable. Thus, she was admitted to our GI ward for MRCP examination on 2023-04-05.
    • Pancreatic MRI plus MRCP was performed on 2023/04/08 and reported A large poor enhancing tumor (8.8x10.0cm) at LUQ with splenic artery, vein, stomach, left adrenal, adjacent bowel and spleen invasion. Proximal portal vein thrombosis with collateral circulation.Transabdominal pancreatic biopsy was done on 2023-04-11 ,the pathology was pending. We will need your surgical evaluation, thank you
  • A
    • Please pending pathology report
    • Poor operation due to r/o pertoneal seeding and proximal portal vein thrombosis was noted.

[MedRec]

• 2023-07-03 Multi-disciplinary Team Recommendations - Social Services
  • Referral Date: 2023-07-03
  • Reason for Referral: The patient lacks self-care ability during hospitalization, and family members are unable to come to the hospital to take care of her.
  • Status: Case opened
  • Family Situation: According to past service records and the visit to the patient on 2023-06-30, and after having a conversation with the patient, the following family situation was obtained:
    • The patient is 43 years old, unmarried, and has a hearing impairment. She works as an administrative assistant with a monthly income of 24,000 NTD. She used to live with her two children on the 8th floor with an elevator in a rented apartment, with a monthly rent of 29,000 NTD. Since June 2023, she has moved in to live with her mother, and her two children are taken care of by her eldest younger sister.
    • The patient has had two intimate relationships, and each relationship has resulted in one son. The elder son is in the fourth grade of Muzha Elementary School, and the younger son is in the middle class of Renmei Kindergarten. According to the patient’s aunt, the elder son maintains contact with his biological father, while the younger son has no contact with his biological father, and both sons have not undergone paternity acknowledgment.
    • The patient’s mother is 64 years old and works in a fruit shop. She has been married twice and has three daughters and one son (female, female, female, male). The patient is the eldest daughter, and her father has passed away. Her two younger sisters are married, and her brother lives abroad. According to the patient’s aunt, due to past family issues, the relationship between the patient and her mother and siblings is somewhat distant. The patient was raised by her maternal grandmother since childhood and is closer to her aunt, who is of a similar age, and thus trusts her aunt more.
    • The patient was diagnosed with malignant sebaceous gland tumor around 2017 years ago and received treatment at the Postal Hospital. After completing the treatment, the patient did not continue to follow up with regular visits.
    • The patient is classified as a fourth-class low-income household in Taipei City and holds a second-class severe disability certificate due to her hearing impairment. She receives a total of 17,576 NTD in disability and low-income living allowances each month.
    • Contact persons: Patient’s mother (Deng XiuZhu), patient’s aunt (Deng YuZhu).
  • Main Problem: Economic issue
  • Problem Details: Issue with hiring caregiver costs
  • Disposition: Referral for economic assistance
  • Responder: Liu SiLing
  • Reply Date: 2023-07-03
  • Physician Response:
    • 2023/07/04 10:48 Dr. Xia Hexiong: Will follow the recommendations, the family relationship in this case is very complicated. The patient’s children are taken care of by her younger sister, but the patient has a poor relationship with her sisters. The patient interacts more with her aunt. The patient now lives with her mother, but during the conversation with her aunt regarding the patient’s condition, it was discovered that even the relationship between the aunt and the patient’s mother is not good. The attending physician hopes to have a complete discussion and explanation of the patient’s condition with all the family members concerned about the patient. A family meeting is scheduled to be held on Friday, 2023/07/07. The aunt has left the mother’s phone number, and the hospital is expected to contact the mother directly. Attempts were made to contact the mother on 2023/07/03 and 2023/07/04, but the calls were not answered.
• 2023-07-02 Multi-disciplinary Team Recommendations - Psychological Oncology
  • Referral Date: 2023-07-02
  • Reason for Referral: Stressful illness event: Psychological response due to physical illness or decision-making regarding treatment options; Emotional distress: Anxiety, fear, depression, anger; shyness, shock, and other emotional categories.
  • Conclusion: (Social) Visit on 7/4, the patient was using a smartphone and responded with gestures that the treatment has not started yet. The first two treatments were okay, and they have been doing well at home and with their eating. Thank you for the concern. (Objective) Diagnosed with pancreatic cancer and renal metastasis on 12/3, previously visited on 4/27 (emotional distress, chronic stress; hearing impairment; unmarried, two children); admitted for the third round of chemotherapy on 6/30, nursing consultation on 7/2 reported psychological stress response. (Intervention) Providing support for the treatment burden of the patient. (Action Plan) The patient remains unwilling to talk; it is advised to consider prognosis, physical condition, family support, and financial burden, and continue discussing the treatment direction with the family. Counseling Psychologist Huang Xiaofang 65628
  • Responder: Huang XiaoFang
  • Reply Date: 2023-07-05 17:42
  • Physician Response:
    • 2023/07/06 07:49 Dr. Xia Hexiong: Will follow the recommendations and continue to monitor and observe the patient’s condition. Will also arrange a family meeting to help the patient and family better understand the current situation. Thank you for the team’s response.
• 2023-06-30 Multi-disciplinary Team Recommendations - Social Services
  • Referral Date: 2023-06-30
  • Reason for Referral: Other: Low-income household
  • Status: Not opened
  • Reason for Not Opening: The social services department has dealt with the case previously and is still in the process.
  • Family Situation: The same as previously mentioned.
  • Social Worker Evaluation and Handling:
    • The patient is undergoing routine chemotherapy during this hospitalization. As a low-income individual, she is exempt from hospitalization fees and has not used any self-paid items. The patient can take care of herself during hospitalization, so there are no economic and care issues assessed.
    • The social worker has provided the above handling, and there are no further derivative problems at this time. If there are any other needs, please refer again. Thank you.
  • Responder: Liu Si-ling
  • Reply Date: 2023-06-30
  • Physician Response:
    • 2023/07/03 08:00 Dr. Xia Hexiong: Will follow the recommendations and continue to monitor and observe the patient’s condition. Will also arrange a family meeting to help the patient and family better understand the current situation. Thank you for the team’s response.
• 2023-04-19 SOAP Hemato-Oncology
  • Assessment and Plan
    • pancrease neuroendocrine carcinoma, large cell type
    • transfer to ER due to anemia with dizzines (blood transfusion and admission)
    • admiited for port A insertion, check 24 urine CCR, audiometry and then C/T with EP
      • etoposide + carboplatin (hearing impairment)

[chemotherapy]

• 2023-06-30 - etoposide 100mg/m2 120mg NS 500mL 1hr D1-3 + cisplatin 25mg/m2 30mg NS 500mL D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-06-07 - etoposide 100mg/m2 130mg NS 500mL 1hr D1-3 + cisplatin 25mg/m2 35mg NS 500mL D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
• 2023-04-27 - etoposide 100mg/m2 130mg NS 500mL 1hr D1-3 + cisplatin 25mg/m2 35mg NS 500mL D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2023-07-25

Episodes of anemia were evident according to the most recent lab results.

• 2023-07-24 HGB 9.1 g/dL
  
• 2023-07-19 HGB 6.4 g/dL **
• 2023-07-10 HGB 10.4 g/dL
  
• 2023-07-07 HGB 8.7 g/dL *
• 2023-07-05 HGB 10.9 g/dL
  
• 2023-07-03 HGB 10.8 g/dL
  
• 2023-07-01 HGB 9.0 g/dL
  
• 2023-06-30 HGB 9.1 g/dL

The most recent chemotherapy administration was initiated on 2023-06-30. Additionally, the patient experienced several GI tumor bleeding events since 2023-03 and received blood transfusions on the following dates: 2023-03-24, 2023-03-25, 2023-04-05, 2023-04-12, 2023-04-19, 2023-04-23, 2023-06-30, 2023-07-07, 2023-07-19, and 2023-07-24. Considering that both tumor bleeding and blood transfusions can affect HGB levels, it is difficult to conclusively attribute anemia solely to chemotherapy, and the potential impact of chemotherapy cannot be completely ruled out.

2023-07-10

Studies indicate that patients with gastroenteropancreatic neuroendocrine carcinoma who receive cisplatin/etoposide treatment can have an Objective Response Rate (ORR) ranging from 14% to 67%, as stated in “Systemic Treatment of Gastroenteropancreatic Neuroendocrine Carcinoma. Curr. Treat. Options in Oncol. 22, 68 (2021).”

The CT scan on 2023-07-05 demonstrated stable disease for the neuroendocrine carcinoma of the pancreatic body and tail, following 3 cycles of the cisplatin/etoposide regimen. This might suggest that the disease could be developing some degree of resistance to the treatment.

2023-07-03

After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were identified.

2023-06-08

The patient sought treatment for unspecified dermatitis at Huang ZhenXian Dermatology Clinic on 2023-05-08 and was prescribed tranexamic acid, betamethasone, prednisolone, and loratadine for a short duration of 3 days. Currently, no dermatitis-related symptoms are observed in the admission note or the active medical problem list. Therefore, no medication reconciliation issues are identified.

700337848

230725

[exam findings]

• 2023-06-26 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
• 2023-06-05 Patho - colon biopsy
  • Large intestine, rectum, 6-7 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2023-06-05 Colonoscopy
  • An ulcerative tumor lesion is located at rectum (6-7cm AAV) with obstruction.
• 2023-06-02 MRI - pelvis
  • Indicaiton
    • 20230528 CC: bloody stool on and off for months
    • 20230530 colonoscopy: circumferential rectal tumor with lumen narrowing, scope cannot pass through since 10cm, 1st fold of rectum.
    • 20230601 CT: upper rectal cancer & obstruction, T4bN2aM0, STAGE: IIIC
  • Findings
    • There is a lobulated soft tissue mass in the upper rectum, measuring 8 cm (the largest dimension), showing hypointensity on T1WI and mild hyperintensity on both T2WI and DWI. During dynamic study, this tumor shows poor enhancement that is c/w adenocarcinoma of the upper rectum.
      • In addition, there is fat plane obliteration between this rectal mass and the urinary bladder and prostate that may be urinary bladder and prostate invasion (T4b).
      • There is fat plane obliteration between this rectal mass and the mesorectal fascia that is c/w mesorectal fascia invasion.
    • There are four enlarged nodes in the perirectal space that are c/w metastatic nodes (N2a).
    • There are enlarged nodes in right and left inguinal area that may be non-regional metastatic nodes (M1a).
      • Please correlate with PET scan.
    • There is a vesical stone 1 cm.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression ( Imaging stage ): T:T4b(T_value) N:N2a(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
• 2023-06-01 CT - abdomen
  • History and indication:
    • rectal cancer with obstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with adjacent fat, prostate, seminal vesicles invasion and regional LAP.
    • Bil. pleural effusions.
    • A stone (1.0cm) in urinary bladder. Left renal staghorn stone. Renal cysts (up to 1.8cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression ( Imaging stage ): T:T4b(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2023-06-01 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (122 - 73) / 122 = 40.16%
    • M-mode (Teichholz) = 40
  • Conclusion:
    • Dilated LA
    • Impaired LV systolic function, generalized hypokinesis
    • LV hypertrophy, Impaired LV relaxation
    • Mild MR, TR, AR, PR
• 2023-06-01 Flow Volume Loop
  • Normal spirometry
• 2023-05-31 KUB
  • Radiopaque spot(s) at left renal region r/o renal stone(s).
  • Presence of ileus.
  • A calcification at right pelvic cavity.
• 2023-05-30 Sigmoidoscopy
  • Finding: circumferential rectal tumor with lumen narrowing, scope can not pass through since 10cm, 1st fold of rectum.
  • Diagnosis: Highly suspect rectal cancer with osbtruction, due to PLVIX only 3 days stopping, no biopsy
  • Suggestion:
    • repeat sigmoidoscopy with biopsy after plavix 6~7 days
    • T colostomy or stenting for rectal cancer obstruction
    • A + P and Chest CT, CEA.
• 2023-05-29 SONO - abdomen
  • Hepatic calcification, right lobe
  • Parenchymal renal disease
  • Renal cyst, RK
  • Renal stone, LK
• 2023-05-29 Esophagogastroduodenoscopy, EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Hiatal hernia
    • Gastric polypoid lesion, prepyloric antrum, LC, s/p biopsy
    • Gastric erosions, pylorus
    • Duodenal ulcer scar with pseudodiverticulum, bulb
  • Suggestion:
    • Pursue pathology report
    • PPI therapy
• 2023-05-27 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
  • Left axis deviation
  • Moderate voltage criteria for LVH, may be normal variant
  • Inferior infarct, age undetermined
  • Abnormal ECG
• 2023-05-27 CXR
  • Cardiomegaly and tortuosity of the thoracic aorta.
  • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
  • Degenerative joint disease of T-spine with marginal osteophytes.
• 2023-05-27 ECG
  • Sinus rhythm with frequent Premature ventricular complexes
  • Left axis deviation
  • Voltage criteria for left ventricular hypertrophy
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG

[MedRec]

• 2023-07-10 SOAP Radiation Oncology
  • A/P
    • RT dose: 2700cGy/15 fractions (15 MV photon) to rectal tumor and lymphatics, 2023/6/16 to 7/07.
      • 5FU: 6/25-30.
    • RT Side effect evaluation, 7/07: Radiation dermatitis, grade 0; N/V, grade 0; enteritis, grade 0; cystitis, grade 0; proctitis, grade 0.
• 2023-07-04 SOAP Dermatology
  • S
    • multiple painful erythematous papule-nodules on face,trunk and 4-limbs
    • multiple erythematous scars and keloids on scalp for months, progressive enlarged recently, itching(+), keloid (+)
  • O
    • Imp: acne on face and trunk for months, multiple pustule (+),inflammation(+), painful(+)
  • P
    • education about drug side effec and explain
    • strongly suggested OPD f/u
  • Prescription
    • triamcinolone suspended 10mg ST IS
    • fusidic acid BID EXT
    • doxycycline 100mg 1# BID PO

[consulation]

• 2023-07-11 Cardiology
  • Q
    • The patient is an 76-year-old male with a history of
      • Hypertension for 20+ years with medication control,
      • Coronary artery disease for 10+ years s/p stent x6 (last one in early of 2023),
      • Type II diabetes mellitus for 10+ years with medication control,
      • Rectal cancer with impending obstruction s/p loop colostomy on 2023/06/02 with perirectal and bilateral inquinal LAP metastasis, stage cT4bN2aM1a, stage IVA
    • He presented with Coronary artery disease for 10+ years s/p stent x6 (last one in early of 2023) and Hypertension for 20+ years with medication control Hx, for CV drug adujst, we need your further evaluation and management.
  • A
    • He is admitted for evaluation of chemotherapy and we are consulted for CV meds adjust
      • ECG shows sinus rhythm with PVCs, LAD
      • CXR shows cardiomegaly
      • echocardiography shows dilated LA, LVH, global LV hypokinesis with impaired LV systolic function
    • CV meds with plavix 1 # qd, concor 2.5 mg qd, diovan 40 mg qd forxiga 1 # qd
    • suggest
      • to keep present CV meds
      • monitor I/O and BW
      • to avoid overhydration

[radiotherapy]

[chemotherapy]

• 2023-07-14 - [fluorouracil 400mg/m2 650mg NS 100mL 10min + leucovorin 20mg/m2 30mg NS 100mL 10min] D1,4-7 (for CCRT, QW)
• 2023-06-26 - [fluorouracil 400mg/m2 650mg NS 100mL 10min + leucovorin 20mg/m2 30mg NS 100mL 10min] D1-5 (for CCRT, QW)

==========

2023-07-25

[tube feeding - Concor]

According to the manufacturer’s instructions for Concor (bisoprolol 5 mg tablets), it should be swallowed with a drink of water and not chewed. However, if the patient is receiving tube feeding, the Simple Suspension Method (SSM) can be used. This method involves dissolving the tablets in warm water for 5-10 minutes and then passing the solution through a feeding tube for administration. The Simple Suspension Method may be appropriate for administration of Concor tablets through a feeding tube.

[renal dosing Tapimycin from Q6H to Q8H]

Kidney function appears to be deteriorating in this patient. 2023-07-25 CrCl 27 mL/min.

• 2023-07-25 Creatinine 2.00 mg/dL
  
• 2023-07-14 Creatinine 1.50 mg/dL
  
• 2023-07-25 eGFR 34.70
  
• 2023-07-14 eGFR 48.36
  
• 2023-07-25 BUN 38 mg/dL
  
• 2023-07-14 BUN 22 mg/dL

When using Tapimycin (piperacillin 4g, tazobactam 0.5g) in patients with a CrCl between 20 and 40, if the intended dose is 4.5g Q6H infused over 30 minutes, then the recommended doses are either 4.5g Q8H or 3.375g Q6H, with the former being preferred.

A dose of 4 mg once daily is recommended when using Urief (silodosin 8 mg) in patients with a CrCl between 30 and 50.

[leukopenia and thrombocytopenia]

Bicytopenia (leukopenia and thrombocytopenia) is evident based on recent lab results after consecutive 5-day fluorouracil administration (for CCRT), which started on 2023-06-26 and 2023-07-14.

• 2023-07-25 WBC 0.16 x10^3/uL
  

• 2023-07-14 WBC 2.82 x10^3/uL
  

• 2023-07-05 WBC 6.47 x10^3/uL
  

• 2023-06-26 WBC 8.28 x10^3/uL
  

• 2023-06-13 WBC 9.43 x10^3/uL

• 2023-07-25 HGB 9.0 g/dL
  

• 2023-07-14 HGB 9.1 g/dL
  

• 2023-07-05 HGB 9.5 g/dL
  

• 2023-06-26 HGB 8.3 g/dL
  

• 2023-06-13 HGB 10.0 g/dL

• 2023-07-25 PLT 80 *10^3/uL
  

• 2023-07-14 PLT 301 *10^3/uL
  

• 2023-07-05 PLT 299 *10^3/uL
  

• 2023-06-26 PLT 340 *10^3/uL
  

• 2023-06-13 PLT 459 *10^3/uL

Blood transfusions are performed on 2023-05-27, 2023-06-01, 2023-06-26, 2023-07-14, 2023-07-25 and Granocyte (lenograstim 250ug) is to be administered since 2023-07-25 for consecutive 6 days. No issue with the use of G-CSF.

2023-07-18

[ARBs Equivalent Dose Conversion]

This patient is currently self-administering Diovan (valsartan 40mg) once daily and the supply is almost exhausted. Upon checking, our hospital only carries a 160mg dosage, which is inconvenient to divide into quarters. However, Olmetec (olmesartan 20mg) or Blopress (candesartan 8mg) is an option, as it belongs to the class of angiotensin II receptor blockers (ARBs) just like valsartan. Considering that approximately 40 mg of valsartan is equivalent to 10 mg of olmesartan or 4 mg of candesartan, it may be advisable to prescribe Olmetec at a dose of 0.5 tablets or Blopress at a dose of 0.5 tablets per day as a suitable alternative.

2023-07-11

Our dermatologist prescribed fusidic acid and doxycycline on 2023-07-04 and these drugs are integrated into the active medication list without reconciliation issues found

2023-06-29

[to replace Forxiga with Jardiance]

• Based on the HIS5 database records, the patient’s eGFR has remained within a range of approximately 40 to 50 mL/min/1.73 m2 for the past 30 days. 2023-06-26 eGFR 43, Cre 1.64mg/dL, age 75 male => CrCl 34mL/min.
• Considering the patient’s type 2 DM and an eGFR below 45, the package insert advises against the use of dapagliflozin. However, empagliflozin can still be used for patients with an eGFR greater than or equal to 30. Therefore, it would be beneficial to switch from Forxiga (dapagliflozin 10mg) 1# QDAC to Jardiance (empagliflozin 10mg) 1# QD.

[patient education: 5-FU]

• I visited the patient on 2023-06-29 at 13:30. The patient was lying in bed while his wife sat on the bench next to the bed. I brought an information sheet about fluorouracil and explained to both of them the precautions and possible side effects of the drug. I emphasized that because of the potential impact on his immune system, he should avoid raw foods and practice good food preparation hygiene. Since the patient’s renal function is relatively poor, I also reminded him to maintain adequate hydration.
• During my visit, the patient seemed somewhat frail, even though he was capable of communicating without any difficulties. He seemed to lack energy and spirit. At the time of the visit, the patient did not express any specific concerns or complaints.

2023-06-26

[reconciliation]

• The patient has had multiple medical appointments at different hospitals over the past few weeks. On 2023-05-23, the patient was seen at JingMei Hospital for hemorrhoids. Additional visits to JingMei Hospital include a visit on 2023-05-08 for contact dermatitis, and another one on 2023-05-01 for tinea corporis.
• The patient also visited WanFang Hospital for various conditions. On 2023-04-30, he was treated for pneumonia; on 2023-04-29, for a gastric ulcer; and on 2023-04-24, for anemia.
• The prescriptions from these visits seem to be mostly short-term, with the exception of a 28-day prescription for lansoprazole 30mg QDAC, which could possibly be refilled. Currently, this medication is included in the patient’s active medication list, therefore no reconciliation issues have been identified.

700787697

230725

[MedRec]

• 2023-07-24 DutyNote Hemato-Oncology
  • The 82 y/o pateint 1) Hypertension, heart disease under control; 2) Diabetes mellitus, type 2 under control; 3) right renal stone; 4) L spine HIVD s/p op had admitted to our ward due to leukocytosis (WBC > 16K) at ER on 7/8. In order to rule out the possibility of multiple myeloma, the patient was admitted to our ward for bone marrow survey and further management. According to himself, he denied fever, chillness, dizziness, or other discomfort but bilateral leg edema with tenderness and slightly short of breathe but with fair saturation under nasal cannula 3L/min given.
• 2023-06-13 SOAP Ophthalmology
  • Prescription (multiple)
    • Combigan Eye Drops (brimonidine 2mg, timolol 5mg) 1# Q12H OS
    • Vidisic Gel (carbomer 10gm) QID OU
    • Tears Naturale (hydroxypropyl methylcellulose 3mg, dextran 70) QID OU
• 2023-06-06 SOAP Neurology
  • Prescription (multiple)
    • dipydidamole 25mg 1# BID
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNQD
    • Rivotril (clonazepam 0.5mg) 0.5# PRNHS
    • Neurontin (gabapentin 100mg) 1# PRNHS
• 2023-05-03 SOAP Metabolism and Endocrinology
  • Prescription (multiple)
    • NovoRapid (insulin aspart, recombinant) 15unit TIDAC
    • Toujeo (insulin glargine) 15unit HS
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
    • Lipanthyl Supra (fenofibrate 160mg) 1# QW1357
    • Through (sennoside 12mg) 2# HS
    • Tulip (atorvastatin 20mg) 1# QD
• 2023-04-06 SOAP Cardiology
  • Prescription (multiple)
    • Norvasc (amlodipine 5mg) 1# BID
    • Syntrend (carvedilol 25mg) 0.5# BID
    • Meletin (mexiletine 100mg) 1# BID
    • Ulstop (famotidine 20mg) 1# QD
    • Plavix (clopidogrel 75mg) 1# QOD
    • Urief (silodosin 8mg) 1# QD

==========

2023-07-25

This patient has been regularly visiting multiple departments at our hospital and receiving several repeat prescriptions.

Cardiology prescribed the following medications: - Norvasc (amlodipine) - Syntrend (carvedilol) - Meletin (mexiletine) - Ulstop (famotidine) - Plavix (clopidogrel) - Urief (silodosin)

Endocrinology prescribed the following medications: - NovoRapid (recombinant insulin aspart) - Toujeo (insulin glargine) - Kentamin (vitamin B1, B6, B12) - Lipanthyl (fenofibrate) - Through (sennoside) - Tulip (atorvastatin)

Neurology prescribed the following medications: - Dipydidamole - Sketa (acetaminophen, chlorzoxazone) - Rivotril (clonazepam) - Neurontin (gabapentin)

Ophthalmology prescribed the following eye medications: - Combigan Eye Drops (brimonidine, timolol) - Vidisic Gel (carbomer) - Tears Naturale (hydroxypropyl methylcellulose, dextran 70)

All the oral drugs have been included in the active medication list, except for the eye medications. Please check if the patient still needs these eye medications.

701453601

230725

[exam findings]

• 2023-06-12 CT - abdomen
  • History and indication: Gastric tumor
  • IMP:
    • S/P gastric operation. No evidence of tumor recurrence.
    • Bil. renal stones (2-4mm).
    • R/O CBD stone (5mm).
• 2023-04-01 Pure Tone Audiometry, PTA
  • Reliabilty Fair
  • R’t : 41 dB HL, normal to severe mixed type HL
  • L’t : 45 dB HL, normal to profound mixed type HL.
• 2023-03-17 CXR
  • S/P Port-A infusion catheter insertion.
  • Interstitial pattern at LLL.
• 2023-03-10 Patho - stomach subtotal/total (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Stomach, subtotal gastrectomy — Neuroendocrine carcinoma
    • Margins, bilateral cutting ends, subtotal gastrectomy — Free of tumor invasion
    • Lymph nodes, D2 LN dissection — Metastatic neuroendocrine carcinoma (10/28)
    • AJCC Pathologic staging — pT4aN3a(cM0), stage IIIB
  • MACROSCOPIC EXAMINATION
    • Specimen type: Stomach and regional lymph nodes
    • Specimen size: 22.5 cm along greater curvature and 12.5 cm along the lesser curvature
    • Number of lesions: Solitary
    • Tumor site: Low body, lesser curvature, 6.0 cm from distal margin
    • Tumor size: 4.8 x 4.2 cm in size
    • Tumor configuration: Ulcerative mass
    • Representative sections as follows: A1= proximal margin, A2= distal margin, A3-A6= tumor, B= LN 1, C= LN 3, D1-D2= LN 4, E= LN 5, F= LN 6, G1-G3= LN 7,8,9,11p
  • MICROSCOPIC EXAMINATION
    • Histologic type: Neuroendocrine carcinoma, combined small cell and large cell types
    • Histologic grade: Poorly differentiation (G3)
    • Depth of tumor invasion: Tumor invades the serosa
    • Margins: Radial margin is involved by carcinoma
    • Perineural invasion: Present
    • Lymphovascular space invasion: Present
    • Regional lymph nodes: Metastatic carcinoma (10/28)
      • 0 (LN 1), 5/5 (LN 3), 1/3 (LN 4), 0/1 (LN 5), 0/3 (LN 6), 4/16 (LN 7, 8, 9, 11p); (Number of LN involved/Number of LN examined)
    • Extracapsular extension: Present
    • Additional pathologic findings: Non-atrophic chronic gastritis
    • Pathologic Staging: pT4aN3a(cM0), stage IIIB
    • IHC (S2023-03207): CK(+), CD56(+), Synaptophysin(+), TTF-1(+), Ki-67= 60%
• 2023-03-007 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 30) / 116 = 74.14%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; impaired LV relaxation.
    • Normal RV systolic function.
    • Moderate MR; mild to moderate AR; mild to moderate TR; mild PR.
    • Mildly dilated ascending aorta.
    • A calcified atheroma (1.04cm of thickness) at aortic root.
• 2023-03-06 ECG
  • Normal sinus rhythm
  • ST & T wave abnormality, consider inferolateral ischemia
  • Abnormal ECG
• 2023-02-27 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Ulcerative mass at gastric body measuring 4.2cm in largest dimension is found. Huge lymph nodes are found at celiac trunk (3.4cm) and gastrohepatic ligment (n＝4) is found.
  • Imp: Gastric cancer at body with reiongal lymphadenopathy (n＝4)
  • Imaging Report Form for Gastric Carcinoma
  • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-02-22 Patho - stomach biopsy
  • Stomach, angularis, biopsy — small cell neuroendocrine carcinoma, origin?, please see microdescription
  • Sections show gastric mucosa with infiltration of large nests of small hyperchromatic tumor cells, scanty cytoplasm and marked crushing artifact.
  • The immunohistochemical stains reveal CK(+), CD56(+), Synaptophysin(+), TTF-1(+), and LCA(-). The Ki-67 is about 60%. Small cell neuroendocrine carcinoma of stomach may also be positive for TTF-1. Please correlate with the clinical presentation and image study to confirm tumor origin from lung, stomach, or other area.
• 2023-02-22 Esophagogastroduodenoscopy, EGD
  • Findings
    • Esophagus: No mucosa break was seen. No definite lesion.
    • Stomach: One A2 ulcer (large 3.5 cm , deep with some old blood clot) over angularis, biopsy was done
  • Diagnosis
    • Gastric ulcer, big, A2 ulcer over angularis

[MedRec]

• 2023-04-28 ~ 2023-04-30 POMR Hemato-Oncology
  • Course of inpatient treatment
    • After admission, he receice chemotherapy with EP (Cisplatin 75mg/m2 D1 –> due to Cr:1.31, eGFR :57, change to Carboplatin AUC:5, Etoposide 100mg/m2 D1-D3) on 2023/04/28-04/30, with adequate hydration. Mopride 5mg/tab 1# TID and Primperan 1amp IVD PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg/tab 1# PO QDAC. Chronic gastric ulce with Nexium 40mg/tab 1# PO QDAC. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/04/30 and OPD followed up later.
  • Prescription
    • Granocyte (lenograstim 250ug) QD SC 3D (on 2023-05-04,05,06)
    • Acetal (acetaminophen 500mg) 1# PRNQ6H (post GCSF, if bone pain or BT > 38’C)
• 2023-04-27 SOAP Hemato-Oncology
  • O - AE: Gr 4 neutropenia -> improved
• 2023-04-20 SOAP Hemato-Oncology
  • O - AE: Gr 4 neutropenia
• 2023-04-13 SOAP Hemato-Oncology
  • O
    • Cancer Treatment - Chemoradiation/Targeted Therapy Side Effects Assessment (2023-04-13)
      • Renal function (Creatinine level): Grade 2: > 1.5-3 times the upper limit of normal.
      • Renal function (Creatinine level) Management: Supportive care.
• 2023-03-31 ~ 2023-04-06 POMR Hemato-Oncology
  • Discharge diagnosis
    • Small cell neuroendocrine carcinoma, cT2N2M0, s/p radical subtotal gastrectomy with D2 lumph node dissection and Roux-en-Y gastrojejunostomy anastomosis on 2023/03/09, pT4aN3a(cM0), stage IIIB, with Perineural invasion+, lymphovascular space invasion
    • Chronic viral hepatitis B without delta-agent
  • Course of inpatient treatment
    • After admission, he received PTA and record 24 hrs Ccr before chemotherapy, PTA on 2023/04/01 showed reliabilty fair, 24 hrs Ccr showed 101.0 mL/min, total urine 1300ml. He receice chemotherapy with EP (Cisplatin 75mg/m2 D1, Etoposide 100mg/m2 D1-D3) on 2023/04/03-04/05, with adequate hydration. Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg/tab 1# PO QDAC. Patient tolerated the chemotherapy with mild nausea without vomiting and hiccup were noted, after treatment improving. With the stable condition, he was discharged on 2023/04/06 and OPD followed up later.
  • Prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Through (sennoside 12mg) 2# HS
    • Bafen (baclofen 5mg) 1# PRNQ8H
• 2023-03-28 SOAP Hemato-Oncology
  • S
    • For further management of the disease
    • Hbs Ag (-), Anti-HBc (+), Anti-HBs (+), Anti-HCV (-)
  • O
    • 2023/03/16 HBsAg = Nonreactive;
    • 2023/03/16 HBsAg (Value) = 0.42 S/CO;
    • 2023/03/16 Anti-HCV = Nonreactive;
    • 2023/03/16 Anti-HCV Value = 0.11 S/CO;
    • 2023/03/16 Anti-HBs = >1000.00 mIU/mL;
    • 2023/03/16 Anti-HBc = Reactive;
    • 2023/03/16 Anti-HBc-Value = 5.76 S/CO;
  • P
    • admisision
      • chest CT (+/- contrast) for complete work up
      • check 24 urine CCR, auditory test,
      • Adjuvant chemotherapy (4-6 cycle platinum-based chemotherapy [etoposide plus cisplatin or carboplatin]).
      • Prophylatic anti HBV medication
    • Arrange admission for 24 hours CCr, audiometry and C/T with EP
• 2023-03-06 ~ 2023-03-18 POMR General and Digestive Surgery
  • Discharge diagnosis
    • Neuroendocrine carcinoma of gastric lower body, pT4aN3a(cM0), stage IIIB status post radical subtotal gastrectomy with D2 lumph node dissection and Roux-en-Y gastrojejunostomy anastomosis on 2023/03/09. ECOG:1
    • Encounter for adjustment and management of vascular access device with port-A on 2023/03/17
  • CC
    • Epigastric pain and regurgitation for 6 months.       
  • Present illness
    • This is a 73-year-old man without specific past history. The patient had epigastric pain for 6 months, so he went to OPD for help since 2022/09. However, symptoms did not improved even after medication by H2 bloker. The pain was postprandially but did not refer to back or RUQ. Paendoscopy was arranged on 2023/02/22 with a finding of a big ulcer at gastric angularis. Pathology showed small cell neuroendocrine carcinoma. Thus, under the impression of Gastric cancer, he is admitted to our ward for subtotal gastrectomy.    
  • Course of inpatient treatment
    • After admmision, he was arranged with radical subtotal gastrectomy with D2 LN dissection with Roux-en-Y GJ anastomosis. After OP, he had moderate pain at wound and surgical site. The pain was tolerable after given pain killer PCA for post OP pain control. TPN starting on 2023/03/10 with NPO and NG decompression, NG removed. He had flatulence on 2023/03/13 and watery diarrhea passage on 2023/03/14. We started PG1 diet and the patietnt tolerated well without nausea or vomiting. Pathology of stomach tumor came out on 2023/03/14, showing Neuroendocrine carcinoma AJCC Pathologic staging pT4aN3a(cM0), stage IIIB. We consulted hematology doctor for further evaluation. Port-A was arranged on 2023/03/17 for future chenotherpay usage. Under good condition with good pain control and diet recovery to PG3 diet, he was discharged on 2023/03/18 for OPD followup and further treatment.
  • Prescription
    • Mopride (mosapride citrate 5mg) 1# TID
    • Pariet (rabeprazole 20mg) 1# QDAC
    • Acetal (acetaminophen 500mg) 1# QID

[consultation]

• 2023-03-18 Hemato-Oncology
  • Q
    • This is a 73-year-old man without specific past history. The patient had epigastric pain for 6 months, Panendoscopy was arranged on 2023/02/22 showed a small cell neuroendocrine carcinoma of gastric with a 4.2cm ulcerative mass, cT2N2M0, s/p radical subtotal gastrectomy with D2 LN dissection Roux-en-Y GJ anastomosis on 2023/03/09, pathology showed Neuroendocrine carcinoma, pT4aN3a(cM0), stage IIIB on 2023/03/14.
    • We need your expertise for further evaluation and treatment, Thx!!
  • A
    • Pathology showed Neuroendocrine carcinoma, pT4aN3a(cM0), stage IIIB, with Perineural invasion+, Lymphovascular space invasion+, margin+, Ki-67= 60%. We are consulted for further evaluation and treatment.
    • Please arrange chest CT(+/- contrast) for complete work up.
    • Adjuvant chemotherapy +/- RT is indicated in this case (4-6 cycle platinum-based chemotherapy [etoposide plus cisplatin or carboplatin]).
    • Please check 24 urine CCR, auditory test, HbsAg, antiHbs, AntiHbc, anti HCV. Arrange port A insertion.
    • Arrange our OPD after discharge. Thanks for your consultation.

[surgical operation]

• 2023-03-09
  • Surgery
    • radical subtotal gastrectomy with D2 LN dissection
    • Roux-en-Y GJ anastomosis
  • Finding
    • 4.5 x 4.5 cm ulcerative mass at lower body lesser curvature with serosa invole
    • large LN4 cm at station 9

[chemotherapy]

• 2023-07-24 - etoposide 80mg/m2 140mg NS 500mL 2hr D1-3 + carboplatin AUC 4 370mg NS 250mL 2hr D1 (Fytosid 100mg/m2 -> 80mg/m2. eGFR 67 carbo AUC 4)
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3
• 2023-06-30 - etoposide 80mg/m2 140mg NS 500mL 2hr D1-3 + carboplatin AUC 4 370mg NS 250mL 2hr D1 (Fytosid 100mg/m2 -> 80mg/m2. eGFR 69 WBC 2980 carbo AUC 4)
  • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3
• 2023-06-13 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3
• 2023-05-22 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1 (Cre 1.08, CrCl 59, carbo AUC 5)
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3
• 2023-04-28 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1 (Cre 1.31, cis -> carbo AUC 5)
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1
• 2023-04-03 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + NS 500mL 3hr (before cisplatin) + cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + NS 1000mL 3hr (post cisplatin)
  • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-2 + NS 250mL D1

==========

2023-07-25

As per the available records, the patient’s general and gastroenterology surgeon issued a prescription on 2023-06-20, following the subtotal gastrectomy. The prescribed medications include B-Red (hydroxocobalamin), Mopride (mosapride citrate), Foliromin (ferrous sodium citrate), and Ulstop (famotidine). These medications were appropriately incorporated into the active medication list, and there were no identified reconciliation problems.

2023-07-03

As per the records, our general and gastroenterological surgery department prescribed a 28-day course of B-Red (hydroxocobalamin), Mopride (mosapride citrate), Foliromin (ferrous sodium citrate), and Ulstop (famotidine) to this patient on 2023-06-20 due to his post subtotal gastrectomy status. These drugs have been correctly incorporated into the active medication list, and no reconciliation issues were identified.

2023-05-23

• A review of the PharmaCloud database shows that all of the patient’s most recent medications were prescribed by our hospital, and no medication reconciliation issues were identified.
• This patient was diagnosed with advanced neuroendocrine carcinoma of the stomach. The patient underwent radical subtotal gastrectomy with D2 lymph node dissection on 2023-03-09. Following this surgery, a chemotherapy regimen of cisplatin and etoposide was initiated on 2023-04-03. However, due to alternations in the patient’s renal function, the chemotherapy regimen was changed to carboplatin and etoposide on 2023-04-28. Neutropenia was noted with a white blood cell (WBC) count of 2.29K/uL on 2023-04-20. Prophylactic granulocyte colony stimulating factor (G-CSF) was prepared for the patient prior to the next round of chemotherapy.
• Lab data on 2023-05-16 showed grossly normal readings and vital signs in the TPR panel indicate that the patient’s condition is stable. All current medications seem appropriate and there appear to be no concerns found with the patient’s current drug regimen.

700385796

230724

[exam findings]

• 2023-07-15 MRI - brain
  • Indication: Esophageal cancer with regional lymph nodes are favored.
  • IMP: no evidence of brain metastasis.
• 2023-07-14 SONO - abdomen
  • Suspected liver cyst,left
  • Suspected GB polyps
• 2023-07-13 PET
  • A glucose hypermetabolic lesion involving the middle portion of the esophagus, compatible with primary esophageal malignancy.
  • Glucose hypermetabolism in two upper left paratracheal lymph nodes. Metastatic lymph nodes may show this picture.
  • A glucose hypermetabolic lesion in the posterior aspect of right acetabulum. The nature is to be determined. Please correlate with other imaging modalities such as MRI to rule out the possibility of bone metastasis.
  • Mild glucose hypermetabolism in a focal area in the anterior aspect of right 4th rib, possibly more benign in nature. However, please follow up bone scan for further evaluation.
• 2023-07-13 Pure Tone Audiometry
  • Reliability FAIR
  • Average RE 33 dB HL; LE 34 dB HL.
  • Bil normal to moderately severe SNHL.
• 2023-07-12 Treadmill Exercise Test
  • Conclusion
    • maximal exercise by RER>1.10
    • low exercise capacity ( VO2 48%, WR 65%) ( normal value >85%)
    • spirometry: normal (FVC 101%, FEV1 98%)
    • respiratory muscle strength: low ( MIP 59%, MEP 51%)
    • Breathing reserve normal
    • desaturation below 90%: nil
    • cardiac response during exercise normal
    • HR response during exercise: normal slope
    • work efficiency low
    • anaerobic threshold low
    • oxygen pulse low
    • BP response: normal
    • EKG: nonspecific findings
    • Health-related quality of life, CAT= 8, poor sleep 3
  • Impression:
    • low exercise capacity
    • low respiratory muscle strength
  • suggestion:
    • Treat underlying disease
    • Exercise training for low exercise capacity
    • Breathing exercise
    • low work efficiency, low AT, low O2p but normal cardiac response, suggest to arrange lower limbs doppler to survey PAOD
• 2023-07-10 Tc-99m MDP bone scan
  • Two hot spots in the ant. aspect of the left 5th rib, and the right 4th rib, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
  • Suspected benign lesions in the maxilla, some C-, T- and L-spine, bilateral shoulders, S-I joints, and hips.
• 2023-07-03 CT - chest
  • Indication: EGD today: favor esophageal cancer. s/p biopsy. arranged chest CT scan. refer to CS OPD on 2023-07-06 for further management.
  • Findings
    • Soft tissue mass at middle third esophagus up to 4.32cm is found.
    • Lymphadenopathy at paratracheal region is found.
    • Minimal tree in bud appearance at both lungs are found. Previous aspiration is suspected.
  • Imp: Esophageal cancer with regional lymph nodes are favored.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-06-30 Patho - esophageal biopsy
  • Esophagus, 25-30 cm below incisor, biopsy — Poorly differentiated squamous cell carcinoma
  • Microscopically, it shows poorly differentiated squamous cell carcinoma composed of a proliferation of non-keratinizing squamous tumor cells with invasive growth pattern, arranged in solid architecture and foci of c debris. The tumor shows nuclear hyperchromasia, pleomorphism and mitotic activity.
  • Immunohistochemical stain reveals P40(+), p63(+), CD56(focal +, 5%), CEA(-) and CDX-2(-).
• 2023-06-30 Esophagogastroduodenoscopy, EGD
  • Highly suspected advanced esophageal malignancy, M/3
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis

[chemotherapy]

• 2023-07-21 - cisplatin 30mg/2 47mg NS 500mL + fluorouracil 1000mg/m2 1580mg NS 500mL 24hr (PF CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

701475030

230724

[exam findings]

• 2023-03-30 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Hepatocellular carcinoma, moderately differentiated
  • The sections show a picture of hepatocellular carcinoma, moderately differentiated, composed of nests of polygonal neoplastic hepatocytes with moderate amount basophilic cytoplasm, arranged in trabecular pattern.
• 2023-03-28 Tc-99m MDP bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, middle C-spine, L4, bilateral shoulders and hips in whole body survey.
  • IMPRESSION:
    • Increased activity in the middle C-spine. Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
• 2023-03-28 CT - abdomen
  • CC: left arm weakness for 3 weeks
    • 20230325 MRI: a heterogeneous enhancing tumor, about 35mm, along the left cervical VA from the level of the C3 to C4 vertebral body. Tumor encasement of the left cervical CA was noted. Tumor invasion to the C4 vertebral body and left prevertebral muscles was noted.
    • 20230325 AFP:70867 ng/mL (< 9). CEA, CA199, CA125, PSA, & SCC: normal Indication: R/O metastasis
  • Findings:
    • There are several kissing masses on right lobe of the liver, measuring 10 cm in size (the largest dimension), and showing contrast washout in delayed phase images.
      • HCCs on right lobe of the liver (T3) are highly suspected.
      • In addition, right superior segment portal vein is not visualized that is c/w tumor compression.
      • In addition, there is no enlarged node in the hepatic hilum (N0).
    • There is osteolytic lesion in left lateral aspect of C4 vertebral body and left transverse process that is c/w bony metastasis (M1）.
    • There is no focal lesion in both lung and mediastinum.
  • Imaging Report Form for Hepatocellular Carcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M1(M_value) STAGE:IVB(Stage_value)
• 2023-03-25 MRI - C-spine
  • Indication: cervical 4-5 and 5-6 herniated interverteb disc disease, r/o tumor formation need enhancement for exclusion.
  • Without-contrast multiplanar spine MRI (including sagittal and axial T1WI, sagittal and axial T2WI and coronal STIR images) revealed
    • normal bone alignment of the spine
    • a heterogeneous enhancing tumor, about 35mm, along the left cervical VA from the level of the C3 to C4 vertebral body. Tumor encaenment of the left cervical CA was noted. Tumor invasion to the C4 vertebral body and left prevertebral muscles was noted. Signal-void curvilinear structures in the lesion was noted.
    • unremarkable change in the visible cord.
    • degenerative change at the middle and lower C-spine disc spaces. Herniated disc in the C4/5 disc cuased moderate anterior indentation on the right C405 cord.
    • unremarkable change in the bone marrow signal intensity.
      
  • IMP:
    • a tumor in the left paravertebral and perivertebral spaces along the left VA at the levels of the C3 and C4 vertebral bodies.
    • herniated disc in the C4/5.

[chemoimmunotherapy]

• 2023-05-09 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
  • diphenhydramine 30mg + NS 250mL

atezolizumab 2023-05-15 https://www.uptodate.com/contents/atezolizumab-drug-information

• Brand Names: Tecentriq

• Pharmacologic Category

  • Antineoplastic Agent, Anti-PD-L1 Monoclonal Antibody; Antineoplastic Agent, Immune Checkpoint Inhibitor; Antineoplastic Agent, Monoclonal Antibody

• Dosing: Adult

  • Note: Per the manufacturer’s labeling, atezolizumab may be dosed at 840 mg IV once every 2 weeks or 1,200 mg IV once every 3 weeks or 1,680 mg IV once every 4 weeks. Indication, combination, and/or trial-specific dosing is listed below; refer to protocols for further information.
  • Alveolar soft part sarcoma, unresectable or metastatic
    • IV: 1,200 mg once every 3 weeks (as a single agent); continue until disease progression or unacceptable toxicity.
  • Hepatocellular carcinoma, unresectable or metastatic
    • IV: 1,200 mg once every 3 weeks (in combination with bevacizumab); continue until disease progression or unacceptable toxicity; may continue beyond disease progression if clinical benefit demonstrated
      • If bevacizumab is discontinued due to unacceptable toxicity, may continue atezolizumab monotherapy (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
  • Melanoma, unresectable or metastatic (BRAF V600 mutation-positive)
    • IV: 840 mg once every 2 weeks (in combination with cobimetinib and vemurafenib); continue until disease progression or unacceptable toxicity; prior to initiating atezolizumab, patients should receive a 28-day treatment cycle of cobimetinib and vemurafenib. Refer to protocol for further information.
  • Non–small cell lung cancer, adjuvant treatment:
    • IV: 1,200 mg once every 3 weeks (as a single agent; after up to 4 cycles of adjuvant platinum-based chemotherapy); continue atezolizumab for up to 1 year, unless disease recurrence or unacceptable toxicity occurs.
      • Note: Select patients for atezolizumab therapy based on the programmed death-ligand 1 (PD-L1) expression on tumor cells.
  • Non–small cell lung cancer (NSCLC), metastatic:
    • Single-agent atezolizumab:
      • First-line treatment NSCLC: IV: 1,200 mg once every 3 weeks; continue until disease progression or unacceptable toxicity.
        • Note: Select patients for atezolizumab therapy based on the PD-L1 expression on tumor cells or on tumor-infiltrating immune cells.
      • Previously treated NSCLC: IV: 1,200 mg once every 3 weeks; continue until disease progression or unacceptable toxicity.
    • Combination therapy:
  • First-line treatment, nonsquamous NSCLC:
    • IV: 1,200 mg on day 1 every 3 weeks (in combination with bevacizumab, paclitaxel, and carboplatin) for 4 to 6 cycles, followed by atezolizumab 1,200 mg on day 1 (followed by bevacizumab) every 3 weeks until disease progression or unacceptable toxicity; if bevacizumab is discontinued after the 4 to 6 cycles of combination chemotherapy, atezolizumab may be continued as a single agent (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
    • IV: 1,200 mg on day 1 every 3 weeks (in combination with paclitaxel [protein bound] and carboplatin) for 4 to 6 cycles; after the 4 to 6 cycles of induction combination chemotherapy, atezolizumab may be continued as a single agent (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
  • Small cell lung cancer (extensive stage), first-line treatment:
    • IV: 1,200 mg once every 3 weeks (in combination with carboplatin and etoposide for 4 cycles), followed by maintenance therapy of single-agent atezolizumab (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
  • Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

==========

2023-07-24

[De-escalation of Cefepime]

Based on in-hospital stock, the only available third-generation oral cephalosporin is Ceficin (cefixime 100mg) at a recommended dosing frequency of 2# Q12H. As the patient’s laboratory data on 2023-07-24 showed normal values for creatinine and blood urea nitrogen (BUN), there is no need to adjust the dosage of Ceficin.

2023-05-15

• This is the patient’s first dose of the immune checkpoint inhibitor atezolizumab during this hospiatalization. While this therapy is designed to boost the immune response against cancer cells, it can sometimes cause the immune system to attack normal organs and tissues in the body. These side effects are commonly referred to as immune-related adverse events (irAEs).
• It’s important to closely monitor the patient for potential irAEs such as dermatologic symptoms (e.g., rash), endocrine and metabolic symptoms (e.g., hypothyroidism), and gastrointestinal symptoms (e.g., constipation, diarrhea, nausea, decreased appetite). Prompt recognition and treatment of these irAEs may help reduce their severity and prevent serious complications.
• Atezolizumab is currently being administered in combination with bevacizumab. It is supposed to continue this combination until there is evidence of disease progression or the occurrence of unacceptable toxicity. If the patient continues to demonstrate clinical benefit, treatment may persist even beyond disease progression.
• In case bevacizumab has to be discontinued due to severe side effects, atezolizumab monotherapy can be maintained until the disease progresses or until there are intolerable side effects.

701468195

230720

[diagnosis] - 2023-04-12 admission note

• Nasopahryngeal Non-keratinizing carcinoma, undifferentiated, with bilateral neck LAPs metastasis, T4N3M1, stage IVB
• Chronic viral hepatitis B without delta-agent
• Constipation, unspecified
• Cachexia

[past history]

• DM(-), HTN(-)    

[allergy]

• NKDA

[family history]

• There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

• 2023-05-26 CT - neck
  • With and Without contrast Neck CT showed
    • an extensive tumors in the nasopharynx with invasion to the posterior cranial fossa, upper C-spine spinal canal, bilateral parapharyngeal space, bilateral prevertebral fascia and left perevertebral space.
    • multiple enlarged heterogeneous enhancing lymph nodes in the bilateral neck, esp. left neck.
    • The major salivary glands were unremarkable.
    • skull bone invasion and bone metastasis at the upper C-spine and upper T-spine.
  • IMP: extensive tumors in the upper neck with LAP and bone metastasis. As compared with previous study on 20230131, the sizes were mildly decreased.
• 2023-02-04 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 60 dB HL, LE 44 dB HL
  • R’t moderate to profound mixed type HL
  • L’t mild to severe HL.
  • (BC masking dilemma)ChatGPT: “BC masking dilemma” refers to a situation that can occur during pure tone audiometry when a sound presented to one ear through bone conduction (BC) also stimulates the opposite ear, making it difficult to determine the true threshold of the stimulated ear.
• 2023-02-01 bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed hot spots in the right frontal region of the skull, some C- and upper T-spine, faint hot spots in both rib cages, and increased activity in the maxilla, sternum, some L-spine, bilateral shoulders, elbows, S-I joints, hips, and feet, in whole body survey.
  • IMPRESSION:
    • Hot spots in some C- and upper T-spine, faint hot spots in both rib cages, and increased activity in the sternum, malignancy with bone mets may be considered, suggesting further investigation and follow-up with bone scan in 3 months.
    • A hot spot in the the right frontal region of the skull, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in the maxilla, some L-spine, bilateral shoulders, elbows, S-I joints, hips, and feet.
• 2023-01-31 MRI - nasopharynx
  • Indication: nasopharyngeal cancer, for cancer workup
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
    • Large nasopharynx tumor, bilateral, up to 11 cm, with skull base invasion, extension to bil. parapharyngeal spaces, encasing bil. carotid arteries.
    • Invasion of right Foramen of Ovale, but No definte intracranial invasion.
      
    • Invasion of right parotid gland (T4).
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • Multiple bil. neck LAPs, especially at left, below the low border of cricoid cartilage.
    • Destructions of left T1 boy and right T3 body were noted.
  • IMP: NPC, bilateral neck LAPs, T4N3M1, stage IVB
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:1(M_value) STAGE:IVB (Stage_value)
• 2023-01-31 SONO - abdomen
  • Diagnosis: negative
• 2023-01-16 Patho - nasopharyngeal / oropharyngeal biopsy
  • Nasopahrynx, left, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B);
  • IHC stain: CK (+).
• 2023-01-16 Nasopharyngoscopy
  • NP tumor(+), suspected NPC

[MedRec]

• 2023-02-07 SOAP Radiation Oncology
  • Diagnosis: Nasopharyngeal carcinoma, non-keratinizing carcinoma, undifferentiated, with extensive LN metastasis and bone metastasis, cT4N3M1, stage IVB; BW loss of 15 kg in 6 months; ECOG =1.
  • He requests CCRT first.
  • Plan: CCRT to NPX tumor and LAPs, C spine metastasis for 7140cGy/34 fx may also be considered.
• 2023-02-07 SOAP Hemato-Oncology
  • Arrange weekly CDDP for CCRT then followed by palliative PF
  • C/T will be given next week
  • RTC on 2023-02-16 for 2023-02-17 C/T

[consultation]

• 2023-05-29 Thoracic Surgery
  • Q
    • This 47-year-old man patient had Nasopahryngeal Non-keratinizing carcinoma, undifferentiated, with bilateral neck LAPs metastasis, T4N3M1, stage IVB s/p chemotherapy with TPF (Taxotere 60mg/m2, CDDP 75mg/m2, 5FU 1000mg/m2x4days) from 2023/02/17.
    • This time, he suffered from poor appetite, easy choking for one weeks.
    • For unable to eat, hope ostomy implantation for intake, we need your further evaluation and management.
    • Thanks a lot!!!
  • A
    • I will arrange interview with his family and himself at my OPD. I will explain risk factor of jejunostomy and maybe tracheostomy if ETT (endotracheal tube) can not be weaning. I will arrange operation this week. Thanks for your consultation!!
• 2023-02-11 Hemato-Oncology
  • A
    • For metastasis NPC, systemic therapy is indicated. Consider cisplatin-based regimens (Gemcitabine plus cisplatin may considered a preferred front-line option). Please arrange port A insertion.
    • Check EBV DNA, 24 urine CCR, HbsAg, Anti Hbc, Anti HCV, auditory test. Thanks for your consultation.
• 2023-02-02 Radiation Oncology
  • Q
    • For CCRT for NPC, T4N3M1, stage IVB
    • This is a 47-year-old man with no known underlying disease. This time, he was admitted to our ward for nasopharyngeal carcinoma work-up. Nasopharynx MRI arranged and showed NPC, bilateral neck LAPs, T4N3M1, stage IVB. Abd echo showed negative. Bone scan was done, and pending result. Concurrent chemoradiotherapy will be arranged after staging. We need your expertise for CCRT evaluation. Thanks a lot!
  • A
    • Subjective:
      • History: This is a 47-year-old man with no known underlying disease. He has suffered from painful left neck mass for 3 months. BW loss of 15 kg in 6 months, nasal obstruction, left hearing impairment, mild dysphagia and mild dyspnea during meal was noticed. He denied epistaxis, diplopia, otalgia, blurred vision or facial numbness. Therefore, the patient came to our OPD for help. Physical exam showed a 75 cm hard mass over left neck level II-III region and a 32 cm firm mass over right level V region. Fiberscopic exam showed nasopharyngeal tumor. Nasopharynx MRI showed NPC, bilateral neck LAPs, T4N3M1, stage IVB with bone metastasis. Abdomen echo showed negative. Bone scan showed multiple spines, ribs, pelvic bone metastasis (pending formal report).
        • Previous RT: denied.
        • Other disease: denied.
        • Family history: denied.
      • Habit: Alcohol: quitted; Smoking: 1 PPD for 20 yr, just quitted.; betel nut: quitted.
      • Single. Caregiver: his mother. Job: car wire. Mild economic stress.
      • Language: Mandarin. Taiwanese.
      • Religion: Buddism.
    • Objective:
      • General Condition-ECOG: 1.
      • PE, 2023/02/02: Extensive LAPs over left and right neck, left SCF.
      • Pathology:
        • Nasopharyngeal Biopsy, 2023/01/16: Nasopahrynx, left, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B); IHC stain: CK (+).
        • left neck mass biopsy, 2023/01/16: Malignancy.
      • Images:
        • Nasopharynx MRI, 2023/01/31: Large nasopharynx tumor, bilateral, up to 11 cm, with skull base invasion, extension to bil. parapharyngeal spaces, encasing bil. carotid arteries. Invasion of right Foramen of Ovale, but No definite intracranial invasion. Invasion of right parotid gland (T4). Multiple bil. neck LAPs, especially at left, below the low border of cricoid cartilage. Destructions of left T1 bony and right T3 body, spinous process of C5-6 were noted. IMP: NPC, bilateral neck LAPs, T4N3M1, stage IVB
        • Bone scan, 2023/02/01: multiple spines, ribs, pelvic bone metastasis (report pending).
        • CXR, liver echo, 2023/01: negative for metastasis.
        • EBV DNA titer: pending.
    • Diagnosis: Nasopharyngeal carcinoma, non-keratinizing carcinoma, undifferentiated, with extensive LN metastasis and bone metastasis, cT4N3M1, stage IVB; BW loss of 15 kg in 6 months; ECOG =1.
    • Plan: Systemic chemotherapy with standard regimen is suggested for systemic control. CCRT to NPX tumor and LAPs, C spine metastasis for 7140cGy/34 fx may also be considered. Possible treatment toxicity of chemotherapy and radiotherapy is told. Diet education is given but nutrition consultation is also recommended.
• 2023-01-30 Oral and Maxillofacial Surgery
  • Q
    • This is a 47-year-old man with no known underlying disease. This time, he was admitted to our ward for nasopharyngeal carcinoma cancer workup. Concurrent chemoradiotherapy will be arranged after staging. We need yout expertise for dental evaluation bfore radiotherapy. Thanks a lot!
  • A
    • This is a 47-year-old man suffering from nasopharyngeal carcinoma and is scheduled for further CCRT treatment. This time, we were consulted for dental evaluation before radiotherapy.
    • S: No specific discomfort over full mouth
    • O:
      • Panoramic findings:
        • Missing: Nil
        • Impaction: 48
        • Caries: Nil
        • Crown and bridges: Nil
      • Periodontal condition: Full mouth chronic periodontitis
      • Trismus due to large tumor compression over left neck was noted.
      • No specific intraoral lesion
    • P:
      • Explained the findings to the patient and his family.
      • Suggest keep good oral hygiene
      • No tooth extraction or treatment is needed at this moment. Suggest OPD follow up every 6 months

[surgical operation]

• 2023-05-30
  • Surgery
    • Feeding jejunostomy + tracheostomy
  • Finding
    • 18 Fr. silicon Foley catheter as feeding jejunostomy.
    • 8.0 mm tracheostomy tube.

[chemotherapy]

• 2023-04-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 75mg/m2 115mg NS 500mL 24hr D1 (with 5-FU) + [furosemide 20mg NS 30mL (30min after cisplatin) + MgSO4 10% 20mL NS 100mL (1hr after cisplatin)] D2 + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (TPF)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-14 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 75mg/m2 115mg NS 500mL 24hr D1 (with 5-FU) + [furosemide 20mg NS 30mL (30min after cisplatin) + MgSO4 10% 20mL NS 100mL (1hr after cisplatin)] D2 + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (TPF)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-17 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 75mg/m2 115mg NS 500mL 24hr D1 (with 5-FU) + [furosemide 20mg NS 30mL (30min after cisplatin) + MgSO4 10% 20mL NS 100mL (1hr after cisplatin)] D2 + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (TPF)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[note]

TPF regimens for Neoadjuvant Chemotherapy (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11) - see No.701240721, with docetaxel 40mg/m2 and cisplatin 40mg/m2

Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-04-13 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438

• Cycle length: Every 21 days for three cycles.

• Regimen

  • Docetaxel
    • 75 mg/m2 IV
    • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
    • Day 1
  • Cisplatin
    • 100 mg/m2 IV
    • Dilute in 250 mL NS and administer over 30 minutes to three hours. Do not administer with aluminum needles or IV sets.
    • Day 1
  • Fluorouracil (FU)
    • 1000 mg/m2/day IV
    • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
    • Days 1 through 4

In search for optimal induction chemotherapy for advanced nasopharyngeal cancer: Standard dosing of Docetaxel, Platinum, and 5-Fluorouracil (TPF) followed by chemoradiation. Published: 2023-02-02. https://doi.org/10.1371/journal.pone.0276651

• induction standard dose T (75 mg/m2) P (75 mg/m2) F (750 mg/m2 IVCI x 5days) x 3 followed by weekly cisplatin (40 mg/m2) or carboplatin (AUC 1.5) x 6 concurrent with radiation therapy of 70 Gy over 6.5 to 7 weeks.
• The 2-year progression free survival (PFS) rate for the M0 cohort was 90% (95% CI: 77.8%-100%), and was sustained at 5 years. The 2-year PFS rate for the M1 cohort was 66.7% (95% CI: 37.9%-00%). The 2-year overall survival (OS) rates for the M0 and M1 cohorts were 100% and 83.3% (95% CI: 58.3%-100%), respectively. At five years, OS was 94.4% for the M0 cohort.
• Conclusion: Administration of standard-dose TPF as induction chemotherapy in this NPC patient population is both feasible and effective when coupled with definitive concurrent chemoradiation.

==========

2023-07-20

[duplicated H2RA]

The concomitant use of histamine H2-receptor antagonists such as Stogamet (cimetidine 300mg) and Ulstop (famotidine 20mg) is generally not recommended. Both drugs work by reducing the production of stomach acid, and using them together may increase the risk of side effects. It is advisable to evaluate the need to use these two drugs together to ensure drug safety.

2023-03-15

• On 2023-02-25, a leukopenia event was observed in the patient with a WBC level of 2.88K/uL. This occurred approximately 1 week after the patient’s first TPF treatment, and will need to be closely monitored.
• No medication reconciliation issues have been identified for the patient.

700906364

230718

[exam findings]

• 2023-06-01 CXR
  • Few nodular opacity projecting in the left lung are suspected. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Spondylosis and Scoliosis of the L-spine with convex to right side.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2023-05-05 All RAS + BRAF
  • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-05-02 L-spine flex & ext
  • Presence of spondylolisthesis at L3/4, grade I.
• 2023-05-02 Bone densitometry
  • Hip BMD performed by DXA revealed:
    • Hip, BMD is 0.574 gms/cm2, about 2.5 SD below the peak bone mass ( 68 %) and 0.0 SD at the mean of age-matched people ( 100 %).
    • IMP: osteoporosis
  • L-spines BMD (AP view) performed by DXA revealed:
    • AP L-spines, BMD of L1-4 0.742 gms/cm2, about 2.5 SD below the peak bone mass ( 73 %) and 0.2 SD above the mean of age-matched people ( 105 %).
    • IMP: osteoporosis
• 2023-04-26 CT - chest
  • lung and pleural metastases, in progresion compared with CT on 2023/01/18.
• 2023-04-17 Colonoscopy
  • No definite mucosal lesion was seen except diverticula at S-colon
• 2023-04-13 CXR
  • Few nodular opacity projecting in the left lung are suspected. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Spondylosis and Scoliosis of the L-spine with convex to right side.
• 2023-01-18 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis and Scoliosis of the L-spine with convex to right side.
• 2023-01-18 CT - abdomen
  • S/P LAR with autosuture retention over the rectum.
  • Prior CT identified two solid nodule in RLL and LLL of the lung are noted again, stationary.
• 2023-01-18 CT - chest
  • lung and pleural metastases, stationary.
• 2022-10-26 CT - chest
  • recurrent left lung and pleural metastases, stationary.
• 2022-07-22 CT - chest
  • Left lower lobe meta. Stationary.
• 2022-02-15 CT - chest
  • recurrent left lung and pleural metastases.
• 2021-09-01 CT - chest
  • no new lung nodule.
• 2021-05-06 CT - chest
  • s/p left upper lobe and left lower lobe op.
  • no evidence of recurrent tumor in the study.
• 2020-12-30 Patho - lung wedge biopsy
  • pathologic diagnosis
    • Lung, left upper lobe (frozen section specimen), wedge — Metastatic colorectal adenocarcinoma
      
    • Lung, left lower lobe, wedge — Metastatic colorectal adenocarcinoma
      
    • Lymph nodes, LN 9, dissection — Negative for malignancy (0/3)
      
    • Parietal pleura, biopsy — Metastatic colorectal adenocarcinoma
  • microscopic examination
    • Tumor Focality: Multiple tumors over LUL, LLL, and parietal pleura
      
    • Histologic Type: Metastatic colorectal adenocarcinoma
      
    • Spread Through Air Spaces (STAS): Not identified
      
    • Visceral Pleura Invasion: Present
      
    • Lymphovascular Invasion: Present
      
    • Lymph nodes, LN 9: Negative for metastatic carcinoma (0/3)
      
    • IHC for tumor cells: CK7(-), CK20(+), and CDX2(+)
• 2020-12-29 Frozen resection
  • Lung, LUL, frozen section — Adenocarcinoma, compatible with metastatic colorectal carcinoma
• 2020-12-11 CT - chest
  • Left upper lobe and left lower lobe nodules. suspected lung mets.
  • Focal Pleural thickening. suspected pleural seeding.
• 2020-12-01 CT - abdomen
  • Left basal lung nodules. Nature? Suggest chest CT
• 2020-09-01 CT - abdomen
  • Post-op at the colon.
  • Right adrenal tumor, suggest follow up.
  • Uterine tumor, suspected myoma.
• 2019-12-30 CT - abdomen
  • Rectal cancer s/p operation. No evidence of tumor recurrence.
• 2018-08-13 CT - abdomen
  • Status post LAR with stable condition.
• 2017-08-31 CT - abdomen
  • Rectal cancer s/p operation. No evidence of tumor recurrence.
• 2017-03-18 CT - abdomen
  • Rectal CA, s/p operation. No evidence of tumor recurrence
• 2013-end pathology
  • adenocarcinoma, metastatic (7/34)
  • pathology stage: pStage IIIC, pT3N2b(cMx),
  • IHC stain of EGFR: weak positive on 30% to 40% of the neoplastic glands.
• 2013-11-29 CT - abdomen
  • rectal cancer with LNs & lung mets (T2N1M1a)

[MedRec]

• 2021-01-12 SOAP Hemato-Oncology Zhang ShouYi
  • S: 68 y/o female. a pt of Rectal CA, pT3N2b (7/34) M0, stage IIIC, s/p Laparoscopic LAR on 12/24 13 by Dr Xiao GuangHong, s/p CCRT by Dr Huang JingMin & Post-CCRT adjuvant C/T wt sLV-5FU (2 days) Q2W x 12 finishing in Oct 2014, recurrence wt lung mets & pleura mets s/p lung metastasectomy in Dec 2020.
• 2017-03-25 SOAP Hemato-Oncology Zhang ShouYi
  • S: 64 y/o female. a pt of Rectal CA, pT3N2b (7/34) M0, stage IIIC, s/p Laparoscopic LAR on 12/24 13 by Dr Xiao GuangHong, s/p CCRT by Dr Huang JingMin & Post-CCRT adjuvant C/T wt sLV-5FU (2 days) Q2W x 12 finishing in Oct 2014,

[surgical operation]

• 2020-12-29 VATS, LUL and LLL wedge + lymph node sampling
  • multiple scattered whitish to translucent nodules about 5mm~10mm on visceral and parietal pleura suspected rectal metastasis parietal biopsy, LLL wedge biopsy and lymph node sampling
  • a volcano like solid nodule about 1.5cm in diameter in LUL S1 segment after wedge biopasy
• 2013-12-24 Laparoscopic LAR + Thoracoscopic wedge or Partial resection of the Lung

[radiotherapy]

• early 2014

[chemoimmunotherapy] (not completed)

• 2023-07-17 - FOLFIRI

• 2023-07-03 - FOLFIRI

• 2023-06-01 - FOLFIRI

• 2022-03-08 ~ 2023-01-13 - FOLFOX

• 2021-02-01 ~ 2021-07-27 - FOLFIRI plus bevacizumab

• 2021-01-18 - FOLFIRI

• 2014-04-03 ~ 2014-10-07 - PF, post CCRT adjuvant, 12 cycles

• 2014-02-10 ~ 2014-03-13 - 5-Fu based

==========

2023-07-18

After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were found.

2022-04-20

• This patient diagnosed with rectal cancer with LNs and lung mets in late 2013, recurrence monitored in late 2020, patient receives FOLFIRI (plus bevacizumab) from 2021-02-01 to 2021-07-27, following VATS, LUL and LLL on 2020-12-29, and recurrence detected again in early 2022. She is currently treated with FOLFOX since 2022-03-08.
• Lab data reported on 2022-04-19 revealed that liver and kidney function, serum electrolytes, and blood cell counts were generally normal. The nursing note does not indicate any intolerances so far since this hospitalization.
• Depending on the patient’s financial situation and there are no contraindications, targeted and/or immunotherapy treatments might also be considered.

700930423

230718

[diagnosis] - 2023-04-10 admission note

• Adenocarcinoma of descending-sigmoid colon with liver metastasis cT3N1M1, stage IVB

[past history] - 2023-01-12 admission note

• Chronic hepatitis C for 40 years
• Diabetes mellitus for 5 years with insulin control.
• Hypertension since 2009 without drug control.
• Panic disorder with medical treatment since 1990

[allergy]

• Omnipaque (iohexol) - skin rash

[family history]

• Father: pancreatic cancer
• Two younger brother: coronary artery disease post PTCA with stenting
• Mother: heart disease
• Elder sister: breast cancer

[lab data]

• 2022-12-13 Anti-HBc Reactive
  
• 2022-12-13 Anti-HBc-Value 6.08 S/CO
  
• 2022-12-13 HBsAg Nonreactive
  
• 2022-12-13 HBsAg (Value) 0.33 S/CO
  
• 2022-12-13 Anti-HCV Reactive
  
• 2022-12-13 Anti-HCV Value 12.14 S/CO

[exam findings]

• 2023-05-18 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Suboptimal study, due to food residuals
    • Reflux esophagitis LA Classification grade A
    • Esophageal varices, F1CbLi. RCS(-) White nipple sign(-). From 32cm to 40cm below incisors.
    • Gastric shallow ulcers, antrum
  • Suggestion
    • Suboptimal study, due to food residuals
    • PPI use
    • Regular follou up
• 2023-03-17 MRI - upper abdomen
  • History and Indication:
    • synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer(pT2N0M0) s/p Lt hemicolectomy on 20180814
    • 2019/09/12 MRI: two metas in S8 dome and S7 s/p Op
    • 2020/04/07 MRI: A poor enhancing nodule (2.9cm) in Rt liver dome
    • 2020/09/15 MRI: A poor enhancing nodule (1.2cm) in Rt liver dome
    • 2022/01/07 MRI: No focal lesion in the right liver dome
    • 2022/12/02 MRI: Two metastases 2.5 cm in S2 and 1 cm in S4.
  • MR Imaging of the abdomen was performed on a 1.5 T superconducting magnet and phase arrayed body coil. Patient kept in supine position with field of view 38 cm, slice thickness 6 mm and gap 1 mm.
    
  • Non-contrast MRI has limitation in diagnosis of solid organ pathology, bowel loop lesion, and vascular system abnormality. We recommend contrast enhanced MRI if patient’s renal function can tolerate Gd-DTPA injection.
    • Prior MRI identified a metastasis 4 cm in S2 of the liver is noted again, decreasing in size to 2.6 cm that is c/w metastasis S/P C/T with partial response.
      • In addition, Prior MRI identified a metastasis 1 cm in S4 of the liver is noted again, stable in size that is c/w metastasis S/P C/T with stable disease.
    • S/P partial resection of S8 dome and S6/7 of the liver.
      • There is mild irregular liver contour that may be cirrhosis.
    • There is splenomegaly (long axis: 12 cm) and small recanalization of paraumbilical vein that is compatible with portal hypertension.
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidneys.
      
    • There is no evidence of ascites or lymphadenopathy.
    • The abdominal aorta and IVC are grossly unremarkable.
      
  • IMP:
    • One metastasis in S2 liver S/P C/T shows partial response.
    • One metastasis in S4 liver S/P C/T shows stable disease.
• 2022-12-02 MRI - upper abdomen
  • History and Indication: synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer(pT2N0M0) s/p Lt hemicolectomy on 20180814.
    • 2019/09/12 MRI:two metas in S8 dome and S7 s/p Op
    • 2020/04/07 MRI: A poor enhancing nodule (2.9cm) in Rt liver dome
    • 2020/09/15 MRI: A poor enhancing nodule (1.2cm) in Rt liver dome
    • 2022/01/07 MRI: No focal lesion in the right liver dome
  • Findings
    • There are two mass lesions measuring 4 cm in S2 and 1 cm in S4 of the liver, showing hypointensity on T1WI and mild hyperintensity on both T2WI and DWI.
      • Two metastases 4 cm in S2 and 1 cm in S4 of the liver are suspected.
    • S/P partial resection of S8 dome and S6/7 of the liver.
      • There is mild irregular liver contour that may be cirrhosis.
    • There is splenomegaly (long axis: 12 cm) and small recanalization of paraumbilical vein that is compatible with portal hypertension.
  • IMP:
    • Two metastases 4 cm in S2 and 1 cm in S4 of the liver are suspected.
• 2022-09-15 SONO - abdomen
  • S/P right liver operation. Mild splenomegaly.
• 2022-06-27 MRI - upper abdomen
  • S/P liver operation. Liver cirrhosis with splenomegaly.
• 2022-06-21 Patho - colorectal polyp
  • Colon, descending colon (40 cm from anal verge), Biopsy removal Specimen: A — Hyperplastic polyp
    • Section shows fragment(s) of polypoid colonic mucosal tissue with crowded benign hyperplastic mucinous glands.
  • Colon, sigmoid colon (25 cm from anal verge), Polypectomy (cold snaring) Specimen: B — Tubular adenoma with low grade dysplasia
    • Section shows fragment(s) of polypoid colonic mucosal tissue with proliferative tubular mucinous glands lined by cells containing hyperchromatic, elongated nuclei with low grade dysplasia.
• 2022-06-21 Colonoscopy
  • Colon cancer s/p op
  • No evidence of recurrence
• 2022-06-06 SONO - abdomen
  • poor echo window
  • Liver cirrhosis (incomplete exam of liver), mild splenomegaly
  • fatty infiltration of pancreas
• 2022-03-31 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2022-03-04 SONO - abdomen
  • Liver cirrhosis
  • Splenomegaly
  • Suboptimal examination of liver due to poor echo window
• 2022-01-07 MRI - upper abdomen
  • History and Indication:
    • synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer (pT2N0M0) s/p Lt hemicolectomy on 20180814
    • 2019/09/12 MRI: two metas in S8 dome and S7 s/p Op,
    • 2020/04/07 MRI: A poor enhancing nodule (2.9cm) in Rt liver dome
    • 2020/09/15 MRI: A poor enhancing nodule (1.2cm) in Rt liver dome
    • 2021/07/09 MRI: No focal lesion in the right liver dome
  • Findings:
    • S/P partial resection of S8 dome and S6/7 of the liver. There is no abnormal signal nodule in the residual liver on both T1WI, T2WI, and DWI.
    • There is mild irregular liver contour that may be cirrhosis.
    • There is splenomegaly (long axis: 12 cm) and small recanalization of paraumbilical vein that is compatible with portal hypertension.
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidney.
      
    • There is no evidence of ascites or lymphadenopathy.
    • The abdominal aorta and IVC are grossly unremarkable.
      
  • IMP:
    • No focal lesion in the residual liver.
    • Cirrhosis of the liver and portal hypertension.
• 2021-12-03 SONO - abdomen
  • Suspected cirrhosis with splenomegaly, mild
  • Pancreas not shown
  • Suboptimal examination of liver due to poor echo window
• 2021-09-30 SONO - abdomen
  • S/P right liver operation.
• 2021-07-16 Bladder sonography
  • PVR 5.12mL
• 2021-07-16 Uroflowmetry
  • Q max: good
  • flow pattern: obstructive
• 2021-07-09 MRI - upper abdomen
  • No focal lesion in the residual liver.
  • Cirrhosis of the liver and portal hypertension.
• 2021-05-12 Patho - stomach biopsy
  • Stomach, mid body, PW side, s/p biopsy — Chronic gastritis, H pylori NOT present
• 2021-03-02 SONO - abdomen
  • S/P partial resection of right lobe liver.
  • Early cirrhosis of the liver and Splenomegaly.
• 2020-12-07 MRI - upper abdomen
  • S/P liver operation. A small hemangioma (0.8cm) at S7 of liver. Tiny liver cysts. Liver cirrhosis with splenomegaly.
• 2020-10-20 Patho - colorectal polyp
  • Colon polyp, splenic flexure, polypectomy — Tubular adenoma with low grade dysplasia
• 2020-10-20 Colonoscopy
  • Colon cancer s/p op
  • No evidence of recurrence
  • Splenic flexure polyp s/p polypectomy
• 2020-09-16 Neurosonology
  • Mild to moderate atheromatous lesions in L middle CCA; mild atheromatous lesions in bilateral CCA bifurcations.
  • Smaller caliber with decreased flow in L cervical VA, possible L VA hypoplasia.
  • Normal extracranial carotid and R vertebral arterial flows.
• 2020-09-15 MRI - upper abdomen
  • Colon cancer s/p operation.
  • Much regression of right liver nodules (up to 1.2cm).
  • Splenomegaly.
• 2020-08-15 MRA - brain
  • Indication: brain concussion with unsteady gait
  • IMP
    • No definite intracranial hemorrhage
    • Brain atrophy
• 2020-08-15 CT - brain
  • Indication: suspected concussion
  • IMP:
    • No definite intracranial hemorrhage
    • Brain atrophy and intracranial arteriosclerosis
• 2020-05-06 Nerve Conduction Velocity, NCV
  • Findings
    • MNCV: decrease amplitude in left peroneal nerve and right tibial nerve acrros popliteal fossa.
    • SNCV: decrease amplitude in bilateral median, ulnar and sural nerves. slow NCV in bilateral median and left ulnar nerves.
    • F-wave: prolonged latencies in bilateral median, left ulnar, bilateral peroneal+ tibial nerves.
    • H-reflex: prolonged latencies bilaterally.
  • Conclusion
    • This NCV study suggests axonal sensory polyneuropathy, may superimposed polyradiaculopathy.
• 2020-05-06 Quantitative Sensory Threshold, QST
  • Findings: Abnormal warm threshold and normal cold threshold in left extremities.
  • Conclusion: This QST study suggests small fiber neuropathy in left extremities.
• 2020-04-14 PET
  • No prominent FDG uptake was noted in the liver dome tumor delineated in the MRI imaging. However, a metastatic lesion of low FDG uptake can not be ruled out. Please correlate with other imaging modalities for further evaluation.
  • A glucose hypermetabolic lesion in the left supraclavicular fossa. The nature is to be determined (a metastatic lesion? other nature?). Please correlate with other clinical findings for further evaluation.
  • A mild glucose hypermetabolic lesion in the left anterior upper chest region near the Port-A implantation. The nature is to be determined. (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • No prominent glucose hypermetabolism in the lesion in the middle lobe of right lung. Please also correlate with other imaging modalities for further evaluation.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammatory process may show this picture.
• 2020-04-07 MRI - liver, spleen
  • History and indication: colon colon cancer with liver & lung mets
  • IMP: Right liver metastases s/p resection. A poor enhancing nodule (2.9cm) in right liver dome suspected metastases.
• 2020-04-07 CT - chest

  • no interval change of a RML perifissural solid nodule as compared with previous CT study on 2019/11/22, more in favor odfan intrapulmonary LN rather metastatic nodule.

  • substantial centrilobular emphysema and subpleural paraseptal emphysema in RUL and LUL.

  • 2019-11-22 CT - chest

    • Indication: colon cancer with liver mets
    • Imp: Very tiny nodule at right upper lobe about 0.6cm in largest dimension is found. Nature to be determined.

  • 2019-10-02 Surgical pathology Level V

    • Clinical diagnosis: Malignant sigmoid colon neoplasm
    • Pathologic diagnosis
      • Liver, S7, segmental hepatectomy — Metastatic colonic adenocarcinoma
        
      • Liver, S8, partial hepatectomy — Metastatic colonic adenocarcinoma
        
      • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
    • Macroscopic examination
      • Procedures: Segmental hepatectomy of S7 and partial hepatectomy of S8
        
      • Specimen Size: 8.4 x 6.8 x 3.0 cm, 178 gm (S7), 5.5 x 4.7 x 2.1 cm and 24 gm (S8)
        
      • Tumor Focality: Multiple (number: 2)
        
      • Tumor Site: S7 and S8
        
      • Tumor Size: 2.5 x 2.3 x 2.2 cm with satellite nodule, 0.3 cm (S7); and 2.0 x 1.8 x 1.5 cm (S8)
        
      • Large vessel involvement: Not identified
        
      • Non-tumorous part: Cirrhotic
        
      • Sections are taken and labeled as: A1-A2= S7 tumor, A3= S7 satellite nodule + margin, B1-B2= S8 tumor
    • Microscopic examination
      • Diagnosis: Metastatic colonic adenoarcinoma
        
      • Histologic grade: Moderately differentiated
        
      • Tumor growth pattern: Infiltrative
        
      • Tumor pseudocapsule: Absent
        
      • Tumor necrosis: Mild (10%)
        
      • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 1.1 cm (S7) and 1.1 cm (S8), respectively
          
      • Vascular invasion: Not identified
        
      • Perineural invasion: Not identified
        
      • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
        
      • Non-neoplastic liver parenchyma: Chronic hepatitis C with cirrhosis
        
      • Fatty Change: Present (5%)
        

  • 2019-09-12 MRI - liver, spleen

    • A case of synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer (pT2N0M0) s/p Laparoscopic left hemicolectomy on 2018-08-14.
      • Hard stool passage
      • liver metastasis
      • obvious tumor at right lobe at least two tumor at S8 and S6-7
    • Findings
      • Hypervascular hepatic tumor at S7 of liver up to 2.7cm, and another less enhanced tumor at dome up to 1.6cm is found. Metastasis is considered.
      • Very tiny nodule at right middle lobe up to 0.2cm is found. lung meta is considered.
    • Impression:
      • Compatible with liver and lung meta.

  • 2019-09-10 SONO - abdomen

    • Diagnosis
      • Parenchymal liver disease
      • Hepatic tumor, nature to be determinated
    • Suggestion
      • Post tumor biopsy, please pursue pathology report

  • 2019-09-09 Surgical pathology level V

    • Indication: Malignant sigmoid colon neoplasm
    • Diagnosis: Liver, clinical history of colorectal carcinoma, CT guided biopsy — Adenocarcinoma.
      • IHC stain CK20 (+), compatible with colorectal adenocarcinoma.

  • 2019-08-26 PET

    • Multiple mildly to moderately glucose hypermetabolic lesions in right lobe of liver, hepatic metastases from tumors of lower FDG avidity (e.g., better differentiated tumors) should be considered. Please correlate with other work-up studies for further evaluation.
    • A nodule-like lesion in the middle lobe of right lung without prominent glucose hypermetabolism, the nature is to be determined (pulmonary metastasis, inflammatory lesion, or else). Please correlate with other work-up studies and keep follow-up for further evaluation.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change in response to locoregional inflammation may show such a picture.

  • 2019-08-19 CT - abdomen

    • Colon cancer s/p operaiton. In favor of lung and liver metastases.

  • 2019-02-14 SONO - abdomen

    • Suspected chronic liver parenchyma disease (Please correlate with liver function)
    • Poor assessment of biliary tract and PV
    • Pancreas not shown
    • Suboptimal examination of liver due to poor echo window

  • 2018-11-16 Brainstem auditory evoked potential, BAEP

    • The BAEP study showed no response of left wave I. The above finding suggest left side lesion distal to auditory nerve. Advise clinical correlation.

  • 2018-11-06 Colon fiberoscopy

    • Colon cancer s/p op
    • No evidence of cancer recurrence

  • 2018-10-13 MRI - L-spine

    • Grade I spondylolisthesis at L4/5 with moderate spinal canal stenosis.

  • 2018-08-02 Surgical pathology Level VI

    • pathologic diagnosis
      • Large intestine, descending-sigmoid colon (and sigmoid?), laparoscopic left hemicolectomy?/ Laparoscopic anterior resection and anastomosis-malignant? — Adenocarcinoma, moderately differentiated x2
      • Resection margins: free
      • Lymph node, mesocolic, dissection — Free (0/16)
      • Lymph node, IMA / SMA, dissection — N/A.
      • AJCC 8th edition Pathology stage:
        • Larger one: pT3N0 (if cM0); pStage: IIA.
        • Smaller one: pT2N0 (if cM0); pStage: I.
        • NOTE: cM might be the same or might be upgraded when more clinical and image data are available for evaluation.
    • macroscopic examination
      • Operation procedure: laparoscopic left hemicolectomy?/ Laparoscopic anterior resection and anastomosis-malignant?
      • Specimen site: descending sigmoid colon
      • Specimen size: 11 cm in length
        
      • Tumor size: the larger one 3.5 x 3 x 3 cm at 1.8 cm away from one end and another smaller one 1 x 0.5 x 0.5 cm at 2.0 cm from the other end.
      • Tumor location: 1.8 cm and 2.0 cm away from the two resection margins, respectively.
      • Depth of invasion grossly: the smaller one: muscularis propria; the larger one: mesocolic soft tissue.
        
      • Mucosa elsewhere: Free.
      • Tissue for sections: A1-2: bilateral margins; A3-5: the larger tumor; A6: the smaller tumor; A7-9: lymph nodes.
    • microscopic examination
      • Histology: Adenocarcinoma,
      • Histology Grade: moderately differentiated
      • Depth of invasion: the smaller one: muscularis propria; the larger one: mesocolic soft tissue.
        
      • Angiolymphatic invasion: Not identified.
        
      • Perineural invasion: Not identified.
      • Discontinuous extramural tumor extension: Not identified.
      • Serosal margin status of colon: Uninvolved, 2 mm in distance.
      • Lymph node metastasis, mesocolic: Free (0/16)
      • Lymph node metastasis,, IMA / SMA: N/A.
      • Extranodal involvement: N/A.
        
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT)
          • Larger one: pT3N0 (if cM0); pStage: IIA.
          • Smaller one: pT2N0 (if cM0); pStage: I.
        • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
        • Distant Metastasis (pM): if cM0
        • NOTE: cM might be the same or might be upgraded when more clinical and image data are available for evaluation.
      • Type of polyp in which invasive carcinoma arose: Not identified
        
      • Additional pathologic findings: None identified.
      • TNM descriptors: N/A.
      • Tumor regression grading S/P CCRT: N/A.
    • REFERENCE:
      • S2018-11971: Colon, splenic flexure 60 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • S2018-11972: Colon, descending 45 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

  • 2018-07-17 Surgical pathology Level IV

    • Colon, descending 45 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Colon, splenic flexure 60 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

  • 2018-07-17 Colon fiberoscopy

    • Splenic flexure cancer with partial obstruction s/p biopsy, tattooed and clipped
    • Suspected synchnous D-colon cancer s/p biopsy tattooed and clipped
    • Colon polyp s/p polypectomy

  • 2018-04-30 24hrs Holtor’s scan

    • Baseline was sinus rhythm with 1st degree AV block
    • A few isolated APCs
    • A few isolated VPCs (mono-form, burden <1%)

  • 2018-04-23 EKG

    • Sinus rhythm with 1st degree A-V block

[consultation]

• 2023-02-06 Psychosomatic Medicine
  • Q
    • Cancer inpatient has suicidal ideation score of >=2.
  • A
    • “I am getting more and more worried as I think about it.”, “It has made my temper very bad and hurt the people closest to me.”, “The relapse is so recurrent that it has made me like this. Living is not just helpless, it’s already meaningless.”
    • The patient has long-term generalized disorder and panic disorder, loss of gollow-up in 2019 after the diagnsois of maliganacy. Long-term floating anxiety to apprehensive rumination adverselty influence his quality of life and quality of mood as easy anger and easy dysphoria. Currently, he mainfests depression as low self-esteem, feeling of helplessness and worthlessness, although he recognises the clinical reality. He worries about bad effect of antidepressant on his physical problems; reassurnace.
    • Please reinstate escitalopram 5mg QN, titrate it up to 10mg a couple days later. Alprazolam 0.5mg hs. Psychiatry outpatient follow up, please. Thanks.

[multiteam]

• 2023-02-07 Psycho-Oncology
  • Reason for consultation: Other: Cancer inpatient has suicidal ideation score of >=2
  • Conclusion:
    • (S)2/7 visit, the patient reported that a psychiatrist had also visited the day before. He has been taking anti-anxiety medication for 6-7 years but has not stopped, only taking it when feeling uncomfortable. He has gone to see a psychiatrist before but did not continue after undergoing liver tumor radiofrequency ablation. He is expected to undergo six rounds of chemotherapy this time, but as there is a liver tumor close to a blood vessel, there is a greater risk. After the chemotherapy, even if he get better, the cancer will likely recur in 1-2 years. This is why he marked the suicide ideation score in the middle - “it’s better to just go, but I don’t have the courage.” After treatment, he will probably feel tired for three days. When anxiety comes on, he cannot control it and have to go to the hospital. He experienced a sudden onset during the Chinese New Year when his child invited them to Hualien. His son went to the pharmacy to buy medication, and after taking it, he felt better. He has been seeing an otolaryngologist for medication, but he does not know why he experience anxiety. He has Arab ancestry and is physically strong.
    • (O)107/8 rectosigmoid colon cancer, postoperative concurrent chemoradiotherapy (CCRT), 108/10 recurrence, postoperative liver metastasis, previously visited for suicidal ideation (moderate). 111/12 recurrence, admitted for the fourth round of chemotherapy on 2/6, BSRS = 8 (mild), suicidal ideation score of 2 (moderate).
    • 1. Reviewed their treatment history and anxiety experiences, encouraged them to complete cancer treatment, follow up with the psychiatrist for medication adjustment, and contact the Love Life Adjustment Association (an anxiety support group).
    • (AP) The patient can express themselves through conversation, is willing to cooperate with cancer treatment, and is hesitant to follow up with the psychiatrist. They have been encouraged to take the initiative to make an appointment and will be cared for again during the next chemotherapy session.
• 2023-02-07 Social Services
  • Referral Date: 2023-02-06
  • Reason for Referral: Other: Patient has suicidal ideation with a score of >=2
  • Handling Status: Not opening a case
  • Reason for Not Opening a Case: Meeting with the patient on 2023-02-07:
    • Family Situation: The patient is 75 years old, married with a daughter and a son. The patient lives with his wife and children.
    • Evaluation and Treatment:
      • The patient just finished meeting with the psychologist and the psychiatrist visited the patient yesterday. The patient reported a history of diagnosed panic disorder and currently feels hopeless and depressed due to long-term illness, but he has no actual suicidal thoughts or plans at present due to family and ethical beliefs. During the meeting, the patient’s mood was still stable. The social worker was concerned about the patient’s sleep and the patient reported that his sleep is sometimes good and sometimes bad, and it can be affected by his mood swings. However, the recent birth of his grandchild at home is something that has made him happy recently.
      • The evaluation meeting determined that the patient’s mood is mainly affected by his illness, but he is currently able to cooperate with related medical treatments. The family has a good level of economic support and there are no current issues. Therefore, the social worker will provide emotional support and counseling to the patient.

[chemoimmunotherapy]

• 2023-04-10 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5630mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2023-03-15 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5650mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2023-02-22 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2023-02-06 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2023-01-12 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2022-12-26 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2022-12-12 - irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5500mg NS 500mL 46hr (FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2020-07-17 - oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5700mg NS 500mL 46hr (FOLFOX, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• …. .. ..

==========

2023-07-18

In addition to visiting our hemato-oncology department, the patient also consulted our urologist on 2023-07-07 and our cardiologist on 2023-07-14. The urologist prescribed Urief (silodosin) and the cardiologist prescribed Concor (bisoprolol). These medications were accurately added to the active formulary and no discrepancies were found during reconciliation.

2023-06-29

According to the current PharmaCloud database, the patient refiled his prescription at Taipei City Hospital on 2023-06-21 for Algitab Chewable Tablets (alginic acid), Avamys Nasal Spray (fluticasone furoate), and Engene Eye Drops Patron (flavineadenine dinucleotide), all of which are valid for 28 days and are currently still valid. However, these medications are not yet on the patient’s active formulary at our hospital. This could lead to potential medication reconciliation discrepancies. It’s advisable for the primary care team to confirm whether these medications are still needed for the patient’s current clinical condition. If these medications are needed, they should be added to the patient’s active formulary accordingly.

2023-06-02

Per the PharmaCloud database, this patient recently had an outpatient visit at Taipei City Hospital on 2023-05-24. He was prescribed Algitab, Broen-C, acetaminophen for oral use, and sulfamethoxazole eye drops for a 28-day duration. Most of these medications are intended to manage GI symptoms. Upon examination of the current medication list, equivalent therapeutic drugs have already been prescribed. Consequently, no issues were identified during the medication reconciliation process.

2023-04-11

Based on the serum glucose level range of 288 mg/dL to 230 mg/dL, it appears that the patient’s underlying condition of type 2 DM is not well-controlled despite taking Galvus Met (vildagliptin + metformin) and Relinide (repaglinide). However, since there is no evidence of renal insufficiency (as of 2023-04-10 with Cre at 1.02mg/dL, eGFR at 75.67, and BUN at 21), the addition of Dibose (acarbose 100mg) 0.5# TIDAC is recommended if the high glucose level persists.

2023-02-23

• The recurrence of cancer has left the patient feeling helpless, and he has been visited by a psychiatrist, a counseling psychologist, and a social worker in early Feb 2023. He is currently still taking alprazolam, but his emotional state is stable.

• The patient’s HbA1c has shown a slow decline trend, blood sugar readings were 145 to 164 mg/dL on 2/22 and 2/23, there is still room for improvement.

  • 2023-02-13 HbA1c 6.1 %
    
  • 2022-09-15 HbA1c 6.6 %
    
  • 2022-06-06 HbA1c 6.4 %
    
  • 2022-03-01 HbA1c 6.1 %
    
  • 2021-12-22 HbA1c 6.2 %
    
  • 2021-09-30 HbA1c 6.8 %
    
  • 2021-06-18 HbA1c 6.6 %
    
  • 2021-02-22 HbA1c 6.4 %
    
  • 2020-11-30 HbA1c 6.5 %
    
  • 2020-09-08 HbA1c 6.8 %
    
  • 2020-06-15 HbA1c 7.0 %
    
  • 2020-03-23 HbA1c 7.2 %
    
  • 2019-09-20 HbA1C 6.7 %
    
  • 2018-04-12 HbA1C 7.1 %

230223

[assessment]

• The recurrence of cancer has left the patient feeling helpless, and he has been visited by a psychiatrist, a counseling psychologist, and a social worker in early Feb 2023. He is currently still taking alprazolam, but his emotional state is stable.

• The patient’s HbA1c has shown a slow decline trend, blood sugar readings were 145 to 164 mg/dL on 2/22 and 2/23, there is still room for improvement.

  • 2023-02-13 HbA1c 6.1 %
    
  • 2022-09-15 HbA1c 6.6 %
    
  • 2022-06-06 HbA1c 6.4 %
    
  • 2022-03-01 HbA1c 6.1 %
    
  • 2021-12-22 HbA1c 6.2 %
    
  • 2021-09-30 HbA1c 6.8 %
    
  • 2021-06-18 HbA1c 6.6 %
    
  • 2021-02-22 HbA1c 6.4 %
    
  • 2020-11-30 HbA1c 6.5 %
    
  • 2020-09-08 HbA1c 6.8 %
    
  • 2020-06-15 HbA1c 7.0 %
    
  • 2020-03-23 HbA1c 7.2 %
    
  • 2019-09-20 HbA1C 6.7 %
    
  • 2018-04-12 HbA1C 7.1 %

700021401

230717

[exam findings] (not completed)

• 2023-05-25 CT - abdomen
  • History and indication: reccurent DLBCL involving right lung,liver,spleen and multiple bone marrow, Lugano stage IV
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Some LNs (up to 1.2cm) at retroperitoneum and right axillary region.
    • Some low attenuations in spleen.
    • Renal cysts (up to 2.4cm).
    • Hyperplasia of right adrenal gland.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Some LNs (up to 1.2cm) at retroperitoneum and right axillary region.
    • Some low attenuations in spleen.
• 2023-03-13 Peropheral Vascular Test - AV fistula
  • Result: adequate size of RIJV
• 2023-03-10 PET
  • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm and involving right lung, liver, spleen and multiple bones/bone marrow as mentioned above (stage IV).
  • In comparison wih the previous study on 2022/05/05, more new FDG avid lesions are noted, suggesting lymphoma in progression.
• 2023-01-31 Spirometry
  • DLCO 48 -> 66 -> 73%
  • TLC: 88%
• 2022-11-08 CXR
  • RRt paratracheal stripe thickening
  • reticular opacities and hazy areas of increased opacities over both lungs scatteredly
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • mild enlarged cardiac silhoutte
• 2022-11-02 Spirometry
  • TLC: 82%.
  • DLCO 66% improved
  • FEV1/FVC<75%.
• 2022-08-16 Spirometry
  • TLC: 68%.
  • DLCO 48%.
• 2022-05-05 PET
  • The FDG PET findings are compatible with recurrent lymphoma involving multiple lymph nodes on both sides of the diaphragm as mentioned above and involving the bone marrow of left femoral shaft (stage IV).
  • Glucose hypermetabolism in a a focal area in the left humeral shaft. The nature is to be determined (lymphoma? other nature?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in multiple focal areas in bilateral lung fields. Inflammation is more likely.
• 2022-04-26 CT - chest
  • History of relapsed lymphoma over neck and mediastinum post autoPBSCT
  • Comparison made with previous CT dated on 2022/01/11
    • Lungs:
      • extensive centrilobular micronodular and branching opacities associated scattered lobular areas of ground-glass opacity
      • focal minimal paraspinal fibrosis in RLL, related to osteophytes of spine.
      • a subpleural paraseptal emphysema at medial right apical lung region.
    • Pleura:
      • minimal bilateral pleural effusions.
      • small pericardial effuion.
    • Mild atherosclerotic change of the aortic arch and descending thoracic aorta. mild coronary arterial calcification.
    • An irregular soft-tissue lesion at Rt axilla (19 mm in longest axial dimension), stationary in size as compared with CT on 2022/1/11
    • Neck, mediastinum and hila: multiple enlarged LNs in visceral space of the mediastinum.
    • Visible abdomen and pelvis:
      • unremarkable of the liver, Rt kidney, spleen, adrenal glands, and pancreas. Several left renal cysts up to 25 mm.no enlarged LNs. mild enlarged prostate.
  • Impression:
    • post treatment change in Rt axillary region, stationary.
    • lung infection, infectious bronchiolitis.
    • new neoplastic LAP in the mediastinum.
• 2022-02-15 SONO - chest
  • Echo diagnosis:
    • pleural effusion, trivial amounts located over left CP angle.
    • Favor arrhythmia, heart failure related pleural effusion and history of pneumonia before.
• 2022-02-14 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
• 2022-01-18 ECG
  • Sinus rhythm with Premature atrial complexes
  • Possible Left atrial enlargement
  • Right bundle branch block

[chemoimmunotherapy] (not completed)

• 2023-07-17 - polatuzumab vedotin 1.8mg/kg 105mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
• 2023-05-24 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
• 2023-04-25 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
• 2023-03-15 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
• 2021-10-27 - busulfan 3.2mg/kg 210mg NS 300mL 3hr D1-3 + etoposide 400mg/m2 690mg NS 250mL 6hr D3-4 + cyclophosphamide 50mg/kg 3300mg NS 500mL 4hr D5-6
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + palonosetron 250ug D1-3 + granisetron D4-6 + NS 250mL D1-2
• 2021-09-03 - etoposide 500mg/m2 400mg NS 1000mL 4hr D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-3
• 2021-06-28 - polatuzumab vedotin 1.8mg/kg 113mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 6hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D2-3 + NS 250mL D1-3 + acetaminophen 500mg PO D1
• 2021-05-28 - polatuzumab vedotin 1.8mg/kg 113mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 6hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D2-3 + NS 250mL D1-3 + acetaminophen 500mg PO D1
• 2021-04-29 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cisplatin 100mg/m2 170mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 3400mg Q12H D2-3 + dexamethasone 20mg BID PO D1-5
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + acetaminophen 500mg PO D1 + palonosetron 250ug D2-4 + NS D1-3
• 2020-01-30 - rituximab 375mg/m2 600mg NS 500mL 6hr D1 + [etoposide 50mg/m2 84mg doxorubicin 10mg/m2 16mg vincristine 0.4mg/m2 0.5mg NS 1000mL] 24hr D1-4 + prednisolone 60mg/m2 50mg PO BID D1-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D5 (R-DA-EPOCH Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO
• 2020-01-03 - rituximab 375mg/m2 600mg NS 500mL 6hr D1 + [etoposide 50mg/m2 84mg doxorubicin 10mg/m2 16mg vincristine 0.4mg/m2 0.5mg NS 1000mL] 24hr D2-5 + prednisolone 60mg/m2 50mg PO BID D1-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D6 (R-DA-EPOCH Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO

==========

2023-07-17

Our cardiologist prescribed Urief (silodosin), spironolactone, Multaq (dronedarone), Lixiana (edoxaban), Atozet (ezetimibe, atorvastatin), Wecoli (bethanechol), and Nirandil (nicorandil) on 2023-06-28, and these drugs are correctly included in the active formulary, so no reconciliation issues were found.

700101071

230717

[diagnosis] - 2023-03-20 admission note

• Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites
• Peripheral T-cell lymphoma T3N3M1 stage4
• Type 2 diabetes mellitus without complications
• Essential (primary) hypertension
• Mixed hyperlipidemia
• Constipation, unspecified
• Chronic viral hepatitis B without delta-agent
• Insomnia, unspecified

[past history] - 2023-03-20 admission note

• Type 2 diabetes mellitus and hypertension for 20+ years under medications treatment.
• Mixed hyperlipidemia for 5 years with medications control and cancle medications treatment recently
• Past operation history: VATS exciosion of mediastinal nodules on 2022/12/06

[exam findings]

• 2023-06-16 CT - abdomen
  • History: T cell lymphoma
  • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status can not be determined without IV contrast.
  • Findings: Comparison prior CT dated 2022/12/15.
    • Prior CT identified multiple enlarged LNs at neck, bil. axillary regions, mediastinum, gastrohepatic ligament, celiac trunk, para-aortic space, para-cava space, mesentery and bil. inguinal regions are noted again, marked decreasing in size that is c/w T-cell lymphoma S/P C/T with partial response.
    • Prior CT identified splenomegaly (the largest dimension: 15.5 cm) is noted again, stationary.
    • Prior CT identified some nodules (up to 7mm) at bil. lungs are noted again, mild decreasing in size.
  • IMP:
    • T-cell lymphoma S/P C/T show partial response.
• 2023-06-10 Nasopharyngoscopy
  • Findings:
    • lump in throat and odynophagia for one month, patient has strong gap reflex, hard to assess NP and larynx by mirror
  • Diagnosis/conclusion
    • Nasopharyngoscope findings: Smooth NP, Laryngx: mild edematous change of laryngeal mucosa
• 2023-04-13 SONO - nephrology
  • right mild hydroureter
  • left renal cyst
• 2023-04-12 KUB
  • increased air in nondistended loops of small bowel over LUQ and RUQ, could be paralytic ileus.
  • The size & contour of the kidneys, visualized portion of spleen and liver, and psoas shadows, properitoneal & pelvis fat lines, are unremarkable.
  • Rt L5-S1 facet joint osteoarthritis.
  • s/p foley catheter insertion in the urinary bladder.
• 2023-02-27 CXR
  • Atherosclerotic change of aortic arch
  • Linear infiltration over both lung zone are noted. please correlate with clinical symptom to rule out inflammatory process.
  • Please correlate with CT.
• 2023-02-27 Nerve Conduction Velocity, NCV
  • Findings
    • The NCV study showed (1) absence of CMAP in left peroneal nerve, (2) prolonged distal motor latency in bilateral median, bilateral ulnar, and left tibial nerves, (3) reduced CMAP amplitude in all the sampled nerves, (4) decreased motor nerve conduction velocity in all the sampled nerves, (5) absence of SAP in left sural nerve, (6) reduced SAP amplitude in left median and ulnar nerves, (7) decreased sensory nerve conduction velocity in all the sampled nerves.
    • The F-wave study showed (1) absence of F-wave in left peroneal nerve, (2) prolonge minimal F-wave latency in all the sampled nerves.
    • The H-reflex study showed (1) absence of H-wave in left tibial nerve, (2) prolonged H-wave latency in right tibial nerve.
    • The EMG showed (1) poor recruitment of MUAP in right biceps brachii and right rectus femoris muscles, (2) fasciculation, fibrillation, and poor recruitment of MUAP in right tibialis anterior muscles.
  • Conclusion
    • The above findings suggest sensorimotor polyneuropathy with demyelinating pattern. Advise clinical correlation.
• 2023-02-15 MRI - L-spine
  • diffuse high SI change on T2WI in the bilateral L-spine posterior perivertebral muslces and bilateral gluteal muscles.
  • herniated disc in the L4/5 idsc.
  • discitis in the L4/5 disc.
• 2023-02-14 CXR
  • Atherosclerotic change of aortic arch
  • Linear infiltration over left lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Few nodular opacities projecting at left lung are suspected.
  • Please correlate with CT.
• 2023-02-13 SONO - abdomen
  • cholecystopathy
  • renal cyst, LK
  • small amouont ascites
• 2022-12-20 ECG
  • Sinus tachycardia
  • poor wave progression
• 2022-12-16 Whole body PET scan
  • The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple lymph nodes on both sides of the diaphragm.
  • Inhomogenously increased FDG uptake in the spleen and in the bone marow of the skeleton. Lymphoma involving the spleen and bone marow should be considered. Please correlate with other clinical findings for further evaluation.
• 2022-12-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 25) / 75 = 66.67%
    • M-mode (Teichholz) = 66
  • Preserved LV and RV systolic function with normal wall motion
  • Grade 1 LV diastolic dysfunction
• 2022-12-15 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Positive for malignant T-cell lymphoma
  • Microscopically, it shows bone marrow tissue with presence of aggregations of T-cell lymphomatous cells.
  • Immunohistochemical stain reveals CD5(+), CD3(+), CD20(-), CD117(-), CD34(-), CD71(focal+), MPO(+),and CD138(-).
• 2022-12-15 CT - abdomen
  • Findings
    • Enlarged LNs at neck, bil. axillary regions, mediastinum, retroperitoneum, peritoneal cavity and bil. inguinal regions.
    • Splenomegaly.
    • Some nodules (up to 7mm) at bil. lungs.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP
    • Lymphoma as described.
• 2022-12-08, -12-06 CXR
  • s/p right chest tube in place, its tip directed medially, projecting over 6th intercostal space
  • minimal right pneumothorax .
  • widening of Rt paratracheal stripe
  • Platelike lung atelectasis over Lt lower lung zone
• 2022-12-06 Patho - lymph node region resection
  • Lymph node, right, paratracheal, excision — Malignant T-cell lymphoma
  • Specimen submitted in formalin consists of 4 pieces of tan, irregular tissue measuring up to 5.0 x 2.0 x 1.5 cm. Several enlarged lymph nodes, measuring up to 3.5 x 2.0 x 1.5 cm, are founs and all for section in 3 cassettes A1-3 (A1-2: the same level).
  • Sections show lymph nodes with diffusely infiltration of medium-sized lymphocytes. Vascular proliferation and hyperplasia of follicular dendritic cells are seen.
  • The immunohistochemical stains reveal CK(-), CD3(+), CD5(+), CD4(+), CD8(+), CD20(-), CD56(-), Granzyme B(-), TdT(-), BCL2(+), CD30(-), CD10(-), BCL6(-), PD1(-), ICOS(-), and SAP(-).
  • The results are consistent with peripheral T-cell lymphoma, NOS. Please correlate with the clinical presentation and image study.
• 2022-11-22 CT - chest
  • Findings
    • Lungs:
      • an oval-shaped LUL-S1/2 solid nodule adjacent to the najor fissure (7.6 mm srs).
      • an oval-shaped RML solid nodule(4mm srs).
      • favor intrapulmonary lymph node
      • normal pulmonary attenuation on inspiratory images, with mild patchy areas air-trapping in both lower lobes.
      • differential diagnosis include obstructive chronic airway disease, hypersensitive pneumonitis, and bronchiolitis obliterans,
    • Mediastinum and hila: enlarged LNs in the visceral space and small LNs in visceral and left anterior prevascular spaces
    • Vessels:
      • calcified plaques of the coronary arteries, extensive in LAD artery
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: multiple enlarged LNs at supraclavicular fossae and both axillary regions.
    • Visible abdominal contents: moderate splenomegaly,
  • Impression:
    • lymphoma or other hematological disease or metastatic tumors in aforementioned regions.
    • suspected obstructive small airways disease in lowef lobes of lungs.
• 2019-10-14 Thyroid Ultrasound
  • Suspected Autoimmune thyroid disease

[MedRec]

• 2022-12-05 ~ 2022-12-09 POMR Chest Surgery
  • Discharge diagnosis
    • Malignant T-cell lymphoma status post video-assisted thoracoscopic surgery exciosion of mediastinal nodules on 2022-12-06
    • Mediastinal lymphadenopathy status post video-assisted thoracoscopic surgery exciosion of mediastinal nodules on 2022-12-06
    • Type 2 diabetes mellitus without complications
    • Essential hypertension
    • Mixed hyperlipidemia
  • Course of Inpatient Treatment
    • After admission, pre-op assessment was done.
    • Operation of video-assisted thoracoscopic surgery exciosion of mediastinal nodules was performed smoothly at 2nd admission day. No complication was noted. Prophylactic antibiotics was prescribed for 1 day.
    • Dysuria was noted after removal foley and ICP U/O 350 ml ST at post op day 1, Bethanechol were prescribed and voiding smoothly by patient himself.
    • Right chest tube with LPS -18 cmH2O was done. Chest tube was removed at post-op 2nd day. He was discharged under stable hemodynamics at post-op 3rd day.
  • Prescription
    • Actein (acetylcysteine 66.7mg) 1# TID
    • MgO 250mg 1# TID
    • Wecoli (bethanechol 25mg) 1# TIDAC
    • Acetal (acetaminophen 500mg) 1# QID
    • Sindine (povidone iodine) QD EXT (for wound dressing change)
• 2022-11-29 SOAP Chest Surgery
  • P
    • arrange admission on 12/5
    • VATS mediastinal nodule excision on 12/6.
• 2022-11-28 SOAP Chest Medicine
  • S: dry cough persist for 3 months, no short of breath
  • O: 2022/11/22 CT: lymphoma or other hematological disease or metastatic tumors in aforementioned regions; r/o obstructive small airways disease in lowef lobes of lungs; calcified plaques of the coronary arteries, extensive in LAD artery
  • P
    • refer to chest surgeon for mediastinal lymphadenopathy suspected lymphoma
    • refer to oncologist for mediastinal lymphadenopathy suspected lymphoma
• 2017-10-30 SOAP Metabolism
  • S: Drugs will be collected at our hospital in the future. referred to the PharmaCloud.
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension, benign [I10]
    • Mixed hyperlipidemia [E78.2]
  • Prescription
    • Aprovel (irbesartan 300mg) 1# QD
    • Tulip (atorvastatin 20mg) 1# QOD
    • Bokey (aspirin 100mg) 1# QD
    • Forxiga (dapagliflozin 10mg) 1# QDCC
    • Glimet (glimepiride 2mg, metformin 500mg) 1# QDCC
• 2017-10-23 SOAP Ophthalmology
  • Diagnosis
    • Vitreous hemorrhage, right eye [H43.11]
    • Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema [E11.351]
• 2017-10-18 SOAP Metabolism
  • S: type 2 DM since 2012 , hypertension , irregular Tx before , hyperlipidemia , hyperuricemia, poor control, family Hx of DM: (+)
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension, benign [I10]
    • Mixed hyperlipidemia [E78.2]
• 2017-10-17 SOAP Ophthalmology
  • S
    • refer from LMD vitrous hemorrha OD
    • Blurred visionBlurred vision
    • DM for fundus exam
    • DM+, HTN-, NKA
  • Diagnosis
    • Vitreous hemorrhage, right eye [H43.11]
  • Prescription
    • Trand (tranexamic acid 250mg) 1# BID

[consultation]

• 2023-05-12 Ear Nose Throat
  • Q
    • for right ear pain & sorethroat R/O otitis media
    • He complained of right ear pain & sorethroat for days. We need expertise to evaluate his condition thanks!
  • A
    • Ear: bilateral cerumen impaction, after removal, bilateral ear drum intact without middle ear effusion.
    • Oral cavity and oropharynx: injected posterior pharyngeal wall.
    • Portable nasopharyngoscopy: smooth nasopharynx, oropharynx and hypopharynx. Patent airway.
    • Impression: Impending acute tonsillitis, bilateral cerumen impaction
    • Plan: Please give sulconazole solution Exelderm for bilateral ear, and please provide Curam for 5 days and analgesic agent if not contraindicated.
• 2023-02-09 Dermatology
  • Q
    • This 60 year-old patient has past history of type II diabetes mellitus and hypertension for 20+ years under medications treatment; mixed hyperlipidemia for 5 years and cancle medications treatment recently; new diagnosis lymphoma in 2022/12.
    • He was under CHOP (cyclophosphenide + doxorubicin + vincrinstine + compesolon) chemotherpay with C1 on 2022/12/22 and C2 on 2023/01/13. This time, he was admitted for C3 CHOP chemotherapy.
    • We strongly need your expertise for lips rash and ulcer, suspected Herpes skin rash. Mucosa inside the mouth showed no ulcer, but there were ulcer noted at his lips. Due to immunosuppression state under chemotherapy, we strongly need your expertise for evaluation and management. Thank you very much.
      
  • A
    • The patient had sufferred from perioral scaling crust with erythematous macules (upper and lower lips and corners of the mouth) with mild stinging and itchy sensation.
      
    • Under the impression of exfoliative chelitis with secondary candidasis.
    • The following sugeetion:
      • Tetracycline onit 2 tube topical bid use first (First, apply it broadly, which can be used as a base for lip balm).
      • Mycomb cream 1 tube topical bid use over regional erythematous scaling lesions (use it locally on areas with surrounding redness and flaking skin).

[surgical operation]

• 2022-12-06 - Op Method: VATS exciosion of mediastinal nodules
  • Finding: Multiple enlarged mediastinal LNs.

[chemoimmunotherapy]

• 2023-06-16 - cyclophosphamide 750mg/m2 800mg NS 250mL 30min + doxorubicin 50mg/m2 40mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, 75% Endoxan for poor renal function, 60% Adriamycin for GPT 88)

  •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug                       + NS 250mL

• 2023-05-15 - cyclophosphamide 750mg/m2 790mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, reduced Endoxan for poor renal function)

  •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL

• 2023-03-24 - cyclophosphamide 750mg/m2 780mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, reduced Endoxan for poor renal function)

  •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL

• 2023-02-14 - cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 60mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP)
  • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
• 2023-01-13 - cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 74mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP)
  • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
• 2022-12-22 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + doxorubicin 50mg/m2 80mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID D1-5 (CHOP)
  • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL

==========

2023-07-17

It appears that there is a suspicion of AKI in this patient due to the decline in renal function.

• 2023-07-16 Creatinine 4.13 mg/dL
  

• 2023-07-03 Creatinine 1.68 mg/dL

• 2023-07-16 eGFR 15.77
  

• 2023-07-03 eGFR 44.52

• 2023-07-16 BUN 71 mg/dL
  

• 2023-07-03 BUN 29 mg/dL

Based on the patient’s current renal status, the dosage of drugs in the active formulary has been reviewed and no adjustment is required.

2023-06-26

• According to the PharmaCloud database, our hospital has been the sole provider of all required medical services and medications for this patient for the past 3 months.

• Our endocrinologist recently prescribed a refillable regimen of Tresiba Flex Touch (insulin degludec), Relinide (repaglinide), Trajenta (linagliptin), Aprovel (irbesartan), Tulip (atorvastatin), and Bokey (aspirin) on 2023-06-20. These drugs were added to the patient’s active medication list. As a result, no medication reconciliation issues were identified.

• The most recent administration of CHOP was on 2023-06-16, and subsequent lab results indicate that leukopenia is still progressing. The use of G-CSF is covered by NHI when WBC < 1000/uL or ANC < 500/uL. Therefore, if the patient’s lab results meet these criteria, the use of G-CSF could be an appropriate management strategy. Please continue monitoring the patient’s WBC and ANC levels to make informed decisions about future treatment strategies.

  • 2023-06-26 WBC 1.24 x10^3/uL
    
  • 2023-06-25 WBC 1.43 x10^3/uL
    
  • 2023-06-14 WBC 4.84 x10^3/uL

2023-06-15

• Upon review of the PharmaCloud database, it is observed that the patient has exclusively sought medical care at our hospital for the past three months. No issues related to medication reconciliation have been identified.

• The patient’s renal function has remained insufficient over the past month, with an eGFR of 26 on 2023-06-15. The dose of cyclophosphamide in the CHOP regimen has been adjusted in response to this renal insufficiency. Please continue to monitor the patient’s renal function and consider whether further dose adjustments are necessary.

  • 2023-06-15 Creatinine 2.64 mg/dL
    
  • 2023-06-14 Creatinine 2.92 mg/dL
    
  • 2023-05-26 Creatinine 2.41 mg/dL
    
  • 2023-05-15 Creatinine 2.11 mg/dL
    
  • 2023-06-15 BUN 54 mg/dL
    
  • 2023-06-14 BUN 56 mg/dL
    
  • 2023-05-26 BUN 64 mg/dL
    
  • 2023-05-15 BUN 44 mg/dL

• In addition, the LFT also demonstrated an increase in ALT. According to Folyd’s 2006 recommendations, when a patient’s transaminases are 2 to 3 times the ULN, the dose of doxorubicin should be reduced to 75% of the standard dose. (The manufacturers’ guidelines suggest adjusting doses based on serum bilirubin levels. However, the most recent test results show that this patient’s bilirubin level is within the normal range.)

  • 2023-06-14 S-GPT/ALT 88 U/L
    
  • 2023-05-26 S-GPT/ALT 27 U/L

2023-05-12

• Based on the PharmaCloud database, the patient has only visited our hospital for medical needs in the past three months. After reviewing the database, no medication reconciliation issues were identified.

• Lab results on 2023-05-11 indicate creatinine 3.26 mg/dL, eGFR 20.72, BUN 83 mg/dL, demonstrating the patient’s renal insufficiency. The rationale for dose adjustment in the CHOP regimen for patients with renal impairment is as follows:

  • cyclophosphamide
    • There are no dosage adjustments provided in the manufacturer’s labeling
    • Aronoff 2007
      • CrCl >=10 mL/minute: No dosage adjustment required.
      • CrCl <10 mL/minute: Administer 75% of normal dose.
    • KDIGO 2012: Lupus nephritis
      • CrCl 25 to 50 mL/minute: Administer 80% of normal dose.
      • CrCl 10 to <25 mL/minute: Administer 70% of normal dose.
  • doxorubicin
    • There are no dosage adjustments provided in the manufacturer’s labeling; however, adjustments are likely not necessary given limited renal excretion.
  • vincristine
    • No dosage adjustment necessary
  • prednisolone
    • No dosage adjustment necessary

• The cyclophosphamide dose has been reduced to 75% since the last administration on 2023-03-24 as indicated without an issue.

• The other medications listed in the active prescription should be used with caution, considering the patient’s renal insufficiency (ref: UpToDate):

  • cimetidine
    • There are no dosage adjustments provided in the manufacturer’s labeling; use with caution. Severe kidney impairment: 300 mg every 12 hours; may increase frequency with caution. When hepatic impairment is also present, further reductions in dosage may be necessary.
    • Alternate recommendations (Aronoff 2007):
      • GFR >50 mL/minute: No dosage adjustment necessary.
      • GFR 10 to 50 mL/minute: Administer 50% of normal dose.
      • GFR <10 mL/minute: 300 mg every 8 to 12 hours.
  • silodosin
    • CrCl >50 mL/minute: No dosage adjustment necessary.
    • CrCl 30-50 mL/minute: 4 mg once daily.
    • CrCl <30 mL/minute: Use is contraindicated.
  • tenofovir alafenamide
    • Tenofovir is renally cleared, and exposures are increased in patients with CrCl <30 mL/minute and those receiving hemodialysis. Close monitoring for adverse effects in the advanced stages of kidney dysfunction is recommended.
    • Kidney impairment prior to treatment initiation:
      • CrCl >=15 mL/minute: No dosage adjustment necessary.
      • CrCl <15 mL/minute: Use is not recommended.

• Please continue to monitor regularly and consider dose adjustments as needed based on patient renal function.

2023-03-21

• The acute kidney injury (AKI) episode that occurred in late Feb 2023 appears to have subsided.
  • 2023-03-21 Creatinine 2.78 mg/dL
    
  • 2023-03-20 Creatinine 3.24 mg/dL
    
  • 2023-03-02 Creatinine 2.60 mg/dL
    
  • 2023-02-27 Creatinine 3.43 mg/dL
    
  • 2023-02-25 Creatinine 3.80 mg/dL
    
  • 2023-02-23 Creatinine 4.66 mg/dL
    
  • 2023-02-22 Creatinine 5.21 mg/dL
    
  • 2023-02-21 Creatinine 5.15 mg/dL
    
  • 2023-02-14 Creatinine 1.50 mg/dL
    
  • 2023-02-10 Creatinine 1.13 mg/dL
    
  • 2023-02-09 Creatinine 1.22 mg/dL
    
  • 2023-02-08 Creatinine 1.84 mg/dL
    
  • 2023-01-20 Creatinine 0.95 mg/dL
    
  • 2023-01-12 Creatinine 1.00 mg/dL
    
  • 2023-01-06 Creatinine 1.41 mg/dL
    
  • 2023-01-03 Creatinine 1.16 mg/dL
    
  • 2023-01-01 Creatinine 1.15 mg/dL
• 2023-03-21 CrCl 19mL/min, eGFR 24.98.
  • Silodosin use is not recommended for patients with a CrCl below 30 mL/minute.
  • Metformin use is contraindicated for patients with an eGFR below 30 mL/minute/1.73m2.
  • For patients with an eGFR between 15 and 60 mL/min/1.73m2, glimepiride use may result in reduced renal clearance of active metabolites, increasing the risk of hypoglycemia.
  • Acarbose use is generally not advised for patients with a serum creatinine level above 2 mg/dL or a CrCl below 25 ml/minute/1.73m2, as the systemic area under the curve (AUC) may increase six-fold.

2023-01-13

• Since around 2022/2023 new year’s eve, there has been no sign of neutropenia in the lab data.
  • 2023-01-12 WBC 9.41 x10^3/uL
    
  • 2023-01-06 WBC 51.96 x10^3/uL
    
  • 2023-01-03 WBC 1.66 x10^3/uL
    
  • 2023-01-01 WBC 0.16 x10^3/uL
    
  • 2022-12-30 WBC 0.30 x10^3/uL
    
  • 2022-12-22 WBC 6.75 x10^3/uL
    
  • 2022-12-14 WBC 9.13 x10^3/uL
    
  • 2022-12-05 WBC 7.96 x10^3/uL
    
  • 2022-11-29 WBC 10.69 x10^3/uL
• A grade 4 neutropenia developed around new year’s eve, just about 10 days after the patient had received last chemotherapy on 2022-12-22. The date of this chemotherapy was 2023-01-12, approximately one to two weeks after that date, when the Chinese New Year holiday is approaching. In order to prevent potential neutropenia during the long holidays, it is recommended to take steps in advance.

700132489

230717

[diagnosis] - 2023-04-06 admission note

• Malignant neoplasm of unspecified site of unspecified female breast

• 2023-03-17 discharged note

  • Malignant neoplasm of unspecified site of unspecified female breast
  • Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
  • Insomnia, unspecified
  • Left breast cancer, 11/2.5 cm s/p SM + SLNB in 2018/07, ER(95%) PR(60%) Her2/neu(+) Ki-67: 60%, with left lower lobe lung metastasis, and bone metastasis - post anastrozole since 2022/03/23, shifted to Kisquali (ribociclib) on 2022/04/20, added Anazo on 2022/04/27, with multiple bilateral lung metastases with pleural involvements, multiple liver metastases, and multiple bony metastases according to the Positron Emission Tomography and computed tomography on 2023/03

[past history] - 2023-03-15 admission note

• old CVA (20100402)
• chronic left leg DVT (2017601)
• HTN,
• HCVD,
• GERD,
• hyperlipidemia,
• cataract, insomnia,
• left metastatic breast carcinoma /p operation and post treated at Taipei Medical University Hospital.

  [allergy]

• NKDA

[family history]

• Unknown of DM, CVA, cancer or CAD in her family

[exam findings]

• 2023-07-06 SONO - abdomen
  • Hepatic tumors R/O metastasis
  • Focal fatty liver, mild
  • Prob. Parenchymal liver disease
  • Cholecystopathy
    
  • Rt renal cyst
  • Minimal ascites
• 2023-07-05, 2023-06-21 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • There are several nodular opacity projecting in both lower lung that are c/w metastases after correlate with CT.
• 2023-07-05, -06-28 KUB
  • Osteoblastic change of right sacrum is highly suspected. Please correlate with CT.
• 2023-05-31 CT - chest
  • Indication: Breast cancer with lung and liver mets
  • Comparison was made with CT on 2023/02/25
    • Lungs: multiple nodules of variable sizes in both lungs upper to 22mm at LLL due to metastases.
    • Vessels: mild calcified plaques of the LAD coronary artery.
    • Thoracic aorta: dilated ascending aorta (4.3cm). mild atherosclerotic change of aortic arch and descending thoracic aorta.
    • Heart: dilated LA, conventric LVH, mild calcified aortic valves
    • Chest wall and visible lower neck: s/p Rt MRM.
    • Visible abdominal-pelvic contents: diffuse heterogeneous enhancement of Lt hepatic lobe, in regression.
    • Extensive atherosclerotic change of the abdominal aorta and bilateral iliac arteries.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • IMP: breast ca with progression of lung metastasis and regression of hepatic metastasis compared with CT on 2023/02/25
• 2023-04-07 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Patchy opacity projecting at right upper lung zone was suspected.
  • Please correlate with CT.
• 2023-03-23 MRI - brain
  • Findings:
    • Mild periventricular small vessel disease. NO acute ischemic infarct.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
    • Left mastoiditis.
  • Impression:
    • Aging brain appearance.
• 2023-03-16 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-03-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (114 - 25) / 114 = 78.07%
    • M-mode (Teichholz) = 78
  • Dilated LA
  • Adequate LV, RV systolic function with normal wall motion
  • LV hypertrophy, Impaired LV relaxation
  • Mild AR
• 2023-02-25 CT - abdomen
  • History and indication: left abdominal pain
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Poor enhancement of left hepatic lobe r/o malignancy. Poor enhancing nodules at S1 and right hepatic lobe.
    • Multiple nodules at bil. lungs.
    • Renal cysts (up to 1.8cm).
    • Normal appearance of spleen, pancreas, adrenals.
    • Normal appearance of gallbladder.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • Suspected liver malignancy with lung metastases.
• 2023-02-25 ECG
  • Normal sinus rhythm
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2023-02-22 Nasopharyngoscopy
  • erosion on bil nasal septum, smooth NPx, OPx, a cyst over R AE fold
• 2022-12-30 CT (Taipei Medical University Hospital)
  • Findings
    • Progressive change of the metastatic nodules at both lung fields, the largest one is 2.1 cm at superior segment of LLL.
    • Still mild radiation pneumonitis at anterior portion of the left lung, stationary.
    • No significant pleural effusion.
    • Calcifications of the aorta and coronary arteries are present.
    • S/P left mastectomy
    • No evidence of local recurrence or axillary lymphadenopathy is noted.
    • There is no evidence of masses in the anterior, middle and posterior compartment.
    • No significant enlarged lymphadenopathy is noted in the mediastinum.
    • Newly developed hypodensity lesions at left lobe liver, suggest MRI for further evaluation.
    • No significant bone destruction is noted.
  • IMPRESSION:
    • Progressive change of the metastatic nodules at both lung fields, the largest one is 2.1 cm at superior segment of LLL.
    • Still mild radiation pneumonitis at anterior portion of the left lung, stationary.
    • S/P left mastectomy without local recurrence or axillary lymphadenopathy is noted.
    • Newly developed hypodensity lesions at left lobe liver, suggest MRI for further evaluation
• 2022-12-02 24hr portable ECG
  • Sinus rhythm
  • Occasional isolated apcs
  • Rare apc couplets
  • A few isolated vpcs
  • A few episodes of 2:1 sinoatrial exit block, longest R-R interval 2.26 secs at 04:44
  • No significant tachyarrhythmia
• 2022-12-02 ECG
  • Normal sinus rhythm
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2022-12-02 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (110 - 33) / 110 = 70%
    • M-mode (Teichholz) = 70
  • Concentric LV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
  • Normal LV and RV systolic function.
  • Aortic valve sclerosis with trivial AR; mild posterior mitral annulus calcification.
  • Prominent aortic root calcification with protruding atheroma (8.8 mm of thickness); dilated proximal ascending aorta (38 mm).
• 2020-09-03 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
• 2019-11-19 CT - chest
  • no mediastinal mass or enlarged LN. (Lateral bulge in right superior mediastinum due to tortousity of innominate artery on chest radiograph).
  • dilated ascending aorta (4.5cm in diameter).
  • 4mm LLL nodule and old granulomas in hilum and mediastinum.
• 2019-10-17 Upper GI panendoscopy
  • Reflux esophagitis, LA classification grade A 　- Chronic superficial gastritis, whole stomach 　- Gastric erosions 　- s/p CLO
• 2019-03-29 C-spine AP + Lat
  • Radiograph of the cervicaloorphic degeneration of C-spine. Decreased disc space at C5-6-7.
• 2019-03-11 SONO - abdomen
  • suspect liver parenchyma disease/ incomplete exam of liver
• 2019-03-11 Carotid PhonoAngiograph, CPA
  • mild atheroma on right ICA, moderate atheroma on right carotid bifurcation with diameter reduction of 42%, mild atheroma on left ICA, moderate atheroma on left carotid bifurcation with diameter reduction of 49%
  • normal flow and flow velocities on bil. extracranial carotid and vertebral arteries
• 2018-11-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (143 - 51) / 143 = 64.34%
    • M-mode (Teichholz) = 64
  • Septal and RV hypertrophy with Gr II LV diastolic dysfunction and impaired RV relaxation.
  • Dilated LV with normal LV and RV systolic function.
  • Mild AV sclerosis and posterior mitral annulus calcification with mild AR; trivial MR; mild TR.
  • Dilated proximal ascending aorta (38mm) with mild calcification; protruding non-mobile atheroma (18 mm x 7mm) at sinotubular junction.

[chemotherapy]

• 2023-05-17 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
• 2023-04-27 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
• 2023-04-07 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
• 2023-03-16 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2

==========

2023-07-17

According to the PharmaCloud database, it appears that the patient has only been receiving medical care at our hospital for the past three months. No medication reconciliation issues were identified during her current admission.

2023-07-14

Recently, a noticeable increase in ALT, AST and bilirubin levels can be seen based on the weekly lab data.

2023-07-12 S-GPT/ALT 119 U/L
2023-07-05 S-GPT/ALT 129 U/L
2023-06-28 S-GPT/ALT 132 U/L
2023-06-21 S-GPT/ALT 145 U/L
2023-06-14 S-GPT/ALT 112 U/L
2023-06-07 S-GPT/ALT 53 U/L
2023-07-12 S-GOT/AST 431 U/L
2023-07-05 S-GOT/AST 279 U/L
2023-06-28 S-GOT/AST 180 U/L
2023-06-21 S-GOT/AST 169 U/L
2023-06-14 S-GOT/AST 115 U/L
2023-06-07 S-GOT/AST 66 U/L
2023-07-12 Bilirubin total 2.73 mg/dL
2023-07-05 Bilirubin total 1.90 mg/dL
2023-06-28 Bilirubin total 1.00 mg/dL
2023-06-21 Bilirubin total 0.56 mg/dL
2023-06-14 Bilirubin total 0.40 mg/dL
2023-06-07 Bilirubin total 0.34 mg/dL

Per UpToDate, Enhertu (trastuzumab deruxtecan) is linked to a raised serum alanine aminotransferase (34% to 53%), elevated serum alkaline phosphatase (22% to 54%), increased serum aspartate aminotransferase (35% to 67%), and elevated serum bilirubin (16% to 24%).

According to the Enhertu label, there are limited data available for patients with moderate hepatic impairment, and none for patients with severe hepatic impairment. Given that metabolism and biliary excretion are the primary elimination routes for the topoisomerase I inhibitor component (DXd) in Enhertu, caution should be exercised when administering Enhertu to patients with moderate or severe hepatic impairment. The package insert does not provide dose adjustment guidelines based on LFT readings. It might be suggested to temporarily withhold the drug until the drug is ruled out as the cause of deterioration of liver function.

2023-04-07

• Based on the patient’s medical history and current condition, it is recommended that Xarelto (rivaroxaban) be resumed after Port-A catheter placement.

2023-03-16

• According to the recommended dosage guidelines, for patients with unresectable or metastatic breast cancer, regardless of HER2-low or HER2-positive status, Enhertu (trastuzumab deruxtecan) should be administered at a dose of 5.4 mg/kg once every three weeks until disease progression or unacceptable toxicity. Based on the patient’s body weight of 57.5kg recorded on 2023-03-15, the appropriate dosage of Enhertu would be 310mg. However, considering the patient’s advanced age and the fact that this is her first time receiving this drug, a reduced dosage of 200mg has been used.
• Interstitial lung disease (ILD) and pneumonitis, including fatal cases, have been reported with fam-trastuzumab deruxtecan. Please monitor for and promptly investigate signs and symptoms including cough, dyspnea, fever, and other new or worsening respiratory symptoms.

700887181

230717

[diagnosis] - 20230103 admission note

• Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
• Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites
• Cardiac arrhythmia, unspecified

[present illness] - 20230103 admission note

• This 75 y/o man is a case of HTN, CKD stage3, urothelial carcinoma, high-grade s/p TURBT on 2009-01-21, 2010-10-01 and 2011-01-20. (TURBT, transurethral resection of bladder tumor)
• He was diagnosed with diffuse large B-cell lymphoma in 201706, stage IV with bone, bone marow involvement. He received chemotherapy with R-DA-EPOCH on 201706 ~ 201710. R-CHOP on 2018/10/17 and 2018/11/29. R-ICE (Mabthera + Etoposide + Ifosfamide) on 2018/12/26 ~ 2019/06/13. He received stem cell collection on 2019/03/05 ~ 07 but inadequate cell number was collected for auto PBSCT.

[past history]

• Diffuse large B-cell lymphoma, stage IV with bone, bone marow involvement, diagnosed on 201706 s/p chemotherapy
• HTN
• CKD stage3
• urothelial carcinoma, high-grade s/p TURBT
• Appendicitis s/p appendectomy

[Allergy]

• NKDA

[family history]

• Father - prostate cancer

[lab data]

• 2022-12-05 Anti-HCV Nonreactive
  
• 2022-12-05 Anti-HCV Value 0.06 S/CO
  
• 2022-12-05 Anti-HBc Reactive
  
• 2022-12-05 Anti-HBc-Value 2.18 S/CO
  
• 2022-12-05 HBsAg Nonreactive
  
• 2022-12-05 HBsAg (Value) 0.41 S/CO
  
• 2022-12-05 Anti-HBs 8.79 mIU/mL

[exam findings]

• 2023-05-12, -05-10, -05-03 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • S/P autosuture projecting at left middle lung.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura thickening or effusion ?
    
  • Compression fracture of T12 vertebral body?
  • Spondylosis with scoliosis of the T-spine with convex to right side.
• 2023-03-28 PET scan
  • In comparison with the previous study on 2022-11-07, the previous lesion in the lymph node in the left posterior lower neck region and the glucose hypermetabolism in the bone marrow of the skeleton are a little more evident. Lymphoma in a little more progression should be watched out. However, other glucose hypermetabolism in the left SCF and right axillary lymph nodes, bilateral pulmonary hilar lymph nodes, mediastinal lymph nodes, bilateral lungs, left lower lung pleua and left rib cage is a little less evident.
  • Increased FDG uptake in the right tonsil. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
• 2023-03-09 CT - neck
  • Indication: relapsed DLBCL, Lugano stage IV
  • Head and Neck CT without IV contrast administration shows (comparison: 2022/11/23 Chest CT with and without contrast)
    • Residual enlarged LNs in left low posterior neck, the supraclavicular fossa.
    • Multiple Small bil. neck LNs also were noted.
      
    • No obvious nasopharynx, oropharynx, hypopharynx or larynx mass.
  • Chest, abdomen and pelvis (noncontrast):
    • An ill-defined nodule in left anterior part of LUL, another smaller one in low posterior part, nature?
    • No evident abnormal enlarged lymph node in the mediastinum, paraaortic spaces or iliac region.
    • Gallstones were noted incidentally.
    • BPH with bladder tumor?
    • Multi-focal osteoblastic change of TL-spine also were found.
• 2022-12-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 30) / 80 = 62.50%
    • M-mode (Teichholz) = 62
  • Adequate LV systolic function with normal resting wall motion
  • Trivial MR and trivial TR
  • Preserved RV systolic function
• 2022-12-05, 2022-11-21, 2021-12-21, 2020-08-17, 2019-03-01 ECG
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2022-11-25 Patho - lymphnode biopsy
  • Lymph node, neck, left, biopsy — Diffuse large B-cell lymphoma and see comment
  • The sections show a picture of diffuse large B-cell lymphoma with following features:
    • Specimen: Lymph node, neck, left
    • Procedure: Biopsy
    • Tumor site: Left neck
    • Histologic type: Diffuse large B-cell lymphoma
    • Immunophenotyping: CD3(-), CD20(+), PAX5(+), BCL6(+), CD10(+), and MUM1(-)
    • Comment: The findings favor germinal center B-cell subtype
• 2022-11-25 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Hypocellular marrow without evidence of lymphoma involvement
  • The sections show hypocellular marrow (5%). Small amount of hematopoietic cells and focal hemosiderin deposition can be found. There is no evidence of lymphoma involvement in CD3, CD20, CD10, PAX5 and BCL6 immunostains.
• 2022-11-23 CT - chest
  • Comparison was made with prior CT dated on 2021/10/30
    • Lungs:
      • a 17mm spiculated nodule at S3 with pleural tail at LUL. a nodular opacit at S6 and a long coarse reticular opacity in LLL. as compared with previous CT study.
    • Mediastinum and hila: large soft-tissue mass along the left anterior prevascular space and A-P window. small LNs in other locations of visceral space.
    • Vessels:
      • Thoracic aorta: normal in caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal in caliber.
      • Heart: normal in size of cardiac chambers.
    • Pleura: small Lt pleural effusion.
    • Chest wall and lower neck: multiple small LNs and a 17mm LAP in left lower posterior triangle of neck. small LNs in bilateral submandibular spaces.
    • Visible abdominal-pelvic contents: splenomegaly mutliple small areas of low attenuations. enlarged prostate.
      • a small Lt renal cyst (30mm) and small-sized of Rt kidney. many gall bladder stones. no enlarged lymph node.
      • unremarkable of the liver, adrenal glands, and pancreas.
    • Visualized bones: blastic change in many vertebrae and sternum, and marked compression fracture of L1 vertebral body.
  • Impression:
    • Diffuse large B-cell lymphoma s/p treatment with residual nodular lesions and fibrotic scar or linear atelectasis in lungs, and bony involvment, stationary, and visible newly splenic involvement and mediastinal and left LAP, compared with CT 2021/10/30.
• 2022-11-07 Whole body PET scan
  • In comparison with the previous study on 2022-01-03, most of above-mentioned lymph node regions and bilateral lungs of glucose hypermetabolism come to more evident.
  • In addition, there are several new lesions of increased FDG uptake in a lymph node in the left post. lower neck region, left ICF, right axillary region, bilateral mediastinal space, left lower lung pleua, and several upper T-spine.
  • Diffuse large B-cell lymphoma s/p treatment with tumor recurrence in multiple lymph node regions on the same side of the diaphragm and involvement of bilateral lungs, left lower lung pleura, left rib cage, and several upper T-spine, rc-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2022-10-26 MRI - L-spine
  • Indication:
    • DLBL, double hit (CT-guided biopsy from rt kidney), involving rt kidney, paraortic LNs, multiple bone. follow up
    • bladder CA
  • IMP:
    • herniated discs in the L1/2, L2/3, L3/4 and L4/5 discs
    • subacute compression fractures at L2 and L4 vertebral bodies
• 2022-10-26 Cystoscopy
  • Clinical History: bladder cancer s/p TUR-BT on 20110119
  • PH:
    • bladder cancer s/p TUR-BT on 20090121 and on 20100930, s/p intravesical C/T with Cistplatin, Adriamycin
    • Hypertension
    • s/p appendectomy.
  • Comment / Suggestion:
    • BPH, No tumor recurrent
• 2022-09-21 Tc-99m MDP whole body bone scan
  • Two new lesions of increased tracer uptake at the L4 spine and post. aspect of the left 6th rib, respectively compared with the previous study on 2021-11-22, the nature is to be determined (post-traumatic change or others ?), suggesting follow-up with bone scan in 3 months for further investigation.
  • Suspected benign lesions in the left high frontal region of skull, maxilla, mandible, L1-2 spines, bilateral shoulders, right S-I joint, hips, and left knee.
• 2022-01-03 Whole body PET scan
  • In comparison with the previous study on 2020-05-18, glucose hypermetabolism lesions in bilateral pulmonary hilar lymph nodes and bilateral mediastinal lymph nodes come to more evident, reactive change in response to locoregional inflammation, however, may show such a picture. Please correlate with clinical findings and keep follow up to exclude the possibility of malignancy involvement.
  • Glucose hypermetabolism lesions in bilateral lungs show no significant chnage, probably inflammation process.
  • Glucose hypermetabolism lesions in the left 4th and 5th ribs become more evident also, post-traumatic change or lymphoma with involvement of bone marrow may show such a picture, suggesting biopsy for investigation.
    
  • Glucose hypermetabolism lesions in the right inguinal lymph nodes, probably reactive nodes.
  • No abnormally increased FDG uptake is evidently delineated elsewhere.
• 2021-12-07 MRI - L-spine
  • Diffuse spinal metastases with mild ventral dural sac compression. Mild to moderate spinal canal stenoses.
• 2021-11-22 Tc-99m MDP whole body bone scan
  • A new lesion of increased tracer uptake at the L2 spine compared with the previous study on 2020-05-27, the nature is to be determined (post-traumatic change, new bone mets or others ?), suggesting follow-up with bone scan in 3 months for further investigation.
  • Suspected benign lesions in the left high frontal region of skull, maxilla, mandible, bilateral shoulders, right S-I joint, hips, and left knee.
• 2021-10-30 CT - chest
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Nodular lesions at both lungs up to 1.4cm at left upper lobe is found. In comparison with CT dated on 2021-07-02, the lesions are stationary.
      • No evidence of bilateral pleural effusion.
      • S/p port-A placement with its tip at Superior vena cava.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Visible abdomen:
      • There is stone at dependent portion of GB. GB stone(s) are noted.
      • The liver, spleen, pancreas, and adrenals are intact.
      • Atrophy of both kidneys are found.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Stationary nodular lesions at both lungs.
    • Bilateral renal atrophy.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
• 2021-07-02 CT - abdomen
  • Comparison: prior CT dated 2021/01/30.
    • Bilateral lung nodules (more at left side), staionary.
      • Fibrotic infiltrates in bilateral upper lung.
    • The spleen shows prominence in size (the greatest anterior-posterior dimention measuring about 12.2 cm in length).
    • A renal cyst measuring 2.6 cm in left upper pole is noted.
      • Atrophy of right kidney is noted that is c/w chronic renal disease.
    • There are two gallstones (< 1 cm).
    • Prior CT identified multiple osteoblastic bony metastases in the spine and pelvic bone are not noted. please correlate with clinical condition.
      • Compression fracture of L1 vertebral body. Spondylosis with scoliosis of the L-spine with convex to left side. Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
  • Impression:
    • Bilateral lung nodules (more at left side), staionary.
• 2021-01-30 CT - abdomen
  • Gallbladder stones.
  • Suspected left renal cyst, 2.7cm.
  • Relative atrophy of right kidney.
  • Enlarged prostate gland.
  • Persistent bilateral lung nodules.
  • Tree-in-bud infiltrates in right lower lung, could be due to inflammation.
• 2020-09-11 Uroflowmetry
  • Q max: low
• 2020-08-17 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (99.8 - 33.3) / 99.8 = 66.63%
    • M-mode (Teichholz) = 66.6
  • Adequate LV systolic function with no regional wall motion abnormality at resting state
  • Trivial tricuspid regurgitation
  • LV hypertrophy
  • Impaired LV relaxation
• 2020-06-17 bladder sonography
  • PVR 9.84 mL
• 2020-05-27 Tc-99m MDP whole body bone scan
  • All lesions are old and show stationary or less evident radioactivity compared with the previous study on 2019-08-14, indicating response to current therapy.
  • Suspected DJD at shoulders, and left knee.
• 2020-05-20 Uroflowmetry
  • Q max: low
  • flow pattern: obstructive
• 2020-05-18 PET
  • A mildly glucose-hypermetabolic nodule in upper lobe of left lung that had been stationary comparing with the previous study on 2019/03/20 and several previous CT scans of chest, an inflammatory lesion is likely. Please correlate with other imaging modalities and clinical findings and keep follow up for further evaluation.
  • Mild to moderate glucose hypermetabolism in bilateral pulmonary hilar lymph nodes and some mediastinal lymph nodes, reactive change in response to locoregional inflammation may show such a picture. Please correlate with clinical findings and keep follow up to exclude the possibility of malignancy involvement.
  • In comparison with the previous study, there were newly developed, mildly to moderately glucose-hypermetabolic lesions in posterior aspect of the left 4th and 5th ribs. Post-traumatic inflammatory changes are likely but possibility of malignancy involvement cannot be totally excluded. Please correlate with clinical findings and keep follow up for further evaluation.
  • Probably reactive change resulting from locoregional inflammation in right inguinal lymph nodes.
  • Probably post-traumatic inflammatory change in right femoral head.
  • Probably an inflammatory lesion in skin overlying right sacral region.
• 2018-09-26 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (83 - 23) / 83 = 72.29%
    • M-mode (Teichholz) = 72
  • Normal chamber size
  • Concentric LV hypertrophy
  • Adequate LV and RV performance
  • Possibly impaired LV relaxation
  • Mild MR, TR and PR
  • AV sclerosis with trivial AR
  • No regional wall motion abnormalities
• 2018-09-22 CT - abdomen
  • History and indication: AKI suspected obstrucitve uropathy
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • Non-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of urinary bladder.
    • A nodule (2.9cm) in left kidney r/o cyst. Right hydronephrosis. Left hydronephrosis and hydroureter. Some LNs at retroperitoneum and bil. pelvic cavity.
    • Tiny gall stones (2-4mm).
    • Normal appearance of liver, spleen, pancreas, adrenals.
    • Compression fracture of L1. Multiple bony metastases.
  • Impression:
    • Wall thickening of urinary bladder.
    • Right hydronephrosis. Left hydronephrosis and hydroureter. Some LNs at retroperitoneum and bil. pelvic cavity.
    • Multiple bony metastases.
    • Tiny gall stones (2-4mm).
• 2018-09-05 MRI - T-spine
  • benign subacute compression fracture in the L1 vertebral body
  • focal heterogeneous enhancement in the T12 and T9 vertebral bodies. Nature?
• 2018-08-16 CT - abdomen
  • Multiple bony metastases. Much regression of LAP. Suspected right renal metastases (2.0cm).
• 2018-05-07 Tc-99m MDP whole body bone scan
  • The old lesions in the skull, multiple C-, T- and L-spine, sternum, left scapula, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, bilateral S-I joints and left femur show less prominent compared with the previous study on 2018/01/05, indicating response to current therapy.
  • However, a new focal lesion in the mandible is noted, and the nature is to be determined (anti-tumor drug-related, dental problem or ther nature ?), suggesting further investigation.
• 2018-05-07 Surgical pathology Level IV
  • pathologic diagnosis
    • Kidney, right, CT guided needle biopsy —– Diffuse large B cell lymphoma
  • macroscopic description
    • Operation procedure: CT guided needle biopsy
    • Topology: Kidney, right
    • Specimen size and number: 2 cores, the longer one, 0.7 x 0.1 x 0.1 cm.
  • microscopic examination
    • 1.Histology type: B-cell neoplasms: Diffuse large B-cell lymphoma
    • Immunohistochemical stain profiles: IHC stain: CD3 (focal+), CD20 (diffuse +), B cell predominance. bcl-2 (+), bcl-6 (+), CD10 (equivocal), CK (-).
    • REFERENCE: C-myc(+, >90%) (S2017-8170) supporting double hit type.
• 2018-04-30 CT - abdomen
  • Multiple bony metastases. Multiple enlarged LNs (0.5-3.5cm) at paraarotic region. Suspected right renal metastases (6.6cm).
• 2018-01-05 Tc-99m MDP whole body bone scan
  • The scintigraphic findings suggest that multiple bone metastases. In comparison with the previous study on 20170323, some of the previous bone lesions in the sacrum and bilateral S-I joints are less evident. However, more bone lesions in the skull, some C- and T-spines, sternum, some ribs, left pubic bone and left femur are more prominent. Please correlate with other clinical findings for further evaluation.
• 2017-12-25 CT - abdomen
  • Multiple bony metastases. A tiny nodule (5mm) at LLL. Gall stones (5-6mm).
  • Enlargement of prostate.
• 2017-11-14 PET
  • In comparison with the previous study on 2017/04/26, the glucose hypermetabolism in right axillary lymph node is much less evident and no prominent FDG uptake is noted in other previous lymph node lesions.
    
  • The previous multiple FDG avid bone lesions are either less evident or disappeared.
• 2017-08-18 CT - abdomen
  • Malignancy lymphoma s/p treatment with regression of paraaortic lymph nodes.
  • Multiple bone metastsis.
  • GB stones.
  • Enlarged prostate gland.
• 2017-05-26 Surgical pathology Level IV
  • Indication: Malignant bladder neoplasm, part unspecified
  • Soft tissue, left neck, excision — Malignant B cell lymphoma, consistent with diffuse large B cell lymphoma
  • Microscopically, the sections show a picture of histiocytes-rich malignant B cell lymphoma consists of some large atypical lymphoid cells.
  • The Immunohistocehmcial study reveals CD3(-), CD20(+), CD10(+), Bcl-2 (+), C-myc(+, >90%), Bcl-6(+, focal), CD30(-), CD68(-) and CK(-).
  • According to the histopathologic findings, it is consistent with diffuse large B cell lymphoma, centroblastic type, and histiocyte-rich variant maybe considered.
• 2017-04-26 PET
  • Glucose hypermetabolic lesions in multiple sites throughout the axial skeleton, bilateral humeri, and bilateral femurs, suggesting multiple lesions of osseous metastasis. In comparison with the skeletal scintigraphy performed on 2017/03/23, the distribution of metastatic lesions in bones had extended to include the skull, both humeri, and both femurs. The finding suggested progression, and hence a very limited response to the previous treatment, of the malignancy. However, flair-up phenomenon sometimes occurs when PET/CT scan is performed too close to the last session of radiation therapy. It is suggested that PET/CT scan be arranged at least 6 weeks after the completion of radiation therapy.
  • Glucose hypermetabolic lymph nodes in bilateral inguinal regions, the right axillary region, bilateral infraclavicular and supraclavicular regions, and the left lower cervical region, suggesting metastases to both regional and distant lymph nodes.
  • Uroepithelial carcinoma of uncertain primary site, with multiple lesions of regional lymph node metastasis, distant lymph node metastasis, and bone metastasis, by this F-18-FDG PET/CT scan.
• 2017-03-31 CT - abdomen
  • Diffuse lymph nodes metastasis (paraaortic and pelvic cavity) and bone metastasis, bladder malignancy? Suggest PSA data correlation for possibility prostate malignancy.
  • Enlarged prostate gland.
  • Suspected liver cysts.
• 2017-03-23 Tc-99m MDP whole body bone scan
  • The scintigraphic findings suggest that multiple bone metastases should be considered. Please correlate with other clinical findings for further evaluation.
• 2017-03-15 MRI - L-spine
  • herniated discs in the L3/4 and L4/5 discs
  • tumors in the visible L-spine and T-spine, and pelvic bones
  • mild spondylolisthesis at L3-4

[MedRec]

[consultation]

• 2023-05-11 Infectious Disease
  • Q
    • The 76 y/o woman has relapse double hit diffuse large B-cell lymphoma with bone marow, right kidney, paraortic LNs and multiple bone involvement, Lugano stage IV will do the stem cell collaction.
    • Due to fever, we gave Tapimycin treatment, but watery diarrhea noted this morning, so we escalated to Doripenam treatment. Thanks!
  • A
    • WBC: 520, Fever: +
    • Agree with your use of Finibax.
    • Please collect B/C.
    • Protective isolation.
• 2021-12-21 Radiation Oncology
  • Q
    • The 74-year-old man patient had history of 1) Hypertension, Chronic renal injury 2) Urothelial carcinoma, high-grade on 2011-01-24. 3) Diffuse large B-cell lymphoma, stage IV with bone, bone marow involvement since 2017. Bone scan on 2021-11-22 showed a new lesion of increased tracer uptake at the L2.
    • This time, he has flank soreness progress and numbness of both leg for 1 month. L-spine MRI on 2021-12-07 revealed diffuse spinal metastases with mild ventral dural sac compression, mild to moderate spinal canal stenoses. We need your help for tissue proof. Thanks!
  • A
    • MRI show multiple thoracic and lumbar spinal metastases.
    • Biopsy can be done at L2, for further confirmation.

[chemoimmunotherapy]

• 2023-06-30 - busulfan 3.2mg/kg 190mg NS 400mL 3hr D1-3 + etoposide 400mg/m2 500mg NS 30mL 6hr D3-4 + cyclophosphamide 50mg/kg 2900mg NS 500mL 4hr D5-6 (BuCyE)
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + palonosetron 250ug D1 + granisetron 2mg D3-6 + aprepitant 125mg D5-7 + NS 250mL D1-6
• 2023-05-03 - etoposide 500mg/m2 600mg NS 30mL 2hr (20% off due to impaired renal function)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-29 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
• 2023-03-07 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
• 2023-02-10 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
• 2023-01-17 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
• 2023-01-03 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
• 2022-12-21 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
• 2022-12-07 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D1 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D1 (R-GemOx)
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + granisetron 2mg

Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients - 20230104 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients

• R-GemOx (Rituximab, gemcitabine, oxaliplatin)
  • Administration - R-GemOx includes rituximab (375 mg/m2 on day -1), gemcitabine (1000 mg/m2 on day 2), and oxaliplatin (100 mg/m2 on day 2).
  • Adverse effects - Severe hematologic toxicity occurs in half of patients and neuropathy can occur.
  • Outcomes - R-GemOx is associated with ORR in up to half of patients and CR in up to one-third of patients with r/r DLBCL.
    • Oxaliplatin has not been approved by the US Food and Drug Administration (FDA) for treatment of r/r DLBCL.

==========

2023-07-17

2023-07-16 (D9) WBC level has risen to 1.64K/uL, the recovery is obvious and the CMV viral load test showed that no virus was detected on 2017-07-17 (today). So far so good.

• 2023-07-16 WBC 1.64 x10^3/uL D9
• 2023-07-14 WBC 0.06 x10^3/uL D7
• 2023-07-13 WBC 0.03 x10^3/uL D6
• 2023-07-11 WBC 0.03 x10^3/uL D4
• 2023-07-09 WBC 0.07 x10^3/uL D2
• 2023-07-07 WBC 0.71 x10^3/uL D0
• 2023-07-05 WBC 3.07 x10^3/uL
  
• 2023-07-03 WBC 3.46 x10^3/uL
  
• 2023-06-25 WBC 5.39 x10^3/uL

After the transplant, the patient’s kidney function levels fluctuate up and down around the upper limits of the normal range. A slight elevation in serum Cre is observed on 2023-07-13 and is to be followed.

• 2023-07-13 Creatinine 1.39 mg/dL D6
• 2023-07-11 Creatinine 1.21 mg/dL D4
• 2023-07-09 Creatinine 1.22 mg/dL D2

The LFT results showed a monotonic increase in bilirubin levels after the transplant, as the enzyme levels started to fall, it might be sufficient to observe for a short time, if bilirubin still remains high, then action might need to be taken. Mycamine (micafungin) is associated with hyperbilirubinemia (UpToDate: <15%).

• 2023-07-13 Bilirubin total 2.51 mg/dL
  
• 2023-07-11 Bilirubin total 1.74 mg/dL
  
• 2023-07-09 Bilirubin total 1.34 mg/dL
  
• 2023-07-03 Bilirubin total 0.63 mg/dL
  
• 2023-07-13 Bilirubin direct 1.63 mg/dL
  
• 2023-07-11 Bilirubin direct 0.81 mg/dL
  
• 2023-07-09 Bilirubin direct 0.43 mg/dL
  
• 2023-07-03 Bilirubin direct 0.16 mg/dL
  
• 2023-07-13 S-GPT/ALT 43 U/L
  
• 2023-07-11 S-GPT/ALT 114 U/L
  
• 2023-07-09 S-GPT/ALT 174 U/L
  
• 2023-07-03 S-GPT/ALT 71 U/L
  
• 2023-07-13 S-GOT/AST 14 U/L
  
• 2023-07-11 S-GOT/AST 38 U/L
  
• 2023-07-09 S-GOT/AST 101 U/L
  
• 2023-07-03 S-GOT/AST 43 U/L

2023-07-10

[liver function]

It seems that the patient’s liver function has declined, as indicated by increased levels of ALT, AST, and bilirubin.

• 2023-07-09 S-GPT/ALT 174 U/L
  

• 2023-07-03 S-GPT/ALT 71 U/L
  

• 2023-06-25 S-GPT/ALT 50 U/L
  

• 2023-06-09 S-GPT/ALT 38 U/L
  

• 2023-06-02 S-GPT/ALT 29 U/L
  

• 2023-05-25 S-GPT/ALT 27 U/L

• 2023-07-09 S-GOT/AST 101 U/L
  

• 2023-07-03 S-GOT/AST 43 U/L
  

• 2023-06-25 S-GOT/AST 40 U/L
  

• 2023-06-09 S-GOT/AST 29 U/L
  

• 2023-06-02 S-GOT/AST 22 U/L

• 2023-07-09 Bilirubin direct 0.43 mg/dL
  

• 2023-07-03 Bilirubin direct 0.16 mg/dL
  

• 2023-06-25 Bilirubin direct 0.13 mg/dL

• 2023-07-09 Bilirubin total 1.34 mg/dL
  

• 2023-07-03 Bilirubin total 0.63 mg/dL

There are several drugs on the patient’s active list that could potentially contribute to the decline in liver function. These include:

• Tenofovir Alafenamide: This drug may cause an increase in serum alanine aminotransferase (grades 3/4: 8%) and serum aspartate aminotransferase (grades 3/4: 3%), impacting liver function.
• Fluconazole: Possible liver-related side effects include cholestatic hepatitis, hepatic failure, mixed hepatitis, hepatocellular hepatitis, hepatotoxicity, and increased serum transaminases.
• Benazepril: This medication may cause cholestatic hepatitis, increase liver enzymes, and increase serum bilirubin levels, which can affect liver function.
• Bisoprolol: Possible (< 1%) liver-related side effects of this medication include increased serum alanine aminotransferase and increased serum aspartate aminotransferase.

Given that another anti-HBV drug Baraclude (entecavir) can also lead to increased serum alanine aminotransferase levels (>5 x ULN: 11% to 12%; >10 x ULN and >2 x baseline: 2%), substituting tenofovir alafenamide with entecavir is not advised at present time. Similarly, another antifungal medication micafungin can lead to an increased serum alkaline phosphatase level (3% to 6%).

Considering the recent dosage increase of BaoGan (silymarin) on 2023-07-09 from 1# TID to 2# TID, rechecking the liver function tests in 2 days could be a practical strategy.

[renal function]

Aside from a slightly elevated BUN, decreasing serum creatinine and increasing eGFR suggest an improvement in the patient’s renal function. The CrCl has increased to 44 mL/min.

• 2023-07-09 Creatinine 1.22 mg/dL
  

• 2023-07-03 Creatinine 1.40 mg/dL
  

• 2023-06-25 Creatinine 1.76 mg/dL

• 2023-07-09 eGFR 61.38
  

• 2023-07-03 eGFR 52.37
  

• 2023-06-25 eGFR 40.21

• 2023-07-09 BUN 26 mg/dL
  

• 2023-07-03 BUN 28 mg/dL
  

• 2023-06-25 BUN 25 mg/dL

If the CrCl remains above 50 mL/min stably for several days and no further decline is expected, the dose of levofloxacin could optionally be increased to 750mg daily. In addition, the fluconazole dose could optionally be increased to 2# QD once it has been determined that it is not the cause of the deterioration in liver function.

2023-07-07

[myeloablative conditioning regimen effect follow-up]

The BuCyE regimen was initiated on 2023-06-30, and there is a notable reduction in WBC, HGB, and PLT levels, which indicates that the regimen is taking effect.

• 2023-07-07 WBC 0.71 x10^3/uL
  

• 2023-07-05 WBC 3.07 x10^3/uL
  

• 2023-07-03 WBC 3.46 x10^3/uL
  

• 2023-06-25 WBC 5.39 x10^3/uL

• 2023-07-07 HGB 9.3 g/dL
  

• 2023-07-05 HGB 11.6 g/dL
  

• 2023-07-03 HGB 12.1 g/dL

• 2023-07-07 PLT 33 x10^3/uL
  

• 2023-07-05 PLT 67 x10^3/uL
  

• 2023-07-03 PLT 80 x10^3/uL

2023-07-06

[renal function follow-up]

• Recent lab results show a decrease in serum Cre and an increase in eGFR, which suggests that kidney function seems to be improving. However, the simultaneous slight increase in BUN has resulted in a BUN-to-creatinine ratio of exactly 20. If the BUN-to-creatinine ratio continues to increase, it might indicate increased BUN reabsorption. This could potentially suggest dehydration or hypoperfusion.
  • 2023-07-03 Creatinine 1.40 mg/dL
    
  • 2023-06-25 Creatinine 1.76 mg/dL
    
  • 2023-07-03 eGFR 52.37
    
  • 2023-06-25 eGFR 40.21
    
  • 2023-07-03 BUN 28 mg/dL
    
  • 2023-06-25 BUN 25 mg/dL

[dosage reviewed for current renal function level]

• Flu-D (fluconazole 150mg) 1# QD has been prescribed. The recommended dose for prophylaxis against candidiasis in patients with hematologic malignancy or hematopoietic cell transplant (HCT) recipients who do not require mold-active prophylaxis is 400 mg orally once daily, with the duration being at least until resolution of neutropenia. However, given that this patient has kidney impairment with a CrCl of 38mL/min (as of 2023-07-03), a reduction of dose by 50% has been recommended. For the time being, no adjustment is necessary, nor is it needed for the current prescription of Cravit (levofloxacin 500mg) 1.5# QOD.
• No other drugs in the active medication list require dose adjustments either.

2023-06-28

[pharmacist shift handover to chemotherapy preparation room]

Stem Cell Infustion Date D0: 2023-07-07 (tentative)

Drug - Dose - Infusion - Frequency - Duration - Date busulfan - 3.2mg/kg - 3hr - QD - D-7 ~ D-5 - 2023-06-30 ~ 2023-07-02 etoposide - 400mg/m2 - 6hr - QD - D-5 ~ D-4 - 2023-07-02 ~ 2023-07-03 cyclophosphamide - 50mg/m2 - 4hr - QD - D-3 ~ D-2 - 2023-07-04 ~ 2023-07-05

2023-06-27

[Recommended Dose Adjustments for the BuCyE Conditioning Regimen and Associated Premedication]

• 2023-06-25 serum Cre 1.76mg/dL, age 76 => CrCl 30mL/min; height 162cm, weight 60kg => BMI 22.9kg/m2, BSA 1.64m2; 2023-06-25 S-GPT/ALT 50U/L, S-GOT/AST 40U/L, DBI/TBI 18.31%.

• For BuCyE conditioning regimen, dose adjustment recommendation for the scheduled ASCT in this impaired renal function patient

  • busulfan
    • no dosage adjustments provided in the manufacturer’s labeling
  • cyclophosphamide
    • CrCl ≥30 mL/minute: No dosage adjustment necessary.
    • CrCl 10 to 29 mL/minute: administer 75% of normal dose.
    • As the patient’s current CrCl is at the borderline of 30, it is recommended to start with 100% dose, while providing adequate hydration, and closely monitor kidney function to determine the direction of dose adjustment in the future.
    • mesna: there are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).
  • etoposide
    • CrCl 15 to 50 mL/minute: administer 75% of normal dose.

• For premedication

  • phenytoin
    • primarily metabolized by the liver to inactive metabolites with <5% of active drug excreted unchanged in the urine
    • no dosage adjustment necessary for any degree of kidney dysfunction
  • fluconazole
    • CrCl <= 50 mL/minute: reduce dose by 50%.
  • levofloxacin
    • CrCl 20 to <50: if usual recommended dose is 500 mg every 24 hours, 500 mg initial dose, then 250 mg every 24 hours
  • palonosetron
    • no dosage adjustment is necessary.
  • granisetron
    • no dosage adjustment necessary
  • betamethasone
    • no dosage adjustments provided in the manufacturer’s labeling
  • mannitol
    • contraindicated in severe renal impairment. Use caution in patients with underlying renal disease.

[Preparation and Administration of Mesna]

• Mesna can be prepared in either 0.9% normal saline (NS) or 5% dextrose in water (D5W).
• Given that the patient’s weight is 60kg, the planned dose of mesna is 12mg/kg. This translates to a total of 720mg of mesna to be dissolved in at least 50mL of the above-mentioned solvents, ensuring that the final concentration does not exceed 20mg/mL.
• For best administration results, it is advised that the injection be given over a duration of at least 30 minutes.

2023-06-26

• According to the PharmaCloud database, our hospital has been the sole provider for all the patient’s medical and pharmaceutical needs in recent months. Alongside treatment from the Hematology-Oncology department, the patient has received refills for Avodart (dutasteride) and Harnalidge (tamsulosin) from our urologist on 2023-06-12 and Concor (bisoprolol) and Amtrel (amlodipine, benazepril) from our cardiologist on 2023-06-06. These medications are included in the patient’s current active medication list. Consequently, there are no medication reconciliation issues identified.
• Based on serum creatinine levels, the patient’s renal function, as indicated by eGFR, has remained relatively stable over the past three years (eGFR between 40 and 50, most recent eGFR on 2023-06-25 was 40.21). This suggests that there is no significant long-term deterioration in renal function or drug-induced impairment. It’s recommended that the patient’s renal function continue to be monitored regularly, especially when new drugs with potential nephrotoxicity are added to the treatment plan. At this time, there is no need for renal function adjustments to current active medications.

2023-01-27

• Anti-HBc tested reactive in the lab on 2022-12-05; Vemlidy (tenofovir alafenamide) is administered appropriately.
• Additionally, Brosym (cefoperazone + sulbactam) was prescribed for the patient’s febrile neutropenia without an issue. ref: Efficacy and safety of cefoperazone-sulbactam in empiric therapy for febrile neutropenia: A systemic review and meta-analysis. Medicine (Baltimore). 2020;99(8):e19321. doi:10.1097/MD.0000000000019321
• As far as the active prescription is concerned, there is no problem.

2023-01-18

• The patient’s serum creatinine has shown a slow upward trend during the past month. R-GemOx, the regimen initiated since 2022-12-07, contains gemcitabine and oxaliplatin, which may cause this. Please continue to follow up as usual.
  • 2023-01-17 Creatinine 1.81 mg/dL
    
  • 2023-01-12 Creatinine 1.60 mg/dL
    
  • 2022-12-30 Creatinine 1.63 mg/dL
    
  • 2022-12-21 Creatinine 1.63 mg/dL
    
  • 2022-12-15 Creatinine 1.62 mg/dL
    
  • 2022-12-07 Creatinine 1.57 mg/dL
• There is a history of hypertension in the patient. During this hospitalization, the patient’s blood pressure appears to be well controlled according to the records of the vital sign panel.

701307426

230717

[past history]

• Nontuberculosis mycobacteria under Tx since 2021-09.
  • 2021-08-27 ~ 2022-03-10 - AKuriT-4 for TB

[lab data]

2023-06-28 HIV Ab-EIA Nonreactive
2023-06-28 Anti-HIV Value 0.09 S/CO
2023-06-26 MTBC PCR DETECTED CFU/ml
2023-06-26 MTBC PCR Value 10000 - 100000 CFU/ml

[exam findings]

• 2023-07-15 CXR
  • Ground glass opacities in bil. lungs.
• 2023-06-21 Patho - esophageal biopsy
  • Low esophagus, near stent proximal end, biopsy — Ulcer with atypical cells, favor reactive atypia
• 2023-06-21 Esophagogastroduodenoscopy, EGD
  • Esophageal fully-covered metallic stent at lower esophagus, across ECJ, without obvious tumor ingrowth
  • Esophageal lesion, near stent proximal end, r/o granulation tissue, s/p biopsy
  • Superficial gastritis, antrum
• 2023-06-17 CT - chest
  • Indication: Esophageal cancer for follow up
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Cystic Bronchiectatic change over right upper lobe and left upper lobe and tree in bud appearance at both lower lobes is found.
      • Left Pneumothorax without mediastinal shifting is noted.
      • s/p espohageal stent placement from middle to lower third esophagus. In comparison with CT dated on 2023-03-27, the condition is stationary.
      • Faint aveolar opacity over right lower lobe is found.
      • No evidence of bilateral pleural effusion.
      • S/p port-A placement with its tip at Superior vena cava.
      • Small lymph nodes are found at both sides of the mediatinum. In enlargement.
    • Visible abdomen:
      • S/P jejunaltube placement from LUQ.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • Increased intestinal gas is found.
      • The urinary bladder is well distended without soft tissue lesion.
      • There is no evidence of destructive bone lesion.
  • Imp:
    • Esophageal cancer s/p stenting with stationary esophageal condition but the mediastinal lymph nodes enlarged. Infected lymph nodes or metastatic lymph nodes should be further determined.
    • Bronchiectatic change and bronchiolitis at both lungs. The bronchiolitis progressed, probably due to repeated aspiration.
• 2023-05-31, -05-03, -04-24, -04-17, -04-10 CXR
  • S/P port-A implantation.
  • S/P esophageal stenting
  • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • Linear infiltration over both lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
  • Enlargement of cardiac silhouette.
• 2023-04-11 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Hiatal hernia
    • Reflux esophagitis,Gr A
    • C/w Esophageal malignant stricture,lower esophagus s/p SEMS
    • Superficial gastritis,antrum
    • Incomplete EGD examination
  • Suggestion
    • Medication and OPD f/u
    • EGD may be planned for Esophageal malignant stricture and Poor distension of stomach f/u later
• 2023-04-06 ECG
  • Sinus tachycardia
  • Right atrial enlargement
  • Right bundle branch block
  • Rightward axis
  • Abnormal ECG
• 2023-03-27 CT - chest
  • Indication: Esophageal cancer for F/U.
  • Comparison was made with previous CT dated on 2022/01/20
    • Lungs: abnormal consolidative opacities with reticular and nodular opacities, cavitary lesions of varying sizes, and bronchiectasis, at both upper lobes and patchy consolidations and reticular opacities at RLL, stationary as compared with previous CT 2022/12/09
    • Mediastinum and hila: s/p esophageal stenting from m/3 to L/3 with increased soft-tissue density in periesophageal fat space. enlarged LNs at Rt precarinal and A-P window regions. small pericardial effusion.
    • Pleura: small Rt pleural effusion.
    • Chest wall and visible lower neck: unremarkable..
    • Visible abdominal-pelvic contents: normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. s/p jejunostomy
    • Visualized bones: unremarkable.
  • Impression
    • esophageal cancer with regional LNs metastases, post stenting from m/3 to L/3, with periesophageal fat space inflammation.
    • RLL pneumonia or treatment related pneumonitis and both upper lobes TB, stable.
• 2023-01-06 CXR
  • S/P esophageal stenting
  • S/P port-A implantation.
  • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • Linear infiltration over right lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2022-12-19 ECG
  • Right bundle branch block
  • indeterminated axis
• 2022-12-19 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Esophageal malignant stricture s/p SEMS
    • Reflux esophagitis LA Classification grade A
  • Suggestion
    • NPO for 12 hours and start liquid food coming morning.
• 2022-12-09 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Cavitatory lesions at bilateral upper lobes and some irregular patches at right lower lobe is found. In comparison with CT dated on 2022-08-18, the lesions incresaed in size and numbers mostly at right lower lobe. Either progressoin of the meta or some new aspiration pneumonitis should be D.D.
      • Wall thickening at lower third esophagus and EG junction is found.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • s/p jejunostomy.
      • Minimal ascites is found.
  • IMp: Lower third esophageal cancer with bilateral lung meta. Increased nodularities at right lower lobe, either new meta or aspiration pneumonia should be D.D.
• 2022-11-30 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • C/W esophageal cancer, s/p CCRT, with scarring (32~36cm below incisor) and luminal stricture (36cm below incisor)
    • Incomplete study due to esophageal stricture
• 2022-11-04 Esophagography
  • Esophagraphy shows
    • Water soluble contrast medium was delivered from oral cavity.
    • Up to 90% stenosis at lower third esophagus is found. The contrast medium could only pass the narrowing lumen slowly.
    • The EG junction is intact.
  • Imp: Compatible with esophageal cancer at lower third with almost complete stenosis.
• 2022-08-18 CT - chest
  • Findings
    • Cavitatory lesions are found at bilateral upper lobes with solid nodularity. Metastatic leion is favored but aspiration is also possible (Less likely due to lobar consideration). In comparison with CT dated on 2022-05-10 and 2021-08-27, the lesions regressed partially.
    • Diffuse wall thickening from upper third esophagus into lower third. Esophageal cancer mixed with esophatitis is favored.
    • The pleural tagging at right lower lobe is still visualized.
  • Imp
    • Long segmental esophageal cancer with bilateal lung and right pleural mets, in regression.
• 2022-08-02 Patho - esophageal biopsy
  • Low esophagus, biopsy — Chronic inflammation with reactive atypia
    
  • Microscopically, the sections show a picture of chronic inflammation with some inflammatory cells infiltration, scant necrotic debris, focal crush artifact and focal mild enlarged nuclei of squamous epithelium, favor reactive atypia, Follow up.
• 2022-08-02 Esophagogastroduodenoscopy, EGD
  • Findings
    • Esophagus: A stricture was noted at 35 cm. The scope cannot advance over the lesion. Biopsy was done.
    • Stomach: Not check
    • Duodenum: Not check
  • Diagnosis
    • Esophageal stricture, low esophagus s/p biopsy
    • Incomplete study
• 2022-05-10 CT - lung/mediastinum/pleura
  • Finding
    • Lungs:
      • abnormal consolidative opacities with reticular and nodular opacities, cavitary lesions of varying sizes, and bronchiectasis, at both upper lobes. in regression as compared with previous CT exam.
    • Mediastinum and hila:
      • significant regression of a Long segmental circumferential wall thickening of the middle to lower third of the thoracic esophagus, with decreased luminal narrowing as compared with previous CT exam.
      • no enlarged LN.
    • Aorta: normal appearance of thoracic aorta and central pulmonary arteries: normal in caliber. Heart: normal in size of cardiac chambers.
    • Pleura: regression of Rt lower pleural metastasis with effusion as compared with previous CT exam.
    • Chest wall and visible lower neck: unremarkable..
    • Visible abdominal-pelvic contents:
      • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • no enlarged lymph node. s/p jejunostomy
    • Visualized bones: unremarkable.
  • Impression:
    • esophageal cancer with pleural and regional LNs metastases, post treatment, with significant regression of as compared with previous CT exam.
• 2022-02-10 Patho - esophageal biopsy
  • Esophagus, 30cm below incisors, biopsy — squamous cell carcinoma, moderately differentiated, at least.
  • The grade of tumor differentiation might be the same or might be upgraded when the entire tumor is resected for further pathological evaluation.
• 2022-01-20 Patho - esophageal biopsy
  • Labeled as ‘Esophagus, 30cm below incisors’, biopsy — squamous cell carcinoma.
  • IHC stain: p16(-).
• 2022-01-20 CT - lung/mediastinum/pleura
  • Esophageal cancer with lung mets.
  • Previous tubercuosis at bilateral apical lungs.
• 2022-01-20 Miniprobe endoscopic ultrasound
  • Advanced esophageal squamous cell carcinoma, at least T3N2Mx
• 2022-01-19 Whole body PET scan
  • A glucose hypermetabolic lesion in the middle to lower third esophagus, compatible with the primary esophageal cancer.
    
  • A glucose hypermetabolism in the gastrohepatic lymph node, reactive node or cancer with regional lymph node metastasis may show this picture, suggesting biopsy for further investigation.
    
  • Increased FDG uptake in the left pulmonary hilar region, left upper lung, left lower lung, and right upper lung, TB or cancer with both lungs metastases may show this picture.
  • Glucose hypermetabolic lesions in the right lower lung pleura, cancer with pleura metastases should be considered, suggesting biopsy for further investigation also.
    
  • Esophageal cancer, cT4aN0-1M0-1, c-stage III at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2022-01-18 Tc-99m MDP whole body bone scan
  • Increased activity in the lower C-spine. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
• 2022-01-07 Esophagogastroduodenoscopy, EGD
  • One lumen occupied mass lesion with friability was noted at 30cm below incisors. The scope cannot advance over the lesion.
  • Highly suspected esophageal cancer.
• 2021-08-27 CT - lung/mediastinum/pleura
  • Cavitatory lesion at left apical lung about 5.58cm and traction fibrotic mass at right upper lobe are found. Smaller nodules mixed with fibrotic change is found at bilateral upper lobes. Tuberculosis is more favored.

[MedRec]

• 2023-04-06 ~ 2023-04-29 POMR Hemato-Oncology
  • Discharge diagnosis
    • Esophageal cancer, MD squamous cell carcinoma with paraesophageal LAPs, lung, pleural metastasis, cT3N2M1, stage IV, jejunostomy and left Port-A implantation on 2022/01/21 and concurrent chemoradiotherapy and Chemotherapy with PF4 (CDDP 75mg/m2, 5FU 1000mg/m2 x 4 days) from 2022/02/01, regression, s/p Immunity therapy with Q2W OPDIVO (Nivolumab, 3mg/kg) from 2023/01/10.
    • Pneumonia, bilateral lung with 2023/04/17 sputum/C showed Pseudomonas aeruginosa
    • Acute kidney failure, unspecified
    • Chronic obstructive pulmonary disease, unspecified
    • Hypomagnesemia
    • Anemia due to antineoplastic chemotherapy
    • Gastro-esophageal reflux disease with esophagitis
  • CC: Severe cough for 3 days.

[consultation]

• 2022-01-21 hematology & oncology
  • A
    • O
      • CT show Esophageal cancer with lung meta.
      • Previous tubercuosis at bilateral apical lungs.
    • Impression:
      • Advanced esophageal middle third squamous cell carcinoma with lung meta, cT3N2M1
      • History of nontuberculosis mycobacteria under RINA
      • COPD
    • Suggestion
      • advanced or metastasis disease, systemic therapy is indicated. Ex: FLuorouracil (or capecitabine) with cisplatin (or oxaliplatin), or clinical trial
      • please check anti Hbc for HBV evaluation
• 2022-01-20 radiation oncology
  • A
    • Diagnosis: Esophageal cancer, L/3, MD SqCC with paraesophageal LAPs, lung, pleural metastasis, cT3N2M1, jejunostomy and left Port-A implantation (scheduled on 2022/01/21); nontuberculosis mycobacteria (NTM) under treatment; ECOG: 1.
    • Plan: Clinical trial may be considered if he fits the inclusion criteria. RT to esophageal tumor & LAPs for 5040cGy/28 fx is suggested for tumor control.

[surgical operation]

• 2022-01-25
  • Surgery
    • Bowel decompression and revision of jejunostomy
  • Finding
    • Detached peritonization of jejunum over superior direction with exposure of jejunostomy tube.
    • Mild edematous and dilated proximal jejunum without ischemia.
    • Total 4000ml of gastric juice drained by upper gastrointestinal endoscope.
    • Failure of nasogastric tube insertion.
    • Estimated blood loss: 20ml.
• 2022-01-21
  • Surgery
    • mini-laparoscopic feeding jejunostomy + port-A insertion
  • Finding
    • 8 Fr. port-A via left cephalic vein
    • 18 Fr. foley with balloon removal as jejunostomy tube
    • patent tube function during intra-operative feeding test

[radiotherapy]

• Plan: RT to lung metastasis for 4900cGy/14 fractions is suggested for tumor control. Diet education. RTC 9/15. (RTC = return to clinic)
• 2022-07-28 ~ 2022-08-15 - 4550cGy/13 fractions (6 MV photon) to RLL pleural tumors.
• 2022-04-13 ~ 2022-04-25 - 3150cGy/9 fractions (6 MV photon) to RML/RLL tumors (n=3)
• 2022-02-04 ~ 2022-03-16 - 5040cGy/28 fractions (15 MV photon) to esophageal tumor & LAPs

[chemotherapy]

• 2023-05-17 - fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4
  • dexamethasone 4mg + NS 250mL
• 2023-03-30 - carboplatin AUC 5 300mg NS 500mL 2hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, Q4W. in fact, there is no cisplatin this time)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-03-29 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
  • diphenhydramine 30mg + NS 250mL
• 2023-02-23 - carboplatin AUC 5 300mg NS 500mL 2hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, Q4W. in fact, there is no cisplatin this time)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-02-22 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
  • diphenhydramine 30mg + NS 250mL
• 2023-02-03 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
  • diphenhydramine 30mg + NS 250mL
• 2023-01-11 - cisplatin 75mg/m2 110mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-01-10 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
  • diphenhydramine 30mg + NS 250mL
• 2022-12-12 - cisplatin 75mg/m2 110mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-11-08 - cisplatin 75mg/m2 110mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-10-06 - cisplatin 75mg/m2 110mg NS 500mL 24hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-09-08 - cisplatin 75mg/m2 110mg NS 500mL 24hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-08-18 - cisplatin 75mg/m2 105mg 24hr D1 + fluorouracil 1000mg/m2 1450mg 24hr D1-4 (PF4)
• 2022-07-01 - cisplatin 75mg/m2 105mg 24hr D1 + fluorouracil 1000mg/m2 1420mg 24hr D1-4 (PF4)
• 2022-06-08 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1460mg 24hr D1-4 (PF4)
• 2022-05-10 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1460mg 24hr D1-4 (PF4)
• 2022-04-11 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1490mg 24hr D1-4 (PF4)
• 2022-03-14 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1490mg 24hr D1-4 (PF4)
• 2022-02-11 - cisplatin 75mg/m2 120mg 24hr D1 + fluorouracil 1000mg/m2 1600mg 24hr D1-4 (PF4)

==========

2023-07-17

[tube feeding]

For patients on tube feeding, Dexilant (dexlansoprazole 60mg/cap) can be administered by breaking the capsule open and pouring the small granules into an appropriate amount of drinking water. After mixing well, this prepared solution can be administered through the feeding tube. Note that these granules should not be crushed or chewed, and the prepared solution should be used immediately after it’s prepared.

[reconciliation]

According to the PharmaCloud database, it appears that the patient has only been receiving medical care at our hospital for the past three months. No discrepancies or issues were identified during the medication reconciliation process for this patient during his current admission.

[assessment]

It appears that the patient’s renal function deteriorated last weekend. 2023-07-15 CXR showed ground-glass opacities in both lungs. CRP 13.8 mg/dL. There is a high incidence of AKI in patients hospitalized for CAP. It is advisable to be alert for the prevention and early detection of AKI in CAP patients. ref: Incidence and Risk Factors of Acute Kidney Injury in Patients Hospitalized with Pneumonia: A Prospective Observational Study. Med J Islam Repub Iran. 2021;35:150. Published 2021 Nov 10. doi:10.47176/mjiri.35.150

• 2023-07-15 Creatinine 1.76 mg/dL
  

• 2023-07-06 Creatinine 1.08 mg/dL
  

• 2023-07-03 Creatinine 1.05 mg/dL

• 2023-07-15 eGFR 43.10
  

• 2023-07-06 eGFR 75.73
  

• 2023-07-03 eGFR 78.23

The current dosage of Tapimycin (peperacillin 4g, tazobactam 0.5g) at 4.5g Q8H is still within a reasonable range, considering the patient’s current renal function.

2023-06-16

• In patients who are on tube feeding, Dexilant (dexlansoprazole 60mg/cap) can be administered by breaking open the capsule and pouring the tiny granules into an appropriate amount of drinking water. After mixing well, this prepared solution can be delivered via the feeding tube. Do bear in mind that these granules shouldn’t be crushed or chewed, and the prepared solution must be used right after its preparation.

• From 2023-03-28 to 2023-06-16, the patient has experienced significant weight loss, dropping from 53.1kg to 41.6kg. This indicates a loss of over 10kg within a span of approximately 2.5 months. A consultation with a dietitian took place on 2023-05-19. However, cachexia remains a current health issue for this patient. The patient is currently on tube feeding and is also taking the progesterone analogue megestrol without an issue. Glucocorticoids could potentially improve the patient’s appetite to a similar extent as the progesterone analogues. However, considering the potential for toxicities and decreased effectiveness with prolonged use, the application of glucocorticoids as an appetite stimulant is typically reserved for individuals with an estimated life expectancy ranging from a few weeks to a couple of months. Consequently, the use of glucocorticoids is not advised at this time.

• The patient’s renal function markers continue to be elevated, so hydration has been administered (NS 500mL Q8H currently). The TPR panel reveals that the patient was experiencing tachycardia (122/min), tachypnea (21/min), and potentially inadequate SpO2 (92%), alongside a relatively low blood pressure reading (81/52 mmHg). Close monitoring is necessary in this case.

  • 2023-06-16 Creatinine 1.44 mg/dL
    
  • 2023-05-31 Creatinine 1.45 mg/dL
    
  • 2023-05-16 Creatinine 1.58 mg/dL
    
  • 2023-05-03 Creatinine 1.82 mg/dL
    
  • 2023-06-16 BUN 42 mg/dL
    
  • 2023-05-31 BUN 35 mg/dL
    
  • 2023-05-16 BUN 33 mg/dL
    
  • 2023-05-03 BUN 17 mg/dL

2023-05-17

• For tube feeding, Dexilant (dexlansoprazole 60 mg/cap) may be administered by opening the capsule and emptying the small granules into adequate drinking water to complete the preparation.

2022-09-12

• The current regimen is still effective, as evidenced by recent CT scans on (2022-08-27, 2022-08-18, 2022-05-10) showing partially regression, however this does not square with the elevated SCC and CEA levels on 2022-09-09.
• There is a low body mass index (BMI) of 16 in the patient (based on a height of 167 cm and weight of 45 kg on 2022-09-08), suggesting an increase in food intake is necessary.
• Patients with malnutrition (~low body mass index), cirrhosis, diarrhea, or long-term diuretic use are more likely to suffer from hypomagnesemia (1.6mg/dL 2022-09-08). Magnesium supplements might be beneficial.
• There is a gradual decrease in HGB levels (12.7 g/dL 2021-08-27 to 8.3 g/dL 2022-09-08), which should be noted and monitored regularly to determine if an intervention is necessary.

2022-06-09

• Current regimen is effective. CT (2022-05-10) showed esophageal cancer with pleural and regional LNs metastases, post treatment, with significant regression of as compared with previous CT on 2022-01-20.
• Lab data on 2022-06-07 indicated low K (3.1 mmol/L) and low Mg (1.7 mg/dL) have been treated with Radi-K (potassium gluconate) tablets and magnesium sulfate injections.
• As the patient has a low BMI of 15 (based on BH 165 cm and BW 43.3 kg, 2022-06-08), an increase in food intake may be beneficial.
• Trend of HGB is decreasing gradually (12.7 g/dL 2021-08-27 -> 9.5 g/dL 2022-06-07) which should be noted and regularly observed.
• All the oral drugs in active prescription can be administered with nasogastric tube.
• No issue with current medication.

2022-04-12

• An economically not advantaged divorced man living with his school-age daughters has recently learned that he has an advanced esophageal squamous cell carcinoma and is undergoing 5-Fu + cisplatin since early February 2022.
• According to the most recent lab results reported on 2022-04-07, liver and kidney function were normal and there were no obvious abnormalities with CBC and WBC readings.
• Trastuzumab might be added to first-line chemotherapy for HER2 overexpression positive adenocarcinoma (HER2 testing result not found yet).
• Oxaliplatin is generally preferred over cisplatin due to lower toxicity.
  • Oxaliplatin-based regimen is superior to cisplatin-based regimen in tumour remission as first-line chemotherapy for advanced GC, and is associated with less toxicity and better tolerability.
    • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6547983/
  • A comparative analysis of the mutagenicity of platinum-containing chemotherapeutic agents reveals direct and indirect mutagenic mechanisms.
    • https://pubmed.ncbi.nlm.nih.gov/33502495/

2022-04-11

[tube feeding]

• Broen-C (bromelain, L-cysteine) enteric coated tablets should not be ground for tube feeding, acetylcysteine is available to act as an alternative.

701463845

230717

[exam findings]

• 2023-04-29 CT - brain
  • Indication: Traumatic SAH.
  • Without-contrast CT of brain shows:
    • SAH in bilateral frontal and temporal regions, in regression.
    • Prominent sulci, fissures, and cisterns. Dilatation of the ventricles.
    • No midline shift.
    • Left occipital skull linear fracture.
    • Left occipital scalp swelling.
  • Impression
    • Traumatic SAH, in regression
• 2023-04-26 CTA - brain (head, neck)
  • With and without-contrast axial brain CT revealed:
    • Bil. SAH. Swelling of left parietal and occipital scalp.
    • No midline shift.
    • Intact bony structures.
    • Widening of cortical sulci and dilatation of ventricles.
    • No abnormal intracranial enhancement.
  • IMP:
    • Bil. SAH. Swelling of left parietal and occipital scalp.
• 2023-04-26 CT - brain
  • Non-contrast brain CT revealed:
    • Bil. SAH. Swelling of left parietal and occipital scalp.
    • No midline shift.
    • Degeneration and spondylosis of C-spine.
    • Widening of cortical sulci and dilatation of ventricles.
  • IMP:
    • Bil. SAH. Swelling of left parietal and occipital scalp.
• 2023-04-26 Sacrum & Coccyx
  • Minimal fracture of coccyx.
  • S/P left side double J catheter insertion.
• 2023-04-21 PET scan
  • A glucose hypermetabolic lesion in the upper lobe of right lung. A metastatic lesion should be watched out.
  • Mild glucose hypermetabolism in a focal area in the lower lobe of right lung. Post-operative inflammation is more likely. However, please correlate with other clinical findings for further evaluation and to rule out the possibility of recurrent tumor of low FDG uptake.
  • Glucose hypermetabolism in a focal area in the midline anterior lower abdominal wall. The nature is to be determined (post-operative inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
  • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
• 2023-04-08 CT - abdomen
  • Clinical history: 70 y/o female patient with alignant neoplasm of sigmoid colon sigmoid cancer s/p OP and C/T
  • With and without contrast enhancement CT of abdomen–whole:
    • S/P double J catheter drainage, left side. Relative atrophy of left kidney.
    • Bilateral renal cysts, up to 3cm in right kidney.
    • Cystic lesion, 0.8cm in pancreatic body.
    • Soft tissue, 1.3cm in RLL around prior surgical clips. Recurrent tumor?
  • Impression:
    • Post-op at the colon.
    • S/P double J catheter in left kidney, relative atrophy of left kidney.
    • Bilateral renal cysts.
    • Pancreatic body cystic nodule, 0.8cm, suggest follow up.
    • Soft tissue, 1.3cm in RLL around prior surgical clips. Recurrent tumor?
• 2023-01-16 Tc-99m MDP bone scan
  • A hot spot in the lateral aspect of the right 10th rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the maxilla, some C-, T- and L-spine, bilateral sternoclavicular junction, shoulders, S-I joints, and hips.
• 2023-01-13, -01-12 CXR
  • Spondylosis with scoliosis of the T-spine with convex to right side
  • Borderline cardiomegaly
• 2022-12-21 All-RAS + BRAF
  • Cell block No: S2022-22267 A4
  • RESULTS：
    • All-RAS: There was no variant detect in the KRAS/NRAS gene.
    • BRAF: There was no variant detect in the BRAF gene.
• 2022-12-13 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, sigmoid colon, sigmoid colectomy —- Adenocarcinoma, moderately differentiated
      
    • Resection margins: free
      
    • Lymph node, mesocolic, dissection —- Negative for malignacny (0/40)
    • Lymph node, IMA / SMA, dissection —- Not received
    • AJCC 8th edition Pathology stage: pStage IIA, pT3N0(if cM0)
  • Gross Description:
    • Operation procedure: sigmoid colectomy
    • Specimen site: sigmoid colon
      
    • Specimen size: 10.7 cm in length
      
    • Tumor size: 5.2 x 4.1 x 1.5 cm
    • Tumor location: 4.5 cm and 2.1 cm away from the two resection margins, respectively
      
    • Depth of invasion grossly: mesocolic soft tissue
    • Mucosa elsewhere: congestion
    • Macroscopic Tumor Perforation: Not identified
    • Sections are taken and labeled as: A1: colon, non-tumor; A2-5: tumor; A6-12: lymph node, mesocolic; B: proximal cutend; C: distal cutend.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma with marked acute suppurative inflammation
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Uninvolved; Distance of tumor from margin: 5 mm
        
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Not identified
    • Tumor Budding: Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: tubulovillous adenoma
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes: 0/40
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
        • Distant Metastasis (pM): if cM0
    • Additional Pathologic Findings (select all that apply):
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2022-12-13 Patho - lung wedge biopsy
  • PATHOLOGIC DIAGNOSIS:
    • Lung, right, lower lobe, wedge resection —- Atypical carcinoid tumor
    • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/3)
    • AJCC 8th edition pTNM Pathology stage: pStage IA1, pT1aN0(if cM0)
  • MACROSCOPIC EXAMINATION:
    • Specimen:
      • Lung, size: 5.5 x 3.0 x 1.2 cm; 8g
      • Lymph nodes, a bottle, group 9; maximal size: 0.2 x 0.1 x 0.1 cm
    • Tumor Site: Periphery
    • Tumor Size: Solitary: 1.0 x 0.9 x 0.8 cm
    • Gross tumor patterns: poorly defined, Pleural retraction
      
    • Tissue for sections: A1: resection margin; A2 and A4: lung, non-tumor; A3: tumor; B: lymph node, group 9.
  • Microscopic Description
    • Tumor Focality: Single tumor
    • Histologic Type (select all that apply): Atypical carcinoid tumor; The immunohistochemical stains reveal CK(+), TTF-1(+), CD56(+), and Synaptophysin(+). The Ki-67 is about 4%. The Congo red special stain is negative.
      
    • Histologic Grade: G1: Well differentiated
    • Spread Through Air Spaces (STAS): Not identified
    • Visceral Pleura Invasion: Not identified
    • Lymphovascular Invasion (select all that apply): Not identified
    • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 1.2 cm
      • Specify closest margin: resection margin
    • Treatment Effect: No known presurgical therapy
    • Regional Lymph Nodes: group 9: 0/3
    • Extranodal Extension: Not identified
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pT1a: Tumor ≤1 cm or less in greatest dimension;
        • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
    • Additional Pathologic Findings (select all that apply): None identified
• 2022-12-09 CT - abdomen
  • History: 20221208 colonoscopy: Colon cancer at 30 cm from AV with nearly total obstruction, biopsy was done. Tattooing was performed.
  • Indication: sigmoid colon cancer, CT staging
  • Findings:
    • There is segmental asymmetrical wall thickening of the sigmoid colon with medial exophytic growing, measuring 7 cm in length that is c/w adenocarcinoma.
      • The left side obliterated umbilical artery shows increasing thickness that may be tumor invasion? (T4b).
      • In addition, The fat plane between sigmoid tumor and left fallopian tube shows obliteration that also may be tumor invasion.
    • There are at least 10 enlarged nodes in the adjacent mesocolon that are c/w metastatic nodes (N2b).
    • There is a soft tissue nodule in RLL of the lung, measuring 0.8 cm in size at lung window setting.
      • Lung metastasis (M1a) is highly suspected.
    • There is a cystic lesion 1 cm in the pancreatic body.
      • Simple cyst or macrocystic adenoma is highly suspected.
    • There are several renal cysts on both kidney and the largest one measuring 3.3 cm in size at right middle pole.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b (T_value) N:N2b (N_value) M:M1a (M_value) STAGE:IVA(Stage_value)
• 2022-12-09 Flow Volume Loop Chart
  • Mild restrictive ventilatory impairment
• 2022-12-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (118 - 33) / 118 = 72.03%
    • M-mode (Teichholz) = 72
  • Conclusion:.
    • Normal chamber size
    • Thickening of IVS and LVPW
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Calcified mitral annulus with mild MR, mild TR and PR
    • No regional wall motion abnormalities

[MedRec]

• 2023-04-26 ~ 2023-04-29 POMR Neurosurgery

  • Discharge diagnosis
    • Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial encounter
    • Unspecified fracture of skull, initial encounter for closed fracture
    • Essential (primary) hypertension
    • Type 2 diabetes mellitus without complications
    • Malignant neoplasm of sigmoid colon
    • Malignant neoplasm of lower lobe, right bronchus or lung
  • CC
    • collapse, fall down then head injury on 2023/04/25 23:30
  • Present illness
    • This is 70 years old female who sufferred from collapse, fall down then head injury on 2023/04/25 23:30. She was brought to our emergency room for help. At emergency room, dizziness and right lower limbs weakness were noted. Swelling of left parietal and occipital scalp. Follow brain CT showed bilateral traumatic subarachnoid hemorrhage. Swelling of left parietal and occipital scalp. Follow brain computed tomography angiography showed non-specific.
    • Anticonvulsants with keppra use for seizure prevent, hemostatic agent with transamin 1000mg q8h and famotidine 20mg q12h IVD for stress ulcer prevention were given. After neurosurgeon consulted who suggested arrange admission and monitor neurological condition.
  • Course of inpatient treatment
    • After admission, anticonvulsants with keppra use for seizure prevent. Analgesic agents with acetaminophen 1tab qid for pain control. Hemostatic agent with transamin 1000mg q8h. Local ice packing of occipital lobe. Repeat brain CT showed traumatic subarachnoid hemorrhage was in regression. Under her stable condition, she was discharged and outpatient follow-up was mandatory.
  • Discharge prescription
    • Acetal (acetaminophen 500mg) 1# PRNQ12H
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
    • Keppra (levetiracetam 500mg) 1# BID
    • Neurontin (gabapentin 100mg) 1# HS
    • Norvasc (amlodipine 5mg) 1# BID
    • Trynol (amitriptyline 25mg) 1# QN
    • Tulip (atorvastatin 20mg) 1# QN
    • Canaglu (canagliflozin 100mg) 1# QDAC
    • Relinide (repaglinide 1mg) 1# TIDAC15
    • Trajenta (linagliptin 5mg) 1# QD
    • Uformin (metformin 500mg) 1# TIDCC

• 2023-04-18 SOAP Hemato-Oncology

  • P: Arrange Lung/Abd/Pelvis CT Q3M, next on 2023-07-03.

• 2023-04-11 ~ 2023-04-14 POMR Metabolism and Endocrinology (not completed)

• 2023-02-15 SOAP Hemato-Oncology

  • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2022-12-27
    • High risk stage II, post-op Adjuvant Chemotherapy。

• 2022-12-20 SOAP Hemato-Oncology

  • A/P
    • Lab: HBV, HCV, Tumor markers (CEA, CA199)
    • Admission for Lab tests (CBC/DC, biocemistry), Port-A insertion by Chief Hsieh, and C/T with FOLFOX on 2023-01-10
    • Treatment: FOLFOX x 12 courses

[surgical operation]

• 2022-12-12
  • Surgery
    • 3D VATS RLL wedge + LN dissection.
  • Finding
    • One nodular lesion was noted over RLL, size about 0.6cm in diameter.
    • One 20 Fr. straight chest tube was inserted via right 7th ICS.
• 2022-12-12
  • Surgery
    • Sigmoid colectomy        
  • Finding
    • Sigmoid cancer about 7x6x5 cm , nearly total obstruction with left side abdominal wall, peritoneum involved, Mesentaric lymph nodes enlargement also noted
  • Procedure
    • Patient was placed in the modified lithotomy position.
    • The abdomen was prepared and draped in the standard fashion to provide wide exposure.
    • The patient was placed in a steep Trendelenburg position, the surgeon stands on the left side of the patient.
    • Midline incision was made. Dissection and division begin from the left lateral attachment of the sigmoid and identification of left ureter.
    • After the inferior mesenteric vessels have been divided and ligated, the mesenteric vessels & marginal artery were ligated . Left colon is transected using linear stapler.
    • The dissection moves first to the right and then to the left of the rectum, the rectosigmoid is pulled up and rectal washing was done using the B-I solution . Rectosigmoid was transected by TA-linear stapler. Then the specimen was removed.
    • End-to-end anastomosis using double stapled method , air tight was tested and anastomosis was rechecked using rigid proctoscope; Tissel 4ml apply on the anastomosis.
    • Check bleeders and clean the abdominal cavity using warm saline
    • Close the wound in layers
• 2022-12-12
  • Surgery
    • Left DBJ insertion     
  • Finding
    • smooth bladder mucosa
    • bilateral U/O (+)

[chemotherapy]

• 2023-07-03 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL

• 2023-05-23 - FOLFOX @ Thailand

• 2023-05-09 - FOLFOX @ Thailand

• 2023-04-25 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL

• 2023-03-28 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL

• 2023-03-14 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL

• 2023-03-01 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL

• 2023-02-15 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-01-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-01-16 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-07-17

[reconciliation]

• The patient is not from the local area, so no records are available in the PharmaCloud database.

• On 2023-05-03, our endocrinologist prescribed Canaglu (canagliflozin), Trajenta (linagliptin), Uformin (metformin), and Kludone (gliclazide). On the same day, our neurosurgeon prescribed Keppra (levetiracetam), Neurontin (gabapentin), Norvasc (amlodipine), and Tulip (atorvastatin). These prescriptions, which are valid for 70 days, were added to the patient’s current medication list with no discrepancies identified during medication reconciliation.

[assessment]

A recent lab reading taken on 2023-07-11 revealed a significantly elevated serum glucose level of 253mg/dL, despite the administration of four antiglucemic agents - Canaglu (canagliflozin), Trajenta (linagliptin), Uformin (metformin), and Kludone (gliclazide). It would be advisable to ensure regular monitoring of the patient’s blood sugar levels, and these readings should be displayed in the TPR panel.

2023-07-03

[reconciliation]

• The patient is a non-native individual, therefore no records are accessible from the PharmaCloud database.
• On 2023-05-03, our endocrinologist prescribed Canaglu (canagliflozin 100mg) 1# QDAC, Trajenta (linagliptin 5mg) 1# QD, Uformin (metformin 500mg) 1# TIDCC, Kludone (gliclazide 60mg) 1# BID. On the same day, our neurosurgeon prescribed Keppra (levetiracetam 500mg) 1# BID, Neurontin (gabapentin 100mg) 1# HS, Norvasc (amlodipine 5mg) 1# BID, Tulip (atorvastatin 20mg) 1# QN. These prescriptions, valid for 70 days, were added to the patient’s active medication list with no reconciliation discrepancies noted.

[bedside visit, patient education]

• I visited the patient at about 15:00 on 2023-07-03. Two of the patient’s relatives (?) were also present in the room - a man lying on the bench by the window and a woman sitting on a chair. I asked the patient how she was feeling today, and she replied that she was generally well and didn’t have any particular complaints. During my visit, I observed that the patient was in a fairly good state of mind and did not appear to be too tired to respond.
• As the patient has already received several doses of the FOLFOX regimen, including the continuation of the same treatment when she returned to Thailand in May 2023, she was not entirely unfamiliar with this regimen. I provided her with information sheets on the use of oxaliplatin and fluorouracil, highlighting the key points for her to be aware of, and also left the contact details of the pharmacology department’s drug counseling service for her to use if needed.

701469090

230717

[exam findings]

• 2023-06-29 Patho - bone marrow biopsy
  • Bone marrow, clinical history of leukemia s/p chemotherapy, iliac, biopsy — acute myelogenous leukemia.
  • Section shows piece(s) of bone marrow with 80% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with many immature leukocytes. Megakaryocytes are adequate in number.
  • IHC stains: CD117: 10-15%; CD34: 5-10 %; MPO: 80%, CD61: 5 %; CD71: 10% (of the nucleated cells).
• 2023-05-04 Abdomen - standing (diaphragm)
  • Spondylosis with scoliosis of the L-spine with convex to right side
• 2023-02-20 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Acute myeloid leukemia (AML)
  • The sections show hypocellular marrow (10%). Focal reduced fat cells with accumulation of extracellular gelatinous substances, decrease in trilinage hematopoietic cells including megakaryocyts, CD71+ erythroid precursors and MPO+ myeloid cells, scattered CD138+ mature plasma cells, fibroblastic proliferation, vascular dilatation, and stromal edematous change are present. Residual CD34-/CD117+ blasts, account for 20% of nuclear cells can be found. Suggest bone marrow smear evaluation and clinic correlation.
• 2023-02-20 KUB
  • Spondylosis with scoliosis of the L-spine with convex to right side
  • Non-specific bowel gas pattern in the middle abdomen is noted. please correlate with clinical condition. Follow up is indicated.
  • Ascites is highly suspected. Please correlate with sonography.
• 2023-02-08 Abdomen - standing (diaphragm)
  • Spondylosis with scoliosis of the T-spine with convex to right side
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon at left lateral aspect of L3-4.
  • Disk space narrowing and Marginal osteophyte formation of L5-S1.
• 2023-01-30 Patho - bone marrow biopsy
  • Bone marrow, biopsy — acute myeloid leukemia (AML)
  • NOTE: Correlation of peripheral blood, bone marrow smear, flow cytometry, molecular genetic study and clinical feature is recommended.
  • Microscopically, it shows hypercellularity (90%) with proliferation of myeloblasts hightlighted by CD117 (> 90%).
  • Immunohisotchemical stain reveals CD34(-), CD20 (focal+), CD138 (-), MPO(+), CD71(focal+), TdT(-).

[consultation]

• 2023-02-25 Infectious Disease
  • Q
    • The 59 y/o woman has APL post chemotherapy least 2023/02/12. Due to intermittent fever without bacteremia from culture, so we need your help for management. Thanks
  • A
    • intermittent fever still noted despite Mepem, vancomycin, and Mycamine use.
    • No significant culture report available.
    • CxR clear lungs that urinalysis showed mild bacteriuria without pyuria.
    • There are diffuse skin lesions over trunk and lower limbs, etiology uncertain, which should be related to fever.
    • Suggestion:
      • check HSV and VZV viral load
      • check CMV viral load
      • continue the present antibiotic regimen
      • empirical iv steroid can be tried.
• 2023-02-23 Dermatology
  • Q
    • for suspect Herpes Zoster at bilateral waist, and skin rash at bilateral groin, the painful, skin rash at perineum
    • The 59 y/o woman dosen’t have any history.
    • This time, she sufferes from hand, back ecchymosis and both leg petechia, so she sent to Cardinal Tien Hospital. LRP transfusion for thrombocytopenia 16000/uL on 2023/01/20. Due to elevated blast and suspect leukemia, so she transfered to our ED for help. Her BW loss 5 kg around 1 year. Got fatigue noted after postive of COVID (2022-09). At ED, the lab data showed WBC 8170/uL, Hb 10.0 g/dL, PL 44 *10^3/uL, Blast 58%. Under the impression of APL, so she was admitted.
    • chemotherapy with (3+7) Idarubicin/Cytarabine on 2023/02/06 ~ 2023/02/12
    • This time, suspect Herpes Zoster at bilateral waist, and skin rash at bilateral groin, the painful, skin rash at perineum , so we need your help, thanks a lot!!
  • A
    • The patient had sufferred from diffuse non-blanchable erythema lesions over trunk and lower legs.
    • Under the impression of thrombopenia purpura with fine vesicle/bullae formation r/o allergic purpura.
    • The following sugeetion:
      • exclude herpes zoster infection episode currently.
      • correct patient underlying state as your experist.
        • for fine vesicle or bullae, Betason-N onit 2 tube topical bid use.
        • for itchy skin lesions, Mycomb cream 1 tube topical bid use.
      • enhance skin mositurization, Sinphraderm cream 1 tube QN use over fine scales/xerotic area after body clean.

[chemotherapy]

• 2023-06-05 - cytarabine 1500mg/m2 2400mg NS 500mL 3hr Q12H D1-3 (HD Ara-C, Q4W)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D1-3 + NS 250mL D1-3
• 2023-04-28 - cytarabine 1500mg/m2 2400mg NS 500mL 3hr Q12H D1-3 (HD Ara-C, Q4W)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D1-3 + NS 250mL D1-3
• 2023-03-23 - cytarabine 1500mg/m2 2400mg NS 500mL 3hr Q12H D1-3 (HD Ara-C, Q4W)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D1-3 + NS 250mL D1-3
• 2023-02-06 - idarubicin 10mg/m2 16mg NS 100mL D1-3 + cytarabine 100mg/m2 165mg NS 500mL D1-7 (3+7 idarubicin/cytarabine, Q4W)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + palonosetron 250ug D1 + granisetron 2mg D2-3 + NS 250mL D1-3

G-CSF (filgrastim) 150ug

• 2023-03-27 ~ 2023-04-05 (prior C/T on 2023-03-23)
• 2023-02-15 ~ 2023-03-02 (prior C/T on 2023-02-06)

WBC

• 2023-05-02 WBC 2.79 x10^3/uL
• 2023-04-28 WBC 3.57 x10^3/uL 2023-04-28 C/T
• 2023-04-19 WBC 4.14 x10^3/uL
• 2023-04-10 WBC 2.54 x10^3/uL
• 2023-04-08 WBC 4.58 x10^3/uL
• 2023-04-06 WBC 13.57 x10^3/uL
• 2023-04-04 WBC 0.85 x10^3/uL
• 2023-04-02 WBC 0.21 x10^3/uL
• 2023-03-31 WBC 0.56 x10^3/uL
• 2023-03-29 WBC 7.65 x10^3/uL
• 2023-03-27 WBC 2.22 x10^3/uL
• 2023-03-25 WBC 3.79 x10^3/uL 2023-03-23 C/T
• 2023-03-22 WBC 3.84 x10^3/uL
• 2023-03-15 WBC 4.14 x10^3/uL
• 2023-03-08 WBC 1.35 x10^3/uL
• 2023-03-06 WBC 1.76 x10^3/uL
• 2023-03-04 WBC 2.72 x10^3/uL
• 2023-03-02 WBC 3.18 x10^3/uL
• 2023-02-28 WBC 0.91 x10^3/uL
• 2023-02-26 WBC 0.29 x10^3/uL
• 2023-02-24 WBC 0.23 x10^3/uL
• 2023-02-22 WBC 0.21 x10^3/uL
• 2023-02-20 WBC 0.26 x10^3/uL
• 2023-02-18 WBC 0.26 x10^3/uL
• 2023-02-16 WBC 0.25 x10^3/uL
• 2023-02-14 WBC 0.19 x10^3/uL
• 2023-02-12 WBC 0.24 x10^3/uL
• 2023-02-10 WBC 0.53 x10^3/uL
• 2023-02-08 WBC 1.44 x10^3/uL
• 2023-02-06 WBC 8.30 x10^3/uL 2023-02-06 C/T
• 2023-02-04 WBC 7.75 x10^3/uL
• 2023-02-03 WBC 7.53 x10^3/uL
• 2023-02-01 WBC 8.69 x10^3/uL
• 2023-01-30 WBC 11.71 x10^3/uL
• 2023-01-30 WBC 10.55 x10^3/uL
• 2023-01-28 WBC 7.74 x10^3/uL
• 2023-01-26 WBC 6.40 x10^3/uL
• 2023-01-25 WBC 8.17 x10^3/uL

==========

2023-07-17

After reviewing the PharmaCloud database, no reconciliation issues were found.

[exploring CNS involvement]

An increased level of LDH is more common seen in patients with AML involving the CNS. Given that this patient was admitted with symptoms of dizziness and tinnitus, it could be worthwhile to conduct further investigations.

• 2023-07-17 LDH 20297 U/L
  
• 2023-07-03 LDH 7732 U/L
  
• 2023-06-04 LDH 936 U/L
  
• 2023-05-31 LDH 467 U/L
  
• 2023-04-19 LDH 112 U/L
  
• 2023-04-06 LDH 131 U/L
  
• 2023-04-02 LDH 77 U/L

2023-05-02

• The patient experienced 2 episodes of grade 4 neutropenia each time after chemotherapy treatments and showed improvement with more than 1 week of G-CSF use.
• As the patient received her 3rd treatment during this hospitalization, it is suggested that the use of prophylactic G-CSF be considered to prevent recurrence of severe neutropenia.

2023-03-29

• The patient’s WBC count, which had been low, has returned to a normal range after receiving filgrastim (G-CSF) (planned for 10 days) since 2023-03-28. The patient’s oral thrush has also improved.
  • 2023-03-29 WBC 7.65 x10^3/uL
    
  • 2023-03-27 WBC 2.22 x10^3/uL
    
  • 2023-03-25 WBC 3.79 x10^3/uL
• It appears that the patient may be more susceptible to leukopenia when receiving the “HD Ara-C” regimen compared to the “3+7 Idarubicin/Cytarabine” regimen based on the WBC levels observed during these limited treatments.

230502

[exam findings]

• 2023-02-20 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Acute myeloid leukemia (AML)
  • The sections show hypocellular marrow (10%). Focal reduced fat cells with accumulation of extracellular gelatinous substances, decrease in trilinage hematopoietic cells including megakaryocyts, CD71+ erythroid precursors and MPO+ myeloid cells, scattered CD138+ mature plasma cells, fibroblastic proliferation, vascular dilatation, and stromal edematous change are present. Residual CD34-/CD117+ blasts, account for 20% of nuclear cells can be found. Suggest bone marrow smear evaluation and clinic correlation.
• 2023-02-20 KUB
  • Spondylosis with scoliosis of the L-spine with convex to right side
  • Non-specific bowel gas pattern in the middle abdomen is noted. please correlate with clinical condition. Follow up is indicated.
  • Ascites is highly suspected. Please correlate with sonography.
• 2023-02-08 Abdomen - standing (diaphragm)
  • Spondylosis with scoliosis of the T-spine with convex to right side
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon at left lateral aspect of L3-4.
  • Disk space narrowing and Marginal osteophyte formation of L5-S1.
• 2023-01-30 Patho - bone marrow biopsy
  • Bone marrow, biopsy — acute myeloid leukemia (AML)
    • NOTE: Correlation of peripheral blood, bone marrow smear, flow cytometry, molecular genetic study and clinical feature is recommended.
  • Microscopically, it shows hypercellularity (90%) with proliferation of myeloblasts hightlighted by CD117 (> 90%).
  • Immunohisotchemical stain reveals CD34(-), CD20 (focal+), CD138 (-), MPO(+), CD71(focal+), TdT(-).

[consultation]

• 2023-02-25 Infectious Disease
  • Q
    • The 59 y/o woman has APL post chemotherapy least 2023/02/12. Due to intermittent fever without bacteremia from culture, so we need your help for management. Thanks
  • A
    • intermittent fever still noted despite Mepem, vancomycin, and Mycamine use.
    • No significant culture report available.
    • CxR clear lungs that urinalysis showed mild bacteriuria without pyuria.
    • There are diffuse skin lesions over trunk and lower limbs, etiology uncertain, which should be related to fever.
    • Suggestion:
      • check HSV and VZV viral load
      • check CMV viral load
      • continue the present antibiotic regimen
      • empirical iv steroid can be tried.
• 2023-02-23 Dermatology
  • Q
    • for suspect Herpes Zoster at bilateral waist, and skin rash at bilateral groin, the painful, skin rash at perineum
    • The 59 y/o woman dosen’t have any history.
    • This time, she sufferes from hand, back ecchymosis and both leg petechia, so she sent to Cardinal Tien Hospital. LRP transfusion for thrombocytopenia 16000/uL on 2023/01/20. Due to elevated blast and suspect leukemia, so she transfered to our ED for help. Her BW loss 5 kg around 1 year. Got fatigue noted after postive of COVID (2022-09). At ED, the lab data showed WBC 8170/uL, Hb 10.0 g/dL, PL 44 *10^3/uL, Blast 58%. Under the impression of APL, so she was admitted.
    • chemotherapy with (3+7) Idarubicin/Cytarabine on 2023/02/06 ~ 2023/02/12
    • This time, suspect Herpes Zoster at bilateral waist, and skin rash at bilateral groin, the painful, skin rash at perineum , so we need your help, thanks a lot!!
  • A
    • The patient had sufferred from diffuse non-blanchable erythema lesions over trunk and lower legs.
      
    • Under the impression of thrombopenia purpura with fine vesicle/bullae formation r/o allergic purpura.
      
    • The following sugeetion:
      • exclude herpes zoster infection episode currently.
      • correct patient underlying state as your experist.
        • for fine vesicle or bullae, Betason-N onit 2 tube topical bid use.
        • for itchy skin lesions, Mycomb cream 1 tube topical bid use.
      • enhance skin mositurization, Sinphraderm cream 1 tube QN use over fine scales/xerotic area after body clean.

[chemotherapy]

• 2023-04-28 - cytarabine 1500mg/m2 2400mg NS 500mL 3hr D1-3 (HD Ara-C, Q4W)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D1-3 + NS 250mL D1-3
• 2023-03-23 - cytarabine 1500mg/m2 2400mg NS 500mL 3hr D1-3 (HD Ara-C, Q4W)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D1-3 + NS 250mL D1-3
• 2023-02-06 - idarubicin 10mg/m2 16mg NS 100mL D1-3 + cytarabine 100mg/m2 165mg NS 500mL D1-7 (3+7 idarubicin/cytarabine, Q4W)
  • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + palonosetron 250ug D1 + granisetron 2mg D2-3 + NS 250mL D1-3

G-CSF (filgrastim) 150ug

• 2023-03-27 ~ 2023-04-05 (prior C/T on 2023-03-23)
• 2023-02-15 ~ 2023-03-02 (prior C/T on 2023-02-06)

WBC

• 2023-05-02 WBC 2.79 x10^3/uL
  
• 2023-04-28 WBC 3.57 x10^3/uL 2023-04-28 C/T
  
• 2023-04-19 WBC 4.14 x10^3/uL
  
• 2023-04-10 WBC 2.54 x10^3/uL
  
• 2023-04-08 WBC 4.58 x10^3/uL
  
• 2023-04-06 WBC 13.57 x10^3/uL
  
• 2023-04-04 WBC 0.85 x10^3/uL
  
• 2023-04-02 WBC 0.21 x10^3/uL
  
• 2023-03-31 WBC 0.56 x10^3/uL
  
• 2023-03-29 WBC 7.65 x10^3/uL
  
• 2023-03-27 WBC 2.22 x10^3/uL
  
• 2023-03-25 WBC 3.79 x10^3/uL 2023-03-23 C/T
  
• 2023-03-22 WBC 3.84 x10^3/uL
  
• 2023-03-15 WBC 4.14 x10^3/uL
  
• 2023-03-08 WBC 1.35 x10^3/uL
  
• 2023-03-06 WBC 1.76 x10^3/uL
  
• 2023-03-04 WBC 2.72 x10^3/uL
  
• 2023-03-02 WBC 3.18 x10^3/uL
  
• 2023-02-28 WBC 0.91 x10^3/uL
  
• 2023-02-26 WBC 0.29 x10^3/uL
  
• 2023-02-24 WBC 0.23 x10^3/uL
  
• 2023-02-22 WBC 0.21 x10^3/uL
  
• 2023-02-20 WBC 0.26 x10^3/uL
  
• 2023-02-18 WBC 0.26 x10^3/uL
  
• 2023-02-16 WBC 0.25 x10^3/uL
  
• 2023-02-14 WBC 0.19 x10^3/uL
  
• 2023-02-12 WBC 0.24 x10^3/uL
  
• 2023-02-10 WBC 0.53 x10^3/uL
  
• 2023-02-08 WBC 1.44 x10^3/uL
  
• 2023-02-06 WBC 8.30 x10^3/uL 2023-02-06 C/T
• 2023-02-04 WBC 7.75 x10^3/uL
  
• 2023-02-03 WBC 7.53 x10^3/uL
  
• 2023-02-01 WBC 8.69 x10^3/uL
  
• 2023-01-30 WBC 11.71 x10^3/uL
  
• 2023-01-30 WBC 10.55 x10^3/uL
  
• 2023-01-28 WBC 7.74 x10^3/uL
  
• 2023-01-26 WBC 6.40 x10^3/uL
  
• 2023-01-25 WBC 8.17 x10^3/uL

[assessment]

• The patient experienced 2 episodes of grade 4 neutropenia each time after chemotherapy treatments and showed improvement with more than 1 week of G-CSF use.

• As the patient received her 3rd treatment during this hospitalization, it is suggested that the use of prophylactic G-CSF be considered to prevent recurrence of severe neutropenia.

700208930

230714

[exam findings]

• 2023-07-03 Gynecologic ultrasonography
  • ATH + BSO
  • IMP: No obvious uterine or ovarian lesion
• 2023-04-15 MRI - pelvis
  • Clinical history: 44 y/o female patient with EM cancer.
  • Without contrast enhancement MRI: Pelvis
    • S/P hystercctomy.
    • Presence of gallbladder stones.
    • Mild ascites.
    • Disc space narrowing at L5-S1.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T: T0_(T_value) N:N0_(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • Impression:
    • Clinical endometrial malignancy.
    • S/P hysterectomy.
    • GB stones.
• 2023-04-13 Patho - uterus with or without SO non-neoplastic/prolapse
  • PATHOLOGIC DIAGNOSIS
    • Endometrium, uterus, frozen + LSC staging surgery — Endometrioid carcinoma, grade 2
    • Myometrium, uterus, ditto — Tumor invasion, less than half thickness
    • Cervix, uterus, ditto — Stromal invasion
    • Ovary, left, ditto — Free of tumor invasion, cystic follicles
      • Fallopian tube, left, ditto — Free of tumor invasion, paratubal cyst
    • Ovary, right, ditto — Free of tumor invasion
      • Fallopian tube, right, ditto — Free of tumor invasion
    • Lymph nodes
      • Lymph node, left iliac, dissection — Free of tumor metastasis (0/7)
      • Lymph node, left oburator, ditto — Free of tumor metastasis (0/5)
      • Lymph node, right iliac, ditto — Free of tumor metastasis (0/6)
      • Lymph node, right oburator, ditto — Free of tumor metastasis (0/4)
    • Parametrium, bilateral — Free of tumor invasion
    • AJCC Pathologic stage — pT1aN0, if cM0, stage IA / FIGO stage IA
    • Revised diagnosis: 8. AJCC Pathologic stage — pT2N0, if cM0, stage II / FIGO stage II
      • Reason for revision: cervical stromal invasion
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: frozen section + LSC staging surgery (TAH, BSO and BPLND)
    • Specimens include: uterus, bilateral ovaries and fallopian tubes and pelvic LNs
    • Specimen size:
      • uterus: 7.8 x 5.2 x 3.5 cm, 98 gm
      • right ovary: 3.5 x 2.1 x 1.6 cm
      • left ovary: 3.7 x 2.3 x 2.2 cm
      • right fallopian tube: 4.8 cm in length; 0.5 cm in diameter
      • left fallopian tube: 5.1 cm in length; 0.6 cm in diameter with one paratubal cyst 2.6 x 1.7 cm
    • Tumor site: endometrium
    • Tumor size: 4.8 x 4.1 cm, solid mass with many detached tumor fragments
    • The myometrium: up to 1.7 cm in thickness
    • The cervix : mucoid cysts
    • Adnexa (bilateral): left ovary and bilateral tubes are not invaded by tumor
    • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs and right obturator LNs
    • Representative sections as follows: A: left iliac LNs; B: left obturator LNs; C: right iliac LNs; D: right obturator LNs, E1: R’t fallopian tube, E2: R’t ovary, E3: L’t fallopian tube, E4: L’t paratubal cyst, E5-E6: L’t ovary, E7: R’t parametrium, E8: L’t parametrium, E9-E13: mass, E14: cervix and E15: detached tumor fragments [Reference: F2023-00161 blood and some white tumor fragments measured up to 0.7 x 0.5 x 0.3 cm. All embedded as FSA1-FSA2]
  • MICROSCOPIC EXAMINATION
    • Histology type: Endometrioid carcinoma
    • Histology grade: Grade 2
    • Depth of invasion: less than half thickness of myometrium
    • Lymphovascular invasion: absent
    • The cervical stroma involvement: involved
    • Resection margins of the cervix: Free, 1.4 cm away from tumor
    • Additional pathologic findings: focal tumor necrosis
    • Lymph nodes: Free of tumor metastasis (0/22) in total number
    • Immunohistochemistry: P53(wild type), ER(+), PAX-8(+), P16(-) and vimentin(+) for tumor
    • Ascites cytology: negative
• 2023-03-27 Gynecologic ultrasonography
  • R/O Mass ? Cx, 36 x 32 mm, RI: 0.44
• 2023-03-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 23) / 79 = 70.89%
    • M-mode (Teichholz) = 70.4
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA, grade 1 LV diastolic dysfunction
    • Mild MR, PR

[radiotherapy]

[chemotherapy]

• 2023-07-14 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-06-19 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-05-19 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-05-10 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-06-20

• Based on the PharmaCloud records, all recent medications have been prescribed by our hospital. This patient last visited our metabolism OPD on 2023-06-03 for her type 2 diabetes mellitus and hyperlipidemia. Our endocrinologist provided prescriptions for Linicor (niacin 500mg, lovastatin 20mg) 1# QD, Forxiga (dapagliflozin 10mg) 1# QD, Uformin (metformin 500mg) 1# QLCC, Glimet (glimepiride 2mg, metformin 500mg) BIDCC, Lipanthyl (fenofibrate 160mg) 1# QD and Tresiba Flex Touch (insulin degludec) 10 units HS. All these medications have been successfully incorporated into the active medication list, without any reconciliation issues identified.

[patient education]

• At around 15:15 on 2023-06-20, I visited the patient, who was resting with her eyes closed. Her sister, who was sitting in a chair next to the bed, woke her up. I brought the patient information leaflets for paclitaxel and carboplatin, explaining the potential side effects of each drug one by one. I asked her to inform the medical team as soon as possible if any suspicious symptoms occur. The patient reported that she had previously told Dr. Wan about numbness in her fingertips after chemotherapy, and stated that this condition still persists at the time of this visit.

• Although carboplatin has been linked to peripheral neuropathy in 4% to 6% of cases, the association is even stronger with paclitaxel, which is linked to peripheral neuropathy in 42% to 70% of cases (grades 3/4 <= 7%). Therefore, it’s more probable that the numbness in the patient’s fingertips is primarily due to paclitaxel.

• The 2020 ASCO guidelines suggest that clinicians may consider offering duloxetine to patients with chemotherapy-induced peripheral neuropathy. Additionally, the 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for the treatment of neuropathic pain in this context. Reference: “Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325”.

• We currently have Cymbalta (duloxetine 30mg/cap) in stock. For chemotherapy-induced peripheral neuropathy, the oral initial dose is 30 mg once daily for 1 week, then increased to 60 mg once daily. (ref: UpToDate)

700979859

230714

[exam findings]

• 2023-06-09 Nasopharyngoscopy
  • smooth nasopharynx, oropharynx and hypopharynx; fair vocal cord movement.
• 2023-04-27 Aspiration - thyroid
  • Indication: PET - Increased FDG uptake in a focal area in the right lobe of the thyroid gland, another primay thyroid cancer is highly suspected,
  • PATHOLOGIC DIAGNOSIS: Atypia, favor lymphocytic thyroiditis
    
  • MICROSCOPIC EXAMINATION: Two wet smears show colloid, dispersed lymphocytes, neutrophils and some atypical oncocytic follicular cells with mild to moderate anisonucleosis, lymphocytic thyroiditis maybe first considered. Clinical and laboratory correlation is needed. Follow up
• 2023-04-18 Patho - esophagus subtotal/total resection
  • Diagnosis
    • Esophagus, lower third, VATS esophagectomy —- Squamous cell carcinoma, moderately differentiated, s/p CCRT
    • Stomach, cardia, partial gastrectomy —- Squamous cell carcinoma, moderately differentiated, by direct invasion —- Gastrointestinal stromal tumor (GIST)
      
    • Azygos vein, right, excision —- Negative for malignancy
    • Resection margin: Negative for malignancy; proximal cutend of esophagus: Negative for malignancy
    • Lymph node, upper paraesophageal, specimen 1, dissection —- Negative for malignancy (0/1)
    • Lymph node, middle paraesophageal, specimen 1, dissection —- Negative for malignancy (0/4)
    • Lymph node, lower paraesophageal, specimen 1, dissection —- Negative for malignancy (0/0)
    • Lymph node, peri-gastric, specimen 1, dissection — Squamous cell carcinoma, metastatic (1/9)
    • Lymph node, right, group 2+4, dissection —- Negative for malignancy (0/14)
    • Lymph node, right, group 7, dissection —- Negative for malignancy (0/5)
      
    • Lymph node, right, group 11, dissection —- Negative for malignancy (0/1)
      
    • AJCC 8 th edition pT N M Pathology stage:
      • Esophagus: ypStage IIIB, ypT3N1(if cM0)
      • Stomach GIST: pStage IA, pT1N0(if cM0)
  • Gross Description:
    • Procedure: VATS esophagectomy and gastric tube reconstruction; Size: Esophagus: 12.5 cm in length with a portion of gastric tissue measuring 4.7 cm in length. Azygos vein: 1.1 x 0.5 x 0.5 cm
    • Tumor Site: Distal esophagus (low thoracic esophagus) with involving esophagogastric junction (EGJ)
    • Relationship of Tumor to Esophagogastric Junction: Tumor midpoint lies in the distal esophagus and tumor involves the esophagogastric junction
    • Tumor Size: 3.5 x 1.5 cm
    • A calcified nodule, measuring 1.0 x 0.5 x 0.5 cm, is seen in the gastric wall and 0.6 cm away from the distal gastric resection margin.
      
    • Sections are taken and labeled as: A1-2: Distal gastric resection margin; A3: esophagus; A4: stomach tumor; A5: EG junction; A6-9: tumor; A10: lymph node, upper paraesophageal; A11: lymph node, middle paraesophageal; A12: lymph node, lower paraesophageal; A13-14: lymph node, perigastric; B1-2: lymph node, right group 2+4; C: lymph node, right group 7; D: lymph node, right group 11; E: azygos vein; F: proximal cutend of esophagus.
      
  • Microscopic Description:
    • Histologic Type: Squamous cell carcinoma, s/p CCRT; The immunohistochemical stains reveal CK(+) and p40(+).
    • Histologic Grade: G1: Well differentiated
    • Tumor Extension: Tumor invades adventitia
    • Margins: All margins are uninvolved by invasive carcinoma, dysplasia, and intestinal metaplasia
      • Distance of invasive carcinoma from closest margin (millimeters or centimeters): 1 mm ; Specify closest margin: adventitia resection margin
      • Proximal resection margin: 6.0 cm
      • Distal resection margin: 5.0 cm
    • Treatment Effect : Present, Single cells or rare small groups of cancer cells (near complete response, score 1)
    • Lymphovascular Invasion: Not identified
    • Perineural Invasion: Not identified
    • Regional Lymph Nodes: please see diagnosis
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors: y (posttreatment)
        • Primary Tumor (pT): pT3: Tumor invades adventitia
        • Regional Lymph Nodes (pN): pN1: Metastasis in one or two regional lymph nodes
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
    • Additional Pathologic Findings: A gastrointestinal stromal tumor is seen and very close (< 0.1 cm) to serosal surface. The immunohistochemical stains reveal CD34(+), CD117(+), and DOG-1(+). The mitotic rate < 5/5 mm (square).
• 2023-04-14 Treadmill Exercise Test
  • Diagnosis
    • Squamous cell carcinoma of lower third of esophagus, cT3N1M0 stage III
    • Hypertension
    • Carrier of viral hepatitis B
  • Exam Object: Pre-op evaluation
  • Exam Record:
    • Ergometer protocol: incrementa
    • Ergometer type: cycle ergometer, work rate: 15 watt/min
    • Load time: 6.9 min
      • ΔVO2/ΔWR (Normal > 8.6 ~ 10.3): 5.9
      • AT: 628/1830 = 34
    • Predict
      • MIP :143 -( 0.55 * 59 ) = 110.55
      • MEP :268 -( 1.03 * 59 ) = 207.23
    • Meas
      • MIP :125 / 110.55 ) = 113
      • MEP :148 / 207.23 ) = 71
    • Cause of stop:
      • Rest BP: 120/79 mmHg
      • Max BP: 222/99 mmHg
    • Max Exercise: 104 watts
    • Dyspnea: 3-4 points
    • leg fatigue: 7-8 points
    • CAT: 11000121 = 6
  • Conclusion
    • low exercise capacity (VO2 55% <85%, WR 80%)
    • small airway disease with significant reveresibility (FVC 101%, FEV1 83%, MMEF 46 -> 63)
    • normal inspiratory muscle strength (MIP 113%, MEP 71%)
    • No SpO2 desaturation < 90% during exercise
    • normal stroke volume response during exercise
    • maximal HR 74% (<85%) but normal response slope
    • work efficiency low
    • anaerobic threshold low
    • oxygen pulse low
    • high BP response, BP 120/79 -> 222/99
    • EKG: no specific findings
    • Health-related quality of life, CAT = 6, OK
  • Impression:
    • deconditioning with low exercise capacity
    • small airway disease with significant reveresibility (MMEF 46->63)
    • HTN during exercise
  • suggestions:
    • treat underlying condition
    • give bronchodilator for small airway diseases
    • control BP
    • suggest home or hospital based exercise training after operation
• 2023-04-13 MRI - brain
  • No evidence of intracranial lesion.
• 2023-04-12 PET
  • Compared with the previous study on 2022-12-27, the glucose hypermetabolic lesion involving the lower portion of the esophagus and adjacent EG junction is old and comes to less evident, and the glucose hypermetabolic lesion in adjacent paracardial area disappears, indicating cancer with respopsne to current therapy.
    
  • Glucose hypermetabolism in a nodular lesion in the left upper lung, the nature is to be determined (inflammation process, metastasis or other nature ?), suggesting further investigation.
    
  • Mild glucose hypermetabolism in the right mediastinal space and bilateral pulmonary hilar regions, probably reactive nodes.
  • Increased FDG uptake in a focal area in the right lobe of the thyroid gland, another primay thyroid cancer is highly suspected, suggesting biopsy for investigation.
  • No prominent abnormal focal FDG uptake is noted elsewhere.
• 2023-04-11 Tc-99m MDP bone scan
  • In comparison with the previous study on 2022/12/29, no prominent change is noted in the lesions in some T- and L-spines. Degenerative change may show this picture.
  • No prominent change is noted in the faint hot spots in the sternum and bilateral rib cages, possibly more benign in nature.
  • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2023-04-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (82.6 - 20.0) / 82.6 = 75.79%
    • M-mode (Teichholz) = 73.7
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with trivial MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, mild TR, normal IVC size
• 2023-03-07 CT - chest
  • Indication: esophagus cancer, cT3N1M0, stage III
  • Comparison was made with previous CT dated on 2022/12/26
    • Lungs: no abnormal nodule in the lungs,
      • moderate centrilobular emphysema at both upper lobes. and subpleural paraseptal emphysema
      • minimal subpleural fibrosis at LLL and RLL,
    • Mediastinum and hila: no enlarged LN or abnormal enhancing LN.
      • lymphadenopathy in stations
      • interval significant decrease in size of L/3 esophageal tumor with visible luminal wide as compared with CT on 2022/12/26
      • (residual circumferential wall thickness is 11.4mm).
    • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • s/p percutaneous gastrostomy.
    • Mild atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • L/3 esophageal cancer s/p C/T with partial response.
• 2023-03-06 Abdomen - standing (diaphragm)
  • S/P ileostomy
  • S/P posterior instrumentation fixation from L5 to S1.
• 2023-02-06 KUB
  • S/P posterior instrumentation fixation from L5 to S1.
  • Fecal material store in the colon.
  • S/P Foley’s catheter projecting at left abdomen?
• 2023-01-10 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 23) / 100 = 77.00%
    • M-mode (Teichholz) = 77
  • Normal LV filling pressure.
  • Normal LV and RV systolic function.
• 2022-12-30 MRI - brain
  • No evidence of intracranial lesion.
• 2022-12-29 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in the sternum and bilateral rib cages and increased activity in some T- and L-spines, bilateral shoulders, sternoclavicular junctions and hips in whole body survey.
  • IMPRESSION:
    • Increased activity in some T- and L-spines. Degenerative change is more likely.
    • Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2022-12-28 Miniprobe Endoscopic Ultrasound
  • EUS findings
    • Using EUS-DP- 25R, EUS showed a mucosal lesion invading into the adventitia of esophageal wall at the lesion site.
    • At least 2 lymph nodes were noted. The biggest lymph node was noted with size about 4.6 mm.
  • Diagnosis
    • Esophageal cancer, at least cT3N1, 40cm below incisor. s/p chromoendoscopy
• 2022-12-28 SONO - abdomen
  • Finding
    • Mass-like lesion in lower esophagus just above EG junction, suspected to be circumferential wall thickening up to 2.33 cm, compatible with lower esophageal tumor
  • Diagnosis
    • Probable lower esophageal tumor
  • Suggestion
    • Correlate with CT scan and endoscopy
• 2022-12-27 Whole body PET scan
  • There was increased FDG uptake in the lower portion of the esophagus and adjacent EG junction (SUVmax early: 11.59, delay: 18.82), in a focal area in adjacent paracardial area (SUVmax early: 6.52, delay: 10.97) and bilateral pulmonary hilar regions (SUVmax early: 3.23, delay: 5.50). Besides, there was increased FDG accumulation in both kidneys and bilateral ureters.
  • IMPRESSION:
    • A glucose hypermetabolic lesion involving the lower portion of the esophagus and adjacent EG junction, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in a focal area in adjacent paracardial area. A metastatic lymph node should be considered.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammation may show this picture.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2022-12-27 Flow volume chart
  • Suspected small airway obstruction
• 2022-12-26 CT - chest
  • Findings: segmental wall thickening in the lower esophagus.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:3(T_value) N:0(N_value) M:0(M_value) STAGE:IIA(Stage_value)
• 2022-12-19 Patho - esophageal biopsy
  • DIAGNOSIS:
    • Esophagus, lower, from EG junction to 35 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
  • MICROSCOPIC DESCRIPTION:
    • Section shows pieces of squamous mucosa with infiltration of nests of neoplastic squamous cells. The immunohistochemical stain of p40 is positive.
• 2022-12-19 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Advanced Esophageal cancer, lower esophagus, with luminal narrowing, s/p biopsy
    • Reflux esophagitis LA Classification grade A
    • Hiatal hernia
    • Superficial gastritis, antrum and body.
  • Suggestion
    • keep PPI
    • arrange magnified endoscopy/miniprobe EUS, chest/neck CT for cancer stage.
• 2018-10-15 SONO - abdomen
  • Probable parenchymal liver disease
  • Status post cholecystectomy
• 2018-06-09 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Hiatal hernia with Reflux esophagitis, Gr D 　　- Propable Distal esophageal diverticulum 　　- Superficial gastritis, antrum 　　- Duodenitis, bulb
  • Suggestion
    • Medication and OPD f/u 　　- Repeated EGD was suggested for GERD F/u 3 months later
• 2018-06-08 CT - abdomen
  • Long segmental wall edema of colon.
  • Focal dilatation of lower esophagus.
• 2018-01-05 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (122 - 38) / 122 = 68.85%
    • M-mode (Teichholz) = 69
  • Conclusion
    • Mild septal and RV hypertrophy with Gr I LV diastolic dysfunction.
    • Normal LV and RV systolic function.
    • AV sclerosis and mild aortic root calcification.
    • Trivial MR.

[consultation]

• 2022-12-28 Hemato-Oncology
  • A
    • This 58 year old man is a case of lower esophagus squamouse cell carcinoma (inital presentation was postmeal vomiting since 2 weeks ago with acid regurgitation and heartburn sensation). We are consulted for further evaluation.
    • Arrange PET CT scan for staging. If no evidence of M1 unresectable disease, arrange Endoscopic ultrasound (EUS) and consult chest surgeon for possible of resection.
    • If unresectable advance esophagus cancer, CCRT is suggest. -> Arrange port A insertion, For nearing total obstruction esophagus cancer, before CCRT, please arrange jejunostomy for nutrition support.
    • PPN is suggested
• 2022-12-27 Radiation Oncology
  • Diagnosis:
    • Esophageal cancer, MD squamous cell carcinoma, cT3N1M0 at least, with LAP metastasis over EG junction & lumen obstruction (liquid diet only); ECOG =1. PortA implantation and feeding ileostomy is scheduled on 2023/01/02.
  • Plan: EUS for staging if feasible. Preoperative CCRT to esophageal tumor, EG junction LAP & regional lymphatics for 5040cGy/28 fx is suggested for locoregional tumor control. Possible treatment toxicity (radiation esophagitis and pneumonitis) is told. CT simulation is arranged on 2023/01/03 14:30 after PortA implantation and feeding ileostomy is done. Psychological support & diet education is given to him.

[chemotherapy]

• 2023-07-14 - NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (PF4, CDDP 80%, 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-06-12 - NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (PF4, CDDP 80%, 5-FU 80%)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-03-06 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 125mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1670mg NS 500mL 24hr D1-4 (PF4)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-02-03 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 125mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1640mg NS 500mL 24hr D1-4 (PF4)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-01-09 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 125mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF4)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-03-06

• The patient’s renal function is showing a gradual decline and requires close monitoring.
  • 2023-03-06 BUN 29 mg/dL
    
  • 2023-02-15 BUN 28 mg/dL
    
  • 2023-02-06 BUN 17 mg/dL
    
  • 2023-02-02 BUN 22 mg/dL
    
  • 2023-01-09 BUN 15 mg/dL
    
  • 2023-03-06 Creatinine 0.98 mg/dL
    
  • 2023-02-15 Creatinine 0.97 mg/dL
    
  • 2023-02-06 Creatinine 0.85 mg/dL
    
  • 2023-02-02 Creatinine 0.81 mg/dL
    
  • 2023-01-09 Creatinine 0.68 mg/dL
• Cisplatin can cause severe renal toxicity, including acute renal failure. Severe renal toxicities are dose-related and cumulative. Adequate hydration has been considered, specifically, NS 500mL is given both before and after the cisplatin infusion, which is administered in NS 500mL as well. However, if there is continued acceleration of the decline in kidney function, dose reduction or alternative treatment options should also be considered for this patient.

700175888

230713

[exam findings]

• 2023-06-19 CT - abdomen
  • History and indication: Adenocarcinoma of middle rectum with impending obstruction and liver metastases and possible LLL metastases, cT4aN2bM1a, stage IVA
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operation. Much regression of rectal cancer but progression of liver metastases.
    • A nodule (5mm) at LLL.
    • Splenomegaly.
    • Some LNs at pelvic cavity.
    • Atherosclerosis of aorta.
  • IMP:
    • S/P operation. Much regression of rectal cancer but progression of liver metastases. A nodule (5mm) at LLL.
• 2023-06-19 Sigmoidoscopy
  • Rectal cancer s/p CCRT with partial regression (middle rectum, 8-9cm AAV)
• 2023-06-17 CXR
  • Tortuosity of the aorta with atherosclerotic change.
  • Increased lung markings over both lungs.
• 2023-06-01 Esophagogastroduodenoscopy, EGD
  • Superfical gastritis, antrum
  • Duodenal ulcer scar, bulb, AW, LC
• 2023-03-22 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2023-03-03 PET
  • Glucose hypermetabolism involving the rectosigmoid colon, compatible with primary colon malignancy.
  • Glucose hypermetabolism in a regional lymph node. A metastatic lymph node may show this picture.
  • Mild glucose hypermetabolism in some small regional lymph nodes. The nature is to be determined (metastatic lymph nodes of low FDG uptake? inflammation?). Please correlate with other clinical findings for further evaluation.
  • Multiple glucose hypermetabolic lesions in the right and left lobes of the liver, suggesting multiple liver metastases.
  • No prominent FDG uptake was noted in the small nodule in the upper lobe of left lung delineated in the CT scan. Please follow up chest CT scan for further evaluation.
  • Increased FDG uptake/accumulation in a small focal area in the soft tissue in the left upper arm. The nature is to be determined (physiological FDG uptake/accumulation in the vein of the left upper arm? other nature?).
• 2023-03-01 All-RAS + BRAF gene mutation
  • ALL-RAS:
    • There was no variant detected in the KRAS/NRAS gene
  • BRAF
    • There was no variant detected in the BRAF gene.
• 2023-02-21 CT - abdomen
  • Clinical history: 61 y/o female patient with Newly diagnosis of middle rectal adenocarcinomafor staging
  • With and without contrast enhancement CT of abdomen - whole:
    • Thickening wall at rectosigmoid colon with pericolonic infiltrates, r/o colon malignancy.
    • There are liver tumors, up to 3cm in left lobe, r/o liver metastasis.
    • There are lymph nodes in pericolonic and bilateral obturator regions.
    • Left upper lung nodular density, nature?
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4aT_value) N:N2bN_value) M:M1a(M_value) STAGE: IVa Stage_value)
  • Impression:
    • Rectosigmoid colon cancer with lymph nodes and liver metastasis. cstage T4aN2bM1a.
    • Left upper lung nodular density, nature?
• 2023-02-13 Patho - colon biopsy
  • Tumor, middle rectum, biopsy — Adenocarcinoma
  • Microscopically, the sections show a picture of adenocarcinoma characterized by cribriform or glandular tumor cell infiltration with desmoplasia.
  • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.

[MedRec]

• 2023-03-15 SOAP Hemato-Oncology
  • A
    • adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVa (at least)
  • P
    • suggest CCRT followed by C/T + target therapy, then re-evaluation for curative surgery 3-6 months later
    • admission for CCRT with FOLFOX with targeted therapy (already discuss with beva or cetuximab)

[consultation]

• 2023-06-20 Hemato-Oncology
  • Q
    • For continue chemotherapy ?
    • The 61 years old female patient had hepatitis B carrier, and is a case of adenocarcinoma of middle rectum with impending obstruction and liver metastases and possible LLL metastases, cT4aN2bM1a, stage IVA status post T-loop colostomy on 2023/03/02, radiotherapy to rectal tumor and LAPs from 2023/03/16~ and concurrent chemotherapy with FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 5FU 2400mg/m2) from 2023/03/23~
    • This time, she suffered from massive bloody stool noted on yesterday evening (6/17), accompanying with dizziness, abdominal pain, chills, sweating, and back pain. Also, colostomy bag had much blood clot was told. She denied having fever, dysuria, or shortness of breath. While visited our emergency department, her vital signs showed hypotension (98/53mmHg) and tachycardia (107 bpm). Drowsiness consciuosness was found. With the impression of lower GI bleeding, she was admitted for further management.
    • Lab data: Hb: 9.8 (6/17) -> 8.4 -> 10.5 g/dl (6/19).
    • Now the patient no dizziness, no passage bloody stool. So we consult you for evaluation of continue chemotherapy ?
  • A
    • This 61 year old woman is a case of middle rectum with impending obstruction and liver metastases cT4aN2bM1a, stage IVA status post post T-loop colostomy on 2023/03/02, radiotherapy to rectal tumor and LAPs from 2023/03/16~4/28 and concurrent chemotherapy with FOLFOX [FOLFOX on 2023/03/23(C1D1), FOLFOX on 2023/04/11(C1D15), FOLFOX on 2023/04/28(C2D1), FOLFOX on 2023/05/29(C2D15). + Avastin].    
    • She was admiited due to massive bloody stool and accompanying with dizziness, abdominal pain, chills, sweating, and back pain. Also, colostomy bag had much blood clot was told.
    • Sigmoid scopy show rectal cancer s/p CCRT with partial regression (middle rectum, 8-9cm AAV). BUT the scope can not pass through it due to lumen stenosis. Some blood clots retention but no active bleeding. Abdominal CT 2023/6/19 show much regression of rectal cancer but progression of liver metastases. We are consulted for further evaluation.
    • Please arrange panendoscopy and keep PPI and transamin. We will take over this case. Please transfer to 11A and 10B. On Dr Xia.
• 2023-03-03 Hemato-Oncology
  • Q
    • For further evaluation of CCRT
    • A 61 year-old female patient was admitted for adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. After fully explained of the condition, T-loop colosotmy first for tumor impending obstruction then suggest CCRT and C/T+ target therapy. Surgery of T-loop colostomy will arrange on 2023/03/02 on call. We needs your expert experience for evaluation. Thanks a lot !!
  • A
    • This 61 year old woman is a case of middle rectal adenocarcinoma with liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. She will receive T-loop colostomy on 3/2. We are consulted for CCRT.
    • Systemic chemotherapy +/- target therapy is indicated for metastasis rectal cancer.
    • Please arrange port A insertion. Consider arrange PET scan for complete work up. Check All-RAS/BRAF.
    • Arrange our OPD after discharge. Thanks for your consultation.
• 2023-03-02 Radiation Oncology
  • Q
    • For further evaluation of CCRT
    • A 61 year-old female patient was admitted for adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. After fully explained of the condition, T-loop colosotmy first for tumor impending obstruction then suggest CCRT and C/T+ target therapy. Surgery of T-loop colostomy will arrange on 2023/03/02 on call. We needs your expert experience for evaluation. Thanks a lot !!
  • A
    • This 61 year-old female patient was admitted for adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. Plan to establish T-loop colosotmy first for tumor impending obstruction then suggest CCRT and C/T+ target therapy.
    • CT-simulation will be arranged on 3/14. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor (with the invaded uterus) and LAPs to 50.4 Gy/ 28 fx. RT will start around 3/16 or 17. If resection is not feasible by the end of the planned CCRT and C/T + target therapy course, additional RT to the rectal tumor might be considered for longer local control. Thank you very much.
• 2022-12-30 Ophthalmology
  • Q
    • Acute or sudden change in vision - Black spot appears in the right eye, ophthalmological examination reveals retinal detachment.
    • RD, arrange OP today
    • NKDA
  • A
    • S
      • VFD today
    • O
      • Acute floaters for 3 days
      • visited LMD and RRD was told
      • VAcPG od 0.6 os 0.6
      • Pupil od iatrogenic dilated os 3mm +/+
      • Conj np ou
      • K clear ou
      • AC D/clear ou
      • Lens ns+ ou
      • Fd od RRD 11-2 oc, flap tear at 12oc, macula on, fovea on
    • A
      • Phakic RRD od
    • P
      • Arrange admission TKS
      • OP will be arrange today
      • inform the risk of operation

[chemotherapy]

• 2023-05-29 - bevacizumab 5mg/kg 300mg NS 200mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-28 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-11 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-23 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 250mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-07-13

The patient has only visit our hospital in the last 3 months according to the PharmaCloud database, our gastroenterologist prescribed Baraclude (entecavir) for she is a carrier of viral hepatitis B. Baraclude is in the active medication list, no reconciliation issues found.

2023-06-20

On 2023-06-18, the patient’s fecal occult blood test was 2+, indicating a possible GI bleeding. On this date, the patient has been prescribed lansoprazole and tranexamic acid. The prescription for lansoprazole is set to expire on 2023-06-21. It would be beneficial to evaluate whether signs of bleeding persist to decide whether to continue the PPI.

700363763

230713

• 2023-05-15, -05-08, -05-03, -04-27 CXR
  • Port-A catheter inserted via left subclavian vein, its tip overlies Rt paratracheal stripe
  • A poorly defined mass over LUL
  • areas of hyperlucency and decreased upper lung vascular markings due to emphysematous change of both lungs upper lung predominance
  • there is also areas of pulmonary fibrosis in the lungs
  • mild enlarged cardiac silhoutte
• 2023-04-24 Patho - lung transbronchial biopsy
  • Lung, left, CT-guide biopsy — necrotizing granulomatous inflammation with marked interstitial fibrosis
  • Sections show alveolar lung tissue with marked interstitial fibrosis and necrotizing granulomatous inflammation. Several Langhan’s multinuclear giant cells are also seen.
  • The AFB special stain is positive. The PAS special stain is negative. No definite malignancy is found. The immunohistochemical stain of CK reveals no invasive tumor.
• 2023-04-22, -04-20 CXR
  • Patch density at LUL.
  • Blunted left costophrenic angle.
  • Presence of scoliosis of the lumbar spine.
• 2023-04-19 PET
  • Increased FDG uptake at the R-S junction of colon, compatible with rectal malignancy.
    
  • Increased FDG uptake in bilateral peri-rectal lymph nodes, highly suspected rectal cancer with regional lymph nodes metastases.
    
  • Increased FDG uptake in bilateral upper lungs, highly suspected the secondary (priority, colon cancer with lung mets) or another primary (left or right upper lung?) cancer, suggesting biopsy, if necessary, for investigation.
  • Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, and in a left SCF lymph node, highly suspected rectal cancer with distant lymph nodes metastases (priority) or lung cancer with regional lymph nodes metastases.
    
  • Highly suspected rectal cancer with regional and distant lymph nodes, as well as bilateral upper lungs metastases, cTxN2M1b, stage IVB (AJCC 8th ed.), or double cancers of rectum and lung, by this F-18 FDG PET scan.
• 2023-04-18 All RAS + BRAF
  • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-04-14 CT - chest
  • Indication: colon cancer with lung metastases
  • Findings
    • Spculated mass at left upper lobe with central lucency is found measuring 3.2cm in largest dimension. In comparison with CT dated on 2020-08-10, the lesion enlarged. Lung cancer is favored.
    • Severe centrilobular Emphysematous change over both lungs is found.
    • Minimal reticulation at bilateral lower lungs is found.
    • Tiny atelectatic change at left lower lobe with minimal left pleural effusion is found.
    • Small lymph nodes are found in the mediastinum. Stationary.
  • Imp: Left upper lobe spiculated mass. r/o lung cancer.
• 2023-04-07 Patho - colon biopsy
  • Colon tumor, rectum, 10 cm above anal verge, biopsy — Adenocarcinoma
  • Microscopically, the sections show a picture of adenocarcinoma characterized by glandular tumor cell infiltrate with stromal desmoplasia.
  • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
• 2023-04-01 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of S-colon with adjacent fat stranding and colon dilatation. Some LNs at pelvic cavity.
    • Nodules (up to 7mm) at bil. basal lungs.
    • Renal cysts (up to 1.2cm).
    • Atherosclerosis of aorta, iliac arteries.
    • Presence of scoliosis of the lumbar spine.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2022-09-05 CXR
  • upper lung hyperlucency and decreased upper lung vascular markings due to emphysema
  • ill-defined nodular opacity at LUL and several nodular opacities at RUL, stationary as compared with previous image
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • Mild dextroscoliosis of the T-spine
• 2022-07-25 CT - brain
  • Findings
    • Generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
  • Imp: Brain atrophy.
• 2020-08-10 CT - chest
  • Indication: RUL nodule
  • Comparison: none prior CT dated on 2017 2018 2019
    • Lungs and large airways:
      • extensive centrilobular emphysema over bilateral lungs upper predominance.
      • ill-defined, dumbell-like nodular opacity in LUL (37-mm in longest dimension) and several solid nodular opacities up to 24-mm in longest dimension in RUL, and minimal fibrotic change at lung apex in the same lobe. several small calcified granulomas in posterior RUL too.
    • Mediastinum: no LAP or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion,
    • Hila: unremarkable.
    • Vessels:
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
    • Heart: dilated RV and RA?
    • Pleura: no effusion.
    • Chest wall and lower neck: unremarkable.
    • Visible abdomen: no abnormal density in visible portion of the liver, spleen, pancreas, kidneys, adrenal glands, and GB.
      • Mild atherosclerotic change of the abdominal aorta.
    • Visualized bones: unremarkable.
  • Impression:
    • newly developed nodular lesions in both upper lobes compared
    • with CT on 2019/03/26, malignancy or MTB?
    • extensive emphysema.
• 2020-03-02 CXR
  • Increased lung volume and areas of lucency and dirty marking due to emphysematous change of both lungs upper lung predominance
  • a small nodular opacity over RUL and a small nodular opacity (ill-defined) over LUL, may be malignant lesions, suggest do CT study Thoracic aortic arch calcified atheriosclerotic plaque
  • mild levoscoliosis of the L-spine
• 2019-12-09 Bronchodilator test
  • mild obstructive ventilatory impairment
• 2019-03-26 CT - chest
  • Comparison: none prior CT dated on 2017 2018 2019
    • Lungs and large airways:
      • extensive centrilobular emphysema over bilateral lungs upper predominance. minimal fibrotic change at RUL. a 6mm subpleural nodule or atelectatic lung tissue at RML.
    • Mediastinum: no LAP or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion,
    • Hila: unremarkable.
    • Vessels:
      • Aorta: normal in caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Pulmonary arteries: normal in caliber.
    • Heart: normal in size.
    • Pleura: small effusion with parietal pleural thickening, Rt.
    • Chest wall and lower neck: unremarkable.
    • Mild atherosclerotic change of the abdominal aorta.
    • Visualized bones: unremarkable.
  • Impression:
    • Rt pleural effusion, exudate.
    • a 6mm subpleural nodule or atelectatic lung tissue at RML.
    • extensive emphysema.

[consultation]

• 2023-07-10 Gastroenterology
  • Q
    • for abnormal liver function and jaundice
    • This 79-year-old man, a patient of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. Owing to high TBI 2.98mg/dl was noted during anti-TB drugs related. We need expertise to evaluate his condition thnaks!
  • A
    • This 79-year-old male was a case of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. We are consulted for bilirubin elevation.
      • Communicating with a pen at bedside.
      • No abdomen pain noted
    • A: Bilirubin elevation, suspect drug-induced cholestasis, r/o biliary obstruction
    • P:
      • Pending on Abdomen CT report
      • Check AST, ALT, ALP, rGT, TBI/DBI, ALB, PT, APTT to complete liver study
      • Regular monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
      • Contact us, if any porblems
• 2023-07-10 Chest Medicine
  • Q
    • for Tuberculosis of lung & anti-TB drugs evaluation
    • This 79-year-old man, a patient of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. Owing to high TBI :2.98mg/dl was noted during anti-TB drugs related. We need expertise to evaluate his condition thnaks!
  • A
    • Suggestion:
      • hold anti-TB medication
      • arrange liver echo or abdominal CT to define liver condition. May consult GI
      • for much sputum, do sputum culture, airway clearance, give amikin inhalation for anti-inflammatory effects.
• 2023-06-26 Gastroenterology
  • Q
    • Due to the coffee ground noted via NG and tarry stool found via colostomy, we rechecked lab data for him which was revealed decreased level of Hb (12.3 -> 7.8). Thus, we need your expertise for evaluation of PES due to suspected Upper GI bleeding. Thanks!
  • A
    • 79 male with rectal cancer, s/p chemotherapy and colonostomy. However, due to tarry stool with coffee ground, we are consulted.
      • conscious: clear
      • chest: intubation
      • abdomen: soft and flat
    • impresson
      • UGI bleeding
    • suggestion
      • well inform-consent to the patient and the family, including the indication, the risks (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, etc.), and the alternatives (conservative treatment, etc.)
      • if the patient and the family all understand the EGD intervention, would take the risk, and sign the permit for EGD, we would arrange EGD
      • Proton pump inhibitor use
      • Avoid anticoagulants/antiplatelets use, and correct bleeding tendency if any;
      • Arrange adequate blood transfusion and fluid resuscitation for fear of hypovolemic shock;
      • Inform us to follow up if bleeding condition progression or any other GI problem progression
• 2023-06-23 Infectious Disease
  • A
    • Consultation for Mepem antibiotic
      • 79-year-old rectal cancer, COPD and pulmonary TB male patient has a new episode of severe pneumonia, BLL with respiratory failure and severe sepsis now.
      • He was just discharged from our Onco ward two days ago.
      • Use of Mepem acceptable before further culture report available.
    • Suggestion:
      • Continue Mepem for one week first
      • Check blood and sputum culture report.
• 2023-05-24 Dermatology
  • Q
    • This is 78 y/o man who has underlying disease of 1) COPD, 2) Hypertension, 3) GERD, 4) Rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stage IIIC, 5) Tuberculosis of lung under treatment.
    • This time, he complained of abdominal pain and distention for 3 days accompanied with constipation lasting a week. The patient denied chest tightness(-), headache(-), dizziness(-), radiated pain(-), shoetness of breating(-) nauseas(-) and vomitting(-), diarrhea(-). He also denied TOCC history.
    • For skin rash off and on was noted, we need your further evaluation and management. Thanks a lot!!! There are photos on the caregiver’s mobile phone.
  • A
    • The patient had sufferred from discrete reddish swelling papules on the abdomen without pruritus on and off for weeks.
    • xerotic dry skin with post-screthec lesions over four limbs.
      
    • Under the impression of acute urticaria and xerotic dermatits.
    • The following sugeetion:
      • for urticaria, consider keep allegra 1# bid po use -> consider shift to xzyal 1# HS po use if condition turn to stable.
        
      • for xerotic dermatitis, currently apply lotion extensively. Mycomb cream 2 tube topical bid use over itchy reddish papules and sinphraderm 1 tube topical QN use over dry scales.
• 2023-04-28 Hemato-Oncology
  • Q
    • Consult our CRS and then operation of T-colostomy was performed for rectal cancer obstruction on 2023/04/07. General condition is stationary and then transfer to ward on 2023/04/13.
    • Follow chest CT: Left upper lobe spiculated mass, suspect lung cancer, cT2aN0M0 on 2023/04/14.
    • We needs your expert experience for further evaluation and neoadjuvant CCRT. Thaks a lot!!
  • A2 - 2023-04-28
    • This 78 year old man is a case of Rectal cancer with obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM1a stage IVa and suspect lung cancer, cT2aN0M0 on 2023/04/14. We are consulted for further evaluation and CCRT.
    • Please arrange PET CT scan, arrange port A insertion.
    • Please check All-RAS-BRAF, anti HCV, anti HBc, anti HBs, HBsAg.
    • We will discuss with patient about further systemic treatment. Thanks for your consultation.
  • A1 - 2023-04-20
    • Please consult chest surgeon for further OP evaluation. If not suitable operation, may arrange CT guide biopsy for tissue proof (left upper lung lesion).
    • In addition, may also check TB sputum culture. Pending the result. Thanks for your consultation.
• 2023-04-26 Chest Medicine
  • Q
    • For further treatment of TB (Sputum Acid-fast Stain: Positive, MTBC PCR: detected) and take over
      • The uncle of Deputy Director Zheng Jingfeng
      • For deaf and mute individuals, please use written communication
  • A
    • Sputum Acid-fast Stain: Positive, MTBC PCR: detected. recommends isolation and treatment by Infection Control Team.
    • We takeover and give TB medication.
• 2023-04-18 Radiation Oncology
  • A
    • A: Adenocarcinoma of the rectum, stage T4aN2aM1a (stage IVA).
    • P: Neoadjuvant CCRT is indicated for this patient with the following indicators: stage T4aN2aM1a (stage IVA)
      • Goal: palliation
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectal tumor bed.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-04-24.
• 2023-04-07 Colorectal Surgery
  • Q
    • The sigmoidoscopy reveals Rectal cancer obstruction.
    • On 4/7 night, intubation for aspiration pneumonia with acute respiratory failure.
    • Due to Rectal cancer obstruction. consult for colostomy evaluaution. Thanks
  • A
    • RS colon cancer with obstruction for almost 1 week.
    • persist abdomen fullness and aspiration pneumonia
    • CRP: 8 yesterday
    • suggest T colostomy under risk, because bowel inflammation will worse for lont time obstruction.
• 2023-04-07 Infectious Disease
  • A
    • Consultation for Mepem antibiotic
    • Rectal cancer with colon obstruction and severe sepsis case.
    • Serial CxR films showed newly developed pneumonia.
    • Please continue Mepem for 5 days first.
    • Check blood and sputum culture report.

[surgical operation]

• 2023-04-07
  • Surgery
    • T colostomy
  • Finding
    • Severe dilation of T colon and mild ischemia
    • T colon ulcer

[radiotherapy]

[chemotherapy]

• 2023-05-16 - fluorouracil 225mg/m2 300mg NS 100mL 10min D1-5
  • [dexamethasone 4mg + NS 250mL] D1-5

==========

2023-07-13

[optional addition of Genurso for hyperbilirubinemia]

The addition of Genurso (ursodeoxycholic acid 100mg) #1 or #2 TID might be considered to help alleviate the patient’s hyperbilirubinemia. ref: Anti-Tuberculosis Drug Induced Liver Injury and Ursodeoxycholic Acid. Journal of Tuberculosis Research, Vol.8 No.2, 2020. https://doi.org/10.4236/jtr.2020.82007

2023-07-12

[approach to hepatotoxicity caused by antituberculous drugs]

AKuriT-4 was ceased on 2023-07-10, with bilirubin levels subsequently falling, though they still remain above twice the upper limit of normal (ULN).

• 2023-07-12 Bilirubin total 2.04 mg/dL
  
• 2023-07-10 Bilirubin total 2.98 mg/dL
  
• 2023-06-26 Bilirubin total 2.15 mg/dL

As per the “Approach to hepatotoxicity caused by first-line antituberculous drugs in adults” from UpToDate (https://www.uptodate.com/contents/image?imageKey=ID%2F109447), when the bilirubin level is less than 2mg/dL and the enzyme levels are less than twice the upper limit of normal, either a regimen made up of liver-sparing drugs (like ethambutol, a fluoroquinolone or linezolid) may be considered or the gradual reintroduction of first-line agents may be done.

Another study released in the New England Journal of Medicine in 2021 titled “Four-Month Rifapentine Regimens with or without Moxifloxacin for Tuberculosis” deduced that the effectiveness of a four-month regimen based on rifapentine, with or without moxifloxacin, was not inferior to the standard six-month regimen in the treatment of tuberculosis. The manufacturer’s guidelines for rifapentine do not include suggestions for dose adjustments in patients with hepatic impairment. It is believed that the pharmacokinetics of rifapentine in patients with varying degrees of hepatic impairment are similar to those in healthy volunteers.

2023-06-07

[following up on bilirubin and albumin levels]

• Laboratory data indicates that both total and direct bilirubin levels have started to decrease, though they have not yet returned to the normal range. This suggests that the current AKuriT-4 regimen is less likely to have a continuously damaging effect on the liver.
  • 2023-06-06 Bilirubin total 1.24 mg/dL
    
  • 2023-06-06 Bilirubin direct 0.53 mg/dL
    
  • 2023-05-29 Bilirubin total 1.54 mg/dL
    
  • 2023-05-29 Bilirubin direct 0.74 mg/dL
• Moreover, the patient’s albumin level has dropped to a record low of 2.3g/dL. Given that the patient’s kidney function appears normal (Cre 0.98 mg/dL, eGFR 78, BUN 16 mg/dL), the possibility of protein loss due to nephrotic syndrome is less likely. With bowel movements recorded at less than or equal to 3 since June, protein-losing enteropathy also appears less likely. If we rule out malnutrition as a cause, reduced albumin synthesis such as that seen in liver disease could potentially be the reason, warranting further investigation. Please monitor for signs of edema.
  • 2023-06-06 Albumin 2.3 g/dL
    
  • 2023-05-29 Albumin 2.6 g/dL

2023-06-01

[AKuriT-4 follow-up]

• Today, after discussing the patient’s condition with the attending physician and nurse practitioner, I learned that the changes in the patient’s liver function indicators have already been discussed with Dr. Su from the thoracic department. It is believed that there is no need to adjust the medication at this time.

2023-05-31

• A blood transfusion was performed on 2023-05-15 due to the patient’s low hemoglobin (HGB) levels. However, recent lab results still show a decreasing trend in HGB and a stool occult blood test result of 2+, which could suggest the possibility of ongoing GI bleeding. Although the patient is currently on a PPI (esomeprazole), if an upper GI source is suspected, the addition of tranexamic acid may be beneficial to control bleeding.
  • 2023-05-29 HGB 11.0 g/dL
    
  • 2023-05-26 HGB 12.0 g/dL
    
  • 2023-05-15 HGB 9.1 g/dL
    
  • 2023-05-26 stool OB 2+
• Furthermore, the patient’s serum albumin levels seem to be dropping. It’s recommended that the patient increase his protein intake, and nutritional support might be needed. If these measures are implemented and hypoalbuminemia persists, it might be necessary to consider adding an albumin supplement.
  • 2023-05-29 Albumin 2.6 g/dL
    
  • 2023-05-15 Albumin 2.6 g/dL
    
  • 2023-05-08 Albumin 2.9 g/dL
    
  • 2023-05-03 Albumin 2.9 g/dL
    
  • 2023-04-27 Albumin 3.1 g/dL
• This patient is currently being treated for lung TB with AKuriT-4 (rifampin 150mg + isoniazid 75mg + pyrazinamide 400mg + ethambutol 275mg) since 2023-04-26. Rifampin is associated with hepatotoxicity, which can manifest in various patterns including asymptomatic abnormal liver function tests, isolated jaundice or hyperbilirubinemia, symptomatic self-limited hepatitis, or even fulminant hepatic failure and death. Despite the patient’s AST and ALT levels being within normal range as of 2023-05-29, there has been a continuous increase in the patient’s bilirubin levels in 2023-05. This continuous increase in the patient’s bilirubin levels might potentially suggest rifampin-induced hepatotoxicity, particularly once other causes of elevated bilirubin, such as hemolysis, have been ruled out.
  • 2023-05-29 Bilirubin total 1.54 mg/dL
    
  • 2023-05-26 Bilirubin total 1.07 mg/dL
    
  • 2023-05-15 Bilirubin total 0.79 mg/dL
    
  • 2023-05-08 Bilirubin total 0.80 mg/dL
    
  • 2023-05-03 Bilirubin total 0.62 mg/dL
    
  • 2023-05-29 Bilirubin direct 0.74 mg/dL
    
  • 2023-05-26 Bilirubin direct 0.44 mg/dL
    
  • 2023-05-15 Bilirubin direct 0.29 mg/dL
    
  • 2023-05-03 Bilirubin direct 0.14 mg/dL

700385067

230713

• diagnosis - 2022-10-19 discharge note
  • Malignant neoplasm of mediastinum, part unspecified
  • Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2、Cisplatin 15mg/m2 on D1-5 Q3W) since 2022/09/20
  • Unspecified viral hepatitis B without hepatic coma
• lab data
  • 2022-09-17 Urine-Creatinine 142.38 mg/dL
    
  • 2022-09-17 U-Cr (24hr) 2135.7 mg/kg/24 hr
    
  • 2022-09-17 HBsAg Reactive
    
  • 2022-09-17 HBsAg (Value) 3335.07 S/CO
    
  • 2022-09-17 Anti-HBc Reactive
    
  • 2022-09-17 Anti-HBc-Value 7.18 S/CO
    
  • 2022-09-17 Anti-HCV Nonreactive
    
  • 2022-09-17 Anti-HCV Value 0.11 S/CO
    
  • 2022-09-16 beta-HCG 20.2 mIU/mL
    
  • 2022-09-16 AFP 1.6 ng/mL
    
  • 2022-09-15 LDH 397 U/L
    
  • 2022-09-15 AFP (nuclear medicine) 3.617 ng/ml
    
  • 2022-09-15 CEA (nuclear medicine) 12.729 ng/ml
    
  • 2022-09-15 SCC (nuclear medicine) 1.61 ng/mL
    
  • 2022-09-15 CA-199 (nuclear medicine) 23.149 U/ml
    
  • 2022-09-15 CA-125 (nuclear medicine) 24.131 U/ml
    
  • 2022-09-15 CyFra 21-1 (nuclear medicine) 14.0 ng/mL

[exam findings]

• 2023-06-07, -05-19, -05-03, -04-30 CXR
  • Prior plain chest film identified left superior mediastinal widening and enlarged Lt hilum is noted again, stable in size that is c/w Germ cell tumor S/P C/T with stable disease.
• 2023-04-18 CXR
  • Prior plain chest film identified left superior mediastinal widening and enlarged Lt hilum is noted again, marked decreasing in size that is c/w Germ cell tumor S/P C/T with partial response.
• 2023-03-27, -03-20, -03-10 CXR
  • There is left superior mediastinal widening and enlarged Lt hilum that is c/w Germ cell tumor after correlate with CT and pathology.
• 2023-02-18 CT - chest
  • Indication: germ cell tumor of left mediastinal progress and severe cough noted
  • Chest CT with and without IV contrast ehnancement shows:
    • Minimal interstitial change at bilateral peripheral lung fields is found.
    • Huge soft tissue mass with central necrotic part at superior mediastinum encasing great vasculature is found measuring 8.4cm in largest dimension. In comparison with CT dated on 2022-12-13, the lesion is stationary.
    • Calcified coronary arteries is found.
  • Imp:
    • Mediastinal mass, compatible with germ cell tumor. Stationary.
    • Interstitial change at both lungs. Either treatment effect or idiopathic pullmonary fibrosis should be considered. Suggest follow up.
• 2022-12-13 CT - abdomen
  • History and indication: Germ cell tumor of left mediastinal invasion
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Mild regression of germ cell tumors with mediastinnal invasion. S/P Port-A infusion catheter insertion. A thrombus at SVC. Some LNs at bil. neck and mediastinum.
    • Liver cysts (up to 1.0cm).
  • IMP:
    • Mild regression of germ cell tumors with mediastinnal invasion. S/P Port-A infusion catheter insertion. A thrombus at SVC. Some LNs at bil. neck and mediastinum.
• 2022-11-30 CXR
  • There is left superior mediastinal widening and enlarged Lt hilum that is c/w Germ cell tumor after correlate with CT and pathology.
• 2022-11-15, -11-01, -10-19, -10-05, -09-27 CXR
  • There is marked superior mediastinal widening (Lt greater than Rt), and enlarged Lt hilum that is c/w Germ cell tumor after correlate with CT and pathology.
• 2022-10-26 MRI - brain
  • Findings
    • mild dialted intraventricular and extraventricular CSF spaces
    • some white matter gliosis int he bilateral frontal brain parenchyma
    • unremarkable change in the skull base
    • no abnormal brain parenchymal enhancement
  • IMP:
    • no evidence of brain metastasis.
• 2022-09-19 CXR
  • marked superior mediastinal widening (Lt greater than Rt), displacing the trachea to Rt, and prominent soft-tissue over Lt supraclavicular fossa and enlarged Lt hilum, due to extensive lymphadenopathy or tumor and lymphadenopathy
  • Normal heart size
  • no pneumothorax or pleural effusion
• 2022-09-19 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 43 dB HL; LE 39 dB HL.
  • R’t mild to moderately severe MHL.
  • L’t mild to moderate MHL.
• 2022-09-16 CT - abdomen
  • History: Mediastinal mass, pathology: germ cell tumor
  • Indication: for cancer survey
  • Findings:
    • Prior CT identified a heterogeneous soft tissue mass at left upper anterior mediastinum, measuring 10 cm in the largest dimension, with encasement of left subclavian artery and aortic arch, causing mild right lateral deviation of the trachea and esophagus, and multiple enlarged nodes in left lower neck, paratracheal space, and left hilum are noted again, stationary.
      • Germ cell tumor is highly suspected.
    • There are several hepatic cysts in both lobes and the largest one 0.9 cm in size at S5.
  • Impression:
    • Germ cell tumor of left upper anterior mediastinum is highly suspected.
• 2022-09-16 Pulmonary function test
  • normal standard spirometry
  • negative BDT (bronchial dilation test)
  • normal DLCO (diffusion capacity of carbon monoxide)
• 2022-09-14 Bronchoscopy
  • no endotracheal or endobronchial lesion
• 2022-09-12 Patho - lung transbronchial biopsy
  • Mediastinum, CT-guide biopsy — in favor of germ cell tumor
  • Sections show nests of large pleomorphic tumor cells infiltrating in fibrous stroma with tumor necrosis.
  • The immunohistochemical stains reveal CK(+), SALL4(focal +), beta-hCG(focal +), CK7(-), CK20(-), CK5/6(-), TTF-1(-), Napsin A(-), p40(-), GATA3(focal +), PSA(-), CDX2(+), CD117(-), and CD56(-). According to the results, germ cell tumor (embryonal carcinoma or choriocarcinoma) is favored. Thymic tumor, lung cancer, mesothelioma, or lymphoma is less likely. Please correlate with the clinical presentation and image study.
• 2022-08-31 CT at ShuangHo Hospital
  • Findings: A 7.6 cm mass at LUL with mediastinal invasion causing confluence of lymph nodes in the paratracheal, prevascular, subcarinal and left hilar regions. Encasement of left subclavian artery and displacing trachea, esophagus and left CCA noted.
  • DDX: bronchogenic carcinoma, thymic carcinoma or other malignancy. Advise further work-up.
• 2022-08-31 Aspiration Cytology - lymph node
  • Clinical diagnosis: Paralysis of vocal cords and larynx, unspecified
    • Hoarseness for a month.
      
    • Previous URI(+)
      
    • Choking(+)
      
  • Cytological diagnosis
    • Left level IV mass: Positive for malignancy
      
  • Four wet smears show lymphocytes, neutrophils and some hyperchromatic atypical epithelial clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
• 2022-08-31 SONO - neck
  • Findings
    • Multiple LNs in bilateral neck, with size up to 1.42 cm in length at right and 2.37cm at left.
    • No abnormal fluid collection.
  • Imp: Multiple bilateral neck LNs.
• 2022-08-30 SONO - head and neck soft tissue
  • cervical lymph node: 1.34*3.0cm LAP at left supraclavicular fossa
• 2022-08-03 SONO - abdomen
  • Diagnosis
    • GB polyp, large R/O focal wall thickening
    • Parenchymal liver disease
  • Suggestion
    • Keep regular follow up

[MedRec]

• 2023-04-18 ~ 2023-05-05 POMR Hemato-Oncology
  • Discharge diagnosis
    • Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2 and Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/20 to 2023/01/04
    • Neutropenia due to infection post chemotherapy blood culture: no growth for 5 days aerobically & anaerobically
    • Hypokalemia
    • Hypomagnesemia
    • Anemia due to antineoplastic chemotherapy
  • Chief Complaints
    • for C2 chemotherapy with TIP & autologout stem cell collection
  • Present illness
    • Port-A implantation on 2023/03/10.
    • C1 chemotherapy with TIP was given on 3/21-3/25 23 and autologous hematopoietic cell transplantation was performed on 4/3 23.
    • Today, he was admitted for C2 chemotherapy with TIP & autologous hematopoietic cell transplantation on 4/18 23.
  • Course of inpatient treatment
    • After admission, chemotherapy with TIP (Taxol 250mg/m2, self-paid D1 4/19 ) & Mesna (300mg/m2, IVD 15mins, after Ifosfamide at 0, 4, 8 hour on 4/20-4/23), Ifosfamide 1500mg/m2 (D2-D5 4/20-4/23), Cisplatin (25mg/m2, D2-D5 4/20-4/23) were given, smoothly without obvious side effect. Lenograstim started since 4/25 23 was added. He complained of watery diarrhea and Imodium was given for symptom relief. Will arrange autologout stem cell collection on 5/4-5/5 23. Lenograstim 250mcg & G-CSF 150mcg sc qd was given for post C/T. He complained of watery diarrhea post C/T and Imodium 1# po prnq6h was added.
    • Fever with chills was developed on 4/27 23 afternoon and septic work-up was performed and antibiotic with Cefim 2000mg ivd q8h was given for neutropenia fever. The blood culture report showed No growth for 5 days aerobically & anaerobically. Blood transfusion with LPRBC 2U was given on 5/2 23. Double lumen was inserted on 5/3 23 and autologous stem cell collection on 5/3-5/4 23 and CD34+: 0.01% & CD34 + count (5/3 23): 25/uL, CD34+: 0.02% & CD34 + count (5/4 23): 60/uL were noted. Intravenous KCL 10cc & MgSO4 1amp was given for hypokalemia & hypomagnesemia. Double lumen was removed on 5/5 23 and he was discharged on 5/5 23 with stable condition and will follow-up at OPD.
• 2023-03-09 ~ 2023-04-03 POMR Hemato-Oncology
  • Discharge diagnosis
    • Malignant neoplasm of mediastinum, part unspecified
    • Germ cell tumor with left medistainal invastion, stage IV, S/P BEP chemotherapy with refractory, S/P TIP chemotherapy and autologous stem cell collection
    • Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2 and Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/20 to 2023/01/04
  • Present illness
    • This 53 year-old man suffered from hoarsness in 2022/08. He went to local clinic first and they suggested hospital follow up. He then went Shuang Ho Hospital for help. According to CT report from Shaung Ho, there is a 7.6 cm mass at LUL with mediastinal invasion and encasement of left subclavian artery and displacing trachea, esophagus and left CCA noted. Differential diagnosis included bronchogenic carcinoma, thymic carcinoma or other malignancy.
    • He then came to our otorhinolaryngology clinic for further evaluation. Nasopharyngoscopy on 2022/08/30 showed smooth nasopharynx, oropharynx, hypopharynx and left vocal cord palsy. Neck sonography revealed left supraclavicular lymphadenopathy. Moreover, sono-guide fine needle aspiration revealed metastatic malignancy. He was reffered to our chest surgery clinic for further management.
    • After admission, CT-guide biopsy of left mediastinal mass on 2022/09/12 showed left mediastital mass revealed germ cell tumor, embryonal carcnimoa or choriocarcinoma is favored. Upper GI endoscopy on 2022/09/13 revealed reflux esophagitis. Bronchoscopy on 2022/09/14 showed no endotracheal or endobronchial lesion. Abdominal/Pelvic CT on 2022/09/16 showed germ cell tumor of left upper anterior mediastinum is highly suspected.
    • For pre-chemotherapy evaluation, pulmonary function test (FRC + DLCO) on 2022/09/16 normal standard spirometry, 24 urine CCR on 2022/09/17 showed 178.7 ml/min / urine 1500 ml/day, pure-tone audiometry test on 2022/09/19 showed R’t mild to moderately severe MHL, L’t mild to moderate MHL. Port-A insertion on 2022/09/19.
    • Chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2 and Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/20_{2022/09/25(C1D1}D5), 2022/09/28(C1D9), 2022/10/20_{2022/10/25(C2D1}D5), 2022/10/28(C2D9), 2022/11/01(C2D16), 2022/11/15_{2022/11/20(C3D1}D5), 2022/11/22(C3D9), 2022/12/06_{2022/12/11(C4D1}D5), 2022/12/14(C4D9), 2022/12/17-2023/01/01(C5D1~D5), 2023/01/04(C5D9).
    • CXR on 2022/09/27 showed mediastinal widening (left greater than right) improving, and enlarged left hilum. Brain MRI on 2022/10/26 showed no evidence of brain metastasis. CXR on 2022/11/15 showed mediastinal widening (left greater than right) mild improving. Abdominal CT on 2022/12/13 showed mild regression of germ cell tumors with mediastinnal invasion, a thrombus at SVC and some lymph nodes at bil. neck and mediastinum.  
    • He had COVID-19 infection on 2023/02, but he denied cough, sputum or fatigue. But, before C6D1 chemotherapy, he has fever with chills suddenly, so we hold chemo and check blood studies. R’t Port-A was removed by CS for yield Pseudomonas spp on 2023/02/10. Fever also noted durine Cefepime, consider tumor fever related. He received Chest CT showed mediastinal mass, compatible with germ cell tumor stationary and interstitial change at both lungs on 2023/02/18, but image showed mediastinal mass got bigger and due to a 1cm x 1cm LN over left suparclavicle, so we thick the disease in progress. After well infection control, discharged on 2023/02/22.
    • This time, he had mild fever at home (highest to 37.6’C), and he had mild cough without sputum, no fever, mild dysphagia was noted. He was admitted for port-A implantation and receive new regimen chemotherapy.
  • Course of inpatient treatment
    • After admission, consult CS for Port-A implantation on 2023/03/10, funtion well. Pain control with Tramacet 37.5 & 325mg/tab 1# PO Q12H. He was transfered to Dr. Wan service for autologous hematopoietic cell transplantation (autoHCT). Palitaxel on (2023/03/21) -> Ifosfamide, cisplatin (2023/03/22-2023/03/25). G-CSF 150mcg, granocyte 500mcg (2023/03/27-). We would keep on monitoring his clinical manifestation and provide necessary treatments.
    • On 2023/04/03, we placed a double lumen catheter for stem cell collection. After one day with 18 liters of peripheral blood circulation through the cell separater and CD34+ cell collection. Total 1.99 x 10 ^6/kg of CD 34+ cells were collected. Removal of the double lumen catheter and disharged at today. The next chemotherapy and then stem cell collection will be scheduled at April 11.

[consultation]

• 2022-12-08 Dermatology
  • Q
    • This 53-year-old man patient is a case of Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2、Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/20~. He was admitted for chemotherapy with BCP(C4). this time, for left upper arm redness rash without itch, R/O hemangioma. Now, for evaluate left upper arm redness rash therapy. Thank you.
  • A
    • The patient had sufferred from germ cell tumor under chemotherapy. region telangetasia with vascular dialation was noted over left upper limb.
    • Besides, no regional swelling or tenderness was noted.
      
    • Under the impression of peripheral vsaculopathy, be aware of progressive vasculitis, favor IV form medication-related.
    • The following suggestion:
      • notify IV form electrolyte infusion rate, decrease osmotic imbalance as possible.
        
      • Due to no obvious clinical symptom, further regional skin care and moisturization with Sinphraderm cream 1 tube topical bid use.
• 2022-09-26 Hemato-Oncology
  • Q
    • This 53-year-old man was admitted under impression of LUL mediastinal mass.
    • CT-guide biopsy was done and pathology revealed germ-cell tumor (embryonal carcinoma or choriocarcinoma is favored)
      • LDH 397
      • AFP 3.617
      • CEA 12.7
      • CA 199 23.1
      • CA 125 24.1
      • CyFra 14
    • We need your expertise for this patient’s further management
  • A
    • Impression:
      • LUL mediastinal mass s/p CT guide biopsy, pathology show germ cell tumor (embryonal carcinoma or choriocarcinoma is favored) LDH 397, AFP 3.617-B HCG: pending.
    • Suggestion:
      • For germ cell tumor cancer work up, please arrange abdominal/pelvic CT and Pending B-HCG level
      • Prepare cancer treatment, please arrange pulmonary function test (FRC + DLCO), 24 urine CCR, Pure-tone audiometry test, HbsAg, Anti Hbc, Anti HCV
      • On port-A if patient agree further systemic chemotherapy. We wound like to take over this case, if you agree.
      • Thanks for your consultation. If there is any problem, please feel free to let us known

[chemoimmunotherapy]

• 2023-06-07 - paclitaxel 250mg/m2 420mg NS 500mL 24hr D1 + [ifosfamide 1500mg/m2 2600mg NS 500mL + mesna 300mg/m2 510mg NS 250mL 15min (x3 at 0, 4, 8 hr after ifosfamide) + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 250mL 1hr + NS 500mL 2hr (after cisplatin)] D2-5 (for PBHSC harvest)
  • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL] D1-5 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3
• 2023-04-19 - paclitaxel 250mg/m2 430mg NS 500mL 24hr D1 + [ifosfamide 1500mg/m2 2600mg NS 500mL ………………………………………………………………. + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 250mL 1hr + NS 500mL 2hr (after cisplatin)] D2-5 (for PBHSC harvest)
  • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL + palonosetron 250ug] D1-5
• 2023-03-20 - paclitaxel 250mg/m2 420mg NS 500mL 24hr D1 + [ifosfamide 1500mg/m2 2580mg NS 500mL ………………………………………………………………. + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 250mL 1hr + NS 500mL 2hr (after cisplatin)] D2-5 (for PBHSC harvest)
  • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL + palonosetron 250ug] D1-5
• 2023-02-07 - etoposide 80mg/m2 140mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 27mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
  • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5 + famotidine 20mg D1
• 2023-01-04 - bleomycin 30mg NS 100mL 10min D2,9,16
  • dexamethasone 8mg + diphenhydramine 30mg + NS 250mL
• 2022-12-27 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
  • dexamethasone 8mg ST D1 & 8mg QD D2-5 + diphenhydramine 30mg ST & 30mg QD D2-5 + palonosetron 250ug D1 + aprepitant 125mg ST D1 & 125mg QD D2-3
• 2022-12-13 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1222, 1223)
  • dexamethasone 8mg + diphenhydramine 30mg
• 2022-12-06 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
• 2022-11-22 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1130, 1201, 1202)
• 2022-11-15 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
• 2022-11-01 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1101, 1108, 1110)
• 2022-10-28 - bleomycin 30mg NS 100mL 10min D2,9,16
• 2022-10-19 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
• 2022-09-28 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1105, 1106, 1107)
• 2022-09-20 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16

Granocyte (lenograstim) 250mg SC

• 2022-12-22, -23 (20221221 OpdRx)
• 2022-12-01, -02 (20221130 OpdRx)
• 2022-11-30 (20221115 IpdRx)
• 2022-11-08, -10 (20221101 OpdRx)
• 2022-11-01 (20221019 IpdRx)
• 2022-10-05, -06, -07 (20221005 OpdRx)

lab WBC

• 2022-12-27 WBC 9.45 *10^3/uL BEP 1227
• 2022-12-21 WBC 2.00 *10^3/uL G-CSF 1222, 1213
• 2022-12-13 WBC 2.66 *10^3/uL bleomycin 1213
• 2022-12-06 WBC 6.11 *10^3/uL BEP 1206
  
• 2022-11-30 WBC 1.73 *10^3/uL G-CSF 1130, 1201, 1202
  
• 2022-11-23 WBC 3.52 *10^3/uL bleomycin 1122
  
• 2022-11-15 WBC 5.84 *10^3/uL BEP 1115
  
• 2022-11-01 WBC 2.38 *10^3/uL G-CSF 1108, 1110
  
• 2022-10-28 WBC 3.01 *10^3/uL G-CSF 1101; bleomycin 1028
• 2022-10-19 WBC 6.04 *10^3/uL BEP 1019
• 2022-10-12 WBC 6.84 *10^3/uL
  
• 2022-10-05 WBC 1.17 *10^3/uL G-CSF 1105, 1106, 1107
• 2022-09-26 WBC 11.36 *10^3/uL bleomycin 0928
• 2022-09-20 WBC 5.46 *10^3/uL BEP 0920
• 2022-09-12 WBC 4.52 *10^3/uL

[note]

• Germ Cell Tumors http://www.csh.org.tw/dr.tcj/educartion/f/web/Germ%20cell%20tumor/index.htm
  • In patients with pure seminoma, increased AFP levels indicate an undetected nonseminomatous tumor component.
  • Increased levels of beta-HCG are found in seminomas and in nonseminomas.
  • Increased levels reflect tumor burden, growth rate, and cellular proliferation.

==========

2023-07-13

• Over the last three months, this patient has solely been utilizing our hospital’s outpatient and inpatient hemato-oncology services. There have been no issues identified regarding medication reconciliation.

2023-06-08

• Based on the PharmaCloud database, this patient has exclusively been visiting our hospital for outpatient and inpatient hemato-oncology services over the past three months. No medication reconciliation issues have been identified.

2022-12-28

• CT on 2022-12-13 showed mild regression of germ cell tumors with mediastinal invasion, suggesting that the current BEP regimen is effective in inhibiting tumor progression. CS opinioned on 2022-12-22 that the tumor was not suitable for surgical removal due to the fact that it encased large vessels over the mediastinum.
• In accordance with the appropriate G-CSF administration timing, there have been no WBC events less than 2K/uL since December 2022.
• Although magnesium supplements were administered, lab results showed a slow decline in serum magnesium levels (now slight below LLN).
  • 2022-12-27 Mg (Magnesium) 1.8 mg/dL
    
  • 2022-12-21 Mg (Magnesium) 1.8 mg/dL
    
  • 2022-12-13 Mg (Magnesium) 1.6 mg/dL
    
  • 2022-12-06 Mg (Magnesium) 1.7 mg/dL
    
  • 2022-11-30 Mg (Magnesium) 1.6 mg/dL
    
  • 2022-11-23 Mg (Magnesium) 1.7 mg/dL
    
  • 2022-11-15 Mg (Magnesium) 1.9 mg/dL
    
  • 2022-10-28 Mg (Magnesium) 1.8 mg/dL
    
  • 2022-09-26 Mg (Magnesium) 1.9 mg/dL
    
  • 2022-09-20 Mg (Magnesium) 2.0 mg/dL
    
• Magnesium losses from both the upper and lower gastrointestinal tract can induce hypomagnesemia. In general, magnesium depletion is more commonly due to diarrhea than to vomiting. As there have been no recent diarrhea or vomiting-related events recorded, these may be less likely to be to blame.
• Hypomagnesemia due to urinary magnesium wasting occurs in over one-half of cases of cisplatin-induced nephrotoxicity and can be severe. It is dose related and can occur without the presence of concomitant AKI. In patients who receive cisplatin for several months, urinary magnesium wasting may persist even after discontinuation of cisplatin therapy. In addition to its direct clinical manifestations, hypomagnesemia may exacerbate cisplatin toxicity. As always, regular monitoring is essential.
• There is no problem with the active prescription.

2022-12-07

• It appears that the approximate cycled trough WBC count occured around one week after the administration of single bleomycin agent, the G-CSF administration might follow this pattern.

  • 2022-12-06 WBC 6.11 *10^3/uL BEP 1206
    
  • 2022-11-30 WBC 1.73 *10^3/uL G-CSF 1130, 1201, 1202
    
  • 2022-11-23 WBC 3.52 *10^3/uL bleomycin 1122
    
  • 2022-11-15 WBC 5.84 *10^3/uL BEP 1115
    
  • 2022-11-01 WBC 2.38 *10^3/uL G-CSF 1108, 1110
    
  • 2022-10-28 WBC 3.01 *10^3/uL G-CSF 1101; bleomycin 1028
  • 2022-10-19 WBC 6.04 *10^3/uL BEP 1019
  • 2022-10-12 WBC 6.84 *10^3/uL
    
  • 2022-10-05 WBC 1.17 *10^3/uL G-CSF 1105, 1106, 1107
  • 2022-09-26 WBC 11.36 *10^3/uL bleomycin 0928
  • 2022-09-20 WBC 5.46 *10^3/uL BEP 0920
  • 2022-09-12 WBC 4.52 *10^3/uL

• The AFP/beta-HCG/LDH tests might be conducted again in December 2022 to make the monitor frequency not fall below two months. (There were still superior mediastinal widening and an enlarged Lt hilum on the CXR of 2022-11-30)

• Pulmonary fibrosis is the most severe toxicity associated with bleomycin. The most frequent presentation is pneumonitis occasionally progressing to pulmonary fibrosis. Its occurrence is higher in elderly patients and in those receiving more than 400mg total dose, but pulmonary toxicity has been observed in young patients and those treated with low doses.

  • 2022-09-16 pulmonary function test showed the patient with normal standard spirometry, negative BDT, normal DLCO.
  • As of 2022-12-07, there has been 240mg (30mg x 8) of cumulative exposure to bleomycin.
  • Please monitor for signs of lung deterioration on a regular basis.

2022-11-16

• Lab data from selected tumor markers revealed that each marker had a different trend without an overall trend.
  • 2022-11-01 AFP 16.6 ng/mL
    
  • 2022-09-16 AFP 1.6 ng/mL
    
  • 2022-07-05 AFP 1.4 ng/mL
    
  • 2022-11-01 beta-HCG 5.8 mIU/mL
    
  • 2022-09-16 beta-HCG 20.2 mIU/mL
    
  • 2022-10-19 LDH 377 U/L
    
  • 2022-10-12 LDH 349 U/L
    
  • 2022-09-26 LDH 253 U/L
    
  • 2022-09-15 LDH 397 U/L
• The WBC is boosted with lenograstim when neutropenia is observed following the BEP regimen.
• Chronic hepatitis B is treated appropriately with Baraclude (entecavir) 0.5mg QDAC.
• The active prescription is not subject to any issues.

2022-10-20

• The primary chemotherapy regimen for germ cell tumors could be BEP, which consists of the following components (NCCN).

  • Etoposide 100 mg/m2 IV on Days 1-5
  • Cisplatin 20 mg/m2 IV on Days 1-5
  • Bleomycin 30 units IV weekly on Days 1, 8, and 15 or Days 2, 9, and 16
  • Repeat every 21 days

• AST, ALT, Cre, and eGFR (2022-10-19) did not exhibit abnormalities, therefore no dose adjustment would be required for the BEP regimen based on pharmacokinetics.

• The dose used is slightly lower than that recommended by the NCCN (currently: 80mg/m2 of etoposide, 15mg/m2 of cisplatin. NCCN: 100mg/m2, 20mg/m2). Given that the patient’s performance status scale is ECOG 0, it might be an option to upgrade the dose to meet the guideline to obtain more expected effects if no other considerations exist.

701050910

230713

[exam findings]

• 2023-07-06 SONO - abdomen
  • Diagnosis:
    • Splenic fossa tumor, enlarged compared to 2022/08 (DDx: lymphoma?, accessory spleen hyperplasia?)
    • Post splenectomy
    • Parenchymal liver disease, mild
    • Pancreatic cystic lesion, body, size similar
    • Renal cysts, both
  • Suggestion:
    • Consider other image studies for the enlaring splenic tumor
• 2023-07-05 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Hairy cell leukemia, relapsed
  • The sections show hypercellular marrow (60%). Diffuse sheets of monotonous neoplastic cells (80% marrow cells) with oval nuclei surrounded by abundant clear or light pink cytoplasm, and decreased trilineage hematopoiesis are present. Mild marrow fibrosis can be identified.
  • IHC, the neoplastic cells show: CD3(-), CD20(+), DBA 44(+) and Annexin A1(+). The finding is consistent with relapsed hairy cell leukemia.
• 2023-07-05 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2022-08-24 SONO - abdomen
  • Parenchymal liver disease, mild
  • Suspected Pancreatic cystic lesion, body (stationary)
  • Renal cysts
  • Chronic kidney disease (left)
  • Post splenectomy
  • Probable Accessary spleen (2.91 cm)
• 2021-03-15 CXR
  • Linear infiltration over right lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
  • Borderline cardiomegaly
• 2021-03-01 SONO - abdomen
  • Fatty liver, mild
  • s/p splenectomy with small residue spleen
  • Renal cyst, bilateral
• 2021-03-08 CXR
  • Consolidation in right lower lung zone, r/o pneumonia
• 2021-03-08 CT - abdomen
  • Partial consolidation at RLL. R/O pneumonia
  • S/P splenectomy with a accessory spleen ?
  • Bil. renal cysts (up to 6.3cm). Left renal stone (3mm).
• 2020-12-15 Patho - bone marrow biopsy (Y1)
  • Bone marrow, iliac, biopsy — B cell leukemina.
  • Section shows piece(s) of bone marrow with 100% cellularity and M:E ratio of approximately 10:1. There is a predominant small to medium size atypical lymphoid population present.
  • IHC stains: CD3: 2%, CD20: 95%, CD5: 2%, CD19: 95%; CD23: ＜1%.

[MedRec]

• 2021-03-25 ~ 2021-04-02 POMR Hemato-Oncology
  • Discharge diagnosis
    • Chronic lymphocytic leukemia of B-cell type not having achieved remission
    • Relapsed HAIR CELL LEUKEMIA s/p Leustatin (cladribine)
    • Carrier of viral hepatitis B
    • Thrombocytopenia, unspecified
  • CC
    • for scheduled chemotherapy
  • Present illness
    • This 65 year-old male patient has the history of 1. HBV carrier 2. s/p splenectomy on 2016-11-16 3.CLL s/p C/T Splenomegaly was told during routine GI OPD f/u. Thrombocytopenia was also noticed. Thus, splenectomy was performed 2016-11-16. However, leukocytosis and anemia were found recent 2 months. He deined any body weight loss, appetite change, fever and abdominal disconfortable. He then visited our OPD and was admiited for bone marrow pucture on 2016/01/03. The pathology result showed Lymphocytic leukemia, B cell type. Flow cytometry at NTUH and TSGH revealed TRAP (+). Hairy cell leukemia was diagnosed. Evaluation of Abdominal echo was arranged for previous history of HBV and the reprot showed suspect retroperitoneal lesion. Furtehr abdominal CT was performed and the result revealed left renal stone & cyst and accesory spleen on 2016-01-30. Bone morrow aspiration and biopsy were done smoothly on 2020/12/15, pathology showed B cell leukemina.
    • Leustatin (cladribine) from 2016/2/20-2/26 6mg in 500ml saline drip for 24 hrs (10ml/vial, 1mg/1ml)
    • This time, he was admitted for scheduled chemotherapy
  • Course of inpatient treatment
    • After admission, chemotherapy with Leustatin 6g QD was administered from 2021/03/25-31. Fever without chills was noted on 3/25, follow up blood culture yielded negative and Acetaminophen prn used. Blood transfusion with LRP or LPRBC if necessary. With the relatively stable condition, he was discharged on 2021/04/02 and will OPD follow up later.
    • take Lenograstim 250mcg on 4/3, 4/4
  • Discharge prescription
    • Granocyte (lenograstim 250mcg) QD SC 2D on 4/6, 4/7
• 2020-12-13 ~ 2020-12-15 POMR Hemato-Oncology
  • Discharge diagnosis
    • Chronic lymphocytic leukemia of B-cell type not having achieved remission
    • Carrier of viral hepatitis B
    • Chronic viral hepatitis B without delta-agent
    • Neoplasm of unspecified behavior of digestive system
    • Thrombocytopenia, unspecified
  • CC
    • Thrombocytopenia noted for week
  • Present illness
    • This 60 year-old male patient has the history of 1. HBV carrier 2. s/p splenectomy on 2016-11-16 3. CLL s/p C/T Splenomegaly was told during routine GI OPD f/u. Thrombocytopenia was also noticed. Thus, splenectomy was performed 2016-11-16. However, leukocytosis and anemia were found recent 2 months. He deined any body weight loss, appetite change, fever and abdominal disconfortable. He then visited our OPD and was admiited for bone marrow pucture on 2016-01-03. The pathology result showed Lymphocytic leukemia, B cell type. Flow cytometry at NTUH and TSGH revealed TRAP (+). Hairy cell leukemia was diagnosed. Evaluation of Abdominal echo was arranged for previous history of HBV and the reprot showed suspect retroperitoneal lesion. Furtehr abdominal CT was performed and the result revealed left renal stone & cyst and accesory spleen on 2016-01-30. Today, he was admitted for Anemia and thrombocytopenia and further chemotherapy of Leustatin.
  • Course of inpatient treatment
    • After admission, thrombocytopenia was noted. Bone morrow aspiration and biopsy were done smoothly on 12/15. Peripheral blood example was collected for smear. There was no soreness or active bleeding noted. Since relative stable condition, he was discharged on 2020/12/15 and OPD follow up.

[immunochemotherapy]

• 2023-07-07 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cladribine 6mg NS 500mL 24hr D2-8
  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-8 + betamethasone 4mg D2-8
• 2021-03-25 - cladribine 6mg NS 500mL 24hr D1-7
  • [diphenhydramine 30mg + NS 250mL] D1-7

[note]

Hairy Cell Leukemia SUGGESTED TREATMENT REGIMENS - NCCN Evidence Blocks - Version 1.2023 - 2022-10-13 — HCL-A 1 OF 2, p7

• Initial Therapy
  • Preferred Regimens
    • Purine analogs
      • Cladribine ± rituximab
      • Pentostatin
  • Useful in Certain Circumstances (consider for patients who are unable to tolerate purine analogs including frail patients and those with active infection)
    • Vemurafenib + obinutuzumab
• Relapsed/Refractory Therapy
  • Less than complete response after initial treatment OR Relapse < 2 years
    • Preferred Regimens
      • Clinical trial
      • Alternative purine analog + rituximab
      • Vemurafenib ± rituximab
    • Other Recommended Regimens
      • Peginterferon-alfa 2a
      • Alternative purine analog
    • Useful in Certain Circumstances
      • Rituximab, if unable to receive purine analog
  • Relapse >= 2 years
    • Preferred Regimens
      • Retreat with initial purine analog + rituximab
      • Alternative purine analog + rituximab
    • Other Recommended Regimens
      • none
    • Useful in Certain Circumstances
      • Rituximab, if unable to receive purine analog
• Progressive Disease After Relapsed/Refractory Therapy
  • Preferred Regimens
    • Clinical trial
    • Moxetumomab pasudotox
    • Vemurafenib ± rituximab (if not previously given)
  • Other Recommended Regimens
    • Ibrutinib

Cladribine 2023-07-13 https://www.uptodate.com/contents/cladribine-drug-information

• Adult Dosing - Hairy cell leukemia:
  • IV:
    • 0.14 mg/kg/day over 2 hours for 5 days for 1 cycle or
    • 0.1 mg/kg/day continuous infusion for 7 days for 1 cycle or
    • 0.09 mg/kg/day continuous infusion for 7 days for 1 cycle or
    • 0.15 mg/kg/day over 2 hours on days 1 to 5 as a single course (in combination with concurrent or delayed rituximab) or
    • 5.6 mg/m2 over 2 hours once daily for 5 days as a single course, followed 28 days later by rituximab.
  • SUBQ (off-label route):
    • 0.1 to 0.14 mg/kg/day for 5 days for 1 cycle.

Rituximab 2023-07-13 https://www.uptodate.com/contents/rituximab-intravenous-including-biosimilars-drug-information

• Adult Dosing - Hairy cell leukemia (off-label use):
  • In combination with cladribine (as initial treatment or after first relapse): IV:
    • 375 mg/m2 once weekly (beginning 28 days ± 4 days after initiation of 5 days of cladribine) for 8 doses or
    • 375 mg/m2 once weekly (beginning concurrently with cladribine) for 8 doses.
  • In combination with vemurafenib (relapsed or refractory disease): IV:
    • 375 mg/m2 on days 1 and 15 every 6 weeks (in combination with vemurafenib) for 2 induction cycles, followed by 375 mg/m2 once every 2 weeks for 4 rituximab monotherapy consolidation doses (total of 8 rituximab doses).

==========

2023-07-13

[leukopenia]

The recent WBC nadir was noted on 2023-07-10 with a count of 0.88K/uL, and by 2023-07-12, an increase to 1.21K/uL was evident.

• 2023-07-12 WBC 1.21 x10^3/uL **
• 2023-07-10 WBC 0.88 x10^3/uL ***
• 2023-07-07 WBC 3.56 x10^3/uL
  
• 2023-07-05 WBC 2.23 x10^3/uL *
• 2023-07-04 WBC 3.61 x10^3/uL

The patient received the regimen of cladribine plus rituximab on 2023-07-07. It’s well known that cladribine injection often leads to dose-dependent myelosuppression (manifested as neutropenia, anemia, and thrombocytopenia), typically reversible. Additionally, rituximab is associated with an incidence of neutropenia (8% to 14%; grades 3/4: 4% to 49%). As such, the regimen could be the primary cause of the patient’s recent leukopenia.

Given the current trend of increasing WBC count without the administration of G-CSF, it would be advisable to continue monitoring over the next few days to verify if the developed leukopenia is resolved.

[thrombocytopenia]

(this pharmacist note is a continuation of the previous one)

Even as the WBC count gradually recovers, platelet levels continue to decline, noted at 40K/uL on 2023-07-12. If this decrease continues, it is typically recommended to consider transfusion if the platelet count drops to or below a threshold of 10K/uL. If fever, sepsis, or coagulopathy is present, higher thresholds may be needed.

• 2023-07-12 PLT 40 x10^3/uL
  
• 2023-07-10 PLT 75 x10^3/uL
  
• 2023-07-07 PLT 122 x10^3/uL

700014611

230712

(not completed)

[exam findings]

[chemotherapy]

==========

2023-07-12

[reconciliation]

This patient intermittently visits a local ophthalmology clinic due to symptoms in his left eye. His most recent visit was on 2023-06-30, and the prescription given, which was valid for 3 days, has now expired. Please decide whether to refer him to our hospital’s ophthalmology department based on his current clinical condition.

700354357

230712

[diagnosis] - 2023-03-10 admission note

• Malignant neoplasm of other parts of pancreas
• Encounter for antineoplastic chemotherapy
• Type 2 diabetes mellitus without complications
• Malignant neoplasm of other parts of pancreas
• Chronic viral hepatitis B without delta-agent
• Chronic viral hepatitis C
• Status post Liver transplantation
• Cachexia

[past history]

• Medical Hx:
  • Prostate cancer s/p R/T 37 times in 2009.
  • DM for more than 10 years
  • HCV related liver cirrhosis, liver transplantation in 2007 in China.

[allergy]

• NKDA

[family history]

• Family history is unremarkable.
• There is no family history of hypertension, mental diseases or asthma.
• No members of the family with diabetes.  
• Mother has lung cancer

[exam findings]

• 2023-04-28 CT - abdomen
  • Indication
    • 20230113 CC: wight loss from 70 to 52 Kgs in the past 2 months.
      • Anorexia since Sep 2022. Low abdominal pain since 6 Dec 2022.
      • Chronic diarrhea since 3 months ago.
        
      • He had undergone liver transplantation in 2007 in China.
    • 20230113 CT: Adenocarcinoma of pancreatic neck, cT4N1M0, stage III
    • 20230113 CA199: 53.89 U/mL (<35).
    • 20230117 EUS biopsy: adenocarcinoma
    • 20230202 s/p chemotherapy with FOLFIRINOX
  • Past history: Ca of prostate s/p R/T in 2009. D.M > 10 years.
  • Findings comparison prior CT dated 2023/01/13.
    • There is newly developed ascites in the abdomen and pelvis. please correlate with clinical condition.
    • Prior CT identified an ill-defined poor enhancing mass-like lesion in the pancreatic neck is noted again, mild decreasing in size and poor margination.
      • Prior CT identified dilatation of the upstream pancreatic duct is noted again, stationary.
      • In addition, Prior CT identified tumor seeding and encasement in the celiac trunk and common hepatic artery and the distal splenic vein, (beyond the trifurcation) is noted again, stationary.
    • Prior CT identified metastatic nodes in the hepatoduodenal ligament are noted again, mild decreasing in size.
      • Prior CT identified tumor direct invasion the stomach antrum or duodenum 1st portion is noted again, mild decreasing in size.
    • A cystic lesion 1 cm in the pancreatic head is noted.
    • There is mild wall thickening at the gastric antrum. Please correlate with gastroscopy.
    • S/P cadavertic liver transplantation and S/P cholecystectomy.
      • A hepatic cyst measuring 0.6 cm in S2 is noted.
    • A renal cyst measuring 2.1 cm in right middle pole is noted.
      • The spleen shows prominence in size (long axis: 12 cm).
    • Others
      • There is no focal abnormality in the biliary system.
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
  • IMP:
    • Newly developed ascites. please correlate with clinical condition.
    • Adenocarcinoma of the pancreatic neck S/P C/T show partial response.
• 2023-01-17 Patho - pancreas biopsy
  • Labeled as “pancreas, neck”, EUS fine needle biopsy — pancreatic adenocarcinoma.
  • IHC stains: CA19-9 (+), CK19 (+), CD56 (-), CK7 (+), CK20 (focal +).
  • Section shows few loosely cohesive neoplastic glands. IHC stains: CA19-9 (+), CK19 (+), CD56 (-), CK7 (+), CK20 (focal +).
• 2023-01-17 ECG
  • Sinus rhythm with 1st degree A-V block
  • Right bundle branch block
• 2023-01-13 Endoscopic Ultrasonography, EUS
  • Pancreatic neck tumor T4NxMx s/p CEH-EUS & EUS/FNB
  • Pancreatic cystic lesion, head portion
• 2023-01-13 CT - abdomen
  • CC: wight loss from 70 to 52 Kgs in the past 2 months.
    • Anorexia since Sep 2022.
    • Low abdominal pain since 6 Dec 2022.
    • Chronic diarrhea since 3 months ago. Colon polyp was removed on 29 Nov 2022.
    • He had undergone liver transplantation in 2007 in China.
  • Past history: Ca of prostate s/p R/T in 2009. D.M > 10 years.
  • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is an ill-defined poor enhancing mass-like lesion in the pancreatic neck (Srs:601 Img:24), 3.7 x 2 cm in size, causing dilatation of the upstream pancreatic duct 9 mm in diameter.
      • In addition, There are soft tissue lesions in the celiac trunk and common hepatic artery surrounding area that may be tumor encasement. The distal splenic vein, beyond the trifurcation, shows small size that also may be tumor encasement.
      • Adenocarcinoma of the pancreatic neck (T4) is highly suspected.
      • Please correlate with CA199 and MRI.
    • There are soft tissue lesions in the hepatoduodenal ligament that may be metastatic nodes (N1).
    • There is fat plane obliteration between the pancreatic neck mass and the stomach antrum or duodenum 1st portion that may be tumor direct invasion.
    • A cystic lesion 1 cm in the pancreatic head is noted.
    • There is mild wall thickening at the gastric antrum.
      • Please correlate with gastroscopy.
    • S/P cadavertic liver transplantation and S/P cholecystectomy.
      • A hepatic cyst measuring 0.6 cm in S2 is noted.
        
    • A renal cyst measuring 2.1 cm in right middle pole is noted.
    • Others
      • There is no focal abnormality in the liver, biliary system, spleen & left kidney.
      • There is no ascites.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion over the mesentery and omentum.
  • IMP:
    • Adenocarcinoma of the pancreatic neck is highly suspected. Please correlate with CA199 and MRI.
    • If pancreatic cancer is finally proved by pathology. According to American Joint Committee on Cancer(AJCC) staging system, 8th edition for pancreatic cancer: T4 N1 M0, Stage:III

[MedRec]

• 2023-03-28 Hemato-Oncology
  • O: AE Gr 3 Neutropenia -> Improved to Gr 1
• 2023-02-22 Hemato-Oncology
  • O: AE Gr 3 Neutropenia -> Improved
• 2023-02-15 Hemato-Oncology
  • Now on Induction FOLFIRINOX, C1D1 on 2023-02-02
  • Already mention treatment strategy
    • Induction chemotherapy with FOLFIRINOX
    • If OP is feasible, go to OP; if OP is not feasible, go to CCRT.
• 2023-02-14 SOAP Radiation Oncology
  • S
    • For radiotherapy due to pancreatic neck adenocarcinoma.
    • PI: The patient transferred from TSGH (Dr. Chao) for CCRT due to pancreatic carcinoma. He was a case of prostate cancer s/p radiotherapy at TSGH.
    • Chemotherapy: 2023-02-02
    • Family history: (mother: lung cancer)
    • Cancer site specific factors: Alcohol (quit); Smoking (-); Betel nut (-).
    • Personal Hx: DM(-); HTN(+); s/p liver transplantation at China.
    • Allergy(-)
    • Previous RT Hx: radiotherapy of the prostate at TSGH.
  • P
    • Preliminary planning dose: 4500cGy/25 fractions of the pancreatic neck tumor, peripheral involved, and regional lymphatic area.
• 2023-01-13 SOAP Gastroenterology
  • S
    • He came because of weight loss from 70 to 52 Kgs in the past 2 months.
    • Anorexia since Sep 2022.
    • Low abdominal pain since 6 Dec 2022.
    • Chronic diarrhea since 3 months ago. Colon polyp was removed on 29 Nov 2022.
    • He had undergone liver transplantation in 2007 in China.
    • Past history: Ca of prostate s/p R/T 37 times in 2009. D.M for more than 10 years.
  • O
    • P.E.: No icteric sclera, soft abdomen, no leg pitting edema.
    • 2023-01-13: Ca-19-9: 53.89. CT of abdomen: R/O Pancreatic Ca.

[consultation]

• 2023-01-19 Hemato-Oncology
  • Q
    • This is a 73-year-old female with underlying disease of
      • Ca of prostate s/p R/T 37 times in 2009.
      • Liver transplantation in 2007 in China.
      • D.M for more than 10 years.
    • This time, he suffured from left upper abdominal dullness pain and weight loss (70 -> 58kg in 2 months). Associated symptom included nausea and poor appetite but denied Icterus, and back pain. Due to above reason, he came to our GI OPD for further survey.
    • Abdominal CT done on 2023/01/13 revealed suspected pancreatic Ca and blood test showed Ca-19-9: 53.89.
    • Under the impression of pancreatic cancer, he was admitted for further survey. EUS-FNB for pancreas was arranged on 2023/01/17. Thus, we request your expertise for aseessment of the administration of chemotherpy.
  • A
    • This 73 year old man is a case of suspect pancrease cancer cT4N1M0, stage III. We are consulted for further evaluation.
    • Pending EUS pathology and arrange our OPD after discharge. For unresectable pancrease cancer, systemic chemotherapy is indicated (consult GS for further operation evaluation). If pancrease cancer is proven, may check HbsAg, Anti Hbc, and anti HCV. Then, consult GS for port A insertion and complete pancrease cancer work up including chest CT (+/-contrast).

[chemotherapy]

• 2023-07-11

• 2023-06-21

• 2023-05-31 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3

• 2023-05-10 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3

• 2023-04-25 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3

• 2023-04-11 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3

• 2023-03-10 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX, Covorin NS 500 -> 250mL)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC (before Irino) + aprepitant 125mg D1-3

• 2023-02-23 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC (before Irino) + aprepitant 125mg D1-3

• 2023-02-02 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC (before Irino) + aprepitant 125mg D1-3

Granocyte (lenograstim 250ug) CGRAN01

• 2023-05-24 3 days (OPD)
• 2023-05-16 3 days (IPD)
• 2023-05-02 3 days (IPD)
• 2023-04-17 3 days (IPD)
• 2023-04-04 3 days (IPD)
• 2023-03-28 3 days (IPD)
• 2023-03-23 3 days (OPD)
• 2023-03-15 3 days (IPD)
• 2023-03-01 3 days (IPD)
• 2023-02-15 3 days (OPD)

WBC

• 2023-05-31 WBC 3.55 x10^3/uL
  
• 2023-05-24 WBC 2.32 x10^3/uL
  
• 2023-05-10 WBC 3.01 x10^3/uL
  
• 2023-04-25 WBC 2.71 x10^3/uL
  
• 2023-04-11 WBC 4.08 x10^3/uL
  
• 2023-03-28 WBC 3.47 x10^3/uL
  
• 2023-03-23 WBC 2.43 x10^3/uL
  
• 2023-03-09 WBC 4.31 x10^3/uL
  
• 2023-02-22 WBC 5.90 x10^3/uL
  
• 2023-02-15 WBC 2.08 x10^3/uL
  
• 2023-01-30 WBC 4.75 x10^3/uL
  
• 2023-01-13 WBC 6.05 x10^3/uL

==========

2023-07-12

This patient had an appointment at the Tri-Service General Hospital on 2023-06-24 where he was prescribed Trajenta (linagliptin), Diovan (valsartan), Certican (everolimus), and Stilnox (zolpidem). These medications have been correctly incorporated into the patient’s active medication list. No discrepancies were found during the medication reconciliation process.

2023-06-01

• This patient had an appointment at the Tri-Service General Hospital on 2023-05-05, during which he was prescribed a single dose of Zoladex (goserelin acetate 10.8mg). As the suggested administration interval for this medication is every 12 weeks, the next scheduled dose should be on 2023-07-28. No issues were discovered during the medication reconciliation process.

• The patient seems to be showing signs of anemia with an increasing trend towards macrocytosis. As the bilirubin level is still within the normal range, hemolytic anemia may be less likely. A single intramuscular dose of B-Red (hydroxocobalamin 1mg) is scheduled for 2023-06-02, and folate is already included in the current FOLFIRINOX regimen. At this time, there is no concrete evidence indicating a rapid progression in the severity of anemia, so please continue monitoring.

  • 2023-05-31 RBC 3.27 x10^6/uL
    
  • 2023-05-31 HGB 10.5 g/dL
    
  • 2023-05-31 HCT 33.5 %
    
  • 2023-05-31 MCV 102.4 fL
    
  • 2023-05-24 MCV 100.0 fL
    
  • 2023-05-10 MCV 101.5 fL
    
  • 2023-04-25 MCV 102.2 fL
    
  • 2023-04-11 MCV 102.1 fL
    
  • 2023-03-28 MCV 103.6 fL
    
  • 2023-03-23 MCV 99.7 fL
    
  • 2023-03-09 MCV 97.4 fL
    
  • 2023-02-22 MCV 95.0 fL
    
  • 2023-02-15 MCV 91.8 fL
    
  • 2023-01-30 MCV 94.1 fL
    
  • 2023-01-13 MCV 93.6 fL

2023-05-11

• Zoladex (goserelin acetate) 10.8mg was administered Q3M, with the most recent administration occurring on 2023-05-05, at TSGH for the management of the patient’s prostate cancer. Furthermore, antiglycemic, antihypertensive, and anti-rejection medications prescribed at TSGH are correctly reflected in the current active medication list, presenting no issues with medication reconciliation.

• Please be aware, there is a slow yet noticeable upward trend in both AST and ALT lab results. This should be closely monitored for possible potential liver function impairment.

  • 2023-05-10 S-GOT/AST 35 U/L

  • 2023-04-25 S-GOT/AST 42 U/L

  • 2023-04-11 S-GOT/AST 30 U/L

  • 2023-03-28 S-GOT/AST 25 U/L

  • 2023-03-23 S-GOT/AST 30 U/L

  • 2023-03-09 S-GOT/AST 23 U/L

  • 2023-02-22 S-GOT/AST 17 U/L

  • 2023-02-15 S-GOT/AST 16 U/L

  • 2023-01-30 S-GOT/AST 14 U/L

  • 2023-01-13 S-GOT/AST 19 U/L

  • 2023-05-10 S-GPT/ALT 44 U/L

  • 2023-04-25 S-GPT/ALT 55 U/L

  • 2023-04-11 S-GPT/ALT 36 U/L

  • 2023-03-28 S-GPT/ALT 32 U/L

  • 2023-03-23 S-GPT/ALT 35 U/L

  • 2023-03-09 S-GPT/ALT 27 U/L

  • 2023-02-22 S-GPT/ALT 21 U/L

  • 2023-02-15 S-GPT/ALT 22 U/L

  • 2023-01-30 S-GPT/ALT 20 U/L

  • 2023-01-13 S-GPT/ALT 20 U/L

2023-04-26

• Certican (everolimus) has been added to the list of active medications for the patient’s post-liver transplant status without a reconciliation issue.
• 2023-04-25 WBC 2.71K/uL, Granocyte (lenograstim) might be prepared in advance for approximately 1 week after chemotherapy.

2023-03-13

• The patient has been receiving FOLFIRINOX since 2023-02-02, with a reduced dosage of oxaliplatin (85 -> 65mg/m2) and irinotecan (180 -> 90mg/m2) to prevent adverse reactions. Approximately 2 weeks after the first chemotherapy treatment, the patient experienced leukopenia, with a WBC count of 2.08K/uL on 2023-02-15. Following this event, prophylactic G-CSF was administered around 1 week after each subsequent chemotherapy treatment, and no further episodes of leukopenia were observed.
• The previous 84-day refillable prescription of tacrolimus at TSGH on 2022-12-10 was changed to everolimus on 2023-03-04. To manage the trough concentration target range of 3 to 8 ng/mL, patients taking everolimus are recommended to undergo TDM.
• If the patient develops neutropenia again, the dose of everolimus is recommended to be adjusted as follows:
  • For Grade 3 neutropenia (ANC >=500 to <1,000/uL), everolimus treatment will be temporarily interrupted until the condition improves to <= grade 2. Treatment will then be reinitiated at the same dose.
  • For Grade 4 neutropenia (ANC <500/uL), everolimus treatment will be temporarily interrupted until the condition improves to <= grade 2. Treatment will then be reinitiated at 50% of the previous dose. If the reduced dose is lower than the lowest strength available, dosing will be changed to every other day.

2023-01-31

• Although there are case reports of pancreatic adenocarcinoma in liver transplant recipients, there are no systematic review articles on chemotherapy for pancreatic cancer in liver transplant patients found in the public domain.
• If the patient’s performance is evaluated as ECOG 0/1, FOLFIRINOX or modified FOLFIRINOX might be considered as possible regimens for treatment.
• The patient is taking Advagraf (tarcolimus). Tacrolimus is an immunosuppressant, in combination with chemotherapy, it is likely to have an increased immunosuppressive effect, therefore, there may result in potential opportunistic infections which should be closely monitored.

700536529

230712

[MedRec]

• 2023-07-10 MultiTeam - Palliative Care
  • Multidisciplinary Team Suggestions
  • Consultation date: 2023-07-10
  • Response: Together with Dr. Chen from the Department of Family Medicine, the co-care nurse visited the patient, who is in fair spirits and reports no discomfort. The foreign caregiver was taking care of the patient at the bedside. The patient is expected to be discharged tomorrow. The co-care nurse called the patient’s eldest son (0933221580) and introduced the concept of palliative care. The eldest son expressed the wish to discuss palliative care face-to-face with his siblings. He would contact the co-care nurse when he arrives at the hospital tomorrow morning, and left the co-care nurse’s contact number for future follow-ups. In the afternoon, the eldest son called to arrange a face-to-face meeting at 16:30 today. The co-care nurse explained the concept of palliative care (palliative care ward, co-care palliative, home palliative care) to the eldest son, the patient’s daughter, and the patient’s son-in-law. The eldest son agreed to direct the patient’s care towards palliative care, hoping that the patient can be comfortable and not suffer. The patient is aware of his cancer diagnosis and has previously stated that he does not want resuscitation. The co-care nurse introduced the concept of Advance Care Planning (ACP) for palliative care and suggested that they complete the ACP.
  • Conclusion and Suggestions: Palliative co-care, Follow-up on the Advance Care Planning for Palliative Care.
  • Responder: Chen Hui
  • Reply date: 2023-07-10 17:42

==========

2022-01-18

• Recent lab data

  • 2022-01-18 serum glucose 191mg/dL
  • 2022-01-17 serum glucose 164mg/dL
  • 2022-01-11 serum glucose 154mg/dL
  • 2021-11-10 ascites glucose 150mg/dL

• Elevated serum glucose. This patient has type 2 DM and CVD, SGLT2i might be a choice to protect heart while lowering blood sugar.

• SGLT2i such as empagliflozin, dapagliflozin, canagliflozin are available in stock could be prescirbed if UTI is unlikely.

700960001

230712

{not completed}

[diagnosis] - 2023-05-08 admission note

• Serous carcinoma, high grade of left ovary, pTIc1pN0(if cM0); FIGO stage:IC, s/p Debulking sugery on 2021/06/30, IHC stains: ER(-), PR(-) s/p chemotherapy with Taxol(175mg/m2)/Carboplatin(AUC:5) from 2021/07/23 to 2021/11/11 (for 6 cycles) with liver metastasis s/p chemotherapy with Taxol(175mg/m2)/Carboplatin(AUC:5) from 2023/03/14.
• Chronic viral hepatitis B without delta-agent
• Encounter for antineoplastic chemotherapy

[exam findings]

• 2023-03-10 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Compatible with metastatic ovarian serous carcinoma
  • The sections show a picture compatible with metastastic serous carcinoma of ovary, composed of nests large pleomorphic neoplastic cells arranged in solid and subtle papillary pattern in fibrous stroma.
  • IHC shows: PAX8(+) and WT1(-).
• 2023-03-02 CT - abdomen
  • Findings
    • S/P hysterectomy. Right ovary cyst (3.0cm).
    • Poor enhancing tumors (up to 3.3cm) at left hepatic lobe.
    • A tiny nodule (3mm) at left lung.
  • IMP
    • S/P hysterectomy. Poor enhancing tumors (up to 3.3cm) at left hepatic lobe r/o metastases.
    • A tiny nodule (3mm) at left lung.
• 2022-12-01 CT - abdomen
  • S/P hysterectomy.
  • A tiny nodule (3mm) at left lung.
• 2022-09-06 CT - abdomen
  • S/P hysterectomy.
  • A tiny nodule (2mm) at LUL.
• 2022-06-08 CT - abdomen
  • S/P hysterectomy.
  • There is no evidence of tumor recurrence.
• 2022-03-12 CT - chest
  • Left upper lobe tiny subpleural nodule. Stable.
• 2022-03-02 CT - abdomen
  • There is a small soft tissue nodule 4 mm in LLL of the lung. Follow up chest CT 6 months later is indicated.
  • S/P hysterectomy. There is no evidence of tumor recurrence.
• 2021-11-30 CT - abdomen
  • S/P hysterectomy and oophorectomy.
  • Focal fatty density in right subhepatic region, suggest follow up.
• 2021-10-08 Gynecologic ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2021-07-21 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 15 dB HL; LE 16 dB HL.
  • Bil normal to mild SNHL.
• 2021-06-30 Patho - uterus (with or without SO) neoplastic
  • Diagnosis:
    • Ovary, left, oophorectomy with frozen section (F2021-248) — Serous carcinoma, high grade.
      • IHC stains: ER: (-), PR (-), WT-1 (+), PAX8 (+), Napsin-A (-), p53 (+).
        
    • Fallopian tube, left, salpingectomy (F2021-248) — Free
      
    • Omentume, omentectomy —- Free
      
    • Lymph node, bilateral pelvic and right para-aortic, dissection — Free
      
    • pTIc1 pN0 (if cM0); FIGO stage:IC1.
      • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.” … “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologyists are ordered by this hospital adminstration (including the chiefs of cancer committee, hemato-oncology and radiation oncology) to assign the “cM” category although pathologists are not in the position of doing so.
        
  • Gross description:
    • Procedure (select all that apply)- Debulking surgery (Left salpingo-oophorectomy + infracolic omentectomy + pelvic lymph node dissection)
      
    • Specimen Integrity
      • Specimen Integrity of Right Ovary- not received
        
      • Specimen Integrity of Left Ovary- intra-operative rupture
        
      • Specimen Integrity of Right Fallopian Tube – not received
        
      • Specimen Integrity of Left Fallopian Tube- free
    • Tumor Site: Left ovary
      
    • Ovarian Surface Involvement (required only if applicable): Present (Left)
      
    • Fallopian Tube Surface Involvement (required only if applicable): Absent
      
    • Tumor Size-Greatest dimension (centimeters): Ovary: 16 x 12 x 9 cm, solid part: 6.5 x 4 x 4 cm.
      • Sections are taken and labeled as:
        
      • Tissue for frozen sections: F2021-248FSA1-2: left ovarian tumor.
        
      • Tissue for formalin fixation: F2021-248A1-5: left ovarian tumor;
        
      • S2021-8661A: left iliac LN; B: left obturator LN; C: right iliac LN; D: right obturator LN; E: right para-aortic LN; F: omentum.
        
  • Microscopic Description:
    • Histologic Type: Serous carcinoma
      
    • Histologic Grade - high grade
      
    • Implants- Not identified
      
    • Other Tissue/ Organ Involvement (select all that apply): Not identified
      
    • Largest Extrapelvic Peritoneal Focus (required only if applicable): not apllicable
      
    • Peritoneal/Ascitic Fluid - Negative for malignancy (normal/benign)
      
    • Regional Lymph Nodes: negative for metastasis: 0/22 (0/ total No. of nodes) = left iliac LN (0/1); left obturator LN (0/2); right iliac LN (0/7); right obturator LN (0/3); right para-aortic LN (0/9)
      
    • Additional Pathologic Findings - None identified
      
    • Comment(s): IHC stains: ER: (-), PR (-), WT-1 (+), PAX8 (+), Napsin-A (-), p53 (+).
• 2021-06-19 CT - abdomen
  • Indication: Suspect pelvis mass: 160x116mm
  • Abdominal CT with and without enhancement revealed:
    • Cystic lesion at pelvis up to 15.6cm in largest dimension is found. Some solid part is found. Ovarian cancer is considered. The left ureter is obliterated with left hydronephrosis and hydroureter.
  • Imp: Left ovarian cancer without ascites formation.
  • Imaging Report Form for Ovarian Carcinoma
  • Impression (Imaging stage): T:____(T_value) N:____(N_value) M:____(M_value) STAGE:____(Stage_value)
• 2021-06-18 Gynecologic ultrasonography
  • Suspect pelvis mass: 160x116mm
• 2020-07-29 CT - abdomen
  • History and Indication: 2020/07/28 sona: Total hysterectomy ATH, ROV Mass:59 x 31 mm; IMP: R/O Rt ovarian mass(no blood flow)
  • FINDINGS:
    • S/P hysterectomy
    • There is a cystic lesion with septum formation and mural nodule measuring 4.7 x 2.9 cm in right adnexa.
    • There are three kissing mixed solid and cystic lesion in left adnexa.
    • S/P double J catheter insertion, right side urinary tract.
    • A renal cyst measuring 0.7 cm in right middle pole is noted.
  • IMP:
    • Cystic mass lesion in bilateral adnexal area are noted. please correlate with clinical condition and MRI to rule out endometrioma or cystic tumor.
• 2017-03-27 Surgical pathology Level V
  • A. Cervix, uterus, complicated total hysterectomy — Chronic cervicitis, Nabothian cysts
    • Endometrium, uterus, ditto — Proliferative phase
    • Myometrium, uterus, ditto — Adenomyosis
  • B. Ovarian cyst, left, salpingo-oophorocystectomy — Endometriosis
  • C. Ovarian cyst, right, salpingo-oophorocystectomy — Endometriosis
• 2017-03-14 Gynecologic ultrasonography
  • Adenomyosis
  • R/O Bilateral endometrioma

[consultation]

• 2021-07-07 Hemato-Oncology
  • Q
    • For post-op chemotherapy
      
    • This 46 y/o female, she was arranged to admit for Debulking surgery on 20210630.
    • The pathology report: Ovary, left, oophorectomy with frozen section —- Serous carcinoma, high grade. IHC stains: ER: (-), PR (-), WT-1 (+), PAX8 (+), Napsin-A (-), p53 (+). pTIc1 pN0 (if cM0); FIGO stage: IC1.
    • We need your expertise for help her further management for post-op chemotherapy. Thanks for you help!
  • A
    • Patient examined and Chart reviewed. A case of ovarian serous carcinoma, high grade, pathological Stage IC1 is noted. I am consulted for further management.
    • My suggestions would be:
      • Adjuvant CCRT with weekly cisplatin is indicated.
      • Please arrange Port-A insertion (Done)
      • Please arrange family meeting, regarding the issue of adjuvant treatment and genetic test.
      • Thanks for your consultation. Please let me know if any problem.

[surgical operation]

• 2022-09-22
  • Surgery: Internal hemorrhoids rubber band ligation        
  • Finding: Enlarged internal hemorrhoids with congestion at 3 o’clock  
• 2022-09-01
  • Surgery: Internal hemorrhoids rubber band ligation        
  • Finding: Enlarged internal hemorrhoids with congestion at 7 o’clock  
• 2021-07-06
  • Operation
    • Port-A (47080B)
    • Fluoroscopy (32026C) 
• 2021-06-30
  • Surgery
    • Bilateral DBJ catheter insertion
  • Finding
    • External compression at posterior wall of urinary bladder
    • Left lower ureteral angulation
    • Bilateral 6Fr. 24cm DBJ inserted
• 2021-06-30
  • Surgery
    • Diagnosis: Left ovarian tumor r/o malignancy s/p debulking surgery.
    • Operation: Debulking surgery (LSO + infracolic omentectomy + pelvic lymphnode dissection)   - Finding
    • Left ovarian tumor, r/o malignancy.
    • Ovarian cancer, stage , pT1aN0M0(type)
    • Frozen: adenocarcinoma
    • Supraumbilical midline vertical skin incision
    • Uterus:s/p ATH
    • Adnexa:
      • LOV: cystic lesion, 16x12cm, capsule intact, smooth surface. intra-op rupture(+)
      • ROV: not seen.
    • CDS: invisible due to tumor mass occupied
    • Ascites: minimal, washing cytology was done.
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(+)
    • Omentum: infracolic omentectomy was done.
    • Liver: grossly normal & smooth
    • After the operation, optimal debulking surgery was achieved.
    • Residue tumor: <2cm.
    • Estimated blood loss: 500ml
    • Blood transfusion: nil
    • Complication: nil  
• 2020-07-22
  • Surgery: Right ureterorenoscopic exam & double-J stenting  + retrograde pyelography       
  • Finding
    • Right upper ureter kinking was noted and confirmed by retrograde pyelography       
    • 6Fr 24 cm DBJ was placed
• 2017-03-27
  • Cystoscopy + retrograded ureteral catheterization
• 2017-03-27
  • Uterus: Avfl, hypertrophic and disfigured due to adenomyosis
  • RAD: enlarged with chocolate like content with severe adhesion to uterus, rectum, and LAD. cannot totally remove chocolate cyst due to severe adhesion.
  • LAD: enlarged with chocolate like content with severe adhesion to uterus, sigmoid colon, and RAD.
  • CDS: obliteration due to severe endometriosis.
  • Estimated blood loss: 900ml
  • Blood transfusion: pRBC2u
  • Complication: nil

[chemoimmunotherapy]

• 2023-06-02 - bevacizumab 15mg/kg 900mg NS 250mL 90min + paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr (Avastin init)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1
• 2023-05-08 - paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-07 - paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-13 - paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-11-10 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-10-21 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-09-27 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-09-06 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-08-12 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + cisplatin 75mg/m2 120mg NS 500mL 24hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-07-23 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 24hr + NS 250mL 1hr (after cisplatin)
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 750mL

==========

2023-07-12

According to the PharmaCloud database, this patient only receives medical services at our hospital. Cross-referencing this with HIS5 records, there were no active prescriptions issued by other departments. Consequently, no medication reconciliation issues were identified.

2023-05-09

Granocyte (lenograstim) is pre-prescribed for 2 to 3 consecutive days, a few days after each chemotherapy session, as a prophylactic measure against leukopenia. Since mid-Nov 2021, the patient’s WBC count has remained consistently above 3K/uL.

701361625

230712

[exam findings]

• 2023-03-15 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, rectum, previously post Transanal minimally invasive surgery with local excision (2022-03-02), now rectal trsection — no residual primary tumor. Margins free.
    • Lymph node, pericolonic, dissection — metastatic adenocarcinoma (3/19), no extranodal extension. - IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • pTx pN1b (if cM0); pStage: IIIA, at least.
  • Gross Description:
    • Procedure - previously post Transanal minimally invasive surgery with local excision (2022-03-02), now rectal trsection
    • Tumor Site - Rectum 12.5 3.5 x 3.5 cm
      
    • Tumor Size: no rpimary tumor in this specimen.
    • Macroscopic Tumor Perforation: Not identified
    • Sections are taken and labeled as: A1-5: roevious excision site; A6-8 and X1-2: epri-rectal lymph nodes; B: separated proximal margin; C: separated distal margin.
  • Microscopic Description:
    • Histologic Type - Adenocarcinoma
    • Histologic Grade - G2: Moderately differentiated
    • Tumor Extension - No evidence of primary tumor
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Uninvolved
    • Distance of tumor from margin: > 5mm (radial margin)
      
    • Lymphovascular Invasion: Not identified
    • Perineural Invasion: Not identified
    • Tumor Budding - none.
    • Type of Polyp in Which Invasive Carcinoma Arose: no primary tumor in this specimen.
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes
      • Number of Lymph Nodes Involved/Examined: 3/19
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition): IIIA, at least.
      • TNM Descriptors (not applicable)
        • Primary Tumor (pT) - No residual of primary tumor
        • Regional Lymph Nodes (pN) - pN1b: Two or three regional lymph nodes are positive
        • Distant Metastasis (pM) - if cM0
    • Additional Pathologic Findings - None in this specimen identified
    • Ancillary Studies : result of S2023-4391 A6 : IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).
• 2023-02-21 PET
  • Increased FDG uptake in two focal areas in the right pararectal region. Metastatic lymph nodes should be watched out. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the stomach. Inflammatory process may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
• 2023-02-14 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Clinical rectal cancer s/p. There are enlarged lymph nodes, up to 1cm in perirectal region, progression as compare with CT study on 2022-09-01.
    • R/O liver cyst, 1.5cm in S4.
    • Low density tumor, 1.7cm in the uterus, r/o uterine myoma.
  • Impression
    • Clinical rectal cancer s/p. Progressive enlarged perirectal lymph node as compare with CT study on 2022-09-01, r/o metastatic lymph node.
    • R/O liver cyst.
    • R/O uterine myoma.
• 2023-02-14 Colonoscopy
  • Rectal cancer s/p op
  • No evidence of recurrence
• 2023-02-14 Esophagogastroduodenoscopy, EGD
  • Suspect duodenal SET, 2nd portion
  • Gastric polyps, body, GC
  • Reflux esophagitis LA Classification grade A (minimal)
  • Superficial gastritis
• 2022-09-01 CT - abdomen
  • History and indication: Rectal cancer at 5 cm from AV s/p polypectomy stage I
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Rectal cancer s/p operation. Small LNs (4mm, 5mm) at right pararectal region without interval change.
    • Renal cysts (up to 0.7cm).
    • Liver cysts (up to 1.8cm).
• 2022-03-03 Patho - colon segmental resection for tumor
  • DIAGNOSIS:
    • Intestine, large, rectum, 5 cm from anal verge, transanal minimally invasive surgery (s/p polypectomy) — No residual malignant tumor — Margin free
    • Lymph node., regional, transanal minimally invasive surgery — Negative for malignancy (0/1)
  • Microscopically, it shows full-layer of colorectal tissue with a scar at the mucosa. The muscularis propria and perirectal soft tissue are not remarkable. One regional lymph node is not remarkable.
  • Immunohistochemical stain reveals CK(-).

[MedRec]

• 2022-02-17 SOAP Colorectal Surgery
  • 20220113 Rectal cancer at 5 cm from AV s/p polypectomy stage I was diagnosed at ShuangHe Hospital, pT1, margin < 1mm

[surgical operation]

• 2023-03-10
  • Surgery
    • Robotic LAR + Loop ileostomy    
  • Finding
    • Perirectal nodules R/O lymph nodes metastasis Redundant sigmoid colon adhesion to omentum
• 2022-03-02
  • Surgery
    • Transanal minimally invasive surgery (TAMIS) for local excision    
  • Finding
    • Rectal cancer at right anterior wall 5 cm from AV s/p polypectomy, pT1 , margin not involve < 1mm.
    • Whole layer resection of the tumor base deep to vaginal wall anteriorly and perirectal fat

[chemotherapy]

• 2023-07-10 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/2 3700mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-06-27 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/2 3700mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-05-30 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/2 3700mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-05-02 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/2 3700mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-04-18 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/2 3700mg NS 170mL 48hr (infusor)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

701462990

230712

[chemotherapy]

• 2023-07-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-20 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-26 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
  • diphenhydramine 30mg + NS 250mL
• 2023-04-28 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
  • diphenhydramine 30mg + NS 250mL
• 2023-04-03 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
  • diphenhydramine 30mg + NS 250mL

701486110

230712

[exam findings]

• 2023-06-14 CT - chest
  • Indication: One mass was noted in the rectum (12 cm from anal verge) with partial obstruction, for cancer staging
  • Chest CT without IV contrast ehnancement shows:
    • Perifissural nodule at right middle lobe measuring 0.36cm is found. Old insult is more favored.
    • Calcified coronary arteries is found.
  • Imp: Right middle lobe perissural nodule. 0.36cm
• 2023-06-13 Patho - colon biopsy
  • Colorectum, rectum, 12 cm above anal verge, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2023-06-08 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of R-S junction of colon with adjacent fat stranding and fluid collection. Some LNs at pelvic cavity.
    • Tiny liver and renal cysts.
    • Atherosclerosis of aorta, iliac arteries.
    • A nodule (3mm) at RML, nature ?
  • Addendum Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)

[consultation]

• 2023-06-15 Radiation Oncology
  • A
    • Preoperative CCRT first followed by surgical treatment was suggested. CT-simulation will be arranged on 2023/06/20. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 2023/06/26. Thank you very much.
• 2023-06-15 Hemato-Oncology
  • Q
    • For neoadjuvant CCRT
    • This 51-year-old male got intermittent right lower abdominal pain, bloody stool for two months and got worse in recent days. Thus, he vistit our CRS OPD then referred to our ER on 2023/06/08. Lab data revealed leukocutosis and CRP level 10.9. Abdominal CT showed wall thickening of R-S junction of colon with adjacent fat stranding and fluid collection, along with some lymph nodes at pelvic cavity. Uner the diagnosis of diverticulitis of R-S colon, the patient was admitted for further evaluation. After admission, NPO with adequate fluid supplement and empirical antibiotic treatment with Brosym were prescribed. After medical treatment, his abdominal pain improved much. Sigmoidoscopy was arranged and revealed one mass was noted in the rectum (12 cm from anal verge) with partial obstruction. Biopsy was done and pathology proved adenocarcinoma. Chest CT showed right middle lobe perissural nodule. 0.36cm.
    • After fully explained of the condition, preoperative CCRT first followed by surgical treatment was suggested. We needs your expert experience for evaluation of CCRT. Thanks a lot !!
  • A
    • Dear doctor: This 51 year old man is a case of newly diagnosis rectal cancer, cT4aN2b , stage IIIc. We are consulted for total neoajuvant chemotherapy.
    • We will discuss with patient about total neoajuvant chemotherapy (CCRT followed by systemic chemotherapy 12-16 week) and then restaging for operation.
    • Please arrange port A insertion. Please check HBsAg, Anti HBc, AntiHBs, Anti HCV. Transfer to 11A or 10B on Dr

[radiotherapy]

[chemotherapy]

• 2023-06-26 - [leucovorin 20mg/m2 30mg NS 250mL 10min + fluorouracil 400mg/m2 630mg NS 100mL 10min] D1-5 (CCRT)

==========

2023-07-12

The patient previously visited WanFang Hospital on 2023-06-02 for treatment of hemorrhoids and was given a 14-day supply of medication, which has now expired. As the patient did not report any problems related to his hemorrhoids at the time of his current admission, no concerns were identified during the medication reconciliation process.

2023-06-20

Continuing from the previous pharmacist note, confirm that Baraclude (entecavir 0.5 mg) 1# QDAC has been prescribed. There are no other medication-related problems at this time.

2023-06-16

Lab 2023-06-16 Anti-HBc positive. If immunosuppressive chemotherapy is to be used, it is advisable to use either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD as a precaution, at least during the course of chemotherapy. This would help protect against the potential reactivation of HBV infection by chemotherapy.

700067411

230711

[exam findings]

• 2023-06-15 KUB
  • Radiopaque spots are noted at both renal region. Bilateral renal stones are considered.
  • There is no evidence of destructive bone lesion.
• 2023-05-15 Uroflowmetry
  • Q max : fair
  • flow pattern : obstructive
• 2023-05-15 Bladder sonography
  • PVR: 24 mL
• 2023-05-06 CT - abdomen
  • Clinical history: 63 y/o male patient with peri-unbilical pain since 2 hours ago, nausea, no vomtiing. loose stool.
  • WITHOUT contrast enhancement CT of abdomen–whole:
    • Gallbladder stone with wall edema of gallbladder, r/o cholecystitis.
    • Bilateral renal stones.
    • Dilatation of right pelvicaliceal system with right upper ureteral wall thickening, may consider URS study.
  • Impression:
    • GB stones with gallbladder wall edema, r/o cholecystitis.
    • Bilateral renal stones.
    • Right hydronephrosis with upper ureteral wall thickening, suggest URS study.
• 2023-05-06 CXR
  • Presence of ileus.
  • Presence of bil. renal stones.
• 2023-05-06 KUB
  • Presence of bil. renal stones.
  • Intact bony structure(s).
• 2023-02-10 Patho - salivary gland biopsy
  • Labeled as “right parotid”, needle biopsy — poorly differentiated carcinoma.
  • Section shows nests of round blue cells with abundant infiltration of lymphoid cells.
  • IHC stain of CK highlight irregular nests of CK (+) sheets which is also focal P40 (+), morphologically is similar to nasopharyngeal carcinoma.
• 2023-02-09 PET
  • Glucose hypermetabolism involving the nasopharynx, compatible with primary nasopharyngeal malignancy.
  • Glucose hypermetabolism in bilateral retropharyngeal lymph nodes and in multiple neck lymph nodes in bilateral parotid areas, bilateral neck level II to III regions and left neck level IV region, suggesting metastatic lymph nodes.
  • Increased FDG accumulation in both kidneys and urethra. Physiological FDG accumulation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2023-02-08 ENT Hearing Test
  • Tymp:
    • RE type B; LE type Ad.
  • ART:
    • Bil absent.
  • PTA
    • Reliability FAIR
    • Average RE 73 dB HL; LE 36 dB HL.
    • RE normal to moderate SNHL.
    • LE moderate to profound mixed type HL.
• 2023-02-07 MRI - nasopharynx
  • Indication: nasopharyngeal ccancer, for cancer work up
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
    • A right nasopharynx tumor, up to 3.7 cm, no obvious parapharyngeal or skull base invasion.
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • Multiple bilateral retropharyngeal and neck LAPs, with central necrosis, below the low border of cricoid cartilage at left.
    • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
  • IMP: Right NPC with bil. neck LAPs. T1N3Mx stage IVA.
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:T1(T_value) N:N3(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
• 2023-02-06 ECG
  • Sinus rhythm with Premature supraventricular complexes
• 2023-02-06 CXR
  • Borderline heart size. No mediastinal widening. Enlargement of right hilar region?
  • No active lung lesion. Intact bony thorax.
• 2023-02-02 SONO - abdomen
  • Fatty liver, mild
  • Suspected GB stone
  • Suspected chronic renal parenchymal disorders, bil
  • Suspected renal cysts, bil
  • Suspected renal stones, bil
  • Pancreas not shown
  • Suboptimal examination of liver due to poor echo window
• 2023-01-18 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasopharynx, biopsy — Nasopharyngeal carcinoma, non-keratinizing and undifferentiated
    
  • Microscopically, section shows nasopharyngeal carcinoma characterized by diffuse sheets of non-keratinizing invasive carcinoma closely infiltrated by prominent lymphoplasmacytic cells. The tumor shows nclear hyperchromasia, high N/C ratio and mitotic figures.
    
  • Immunohistochemical stain reveals CK(+) for tumor cells.
• 2023-01-18 Nasopharyngoscopy
  • Findings
    • smooth oropharynx, hypopharynx
    • yellowish mucopus over nasopharyngeal granular tumor
    • s/p submucosla turbinectomy,bil
  • Diagnosis, conclusion
    • Nasopharyngeal tumor, occupying bil choanae s/p biopsy

[consultation]

• 2023-02-10 Radiation Oncology
  • A
    • Diagnosis: Nasopharyngeal cancer, nasopharyngeal carcinoma, non-keratinizing and undifferentiated, cT1N3M0, with bilateral neck and retropharyngeal LAP metastasis; 2.2-cm Rt parotid tumor s/p biopsy on 2023/2/10; ECOG =1.
    • Plan: After teeth treatment, CCRT to NPX tumor & LAPs (and parotid tumor) for 7140cGy/34 fx is suggested for tumor control. CT simulation will be arranged after teeth extraction. Possible treatment toxicity of radiotherapy (radiation dermatitis, mucositis, pharyngitis & esophagitis) is told.
• 2023-02-08 Oral and Maxillofacial Surgery
  • Q
    • This is a 63 y/o male with history of HBV carrier
    • This time, he was admitted to our ward for Nasopharyngeal cancer survey. Under the impression of NPC, T1N3Mx, stage IVA, CCRT is indicated. We need your expertise on dental evaluation before radiotherapy.
  • A
    • This is a 63 y/o male with history of HBV carrier. This time, he was admitted due to nasopharynx carcinoma, cT1N3Mx, stage IVA and was scheduled for further CCRT. We were consulted for pre-RT dental evaluation.
    • O:
      • Panoramic findings:
        • Missing: 18,17,16,11,21,22,28,38-34,32-48
        • Impaction: Nil
        • Caries: 14,13,23,26,27
        • Crown and bridges: nil
        • Periodontal condition: Severe periodontitis
      • Full mouth severe periodontitis with advanced periodontal bone destruction was noted.
      • Multiple deep caries and residual roots was noted.
      • Poor oral hygiene.
    • P:
      • Explained the findings and treatment plan to the patient
      • Suggest extraction of all teeth including 15,14,13,12,23,24,25,26,27,33
      • Patient needed to consider.
      • If the patient needs a tooth extraction, please contact Dr. Xia’s clinic assistant to arrange the extraction time and prescribe prophylactic antibiotics. Thank you.

[chemotherapy]

• 2023-07-10 - cisplatin 75mg/m2 100mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF Q4W, 5-FU 800mg/m2)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-07 - cisplatin 75mg/m2 100mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF Q4W, 5-FU 800mg/m2)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-11 - cisplatin 40mg/m2 70mg NS 500mL (Y-sited with NS 500mL) (CDDP QW)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-27
• 2023-04-13
• 2023-04-06
• 2023-03-30
• 2023-03-23
• 2023-03-16
• 2023-03-09
• 2023-03-02

==========

2023-07-11

This patient just refilled a prescription for Harnalidge (tamsulosin) on 2023-07-06 for his benign prostatic hyperplasia with lower urinary tract symptoms. This drug has been included in the active medication list with no reconciliation issues identified.

700370136

230711

[exam findings]

• 2023-05-24 Nasopharyngoscopy
  • Findings
    • Nose: no tumor lesion
    • Nasopharynx: smooth
    • Oropharynx: no tumor lesion, mucosa erythema
    • Larynx: left vocal fixation
    • Hypopharynx: left hypopharygeal tumor with left vocal fixation, some ulcer
    • airway patent
  • Diagnosis/Conclusion:
    • Left hypopharynx SqCC, T4aN2bM0. Stage IVA under induction C/T
    • Gr II mucositis
• 2023-05-16 ENT hearing test
  • PTA
  • Reliability FAIR
  • Average RE 23 dB HL; LE 33 dB HL.
    • RE normal to moderate SNHL
    • LE normal to moderately severe SNHL
• 2023-05-03 Nasopharyngoscopy
  • Findings
    • Nose: no tumor lesion,
    • Nasopharynx: smooth
    • Oropharynx: no tumor lesion
    • Larynx: no tumor lesion, bilateral vocal movement: left vocal cord fixation
    • Airway patent currently
    • Hypopharynx: left hypopharyngeal tumor
  • Diagnosis/Conclusion
    • hypopharyngeal SqCC cT4aN2bM0
    • Airway patent currently
• 2023-04-28 Tc-99m MDP bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, upper C-spine, some L-spines, bilateral shoulders, hips, knees and feet in whole body survey.
  • IMPRESSION:
    • Mildly increased activity in the upper C-spine and some L-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
    • No definite evidence of bone metastasis.
• 2023-04-28 SONO - abdomen
  • Liver calcification, S5/8
  • Gallbladder polyp
• 2023-04-28 Patho - larynx biopsy
  • Labeled as “left hypopharyngeal tumor”, biopsy — squamous cell carcinoma.
  • Section shows squamous cell carcinoma.
  • IHC stain: p16 (-).
• 2023-04-17 ECG
  • Right bundle branch block
  • Inferior infarct, age undetermined
• 2023-04-10 CT - neck
  • Head and Neck CT with and without IV contrast administration shows:
    • A left hypopharynx tumor mass, up to 38 mm in length, with thyroid cartilage invasion.
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • Multiple enlarged necrotic left neck LNs.
  • IMP: Left hypopharynx CA, T4AN2BMX, Stage IVA.
  • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T: 4A(T_value) N: N2B(N_value) M: M0(M_value) STAGE: IVA (Stage_value)
• 2023-04-06 Nasopharyngoscopy
  • left hypopharyngeal tumor with left vocal fixation, suspect malignancy
• 2018-02-05 Bladder sonography
  • bladder volume: 27.1 CC
• 2018-01-15 Post Void Residual, PVR
  • acceptable PVR: 15.99 CC
• 2017-09-28 Pure Tone Audiometry, PTA
  • R’t mild SNHL
  • L’t mild to moderately severe MHL

[MedRec]

• 2023-05-04 SOAP Hemato-Oncology
  • A/P
    • Already discussion with patient regarding the options:
      • OP -> first option
      • Induction C/T -> OP
      • CCRT -> OP
    • After discussion with patient favor neoadjuvant chemtoehrapy
    • Admission for 24 hours CCr, audiometry, TPF
• 2023-05-03 SOAP Ear Nose and Throat
  • S
    • patient asked for organ preservation
    • refer to oncologist for induction CCRT
  • O
    • finish staging.
    • left hypopharynx SqCC, T4aN2bM0.
• 2023-01-12 SOAP Metabolism and Endocrinology
  • O
    • 2023/01/03 Cholesterol total = 245 mg/dL;
    • 2023/01/03 LDL-C = 147 mg/dL;
    • 2023/01/03 Triglyceride (TG) = 217 mg/dL;
  • A/P
    • reinforce compliance to medication
    • reinforce diet control
    • SMBP (self-measured blood pressure monitoring)
    • 3m
  • Diagnosis
    • Nontoxic goiter, unspecified E04.9
    • Hyperlipidemia, unspecified E78.5
    • Essential (primary) hypertension I10
    • Impaired fasting glucose R73.01
  • Prescription
    • Crestor (rosuvastatin 10mg) 1# QD
    • Diovan (valsartan 160mg) 0.5# QD
    • Suwell (aluminum hydroxide 200mg, magnesium hydroxide 200mg, simethicone 25mg) 1# QD
    • Norvasc (amlodipine 5mg) 2# QD
    • Lipanthyl (fenofibrate 160mg) 1# QD

[chemotherapy]

• 2023-07-10 - docetaxel 75mg/m2 140mg NS 250mL 1hr D1 + cisplatin 75mg/m2 150mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) D3 + furosemide 20mg NS 30mL 10min (after CDDP) D3 + 1000mg/m2 2000mg NS 500mL D2-5
  • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4
• 2023-06-12 - docetaxel 75mg/m2 140mg NS 250mL 1hr D1 + cisplatin 75mg/m2 150mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) D3 + furosemide 20mg NS 30mL 10min (after CDDP) D3 + 1000mg/m2 2000mg NS 500mL D2-5
  • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4
• 2023-05-17 - docetaxel 75mg/m2 140mg NS 250mL 1hr D1 + cisplatin 75mg/m2 150mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) D3 + furosemide 20mg NS 30mL 10min (after CDDP) D3 + 1000mg/m2 2000mg NS 500mL D2-5
  • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4

==========

2023-07-11

Our otorhinolaryngologist prescribed a regimen on 2023-07-05 that included Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), Shitan (bromhexine), Acetal (acetaminophen), Ulstop (famotidine), and Nincort Oral Gel (triamcinolone). Additionally, our endocrinologist provided prescriptions for Crestor (rosuvastatin), Diovan (valsartan), Suwell (aluminum hydroxide, magnesium hydroxide, simethicone), Bokey (aspirin), Norvasc (amlodipine), and Lipanthyl (fenofibrate) on 2023-06-29. All these medications are currently present on the patient’s active medication list, with no detected issues relating to medication reconciliation.

2023-06-13

• Our otorhinolaryngologist issued a prescription on 2023-06-07, which included Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), Broen-C (bromelain, L-cysteine), Tramacet (tramadol, acetaminophen), and Nincort Oral Gel (triamcinolone) to address the patient’s ENT symptoms. The prescription was given a 14-day duration and is currently still valid. However, none of these drugs appear on the active medication list. Please verify if the related symptoms have resolved, which would explain the absence of these medications from the active list. Thank you!

• Laboratory data show that the patient experienced an episode of leukopenia with a WBC count of 2.39K/uL on 2023-05-24, one week after starting his 1st dose of the current treatment regimen on 2023-05-17. Granocyte (lenograstim 250ug) was administered for 3 consecutive days (from 2023-05-24 to 2023-05-26) to increase the WBC count. The 2nd administration of the regimen began on 2023-06-12, maintaining the same dose level as the first cycle. Therefore, a similar incidence of leukopenia might be expected and prophylactic use of G-CSF may be considered to mitigate this potential risk.

  • 2023-06-12 WBC 7.44 x10^3/uL
    
  • 2023-06-01 WBC 7.14 x10^3/uL
    
  • 2023-05-24 WBC 2.39 x10^3/uL
    
  • 2023-05-16 WBC 6.75 x10^3/uL
    
  • 2023-05-04 WBC 7.63 x10^3/uL
    
  • 2023-04-17 WBC 7.96 x10^3/uL

700370264

230711

{Recurrent hepatocellular carcinoma with lung metastasis, rycT3N0M1, stage IVB}

[diagnosis] - 2022-11-19 admission note

• Encounter for antineoplastic chemotherapy
• Liver cell carcinoma
• Secondary malignant neoplasm of unspecified lung
• Malignant neoplasm of pancreas, unspecified
• Encounter for antineoplastic immunotherapy
• Mild intermittent asthma, uncomplicated

[past history] - 2022-11-19 admission note

• Chronic hepatitis
• Frequent acute pancreatitis episodes in 2006, 2007, 2008, 2014/03/05 and 2014/09/30,
• Pancreatic intraductal papillary mucinous carcinoma, invasive pStage (pT1N0M0) s/p PPPD in 2014
• HCC s/p S8 segmentectomy on 2016/06/30, pT2Nx(cMx), stage II.
• Post S8 segmentectomy with liver abscesss/p pig-tail drainage on 2016/07/12, discharged on 2016/07/20.
• Hepatocellular carcinoma, recurrent (S2-3 and S7) rpT3bNx(cMx) stage IIIb s/p S2-3 hepatectomy and S7 partial hepatectomy on 2016/10/03. Keep Target therapy (Nexavar) side effect management since 2016/10/23-10/26. Post operation, liver abscess again s/p pig-tail insertion on 2016/11/02.
• Recurrent hepatocellular carcinoma, s/p TACE on 2017/08/08 and 2020/09/29, s/p S7 partial hepatectomy, adhesivelysis with bowel repair, and diaphragm resection with repair by chest surgeon on 2020/11/16; recurrent HCC s/p TACE on 2021/09/14, 2021/12/30, 2022/03/23 and immunotherapy with Nivolumab on 2021/09/08, 2021/10/08, 2021/12/07, 2021/12/31, 2022/01/24, 2022/03/23.     

[exam findings]

• 2023-05-29 CT - abdomen
  • History and indication: Recurrent hepatocellular carcinoma with lung metastasis
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P liver operation and TACE. Liver cirrhosis with portal hypertension and splenomegaly. A nodule (9.4mm) at RUL.
    • Some fluid collection in right subphrenic region.
    • Old fracture of right rib. R/O an osteolytic lesion at T11.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P liver operation and TACE. Liver cirrhosis with portal hypertension and splenomegaly. A nodule (9.4mm) at RUL.
    • R/O an osteolytic lesion at T11.
• 2023-05-25 ECG
  • Normal sinus rhythm
  • Right bundle branch block
• 2023-05-08, -04-07, -03-20, -03-13, -03-01 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Peri-bronchial wall thickening of the right lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2023-03-13 SONO - chest
  • No pleural effusion but right pleural thickening.
• 2023-03-11 CT - abdomen
  • Clinical history: 58 y/o male patient with fever and chills, SOB.
  • With and without contrast enhancement CT of abdomen
    • Focal loculated fluid (4x1.8cm) in right subphirenic region.
    • Segmental wall edema of S-colon.
    • Uneven surface of liver parenchyma, suggesting liver cirrhosis.
    • Post-op at the liver and pancrease.
    • Presence of splenomegaly.
    • No enlarged lymph node in the paraaortic region.
    • Consolidation in right lower lung and pleural effusion.
    • Bilateral lung nodules, stationary.
  • Impression:
    • Focal loculated fluidin right subphirenic region. Stationary as compare with CT study on 2023-02-10.
    • Post-op at the liver.
    • Liver cirrhosis and splenomegaly.
    • Segmental wall edema of S-colon.
    • Consolidation in RLL. Bilateral lung metastasis, stationary.
• 2023-03-11 ECG
  • Sinus tachycardia
  • Right bundle branch block
• 2023-03-09 Bladder Sonography
  • PVR 7.94mL
• 2023-03-09 Uroflowmetry
  • Q max: fair
  • flow pattern: obstructive
• 2023-03-03 Abdomen - standing (diaphragm)
  • Fecal material store in the colon.
  • splenomegaly.
  • Left hemi-diaphragm elevation is noted, which may be due to eventration or splenomegaly.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2023-02-25 Uroflowmetry
  • Q max: low
  • flow pattern: obstructive
• 2023-02-25 Bladder sonography
  • PVR 21 mL
• 2023-02-10 CT - chest
  • Indication: Liver cell carcinoma
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Consolidation over right lower lobe is found.
      • Nodular lesion at right upper lobe and left upper lobe is found. In comparison with CT dated on 2022-11-23, the lesions are regressed slightly.
      • Some lymph nodes are found at paratracheal and subcarina region.
      • Mild bilateral pleural effusion is found.
    • Visible abdomen:
      • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
      • s/p partial pancreatectomy.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • The portal vein and IVC are patent.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
      • Minimal ascites is found.
  • IMp:
    • Liver cirrhosis with splenomegaly
    • Bilateral lung meta. In regression.
    • mediastinal lymphadenopathy. Stable.
• 2023-02-08 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-01-03 Bronchodilator Test
  • FEV1/FVC= 87%, FVC 51%, FEV1 56%
• 2022-12-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (62 - 11) / 62 = 82.26%
    • M-mode (Teichholz) = 83
  • Normal LV filling pressure and impaired RV relaxation.
  • Normal LV and RV systolic function.
  • Trivial TR.
• 2022-11-23 CT - chest
  • HCC with lung mets dyspnea
  • multiple lung metastases, seem stationary, and newly extensive lung infecion with hyperplastic mediastinal LAP r/o metastatic LAP as compared with CT on 2022/09/14
• 2022-11-22 SONO - abdomen
  • Chronic liver parenchymal disease
  • Hepatic tumor, rule out hemangioma
  • Post left lobectomy of liver
  • Post choleystectomy
  • Fluid collection, right subphrenic region
  • Splenomeglay, mild
• 2022-11-19 KUB
  • S/P clips projecting at right lobe liver.
  • S/P metalic autosuture at left middle abdomen.
  • Fecal material store in the colon.
• 2022-09-14 CT - chest
  • multiple lung metastases, with significant in regression as compared with CT on 2022/06/15 s/p C/T.
• 2022-06-15 CT - abdomen, pelvis
  • Findings:
    • Prior CT identified mutiple HCCs (> 10 lesions) in right hepatic lobe S/P TACE and Nivolumab are noted again, decreasing in size that are c/w HCCs S/P TACE and Nivolumab with partial response.
      
    • Prior CT identified multiple lung metastases are noted again, decreasing in size that is c/w lung metastases S/P Nivolumab with partial response.
      
    • S/P surgical enucleation of S7 HCC.
      • S/P cholecystectomy, Whipple operation, and left lateral segmentectomy and partial resection of S4/7/8 of the liver.
        
    • There is a osteolytic lesion in T11 vertebral body that may be bony metastasis.
    • There is no focal abnormality in the biliary system, spleen & both kidney.
      
    • There is no ascites or lymphadenopathy.
      
    • There is no bowel wall thickening, and no bowel obstruction.
      
    • The abdominal aorta and IVC are grossly unremarkable.
      
    • There is no evidence of intrinsic or extrinsic bladder mass.
      
    • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • Multiple HCCs in right hepatic lobe S/P TACE and Nivolumab show partial response.
      
    • Multiple lung metastases S/P Nivolumab show partial response.
    • Bony metastasis in T11 vertebral body is suspected. Please correlate with bone scan.
• 2022-05-18 CXR
  • S/P Port-A infusion catheter insertion.
  • Multiple nodules at bil. lungs.
  • HCCs s/p TACE.
• 2022-05-06 CT - liver, spleen, biliary duct, pancreas
  • Three recurrent HCCs in right hepatic lobe show stable in size. However, Several newly-developed recurrent HCCs in the right lobe liver are noted.
  • Multiple lung metastases show mild increasing in size.
• 2022-03-11 CT - liver, spleen, biliary duct, pancreas
  • Three recurrent HCCs in right hepatic lobe show mild increasing in size.
  • Multiple lung metastases show stable disease.
• 2021-12-29 CT - liver, spleen, biliary duct, pancreas
  • Three recurrent HCCs in right hepatic lobe are noted.
  • Multiple lung metastases show progressive disease.
• 2021-09-01 CT - liver, spleen, biliary duct, pancreas
  • Two recurrent HCCs 1.4 x 1.1 cm and 1.4 x 1.2 cm in right hepatic lobe are highly suspected.
  • Multiple lung metastases are highly suspected.
• 2021-06-01 SONO - abdomen
  • S/P surgical enucleation of S7, left lateral segmentectomy and partial resection of S4/7/8 of the liver.
    
  • S/P cholecystectomy and Whipple operation.
• 2021-02-19 CT - liver, spleen, biliary duct, pancreas
  • S/P surgical enucleation of S7 HCC.
  • There is no evidence of tumor recurrence.
• 2020-11-17 Patho - liver partial resection
  • pathologic diagnosis
    • Liver, segment 7, partial hepatectomy — Hepatocellular carcinoma
      
    • Pathologic Staging (AJCC) — rypT4 (if cN0 and cM0), stage IIIB
      
    • R’t diaphragm, frozen section (F2020-00457) — Tumor invasion
      
  • microscopic examination
    • Histologic Type: Hepatocellular carcinoma
      
    • Histologic Grade: G3, poorly differentiated
    • Cytological grade: III
      
    • Tumor necrosis: Present
      
    • Inflammatory cell infiltration: Mild
      
    • Tumor capsule: incomplete with capsular invasion
      
    • Satellite nodule: present
      
    • Venous (Large Vessel) Invasion: Absent
      
    • Portal Vein Thrombosis: (-), Capsular vein invasion: (-)
      
    • Perineural Invasion: Absent
      
    • Bile duct Invasion: Absent
      
    • Pathologic Staging (pTNM): Stage IIIB (pT4)
      
    • Margins
      • Parenchymal Margin: Free, 0.8 cm from closest margin
        
      • Hepatic capsule: involved by invasive carcinoma
        
    • Additional Pathologic Findings: clear cell change and fibrosis
      
    • Hepatitis (specify type): unknown (by medical record)
      
    • Ishak modified HAI grading: Necroinflammatory Scores 2
      
    • Ishak staging: 3 (occasional bridging)
      
    • Fatty change: focal and mild
      
    • Immunohistochemistry (F2020-00457): Arginase(+, focal), hepa-1(+, scant) for tumor cells
• 2020-11-16 Frozen resction
  • Diaphragm, right, frozen section — Tumor invasion
    
  • Margins — Tumor present at muscle side, other margins are free
• 2020-10-27 MRI - liver, spleen
  • HCC s/p operation. A biloma (2.6cm) at left liver margin. Right HCC s/p TACE with stable size (2.3cm).
  • Liver cirrhosis with splenomegaly.
• 2020-09-18 CT - liver, spleen, biliary duct, pancreas
  • A newly-developed HCC 2.3 cm in S7 of the liver is suspected. please correlate with AFP, sonography, or MRI.
• 2020-06-26 SONO - abdomen for follow-up
  • S/P surgical resection S2. S3, S4, and S7, and cholecystectomy.
• 2020-04-02 SONO - abdomen for follow-up
  • S/P left hepatic lobe operation and cholecystectomy.
• 2020-01-10 CT - liver, spleen, biliary duct
  • S/P cholecystectomy, Whipple operation, left lateral segmentectomy and partial resection of S4/7/8 of the liver.
    
  • There is no evidence of tumor recurrence.
• 2019-10-29 SONO - abdomen for follow-up
  • S/P surgical resection S2. S3, S4, and S7, and cholecystectomy.
• 2019-07-31 CT - liver, spleen, biliary duct
  • Liver cirrhosis
  • HCC s/p op. and TACE without evidence of tumor recurrence.
• 2019-05-06 SONO - abdomen for follow-up
  • Hepatic fibrocalcified lesion
  • Parenchymal liver disease
  • Status post cholecystectomy, left lateral segmentectomy, and partial resection of S4/7/8
  • Mild splenomegaly
• 2019-02-12 CT - liver, spleen, biliary duct
  • S/P cholecystectomy, Whipple operation, left lateral segmentectomy and partial resection of S4/7/8 of the liver.
    
  • There is no evidence of tumor recurrence.
• 2018-11-01 SONO - abdomen
  • diagnosis
    • Suspected chronic liver parenchyma disease (Please correlate with liver function)
    • S/p left lobectomy
    • S/p cholecystectomy
    • Pancreas not shown
  • suggestion
    • OPD f/u
    • Follow liver function test and AFP
• 2018-07-10 CT - liver, spleen, biliary duct
  • s/p op. and TACE with radiopaque materials in the rest of the liver.
  • Lobulated appearance of the liver is found. No significant abnormal enhancement is found but lobulated nodule at dome up to 4.6cm is found. suspected regereration nodule. In comparison with CT dated on 2017-10-27, the lesion is stationary.
• 2018-04-09 SONO - abdomen
  • Liver cirrhosis with mild splenomegaly
  • Compatible with HCC s/p resection
• 2018-02-06 CT - liver, spleen, biliary duct
  • S/P operation and TACE with minimal viable tumors.
• 2018-01-04 CT - lung/pleura (chest and upper abdomen)
  • Loculated Rt subphrenic fluid collection and diaphgramatic pleural effsuion, post op change or infection fluid collections.
  • No lung lesion.
• 2018-01-03 Echo - chest
  • Echo diagnosis:
    • Pleural thickening, right CP angle
    • No pleural effusion
    • Consolidation, minimal, RLL
  • Comment:
    • Arrange abdominal echoi, AFP recheck and abdominal/lung CT may be indicated also
• 2017-12-15 SONO - hepatobiliary
  • S/P operation. Mild liver cirrhosis.
  • A hypoechoic lesion (1.92x2.51cm) at left hepatic lobe.
  • S/P cholecystectomy.
  • Mild splenomegaly.
  • A hypoechoic lesion (2.21x3.95cm) at left kidney.
• 2017-10-27 CT - liver, spleen, biliary duct
  • Post-op and S/P TACE for HCCs, with decreased liver size and some defects, could be due to some viable tumors, suggest further treatment.
• 2017-07-28 CT - liver, spleen, biliary duct
  • HCC and pancreas tumor, s/p operation
  • suspected recurrent HCCs
  • suspected peritoneal seeding
• 2017-05-02 SONO - abdomen
  • Chronic liver parenchymal disease
  • Post operation change
  • Focal liver lesion, S6, possible tumor or previous abscess in regression.
  • Post cholecystectectomy
• 2017-02-07 CT - liver, spleen, biliary duct
  • S/P operation. No evidence of tumor recurrence.

[MedRec]

• 2023-07-06 MultiTeam - Palliative Care
  • Palliative Care Multidisciplinary Recommendation
  • Referral Date: 2023-07-05
  • Response Content:
    • The patient has cancer with distant metastasis and is still undergoing treatment. The original medical team referred the case to the palliative care team due to the patient’s flu and slight breathlessness. However, when the palliative care nurse and Dr. Xia visited together, the patient seemed a bit startled. The nurse explained that this is a routine referral for cancer patients to enhance the understanding of palliative care, to advocate against emergency resuscitation, and to complete a pre-established palliative care wish form. The patient seemed more relaxed and indicated that he understands the concept of palliative care and is inclined to forego emergency resuscitation. The nurse explained that if the patient does not fill out the form, it will be completed by the family. The patient said he would discuss it with his wife. The patient himself agreed to palliative co-care and to befriend the care team first.
  • Conclusion and Recommendation: Co-management with palliative care
  • Respondent: Yu XiuHong
  • Response Date: 2023-07-05 19:03

[consultation]

• 2023-07-05 Family Medicine
  • Q
    • A 58 years old man is a patient of pancreatic intraductal papillary mucinous carcinoma and hepatocellular carcinoma with bilateral lung metastasis and bone T11 metastasis, he was admitted under the impression of influenza A in this time, we need your help in planning future medical care due to terminal cancer, thank you
  • A
    • A 58 years old male had history of pancreatic intraductal papillary mucinous carcinoma and hepatocellular carcinoma with bilateral lung metastasis and bone T11 metastasis.
      • He was admitted for influenza A.
      • con’:E4V5M6
      • ECOG:1
    • We will arrange hospice combine care and follow up his condition.
    • Patient said he will discussed with his wife and other family.
    • Indication: pancreatic cancer, HCC with lung and bone metastasis.
    • Plan: hospice combined care
• 2023-05-30 Radiation Oncology
  • Q
    • The consultation is for T11 bone lesion radiotherapy evaluation.
    • Brief history: This was a 58 yr case of HCC with lung mets post partial hepaectomy and TACE; first diagnosed in 2016, then recurrent several times after. The patient was now on palliative chemotherapy with FOLFOX and Nivolumab.
    • This time he was admitted for unspecific origin fever; we treated with Brosym, no fever was detected during admission and CRP today was 2.7.
    • However, in the follow up ABD CT on 20230529, we found a osteolytic lesion in T11, may paralleled with the patient’s complaint about back pain.
    • We would love to have your consultation for radiotherapy
  • A
    • The ABD CT on 2023/5/29 showed a osteolytic lesion in T11. However, he said he had no backpain for now. Only his Rt flank pain was mentioned. Tracing back the previous CTs, the spine T11 metastatic lesion was first shown on Abd. CT on 2021/09/01. After long period of palliative systemic treatment, the T11 lesion has been under control and the re-ossification can be observed on recent CT images. Therefore, immediate RT to the T11 might not be indicated for now. If new back pain develops, palliative RT might be considered by then. Thank you very much.
• 2022-11-25 Chest Medicine
  • Q
    • The 58 y/o man has HCC with lung metastasis. Due to pneumonia with green like sputum, so he received antibiotics as Tapimycin and Targocid for infection control. Today, his SOB in progress and CXR showed right lung space decrease. We need your help for assessment. Thanks!
  • A
    • We were consulted for PN progression.
    • PE
      • E4V5M6, clear cons, shallow/rapid respiratory pattern with accessory muscle use
      • SpO2 > 95% under NRM full, no wheezing
      • much greenish/sticky sputum formation
    • ABG(2022/11/22)
      • PH 7.4/PCO2 39.9/PO2 163/HCO3 24.3/SpO2 99, FiO2 100%
      • PF ratio 163
    • Chest CT (2022/11/23)
      • lobar consolidation with air-bronchograms over both lower lobes and extensive consolidation over RML.
      • stationary of metastatic nodules in both lungs as compared with previous CT on 9/14
    • Impression
      • Bilateral pneumonia, impending hypoxic respiratory failure
      • Recurrent HCC with lung metastasis
    • Suggestion
      • May adjusted antibiotic treatment according to clinical condition and Sp/C reports
      • May check atypical pneumonia pathogen and TB/C*3
      • keep O2 support, if hemodynamic unstable or conscious change due to hydercapnia or hypoxia, ETT intubation is indicated
      • Chest care, percussion, and suction frequently
      • Treat underlying disease as your expertise
• 2020-11-17 Thoracic Surgery
  • Q
    • for diaphragm repair
    • This 56-year-old man had past histories of
      • Chronic hepatitis
      • Frequent acute pancreatitis episodes in 2006, 2007, 2008, 2014/03/05 and 2014/09/30,
      • Pancreatic intraductal papillary mucinous carcinoma, invasive pStage(pT1N0M0)s/p PPPD in 2014
      • HCC s/p S8 segmentectomy on 2016/06/30, pT2Nx(cMx), stage II.
      • Post S8 segmentectomy with liver abscesss/p pig-tail drainage on 2016/07/12, discharged on 2016/07/20.
      • Hepatocellular carcinoma, recurrent (S2-3 and S7) rpT3bNx(cMx) stage IIIb s/p op on 2016/10/03 discharge on 2016/10/08.
      • Hepatocellular carcinoma, recurrent (S2-3 and S7) rpT3bNx(cMx) stage IIIb s/p op on 2016/10/03. with Target therapy (Nexavar) side effect management since 2016/10/23 ~ 2016/10/26.
      • Post Hepatocellular carcinoma, recurrent (S2-3 and S7)rpT3bNx(cMx) stage IIIb operation, liver abscess again s/p pig-tail insertion on 2016/11/02.
    • This time, abdomen CT on 2020/09/18 which revealed a newly-developed HCC 2.3 cm in S7 of the liver is suspected. AFP on 2020/09/18 showed 10.3ng/mL was noted. TACE was performed on 2020/09/29. Liver MRI was performed on 2020/10/27 which revealed a biloma (2.6cm) at left liver margin. Right HCC s/p TACE with stable size (2.3cm). This time, he was admitted for S7 resection today. We need your help for combine surgery for diaphragm repair. Thanks for your help!!
  • A
    • I have performed diaphragm repair for this patient. Thanks for your consultaiton!

[surgical operation]

• 2020-11-16
  • Surgery
    • Diaphragm repair
  • Finding
    • HCC invasion to right diaphragm.
  • Procedure
    • Under GA, the patient was put in supine position. We was consulted for suspected tumor invasion to diaphram. Elliptical incision was made for involving area of diaphragm with electrocautery. Pneumolysis was performed for underlying lung parechyma. The resected diraphgram was sent for frozen section. The margin showed negative to malignancy. The residual diaphragm was repaired with No.2 silk with vertical matress suture. Then, GS Dr. Wu took over for following procedure.
• 2020-11-16
  • Surgery
    • S7 paritla hepatectomy
    • adhesivelysis with bowel repair
    • diaphragm resection with repair by chest surgeon
    • IOE
  • Finding
    • IOE revealed 1.8 x 1.8cm hypereechoic tumor at S7
    • tumor direct invadion to right diaphragm
    • severe intraabdominal adhesion
    • chronic abscess at previous resection space
  • Procedure
    • ETGA
    • midline extended to right subcostal laparotmy
    • adhesivelysis with small bowel repair
    • IOE
    • S7 partial resection
    • diaphragm partial resection with repair by chest surgeon
    • tow J-vac inserted
    • wound closed

[embolization]

• 2022-05-17 Embolization (TAE) - abdomen for tumor
• 2022-03-23 Embolization (TAE) - abdomen for tumor
• 2021-12-30 Embolization (TAE) - abdomen for tumor
• 2021-09-14 Embolization (TAE) - abdomen for tumor
• 2020-09-29 Embolization (TAE) - abdomen for tumor
• 2017-08-08 Embolization (TAE) - abdomen for tumor

[chemoimmunotherapy]

• 2023-07-10 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 200mg/m2 350mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 700mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1050mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-06-12 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 200mg/m2 360mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 730mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1095mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-05-08 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 710mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 710mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1065mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-07 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 710mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 710mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1065mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-01 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 690mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1035mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-08 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 670mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1035mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-02 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 700mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-10-06 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 700mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-09-05 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 670mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-08-08 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 660mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 990mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-07-05 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + leucovorin 200mg/m2 330mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 660mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 990mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-06-07 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + leucovorin 200mg/m2 330mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 660mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-03-23 - nivolumab 3mg/kg 100mg 1hr
• 2022-01-24 - nivolumab 3mg/kg 100mg 1hr
• 2021-12-30 - nivolumab 3mg/kg 100mg 1hr
• 2021-12-07 - nivolumab 3mg/kg 100mg 1hr
• 2021-11-09 - nivolumab 3mg/kg 100mg 1hr
• 2021-10-05 - nivolumab 3mg/kg 100mg 1hr
• 2021-12-31 ~ 2022-08-19 - Stivarga (regorafenib 40mg/tab) 4# QD (hand foot syndrome due to stivarga side effect?)
• 2017-10-06 ~ 2018-01-16 - Nexavar (sorafenib 200mg/tab) 1# BIDAC

[note]

Chemotherapy for advanced or metastatic disease treatment regimen listed in in-hospital “Revised Edition of Chemotherapy Prescription Collection for Liver Cancer” version 2022-03-01

• FOLFOX4
  • Oxaliplatin 85 mg/m2 I.V D1
  • Leucovorin 200 mg/m2 I.V 2 hrs D1 & D2
  • 5-FU 400 mg/m2, I.V bolus D1 & D2
  • 5-FU 600 mg/m2, I.V 22 hrs D1 & D2
  • Every 2 weeks
  • References: Qin S et al, J Clin Oncol. 2013;31:3501-3508

Principles of Systemic Therapy - NCCN Clinical Practice Guidelines in Oncology - Hepatocellular Carcinoma - Version 1.2023 - 2023-03-10 - HCC-G 1 of 2, p23

• First-Line Systemic Therapy
  • Preferred Regimens
    • Atezolizumab + bevacizumab (Child-Pugh Class A only) (category 1)
    • Tremelimumab-actl + durvalumab (category 1)
  • Other Recommended Regimens
    • Sorafenib (Child-Pugh Class A [category 1] or B7)
    • Lenvatinib (Child-Pugh Class A only) (category 1)
    • Durvalumab (category 1)
    • Pembrolizumab (category 2B)
  • Useful in Certain Circumstances
    • Nivolumab (Child-Pugh Class B only)
    • Atezolizumab + bevacizumab (Child-Pugh Class B only)
    • For TMB-H tumors:
      • Nivolumab + ipilimumab (category 2B)
• Subsequent-Line Systemic Therapy if Disease Progression
  • Preferred Regimens
    • Regorafenib (Child-Pugh Class A only) (category 1)
    • Cabozantinib (Child-Pugh Class A only) (category 1)
    • Lenvatinib (Child-Pugh Class A only)
    • Sorafenib (Child-Pugh Class A or B7)
  • Other Recommended Regimens
    • Nivolumab + ipilimumab (Child-Pugh Class A only)
    • Pembrolizumab (Child-Pugh Class A only)
  • Useful in Certain Circumstances
    • Ramucirumab (AFP >=400 ng/mL and Child-Pugh Class A only) (category 1)
    • Nivolumab (Child-Pugh Class B only)
    • For MSI-H/dMMR tumors
      • Dostarlimab-gxly (category 2B)
    • For RET gene fusion-positive tumors:
      • Selpercatinib (category 2B)
    • For TMB-H tumors:
      • Nivolumab + ipilimumab (category 2B)

Nivolumab: Drug information 2023-03-02 https://www.uptodate.com/contents/nivolumab-drug-information

• Dosing: Adult
  • Hepatocellular carcinoma
    • Hepatocellular carcinoma: IV: 1 mg/kg once every 3 weeks (in combination with ipilimumab) for 4 combination doses, followed by 240 mg once every 2 weeks (Yau 2020) or 480 mg once every 4 weeks (nivolumab monotherapy) until disease progression or unacceptable toxicity.

Regorafenib: Drug information 2023-03-02 https://www.uptodate.com/contents/regorafenib-drug-information

• Dosing: Adult
  • Hepatocellular carcinoma
    • Hepatocellular carcinoma: Oral: 160 mg once daily for the first 21 days of a 28-day cycle; continue until disease progression or unacceptable toxicity (Bruix 2017).
• Dosing: Adjustment for Toxicity: Adult
  • If dose reduction is necessary, reduce in 40 mg increments; the lowest recommended dose is 80 mg/day.
    • Dermatologic:
      • Grade 2 hand-foot skin reaction (HFSR; palmar-plantar erythrodysesthesia syndrome [PPES]) of any duration: Reduce dose to 120 mg once daily for first occurrence. If grade 2 HFSR recurs at this dose, further reduce the dose to 80 mg once daily. Interrupt therapy for grade 2 HFSR that is recurrent or fails to improve within 7 days in spite of dosage reduction.
      • Grade 3 HFSR: Interrupt therapy for a minimum of 7 days. Upon recovery, reduce dose to 120 mg once daily. If grade 2 to 3 toxicity recurs at this dose, further reduce dose to 80 mg once daily upon recovery. Interrupt therapy for grade 2 to 3 HFSR that is recurrent or fails to improve within 7 days in spite of dosage reduction.
      • Recurrent or persistent HFSR at 80 mg once daily: Discontinue treatment.
      • Other dermatologic toxicity: Withhold treatment, reduce dose or permanently discontinue treatment depending on the severity and persistence of the dermatologic toxicity. Symptomatic relief may be managed with supportive measures.
    • Hypertension: Grade 2 (symptomatic): Interrupt therapy.
    • Infection: Grade 3 or 4 (or worsening infection of any grade): Interrupt therapy; resume regorafenib at the same dose following infection resolution.
    • Other toxicity: Any grade 3 or 4 adverse reaction (other than hepatotoxicity or infection): Interrupt therapy; upon recovery, reduce dose to 120 mg once daily (except infection). If any grade 3 or 4 adverse reaction occurs (other than hepatotoxicity or infection) while on this reduced dose, may further reduce dose to 80 mg once daily upon recovery. For any grade 4 adverse reaction, only resume therapy if the benefit outweighs the risk. Permanently discontinue therapy if unable to tolerate 80 mg once daily.
    • Gastrointestinal perforation/fistula: Discontinue permanently.
    • Hemorrhage (severe or life-threatening): Discontinue permanently.
    • Reversible posterior leukoencephalopathy syndrome (RPLS): Discontinue.
    • Dosage adjustment for surgery: Temporarily withhold regorafenib at least 2 weeks prior to elective surgery; do not administer regorafenib for at least 2 weeks following major surgery and until adequate wound healing.

==========

2023-07-11

Our gastroenterologist prescribed a multiple refill prescription for Baraclude (entecavir) on 2023-06-26, which the patient is using for prophylaxis of his HBV reactivation. This medication is included in the patient’s active medication list as a patient-carried item and no reconciliation issue has been identified.

2023-06-13

• This patient relies only on our hospital for his medical need on liver cell carcinoma, no other healthcare providers found in the PharmaCloud database, no medication reconciliation issues identified.

• The dosage of FOLFOX4 administered to this patient during this current treatment cycle has been adjusted in accordance with our in-hospital guidelines outlined in the “Revised Edition of Chemotherapy Prescription Collection for Liver Cancer, version 2023-03-01.” No issues have been identified with this adjustment.

• The lab data show a fluctuation in the tumor marker AFP levels, which initially decreased (2022 Q2 to Q3), troughed around 2022 Q3/Q4, and then increased after 2022Q4. This pattern suggests that the “nivolumab + FOLFOX4” regimen, administered monthly since 2022-06, might have become less effective after approximately a year of treatment, indicating potential disease resistance.

  • 2023-06-12 AFP 23.6 ng/mL
    
  • 2023-03-28 AFP 13.9 ng/mL
    
  • 2022-10-06 AFP 4.1 ng/mL
    
  • 2022-09-14 AFP 4.4 ng/mL
    
  • 2022-06-15 AFP 77.4 ng/mL
    
  • 2022-06-07 AFP 94.0 ng/mL
    
  • 2022-05-06 AFP 170.4 ng/mL

• This patient has previously been treated with sorafenib (from 2017-10 to 2018-01), regorafenib (from 2021-12 to 2022-08), and nivolumab (since 2021-10). If the disease is confirmed to have developed resistance to these treatments, then potential next-line therapy options could include cabozantinib or lenvatinib.

• According to the current version (2023-05-23) NHI medication reimbursement rules, for advanced hepatocellular carcinoma, patients can only choose to use either sorafenib or lenvatinib, but they cannot switch between the two. Additionally, cabozantinib is only covered for patients with intermediate or high-risk advanced renal cell carcinoma who have not previously undergone treatment. Thus, in this patient’s case, it appears cabozantinib or lenvatinib may not be covered based on these regulations.

2023-05-09

• During this chemotherapy session, facial flushing was noted approximately halfway through the oxaliplatin infusion (at 133 cc of a total of 250 cc). It might be beneficial to consider extending the infusion time beyond the current 2 hours to minimize this reaction.
• According to PharmaCloud records, all recent medications were prescribed at our hospital and no medication reconciliation issues were identified.

2023-03-02

• The CT scan conducted on 2023-02-10 revealed that the bilateral lung mets were regressing, indicating that the current treatment regimen (nivo + FOLFOX4) was still effective.
• Pulmonary symptoms was properly managed with the patient’s self-carried medications.

2022-12-06

Currently, Tecopin (teicoplanin 200mg/vial) is out of stock and has been replaced with Targocid (teicoplanin 200mg/vial). If the teicoplanin treatment should continue, please prescribe Targocid.

2022-11-21

• As of 2022-11-19 and 2022-11-20, the urine volume was recorded as 3850mL and 3350mL, respectively. This problem “decreased urine output” registered since 2022-11-19 should have been mitigated.
• As long as the body temperature remains high (38.5 degrees Celsius at 08:43 on 2022-11-21), there is no issue with the ongoing use of antimicrobial flomoxef.
• Please monitor the patient for anymore GI bleeding signs to determine the need to adjust the PPI.

2022-09-06

• A multicenter phase II trial (RENOBATE) demonstrated that regorafenib plus nivolumab as first-line therapy for unresectable hepatocellular carcinoma shows promising efficacy outcomes without unexpected safety signals. (ref: Regorafenib plus nivolumab as first-line therapy for unresectable hepatocellular carcinoma (uHCC): Multicenter phase 2 trial (RENOBATE). Changhoon Yoo, etc. Journal of Clinical Oncology 2022 40:4_suppl, 415-415. https://ascopubs.org/doi/abs/10.1200/JCO.2022.40.4_suppl.415 )

• Since the end of 2021, Stivarga (regorafenib 40mg/tab) has been prescribed. It is administered at 160mg once daily (4# QD) for the first 21 days of a 28-day cycle. Hand-foot skin reaction has been observed.

  • For grade 2 hand-foot skin reaction of any duration, it is recommended to reduce dose to 120 mg once daily for first occurrence. If grade 2 hand-foot skin reaction recurs at 120mg once daily, further reduce the dose to 80 mg once daily. Interrupt therapy for grade 2 hand-foot skin reaction that is recurrent or fails to improve within 7 days in spite of dosage reduction.
  • For grade 3 hand-foot skin reaction, it is recommended to interrupt therapy for a minimum of 7 days. Upon recovery, reduce dose to 120 mg once daily. If grade 2 to 3 toxicity recurs at 120 mg once daily, further reduce dose to 80 mg once daily upon recovery. Interrupt therapy for grade 2 to 3 hand-foot skin reaction that is recurrent or fails to improve within 7 days in spite of dosage reduction.
  • For recurrent or persistent hand-foot skin reaction at 80 mg once daily, it is recommended to discontinue the treatment.

2022-07-06

• Nivolumab was administered from early October 2021 to late March 2022. On 2022-06-25 CT, several recurrent HCCs were found in the right lobe liver, and on 2022-03-11 CT, recurrent HCCs were found with mild increases in size.
• There has been a shift in the regimen to FOLFOX4 + nivolumab since 2022-06-07. The AFP level declined to 77 (2022-06-15) from its recent peak 170 (2022-05-06), while CT results (2022-06-15) showed partial responses in right hepatic lobe and lung mets.
• A rapid drop in blood pressure (92/63 at 9:19 2022-07-06) has been recorded. Tracking of hemodynamics might be necessary.

701475086

230711

[lab data]

2023-04-07 Anti-HBc Reactive
2023-04-07 Anti-HBc-Value 6.97 S/CO
2023-04-07 Anti-HBs 49.82 mIU/mL
2023-04-07 SCC 1.9 ng/mL
2023-04-07 CEA 0.82 ng/mL

2023-03-29 RPR/VDRL Nonreactive
2023-03-29 HBsAg Nonreactive
2023-03-29 HBsAg (Value) 0.44 S/CO
2023-03-29 Anti-HCV Nonreactive
2023-03-29 Anti-HCV Value 0.09 S/CO
2023-03-29 HIV Ab-EIA Nonreactive
2023-03-29 Anti-HIV Value 0.06 S/CO

[exam findings]

• 2023-05-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 27) / 81 = 66.67%
    • M-mode (Teichholz) = 66
  • Conclusion:
    • Concentric LV hypertrophy and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild PR; mild aortic root calcification.
    • Sinus tachycardia.
• 2023-05-08 CXR
  • Enlargement of cardiac silhouette.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-04-17 Pure Tone Audiometry
  • Reliabilty Fair
  • PTA
  • R’t : 14 dB HL
  • L’t : 16 dB HL
  • Bil WNL
• 2023-04-01 CT - abdomen
  • No definite abnormality in this study
• 2023-03-31 MRI - larynx
  • Impression (Imaging stage) : T:4a N:2b M:0 STAGE:IVA
• 2023-03-29 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, elbows, sternoclavicular juncions, S-I joints, hips, knees, and right ankle.
• 2023-03-29 Patho - stomach biopsy
  • Stomach, midbody, GC side. Biopsy (A) — Hyperplastic polyp
  • EC junction, biopsy (B)— low grade dysplasia. Please follow up.
• 2023-03-20 Patho - tongue biopsy
  • Tongue, right, biopsy— moderately differentiated squamous cell carcinoma
  • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests of tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis.The tumor cells have abundant eosinophilic cytoplasm,round to oval nuclei,prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
  • Immunohistochemical stain reveals CK(+) and p16(-).

[consultation]

• 2023-04-17 Dermatology
  • Q
    • The 49 y/o man has right tongue cancer, moderately differentiated squamous cell carcinoma, cT4aN2b stage IVA. He was admitted for chemotherapy. Due to skin itchy over legs, scrotum, axillary. We need your help for r/i scabies. Thanks!
  • A
    • This patietn suffered from multiple erytheamtous papules on trunk for days.
    • Imp: Scabies
    • Suggestion:
      • BB lotion (benzyl benzoate) x 1 BT /QD
      • Ulex cream (hydrocortisone, crotamiton) x 15 tubes /BID
• 2023-04-01 Hemato-Oncology
  • Q
    • For chemotherapy.
    • This 49-year-old male denied of having chronic disease before. The patient is a case of right lateral tongue cancer. He was admitted for cancer work up. Larynx MRI arranged and showed right lateral tongue cancer T4aN2bM0, STAGE:IVA. We request your consultation for chemotherapy.
  • A
    • Patient examined and Chart reviewed, my suggestions would be:
      • Well explain and educate to the patient (Already done).
      • Surgical intervention would be first considered if no distant mets.
      • If the surgical intervention is not feasible, may consider CCRT.
      • Please arrange my OPD visit after being discharged.
• 2023-03-30 Oral and Maxillofacial Surgery
  • Q
    • This 49-year-old male denied of having chronic disease before. The patient is a case of right lateral tongue cancer. He was admitted for cancer work up. We request your consultation for dental evaluation.
  • A
    • Panoramic findings:
      • impacted tooth: 38,48
      • deep caries: tooth 18
      • Missing tooth: nil
      • cystic change of impacted tooth 48 was present
    • Plan:
      • Explain the findings
      • suggest extraction of tooth 18 and 48 prior to radiotherapy or remove the tooth 18 and 48 perioperatively

[MedRec]

• 2023-04-13 SOAP Hemato-Oncology
  • Anti-HBc (+), Anti-HBs (+), HBs Ag (-), Anti-HCV (-)
• 2023-04-13 SOAP Oral and Maxillofacial Surgery
  • O: full mouth heavy plaque and calculusdeposition
  • P: full mouth scaling
• 2023-04-07 SOAP Radiation Oncology
  • This 49 year old man is a case of right tongue cancer, moderately differentiated squamous cell carcinoma, cT4aN2b stage IVA
  • Suggest (OP + adjuvant CCRT) or (induction C/T + OP + adjuvant CCRT)
• 2023-04-06 SOAP Oral and Maxillofacial Surgery
  • S: pre-CCRT dental evalution
  • O: deep caries of tooth 18 and cystic change of impacted tooth 48
  • A: Tongue cancer, prepared for CCRT.
  • P:
    • Explain the risk/benefit of the treatment to the patient, about the risk of communication between the maxillary sinus and oral cavity
    • Sign informed consent.
    • Block anesthesia of right maxilla
    • Complicated extraction of tooth 18
    • Suture the gingiva with Vicryl 4-0.
    • Prescribe Acetal and Amoxicillin.
    • Teach the patient how to do home care and OPD follow-up.
• 2023-04-06 SOAP Hemato-Oncology
  • A:
    • cT4aN2bM0, Stage IVA.
      • Suggest OP is the first consideration.
      • If OP is not feasible, then consider CCRT.
  • P:
    • Surgical intervention would be first considered if no distant mets.
    • If the surgical intervention is not feasible, may consider CCRT.
• 2023-03-24 SOAP ENT
  • 2023/03/20 PATHO - tongue biopsy: Tongue, right, biopsy — moderately differentiated squamous cell carcinoma
  • suggest admission for staging
• 2023-03-14 SOAP ENT
  • right tongue swelling tender ulcer for 6 months
  • right tongue border indurated ulcer, suggest biopsy first

[chemotherapy]

• 2023-07-10 - docetaxel 60mg/m2 120mg NS 250mL 1hr D1 + cisplatin 75mg/m2 145mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) D3 + furosemide 20mg NS 30mL 10min (after cisplatin) D3 + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D2-5 (TPF Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D2 + NS 250mL D2 + aprepitant 125mg PO D2-4
• 2023-06-09 - docetaxel 60mg/m2 120mg NS 250mL 1hr D1 + cisplatin 75mg/m2 145mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) D2 + furosemide 20mg NS 30mL 10min (after cisplatin) D2 + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D2-5 (TPF Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D2 + NS 250mL D2 + aprepitant 125mg PO D2-4
• 2023-04-24 - docetaxel 60mg/m2 120mg NS 250mL 1hr D1 + cisplatin 75mg/m2 145mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) D2 + furosemide 20mg NS 30mL 10min (after cisplatin) D2 + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D1-4 (TPF Q3W)
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg PO D1-3

TPF regimen in in-hospital “Prescription Collection of Chemotherapy for Head and Neck Cancer” protocol (dated 2023-03-31)

• Neo-adjuvant Chemotherapy regimen - TPF
  • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
  • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
  • 5-FU 750~1000 mg/m2 IVD (24 hs) D1-2, D8-9
  • Q3W for 1~3 cycles
  • Modified from Posner MRI et al. N.Engl.J.Med.357 (2007):1705-1715.
• Induction Chemotherapy modified with TPF
  • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
  • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
  • 5-FU+Leucovorin 1000mg/m2+100mg/m2 IVD (24 hs) D2, 9
  • Q3 week x 3cycles (Q1W, Q2W, Q3W: rest)
  • Modified from Jérôme Fayette et al. Oncotarget 2016；7(24):37297-37304

Docetaxel, cisplatin, and fluorouracil induction chemotherapy followed by radiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX323) 2023-06-12 https://www.uptodate.com/contents/image?imageKey=ONC%2F72461&topicKey=ONC%2F85694

• Cycle length: Every 21 days for 4 cycles.

• Regimen

  • Docetaxel
    • 75 mg/m2 IV
    • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
    • Day 1
  • Cisplatin
    • 75 mg/m2 IV
    • Dilute in 250 mL NS and administer over 60 minutes. Do not administer with aluminum needles or IV sets.
    • Day 1
  • Fluorouracil (FU)
    • 750 mg/m2/day IV
    • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
    • Days 1 through 5

Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-06-12 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438&topicKey=ONC%2F85694

• Cycle length: Every 21 days for 3 cycles.

• Regimen

  • Docetaxel
    • 75 mg/m2 IV
    • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
    • Day 1
  • Cisplatin
    • 100 mg/m2 IV
    • Dilute in 250 mL NS and administer over 30 minutes to three hours. Do not administer with aluminum needles or IV sets.
    • Day 1
  • Fluorouracil (FU)
    • 1000 mg/m2/day IV
    • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
    • Days 1 through 4

==========

2023-07-11

[reconciliation]

According to the PharmaCloud database, the patient only receives medical services from our hospital. Therefore, there are no identified medication reconciliation issues.

2023-06-12

• After examining the PharmaCloud medical records, it’s evident that this patient has been solely receiving care from our hospital over the past three months. All prescriptions have been issued by our outpatient and inpatient hemato-oncology services. Consequently, no medication reconciliation issues have been identified.

• The docetaxel/cisplatin/fluorouracil regimen was administered to the patient on 2023-04-24 and 2023-06-09. Historical lab data showed a drop in WBC count below 1000/uL from 2023-05-01 to 2023-05-05, indicating leukopenia roughly 1 to 2 weeks after the initial round of the regimen. A total of 6 doses of Granocyte (lenograstim 250ug) were administered daily between 2023-05-01 and 2023-05-07. Given that the seconnd round of the regimen started on 2023-06-09 with the same dosage as the first, it is plausible that another leukopenia episode could occur about one week after treatment. Therefore, a prophylactic administration of G-CSF post-chemotherapy might be considered.

  • 2023-06-09 WBC 7.39 x10^3/uL
    
  • 2023-05-23 WBC 6.43 x10^3/uL
    
  • 2023-05-16 WBC 7.54 x10^3/uL
    
  • 2023-05-12 WBC 6.38 x10^3/uL
    
  • 2023-05-10 WBC 9.71 x10^3/uL
    
  • 2023-05-08 WBC 15.33 x10^3/uL
    
  • 2023-05-06 WBC 1.89 x10^3/uL
    
  • 2023-05-05 WBC 0.57 x10^3/uL
    
  • 2023-05-04 WBC 0.30 x10^3/uL
    
  • 2023-05-03 WBC 0.16 x10^3/uL
    
  • 2023-05-02 WBC 0.12 x10^3/uL
    
  • 2023-05-01 WBC 0.52 x10^3/uL
    
  • 2023-04-17 WBC 6.25 x10^3/uL
    
  • 2023-03-28 WBC 5.14 x10^3/uL

2023-04-18

• Our dermatologist suggested BB lotion (benzyl benzoate) and Ulex cream (hydrocortisone, crotamiton) for the patient’s scabies treatment. If the symptoms do not improve, topical permethrin or oral ivermectin may also be considered as subsequent treatment options.

701478306

230711

[exam findings]

• 2023-07-04, -06-06, 05-24 CXR
  • Atherosclerotic change of aortic arch
  • Pleura effusion of right costal-phrenic angle
  • Widening of the right upper mediastinum is noted that is c/w lymphoma after correlate with CT.
• 2023-06-16 SONO - chest
  • left side minimal amount of pleural effusion
  • right side moderate amount of pleural effusion, 1000cc serosangious fluid was aspirated for analysis.
• 2023-06-12 CXR
  • Increased infiltration in right lung zone
  • Bilateral pleural effusion, more on right side
• 2023-06-12 SONO - chest
  • Pleural tapping - right side 1150 mL yellowish, cloudy
  • Echo diagnosis: Bilateral pleural effusion (Left minimal to small and Right massive), post right therapeutic thoracentesis.
• 2023-05-24 SONO - chest
  • Pleural tapping - 1100mL yellow fluid was drained.
  • Echo diagnosis:
    • pleural effusion, massive, right
    • atelectasis, LLL, RLL
• 2023-04-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (69 - 17) / 69 = 75.36%
    • M-mode (Teichholz) = 75.9
  • Conclusion:
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Minimal amount pericardial effusion, No tamponade, No pericardial constriction at present
    • Trivial MR
    • Moderate TR
    • Moderate Pulmonary HTN
    • Left pleural effusion
• 2023-04-21 SONO - chest
  • Echo diagnosis
    • left side minimal amount of pleural effusion
    • right side massive amount of pleural effusion, 1200cc serosangious fluid was aspirated for analysis
• 2023-04-17, -04-13 CXR
  • Patchy consolidation over RLL.
  • Suspected superior mediastinal lesion.
  • Increased infiltration over both lower lungs. May be active infection.
  • Bilateral pleural effusion.
• 2023-04-13 Patho - bone marrow biopsy
  • Bone marrow, biopsy — involved by B-cell lymphoma
  • Microscopically, the bone marrow shows presence of aggregations of B-cell lymphoma. The bone marrow component shows 40% of cellularity, 3:1 of myeloid to erythroid ratio and 3 megakaryocytes of per HPF. No blast is seen.
  • Immunohistochemical stain CD20 and Bcl-2: positive at lymphoma, CD117(-), CD34(-), CD71(+ at erythroid cells), CD61( + at megakaryocytes), TdT(-).
• 2023-04-14 PET scan
  • The FDG PET findings are compatible with lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm.
  • Mildly increased FDG uptake in some focal areas in the right lung. The nature is to be determined (inflammation? lymphoma?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
• 2023-01-13 SONO - chest
  • Echo diagnosis:
    • pleural effusion
    • Chest echography was performed first. The suitable intercostal space was selected and located.
    • Catheter was inserted with negative pressure smoothly.
    • Right side pleural effusion was drawn smoothly.
    • Watch out BP after tapping.
  • Suggestion:
    • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR.
• 2023-04-12 CXR
  • R/O mass lesion over superior mediastinum.
  • Patchy consolidation or atelectasis of RLL. Suggest check CT scan.
  • Moderate amount of right pleural effusion.
  • Small amount of left pleural effusion.
• 2023-04-10 Nasopharyngoscopy
  • 2023/4/10 Admission
    • consult Hema (arrange staging workup and thne bed transfer + treatment)
    • multiple bil cervical LAPs since 2yr ago
    • dyspnea+, cough with much sputum, cough with blood+
    • BWL-, fever-, cold sweating-, NVR supraclavicular Bx in 2023/02 by Dr. Lin JiengFu at Mackey (refer to Hema, but he escaped? or nurse sign permit)
    • R lung effusion s/p regular tapping (around 700-1000mL)
    • fiber = much mucopus with PND, no vocal palsy

[chemoimmunotherapy]

• 2023-07-11 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cisplatin 75mg/m2 120mg NS 500mL D2 + cytarabine 2000mg/m2 3000mg NS 500mL 3hr Q12H D3 + dexamethasone 40mg PO QD D2-5 (R-DHAP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D2-3
• 2023-06-19 - rituximab 375mg/m2 580mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1150mg NS 250mL 30min D1 + doxorubicin 50mg/m2 75mg NS 100mL 30min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + prednisolone 60mg/m2 90mg PO D1-5 (R-CHOP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-2
• 2023-05-24 - rituximab 375mg/m2 590mg NS 500mL 8hr D1 + cisplatin 75mg/m2 120mg NS 500mL D2 + cytarabine 2000mg/m2 3000mg NS 500mL 3hr Q12H D3 + dexamethasone 40mg PO QD D2-5 (R-DHAP)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D2-4
• 2023-04-20 - rituximab 375mg/m2 580mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1170mg NS 250mL 30min D1 + doxorubicin 50mg/m2 75mg NS 50mL 30min D5 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + prednisolone 60mg/m2 90mg PO D1-5 (R-CHOP where doxorubicin was administered last, is pending the results of a 2D transthoracic echocardiography)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3

R-DHAP (Rituximab, dexamethasone, high dose cytarabine, cisplatin) - DLBCL Salvage regimens - 2023-06-13 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients

• Administration
  • R-DHAP includes
    • rituximab (375 mg/m2 on day -1),
    • dexamethasone (40 mg/d on days 1 to 4),
    • cisplatin (100 mg/m2 on day 1 by continuous infusion), and
    • cytarabine (2 g/m2 in a three-hour infusion on day 2)
    • every three weeks.
  • For patients with pre-existent kidney insufficiency, some experts replace cisplatin with carboplatin or oxaliplatin to lessen nephrotoxicity, but there are limited outcomes data with these regimens.
• Adverse effects
  • Hematologic toxicity is universal, with one-third of patients requiring transfusions, and grade >=3 nonhematologic adverse effects include infection (in up to one-quarter of patients) and occasional nephrotoxicity.

R-DHAP - Cisplatin, Cytarabine and Dexamethasone +/- Rituximab - ref https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2018/11/RDHAP.pdf

• Indication
  • Salvage chemotherapy for relapsed/refractory Hodgkin’s or Non-Hodgkin’s Lymphoma
  • First line therapy in combination with alternating R-CHOP in patients with Mantle Cell Lymphoma with stage III/IV disease up to 65 years of age.
• ICD-10 codes
  • Code with prefix C81-86
• Regimen details
  • Day 1-4 = Dexamethasone 40mg IV or PO
  • Day 1* = Rituximab 375mg/m2 IV infusion
  • Day 1 = Cisplatin 100mg/m2 IV infusion
  • Day 2 = Cytarabine 2g/m2 BD (12 hours apart) IV infusion
  • • Rituximab for B cell Non Hodgkin’s lymphoma patients only.
  • Consider starting GCSF (according to local policy, dose based on weight) either to shorten the duration of neutropenia (days 3-9) or to facilitate peripheral bloods stem cell collection (days 6-12).
• Cycle frequency
  • Repeated every 21-28 days - as soon as blood counts recovered i.e. neutrophils >1.0x10^9/L and platelets (unsupported) > 100x10^9/L (unless cytopenias related to disease).
• Number of cycles
  • Relapse setting: 2 cycles - then reassess disease for suitability for consolidation with stem cell transplant.
  • Non-transplant eligible: up to 6 cycles (total).
  • Mantle cell lymphoma: 3 cycles alternating with R-CHOP followed by consolidation with autograft.
• Administration
  • Day 1
    • Rituximab is administered in 500mL sodium chloride 0.9%. The first infusion should be initiated at 50mg/hour and if tolerated the rate can be increased at 50mg/hour every 30 minutes to a maximum of 400mg/hour. Subsequent infusions should be initiated at 100 mg/hour and if tolerated increased at 100mg/hour increments every 30 minutes to a maximum of 400 mg/hour.
    • Cisplatin is administered in 1000mL sodium chloride 0.9% over 2 hours following the pre and post hydration as per protocol below:
      • Sodium Chloride 0.9% 1000mL 1 hour
      • Mannitol 20% 200mL 30 minutes or Mannitol 10% 400mL 30 minutes
      • Cisplatin in Sodium Chloride 0.9% 1000mL 2 hours
      • Sodium Chloride 0.9% + 2g MgSO4 + 20mmol KCL. 1000mL 2 hours
      • TOTAL 3200mL or 3400mL 5 hours 30 minutes
      • Ensure urine output > 100mL/hour prior to giving cisplatin. Give a single dose of furosemide 20mg IV if necessary.
    • Additional pre hydration may be given as per local policy or required for individual patients.
    • Patients with low magnesium levels (< 0.7 mmol/L) should have an additional 2g magnesium sulphate added to the pre-hydration bag.
    • An accurate fluid balance record must be kept.
    • All patients must be advised to drink at least 2 litres of fluid over the following 24 hours.
  • Day 2
    • Cytarabine is administered in 1000mL sodium chloride 0.9% over 3 hours. Start time of each infusion must be 12 hours apart. A total of 2 doses are given.
    • Pre-medication
      • Rituximab premedication:
        • Paracetamol 500mg-1g PO 30-60 minutes prior to rituximab infusion
        • Chlorphenamine 10mg IV bolus 15-30 minutes prior to rituximab infusion
        • Dexamethasone 8mg IV bolus or hydrocortisone 100mg IV bolus 15 minutes prior to rituximab infusion (may be omitted if day 1 dexamethasone has been taken at least 30 minutes prior to the start of the rituximab infusion)
    • Emetogenicity
      • This regimen has high emetic potential
    • Additional supportive medication
      • Allopurinol 300mg OD (100mg OD if CrCl < 20mL/min) for the first 2 weeks.
      • Antiemetics as per local policy
      • Antiviral prophylaxis as per local policy.
      • Prophylactic antibiotics may be required e.g. ciprofloxacin (or as per local policy) when neutrophil count < 0.5 x10^9/L.
      • Consider antifungal and PCP prophylaxis as per local policy.
      • Mouthwashes as per local policy.
      • H2 antagonist or proton-pump inhibitor if required.
      • Prednisolone 0.5% eye drops 1 drop QDS to both eyes (to avoid chemical conjunctivitis from high dose cytarabine) to start on day 2 for 5-7 days.
      • If magnesium/potassium levels < normal reference range, replace as per local policy.
    • Extravasation
      • Rituximab and cytarabine are neutral (Group 1)
      • Cisplatin is an exfoliant (Group 4)
• Dose modifications (omitted, please refer to the original document)
  • Haematological toxicity
  • Renal impairment
  • Hepatic impairment
  • Other toxicities
• Adverse effects (omitted, please refer to the original document)
• Significant drug interactions (omitted, please refer to the original document)

R-CHOP/R-DHAP (Rituximab + Cyclophos­phamide + Doxorubicin + Vincristine + Prednisone + Dexamethasone + Cytarabine + Cisplatin) is a Chemotherapy Regimen for Lymphoma, Mantle Cell - 2023-06-13 https://www.chemoexperts.com/rchop-rdhap-mcl.html

• R-CHOP

  • R - Rituximab (Rituxan)
  • C - Cyclophosphamide (Cytoxan)
  • H - Hydroxydaunorubicin (Doxorubicin, Adriamycin)
  • O - Oncovin (Vincristine)
  • P - Prednisone

• R-DHAP

  • R - Rituximab (Rituxan)
  • D - Dexamethasone (Decadron)
  • HA - High-dose Ara-C (Cytarabine)
  • P - CisPlatin (Platinol)

• Goals of therapy:

  • R-CHOP/R-DHAP is given to shrink tumors and decrease symptoms of mantle cell lymphoma. It is commonly given with the goal of cure, but may require a bone marrow transplant.

• Schedule

  • Cycles
    • R-CHOP cycles:
      • Rituximab intravenous (I.V.) infusion on Day 1
      • Cyclophosphamide I.V. infusion over 30 to 60 minutes on Day 1
      • Doxorubicin I.V. push or I.V infusion over 10 to 30 minutes on Day 1
      • Vincristine I.V. infusion over 10 to 30 minutes on Day 1
      • Prednisone 100 mg (two 50 mg tablets) by mouth once daily on Days 1, 2, 3, 4, and 5
    • R-DHAP cycles:
      • Rituximab I.V. infusion on Day 1
      • Dexamethasone 40 mg (ten 4 mg tablets) by mouth once daily on Days 1, 2, 3, and 4
      • Cytarabine I.V. infusion over 3 hours every 12 hours on Day 2
      • Cisplatin I.V. infusion over 24 hours on Day 1
  • Estimated total infusion time for this treatment:
    • R-CHOP cycles: Up to 6 hours for Cycle 1; as short as 3 for the first day of next cycles if well tolerated
    • R-DHAP cycles: 24 hours for Day 1 of each cycle; 3 hours for each dose of cytarabine on Day 2
    • Infusion times are based on clinical studies but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time.
    • The R-CHOP portion of treatment is usually given in an outpatient infusion center, allowing the person to go home afterwards. The R-DHAP portion of treatment typically requires a 2 to 3 day stay in a hospital.
    • R-CHOP is alternated with R-DHAP every 21 days. When one treatment of each is given, this is known as one Cycle (one treatment of R-CHOP + one treatment of R-DHAP = 1 cycle). Each cycle may be repeated up to 3 times, depending upon the stage of the disease. Duration of therapy may last up to 5 months, depending upon response, tolerability, and number of cycles prescribed.

• Side Effects (omitted, please refer to the original document)

• Monitoring (omitted, please refer to the original document)

==========

2023-07-11

Lab data:

• 2023-07-11 WBC 9.14 x10^3/uL
  
• 2023-07-04 WBC 2.16 x10^3/uL *
• 2023-06-19 WBC 16.08 x10^3/uL

Regimen administered:

• 2023-07-11 R-DHAP
• 2023-06-19 R-CHOP
• 2023-05-24 R-DHAP
• 2023-04-20 R-CHOP

The patient, who has been diagnosed with mantle cell lymphoma, is currently receiving an alternating regimen of R-CHOP and R-DHAP. The most recent cycle of R-CHOP began on 2023-06-19, and the latest cycle of R-DHAP just started today on 2023-07-11.

The lowest point of the patient’s white blood cell count (nadir) occurred on 2023-07-04, when it was recorded at 2.16K/uL. On both 2023-07-04 and 2023-07-06, the patient was administered a dose of Granocyte (lenograstim 250ug). The white blood cell count has significantly recovered by 2023-07-11, reaching 9.14K/uL, which should not hinder the delivery of the R-DHAP regimen.

2023-06-13

Lab data revealed an episode of leukopenia on 2023-06-08 with a WBC of 1.3K/uL. This was managed with a consecutive 3 day course of Granocyte (lenograstim 250ug). The leukopenia is believed to be related to the R-DHAP treatment administered on 2023-05-24, approximately 2 weeks prior to the identified episode. In addition, the first administration of R-CHOP on 2023-04-20 also resulted in a decrease in the WBC count, which reached its lowest level on 2023-05-02. Currently, the patient is not experiencing leukopenia. Instead, he is experiencing leukocytosis.

• 2023-06-12 WBC 57.96 x10^3/uL
  
• 2023-06-08 WBC 1.30 x10^3/uL
  
• 2023-06-01 WBC 6.12 x10^3/uL
  
• 2023-05-23 WBC 14.43 x10^3/uL
  
• 2023-05-10 WBC 6.97 x10^3/uL
  
• 2023-05-02 WBC 4.99 x10^3/uL
  
• 2023-04-24 WBC 12.13 x10^3/uL
  
• 2023-04-21 WBC 13.62 x10^3/uL
  
• 2023-04-20 WBC 10.14 x10^3/uL
  
• 2023-04-12 WBC 16.90 x10^3/uL

2023-04-21

• The patient started R-COP treatment on 2023-04-20 and shortness of breath (SOB) and dyspnea were observed at 69.8 mL of Mabthera. Subsequently, a slower infusion rate was applied and the patient’s condition improved.
• Feburic (febuxostat) has been prescribed for prophylaxis of hyperuricemia, and no issues have been identified with the current prescription.

701325918

230710

{metastatic renal cell carcinoma} (not completed)

[history]

• left renal cancer with gastric and lung metastasis, status post target therapy and immunotherapy at Taipei Veterans General Hospital
• nodular goiter s/p total thyroidectomy 10+ years ago
• breast nodular s/p operation.

[exam findings]

• 2023-07-07 Tc-99m MDP bone scan
  • A hot spot in the left 1st rib. Bone metastasis should be watched out.
  • Increased activity in the upper L-spine. Either bone metastasis or severe degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the lower L-spine. Degenerative change is more likely. Please follow up bone scan for further evaluation and to rule out other possibilities.
  • Some faint hot spots in the skull. The nature is to be determined (post-traumatic change? early bone metastases). Please also follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
• 2023-07-06 CT - abdomen
  • History and indication: Left renal cell carcinoma
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Clinical history of left renal cancer with calcifications. Some LNs at retroperitoneum with calcification.
    • A calcification (3.2cm) at left neck.
    • Multiple nodules in bil. lungs.
    • R/O bony metastases at right iliac bone and L2.
    • S/P gastric bypass procedure.
  • IMP:
    • Clinical history of left renal cancer with calcifications. Some LNS at retroperitoneum with calcification. A calcification (3.2cm) at left neck. Multiple nodules in bil. lungs. R/O bony metastases at right iliac bone and L2.
• 2023-04-17 Patho - lymphnode biopsy
  • Labeled as “neck mass, left”, SONO guided biopsy — papillary carcinoma.
  • Section shows soft tissue with many papillary carcinoma. Numerous psammoma bodies are present.
  • IHC stains: PAX-8 (+), TTF-1 (-), Thyroglobulin (-), CD10 (equivocal), RCC (equivocal). Please correlate with clinical and image findings.
• 2023-03-25, -03-09, -03-07 KUB
  • S/P hot AXIOS lumen apposing metallic stent is placed between the stomach and jejunum loop.
• 2023-03-13 Gastric emptying study
  • The gastric emptying study was performed after the patient consumed a standard test meal of two eggs radiolabeled with 0.3 mCi of Tc-99m phytate, two slices (50 gm) of white bread, and 300 ml of orange juice. The gastric emptying study in solid phase revealed fair gastric emptying, and the half time of radioactivity (T1/2) was 92.76 min according to the exponential fitting of the time-activity curve.
  • IMPRESSION: The half time (T1/2) of gastric emptying of solid phase is 92.76 min (within normal limit).
  • COMMENT: The normal half time (T1/2) of gastric emptying of solid phase for adults is 45 to 110 minutes.
• 2023-03-06 Endoscopic Ultrasonography, EUS
  • Indication: RCC with duodenal 3rd portion obstruction
  • Symptoms: refractory vomiting
  • Pre-EUS diagnosis: duodenal outlet obstruction
  • Diagnosis: Recurrent RCC with duodenal 3rd portion obstruciton s/p AXIOS LAMS
  • Suggestion: standing abdomen C.M.
• 2023-03-02 Upper GI series
  • Retention of contrast medium in the duodenum, 3rd portion, could be due to obstruction.
• 2023-02-14 CT - abdomen
  • Diffuse dense calcified tumors in left retroperitoneum and paraaortic regions, stationary.
  • Diffuse nodules in bilateral lungs, r/o lung metastasis.
  • Enlarged lymph nodes in bilateral inguinal and axillary regions.
  • Dilatation of duodenum due to tumor compression at duodenojejunal area.
• 2022-10-28 CT - abdomen
  • History and indication:
    • Left renal cell carcinoma, pT1a, FG2 type II s/p left partial nephrectomy, local recurrent of left retroperitoneal s/p target therapy with Erlotinib/Bevacizumab s/p Nivolumab/Cabozantinib, local recurrent of retroperitoneum LN metas
    • Findings:
      • Prior CT identified lobulated mass with dense calcification in left retroperitoneal space (in between left kidney, left pasoas muscle, and para-aortic space) is noted again, mild decreasing in size that is c/w local recurrent renal cell carcinoma S/P target therapy with partial response.
        • In addition, Left kidney shows small size and thin parenchyma that is c/w S/P partial nephrectomy and chronic renal disease.
      • Prior CT identified Some small nodules in bil. lungs are noted again, stationary.
      • Prior CT identified bony metastases at left lateral aspect of L2 vertebral body is noted again, stationary.
      • Prior CT identified scattered calcified nodes in para-aortic space and para-cava space are noted again, stable in size that are c/w metastatic nodes S/P target therapy with complete response.
      • Prior CT identified several enlarged nodes in bilateral inguinal area are noted again, decreasing in size that are c/w metastatic nodes S/P C/T with partial response. please correlate with clinical condition.
  • Impression:
    • Local recurrent RCC at left retroperitoneal space S/P target therapy show partial response.
    • Lymph nodes in bilateral inguinal area show partial response.
• 2022-03-25 CT - abdomen
  • Findings:
    • Prior CT identified lobulated mass with dense calcification in left retroperitoneal space (in between left kidney, left pasoas muscle, and para-aortic space) is noted again, stable in size that is c/w local recurrent renal cell carcinoma S/P target therapy with stable disease.
      • In addition, Left kidney shows small size and thin parenchyma that is c/w S/P partial nephrectomy and chronic renal disease.
    • Prior CT identified Some small nodules in bil. lungs are noted again, stationary.
    • Prior CT identified bony metastases at left lateral aspect of L2 vertebral body is noted again, stationary.
    • Prior CT identified scattered calcified nodes in para-aortic space and para-cava space are noted again, stable in size that are c/w metastatic nodes S/P target therapy with complete response.
    • Prior CT identified several enlarged nodes in bilateral inguinal area are noted again, increasing in size. please correlate with clinical condition.
  • Impression:
    • Local recurrent RCC at left retroperitoneal space with lung, lymph nodes, and bone metastases S/P target therapy show stable disease.
    • Lymph nodes in bilateral inguinal area show mild increasing in size.
• 2021-12-23 CT - abdomen
  • Findings
    • Clinical history of left renal tumor (3.5x5.2cm) with calcifications. Some LNS at retroperitoneum.
    • Some small nodules in bil. lungs.
    • R/O bony metastases at right iliac bone and L2.
  • IMP:
    • Clinical history of left renal tumor (3.5x5.2cm) with calcifications. Some LNS at retroperitoneum. R/O lung and bony metastases.
• 2021-12-03 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (98.8 - 30.3) / 98.8 = 69.33%
    • M-mode (Teichholz) = 69.3
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Very trivial tricuspid regurgitation
    • Mildly thick IVS and LVPW
• 2021-08-12 CT - whole abdomen, pelvis
  • clinical history of left renal tumor (6.0cm) with solid/cystic components and calcifications. probable abscess formation (6.7x12.9cm) at left retroperitoneum with adjacent muscle invasion. some LNs at retroperitoneum.
• 2021-08-12 general and gastroenterological surgery
  • less likely cholecystitis related
  • favor left retroperitoneal abscess related
• 2021-08-13 gastroenterology
  • upper gastrointestinal bleeding, gastric metastasis related?

[MedRec]

[immunotherapy]

• 2023-07-10 - nivolumab 3mg/kg 100mg NS 100mL 1hr

  • diphenhydramine 30mg + NS 250mL

• 2023-06-13 - nivolumab 3mg/kg 100mg NS 100mL 1hr

  • diphenhydramine 30mg + NS 250mL

• 2023-05-12 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

  • diphenhydramine 30mg + NS 250mL

• 2023-04-14 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

  • diphenhydramine 30mg + NS 250mL

• 2023-03-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

  • diphenhydramine 30mg + NS 250mL

• 2023-02-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

  • diphenhydramine 30mg + NS 250mL

• 2022-04-22 - nivolumab 3mg/kg 100mg NS 100mL 1hr

  • diphenhydramine 30mg + NS 250mL

• 2023-03-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

  • diphenhydramine 30mg + NS 250mL

• 2023-03-01 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

  • diphenhydramine 30mg + NS 250mL

• 2022-02-09 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

  • diphenhydramine 30mg + NS 250mL

• 2022-01-18 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2021-12-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

• 2021-11-30 - pembrolizumab 200mg NS 100mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL

• 2021-11-05 - pembrolizumab 200mg NS 100mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL

• 2021-10-15 - pembrolizumab 200mg NS 100mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL

• 2021-09-08 - pembrolizumab 200mg NS 100mL 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL

• 2020-10 erlotinib + bevacizumab followed with nivolumab + carboplatin.

==========

2023-07-10

[availability of entrectinib and/or alectinib]

According to the latest National Health Insurance (NHI) Drug Reimbursement Guidelines (version dated 2023-05-23), Rozlytrek (entrectinib) is only covered when used alone in adults with ROS-1 positive locally advanced or metastatic NSCLC. Alecensa (alectinib) is covered only for first-line treatment of ALK-positive advanced NSCLC. Both are not covered for papillary renal cell carcinoma.

Both Rozlytrek (entrectinib 200mg/capsule) and Alecensa (alectinib 150mg/capsule) are available in the hospital’s inventory, so no prior authorization is required (no temporary purchase procedure is necessary). The out-of-pocket cost for the former is 1802.5 TWD (NHI price 1530 TWD) and for the latter 487.5 TWD (NHI price 390 TWD).

700072194

230707

{autologous Peripheral Blood Stem Cell Transplantation}

• past history
  • DM with triopathy for 10+ years with regular OHA control. (triopathy of diabetes - retinopathy, nephropathy, and neuropathy.)
• lab data
  • 2022-08-18 EB VCA IgG Positive Ratio
    
  • 2022-08-18 EB VCA IgG Value 6 Ratio
    
  • 2022-08-17 EB VCA IgM Negative Ratio
    
  • 2022-08-17 EB VCA IgM Value 0.2
    
  • 2022-08-15 RPR/VDRL Nonreactive
    
  • 2022-08-15 Anti-HCV Nonreactive
    
  • 2022-08-15 Anti-HCV Value 0.04 S/CO
    
  • 2022-08-15 Anti-HBc Reactive
    
  • 2022-08-15 Anti-HBc-Value 5.04 S/CO
    
  • 2022-08-15 HBsAg Nonreactive
    
  • 2022-08-15 HBsAg (Value) 0.39 S/CO
    
  • 2022-08-15 Anti HTLV I/II Nonreactive
    
  • 2022-08-15 Anti HTLV I/II Value 0.06 S/CO
    
  • 2022-08-15 CMV IgM Nonreactive
    
  • 2022-08-15 CMV IgM Value 0.04 Index
    
  • 2022-08-15 CMV_IgG Reactive
    
  • 2022-08-15 CMV_IgG Value 157.5 AU/mL
    
  • 2022-08-15 HIV Ab-EIA Nonreactive
    
  • 2022-08-15 Anti-HIV Value 0.06 S/CO
    
  • 2022-05-25 %CD34+ 0.09 %
    
  • 2022-05-25 CD34+ Count 322 /uL
    
  • 2022-05-25 %CD34+ 0.01 %
    
  • 2022-05-25 CD34+ Count 4 /uL
    
  • 2022-05-24 %CD34+ 0.13 %
    
  • 2022-05-24 CD34+ Count 535 /uL
    
  • 2022-05-24 %CD34+ 0.02 %
    
  • 2022-05-24 CD34+ Count 10 /uL
    
  • 2022-05-23 %CD34+ 0.14 %
    
  • 2022-05-23 CD34+ Count 610 /uL
    
  • 2022-05-23 %CD34+ 0.04 %
    
  • 2022-05-23 CD34+ Count 17 /uL
    
  • 2022-02-17 %CD34+ 0.21 %
    
  • 2022-02-17 CD34+ Count 880.0 /uL
    
  • 2022-02-16 %CD34+ 0.27 %
    
  • 2022-02-16 CD34+ Count 1030 /uL
    
  • 2022-02-15 %CD34+ 0.31 %
    
  • 2022-02-15 CD34+ Count 1638 /uL
    
  • 2022-01-14 %CD34+ 0.02 %
    
  • 2022-01-14 CD34+ Count 50 /uL
    
  • 2022-01-13 %CD34+ 0.05 %
    
  • 2022-01-13 CD34+ Count 100 /uL
    
  • 2022-01-12 %CD34+ 0.04 %
    
  • 2022-01-12 CD34+ Count 60 /uL
    
  • 2022-01-11 %CD34+ 0.04 %
    
  • 2022-01-11 CD34+ Count 20 /uL
    
  • 2019-08-09 %CD34+ 0.11 %
    
  • 2019-08-09 CD34+ Count 610 /uL
    
  • 2019-08-08 %CD34+ 0.08 %
    
  • 2019-08-08 CD34+ Count 410 /uL
    
  • 2019-08-07 %CD34+ 0.07 %
    
  • 2019-08-07 CD34+ Count 255 /uL
    
  • 2019-07-05 %CD34+ 0.14 %
    
  • 2019-07-05 CD34+ Count 230 /uL
    
  • 2019-07-04 %CD34+ 0.06 %
    
  • 2019-07-04 CD34+ Count 55 /uL
• exam finding
  • 2022-07-18 Whole body PET scan
    • 1. The increased FDG uptake in the right posterior pleura and adjacent soft tissue, in bilateral axillary lymph nodes, and in an upper abdominal preaortic lymph node disappears or comes to very faint compared with the previous study on 2021-09-16, indicating partial to good response to current therapy.
    • 2. Increased FDG accumulation in bilateral kidneys, probably physiological uptake of FDG.
    • 3. Lymphoma s/p treatment with partial to good response, by this F-18 FDG PET scan.
  • 2022-07-09 CT - chest
    • S/p port-A placement with its tip at Superior vena cava
    • No evidence of lymphadenopathy in the study.
  • 2022-06-30 CXR
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Atherosclerotic change of aortic arch
  • 2022-03-08 CT - chest
    • stationary of Rt posterior inferior pleural thickening as compared with CT on 2021/12/17, could be posterior treatment change.
  • 2022-01-17 Bronchoscopy
    • Diagnosis
      • 1. LUL and Left lingular lobe acute bronchitis
      • 2. Sleep apnea
      • 3. Chronic sinusitis
    • Findings
      • The nasal mucosa was hypertrophic.
      • The nasal lumen was severely narrowed.
      • The was copious mucoid nasal discharge retained in the nasal cavity.
      • Mucosa of nasopharynx was hypertrophic .
      • Nasopharynx was severely narrowed.
      • Mucosa of pharynx cobble-stone in shape .
      • Movement of the both. vocal cord(s) was / werenormal .
      • Bilateral arytenoid proceww was normal .
      • Trachea whole segment . : patent and the mucosa was hypertrophic .
      • Main carina: sharp and movable on deep breathing.
      • Bilateral endobronchial trees:
        • LUL, left lingular lobe mucosal swelling with some purulent sputum.
        • No endobronchial lesions
  • 2021-12-17 CT - chest
    • No evidence of recurrent/residual lymphadenopathy in the study.
    • Calcified coronary arteries is found.
  • 2021-10-06 Patho - bone marrow biopsy
    • Bone marrow, iliac, (clinical history of Hodgkin’s lymphoma stage IV, biopsy — Negative for malignancy.
    • IHC stains: CD30: (-).
      
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2021-09-27 Patho - pleural/pericardial biopsy
    • Tissue, labeled “right chest”, CT-guide biopsy — Nodular sclerosis classical Hodgkin lymphoma, recurrent
      
    • Immunohistochemical stain profiles: CD3: positive, CD20: positive, CD15: focal positive, CD30: focal positive
  • 2021-09-25 CT guide biopsy
    • Right pleural mass, s/p CT-guided biopsy
  • 2021-09-16 Whole body PET scan
    • The FDG PET finding are compatible with recurrent lymphoma (stage IV) involving the right posterior pleura and adjacent soft tissue (Deauville 5), some bilateral axillary lymph nodes (Deauville 4) and an upper abdominal preaortic lymph node (Deauville 5) 2. Mild glucose hypermetabolism in some bilateral inguinal lymph nodes (Deauville 2). The nature is to be determined (inflammation? lymphoma of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
  • 2021-09-08 CT - chest
    • progression of Rt posterior inferior pleura tumor compared with CT on 20210209.
  • 2021-02-09 CT - abdomen
    • 1. Stationary right lower pleural thickening.
    • 2. Bilateral inguinal lymph nodes.
    • 3. Ascending colon diverticula.
  • 2020-11-16 Tc-99m MDP whole body bone scan
    • 1. In comparison with the previous study on 2017/12/29, the lesion in L3 spine had disappeared, indicating a malignant lesion with response to treatment and in metabolic regression.
    • 2. Mildly increased radiotracer uptake in diffusely increased radiotracer uptake in posterior aspect of right lower rib cages was newly noted in this study. Increased vascularity and vascular permeability associated with malignant pleural effusion in right lower posterior pleural space may show such a picture. Please correlate with other imaging modalities and keep follow up, however, to exclude the possibility of lymphomatous marrow involvement in multiple right lower ribs.
    • 3. Mildly and non-focally increased radiotracer uptake in middle T-spine, lower L-spine and sacrum, degenerative spine diseases may show such a picture.
    • 4. Some areas of mildly increased radiotracer uptake in maxilla and mandible, dental lesions may show such a picture.
    • 5. Probably degenerative joint lesions in shoulders, sternoclavicular junctions, and knees.
  • 2020-11-05 CT - abdomen
    • Thickening of right lower pleura.
    • Some LNs (5-11mm) in bil. inguinal regions.
  • 2020-07-02 CT - chest
    • Mild bronchiectatic change over right middle lobe with increased peribronchial infiltration at right middle lobe
    • Right pleural effusion. Mild.
    • Small left axillary lymph nodes
  • 2020-03-06 CT - abdomen
    • Finding
      • 1. Prior CT identified some enlarged lymph nodes in bilateral inguinal area are noted again, stable in size. However, a newly-developed soft tissue mass measuring 2.8 cm in right inguinal area, near the penis base is noted that may be recurrent lymphoma.
      • 2. Mild thickening in right posterior basal CP angle pleura area is noted that also may be recurrent lymphoma. please correlate with clinical condition.
    • IMP:
      • Recurrent lymphoma in right posterior basal CP angle pleura and right inguinal area are suspected. please correlate with clinical condition.
  • 2019-10-24 Whole body PET scan
    • 1. In comparison with the previous study on 2019/04/01, the previous FDG avid lesions in the right posterior chest wall, multiple skeletal sites, and a right supraclavicular lymph node all disappeared (Deauville score 1).
    • 2. Faint glucose hypermetabolism (Deauville score 2) in some bilateral inguinal lymph nodes. The nature is to be determied (inflammatory process? other nature?). Please correlate with other clinical findings for further evaluation.
    • 3. Mild glucose hypermetabolism in the right hip. Benign joint lesion such as arthritis may show this picture.
    • 4. Increased FDG accumulation in the colon. Physiological FDG accumulation is more likely.
  • 2019-10-21 CT - abdomen
    • Some LNs (5-10mm) in bil. inguinal regions.
  • 2019-08-05 CXR - chest
    • Hypoinflation of both lung is noted.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura thickening or effusion ?
  • 2019-07-20 CT - abdomen
    • 1. Regression of right posterior intercostal tumor as compare with CT study on 20190307.
    • 2. Ascending colon diverticula.
  • 2019-04-01 PET
    • In comparison with the previous study on 2018/07/06, the lesions in the right posterior chest wall, multiple skeletal sites, and a right supraclavicular lymph node were all new lesions (Deauville 5), suggesting lymphoma in progression.
    • 2. Hodgkin’s lymphoma, rc-stage IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2019-03-18 Surgical pathology Level IV
    • clinical diagnosis
      • Hodgkin’s disease, nodular sclerosis, intra-abdominal lymph nodes;
    • pathologic diagnosis
      • Mass, unspecified ciste?, biopsy — Compatible with Hodgkin lymphoma
    • Microscopically, the section shows a picture of some lymphoid cells with follicles embedded in collagenous stroma, consists of mixed lymphocytes, neutrophils, eosinophils, macrophages and a few atypical large cells, which immunohistocehmcial study reveals CD15(+, focal), CD30(+), CK(-), CD20(-) and EMA(+, scatter). According to above histopathologic findings and previous pathologic report, it is compatible with Hodgkin lymphoma.
  • 2019-03-07 CT - abdomen
    • A mass lesion (5x6cm) in right posterior back.
  • 2018-11-02 CT - abdomen
    • Stationary lymph nodes in left pelvic cavity and inguinal regions.
  • 2018-07-06 PET
    • 1. In comparison with the previous study on 2017/12/19, the glucose hypermetabolism at multiple lymph nodes in the abdominal left paraaortic region (Deauville score 2), right inguinal region (Deauville score 2), left lower pelvic region (Deauville score 2) and left inguinal region (Deauville score 3) and the glucose hypermetabolism at the L3 spine (Deauville score 2) are all less evident, suggesting partial response to the treatment. Please correlate with other clinical findings for further evaluation.
    • 2. Increased FDG accumulation in the colon. Physiologic FDG accumulation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2018-06-19 CT - abdomen
    • Left inguinal lymph nodes, in regression
  • 2018-03-02 CT - abdomen
    • Regression of enlarged lymph nodes in left inguinal region and pelvic cavity.
  • 2017-12-29 Tc-99m MDP whole body bone scan
    • 1. Increased activity in the L3 spine. Bone metastasis can not be ruled out. Please correlate with other imaging modalities for further evaluation.
    • 2. Increased activity in the lower C-spines. Degenerative change may show this picture. However, please follow up bone scan to rule out the possibility of bone metastasis.
    • 3. Some faint hot spots in the lateral aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • 4. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesion.
  • 2017-12-19 PET
    • 1. Glucose hypermetabolism at multiple lymph nodes in the abdominal left paraaortic region (Deauville 4), right inguinal region (Deauville 4), left lower pelvic region (Deauville 4) and left inguinal region (Deauville 5), compatible with lymphoma involving multiple lymph node regions on the same side of the diaphragm.
    • 2. Glucose hypermetabolism in the L3 spine (Deauville 5). Lymphoma involving L3 spine should be considered. Please correlate with other clinical findings for further evaluation.
  • 2017-12-18 Doppler color flow mapping
    • 1. Borderline dilated LA and LV; adequate LV systolic function with normal resting wall motion
    • 2. Trivial MR and trivial TR
    • 3. Preserved RV systolic function
  • 2017-12-07 Surgical pathology Level IV
    • clinical diagnosis
      • Neoplasm of uncartain behavior of connective and other soft tissue;
    • pathologic diagnosis
      • Tumor, left pelvis, excisional biopsy — Compatible with Hodgkin lymphoma, nodular sclerosis
    • Microscopically, the section shows a picture of broad bands of collagen replace patches of remaining tissues with focal marked crushed artifact, consists of mixed lymphocytes, neutrophils, eosinophils, macrophages and a few atypical individual or multinucleated large cells, which immunohistocehmcial study reveals CD15(+), CD30(+), PAX-5(scant, weakly +), CK(-), S-100(-), SMA(-) and ALK(-). According to above histopathologic findings, it is compatible with Hodgkin lymphoma, nodular sclerosis type.
  • 2017-11 Initial presentation
    • the patient noted fever and cold sweating, and palpable abdominal mass over left lower abdomen also found.

chemotherapy with Mabthera on 12/27,Etoposide 500mg/m2 total given 963mg Q12H on 12/28-30 followed by PBSC harvest,GCSF 300mcg QD on 12/31-1/14.Port-A removal on 2022/1/14.

• radiotherapy
  • 2017 after ABVD chemotherapy

[chemoimmunotherapy]

• 2023-07-07 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-05-30 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-05-08 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-04-17 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-08-17 - busulfan 3.2mg/kg 260mg 2hr D1-3 + etoposide 400mg/m2 567mg 1hr D3-4 + cyclophosphamide 50mg/kg 4000mg D5-6 (BuCyE)

• 2021-12-27 - rituximab 375mg/m2 720mg 8hr D1 + etoposide 500mg/m2 963mg 4hr D2-4

• 2021-11-19 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE) followed by PBSC harvest, GCSF 300mcg QD on 2021-12-31 ~ 2022-01-14.

• 2021-10-27 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE)

• 2021-10-06 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE)

• 2019-04-03 ~ 2019-09-07 - ESHAP 7 cycles

• 2017-12-30 ~ 2018-06-01 - ABVD

==========

2023-07-07

The patient underwent an autoPBSCT procedure in August 2022, almost a year ago. Based on the Guidelines for Vaccination of Adult BMT Patients provided by Stanford Healthcare, the proposed vaccination schedule is as follows (ref: https://med.stanford.edu/content/dam/sm/bugsanddrugs/documents/clinicalpathways/SHC-Vaccination-BMT.pdf):

• Influenza: Annually starting at 6 months post transplant
• Pneumococcal: 12 months post transplant
• Meningococcal Group A: 12 months post transplant
• Haemophilus: 12 months post transplant
• Diptheria/tetanus/pertussis: 12 months post transplant
• Hepatitis: 12 months post transplant
• Papillomavirus: 12 months post transplant

According to the guideline, most vaccinations are started 12 months after transplant, so it may be an appropriate time to start planning the vaccination schedule for this patient. This can help reduce the risk of infection and promote the patient’s overall health and recovery.

2022-08-19

[preparation and administration of mesna]

• Usual diluents
  • D5W, NS
• Usual dose
  • 100 ml, 15-30 min, concentration range: 1-20 mg/ml
• Dosing
  • usual dose=20% of ifosfamide dose given just before and 4 and 8 hours after ifosfamide (total=60%).
  • May also be given as a continuous IV infusion concurrently with ifosfamide. Total daily dose= 60% to 160% of ifosfamide dose or 60% to 200% of cyclophosphamide dose. May give 20% W/W 15min prior, and then q3hrs x 3-6 doses.
• Administration
  • IVPB in 50 ml or more of D5W or normal saline over 5 minutes or longer. Also by continuous IV infusion.
• Storage/stability:
  • Vials stored at RT. Diluted solutions (1-20 mg/ml) - 24 hrs. 20 mg/ml (D5W) - 48hrs RT; 1-mg/ml (D5W) - 24 hours RT.
• Preparation:
  • May be further diluted in D5W, NS, D5/.45NS, or LR to a final concentration of 1-20 mg/ml.
• Prevention of cyclophosphamide-induced hemorrhagic cystitis: Limited data available: Note: Specific protocols should be consulted for combination regimens with cyclophosphamide. Mesna dosing schedule is typically repeated with each day cyclophosphamide is received; mesna dosing should be adjusted if cyclophosphamide dose is adjusted (decreased or increased) to maintain the mesna-to-cyclophosphamide ratio for the protocol.
  • Infants, Children, and Adolescents:
    • Standard (low)-dose cyclophosphamide: Note: Some pediatric oncology experts have defined as cyclophosphamide dose <1800 mg/m2/day in protocols.
      • IV: Reported regimens variable: Mesna doses equivalent usually 60% to 100% of the cyclophosphamide daily dose although some protocols have used up to 160%.
        • Short IV infusion (intermittent): Mesna dose equal to 60% of the cyclophosphamide dose given in 3 divided doses (0, 4, and 8 hours after the start of cyclophosphamide) has been used by some centers; others have used a mesna dose equal to 100% of the cyclophosphamide dose as short IV infusions in 5 divided doses (0, 3, 6, 9, and 12 hours after the start of cyclophosphamide) (Gal 2007).
        • Continuous IV infusion: Some centers have used a mesna dose equal to 60% of the cyclophosphamide dose as a continuous IV infusion beginning 15 to 30 minutes before the first cyclophosphamide dose and completed at least 8 hours after the end of the cyclophosphamide infusion.
      • Oral: Some centers have used a total mesna dose equal to 100% of the cyclophosphamide dose, begin with IV dose equal to 20% for initial dose followed by oral dose at 40% of the cyclophosphamide dose at 2 and 6 hours after start of cyclophosphamide; Note: Typically, oral doses of mesna are twice the IV dose.
    • High-dose cyclophosphamide: Note: Some pediatric oncology experts have defined cyclophosphamide dose ≥1800 mg/m2/day in protocols: IV: Some centers have used a mesna dose equal to 100% of the cyclophosphamide dose as short IV infusions in 5 divided doses (0, 3, 6, 9, and 12 hours after the start of) (Gal 2007) or as a continuous IV infusion beginning 15 to 30 minutes before the first cyclophosphamide dose.
  • Other dosing strategies have been used in combination with cyclophosphamide for specific regimens/protocols: Limited data available: HDCAV/IE regimen for Ewing sarcoma: Children and Adolescents: IV: 2100 mg/m2/day continuous infusion (mesna dose is equivalent to the cyclophosphamide dose) for 2 days with cyclophosphamide infusion during cycles 1, 2, 3, and 6 (Kolb 2003).
• reference:
  • https://globalrph.com/dilution/mesna-mesnex/
  • https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/019884s016,020855s003lbl.pdf
  • https://www.medicines.org.uk/emc/product/1838/smpc
  • https://www.uptodate.com/contents/mesna-drug-information

2022-11-01

[Teicoplanin Dose]

• blood creatinine readings reported:
  • 2022-01-10 1.64mg/dL
  • 2022-01-08 1.83mg/dL
  • 2022-01-06 1.72mg/dL
  • 2022-01-03 1.31mg/dL
• teicoplanin has been administered since 2022-01-06, the elevated serum creatinine maintains stable for half week, no dose adjustment needed for now, keep monitoring renal function as regular.

700360518

230707

[diagnosis] - 2023-05-01 admission note

• Diffuse large B-cell lymphoma, intra-abdominal lymph nodes
• Other malaise
• Malignant neoplasm of pyloric antrum
• Cardiomegaly
• Peritonitis, unspecified
• Enterococcus as the cause of diseases classified elsewhere
• Resistance to vancomycin
• Type 2 diabetes mellitus with diabetic chronic kidney disease
• Chronic kidney disease, stage 3 (moderate)
• Heart failure, unspecified
• Chronic atrial fibrillation
• Alcoholic cirrhosis of liver with ascites
• Hypo-osmolality and hyponatremia
• Hypocalcemia
• Other disorders of plasma-protein metabolism, not elsewhere classified
• Pleural effusion in other conditions classified elsewhere
• Chronic obstructive pulmonary disease, unspecified
• Mixed hyperlipidemia
• Enlarged prostate with lower urinary tract symptoms
• Unspecified symptoms and signs involving the genitourinary system
• Other ascites
• Hyperkalemia

[past history]

• HFmrEF
• Af under edoxaban
• DM
• dyslipidemia
• alcoholic liver cirrhosis.    

[allergy]

• NKDA     

[family history]

• Father: pancreatic cancer
• Mother: hypertension

[exam findings]

• 2023-06-12 ECG
  • Atrial fibrillation
  • Low voltage QRS
  • Abnormal ECG
• 2023-05-24 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Spondylosis of the T-spine
• 2023-05-02 KUB
  • Spondylosis of the L-spine is noted.
  • Disc space narrowing with marginal osteophyte formation at left lateral aspect of L4-5.
  • Splenomegaly is highly suspected.
• 2023-04-17 PET
  • Glucose hypermetabolism lesions in the gastric wall (Deauville score 5), in the celiac chain (Deauville score 5), in the left sub-diaphragm lymph nodes (Deauville score 5), in soft tissue in the RLQ of abdomen (Deauville score 5), and in lymph nodes of peritonium (Deauville score 5), highly suspected diffuse large B-cell lymphoma with involvement of stomach and intraabdominal lymph nodes.
    
  • Glucose hypermetabolism lesion in a peri-cardial lymph node (Deauville score 5), highly suspected diffuse large B-cell lymphoma with involvement of regional lymph node.
  • Diffuse large B-cell lymphoma, c-stage III or IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2023-03-30 KUB
  • Degeneration and spondylosis of L-S spine.
  • S/P operation with retention of surgical clips.
• 2023-03-30 CXR
  • S/P operation with retention of surgical clips.
  • Degeneration of T-L spine.
  • Right catheterization to SVC in position.
  • Normal appearance of trachea and bil. main bronchus.
  • Left pleural effusion.
  • Cardiomegaly.
• 2023-03-26 ECG
  • Atrial fibrillation with rapid ventricular response with premature ventricular or aberrantly conducted complexes
• 2023-03-24 Patho - stomach subtotal/total (tumor)
  • Diagnosis
    • Stomach, antrum, laparoscopic subtotal gastrectomy (S2023-5511) with frozen section for margins (F2023-124) — Diffuse large B cell lymphoma, non-germinal center type.
      • IHC stains: CD3 and CD20: a predominant B cell sub-population. Bcl-2 (+), Bcl-6 (+), CD10 (-), MUM-1 (+, > 30%), c-myc (-), Ki-67: 95%, CK (-), CD23 (-) .
    • Margins, bilateral cut ends: free. radial surface postive for tumor.
    • Lymph node, perigastric, D2 dissection — free. CD3, CD20, Bcl-2, and Bcl-6 demonstrate a reactive pattern.
    • Omentum, omentectomy — Free
  • Microscopic Description:
    • Histologic Type - Diffuse large B cell lymphoma, non-germinal center type.
    • Histologic Grade - high grade, non-germinal center type.
    • Tumor Extension - Tumor invades the serosa (visceral peritoneum)
    • Margins
      • Proximal margin: uninvolved
      • Distal margin: uninvolved
      • Radial margin: involved
    • Lymphovascular Invasion: not identified
    • Perineural Invasion: not identified
    • Regional Lymph Nodes: free
      • S2023-5511A: LN1 (0/0); B1-3: LN3 (0/10); C1-4: LN4 (0/8); D1-2: LN5-6 (0/17); E1-2: LN7-8-9 (0/7); F1-2: LN12 (0/5); G1-4: omentum (0/1);
        
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition) : Further work up is needed for staging.
• 2023-03-22 ECG
  • Atrial fibrillation
  • Low voltage QRS
  • Abnormal ECG
• 2023-03-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (186 - 106) / 186 = 43.01%
    • M-mode (Teichholz) = 43
  • Conclusion:
    • Dilated LV with global hypokinesis; impaired LV systolic function.
    • Mild RV hypertrophy with mild global hypokinesis and borderline RV systolic function.
    • Aortic valve sclerosis with mild AR; mild MR; mild to moderate TR.
    • Possible mild pulmonary hypertension (the estimated systolic PA pressure 46 mmHg).
    • Mild aortic root calcification.
    • Atrial fibrillation; severely dilated LA/RA.
• 2023-03-06 Flow Volume Loop
  • Mild obstructive ventilatory impairment
• 2023-03-04 Esophagogastroduodenoscopy, EGD
  • Superficial gastritis, s/p CLO test
  • Gastric ulcer, antrum, suspected malignancy, s/p biopsy
• 2023-03-04 SONO - abdomen
  • Liver parenchymal disease (suboptimal exam of liver)
  • mild gallbladder wall thickening
  • splenomegaly
  • chronic renal parenchymal disease
  • bilateral pleural effusion
• 2023-03-02 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • S/P NG tube placement.
  • Increased pulmonary vasculature is found.
  • Osteopenia of the bony structure is noted.
• 2022-10-06 ECG
  • Atrial fibrillation
  • Low voltage QRS of limb leads
  • Abnormal ECG
• 2022-10-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (190 - 102) / 190 = 46.32%
    • M-mode (Teichholz) = 46
    • 2D (M-simpson) = 48
  • Conclusion:
    • Dilated LA, LV, RA, RV and IVC; mildly abnormal LV systolic function with global hypokinesia
    • Moderate MR, mild AR, mild to moderate TR and trivial PR
    • Preserved RV systolic function
    • Atrial fibrillation with HR 62~83 bpm.
• 2019-12-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (224 - 102) / 224 = 54.46%
    • M-mode (Teichholz) = 54
  • Conclusion:
    • Dilated LV with mild global hypokinesis and borderline LV systolic function.
    • Preserved RV systolic function.
    • Moderate MR and moderate TR (both due to chamber dilatation); mild AV sclerosis with trivial AR.
    • Possible mild to moderatre pulmonary hypertension (the estimated systolic PA pressure 50 mmHg).
    • Atrial fibrillation; severely dilated LA/RA.

[consultation]

• 2023-03-06 General and Digestive Surgery
  • Q
    • for management of gastric cancer. Pending pathology.
    • This 70 y/o man with history of heart failure, Af, DM, hyperlipidemia, alcoholic liver cirrhosis with medication (Lixiana) control. This time, he suffered from passage tarry stool, vomiting blood, general weakness, dizziness since 20230227 morning. Abdominal CT showed gastric cancer T3N0M0. Under the impression of Gastrointestinal hemorrhage and suspected gastric cancer, he was admitted to MICU for further care on 2023-02-27.
    • After admitted MICU, the patient received anti with Sintrix (2/27~) for Infection prevention. kept NPO and high does PPI pump (2/27~3/2), then taper to Pantoloc 40mg IVD Q12H (3/2~), also disconnect Lixiana since 2/26. IV fluid for supply. Blood transfusion with LRBC for correct anemia (Hb: 7.9 => 9.2). There was no coffee ground or tarry stool was noted after try oral diet. However, dyspnea on exertion with breathing sound wheezing grade 1 was note, broncodilator with Butanyl plus Ipratran was prescribed. IV fluid and Const-K for correct imbalance electrolyte. The symptom got improvement after medical treatment, he will transfer to ward for further treatment and arrange 2nd PES (for supected gatric cancer biopsy).
      
    • At GI ward, his vital signs stable. Checked breathing sound: no wheezing. Try oral intaking but his care giver said easy choking.
    • Second look of EGD and the biopsy were all done, Now, we need your management of gastric cancer. Thanks a lot !!!
  • A
    • S:
      • Due to CT and panendoscopy highy suspected gastric antrm cancer, surgical treatment is consulted.
    • O: vital signs: stable, no fever
      • abdomen: soft, ovoid, normal bowel sound, no tenderness, no rebounding pain
        
      • lab data: see chart
    • A: Gastric antrum Ca, cT3N2M0, stage III, ECOG I
    • P:
      • I will take over this case for pre-op evaluation including heart echo and lung function test and nutritional support such as PPN
      • If heart & lung function is OK and the patietn is willing to receive operation, I will arrange laparoscopic resection later.

[surgical operation]

• 2023-03-23
  • Surgery
    • Laparoscopic subtotal gastrectomy and D2 lymph node dissection
    • Post-OP Dx: gastric antrum Ca, cT3N2M0, stage III, ECOG 1       
  • Finding
    • An ulcerative tumor about 5x7 cm over antrum, lesser curvature site of antrum posterior wall with suspect serosal invasion.
    • Enlarged lymph nodes over area 3, 5, 7, 8, 9, 12 were noted.
    • Proximal cutting end 10 cm form tumor and distal cutting end 1 cm from tumor. Both cutting ends were margin free via frozen section.

[MedRec]

• 2023-04-24 SOAP Hemato-Oncology
  • S
    • 3 daughters (the elderest daughter works in another hospital)
    • her daughter came to OPD for him
• 2023-04-12 SOAP General and Digestive Surgery
  • A:
    • Gastric antrum lymphoma, cT4N0M0, stage II, ECOG:1, s/p laparoscopic subtotal gastrectomy and D2 lymph node dissection on 2023/03/23
    • Peritonitis, culture: VREfm(E.faecium)
    • Heart failure, New York Heart Association functional classification II
    • Chronic kidney disease, stage 3
    • Chronic atrial fibrillation
    • Alcoholic liver cirrhosis
    • Type 2 diabetes mellitus
    • Mixed hyperlipidemia
    • Hypocalcemia
    • Hypoalbuminemia
    • Hypo-osmolality and hyponatremia
    • Pleural effusion, bilateral sides
    • Massive ascites
    • Suspected Chronic Obstructive Pulmonary Disease
    • Enlarged prostate with lower urinary tract symptoms
  • P:
    • refer to ONC for further study and chemotherapy evaluation
    • PPI, vita B12, education, & OPD follow up
• 2018-04-19 SOAP Cardiology
  • S: adjust carvedilol dose; add ARB for BP control
  • Prescription
    • Blopress (candesartan 8mg) 1# QD
    • Uretropic (furosemide 40mg) 1# Q3D
    • Lixiana (edoxaban 30mg) 1# QD
    • Robestar (rosuvastatin 10mg) 0.5# QD
    • Through (sennoside 12mg) 2# HS
    • Glucobay (acarbose 100mg) 1# BID
    • Syntrend (carvedilol 6.25mg) 1# QD
• 2017-03-16 SOAP Cardiology
  • Diagnosis
    • Heart failure, unspecified [I50.9]
    • Atrial fibrillation [I48.2]
    • Cirrhosis of liver without mention of alcohol [K74.69]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Mixed hyperlipidemia [E78.2]
    • Neuralgia and neuritis, unspecified [M79.2]
  • Prescription
    • Robestar (rosuvastatin 10mg) 0.5# QD
    • Through (sennosides 12mg) 2# HS
    • Glucobay (acarbose 100mg) 1# BID
    • Syntrend (carvedilol 6.25mg) 0.5# QD
    • Bokey (aspirin 100mg) 1# QD
    • Aldactin (spironolactone 25mg) 0.5# QD

[chemoimmunotherapy]

• 2023-06-13 - rituximab 375mg/m2 693mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-05-24 - rituximab 375mg/m2 693mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
• 2023-05-03 - rituximab 375mg/m2 660mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-COP)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2

==========

2023-07-07

[reconciliation]

• According to the PharmaCloud database, besides our hospital, this patient has also visited a local dermatology clinic for problems related to skin and subcutaneous tissue infections on 2023-06-25, and for irritant contact dermatitis on 2023-06-04. Both times, he was prescribed medications for 7 days and 3 days respectively, which are now expired. No reconciliation issues were identified in this context.
• Our cardiologist had prescribed Lixiana (edoxaban), Blopress (candesartan), Hexal (carvedilol), Dibose (acarbose), Glimet (glimepiride, metformin), and Galvus Met (vildagliptin, metformin) on 2023-06-15. All these drugs are included in the current active medication list without any identified reconciliation issues.

[to adjust Dibose (acarbose) from BID to BIDCC]

• The optimal usage of Dibose (acarbose) involves taking it with the first bite of each main meal or immediately before starting a meal to ensure maximum effectiveness. Therefore, it is suggested that the patient’s current BID prescription should be adjusted to BIDCC. Ref: The effect of the timing and the administration of acarbose on postprandial hyperglycaemia. Diabet Med. 1995;12(11):979-984. doi:10.1111/j.1464-5491.1995.tb00409.x

2023-05-03

• Given the patient’s history of heart failure, doxorubicin may not be an appropriate component of the treatment regimen. Instead of R-CHOP, R-COP was chosen as the treatment regimen to avoid the potential cardiotoxic effects of doxorubicin.

• On 2023-05-03, the progress note indicated that the patient had increased frequency of vomiting and difficulty with oral intake due to NG tube cough. Metoclopramide, a dopamine (D2) receptor antagonist, is currently prescribed. If symptoms persist, the addition of serotonin (5-HT3) receptor antagonists (such as ondansetron, granisetron, or palonosetron) and/or neurokinin-1 (NK1) receptor antagonists (such as aprepitant, fosaprepitant, rolapitant, or netupitant) may be considered. These medications work through different mechanisms to control nausea and vomiting and may provide additional relief for the patient.

• Dibose (acarbose) should be taken with the first bite of each main meal or just before starting a meal for best results. Acarbose works by slowing down the digestion of carbohydrates in the intestines, helping to control blood sugar levels. Taking it at the beginning of a meal ensures its optimal effect on carbohydrate digestion. It is recommended to change the medication from current BID to BIDCC.

700904907

230707

[diagnosis] - 2023-03-09 admission note

• Malignant neoplasm of sigmoid colon
• Adenocarcinoma of sigmoid colon with obstruction s/p colostomy (2023-01-05), and s/p Exp. Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings and closure of T-loop colostomystatus post open sigmoidectomy on 2023/02/03, pT4aN0M1c(0/19), LVI(+), PNI(+), CRM(+), stage IVc (metastases of omentum, low abdomen wall and pelvic seedings, carcinomatosis)
• Hypertensive heart disease without heart failure
• Mixed hyperlipidemia
• Type 2 diabetes mellitus with hyperglycemia

[past history] - 2023-03-09 admission note

• under medication control
  • HTN
    • Norvasc 5mg/tab 0.5# PO QD, Hyzaar 100mg & 12.5mg/tab 1# PO QD, Coxine 20mg/tab 1# PO QD, Concor 5mg/tab 1# PO QD
  • DM
    • Dibose F.C. 100mg/tab 1# PO TIDAC, Uformin 500mg/tab 1# PO TIDCC, Kludone MR 60mg/tab 1# PO BID, Canaglu 100mg/tab 1# PO QDAC
• surgical
  • thyroid goiter s/p op
  • s/p LC    
  • T-loop colostomy on 2023/01/05
  • Exp. Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings over omentum, pelvic and abdominal wall and closure of T-loop colostomy on 2023/02/02
  • left cephalic vein port A implantation on 2023/02/22

[allergy]

• NKDA

[family history]

• No family history of chronic medical disease or cancer  

[exam findings]

• 2023-02-06 All-RAS + BRAF
  • ALL-RAS: Detected (KRAS codon 12 GGT > GAT, p.G12D)
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-02-03 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Sigmoid colon, open sigmoidectomy — Adenocarcinoma, moderately differentiated
      
    • Resection margins, open sigmoidectomy — Radial margin is invoved by carcinoma
      
    • Lymph nodes, mesocolic, open sigmoidectomy — Negative for malignancy (0/19)
      
    • Omentum, tumor removal — Metastatic adenocarcinoma
    • Pelvis, tumor removal — Metastatic adenocarcinoma
    • Colostomy, closure T-loop colostomy — Metastatic adenocarcinoma
    • Pathology stage: pT4aN0M1c; Stage IVC
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: Open sigmoidectomy + removal tumor seeding + closure T-loop colostomy
    • Specimen site: Sigmoid colon, omentum, pelvic tissue, and colostomy
      
    • Specimen size: 10.5 cm (sigmoid colon), 18 x 12 x 5 cm (omentum), multiple pieces up to 1.5 x 1.2 x 1.2 cm (pelvic seeding) and 8 x 4 x 3 cm (colostomy)
      
    • Tumor size: 6.5 x 3.5 cm
      
    • Tumor location: 2.5 cm away from the one resection margin
    • Depth of invasion grossly: Pericolic soft tissue
    • Mucosa elsewhere: Unremarkable
    • Representative parts are taken for section and labeled: A1-A5= tumor, A6-A8 and X1-X4= regional lymph nodes, B= proximal end, C= distal end, D1-D2= omentum, E1-E2= pelvic seeding, F1-F2= colostomy
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
      
    • Histology Grade: Moderately differentiated
      
    • Depth of invasion: To serosa
    • Angiolymphatic invasion: Present
      
    • Perineural invasion: Present
      
    • Tumor cell budding: High
      
    • Circumferential (radial) margin: Involved by carcinoma
    • Lymph node metastasis, mesocolic: Negative for malignancy (0/19) (No. Positive / No. Total)
      
    • Extranodal involvement: N/A
      
    • Omentum: Metastatic adenocarcinoma
    • Pelvic seeding: Metastatic adenocarcinoma
    • Colostomy: Metastatic adenocarcinoma
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT): pT4a (Tumor invades serosa)
      • Regional Lymph Nodes (pN): pN0 (no regional lymph node metastasis)
      • Distant Metastasis (pM): pM1c (metastatic to the peritoneal surface)
    • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma
    • Additional pathologic findings: None identified
    • Tumor regression grading S/P CCRT: N/A
    • IHC (S2023-00555): EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2023-02-01 ECG
  • Possible Left atrial enlargement
  • Septal infarct, age undetermined
  • Nonspecific ST and T wave abnormality
• 2023-01-09 Patho - colon biopsy
  • Sigmoid colon, 30 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
  • The sections show adenocarcinoma, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction.
  • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
• 2023-01-09 Simoidoscopy
  • One tumor mass was noted in the sigmoid colon with lumen obstruction, Size 4.0 cm. ( 30 cm from anal verge)
• 2023-01-04 KUB
  • S/P operation with retention of surgical clips.
  • Compression fracture of T12.
• 2023-01-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (73.4 - 22.5) / 73.4 = 69.35%
    • M-mode (Teichholz) = 69.3
  • Adequate LV systolic function with no regional wall motion abnormality at resting state
  • Mild MR, trivial TR
  • Impaired LV relaxation
  • Mildly dilated LA, thick IVS
• 2023-01-02 CT - abdomen
  • IMP: Sigmoid colon segmental wall thickening with ascites formation. Sigmoid colon cancer is favored.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T: T2(T_value) N: N0(N_value) M: M0(M_value) STAGE: ____(Stage_value)
• 2022-12-30 Abdomen - standing (diaphragm)
  • S/P operation with retention of surgical clips.
  • Degeneration and spondylosis of L-S spine.
• 2020-12-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (63.1 - 12.7) / 63.1 = 79.87%
    • M-mode (Teichholz) = 79.9
  • Normal heart size.
  • Normal RV & LV systolic function. No regional wall motion abnormalities.
  • Impaired LV relaxation.
  • Mild mitral regurgitation.
  • Mild tricuspid regurgitation.
  • Mild pulmonic regurgitation
• 2020-11-20 Treadmill Exercise Test
  • Resting ECG : non specific ST changes
  • ST changes during TET : 1-mm upslope ST-segment depression at leads II, III, AVF and V4-6 at recovery phases
  • Interpretation : Submaximal heart rate achievement, Non-diagnostic test
• 2017-08-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (87.9 - 19.5) / 87.9 = 77.82%
    • M-mode (Teichholz) = 77.8
  • Adequate LV systolic function with no regional wall motion abnormality at resting state
  • Trivial MR
  • Mildly thicked IVS

[MedRec]

• 2023-07-04 SOAP Hemato-Oncology
  • P
    • During admission, arrange colonscopy but no biopsy due to avastin use.
    • consult CV due to SBP 160
• 2023-04-25 SOAP Hemato-Oncology
  • Prescription
    • Smecta (dioctahedral smectite 3mg) 1# TIDAC
    • Ulstop (famotidine 20mg) 1# BID
    • loperamide 2mg 1# PRNQD
• 2023-03-09 ~ 2023-03-11 POMR Hemato-Oncology
  • Discharge disgnosis
    • Adenocarcinoma of sigmoid colon with obstruction s/p colostomy on 2023/01/05, and s/p Exp.Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings and closure of T-loop colostomy s/p open sigmoidectomy on 2023/02/03, pT4aN0M1c(0/19), LVI(+), PNI(+), CRM(+), stage IVC (metastases of omentum, low abdomen wall and pelvic seedings, carcinomatosis), KRAS codon 12 GGT＞GAT, p.G12D, s/p FOLFOX from 2023/03/09~
    • Hypertensive heart disease without heart failure
    • Type 2 diabetes mellitus with hyperglycemia
    • Mixed hyperlipidemia
• 2023-03-07 SOAP Hemato-Oncology
  • O: Now on FOLFOX +/- bevacizumab
  • P: C/T with FOLFOX +/- bevacizumab
• 2023-03-04 SOAP Colorectal Surgery
  • S: doing well, s/p port-A, suggest CCRT followed by C/T + target
  • P:
    • stage IVc, suggest CCRT (pelvic tumor seedings), then C/T + target therapy
    • refer to oncologist
• 2023-02-20 SOAP Radiation Oncology
  • A/P: CT-simulation will be arranged on 20230306. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the visible residual tumor and preOP S-colon tumor bed to 54 Gy/ 30 fx. RT will start around 20230308.
• 2023-02-14 SOAP Colorectal Surgery
  • A: Adenocarcinoma of sigmoid colon with obstruction s/p colostomy (2023-01-05), and s/p Exp.Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings and closure of T-loop colostomystatus post open sigmoidectomy on 2023/02/03, pT4aN0M1c(0/19), LVI(+), PNI(+), CRM(+), stage IVc (metastases of omentum, low abdomen wall and pelvic seedings, carcinomatosis)
  • P:
    • stage IVc, suggest CCRT, then C/T+ target therapy
    • check RAS status
• 2023-01-20 SOAP Colorectal Surgery
  • S
    • Tumor of sigmoid colon with obstruction status post T-loop colostomy on 2023/01/05
    • doing well, arrange staged surgery
  • A: Adenocarcinoma of S-colon with obstruction s/p colostomy (2023-01-05)
  • P: admission (20230201), ERAS, then laparoscopic sigmoidectomy+ close colostomy (20230202, BUT may laparotomy)
• 2023-01-10 SOAP Metabolism
  • Prescription
    • Zulitor (pitavastatin 4mg 1# QN
    • Canaglu (canagliflozin 100mg) 1# QDAC
    • Kludone (gliclazide 60mg) 1# BID
    • Uformin (metformin 500mg) 1# TIDCC
    • Dibose (acarbose 100mg) 1# TIDAC
• 2023-01-03 SOAP Colorectal Surgery
  • S: Intermittent and progressively abdominal cramping pain with difficult passage of stool in recent 2 weeks and obstipation for 4-5 days
  • O: 2023/01/02 CT: ABD - Imp: Sigmoid colon segmental wall thickening with ascites formation. Sigmoid colon cancer is favored. Dilated loops of colon with wall edema(+)
  • A: Tumor of S-colon with obstruction
  • P: admission, nutritional support (PPN), clear liquid diet, suggest colostomy first (20230105) followed by sigmoidectomy 3-4 weeks later
• 2017-01-18 SOAP Metabolism
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, uncontrolled [E11.65]
    • Gouty arthropathy [M10.00]
    • HCVD, malignant without CHF [I11.9]
    • Mixed hyperlipidemia [E78.2]
    • Other specified acquired hypothyroidism [E01.8]
    • Obesity, unspecified [E66.9]
  • Prescription
    • Jardiance (empagliflozin 25mg) 1# QD
    • Uformin (metformin 500mg) 1# TIDCC
    • Glucobay (acarbose 100mg) 1# TIDAC
    • NovoNorm (repaglinide 1mg) 2# TIDAC
• 2017-01-03 SOAP Cardiology
  • Diagnosis
    • Other and unspecified angina pectoris [I20.9]
    • HCVD, benign without CHF [I11.9]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
  • Prescription
    • Hyzaar (losartan 100mg + hydrochlorothiazide 12.5mg) 0.5# QD
    • Coxine (isosorbide-5-mononitrate 20mg) 1# QD
    • Concor (bisoprolol 5mg) 1# QD

[surgical operation]

• 2023-02-02
  • Surgery
    • Exp. Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings over omentum, pelvic and abdominal wall and closure of T-loop colostomy        
  • Finding
    • Much adhesions and tumor seedings was found after initial laparoscopic procedure, thus we chenged to open laparotomy method    
    • A locally advanced tumor over S-colon with multiple tumor seedings over pelvic wall, and near bil.overy sites, pelvic floor, low abdominal wall and great omentum. Excisions of the gross seeding tumors was performed except seeding tumors at pelvic floor (densely invasion), some clips was put around pelvic floow and bil.ovary sites for possible further R/T treatment.    
    • Sigmoidectomy was done and anastomosis was achieved using endo-GIA EZ/green 60+ CDH-29+ TISSEEL. Air test is ok.     
    • Closure of T-loop colostomy was also done by segmental resection of T-colon and anastomosis was achiseved using hand-sewn side-to-side anastomosis (endo-GIA EZ/green for both ends, then 4/0 PDS + silk)    
    • The whole procedure was smooth. Blood loss was anout 100ml.  
• 2023-01-05
  • Surgery
    • T-loop colostomy        
  • Finding
    • Dilation of colon due to S-colon tumor obstruction    
    • T-llop colostomy was created at RUQ adbomen

[immunochemotherapy]

• 2023-06-20 - bevacizumab 5mg/kg 300mg NS 100mL + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-31 - bevacizumab 5mg/kg 300mg NS 100mL + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-04 - bevacizumab 5mg/kg 300mg NS 100mL + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-14 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-27 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-09 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-07-07

[reconciliation]

• The patient has two prescriptions that are eligible for refill, one given by our department of metabolism and endocrinology dated 2023-04-11, which includes Canaglu (canagliflozin), Zulitor (pitavastatin), Kludone (gliclazide), Uformin (metformin), and Dibose (acarbose) to address her type 2 diabetes mellitus. The other prescription was provided by the cardiology department on 2023-06-30, encompassing Concor (bisoprolol), Coxine (isosorbide-5-mononitrate), Hyzaar (losartan, hydrochlorothiazide), and Norvasc (amlodipine) for her hypertensive heart disease and angina pectoris. All these medications are accounted for in the present medication list and no discrepancies have been detected during the reconciliation process.
• Be aware that the refillable prescription’s validity is capped at a duration of 3 months. As such, the supply of medication prescribed by the metabolism and endocrinology department should be nearing exhaustion soon. Please ensure to advise the patient about the necessity to schedule another appointment with our endocrinologist for a prescription renewal.

[optionally increase Norvasc to 1# daily]

• If the patient’s SBP persistently remains above 140 in most situations, as observed at 14:22 (163mmHg) and 16:52 (150mmHg) on 2023-07-06, it would be advisable to consider increasing the dosage of Norvasc (amlodipine 5mg) from 0.5# to 1# QD.

2023-06-21

• This patient has two refillable prescriptions, one from our Metabolism and Endocrinology department issued on 2023-04-11 for Canaglu (canagliflozin), Zulitor (pitavastatin), Kludone (gliclazide), Uformin (metformin), and Dibose (acarbose) to manage her type 2 DM. The other prescription was issued on 2023-03-24 by the Cardiology department for Concor (bisoprolol), Coxine (isosorbide-5-mononitrate), Hyzaar (losartan, hydrochlorothiazide), and Norvasc (amlodipine) for her hypertensive heart disease and angina pectoris. All these medications have been integrated into the current formulary with no reconciliation issues found.
• Please note that the maximum validity duration of a refillable prescription is limited to 3 months. Therefore, the medication prescribed by the Cardiology department should soon be depleted. Please remind the patient to revisit our cardiologist to renew her prescription.

2023-06-01

• According to PharmaCloud, this patient visited a local clinic for heartburn on 2023-05-03. However, the prescribed medication for a duration of 3 days is now expired. Currently, no issues with medication reconciliation have been identified.

• Aside from anemia, the laboratory results from 2023-05-31 were largely within normal limits. There appears to be a downward trend in HGB levels in this patient following the initiation of FOLFOX treatments on 2023-03-09, with hemoglobin levels not fully recovering. This trend warrants continued monitoring.

  • 2023-05-31 HGB 9.9 g/dL
    
  • 2023-04-25 HGB 10.5 g/dL
    
  • 2023-03-22 HGB 10.7 g/dL
    
  • 2023-02-03 HGB 11.8 g/dL

2023-05-05

• Although the patient is taking metformin, acarbose, gliclazide, and canagliflozin, all serum glucose measurements during this hospitalization were above 200 mg/dL, suggesting inadequate glycemic control.
• Bevacizumab, part of the patient’s current treatment regimen, has been associated with hyperglycemia (26% of cases). If elevated blood glucose levels continue to be a problem, it may be worthwhile to consider adding insulin to help control the patient’s blood glucose.

2023-03-28

• Despite receiving metformin, acarbose, gliclazide, and canagliflozin, the patient has experienced episodes of serum glucose above 200mg/dL during her current hospital stay, indicating poor glycemic control. It is recommended that the patient be arranged to the metabolism and endocrinology outpatient department to renew her prescription for diabetes medications, as her previous refillable prescription is only valid for a limited time (approximate early Apr 2023).

2023-03-10

• The patient has an underlying condition of type 2 diabetes with blood sugar levels fluctuating between 272, 263, and 159mg/dL in high variability, serum glucose management might be further improved. By the way, the patient’s hypertension is well managed, and their vital signs are stable according to the TPR panel.
• The evidence supports that the patient’s diabetes is showing a worsening trend in the mid-term blood sugar index. It is recommended to measure a new value for HbA1c.
  • 2022-12-30 HbA1c 8.1 %
    
  • 2022-10-07 HbA1c 7.9 %
    
  • 2022-07-15 HbA1c 7.0 %

700068505

230706

{Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC}

• diagnosis
  • 2022-08-18 discharge diagnosis
    • Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04, partial response
    • Hypertensive heart disease without heart failure
    • Type 2 diabetes mellitus without complications
    • Hyperlipidemia, unspecified
    • Chronic viral hepatitis B without delta-agent
• past history (as of Aug 2022)
  • 1. Hypertension and hyperlipidemia for 20 years with regular medication at Tzu Chi H.
  • 2. Hyperuricemia and gout for years with irregular medication.
  • 3. Pre-diabetes mellitus was noted for 13 years with diet control.
  • 4. Birth control s/p vasectomy at 2013-06-19 at Tzu Chi H.
• initial presentation
  • 2021 Feb low back pain, pain aggravated when changing position

[lab data]

• 2021-07-20
  • All-RAS mutation detected
  • BRAF mutation not detected

[exam findings]

• 2023-06-15 CT - abdomen
  • History and indication: Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Progression of peritoneal seeding, LNs, bony/ liver and lung metastases. Ascites and right pleural effusion. General subcutaneous edema.
    • S/P Port-A infusion catheter insertion.
    • Renal cysts (up to 5.7cm).
    • Hyperplasia of bil. adrenal glands.
    • Atherosclerosis of aorta.
    • S/P posterior longitudinal transpedicular screws and rods fixation.
  • IMP:
    • Progression of peritoneal seeding, LNs, bony/ liver and lung metastases. Ascites and right pleural effusion. General subcutaneous edema.
• 2023-06-14, -04-19, -04-03 Forearm LT
  • Pathologic fracture of left proximal radius S/P external fixation.
• 2023-04-18 AP and lateral films of the T-L spine
  • S/P posterior longitudinal transpedicular screws and rods fixation.
  • Degeneration and spondylosis of L-S spine.
• 2023-04-18 KUB
  • S/P foley catheter indwelling.
  • Degeneration and spondylosis of L-S spine.
• 2023-03-14 T-spine AP + Lat.
  • S/P posterior instrumentation fixation from T7 To T9.
  • Spondylosis of the T-spine and L-spine .
• 2023-03-13 Patho - interveterbral disc (Y1)
  • Bone and joint, vertebra, thoracic 8, excision of intraspinal malignant tumor and posterior spinal fusion with instrumentation — adenocarcinoma.
  • Section shows pieces of bone, degenerated ligament, and cartilage with focal adenocarcinoma.
  • IHC stains: CDX2 (+), CK7 (-), CK20 (+), PSA- (-), TTF-1 (-), a pattern, in favor of colorectal origin.
• 2023-03-11 Long Bones series
  • Osteolytic fracture of left proximal radius is noted that is c/w bony metastasis.
• 2023-03-09 ECG
  • Normal sinus rhythm
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2023-03-09, 2022-10-07 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2023-03-08 MRI - T-spine
  • Indication: Sigmoid cancer with T-spine bone metastasis, T3N2aM1c, stage IVC, with severe back pain
  • With and Without-contrast multiplanar spine MRI revealed
    • severe extenal mass effect on the T8 cord.
    • heterogeneous enhancing tumors in the T8, L2, S1, S2, S3 and S4 vertebral bodies with peri-vertebral invasion and invasion the the T7, T8 and T9 spinal canal.
      
    • multiple hepatic metastasis.
  • IMP
    • multiple vertebral body metastasis, more on the T8 vertebral body with significant mass effect on the T8 cord.
    • multiple hepatic metastasis.
• 2022-12-28 Tc-99m MDP whole body bone scan
  • As compared with the previous study on 2022-10-04, some new bone lesions in the right rib cage nd left S-I joint are noted and most of the previous bone lesions are more evident, suggesting multiple bone metastases in progression.
    
  • Suspected benign lesions in the maxilla, sternum and right shoulder.
• 2022-12-28 CT - abdomen
  • Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04, partial response
  • Findings:
    • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size in most lesions.
    • Prior CT identified multiple metastases in the omentum and mesentery are noted again, stable in size.
    • Prior CT identified regional/ non-regional LNs, are noted again, stable in size.
    • Prior CT identified lung metastases are noted again, decreasing in size.
    • Prior CT identified bony metastases in right sacrum and bilateral acetabulum, and T8 vertebral body are noted again, stable in size.
    • Hyperplasia of bil. adrenal glands.
    • Renal cysts (up to 3.5cm).
  • Impression:
    • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size in most lesions. please correlate with clinical condition.
• 2022-10-05 CT - abdomen
  • Indication: Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04, partial response
  • Findings:
    • Prior CT identified several metastases on both hepatic lobes are noted again, stable in size in few lesions. However, three of them show mild increasing in size.
    • Prior CT identified multiple metastases in the omentum and mesentery are noted again, stable in size.
    • Prior CT identified regional/ non-regional LNs, are noted again, stable in size.
    • Prior CT identified two lung metastases are noted again, stable in size.
    • Renal cysts (up to 3.5cm).
    • Hyperplasia of bil. adrenal glands.
  • Impression:
    • Prior CT identified several metastases on both hepatic lobes are noted again, stable in size in few lesions. However, three of them show mild increasing in size. please correlate with clinical condition.
• 2022-10-04 Tc-99m MDP whole body bone scan
  • As compared with the previous study on 2022-06-29, some new bone lesions are noted and most of the previous bone lesions are a little more evident, suggesting multiple bone metastases in progression.
    
  • Suspected benign lesions in the maxilla, sternum and right shoulder.
• 2022-06-30 CT - abdomen
  • Findings
    • Stable condition of S-colon cancer, regional/ non-regional LNs, peritoneal seeding, bony/liver and lung metastases.
    • S/P Port-A infusion catheter insertion.
    • Renal cysts (up to 3.5cm).
    • Hyperplasia of bil. adrenal glands.
    • Atherosclerosis of aorta.
  • IMP:
    • Stable condition of S-colon cancer, regional/non-regional LNs, peritoneal seeding, bony/liver and lung metastases.
• 2022-06-29 Tc-99m MDP whole body bone scan
  • Most of the previous metastatic bone lesions come to less evident compared with the previous study on 2021-10-06; a lesion in middle T-spine, however, becomes more prominent, and the nature is to be determined (severe DJD, new bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    
  • Suspected benign lesions in the maxilla, sternum, L3-4 spine, and bilateral shoulders.
• 2022-03-31 CT - abdomen, pelvis
  • Stable condition of S-colon cancer, regional/non-regional LNs, peritoneal seeding, bony/ liver and lung metastases.
• 2022-01-24 2D transthoracic echocardiography
  • Adequate LV systolic function with normal resting wall motion
  • Dilated LA, concentric LVH; impaired LV relexation
  • Trivial MR, mild AR and trivial TR
  • Preserved RV systolic function
• 2022-01-06 CT
  • Much regression of S-colon cancer, regional/non-regional LNs, peritoneal seeding, bony/liver and lung metastases.
• 2021-10-06 Tc-99m MDP whole body bone scan
  • Multiple hot spots in bilateral rib cages and increased activity in the sacrum, bilateral S-I joints, and right acetabulum, cancer with bone metastasis is highly suspected.
  • Suspected benign lesions in the maxilla, sternum, middle T-spine, L3-4 spine, bilateral shoulders and right foot.
• 2021-10-05 CT
  • Diffuse metastatic tumors in the liver, peritoneum, bones, metastatic lymph nodes in paraaortic and left neck.
  • Regression as compare with CT study on 2021-6-21.
  • Mild pericardial effusion.
• 2021-06-25 Patho - Colon biopsy
  • Colon, sigmoid 20cm above anal verge, biopsy - Adenocarcinoma.
    
  • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
• 2021-06-22 Tc-99m MDP whole body bone scan
  • Increased activity in the sacrum, right S-I joint and right iliac bone. Bone metastases should be considered first.
  • Increased activity in the middle T-spines and L4 spine. Either degenerative change or bone metastases may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Multiple hot spots in the sternum and bilateral rib cages and mildly increased activity in bilateral femoral trochanters. The nature is to be determined (bone metastases? post-traumatic change? other nature?).
  • Increased activity in bilateral shoulders. Benign joint lesions is more likely.
• 2021-06-21 CT
  • Impression (Imaging stage): T3N2aM1c, stage IVC
• 2021-06-15 Patho - Bone pathologic fragment, at right first sacral tumor/mass.
  • Labeled as “sacrum”, CT guided biopsy - adenocarcinoma.
  • IHC:
    • CK20(+), CDX2(+): please check gastrointestinal tract first.
    • PSA(-): dis-favor prostatic origin.
    • TTF-1(-), Napsin-A(-): dis-favor pulmonary origin.
• 2021-06-02 MRI - L-spine:
  • tumors in the sacrum.

[consultation]

• 2023-04-20 Oral and Maxillofacial Surgery
  • Q: For 1) The area behind the left tooth has collapsed, and the tooth keeps scraping the tongue. 2) Xgeva use. We need your consultation for evaluation.
  • A
    • We are consulted for dental problem.
    • As the patient appeared with weakness muslce strength, we wil examine the condition at bedside this afternoon.
• 2023-04-20 Orthopedics
  • Q: For left proximal radius pathological fracture was noted since 2023/03/11, we need your consultation for evaluation.
  • A:
    • 59 Male
    • Dx: Left proximal radius pathological fracture, displaced
    • Plan:
      • OPD f/u
      • Keep current management
      • Pain management
      • Surgical intervention not indicated due to poor prognosis of the underlying disease
• 2023-03-11 Orthopedics
  • Q: For radial bone fracture
  • A
    • left proximal radius pathological fracture was noted
    • considering patient’s condition
    • splint immobilization and sling protection is suggested
• 2023-03-09 Anesthesiology
  • Q
    • This time, for prepare 2023/03/10 T8 spine OP. Now, for anesthesia assessment. Thank you.
  • A
    • I’ve vistied the patient and reviewed the past history:
      • Pt: 58 y/o M
      • Current problem: T8 spine bone metastasis
      • Operation: intraspinal tumor excision on 3/10
      • Past History : Sigmoid cancer with lung, liver and bone metastasis s/p bone radiotherapy and chemotherapy; HTN, DM, HBV
      • GCS: E4 V5 M6
      • Vitals stable
      • Labs : Within acceptable range for anesthesia
        • Hb 12.7
          
        • EKG pending
        • CXR pending
      • 2021 Cardiac echo LVEF 75%
    • Assessment: ASA 3
    • Plan
      • We will arrange ETGA for this patient
      • The patient and his family have been informed on the anesthesia- and surgery-associated risks, including cardiovascular risks (hypotension, stroke, acute myocardial infarction, shock), pulmonary risks (hypoxia, pulmonary embolism,delay extubation) and other possible complications
      • Postoperative ICU care might be needed
• 2023-03-08 Neurosurgery
  • Q
    • This 58-year-old man patient is a case of sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04 to 2022/09/16 for 25 cycles, progression s/p palliative chemotherapy with FOLFOX from 2022/10/05 to 2023/02/21 for 9 cycles, progression of liver tumor and bone metastases. palliative radiotherapy evaluation of S-I joint, 1600cGy/8 fractions of the right SI joint to right hip area from 2023/02/15 to 2023/02/24. T-spine MRI on 2023/03/08 showed multiple vertebral body metastasis, more on the T8 vertebral body with significant mass effect on the T8 cord and multiple hepatic metastasis. Now, for evaluate T8 spine surgery of pain control. Thank you.
  • A
    • T8 spine surgery is indicative for the patient.
    • We will arrange operation for the patient this Friday. We will full explained risk and outcome to the patient and family.
• 2023-02-09 Radiation Oncology
  • A
    • A: Adenocarcinoma of the sigmoid colon, stage cT3N2aM1c, with liver, lung, and bone metastasis, s/p palliative radiotherapy, with progression.
    • P: Radiotherapy is indicated for this patient with the following indicators: pain of the right SI joint to right hip area.
      • Goal: palliation
      • Treatment target and volume: right SI joint to right hip area.
        
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 1600cGy/8 fractions of the right SI joint to right hip area.
      • The treatment modality and the possible effects of re-irradiation were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2023-2-13.
• 2021-07-14 Rehabilitation
  • Assessment
    • sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p Palliative radiotherapy to sacrum, right S-I joint and peripheral involved area from 2021/07/01~2021/07/14 for 2000cGy/10 fractions. Chemotherapy with FOLFOX(Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2)(C1D1) from 2021/07/02~2021/07/04.
    • Polio with LLE weakness
  • Plan
    • Rehabilitation programs: Bedside PT rehabilitation programs
    • Goal: recondition, improve endurance and muscle strength
• 2021-07-01 Dermatology
  • This patient suffered from erytheamtous plaque on back and buttock for days
  • Imp: Tinea corporis
  • Suggestion: Excelderm cream x 2 tubes/bid

[surgical operation]

• 2023-03-10
  • Surgery: Excision of intraspinal malignant tumor and posterior spinal fusion with instrumentation, microscopy and fluoroscopy
  • Finding: Thoracic 8 level pathological fracture (metastaticl lesion)

[chemoimmunotherapy]

• 2023-06-12 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRINOX, no 5-FU bolus, reduced Oxa)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

• 2023-05-17 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRINOX, no 5-FU bolus for 20230515 WBC 2.9K)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

• 2023-04-24 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRINOX)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

• 2023-03-31 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRINOX) (20230419 WBC 2.27K)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

• 2023-02-21 - oxaliplatin 65mg/m2 114mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-02-07 - oxaliplatin 65mg/m2 114mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

• 2023-01-17 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3

• 2022-12-29 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3

• 2022-12-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3

• 2022-11-28 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3

• 2022-11-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3

• 2022-10-24 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3

• 2022-10-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3

• 2022-09-16 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • diphenhydramine 30mg + dexamethasone 4mg + palonosetron 250ug + atropine 0.5mg SC

• 2022-08-30 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • diphenhydramine 30mg + dexamethasone 4mg + palonosetron 250ug + atropine 0.5mg SC

• 2022-08-15 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

• 2022-08-01 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

• 2022-07-15 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

• 2022-06-30 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

• 2022-06-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

• 2022-05-25 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

• 2022-05-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

• 2022-04-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

• 2022-03-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

• 2022-03-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

• 2022-02-24 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

• 2022-02-11 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

• 2022-01-24 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

• 2022-01-03 - irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

• 2021-12-20 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)

• 2021-11-23 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)

• 2021-11-10 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)

• 2021-10-22 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

• 2021-10-07 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

• 2021-09-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

• 2021-09-01 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

• 2021-08-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

• 2021-08-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

• 2021-07-16 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFOX, Q2W)

• 2021-07-02 - oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 3900mg 46hr (FOLFOX, Q2W)

==========

2023-07-06

• This patient has only been visiting our hospital for the past three months, primarily to the Hemato-Oncology Department and secondarily to the Cardiology Department. The former is for the treatment of sigmoid colon cancer, while the latter is for the treatment of type 2 diabetes mellitus and hypertensive heart disease.
• The medications Concor (bisoprolol), Doxaben (doxazosin), Forxiga (dapagliflozin), Hyzaar (losartan, hydrochlorothiazide), Pravafen (pravastatin, fenofibrate), and Zanidip (lercanidipine) prescribed by our cardiologist on 2023-04-12 have been added to the active formulary. No medication reconciliation issues were identified.

2023-06-13

• Based on the PharmaCloud database, it’s evident that this patient has been receiving outpatient and inpatient medical services exclusively at our hospital for the past three months. As per the records, our Cardiologist prescribed a refillable order of Concor (bisoprolol), Doxaben (doxazosin), Forxiga (dapagliflozin), Hyzaar (losartan, hydrochlorothiazide), Pravafen (pravastatin, fenofibrate), and Zandip (lercanidipine) on 2023-04-12. These medications are accurately reflected in the patient’s active medication list. Consequently, no medication reconciliation issues have been identified.

• Lab data showed a worsening liver function. The patient is currently prescribed OxyNorm (oxycodone 5mg). The package insert for OxyNorm indicates that plasma concentrations may increase in patients with mild to moderate renal impairment and mild hepatic impairment. Therefore, a conservative approach should be taken when adjusting the dosage. For patients with hepatic impairment, the starting dose should be one third to half of the usual initial dose, followed by careful dose adjustment. It is worth noting that 10 mg oral oxycodone is equivalent to 20 mg oral morphine. There is no evidence to suggest that the current dosage of 5mg Q6H is inappropriate. However, close monitoring for potential adverse reactions is recommended.

  • 2023-06-12 Bilirubin total 2.06 mg/dL
    
  • 2023-05-15 Bilirubin total 0.90 mg/dL
    
  • 2023-06-12 Bilirubin direct 1.15 mg/dL
    
  • 2023-05-15 Bilirubin direct 0.26 mg/dL
    
  • 2023-06-12 S-GOT/AST 74 U/L
    
  • 2023-05-15 S-GOT/AST 45 U/L
    
  • 2023-06-12 S-GPT/ALT 24 U/L
    
  • 2023-05-15 S-GPT/ALT 13 U/L

2023-06-12

• The most recent lab data (2023-05-16) shows a direct bilirubin level of 0.26mg/dL and an AST level of 45U/L, both slightly exceeding the upper limit of normal. This could indicate potential liver insufficiency. Since fentanyl is primarily metabolized into inactive metabolites in the liver, hepatic insufficiency could potentially slow its elimination. Therefore, patients with impaired liver function using the fentanyl transdermal patch should be monitored for signs of toxicity, and the dose might need to be reduced if necessary. Please update the patient’s liver function readings. If mild to moderate hepatic impairment is confirmed, then the dose is adviced to be reduced by 50%. It’s not recommended to use the fentanyl patch in patients with severe hepatic impairment.

• The patient was treated with FOLFIRI from 2021-08 to 2022-09, then with FOLFOX from 2022-10 to 2023-02, and then with FOLFIRINOX since 2023-03. However, due to the obvious upward trend of tumor markers, it is possible that the disease may have developed further resistance to these changed regimens.

  • 2023-06-12 CEA 733.40 ng/mL
    
  • 2023-05-16 CEA 621.44 ng/mL
    
  • 2023-04-19 CEA 676.57 ng/mL
    
  • 2023-03-31 CEA 450.06 ng/mL
    
  • 2023-01-11 CEA 189.62 ng/mL
    
  • 2022-11-22 CEA 156.62 ng/mL
    
  • 2022-10-19 CEA 53.26 ng/mL
    
  • 2022-09-13 CEA 33.27 ng/mL
    
  • 2023-05-16 CA199 1794.87 U/mL
    
  • 2023-04-19 CA199 1447.66 U/mL
    
  • 2023-03-31 CA199 1173.49 U/mL
    
  • 2023-01-11 CA199 497.53 U/mL
    
  • 2022-11-22 CA199 285.59 U/mL
    
  • 2022-10-19 CA199 180.53 U/mL
    
  • 2022-09-13 CA199 156.34 U/mL

• The current FOLFIRINOX regimen is being administered without a bolus of 5-FU and with a reduced dose of oxaliplatin, due to observed adverse events and/or patient’s performance status. This is considered an appropriate adjustment and there are no issues identified with this approach.

2023-05-16

• This patient has been diagnosed with sigmoid colon cancer that has metastasized to the lungs, liver and bones. He has also undergone posterior longitudinal transpedicular screw and rod fixation and is dealing with degeneration and spondylosis of the L-S spine as well as a pathologic fracture of the left proximal radius for which he has undergone external fixation.
• Given the high risk of fractures, it is advisable to consider adding therapeutics such as oral bisphosphonates, zoledronic acid, vitamin D3, denosumab, or teriparatide to the patient’s treatment regimen, as these may help reduce the risk of potential fractures. ref: Bone health in cancer: ESMO Clinical Practice Guidelines https://www.annalsofoncology.org/article/S0923-7534(20)39995-6/fulltext

2022-12-28

• It has been arranged for a CT and bone scan to be performed during this hospitalization at intervals of three months.
• The patient’s blood pressure has returned to normal range (186/121 -> 135/72 mmHg) and there are no abnormalities in his vital signs or 2022-12-27 laboratory results.
• The underlying conditions of hypertension, diabetes mellitus, hyperlipidemia, and hepatitis B are appropriately managed with self-carried medication without complications.

2022-12-13

• The blood pressure was still high (at around 170/95) under Concor (bisoprolol), Doxaben (doxazosin), Hyzaar (losartan, hydrochlorothiazide) and Zanidip (lercanidipine).
• For hypertensive emergencies, hydralazine 10 to 20 mg every 4 to 6 hours might be used (a beta-blockers has been used to prevent reflex tachycardia).

2022-11-29

• After image studies in early Oct 2022 revealed a number of lesions with a mild increase in size, and multiple bone metastases in progress, the regimen was changed from FOLFIRI to FOLFOX.

• In the past three months, certain tumor markers have been elevated.

  • CEA
    • 2022-11-22 CEA 156.62 ng/mL
      
    • 2022-10-19 CEA 53.26 ng/mL
      
    • 2022-09-13 CEA 33.27 ng/mL
      
  • CA199
    • 2022-11-22 CA199 285.59 U/mL
      
    • 2022-10-19 CA199 180.53 U/mL
      
    • 2022-09-13 CA199 156.34 U/mL

• As SBP highly fluctuated between 136 and 231 under treatment with (patient-carried medication) Concor (bisoprolol), Zanidip (lercanidipine) and Hyzaar (losartan + hydrochlorothiazide), please monitor this closely. The drug Atanaal (nifedipine 5mg) 1# PRNQ6H might be considered in case where the blood pressure exceeds 200mmHg.

• SBP flucturated at a wide range 136~231mmHg under patient-carried antihypertensive agents Concor (bisoprolol) and Hyzaar (losartan + hydrochlorothiazide), please keep a closer eye on it.

• Pre-prandial blood sugar levels were higher than 170mg/dL for 2 days; metformin 500mg BID is recommended.

2022-10-25

• The blood pressure remains high, around 185/100, since this hospital stay, despite the use of current antihypertensive medications: Concor (bisoprolol 5mg) 1.5# QD + Hyzaar (losartan 100mg + hydrochlorothiazide 12.5mg) 1# QD + Zanidip (lercanidipine 10mg) 1# QD + Atanaal (nifedipine 5mg) 1# PRNQ6H.
• For severe asymptomatic hypertension, might consider hydralazine short-term use for blood pressure lowering (eg, over hours) if there is concern that severe blood pressure elevation will precipitate an acute cardiovascular event. Hydralazine initial: 10 mg 4 times daily for 2 to 4 days, then 25 mg 4 times daily for the remainder of the week followed by titration based on response to 50 mg 4 times daily; usual dosage range: 100 to 200 mg/day in divided doses.
• Besides, minoxidil (not available in this hospital at present) is reserved for patients with resistant hypertension who do not respond adequately to an optimized 4-drug regimen, ideally consisting of a thiazide-like diuretic and a mineralocorticoid-receptor antagonist. Minoxidil is usually used in combination with a beta-blocker to prevent reflex tachycardia.

2022-08-31

• The underlying diseases were managed with self-carried medications without the need for urgent adjustment. At the time of this hospital stay, blood pressure levels were 170(+-10)/90(+-10), blood sugar levels were 146~162, which were just slightly above normal ranges. The lab data on 2022-08-30 were generally normal.
• Bevacizumab was last administered on 2022-06-13. The levels of CEA and CA199 have increased in the last three months.
• CEA
  • 2022-08-10 CEA 31.80 ng/mL
    
  • 2022-07-12 CEA 21.34 ng/mL
    
  • 2022-06-10 CEA 17.51 ng/mL
    
  • 2022-05-03 CEA 10.98 ng/mL
    
  • 2022-03-29 CEA 10.39 ng/mL
    
• CA199
  • 2022-08-10 CA199 171.05 U/mL
    
  • 2022-07-12 CA199 174.30 U/mL
    
  • 2022-06-10 CA199 162.79 U/mL
    
  • 2022-05-03 CA199 92.68 U/mL
    
  • 2022-03-29 CA199 92.15 U/mL

2022-08-02

• The patient’s blood glucose level was approximately (140 +- 10) mg/dL, and his blood pressure was approximately (160 +- 20 ) / (95 +- 10) mmHg during this hospitalization.
• Norvasc (amlodipine 5mg/tab) #1 QD for HTN is recommended.

2022-05-26

• CT images taken on 2022-01-24 showed a regression, while CT images taken on 2022-03-31 showed the disease stable, which could hint a decline in the effect of the regimen or the tumor has acquired a certain degree of resistance, this is consistent with the slow rise in tumor markers in recent months.
• Lab data
  • CEA
    • 2022-05-03 92.68 U/mL
    • 2022-03-29 92.15 U/mL
    • 2022-02-23 82.61 U/mL
    • 2022-01-18 72.41 U/mL
    • 2021-12-14 69.99 U/mL
  • CA199
    • 2022-05-03 10.98 ng/mL
    • 2022-03-29 10.39 ng/mL
    • 2022-02-23 8.55 ng/mL
    • 2022-01-18 6.69 ng/mL
• In the event the disease progresses, since this patient is receiving irinotecan-based therapy without oxaliplatin, the next regimen candidates could be FOLFOX or CAPEOX.
• Lab results on 2022-05-18 showed liver and kidney function, blood electrolytes were normal, however WBC 2700/uL (Neutrophil 61%) was relatively lower which should be addressed.
• Since the evening of 2022-05-25, the SBP has risen up to 180mmHg, even with the use of bisoprolol, losartan, hydrochlorothiazide, and lercanidipine. Keeping a close eye on the blood pressure should be done to check if more intervention is necessary.

2022-03-31

• According to latest CT images on 2022-01-06, the disease showed response to current regimen which has been introduced since 2021-08, compared with the images on 2021-10-25, 2021-06-21.
• There has been an increase in biomarker readings since 2022 [CEA 10.39(2022-03-29) <- 8.55(2022-02-23) <- 6.69(2022-01-18); CA199 92.15(2022-03-29) <- 82.61(2022-02-23) <- 72.41(2022-01-18)], which is not consistent with the CT images that are updated not so frequently.
• When the disease becomes resistant to current treatment, since this patient is on irinotecan-based therapy without oxaliplatin, the next regimen candidates might be FOLFOX or CAPEOX.

700575407

230706

[diagnosis] - 20221220 admission note

• Follicular lymphoma, grade 1 with left axillary, mediastinum, mesentery and retroperitoeum invasion, stage III, FLIPI:4, IPI:2
• Irritable bowel syndrome with diarrhea
• Type 2 diabetes mellitus without complications
• Pure hypercholesterolemia
• Chronic viral hepatitis B without delta-agent

[exam findings]

• 2023-06-20 Mammography
  • Impression: No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
  • BI-RADS: Category 1: negative. - annual screening.
• 2023-06-08 Sono-guide aspiration of right thyroid
  • Benign follicular nodule
    
  • Two wet smears show colloid, blood, lymphocytes, pigmented macrophages and benign follicular cell clusters with focal reactive atypia.
• 2023-05-10 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2023-05-05 Thyroid Ultrasound
  • Echo: Heterogeneous echo
  • Ultrasound Result - Nodules:
    • Right side: 0.30.20.4 cm ; 1.10.91.5 cm
  • Diagnosis: Multinodular goiter, Autoimmune thyroid disease
• 2023-04-18, -04-14 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
  • There are several nodular opacities on both lung and Patchy consolidation at right lower lung. Please correlate with clinical condition and CT.
• 2023-04-13 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A (minimal)
• 2023-04-12 CT - abdomen
  • History and indication: Follicular lymphoma
  • Findings:
    • There are several patchy consolidations of the RML, RLL and LLL of the lung.
      • In addition, few nodular infiltrations in RUL and LUL of the lung are suspected.
      • Bronchopneumonia is highly suspected. please correlate with clinical condition.
    • Mild bilateral pleura effusion are noted.
    • Prior CT identified a cystic lesion (7.8cm) at left axillary region. is noted again, marked decreasing in size to 2.4 cm.
    • Prior CT identified some LNs (up to 2.3cm) at bil. axillary regions, inguinal regions, mediastinum, mesentery and para-aortic space are noted again, decreasing in size.
    • Prior CT identified prominence in size of the spleen (long axis: 11.8 cm) is noted again, mild decreasing in size to 10.5 cm.
  • Impression:
    • Bronchopneumonia on both lungs are suspected.
• 2023-04-08 CXR
  • Consolidation in right lower lung.
  • Thoracic spondylosis.
• 2023-03-06 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2023-01-17 Sacrum & Coccyx
  • Spondylolisthesis of L4-5 or L5-S1 (< Grade I) is noted.
  • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
• 2023-01-03, 2022-11-30 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
• 2022-11-29 Whole body PET scan
  • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm as mentioned above (stage III).
• 2022-11-28 Patho - bone marrow biopsy
  • PATHOLOGIC DIAGNOSIS
    • Bone marrow, buttock, biopsy — Free from lymphoma involvement
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consisted of two strips of bone marrow tissue measuring up to 1.8 x 0.3 x 0.3 cm in size, fixed in B-5 solution. Grossly, it was red-tan in color and bony hard in consistence. All embedded for sections after short decalcification.
  • MICROSCOPIC EXAMINATION -Relatively normocellularity for her age, 40% -No increase of blast -A few lymphocyte aggregates, a mixture of T and B cells, interstitial or paratrabecular distribution, CD10(-) and Bcl-6(-), compatible with benign aggregates and free from follicular lymphoma involvement -Immunohistochemistry: CD3(+), CD20(+), CD34(+ for blast), CD10(-) and Bcl-6(-)
• 2022-11-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (85 - 27) / 85 = 68.24%
    • LVEF (%) = 68
    • M-mode (Teichholz) = 68
  • Normal LV systolic function with normal wall motion.
  • Normal LV diastolic function.
  • Normal RV systolic function.
  • Mild MR; mild TR.
• 2022-11-26 CT - abdomen
  • A cystic lesion (7.8cm) at left axillary region. Some LNs (up to 2.3cm) at bil. axillary regions, inguinal regions, mediastinum, mesentery and retroperitoeum. Splenomegaly.
• 2022-11-17 Thyroid Ultrasound
  • R’t : 0.30.20.3 cm ; 1.10.91.5 cm
  • Multinodular Goiter, Autoimmune thyroid disease
• 2022-11-09 Patho - lymph node region resection
  • DIAGNOSIS:
    • A: Lymph node, left mediastinum, group 5, dissection — Follicular lymphoma, grade 1
    • B: Lymph node, left mediastinum, group 11, dissection — Follicular lymphoma, grade 1
    • C: Lymph node, left axillary, dissection — Follicular lymphoma, grade 1
  • GROSS DESCRIPTION:
    • A: Specimen submitted in formalin consists of several lymph nodes measuring up to 1.3 x 1.1 x 0.5 cm. All for section in one cassette A.
    • B: Specimen submitted in formalin consists of a lymph node measuring 1.3 x 0.6 x 0.5 cm. All for section in one cassette B.
    • C: Specimen submitted in formalin consists of several lymph nodes measuring up to 4.0 x 2.2 x 1.5 cm. Representative sections are taken in 4 cassettes C1-4.
  • MICROSCOPIC DESCRIPTION:
    • Sections of specimens A, B, and C show enlarged lymph nodes with closely packed, atypical follicles.
    • The immunohistochemical stains reveal CD3(-), CD20(+), BCL2(+), BCL6(+), CD10(+), CD43(-), Cyclin D1(-), CD15(-), and CD30(-).
    • The centroblasts are < 5/HPF. The results are consistent with grade 1 follicular lymph
• 2022-10-17 Patho - lymphnode biopsy
  • DIAGNOSIS:
    • Lymph node, left axillary, core needle biopsy — reactive lymphoid hyperplasia
  • Description:
    • The specimen submitted consists of 2 tissue fragments measuring up to 0.8x 0.1x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic.
    • Microscopically, it shows hyperplasia of small-type lymphocytes.
    • Immunohistochemical stain reveals CK(-), CD3 (immunoreative at T-cells), CD20 (immunoreative at B-cells),
• 2022-10-13 CT - chest
  • Indication:
    • Neoplasm of uncertain behavior of skin
    • Unspecified lump in breast
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Extensive lymphadenopathy at left axillary region and in lesser degree at right axillary area.
      • Small lymph nodes are found at both sides of the mediastinum and subcarina region.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Small lymph nodes are found in the mesentery.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Bilateral axillary lymphadenopathy and mediastinal, mesenterric lymphadenopathy
• 2022-10-03 Patho - lymphnode biopsy
  • Lymph node, left axillary, CNB — Negative for malignancy
• 2022-10-03 SONO - breast
  • Findings
    • Parenchymal pattem, Involuted
    • Focal sonographic lesion, enlarged left axillary LNs
  • Diagnosis
    • enlarged left axillary lymph nodes, suspected LAPs
  • Treatment
    • Sono-guided biopsy, Core-needle biopsy
  • Suggestion and Plan
    • arrange biopsy
    • BI-RADS 4B - intermediate suspicion of malignancy Biopsy Should Be Considered
• 2022-09-29 SONO - breast
  • CC and Indication
    • Palpable axillary lymph nodes
  • History
    • No specific risk factors
  • Findings
    • Parenchymal pattem
      • Involuted
    • Focal sonographic lesion
      • tiny FCDs
      • enlarged left axillary LNs
  • Diagnosis
    • Benign neoplasm of breast, infavor of benign fibrocystic disease(FCD)enlarged left, axillary lymph nodes, suspected LAPs
  • Treatment
    • Sono-guided biopsy,Core-needle biopsy
  • Suggestion and Plan
    • arrange biopsy
    • chest CT scan
    • BI-RADS 4B - intermediate suspicion of malignancy Biopsy Should Be Considered
• 2022-08-18 Thyroid Ultrasound
  • R’t : 0.20.10.3 cm ; 1.00.71.5 cm
  • Multinodular Goiter
• 2022-04-19 SONO - breast
  • Findings
    • Parenchymal pattem, Involuted
    • Focal sonographic lesion, tiny FCDs
  • Diagnosis
    • Benign neoplasm of breast, infavor of benign fibrocystic disease (FCD)
  • Treatment
    • No need to biopsy
  • Suggestion and Plan
    • Regular OPD follow-up, Follow up breast sonography in next OPD visit
    • BI-RADS 2 - Benign Finding

[surgical operation]

• 2022-10-03
  • Surgery
    • Lymph node biopsy
    • Intraoperative sonography (19002B)
  • Finding
    • IOUS: multiple enlarged axillary LNs, suspected LAPs, or occult breast cancer with axillary LAPs

[chemoimmunotherapy]

• 2023-07-05 - rituximab 375mg/m2 600mg NS 500mL 12hr + vincristine 1mg NS 50mL 10min (rituximab maintenance, Q3M x8 cycles for 2 years, vincristine will be DC next time)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + acetaminophen 500mg PO + NS 250mL
• 2023-03-27 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W) (WBC 180/uL 2023-04-08)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
• 2023-03-06 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W) (WBC 760/uL 2023-03-16)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
• 2023-02-13 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-COP, leukopenia, WBC 620/uL 2022-12-13)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
• 2023-01-16 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
• 2022-12-20 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
• 2022-12-01 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
• G-CSF Granocyte (lenograstim 250ug) CGRAN01
  • 2023-04-08 ~ 2023-04-15 (20230408 IPD)
  • 2023-04-08 (20230408 OPD)
  • 2023-03-16 ~ 2023-03-18 (20230316 OPD)
  • 2023-02-20 ~ 2023-02-22 (20230213 IPD)
  • 2023-01-23 ~ 2023-01-25 (20230116 IPD)
  • 2022-12-27 ~ 2022-12-29 (20221220 IPD)
  • 2022-12-13 ~ 2022-12-15 (20221213 OPD)
• WBC
  • 2023-04-10 WBC 2.59 x10^3/uL
    
  • 2023-04-08 WBC 0.18 x10^3/uL *
  • 2023-03-23 WBC 5.89 x10^3/uL
    
  • 2023-03-16 WBC 0.76 x10^3/uL *
  • 2023-03-02 WBC 5.64 x10^3/uL
    
  • 2023-02-23 WBC 7.05 x10^3/uL
    
  • 2023-02-13 WBC 2.64 x10^3/uL
    
  • 2023-01-31 WBC 3.35 x10^3/uL
    
  • 2023-01-10 WBC 4.36 x10^3/uL
    
  • 2023-01-03 WBC 3.45 x10^3/uL
    
  • 2022-12-20 WBC 5.59 x10^3/uL
    
  • 2022-12-13 WBC 0.62 x10^3/uL *
  • 2022-12-01 WBC 3.65 x10^3/uL
    
  • 2022-11-24 WBC 5.56 x10^3/uL
    
  • 2022-11-08 WBC 3.07 x10^3/uL
    
  • 2022-10-25 WBC 4.92 x10^3/uL

==========

2023-07-06

• This patient has only visited our hospital in the past three months, mainly attending the hemato-oncology department, followed by the metabolism and endocrinology department. The former is for the treatment of follicular lymphoma, while the latter is for the management of type 2 diabetes mellitus.

• The Uformin (metformin 500mg) 1# BID and Januvia (sitagliptin 100mg) 1# QD prescribed on 2023-05-12 by the metabolism and endocrinology department have been listed as patient-carried items in the active medication list. No medication reconciliation issues have been identified.

• The last CT is dated on 2023-04-12, now in the beginning of July, a new CT scan could be considered to be arranged.

2023-04-10

• The patient’s ANC was 12.7/uL on 2023-04-08. However, after receiving lenograstim 250ug daily since that day, her ANC increased to 1725/uL on 2023-04-10.
• The patient has been experiencing intermittent fever since 2023-04-08. She is currently being treated with cefepime 2g Q8H for neutropenic fever.
• The management of serum glucose has been better during this hospitalization as it has not exceeded 200mg/dL except for the first day, which is an improvement compared to before.
• There is no problem with the active prescription when it comes to medication reconciliation.

2023-03-07

• WBC > 5K/uL post last leukopenia (WBC 620/uL 2022-12-13).
• The patient’s pre-prandial blood sugar level has increased from 208 to 225 mg/dL during this hospitalization. If hyperglycemia persists or worsens, the addition of some insulin regimen may be beneficial.

2023-02-14

• A leukopenia event was observed (WBC 620/uL 2022-12-13). The R-CHOP was changed to the R-COP (hold doxorubicin, 2023-02-13 lab WBC 2.65K/uL, Neutrophil 55% => ANC 1450/uL) during this hospitalization.
• The level of blood sugar is rising (127 -> 170 -> 232mg/dL). For individuals with pre-existing diabetes, their diabetes medications might need to be adjusted while taking steroids (R-COP’s P). If preprandial blood sugar level >= 200mg/dL, it is suggested to add some insulin to mitigate the steroid-induced hyperglycemia. (ref: Steroid hyperglycemia: Prevalence, early detection and therapeutic recommendations: A narrative review. World J Diabetes. 2015;6(8):1073-1081. doi:10.4239/wjd.v6.i8.1073)

2023-01-17

• 2023-01-10 lab data showed HGB 10.5g/dL, MCV 69.4fL, MCH 20.8pg, MCHC 30.0g/dL. These readings were all below their normal ranges.

• Assessment based on the above lab items:

  • MCV (mean corpuscular volume) is the average volume (size) of the RBCs. Microcytosis (low MCV), a decreased MCV (usually <80 fL) reflects a defect in cellular hemoglobin synthesis. Iron deficiency and thalassemia are the most likely causes of a very low MCV (<80 fL).
  • MCH (mean corpuscular hemoglobin) is the average hemoglobin content in a RBC. A low MCH is typically reflected in an enlarged area of central pallor in RBCs on the peripheral blood smear (greater than one-third of the RBC diameter), which defines “hypochromia” on the blood smear. This may be seen in iron deficiency and thalassemia.
  • MCHC (mean corpuscular hemoglobin concentration) is the average hemoglobin concentration per RBC. Very low MCHC values are typical of iron deficiency anemia

• Recommendation:

  • Foliromin (ferrous sodium citrate 50mg/tab) 1~2# BID PO

2022-12-21

• Pre-prandial FS glucose levels recorded as 222, 346, 241 mg/dL, under current oral metformin and RI injection, still remain high, so it might be appropriate to gradually increase the dose of RI by 2 to 3 units or to add back Januvia (sitagliptin 100mg) QD.
• A grade 4 leukopenia event occurred 2 weeks after the first R-CHOP treatment (WBC 620/uL 2022-12-13). The event is no more observed after immediate administration of G-CSF for the next 3 consecutive days. WBC levels might be monitored closely after chemotherapy, especially for the first 1 to 2 weeks.
• The bowl movement in this patient reached four times during the first half of the day 2022-12-21. Loperamide can help with short-term diarrhoea or irritable bowel syndrome. Loperamide can also be used for recurring or longer lasting diarrhoea from bowel conditions such as Crohn’s disease, ulcerative colitis and short bowel syndrome.

701090711

230706

[lab data]

2023-06-07 HBsAg Nonreactive
2023-06-07 HBsAg (Value) 0.28 S/CO
2023-06-07 Anti-HBc Reactive
2023-06-07 Anti-HBc-Value 7.60 S/CO
2023-06-07 Anti-HCV Nonreactive
2023-06-07 Anti-HCV Value 0.11 S/CO
2023-06-07 Anti-HBs 4.14 mIU/mL

[exam findings]

• 2023-06-07 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 25 dB HL, LE 28 dB HL
  • bil normal to moderate SNHL
• 2023-06-02 CXR
  • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
  • widening of Rt and Lt paratracheal stripes and prominent Rt supraclavicular soft-tissue due to paratracheal lymph node enlargement
• 2023-05-31 Tc-99m MDP bone scan
  • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic reaction, early bone mets or other nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
  • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, knees, and feet.
• 2023-05-30 Patho - esophageal biopsy
  • Middle esophagus, 25 cm to 28 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
  • Middle esophagus, 24 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
  • The sections of both parts show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.
• 2023-05-30 PET scan
  • Glucose hypermetabolism involving the middle portion of the esophagus, compatible with primary esophageal malignancy.
  • Glucose hypermetabolism in a right lower paratracheal lymph node, confluent left upper paratracheal lymph nodes and confluent right supraclacular lymph nodes. Metastatic lymph nodes may show this picture.
  • Increased FDG in the colon, right kidney and right ureter. Physiological FDG accumulation is more likely.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2023-05-29 SONO - abdomen
  • Liver cysts
  • Liver calcification, S7
  • Renal cysts
  • R/o lymphadenopathy, near heptic hilum area
• 2023-05-27 MRI - brain
  • No brain nodule or metastasis. Old right putamen lacunar infarcts. Mild cortical brain atrophy.
• 2023-05-26 Patho - bronchus biopsy
  • Lung, left, bronchoscopic biopsy —- mild chronic inflammation
  • Section shows bronchial mucosa with mild chronic inflammation. No granuloma or malignancy is found.
  • The immunohistochemical stains of CK and p40 show no invasive tumor.
• 2023-05-25 CXR
  • widening of Rt and Lt paratracheal stripes and prominent Rt supraclavicular soft-tissue due to paratracheal lymph node enlargement
  • Tortousity of thoracic aorta
• 2023-05-17 CT - chest
  • Findings
    • Lungs: centrilobular nodular opacities at RLL and RUL, may be aspiration bronchiolitis. substantial subpleural paraseptal emphysema in both upper lobes and superior segment of LLL. partial atelectasis with focal fibrosis or subpleural paraseptal emphysema in RML
    • visible lowee neck, chest wall, mediastinum and hila: marked Rt medial wall thickening at M/3 of thoracic esopahgus (65mm in lenght) with luminal narrowing and invading adjacent mediastinal fat. multiple metastatic lymphadenopathy in the visceral space and left anterior prevascular space, and Rt supraclavicular fossa(large left upper paratracheal LAP indents and displaces the trachea and adjacent greater vessels) RT vocal cord palsy.
    • Heart: normal in size of cardiac chambers.
    • Pleura: no effusion or nodule.
    • Visible abdominal contents: multiple small low attenuations in the liver, may be hepatic cysts and metastatic lesions.
    • normal appearance of gall bladder..several RT and Lt renal cysts up to 3.7cm, unremarkable of the spleen, both adrenal glands, pancreas, and Lt kidneyno enlarged lymph node.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression: M/3 esophageal cancer T4N3M1(E1)
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:M1(M_value) STAGE:____(Stage_value)

[MedRec]

• 2023-07-05 SOAP Hemato-Oncology
  • O
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 20230627
      • cT4bN3M0 stage IVA => CCRT.
• 2023-06-21 SOAP Hemato-Oncology
  • O
    • Cancer Treatment Chemoradiotherapy/Targeted Therapy Side Effects Assessment (20230621)
      • Vomiting: G1: 1-2 times within 24 hours
        • Vomiting [Treatment]: Observe
• 2023-06-16 SOAP Radiation Oncology
  • P
    • Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, U/3+M/3 esophagus and adjacent lymphatic drainage area. Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fx.
• 2023-05-25 ~ 2023-06-14 POMR Hemato-Oncology
  • Discharge diagnosis
    • Squamous cell carcinoma of middle third of esophagus, cT4N3M0 stage IVA status post feeding jejunostomy and left port-A implantation on 2023/06/02
    • Hypertension
    • Anxiety disorder
    • Constipation, unspecified
    • Chronic viral hepatitis B without delta-agent
  • CC
    • suffered from dysphagia for solid material with epigastric dull pain for 6 months, associated with weight loss 6-7 kg in recent 2 months.        
  • Present illness
    • This 68-year-old man, a heavy smoker and alcoholism. He has suffered from dysphagia for solid material with epigastric dull pain for 6 months, associated with body weight loss 6-7 kg in recent 2 months.
    • According to the patient statement, he suffered from dysphagia with epigastric dull pain since 6 months ago. He didn`t pay much attention to it in the beginning.
    • In recent one month, he suffered from hoarseness and visited otolaryngology clinic for help. Nasopharyngoscopy showed left vocal palsy. Right supra-clavicular mass status post fine needle aspiration was done on 2023-05-16. The cytology report showed negative finding. Due to right eye ptosis for 2 months.
    • He visited ophthalmology clinic and Ach receptor Ab, chest CT were checked. It revealed medial wall thickening at middle third of esopahgus (65mm in lenght) with luminal narrowing and invading adjacent mediastinal fat. Multiple metastatic lymphadenopathy in the visceral space and left anterior prevascular space, and right supraclavicular fossa. Impression: M/3 esophageal cancer T4N3M1.
    • He was treferred to our chest surgery clinic for help. After discussing with the patient and his family about further treatment. He was admitted for cancer work-up under impression of middle third esophageal cancer, cT4N3M1 stage IVB.        
  • Course of inpatient treatment
    • After admitted, Chest CT on 2023/05/17 showed M/3 esophageal cancer T4N3M1. Brain MRI on 2023/05/27 showed no brain nodule or metastasis, old right putamen lacunar infarcts and mild cortical brain atrophy. Abdominal echo on 2023/05/29 showed liver cysts, liver calcification, S7, renal cysts and R/O lymphadenopathy, near heptic hilum area.
    • PES on 2023/05/29 showed 1. Advanced esophageal cancer(Lesion B-25 28cm), middle esophagus, s/p biopsy(B) 2. Advanced esophageal cancer(Lesion A-24cm), middle esophagus, s/p biopsy(C) 3. Lugol voiding area, lower esophagus, s/p biopsy(D) 4. Reflux esophagitis LA Classification grade A 5. Gastric polyp, multiple, s/p biopsy(A). Middle esophagus, 25 cm to 28 cm pathology showed Squamous cell carcinoma, moderately differentiated and Middle esophagus, 24 cm pathology showed Squamous cell carcinoma, moderately differentiated.
    • Whole body PET scan on 2023/05/30 showed middle portion of the esophagus, compatible with primary esophageal malignancy with right lower paratracheal lymph node, confluent left upper paratracheal lymph nodes and confluent right supraclacular lymph nodes metastases. Whole body bone scan on on 2023/05/31 showed no bone metastases. Feeding jejunostomy and Left Port-A catheter implantation on 2023/06/02. PTA on 2023/06/07 showed reliability FAIR, average RE 25 dB HL // LE 28 dB HL.
    • Actein 600mg 1# po BID for sputum. Famotidine 1# po BID for GERD. Morphine 1# po Q8H, Panadol 1# po Q8H and Morphine 5mg IVD PRNQ6H for pain control. Radiotherapy for 45 Gy/ 25 fractions to the bil. SCFs, U/3+M/3 esophagus and adjacent lymphatic drainage area. Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fractions from 2023/06/08~.
    • Chemotherapy with PF(CDDP 75mg/m2, 5FU 1000mg/m2) on 2023/06/09~2023/06/13(C1). Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. NS 1000ml IVF Q8H Y-sited chemotherapy -> change NS 500ml IVF Q8H for bilateral hand edeam on 2023/06/12. Hypertension with Concor 1.25mg 1# po QD and Olmetec 20mg 1# po QD. Anxiety disorder with Ativan 1# po HS and Eurodin 1# po PRNHS for insomnia. Constipation with Bisadyl supp 1 pill RECT PRNQD and Lactulose 20ml po PRNBID. Chronic viral hepatitis B with Vemlidy 1# po QD. Xylocaine 2pc in NS 500ml for mouse rinse.
    • Patient tolerated the chemotherapy with nausea without vomiting. With the stable condition, he was discharged on 2023/06/14 and OPD followed up later.
  • Discharge prescription
    • Actein (acetylcysteine 600mg) 1# BID
    • Lactul (lactulose 666mg/mL) 20mL PRNBID
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg , lysozyme 90mg) 1# TID
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Ulstop (famotidine 20mg) 1# BID
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • morphine 15mg 1# Q8H
    • Eurodin (estazolam 2mg) 1# PRNHS
    • Acetal (acetaminophen 500mg) 1# Q6H
    • Bisadyl supp (bisacodyl 10mg) 1# PRNQD RECT
    • Nincort Oral Gel (triamcinolone) PRNBID TOPI
    • Parmason Gargle Solution (chlorhexidine) BID GAR

[consultation]

• 2023-06-07 Hemato-Oncology
  • Q
    • This 68-year-old man, a heavy smoker and alcoholism. He has suffered from dysphagia for solid material with epigastric dull pain for 6 months, associated with body weight loss 6-7 kg in recent 2 months. Chest CT revealed medial wall thickening at middle third of esopahgus (65mm in lenght) with luminal narrowing and invading adjacent mediastinal fat. Multiple metastatic lymphadenopathy in the visceral space and left anterior prevascular space, and right supraclavicular fossa. Impression: M/3 esophageal cancer T4N3M0. He was admitted for cancer work-up under impression of middle third esophageal cancer, cT4N3M0 stage IVA.
    • After admission, cancer work-up were done, the cancer staging revealed squamous cell carcinoma of middle third of esophagus cT4N3M0, stage IVA. We had well explaining with patient and his family about further treatment. Operation of port-A and feeding jejunostomy implantation was done on 2023-06-02. Now smooth digestion was presented after jejunostomy feeding, advanced diet to 1230 Kcal/day.
    • We need consult you for further chemotherapy. Thank you very much.
  • A
    • This 68 year old man is a case of squamous cell carcinoma of M/3 esophagus, c T4N3M0, stage IVA s/p port-A and feeding jejunostomy implantation was done on 2023-06-02. Initial presentation was dysphagia for solid material with epigastric dull pain for 6 months, associated with weight loss 6-7 kg in recent 2 months.      
    • We are consulted for CCRT.
    • Please check 24 urine CCR and arrange auditory test and check HBsAg, Anti HBc, Anti HBs, Anti HCV. Book 11A or 10B.
• 2023-06-02 Radiation Oncology
  • A
    • He can still have porridge and drink water. CCRT is indicated. CT-simulation will be arranged on 6/5. Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, U/3+M/3 esophagus and adjacent lymphatic drainage area. Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 6/7 or 8. Thank you very much.

[surgical operation]

• 2023-06-02
  • Surgery
    • Feeding jejunostomy + port-A insertion.
  • Finding
    • 8.0 Fr. Polysite, left cephalic vein. cut-down method.
    • 18 Fr. silicon Foley catheter.

[chemotherapy]

• 2023-07-05 - cisplatin 75mg/m2 100mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, Q4W, lower CDDP and 5-FU)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-06-09 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF, Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-07-06

According to the PharmaCloud database, this patient sporadically visits local clinics for his sleep disorder, chest pain, and acute upper respiratory infections. He has been given prescriptions with a duration of only three days, all of which are now invalid. The patient has sought medical attention multiple times due to his sleep disorder, and Eurodin (estazolam) is listed among his active medications. No reconciliation issues have been identified.

2023-07-05

Mild hyponatremia was observed in the patient on 2023-07-05, with a serum sodium level of 131 mmol/L. The planned administration of furosemide on 2023-07-06 (concurrent with the PF regimen) may exacerbate this condition, as furosemide may cause increased sodium excretion. Please continue to monitor the patient’s sodium levels closely to determine if further intervention is needed.

700852752

230705

[exam findings] (not completed)

• 2023-06-21 Nasopharyngoscopy
  • Findings: smooth np, larynx and hp
  • Diagnosis: lt deep neck infection s/p IV ABX
• 2023-06-14 CT - neck
  • Indication: r/o deep neck infection
  • Without-contrast Ct scan of head and neck region with 3-mm axial, sagittal and coronal images reveals:
    • Enlargement of left palatine tonsil and thickening of left oropharyngeal and hypopharyngeal wall.
    • Multiple lymph nodes at both side of the neck, more prominent on left side with the largest one about 18 mm at left level II.
    • Extensive severe beam-hardening artifacts over oral cavity.
  • IMP:
    • Enlargement of left palatine tonsil and thickening of left oropharyngeal and hypopharyngeal wall, associating with enlarged lymph nodes at left neck.
    • D/D: tonsilitis, malignancy.
• 2023-06-12 Nasopharyngoscopy
  • Scope: smooth NPx, larynx, hypopharynx
  • adequate airway curently
  • left tongue base, lateral pharyngeal wall, post. pharyngeal wall bulging with pus coating
• 2023-05-09 CT - brain
  • No brain lesion.
  • Intracranial ICAs atherosclerosis.
  • Age-appropriate cerebral atrophy.
• 2023-04-13 CT - abdomen
  • History and indication: Pancytopenia
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy.
    • Bil. minimal pleural effusions.
    • Tiny liver and renal cysts.
    • Mild hyperplasia of left adrenal gland.
    • Wall edema of gallbladder.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • S/P hysterectomy.
    • Bil. minimal pleural effusions.
• 2023-04-12 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with myelodysplastic syndrome with excess blasts-1
  • The sections show hypercellular marrow (70%). M/E ratio = 1:2 in CD71 and MPO stains. The erythoid precursors are marked increased, dispersed and scattered. The megakaryocytes are normal in number, and few micromegakaryocytes are present. Increased CD34+ and/or CD117+ immature cells, account for 5-10% of nucleated cells. No metastatic carcinoma can be identified in CK stain. The finding is compatible with myelodysplastic syndrome with excess blasts-1. Suggest further bone marrow smear evaluation and clinic correlation.

[consultation]

• 2023-06-27 Oral and Maxillofacial Surgery
  • Q
    • For gum pain
    • This 73 years old woman is a patient of myelodysplastic syndrome with excess blasts-1 s/p Target therapy as Decitibine 20mg/m2 IVD 1hr since 5/16-5/20, past history of
      • ptosis of eyelid,
      • hyperlipidemia,
      • gastric ulcer,
      • right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA)
      • uterine myoma s/p abdominal total hysterectom
    • this time was admitted to our ward for acute-tonsilitis.
    • Now her tonsilitis improved with no fever.
    • She complainted about pain in the upper left gums for about 6 days.
    • We need your expertise for evaluation of gum pain, thank you!
  • A
    • This is a 73-year-old woman with pain over her upper left gingiva for 6 days.
    • O:
      • A white patch with ulcerative surface over upper right gingiva near the palatal side of tooth 24, palpation pain was noted.
      • Mild swelling over her upper left posterior gingiva near the buccal side of tooth 26, percussion pain of tooth 26 was noted.
    • A:
      • Oral ulcer of tooth 24 palatal side due to low immunity
      • Apical abcess of tooth 26
    • P:
      • Physical exam
      • Keep observation of the oral ulcer, please contact us after her ANC raise to normal level.
• 2023-06-13 Infectious Disease
  • Q
    • For antiobiotics of acute pharyngitis/tonsillitis, ENT suggested consulting for ABX
    • This 73 years old woman is a patient of compatible with myelodysplastic syndrome with excess blasts-1, and past history of ptosis of eyelid, hyperlipidemia, gastric ulcer, right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA), and uterine myoma s/p abdominal total hysterectomy.
    • She received target therapy with cycle 1 Decitabine since 2023/05/16 to 05/20.
    • This time, she is admiited to our Hematology Oncology ward for planned target therapy schedule.  
    • sore throat with dysphagia for since 5/16 after target therapy, left more severe
    • odynophagia+, fever-, WBC:2l, CRP:2.1
    • We consulted ENT for acute pharyngitis/tonsillitis, Abx was suggested.
    • We need your expertise for antiobiotics of acute pharyngitis/tonsillitis, thank you！
  • A
    • The patient’s conditin as your description.
    • Tapimycin 4.5g iv q8h is suggested for the acute pharyngitis/tonsillitis.
    • Please arrange neck CT to exclude deep neck infection.
    • Please collect adequte culture.
• 2023-06-12 Ear Nose Throat
  • Q
    • For evaluation of dysphagia after first dose of target therapy, cycle 1 Decitabine since 2023/05/16 to 05/20
    • This 73 years old woman is a patient of compatible with myelodysplastic syndrome with excess blasts-1, and past history of ptosis of eyelid, hyperlipidemia, gastric ulcer, right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA), and uterine myoma s/p abdominal total hysterectomy.
    • She received target therapy with cycle 1 Decitabine since 2023/05/16 to 05/20.
    • After last chemotherapy, she complained dysphagia, sore throat and cough. No fever.
    • This time, she is admiited to our Hematology Oncology ward for planned target therapy schedule.  
    • We need your expertise for evaluation of dysphagia before second target therapy, thank you!
  • A
    • S:
      • sore throat with dysphagia for since 5/16 after target therapy, left more severe
      • odynophagia+, fever-, dyspnea-
      • Allergy: denied
    • O:
      • Oral cavity and oropharynx: left post. pharyngeal wall bulging
      • no uvula deviation
      • Scope: smooth NPx, larynx, hypopharynx
        • adequate airway curently
        • left tongue base, lateral pharyngeal wall, post. pharyngeal wall bulging with pus coating
      • left upper neck tenderness
    • A: acute pharyngitis/tonsillitis, deep neck infection can’t be ruled out
    • Plan:
      • After discussing with Dr. Lan
        • Consult infection for IV antibiotic suggestion (stronger is favored)
        • suggest hold target/chemo therapy, infection control first
        • Pain control
        • self-paid Difflam spray and parmason for oral hygiene if the patient agreed
        • Instruct the patient to rinse her mouth after meals and avoid eating hot and spicy foods.
        • Monitor airway, well educated about airway issue
        • check infection profile
        • if s/s still progressed after antibiotic Tx, consider CT with/without contrast exam if no contraindication to rule out deep neck infection/mediastinitis
        • ENT OPD f/u
      • neck CT (without contrast CT): no obvious abscess formation, left pharyngeal wall swelling with enlarged LNs
      • leading Dx: infection with reactive LN
      • DDx: malignancy can’t be ruled out, lymphoma……..
      • please keep IV anti for 2 weeks
      • if s/s no improvement, suggest left tonsillectomy to rule out malignancy

[chemotherapy]

• 2023-05-16 - decitabine 20mg/m2 32mg NS 100mL 1hr D1-5

==========

2023-07-05

• I visited the patient around 11:15 on 2023-07-05 carrying the decitabine medication usage information. The patient was lying in bed and her awake husband was sitting in the bench by the window.

• I first asked the patient’s husband how the patient’s recent condition was and whether the discomfort in the mouth had worsened or improved? The husband said that the patient is currently using the oral paste prescribed by the doctor, and the condition is manageable. He also asked if the infection was caused by the use of decitabine. I responded that since April, the patient’s white blood cell count has consistently remained around 2000 +- 500, and there was no significant fluctuation due to the administration of decitabine in mid-May. Although the effect of decitabine on white blood cells can’t be entirely ruled out, it does not seem to be the primary cause based on the observations.

700938395

230705

[lab data]

2023-06-27 Urine-Creatinine 105.41 mg/dL
2023-06-27 U-Cr (24hr) 1633.9 mg/kg/24 hr
2023-06-27 Total Volume(24hr) 1550 mL
2023-06-27 C.C.R. 120.7 mL/min

2023-06-20 EBV DNA PCR 159 copies/mL

2023-06-14 Anti-HBc Nonreactive
2023-06-14 Anti-HBc-Value 0.06 S/CO
2023-06-14 Anti-HBs 0.40 mIU/mL

2023-06-07 RPR/VDRL Nonreactive
2023-06-07 HBsAg Nonreactive
2023-06-07 HBsAg (Value) 0.27 S/CO
2023-06-07 Anti-HCV Nonreactive
2023-06-07 Anti-HCV Value 0.11 S/CO
2023-06-07 HIV Ab-EIA Nonreactive
2023-06-07 Anti-HIV Value 0.07 S/CO
2021-08-17 RPR/VDRL Nonreactive

[exam findings] (not completed)

• 2023-06-29 Pure Tone Audiometry, PTA
  • Reliabilty Fair
  • R’t : 59 dB HL, mild to severe mixed type HL
  • L’t : 21 dB HL, normal to mild SNHL.
• 2023-06-09 Tc-99m MDP bone scan
  • Mildly increased activity in the skull base. Local hyperemia may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Mildly increased activity in some L-spines. Degenerative change may show this picture.
  • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, elbows, hips, knees and feet, compatible with benign joint lesions.
• 2023-06-08 SONO - abdomen
  • Fatty liver, moderate
  • Gallbladder polyps
  • Renal cyst, right kidney
• 2023-06-07 MRI - nasopharynx
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:1(T_value) N:2(N_value) M:0(M_value) STAGE:III(Stage_value)
• 2023-06-06 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
• 2023-05-30 Patho - nasopharyngeal/oropharyngeal biopsy
  • Tumor, left nasopharynx, biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated subtype
    
  • Microscopically, the sections show a picture of squamous cell carcinoma, non-keratinizing, undifferentiated subtype of the nasopharyngeal tissue characterized by tumor cells with ovoid vesicular nuclei, prominent nucleoli, and indistinct cell borders arranged in syncytial pattern, infiltrate in the inflamed stroma.
  • Immunohistochemistry shows CK(+) and P63(+) for tumor.

[consultation]

• 2023-06-06 Oral and Maxillofacial Surgery
  • Q
    • This is a 46 y/o male with history of GERD
    • This time, he was admitted to our ward for Nasopharyngeal cancer survey. Under the impression of NPC, radiotherapy is indicated. We need your expertise on dental evaluation before radiotherapy.
  • A
    • After the exam of this 46 y/o male
    • O:
      • Fair oral hygiene
      • Caries over tooth 27 was noted
    • Pano finding:
      • Missing: 18 28 38 48
      • Crown and bridge: 35X37
      • Impaction: Nil
    • There is no tooth extraction is indicated now, radiotherapy can be delivered safely.
    • Suggest restoration of 27 caries after him discharge

[chemotherapy]

• 2023-06-30 - docetaxel 75mg/m2 140mg NS 250mL D1 + cisplatin 75mg/m2 150mg NS 500mL D2 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 2000mg NS 500mL D2-5 (TPF Q3W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + NS 250mL D1-2 + aprepitant 125mg PO D1-3

==========

2023-07-05

[bedside visit: poor appetite. patient education: docetaxel, cisplatin, fluorouracil]

• I visited the patient at about 13:15 on 2023-07-05. He was lying on his bed with his eyes closed, and I saw that the medications on his IV stand had been changed to KCl and Nako No.5, indicating that his chemotherapy had ended.
• I gently woke him up, gave him the patient medication information for docetaxel, cisplatin, and fluorouracil, and highlighted the serious side effects of each drug with a colored marker.
• I advised him to stay hydrated to maintain kidney function. I asked if he had any family or friends to take care of him while he was in the hospital, and he said he was alone.
• I asked if he was feeling unwell in any way and he replied that he had a poor appetite. I told him that the medication he was taking included an appetite stimulant and suggested that we wait a few days to see if his appetite improved.

701020753

230705

[exam findings] (not completed)

• 2023-06-26 CT - abdomen

  • Findings
    • Enhanced, thickening mucosa at sigmoid colon is found. In comparison with CT dated on 2023-05-31, thelesion is stationray.
    • Severe dilated intestines is found. There is right abdominal wall herniation. No strangulation at the herniated sac is found but narrowing of the intestinal lumen at sigmoid colon wall thickning region is found.
  • Imp
    • Wall thickneing at sigmoid colon with proximal intestinal dilatation. r/o recurrent/residual tumor with intestinal obstruction.

• 2023-06-26 CXR

  • Cardiomegaly is noted.
  • S/p port-A placement with its tip at left brachiocephalic vein.
  • Faint aveolar opacity over right lower lobe and ll is found.
  • Osteopenia of the bony structure is noted.
  • Increased intestinal gas is found.

• 2023-06-26 ECG

  • Sinus tachycardia
  • ST & T wave abnormality, consider anterior ischemia

• 2023-05-31 CT - abdomen

  • History: D-colon CA wt obstruction, pT3N1c cM0, pStage IIIB, s/p Op on 2021/02/17
    • 20220520 CT: two kissing lesions with soft tissue and cystic component in right adnexa, measuring 4.8 cm and 2.8 cm in size.
      • The differential diagnosis includes cystic adenocarcinoma of right ovary or tumor seeding of the colon cancer.
        
    • 20220617 Rt, oophorectomy: adenocarcinoma, metastatic, colon origin.
  • Findings:
    • There is segmental circumferential wall thickening at the sigmoid colon, 5 cm in size, causing marked dilatation of the proximal colon.
      • Recurrent adenocarcinoma of the sigmoid colon is highly suspected.
      • Please correlate with colonoscopy and CEA.
    • S/P left hemicolectomy
    • Prior CT identified multiple lymph nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space, para-cava space, mesentery, and right supra-diaphragm cardiac-phrenic space are noted again.
      • Some of them show enlarged in size.
      • Metastatic nodes are highly suspected.
        
    • Right middle abdominal wall herniation.
    • Mild fatty liver.
    • A renal stone 5 mm in left upper pole.
    • Prior CT identified multiple small poor enhancing lesions in the spleen are noted again, stationary.
  • Impression:
    • Recurrent adenocarcinoma of the sigmoid colon is highly suspected.
      • Please correlate with colonoscopy and CEA.
    • Metastatic nodes in para-aortic space and para-cava space.

• 2023-05-24 Peripheral Echography

  • Report:
    • Right side:
      • SVC: 14.1 mmHg ; 15.7 mmHg ;
      • MVO/SVC: 89 % ; 87 % ;
      • Average MVO/SVC: 88 %
    • Left side:
      • SVC: 11.9 mmHg ; 14.4 mmHg ;
      • MVO/SVC: 84 % ; 80 % ;
      • Average MVO/SVC: 82 %
    • Thrombus : None
      
    • Varicose vein : None
      
  • Conclusion
    • No evidence of DVT, bilateral lower legs
    • Right CFV trivial reflux
    • Left CFV trivial reflux

• 2023-05-24 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (123 - 31) / 123 = 74.80%
    • M-mode (Teichholz) = 75

• 2023-04-07, -02-23 CXR

  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.

• 2023-02-23 CT - abdomen

  • History and indication:
    • Malignant neoplasm of descending colon
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operaiton. Enlarged LNs (up to 2.0cm) at mesentery and retroperitoneum.
    • Right abdominal wall herniation.
    • Left ovary cyst (2.0cm).
    • Left renal stone (5mm).
    • Grade 4 fatty liver.
    • Interstitial pattern at bilateral basal lungs.
  • Imp
    • S/P operaiton. Enlarged LNs (up to 2.0cm) at mesentery and retroperitoneum.

• 2023-01-27 Colonoscopy

  • The scope only reach the D-colon (40cm AAV, previous anastomosis) under good colon preparation. No mucosal lesion was found. The scope can not be advanced more.

• 2023-01-27 Esophagogastroduodenoscopy, EGD

  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
  • Gastric polyp, fundus, favor fundic gland polyp
  • Suspect gastric subepithelial lesion, fundus

• 2022-11-14 CT - abdomen

  • Abdominal CT with and without enhancement revealed:
    • Left renal tiny stone about 0.2cm is found.
    • The spleen, liver, pancreas and adrenals are intact.
    • The GB is well distended without soft tissue lesion
    • Abdominal wall herniation is found at RLQ.
    • s/p LAR.
    • Mininmal interstitial change at bilateral basal lungs. previous viral infection is favored.
  • Imp:
    • s/p LAR.
    • No evidence of recurrent/residual tumor in the study.
    • Left renal stone.

• 2022-10-12 Carotid angiography bilat. Vertebral angiography

  • Diagnostic intraarterial angiography of brain vasculature by way of bilateral internal carotid and left vertebral arteries was performed. The related benefit and risk of this procedure was explained to patient and patient family member with written consent being obtained in advance.
  • Imaging findings:
    • Fenetration of V-B junction. Suggest follow up by MRA annually.
    • The whole procedure was smoothly done without apparent immediate complication and the patient stood it well under local anesthesia.

• 2022-10-12 Aortography - thoracic

  • Diagnostic aortography was performed. The related benefit and risk of this procedure was explained to patient and patient family member with written consent being obtained in advance.
  • Imaging findings:
    • Type I aortic arch.
    • No critical stenosis of bilateral proximal carotid and vertebral arteries.
    • The whole procedure was smoothly done without apparent immediate complication and the patient stood it well under local anesthesia.

• 2022-10-11 ECG

  • Normal sinus rhythm
  • T wave abnormality, consider anterior ischemia

• ……

• 2022-06-17 Patho - soft tissue tumor, extensive resection

  • PATHOLOGIC DIAGNOSIS
    • Ovary, right, salpingo-oophorectomy with frozen section (F2022-283) —- adenocarcinoma, metastatic. IHC stains: CK7 (-), CK20 (+), CDX-2 (+), PAX-8 (-), WT(-): a pattern of colon origin.
    • Ovary, left, salpingo-oophorectomy —- Free
    • Fallopian tube, left, salpingo-oophorectomy —- free.
    • Fallopian tube, right, salpingo-oophorectomy —-adenocatcinoma, metastatic
    • Uterus, corpus, total hysterectomy (S2022-9791A) — free; Endometrium: benign atrophic
    • Uterus, cervix, total hysterectomy — free
    • Abdominal tumor, excision (S2022-9791B) — one tumor nodule and one of two lymph node with tumor metastasis (½).
    • Abdominal tumor, excision (S2022-9791C) — calcified fibrotic nodes and one benign lymph node (0/1)
    • Lymph node, Bilateral pelvic iliac and obturator, dissection (S2022-9791D-G) — Free.
  • MACROSCOPIC EXAMINATION
    • Procedure
      • Debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymphnode dissection + abdominal tumor excision) + enterolysis
      • Peritoneal washing
    • Specimen size:
      • right ovary: 8 x 6 x 4 cm (opened by surgeon) with multiple solid component inside and on the serosal surface of the ovary, the largest tumor focus 3 x 2.2 x 2.2 cm.
      • left ovary: 2 x 1.5 x 1 cm;
      • right tube: 4.5 x 0.5 x 0.5 cm;
      • left tube: 4 x 0.5 x 0.5 cm;
      • uterus: 8 x 5 x 3 cm
      • 2. abdominal tumor: 3 pieces, up to 0.8 x 0.4 x 0.4 cm.
      • 3. abdominal tumor”: 3 pieces, up to 1.2 x 0.8 x 0.8 cm.
    • Specimen Integrity
      • Specimen Integrity of Right Ovary
        • Capsule – opened by the surgeon
      • Specimen Integrity of Left Ovary
        • Capsule intact
      • Specimen Integrity of Right Fallopian Tube – tumor seeding
      • Specimen Integrity of Left Fallopian Tube-Serosa intact
    • Tumor Site: Right ovary
    • Ovarian Surface Involvement- Present (Right)
    • Fallopian Tube Surface Involvement -Present (Right)
    • Tumor Size -multiple solid component inside and on the serosal surface of the ovary, the largest tumor focus 3 x 2.2 x 2.2 cm.
      • Greatest dimension (centimeters): 3 cm
      • Additional dimensions (centimeters): 2.2 x 2.2 cm
    • Sections are taken and labeled as:
      • Tissue for frozen section: F2022-282FSA1-4: right ovarian tumor.
      • Tissue for formalin fixation: F2022-282X1: right Fallopian tube; X1-8: additional sampling of tumor in and on the right ovary.
      • S20229791A1: left Fallopian tube; A2: left ovary; A3-4: endometrium and uterine corpus; A5-6: uterine cervix; B: “02. abdominal tumor”; C: “03. abdominal tumor”; D: “04 right iliac lymph nodes”; E: “05. right obturator lymph nodes”; F: “ 06. left iliac lymph nodes”; G: “07. left obturator lymph nodes”.
  • MICROSCOPIC EXAMINATION:
    • Histologic type: adenocarcinoma.
    • Contralateral ovary involvement: absent
    • Tumor side ovarian surface involvement: present
    • Contralateral ovary surface involvement: absent
    • Right tube involvement: absent
      
    • Left tube involvement: present
    • In situ adenocarcinoma in right ＆/or left fallopian tube: absent
    • Right adnexa soft tissue involvement: present
    • Left adnexa soft tissue involvement: absent
    • Pelvic soft tissue involvement: present (tissue labeled as “02. abdominal tumor”)
    • Uterine serosa involvement: absent
    • Omentum involvement: no tissue submitted.
    • Uterine Cervix involvement: absent
    • Endometrium involvement: absent
    • Myometrium involvement: absent
    • Appendix involvement: not received
    • Peritoneal/Ascitic Fluid- Negative for malignancy (normal/benign)
    • Regional Lymph Nodes: Negative for metastasis: describe locations - 0/29= D: “04 right iliac lymph nodes” 0/9; E: “05. right obturator lymph nodes” 0/7; F: “06. left iliac lymph nodes” 0/7; G: “07. left obturator lymph nodes” 0/6.
    • Other organs or specimens involvement: absent.

• ……

• 2021-02-18 Patho - colon segmental resection for tumor

  • PATHOLOGIC DIAGNOSIS
    • Large intestine, descending colon, extensive left hemicolectomy
      • Adenocarcinoma, moderately differentiated
        
      • A tumor deposit is seen
        
      • A colostomy is present
        
    • Small intestine, ileum, extensive left hemicolectomy —- Negative for malignancy
      
    • Omentum, extensive left hemicolectomy —- Negative for malignancy
      
    • Resection margins: free
      
    • Lymph node, mesocolic, dissection —- Negative for malignancy (0/70)
      
    • Lymph node, IMA / SMA, dissection —- Not received
      
    • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1c(if cM0)
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: extensive left hemicolectomy
      
    • Specimen site: descending colon
      
    • Specimen size: colon: 57 cm in length, ileum: 7 cm, omentum: 28 x 6 x 2 cm, appendix is not found; with a colostomy
      
    • Tumor size: 3.5 x 3.0 cm, annularly ulcerated
      
    • Tumor location: 3.0 cm and 55 cm away from the two resection margins, respectively
      
    • Depth of invasion grossly: mesocolic soft tissue
      
    • Mucosa elsewhere: congestion
      
    • Representative sections are taken and labeled as: A1-2: bilateral resection margins; A3: colon, non-tumor; A4: colostomy; A5:omentum; A6-9: tumor; A10-15: lymph node, mesocolic.
  • MICROSCOPIC EXAMINATION
    • Histology: adenocarcinoma
      
    • Histology Grade: moderately differentiated
      
    • Depth of invasion: mesocolic soft tissue
      
    • Angiolymphatic invasion: Present.
      
    • Perineural invasion: Present.
      
    • Discontinuous extramural tumor extension: Not identified.
      
    • Serosal margin status of colon: Uninvolved, 2 mm in distance.
      
    • Lymph node metastasis, mesocolic: 0/70
      
    • Lymph node metastasis, IMA / SMA: Not received
      
    • Extranodal involvement: Not identified.
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        
      • Regional Lymph Nodes (pN): pN1c: No regional lymph nodes are positive, but there are tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic, or perirectal/mesorectal tissues.
        
      • Distant Metastasis (pM): if cM0
        
    • Type of polyp in which invasive carcinoma arose: Tubular adenoma.
      
    • Additional pathologic findings:
      • A tumor deposit is seen.
        
      • A colostomy is present.
        
      • The immunohistochemical stains reveal EGFR(-), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
        
      • Tumor Budding: Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2): Low score (0-4)
        
      14. TNM descriptors: unknown
          
    • Tumor regression grading S/P CCRT: patient not received

[surgical operation]

[chemotherapy]

• 2023-06-20 - irinotecan 160mg/m2 260mg D5W 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg SC
• 2023-05-12 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-07 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-17 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-21 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-31 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-13 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-22 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-01 - oxaliplatin 80mg/m2 130mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-10-04 - oxaliplatin 80mg/m2 130mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-09-13 - bevacizumab 5mg/kg 300mg NS 150mL 90min + oxaliplatin 80mg/m2 130mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-08-23 - oxaliplatin 70mg/m2 110mg D5W 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-08-08 - irinotecan 160mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2022-07-22 - irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4590mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
• 2021-05-14 - oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4530mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-04-30 - oxaliplatin 85mg/m2 137mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-04-16 - oxaliplatin 60mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-08-23 ~ undergoing - Xeloda (capecitabine 500mg) 3# BID
• 2021-06-25 ~ 2021-11-29 - Xeloda (capecitabine 500mg) 2# BID

==========

2023-07-05

[leukopenia]

• The temporal changes in the WBC count are summarized in the following table, where records marked with an asterisk represent WBC counts < 3K/uL.

  • 2023-07-03 WBC 2.81 x10^3/uL *
  • 2023-07-01 WBC 3.68 x10^3/uL
  • 2023-06-29 WBC 4.66 x10^3/uL
  • 2023-06-28 WBC 3.10 x10^3/uL
  • 2023-06-27 WBC 2.23 x10^3/uL * filgrastim
  • 2023-06-26 WBC 2.48 x10^3/uL *
    
  • 2023-06-20 WBC 9.57 x10^3/uL irinotecan - can be associated with leukopenia (63% to 96%, grades 3/4: 14% to 28%)
  • 2023-06-14 WBC 5.16 x10^3/uL
  • 2023-06-07 WBC 5.72 x10^3/uL
  • 2023-05-12 WBC 5.62 x10^3/uL oxaliplatin
  • 2023-04-28 WBC 4.95 x10^3/uL
  • 2023-04-07 WBC 6.58 x10^3/uL oxaliplatin
  • 2023-03-17 WBC 7.04 x10^3/uL oxaliplatin

• The dosage of irinotecan used on 2023-06-20 was adjusted down from the standard 180mg/m2 to 160mg/m2.

• On 2023-07-03, the ANC was 2.81K/uL x 41.9% = 1177/uL, which is a grade 2 neutropenia (1000~1499/uL). If this value occurs during a therapy cycle, a further decrease of 20mg/m2 to 140mg/m2 could be considered.

701344079

230705

[lab data]

2021-11-10 ROS1 FISH NOT detected

2021-11-09 EGFR G719X not detected
2021-11-09 EGFR Exon19 del detected
2021-11-09 EGFR S768I not detected
2021-11-09 EGFR T790M not detected
2021-11-09 EGFR Exon20 ins not detected
2021-11-09 EGFR L858R not detected
2021-11-09 EGFR L861Q not detected

2021-11-08 PD-L1 (28-8) TC <1%
2021-11-03 PD-L1 (22C3) TPS<1%

2021-11-03 ALK IHC Negative

2021-10-27 Aspergillus Ag Negative
2021-10-27 Aspergillus Ag Value 0.05 Ratio
2021-10-27 Aspergillus Ag Negative
2021-10-27 Aspergillus Ag Value 0.08 Ratio

2021-10-25 Mycoplasma IgM Negative Index
2021-10-25 Mycoplasma IgM Value 0.1 Index

2021-10-22 Anti-HBs 11.64 mIU/mL

2021-10-22 HBsAg Nonreactive
2021-10-22 HBsAg (Value) 0.47 S/CO

2021-10-22 Anti-HBc Nonreactive
2021-10-22 Anti-HBc-Value 0.31 S/CO

2021-10-22 Anti-HCV Nonreactive
2021-10-22 Anti-HCV Value 0.04 S/CO

2021-10-22 HIV Ab-EIA Nonreactive
2021-10-22 Anti-HIV Value 0.06 S/CO

[exam findings] (not completed)

• 2023-06-29 CXR
  • Scoliosis of the T-spine with convex to right side.
  • Atherosclerotic change of aortic arch
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
• 2023-06-27 Patho - stomach biopsy
  • Stomach, PW of low body, biopsy — Hyperplastic polyp. No H.pylori present
• 2023-06-26 SONO - abdomen
  • suspected liver parenchymal disease (incomplete exam of liver)
  • bilateral renal cysts
  • pancreas obscured
• 2023-06-26 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade D
  • Hiatal hernia
  • Atrophic gastritis, s/p CLO test
  • Gastric polyp, PW of low body, s/p biopsy
• 2023-06-23 MRI - brain
  • Indication: Lung cancer with lymph node, pleural and bone metastases, T2N2M1, Stage IVB
  • IMP: No evidence of brain metastasis. General brain atrophy.
• 2023-05-28 CXR
  • Known a case of Lung cancer with bone mets.
  • Tortuosity of the aorta with atherosclerotic change.
  • Degenerative joint disease of T-spine with marginal osteophytes.
• 2023-05-28 KUB
  • No definite opaque stone detected.
  • Degenerative joint disease of lumbar spine with marginal osteophytes.
  • Scoliosis of L-spine.
  • There is fecal materials impaction in the course of colons.

[MedRec]

• 2023-06-07 SOAP Urology
  • S
    • hematuria today
    • chronic frequency
  • A: r/o UTI
  • P: RTC with report
  • Prescription
    • Transamin (tranexamic acid 250mg) 1# BID 3D
    • cephalexin 500mg 1# TID 7D
    • Harnalidge (tamsulosin 0.4mg) 1# QD 7D
• 2023-05-23 SOAP Nephrology
  • Prescription
    • Pentop (pentoxifylline 400mg) 0.5# HS
• 2023-05-18 SOAP Hemato-Oncology
  • Plan: Request visit ER if SBP < 80
  • Prescription
    • Tagrisso (osimertinib 80mg) 1# QD 28D
• 2023-03-30 SOAP Hemato-Oncology
  • P: Chest CT on 2022-10-20 -> 2023-01-20 -> 2023-04-10, Bone scan on 2022-10-18 -> 2023-01-18 -> (May consider non-contrast Chest CT due to impaired renal funciton)
• 2023-03-02 SOAP Hemato-Oncology
  • Plan: On 2023-02-02 and 03-02, request salt intake again and again
• 2023-02-02 SOAP Hemato-Oncology
  • Prescription
    • Tagrisso (osimertinib 80mg) 1# QD 28D
    • Norvasc (amlodipine 5mg) 1# QL 28D
• 2022-12-08 SOAP Hemato-Oncology
  • Chest CT on 2022-10-20 -> 2023-01-20, Bone scan on 2022-10-18 -> 2023-01-18 (May consider non-contrast Chest CT due to impaired renal funciton)
• 2022-09-16 SOAP Nephrology
  • O
    • 2022/09/15 Creatinine = 2.17 mg/dL;
    • 2022/09/15 eGFR = 31.02;
    • 2022/07/21 Creatinine = 1.60 mg/dL;
    • 2022/07/21 eGFR = 44.09;
• 2022-09-01 SOAP Neurology
  • O
    • 2022/08/29 NCV: This abnormal NCV study suggested bilateral lumbosacral rdiculopathy.
  • Prescription
    • Saline (nicametate citrate 50mg) 1# TID 28D
• 2022-08-18 SOAP Neurology
  • S
    • P’t is a case of lung CA and received tagrisso treatment.
    • P’t noted left leg pain about 2 years ago and noted lung CA with L-spine meta. After treatment, condition statioanry but bilateral feet numbness was noted about 1 year but in recent numbness ascent to bilateral lower leg.
  • Prescription
    • Saline (nicametate citrate 50mg) 1# TID 14D
• 2022-08-18 SOAP Hemato-Oncology
  • Plan: Refer to Neuro for numbness
• 2022-01-06 SOAP Hemato-Oncology
  • Plan: May consider XGEVA after bone scan in 2022-01
• 2021-12-08 SOAP Hemato-Oncology
  • Plan
    • Shift Estengy (Amlodipine / Valsartan 5/80 mg) 1# QD to Diovan (160) 0.5# QD
  • Prescription
    • Tagrisso (osimertinib 80mg) 1# QD 15D
    • Diovan (valsartan 160mg) 0.5# QD 15D
• 2021-11-25 SOAP Hemato-Oncology
  • Prescription
    • Tagrisso (osimertinib 80mg) 1# QD 13D
• 2021-10-21 ~ 2021-11-11 POMR Hemato-Oncology
  • Discharge diagnosis
    • Malignant neoplasm of unspecified part of unspecified bronchus or lung
    • Lung cancer with lymph node, pleural and bone metastases, T2N2M1, Stage IVB
    • Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
    • Pleural effusion in other conditions classified elsewhere
    • Chronic obstructive pulmonary disease, unspecified
    • Enlarged prostate with lower urinary tract symptoms
  • Present illness
    • This 82y/o male was a case of denied any majort systemic disease or operation history.
    • According to the statement of the patient families and ER medical record. This time, he had suffered from dyspnea for 4 days, the symptoms became to serious and visited frist to Cardinal Tien Hospital. Due to massive amount left pleraul effusion and bed adjustment mechanism, referred to our hospital.
    • At MER, O2 therapy and the chest films disclosed left massive plerual effusion. Chest CT was arranged and the conculsion of severe left pleural effusion with suspected left hilar lung mass. However, elevation of breathing work with paradoxical movement were also note, then emergency intubation was done. Empiric antiboltic with Rocephin was perscribed.
    • Under the impression of acute respiratory failure s/p intubation and severe left plerual effusion, R/I lung cancer. He was admitted to our ICU for further observation and management.
  • Course of inpatient treatment
    • After admitted, Left pigtail insertion on 2021/10/21 and keep left pigtail drainage for Left massive amount plerual effusion. Chest CT on 2021/10/21 showed severe left pleural effusion with suspected left hilar lung mass, R/O lung cancer, T2N2M0, suggest contrast enhanced study, enlarged prostate and infra-renal aortic aneurysm. 2D echo on 2021/10/25 showed 1. Thickened AV with mild AR 2. Thickened and calcification of MV, no MR 3. LV septal hypertrophy 4. Preserved LV and RV systolic function 5. Moderate PR, mild TR, normal IVC size. Explain his condition to his family.
    • Acetin 1pk po BID and Cough mixture 10ml po HS for cough with sputum. Brain MRI on 2021/10/29 showed no evidence of brain metastasis, general brain atrophy, hydrocephalus and cervical spondylosis. Whole body bone scan on 2021/10/29 showed the scintigraphic findings suggest multiple bone metastases. Chest CT on 2021/10/30 showed left lower lobe lung cancer with left malignant pleural effusion and extensive lymphadenopathy. A family meeting was held to explain his condition and therapy to patient and his family on 2021/11/01. Consult rahabilitation department for bedside rehabilitation exercises on 2021/11/01. Remove NG tube on 2021/11/02. Target therapy with Iressa 1# po QD from 2021/11/02. Remove left pigtail on 2021/11/08. Explain his deta and condition to his family on 2021/11/09. Major illness was applied on 2021/11/11.
    • Foster 4puff INHL BID and Spiriva 2puff INHL HS for Chronic obstructive pulmonary disease. Urief F.C 0.5# po QD for BPH. With the stable condition, he was discharged on 2021/11/11 and OPD followed up later.
  • Discharge prescription
    • Cough Mixture (platycodon) 10mL HS
    • Urief (silodosin 8mg) 0.5# QD
    • Actein (acetylcysteine) 1pk BID
    • Iressa (gefitinib 250mg) 1# QD

[treatment]

• 2021-11-25 ~ undergoing - Tagrisso (osimertinib 80mg) 1# QD

• 2021-11-11 ~ 2021-11-24 - Iressa (gefitinib 250mg) 1# QD

==========

2023-07-05

• I visited the patient around 11:10 on 2023-07-05 with the osimertinib medication pamphlet. The patient was lying in bed and his son was on a bench against the wall.

• I explained to the patient and his son that he has been using osimertinib for a relatively long period of time and based on the pamphlet, I described the potential side effects to watch for during the use of this drug. The patient’s son said that the main issue was digestive tract symptoms, but other than that, everything else felt fine, and the tumor has been controlled for a good period of time, they are still satisfied with the efficacy. I left the contact information for the hospital’s pharmacy counseling window, so the patient and his family can call when needed.

701473497

230705

[exam findings]

• 2023-05-28 CXR
  • Normal sinus rhythm
  • Right atrial enlargement
  • Rightward axis
  • Pulmonary disease pattern
  • Abnormal ECG
• 2023-05-25 CT - abdomen
  • History and indication: Colon cancer with bladder invasion s/p op; stage III
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion. Some LNs at pelvic cavity. S/P colostomy.
    • Some nodules in bil. lungs. A small calcificaiton at RLL.
    • Some calcifications in bil. scrotum.
    • Atherosclerosis of aorta.
    • S/P left side double J catheter insertion and the lower end in urethra. Still dilatation of left renal pelvis.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion, LNs and lung metastases. Left hydronephrosis.
• 2023-04-15 Urology SONO - kidney
  • CC
    • Colon cancer s/p colectomy and partial cystectomy in 2021/05 at Cathay GH
    • Followed by R/T and C/T
    • Fecaluria noted on 2023/02/28
    • Obstructive uropathy s/p URS and DBJ before colostomy
    • Right side colostomy performed in 2023/03
• 2023-04-15 Bladder sonography
  • PVR 11.55 ml
• 2023-03-10 Patho - colon biopsy
  • Colon tumor, sigmoid (15 cm from anal verge), biopsy — Compatible with adenocarcinoma, recurrent
  • Microscopically, the sections show a picture of mainly benign mucosa with focal ulcer, necrotic debris and few tumor cells show subtle cribriform pattern, compatible with recurrent adenocarcinoma.
• 2023-03-09 Signoidoscopy
  • Sigmoid cancer recurrence with lumen narroing at 15 cm from AV, biopsy was done
• 2023-03-02 CT - abdomen
  • History and indication: Colon cancer with bladder invasion s/p op; stage III
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion. Some LNs at pelvic cavity.
    • Some calcifications in bil. scrotum.
    • Atherosclerosis of aorta.
    • S/P left side double J catheter insertion and the lower end in urethra.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)

[MedRec]

• 2023-05-04 SOAP Hemato-Oncology
  • P
    • Urologist: C/T goes first and then repair fistula
    • Port-A flush Q3M on 2023-05-04
• 2023-04-15 SOAP Urology
  • S
    • Colon cancer s/p colectomy and partial cystectomy in 2021/05 at Cathay GH
    • Followed by R/T and C/T
    • Fecaluria noted on 2023/02/28
    • Obstructive uropathy s/p URS and DBJ before colostomy
    • Right side colostomy performed in 2023-03
  • O
    • 2023/04/14 Renal sona: no hydronephrosis, bladder sona: thick bladder wall, small PVR, adviuse hydration and follow-up
  • Diagnosis
    • Dysuria R30.0
  • Prescription
    • Urief (silodosin 8mg) 1# QD
• 2023-04-13 SOAP Hemato-Oncology
  • S
    • CCRT with CapOx (2- cycles) -> Avstin plus Oxaliplatin x 10 cyces -> shift to Avastin plus irinotecan due to oxaliplatin-induced neuropathy -> Hold avastin for 5-6 months plus irinotecan due to ulcer over anastomic site by avastin -> due to left hydronephrosis, fistula between tumor and posterior wall of bladder was noted. D-J was done and PD was confirmed -> Shift to regorafenib (taken for 2 weeks) since 2023-01. For avoiding infection over fistula, colostomy was conducted on 2023-03-08.
  • P
    • Consider FOLFIRI with or without Anti-EGFR dependent on RAS.
    • Waiting for infection under control and RAS data
• 2023-03-16 SOAP Hemato-Oncology
  • P: Request to visit Urologist for manage the fistula between bladdner and tumor
• 2023-03-02 ~ 2023-03-10 POMR Colorectal Surgery
  • Discharge diagnosis
    • Sigmoid colon cancer recurrence with bladder wall invasion, T4bN2aM0, STAGE:IIIC, status post T-loop colostomy on 2023/03/08
    • Enterovesical fistula with urinary tract infection
  • CC
    • Urination with stool content for weeks
  • Present illness
    • This is a 46-year-old male with past history of
      • 1. Moderate differentiated adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C
        • s/p anterior reseection with radical lymph node dissection on 2021/05/18
        • s/p radiotherapy with 5400 cGy/30 Fx (2021/06/21 - 2021/08/03, s/p oxaliptin + capecitabine (C1D1 - C2D1 -2022/11/29, 2021/06/22 ~ 07/13)
        • s/p mFOLFOX + Avastin (CIDI ~ C11D1 = 2021/08/10 ~2022/01/12)
        • s/p FOLFIRI (CID1 = 2022/01/25)
        • s/p Strivaga (2023/2/18-3/2)
      • 2. Right lower lung atypical adenomatous hyperplasia, s/p Video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis on 2022/02/10
      • 3. Cystoscopy + left ureteroenoscopy (URS) revealed bladder papillary tumor at posterior wall (S-colon invasion?), left UVI stricture, left middle ureter severe toturous & dilation
      • 4. HBV carrier, on tenofovir
    • Tracing back to his previous medical history initially he suffered from periumbilical pain then intermittent LLQ abdomen pain for 3 months. The pain sustained more than one hour, described as cramping and severe. He had visited Xindian Cardinal Tien Hospital on 12/07 and then transferred to Taipei Medical University Hospital.
      • Due to above symptoms, he went to Cathay General Hospital GI Dr. Li JiaLong OPD. There was no tenesmus. Body weight lost 7 kg (from 57 to 50）was noted. 2021/05/04 coloscopy was proceeded up to tumor location. It is about 4cm luminal colon tumor mass with nearly total occlusion 40 cm from anal verge s/p biopsy. Pathology report revealed adenocarcinoma. The whole abdomen CT scan performed and finding: Irregular annular thickening of sigmoid colon nearly 6.8 x 3.3cm in size, with perfocal fat stranding.
      • Anterior resection with radical lymph node dissection + partial cystectomy and bladder wall repair was performed on 2021/05/18.
      • After operation , he received CRT of radiotherapy with 5400 cGy/30 fractions during 2021/06/21 - 2021/08/03 and chemotherapy with oxaliptin + capecitabine (CID1 ~ C2D1 = 2021/06/22 ~ 07/13）then mFOLFOx + Avastin (C1D1 ~ C11D1 = 2021/08/10 ~ 2022/01/12). Follow-up Chest CT on 2021/12/31 revealed two new subpleural nodules (5. 5mm and 3mm at RLL of lungs, suspected lung metastasis. so video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis was performed on 2022/02/10 and the pathology revealed atypical adenomatous hyperplasia.
      • Chemotherapy regimen was shifted to FOLFIRI cycle 1 - cycle 4 on 2022/01/25-2022/04/13.
      • He received FOLFIRI(46) & avastin on 20220413 cycle 4 but nausea, change in bowel habit (stool passage turn less and thin), mild periumbilical pain and tenderness were noted. There were no other symptoms such as fever with chills headache, dizziness, vomiting, diarrhea, constipation, cough with sputum production, dysuria, gross hematuria, diaphoresis (cold sweating) or dyspnea.
    • This time, ever since the AR on 2021/05/18, dirty urine was noted, but recently more stool content has been found. Therefore, he transferred from Cathay General Hospital to our OPD due to recommendation by his father-in-law.
    • Therefore, under the impression of adhesion of bladder and colon he was admitted for further investigation of cancer invasion or possible colonstomy evaluation.
  • Course of inpatient treatment
    • After admission with ward routine and blood examination were done. Operation of T-loop colostomy under general anesthesia were performed on 2023/03/08. NPO and IV fluids support. The wound healing well and no erythema change. Chewing cookies, toast, rice with gum was started at op day. No nausea and no vomiting, flatus passage. On low residual diet was started at post-op day 1. Patient education with colostomy care was done. Normoactive bowel movement and stools passage with diet better tolerated. There wrew no fever and no complication. So he was arranged for discharge for hisstable general condition on 2023/03/10 and will be followed up in ONCOLOGY for further chemotherapy.
  • Discharge prescription
    • Uroprin (phenazopyridine 100mg) 1# TID
    • Morcasin (sulfamethoxazole 400mg, trimethoprim 80mg) 2# BID
    • Vemlidy (tenofovir alafenamide 25mg) 1# QD
    • Defram-K (diclofenac 25mg) 1# PRNQ8H
• 2023-03-02 SOAP Colorectal Surgery
  • S
    • Colon cancer with bladder invasion s/p op; stage III, 2021-05-19
    • post-OP chemotherapy + target therapy ; DJ insertion
    • Stool passage from urine for one week
    • Septicemia 2023-01

[consultation]

• 2023-06-29 Colorectal Surgery
  • Q
    • This is a 46-year-old male with past history of
      • 1. Moderate differentiated adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C
        • s/p anterior reseection with radical lymph node dissection on 2021/05/18
        • s/p radiotherapy with 5400 cGy/30 Fx (2021/06/21 - 2021/08/03, s/p oxaliptin + capecitabine (C1D1 - C2D1 - 2022/11/29, 2021/06/22 ~ 07/13)
        • s/p mFOLFOX + Avastin (CIDI ~ C11D1 = 2021/08/10 ~2022/01/12) - s/p FOLFIRI (CID1 = 2022/01/25)
        • s/p Strivaga (regorafenib) (2023/2/18-3/2),
      • 2. Right lower lung atypical adenomatous hyperplasia, s/p Video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis on 2022/02/10,
      • 3. Cystoscopy + left ureteroenoscopy (URS) revealed bladder papillary tumor at posterior wall (S-colon invasion?), left UVI stricture, left middle ureter severe toturous & dilation,
      • 4. HBV carrier, on tenofovir.
    • since the AR on 2021/05/18, dirty urine was noted, but recently more stool content has been found, CT showed Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion, s/p T-loop colostomy on 2023/03/08.
    • He presented anal pain when sit, we need your further evaluation and management.
  • A
    • this is a 46-year old man with adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C - s/p anterior reseection with radical lymph node dissection on 2021/05/18
      • and anal pain was told for 8 days
    • DRE: no obvious hemorrhoid but firm mass over ant rectum region about 5cm aav region, possible progress of rectal cancer
    • P:
      • add alcos anal and posuline for supp use
      • warm water sitz bath
• 2023-06-29 Urology
  • Q
    • He received Left double J catheter replacement on 2023/05/31, he presented with scrotal pain when urination, we need your further evaluation and management.
  • A1
    • After change DBJ last month, urinary incontinence disappeared
    • Drainage effect of stent will be followed (he insist NOT tumor stent for fear of pain )
    • He said he had left scrotal discomfort since last week
    • Physical examination showed no obvious swelling or heating
    • Scrotal ultrasound will be arranged
  • A2 2023-06-30 09:55:48
    • little fluid around testis (malnutriotion may be related)
      • the pain is related to voiding
    • try doxaben HS may be beneficial for voiding
• 2023-03-06 Gastroenterology
  • Q
    • For HBV medication, tenofovir use
    • This is a 46-year-old male with past history of
      • 1. Moderate differentiated adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C
        • s/p anterior reseection with radical lymph node dissection on 2021/05/18
        • s/p radiotherapy with 5400 cGy/30 Fx (2021/06/21 - 2021/08/03),
        • s/p oxaliptin + capecitabine (C1D1 - C2D1 -2022/11/29, 2021/06/22 ~ 07/13)
        • s/p mFOLFOX + Avastin (CIDI ~ C11D1 = 2021/08/10 ~2022/01/12) - s/p FOLFIRI (CID1 = 2022/01/25)
        • s/p Regorafenib (Strivaga, 2/18-3/2)
      • 2. Right lower lung atypical adenomatous hyperplasia, s/p Video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis on 2022/02/10
      • 3. Cystoscopy + left ureteroenoscopy (URS) revealed bladder papillary tumor at posterior wall (S-colon invasion?), left UVI stricture, left middle ureter severe toturous & dilation
      • 4. HBV carrier , on tenofovir
    • Under the impression of adhesion of bladder and colon he was admitted to our CRS ward for further investigation of cancer invasion or possible colostomy evaluation. During hospitalization, Tenofovir has been used up. We need your expertise for medication use.
  • A
    • 46 years old man has sigmoid cancer, s/p CCRT, chemotherapy, Target therapy, HBV carrier under tenofovir. He has admitted for adhesion of bladder and colon. Therefore, we are consulted for tenofovir.
    • PE
      • conscious: clear
      • chest: smooth breath pattern
      • abdomen: soft and flat
    • Impression
      • Sigmoid cancer, s/p CCRT, target therapy
      • HBV carrirer under Tenofovir
    • Suggestion
      • If the PharmaCloud database indicates that the patient has been prescribed Tenofovir at an outside hospital, the issuing institution should be changed to our hospital (pending confirmation).

[surgical operation]

• 2023-03-08
  • Surgery: T-loop colostomy        
  • Finding: T-loop colostomy was created at RUQ area        
  • Procedure
    • Patient was put on supine position under ETGA
    • Sterized and drapped as routine
    • RUQ skin incision and muscular layer was splitted, fasia and peritoneum was opened
    • Iluem was identified and externalization, looped with a rubber tube
    • Colostomy was opened and matured by suturing with 3-0 monopril
    • Covered with stoma bag  

[radiotherapy]

[chemotherapy]

• 2023-07-05 - irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL
• 2023-06-09 - irinotecan 120mg/m2 160mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-07-05

[UTI follow-up]

• Urine culture results from 2023-06-28 identified Escherichia coli > 100K CFU/cc. The patient has been administered Brosym (cefoperazone, sulbactam) 4g IVD Q12H since that day. Lab results of urine analysis showed a decrease in bacteria from 3+ on 2023-06-28 to 1+ on 2023-07-04. Similarly, leukocyte esterase decreased from 2+ on 2023-06-28 to 1+ on 2023-07-04, sediment WBC dropped from > 50/HPF on 2023-06-28 to < 10/HPF on 2023-07-04, and urine color improved from turbid yellow on 2023-06-28 to clear light yellow on 2023-07-04. These results indicate that the antimicrobial agent is effective and the urinary tract infection is improving.
• Kidney and liver functions appeared normal according to lab data on 2023-07-03, so no drug dose adjustment is required.

701485811

230705

[exam findings]

• 2023-07-04 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 31 dB HL; LE 40 dB HL.
  • RE normal to moderate SNHL.
  • LE normal to moderately severe SNHL but have A-B gap at 4k Hz.
• 2023-06-10 MRI - larynx
  • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T: T3(T_value) N: N3(N_value) M: M0(M_value) STAGE: IVB(Stage_value)
• 2023-06-09 PET scan
  • Glucose hypermetabolism in the left hypopharynx, compatible with primary hypopharyngeal malignancy.
  • Glucose hypermetabolism in a focal area in the left neck level II to III regions, compatible with a metastatic lymph node.
  • Mild glucose hypermetabolism around bilateral hips. Post-operative change may show this picture.
  • Increased FDG uptake/accumulation in bilateral inguinal regions. The nature is to be determined (hernia? other nature?). Please correlate with other clinical findings for further evaluation.
• 2023-06-08 Patho - larynx biopsy
  • Hypopharynx, left, biopsy — Squamous cell carcinoma, moderately differentiated
  • The sections a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident.
• 2023-06-08 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A (minimal)
  • Superficial gastritis, s/p CLO test
  • Gastric erosions, multiple
  • Duodenal shallow ulcers, bulb, SDA
• 2023-06-08 SONO - abdomen
  • Suspected chronic liver parenchyma disease
  • Suspected fatty infiltration of pancreas
  • Suboptimal examination of liver,especially the subcostal view due to poor echo window
• 2023-06-07 CXR
  • Degenerative joint disease of T-spine with marginal osteophytes.
• 2023-06-07 Nasopharyngoscopy
  • left hypopharyngeal tumor, s/p biopsy under flexible laryngoscope with working channel

[MedRec]

• 2023-06-13 SOAP Hemato-Oncology
  • A: left hypopharyngeal cancer, cT3N3bM0, stage IVb
  • P: explanation about induction chemotherapy +- CCRT or CCRT, op not recommended because left LAP attached on left ICA
    • After SDM (Induction C/T or CCRT), patient would like to take induction chemotherapy.

[chemotherapy]

• 2023-07-04 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + carboplatin AUC 5 300mg NS 250mL 2hr D2 + fluorouracil 1000mg/m2 1700mg D5W 500mL 24hr D2-5 (TPF, Q3W)
  • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4

==========

2023-07-05

[renal dose for carboplatin, metoclopramide and cimetidine]

2023-07-04 Cre 1.56mg/dL, eGFR 46.6, weight 75.9kg => CrCl 45mL/min. The patient has kidney impairment, which might necessitate dose adjustments for some medications in the active list:

• Carboplatin (in TPF regimen): For patients with a CrCl between 10 and 50 mL/minute, it’s recommended to administer approximately 50% of the usual dose (Aronoff 2007).
• Metoclopramide: For patients with a CrCl between 10 and 60 mL/minute, it’s recommended to administer approximately 50% of the usual total daily dose.
• Cimetidine: For patients with a eGFR between 10 and 50 mL/minute, it’s recommended to administer 50% of the normal dose (Aronoff 2007).

Please review the dosages and clinical conditions accordingly to ensure safe and effective therapy for the patient.

700731896

230704

• diagnosis - 2022-12-02 admission note
  • Acute kidney failure, unspecified
  • Dyspnea, unspecified
  • Malignant neoplasm of cecum
  • Secondary malignant neoplasm of retroperitoneum and peritoneum
  • Secondary malignant neoplasm of liver and intrahepatic bile duct
  • Essential (primary) hypertension

[lab data]

2022-09-09 Anti-HBc Reactive
2022-09-09 Anti-HBc-Value 2.22 S/CO
2022-09-09 Anti-HBs 81.03 mIU/mL
2022-09-09 HBsAg (quantative) Nonreactive
2022-09-09 HBsAg Value (quantative) 0.00 IU/mL
2022-09-09 Anti-HCV Nonreactive
2022-09-09 Anti-HCV Value 0.11 S/CO

[exam finding]

• 2023-07-03, -06-20, -05-22, -05-14 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Spondylosis with scoliosis of the T-spine with convex to right side
• 2023-06-20 KUB
  • Spondylosis of the L-spine is noted.
  • One segmental small bowel in LMQ abdomen shows mild dilatation.
  • Follow up is indicated. Otherwise, Please correlate with CT.
• 2023-06-19 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in both rib cages, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, and hips.
• 2023-05-25 CT - abdomen
  • History and indication: adenocarcinoma of cecum with total small bowel obstruction and carcinomatosis and liver metastases, stage IVC
  • IMP:
    • S/P ileostomy. Stable condition of cecal cancer, liver metastases and peritoneal carcinomatosis. Minimal ascites.
    • Minimal pleural effusion.
• 2023-05-11 KUB
  • Degeneration of bony structures.
  • Stool retention in bowl.
• 2023-04-12 KUB
  • Disk space narrowing with spurs formation at L3-L4, L4-L5, and L5-S1 levels due to spondylosis
  • mild dextroscoliosis of the L-spine
• 2023-04-12 CXR
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch;. dilated ascending aorta
  • skin folds over Lt hemithorax otherwise clean lung fields based on plain image
  • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, T-spine.
  • Mild dextroscoliosis of the T-spine
• 2023-04-12 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
• 2023-02-06 CT - abdomen
  • S/P ileostomy. Mild regression of cecal cancer and liver metastases but mild progression of peritoneal carcinomatosis.
• 2023-01-12 SONO - nephrology
  • Bilateral chronic change of both kidneys.
• 2022-12-22 SONO - kidney
  • Normal echogenicity of the bil. kidneys.
  • Normal cortical thickness of the kidneys.
  • No evidence of urolithiasis.
  • No evidence of hydronephrosis.
• 2022-12-02 CXR
  • Sinus tachycardia
  • T wave abnormality, consider lateral ischemia
  • Abnormal ECG
• 2022-11-15 CXR
  • enlarged cardiac silhoutte may be prominent cardiophrenic angle mediastinal fat pad/ supine position
• 2022-11-09 CXR
  • enlarged cardiac silhoutte may be prominent cardiophrenic angle mediastinal fat pad/ supine position
  • marginal spurs of multiple vertebral bodies of T-L spine due to spondylosis.
• 2022-10-24 CXR
  • S/P nasogastric tube insertion
    
  • Enlargement of cardiac silhouette.
  • Spondylosis with scoliosis of the T-spine with convex to right side
• 2022-10-17 CXR
  • appropriately positioned gastric tube
  • Port-A catheter inserted into SVC via left subclavian vein.
  • enlarged cardiac silhoutte may be due to dilated cardiac chambers and prominent cardiophrenic angle mediastinal fat pad/ supine position
  • Rt and Lt subpulmonary effusion?
• 2022-10-14, -10-12, -10-10 CXR
  • enlarged cardiac silhoutte may be due to dilated cardiac chambers and prominent cardiophrenic angle mediastinal fat pad/ supine position
  • Rt and Lt subpulmonary effusion?
  • appropriately positioned gastric tube
• 2022-10-07 CXR
  • Port-A catheter inserted into SVC via left subclavian vein.
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta. dilated ascending aorta
  • enlarged cardiac silhoutte may be due to dilated cardiac chambers (LVD) or LVH and prominent cardiophrenic angle mediastinal fat pad/ supine position?
  • Rt and Lt subpulmonary effusion?
  • appropriately positioned gastric tube
• 2022-09-07 CT - abdomen, pelvis
  • Inidcation:
    • epigastric pain for one month,
    • abdominal fullness with crampying pain, intermittent
  • Findings:
    • There is ill-defined Eqivocal soft tissue mass-like lesion in the RLQ abdomen, near the cecal base, appendix, and ileocecal valve area, that may be adenocarcinoma. The differential diagnosis include metastasis.
      • In addition, this mass lesion causinig mechanical small bowel obstruction.
    • There is long segmental symmetrical mild wall thickening of the small intestine at the lower abdomen and upper pelvis causing marked dilatation of the proximal small bowel that may be tumor seeding or Crohn disease?
    • There is ascites, soft tissue lesions in the RLQ omentum and the mesentery that may be carcinomatosis. Please correlate with ascites cytology.
    • There is Eqivocal wall thickening of the sigmoid colon that may be primary adenocarcinoma or tumor seeding? Please correlate with colonoscopy.
    • There are three poor enhancing mass measuring 0.8 cm in S8 dome, 0.6 cm in S8, and 1.8 cm in S6 of the liver. Metastases are highly suspected.
    • The pancreas shows small size that is c/w senile atrophy.
    • Abdominal aorta shows atherosclerosis and ectasia 2.7 cm.
    • There is a enlarged node in pre-cava space measuring 2.2 x 1 cm that may be metastatic node.
    • There is no focal abnormality in the gallbladder, biliary system, spleen & both kidney. .
    • The IVC are grossly unremarkable.
    • There is no evidence of intrinsic or extrinsic bladder mass.
  • Impression:
    • Adencoarcinoma of the cecum or appendix causing high grade small bowel obstruction, carcinomatosis, and liver metastases is highly suspected.
    • The differential diagnosis include metastases, origin?
    • Please correlate with colonoscopy.
• 2022-09-07 KUB
  • Presence of ileus.
  • Degeneration and spondylosis of L-S spine.
  • A calcified spot at left pelvic cavity.
• 2022-09-07 CXR
  • Presence of ileus.
  • Interstitial pattern at bil. lower lungs.

[consultation]

• 2023-05-18 Infectious Disease
  • Q
    • This 82-year-old man patient is a case of Lung cancer with lymph nodes and bone metastases, cT4N3M1b, stage IVA. This time, for Pneumonia, bilateral lung with Antibiotic with Tapimycin 4.5gm iv Q6H from 2023/04/26~. Cytomegaloviral disease with Valcyte F.C 450mg 2# po QD. Chronic obstructive pulmonary disease with Medason 40mg iv BID from 2023/04/27~, Symbicort Rapihaler 2 puff INHL BID and Spiriva Respimat 2 puff INHL QD. Pneumocystosis jirovecii pneumonia (2023/05/02 P.jiroveci DNA-Sp showed Positive) with Antibiotic with Sevatrim 400mg & 80mg 10ml IV Q8H from 2023/05/01~. O2 Mask 5L 31% use, SpO2:95%. Now, for evaluate antibiotic therapy. Thank you.
  • A
    • KP bacteremia on May 14, possible Port-A related.
    • Urine culture disclosed MRSH and Enterococcus faecalis mixed infections, with low colony count.
    • There is complete defervescence since yeterday morning under Brosym and Targocid use.
    • Change of antibiotic regimen should be not necessary.
    • Please keep Targocid for one week, and follow up urine culture 4-5 days later.
    • Port-A blood culture should be rechecekd tomorrow to see if there is sterile blood.
    • Brosym can be replaced by Cipro or Cravit on May 21 as sequential therapy.
• 2022-10-13 Dermatology
  • Q
    • For skin rash
    • This 68-year-old male has past history of
      • hypertension
      • Adencarcinoma of the cecum with total small bowel obstruction and carcinomatosis, liver metastases, stage IVC status post Loop ileostomy on 2022/09/09~09/17.
    • Current problem: Due to skin rash around back, chest, abdomen and inguinal area, so we need your help for evaluation. Thanks!!
  • A
    • The patient had sufferred from diffuse fine reddish papules with minimal pruritus on the trunk, majorly on the compression sweat area.
    • several erythematous annular lesions with active borders over lower legs.
      
    • Under the impression of milaria over trunk and tinea pedis over foot and lower leg.
    • The following sugeetion:
      • for trunk, keep body position change and avoid too long compression, consider Sinbaby 1 bot topical PRN use for occlusion if pruritus development
      • for lower leg and foot, Exelderm 1 tube topical bid use on the lower leg and foot area.
• 2022-10-13 Metabolism and Endocrinology
  • Q
    • For abnormal thyroid function (20221012 (nuclear medicine) Free T4: 1.81, TSH: 0.078, T3: 58.119), so we need your help for evaluation. Thanks!
  • A
    • S: For abnormal TFT
    • O:
      • TPR- 37.1/79/12; BP-147/88
      • free T4-1.810, T3-58.119, TSH-0.078
      • HbA1C-6.4
      • No sig. blood flow on bedside thyroid echo
    • A:
      • Favor sick euthyroidism or low T3 syndrome
      • Suspected DM
    • Suggestions:
      • It is unnecessary to medication for thyroid at this timing
      • Just to follow free T4, T3 and TSH after 1 week is fine
      • Any problem, please call me
• 2022-10-12 Cardiology
  • Q
    • Lab 2022-10-12
      • Mg (Magnesium) 1.5 mg/dL
        
      • Na (Sodium) 138 mmol/L
        
      • K(Potassium) 4.0 mmol/L
        
    • Current problem: For short run VT with pulse around 8 sceonds, so we need your help for evaluation
  • A
    • O
      • BUN: 28
      • Cr: 0.66
      • Hb: 9.4
    • Suggestion:
      • Please add carvedilol (6.25mg) 0.5#bid-1#bid if no contraindication
      • Follow-up on call, Thanks.
• 2022-10-07 Gastroenterology
  • Q
    • Lab 2022-09-09
      • Anti-HBc Reactive
        
      • Anti-HBc-Value 2.22 S/CO
        
      • Anti-HBs 81.03 mIU/mL
        
      • HBsAg Nonreactive
        
      • HBsAg Value 0.00 IU/mL
        
      • Anti-HCV Nonreactive
        
      • Anti-HCV Value 0.11 S/CO
        
    • Current problem: Due to chemotherapy will be conducted, we need your help for evaluation of prescription anti-Hepatitis B virus drug.
  • A
    • The patient has Adencoarcinoma of the cecum with total small bowel obstruction and carcinomatosis, liver metastases, stage IVC status post Loop ileostomy on 2022/09/09. This time, he was admitted for respiratory distress, AKI with hyperkalemia, start hemodialysis for oligouria, acidosis during this hospitalization. For planned chemotherapy, and his lab data: HBc(+), we are consulted for HBV therapy.
    • Lab
      • Anti-HBc Reactive
        
      • HBsAg Nonreactive
        
    • Impression
      • Resolved HBV infection
      • Acute kidney injury with metabolic acidosis, hyperkalemia, now under hemodialysis
      • Adencarcinoma of the cecum, plan for chemotherapy
    • Suggestion
      • Currently, chemotherapy has not been scheduled, and the NHI only covers HBV insurance covers drugs from one week before chemotherapy to half a year after chemotherapy; and the renal function is not stable, which will affect the dosage of anti-HBV drugs; please call the gastroenterology department to evaluate medicine if the date of chemotherapy has been determined.
• 2022-10-04 Nephrology
  • A
    • Consult for AKI and renal function impairment
    • Lab data:
      • VBG PH: 7.372, PCo2: 31.5, HCO3: 17.9, BE: -7.6
      • WBC: 16.94, HbL: 17.4, Plt: 314
      • CK :436, CLMB: 37.9, TroponinI: 595.4
      • Na: 115, K: 6.6
      • BUN/ cre: 12/0.47(9/12)-＞ 139/7.83(9/29)-＞ 218/15.83(10/4)
      • CEA: 507.17,CA 199: 1052.27
      • U/O: decrease ( no foley)
      • GPT: 281, GOT: 93, T bil :1.52,albumin:5.1
      • BP:70/50mmHg, SOB
    • Impression:
      • Acute kidney injury stage 3 suspect prerenal, septic shock and dehydration
    • Suggestion:
      • Admit ICU
      • Correct metabolic acidosis with sodium bicarbonate 20ml per hr
      • Correct hyperkalemia with D50+ RI, kalimate
      • Correct hyponatremia with 3% NS
      • Suggest IV adequate Hydration
      • Explain family about Emergent CRRT
      • We will arrange RRT if family agree
      • Thank you for your consultation !
• 2022-09-07 Colorectal Surgery
  • Q
    • epigastric pain for one month
    • panendoscopy at local clinic found DU
    • abdominal fullness with crampying pain, intermittent
    • deny abd op Hx
  • A
    • this patient told me that he got this problem abdout 2-3 months ago and start to feel abdomen distension about one wks ago
    • CT revealed that carcinomatosis was found
    • pt still passage of gas and stool now
    • there’s no need for emergency surgery now
    • thanks for your consultation

[chemoimmunotherapy]

• 2023-05-02 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-18 - (Avastin + FOLFOX, Q2W)
• 2023-03-29 - (Avastin + FOLFOX, Q2W)
• 2023-03-16 - (Avastin + FOLFOX, Q2W)
• 2023-02-15 - (FOLFOX, Q2W)
• 2023-02-02 - (FOLFOX, Q2W)
• 2023-01-16 - (FOLFOX, Q2W)
• 2022-12-22 - (FOLFOX, Q2W)
• 2022-11-25 - oxaliplatin 75mg/m2 135mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
• 2022-11-07 - oxaliplatin 65mg/m2 120mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
• 2022-10-24 - oxaliplatin 65mg/m2 120mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
• 2022-10-11 - leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg 4500mg 46hr

==========

2023-07-04

[renal function follow-up]

Given the recent serum Cre and BUN records, it appears that the patient’s AKI status has been resolved for some time. Therefore, this might be marked as an inactive or resolved item in the medical problem list.

• 2023-06-27 Creatinine 1.10 mg/dL
  
• 2023-06-20 Creatinine 1.06 mg/dL
  
• 2023-06-19 Creatinine 0.99 mg/dL
  
• 2023-06-14 Creatinine 1.62 mg/dL
  
• 2023-06-27 BUN 20 mg/dL
  
• 2023-06-20 BUN 10 mg/dL
  
• 2023-06-19 BUN 11 mg/dL
  
• 2023-06-14 BUN 27 mg/dL

2022-12-05

• On 2022-12-05, both serum creatinine and BUN were lower than on 2022-12-03 (Cre 3.63 -> 1.90 mg/dL; BUN 71 -> 48 mg/dL), which indicates that the patient’s kidney function has improved.
• The administration of KCl in normal saline is used to treat hypokalemia (2.9 mmol/L 2022-12-05) as well as hyponatremia (127 mmol/L 2022-12-05).
• In the past three days, the blood pressure has remained approximately 110/60 +- 10 mmHg; in the event that successive data points show BP lower than 100/60, Norvasc (amlodipine) could be held (while Carvedilol is continued for his 90 +-20 heart rate; 2022-10-12 short run VT with pulse around 8 sceonds).

2022-09-08

• It is suspected that the patient has cecum or colon cancer and is undergoing a workup. There is no issue with the active prescription.

700374777

230703

[exam findings]

• 2023-05-10 PET
  • Increased FDG uptake in the middle third of esophagus, compatible with the primary esophageal cancer.
    
  • Increased FDG uptake in lymph nodes in bilateral upper mediastinum and in the left supraclavicular fossa, highly suspected cancer with regional lymph nodes metastases.
    
  • Increased FDG uptake in bilateral pulmonary hilar and right lower mediastinal lymph nodes, probably reactive nodes.
    
  • Increased FDG uptake at the left shoulder, probably benign in nature.
  • Increased FDG accumulation in bilateral kidneys and colon, physiological uptak of FDG is more likely.
  • Esophageal cancer, cTxN2M0, stage III at least (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-05-09 Patho - esophageal biopsy
  • Esophagus, 20 cm below incisor, biopsy — No significant pathologic change
  • Esophagus, 21-24 cm below incisor, biopsy — severe squamous dysplasia
  • Microscopically, section A shows bland squamous mucosal epithelium and no significant pathologic change. Section B shows severe squamous dysplasia with high grade nuclear atypia of the squamous cells and loss of polarity.
• 2023-05-09 MRI - brain
  • No evidence of brain metastasis.
• 2023-05-08 Miniprobe Endoscopic Ultrasound
  • Advanced esophageal SCC, middle esophagus, EUS staging T3Nx
  • Suspected esophageal dysplasia, 20 cm below incisors, s/p biopsy (A)
  • Suspected early esophageal SCC, 21-24 cm below incisors, uT1a, s/p biopsy (B)
  • Esophageal inlet patch, c/w heterotopic gastric mucosa
• 2023-05-08 SONO - abdomen
  • Renal stones, both
• 2023-05-05 ECG
  • Normal sinus rhythm
  • Minimal voltage criteria for LVH, may be normal variant
  • Borderline ECG
• 2023-05-05 CXR
  • Rt-sided convexity of the azygoesophageal recess interface, due to esophageal tumor
• 2023-04-28 CT - chest
  • Indication: 20230418 EGD: Esophageal mass like lesion, 25cm to 30cm below incisors, s/p biopsy, R/O malignancy; Stenosis at 30cm below
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Lymphadenopathy at left lower neck and bilateral paratracheal is found.
      • Long segmental wall thickening at esophagus up to 6.7cm is found. Esophageal cancer is considered.
    • Visible abdomen:
      • Bilateral renal stones are found.
      • The spleen, liver, pancreas and adrenals are intact.
  • Imp: Esophageal cancer with mediastinal lymph nodes and left lower neck.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression ( Imaging stage ): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-04-27 Tc-99m MDP bone scan
  • Increased activity in the L3 spine. Severe degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Mildly increased activity in the lower T-spines, L4-5 spines and bilateral S-I joints. Degenerative change is more likely.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, left wrist, right knee, bilateral ankles and feet, compatible with benign joint lesions.
• 2023-04-19 Patho - esophageal biopsy (Y2)
  • Esophagus, 25 cm to 30 cm below incisor, biopsy — moderate differentiated squamous cell carcinoma
  • Microscopically, section shows moderate differentiated squamous cell carcinoma consisting of invasive irregular squamous epithelial tumor nests arranged in solid architecture. The tumor cells display nuclear pleomorphis, hyperchromasia, high N/C ratio and prominent nucleoli.
• 2023-04-18 Esophagogastroduodenoscopy, EGD
  • Esophageal mass-like lesion, 25cm to 30cm below incisors, s/p biopsy, R/O malignancy
  • Stenosis at 30cm below incisors

[chemotherapy]

• 2023-05-30 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 137mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1800mg NS 500mL 24hr D1-4
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-07-03

• According to the PharmaCloud database, our hospital was the sole provider for this patient’s healthcare needs. In addition to the hemato-oncology department, the patient had an appointment with our gastroenterologist on 2023-04-24 who prescribed a 28-day course of a PPI Pariet (rabeprazole) for his gastroesophageal reflux disease with esophagitis. This prescription is currently invalid and the symptoms are no longer listed on the active medical problem list. As a result, no problems were identified during the medication reconciliation process.

700561643

230703

[exam findings]

• 2023-07-01 CXR
  • Tortous aorta with calcification is noted.
  • Superior mediastinum mass like lesion is found. Suggest CT.
  • Osteopenia of the bony structure is noted.
• 2023-07-01 CT - chest
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Confluent soft tissue mass at superior, anterior mediastinum and middle mediastinum is found. The SUPERIOR VENA CAVA is compressed. Lymphoma or germ cell tumor is suspected and lymphoma is most likely.
      • The lung fields are clear.
      • Patent airway is found.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Confluent soft tissue mass at mediastinum with SUPERIOR VENA CAVA compression. Lymphoma is favored.

[MedRec]

• 2023-07-01 Hemato-Oncology VS note on admission day
  • She experienced troublesome cough and it could be exaggerated by lying down.
  • CT revealed mediastinum tumor with compression of trachea and SVC, Tissue proof will be done on 2023-07-03.

[consultation]

• 2023-07-01 Hemato-Oncology
  • Q
    • Productive cough and orthopnea for 2 months
    • Face edema was told by daughter
    • Past history: anxiety, HTN
    • Allergy: NKA
    • Surgical hx: thyroid s/p OP now under eltroxin
  • A
    • This 73 year old woman is a case of anterior mediastinum tumor r/o lymphoma. We are consulted for further evaluation.
    • Please arrange admission for CT guide biopsy. Add steroid for r/o lymphoma related SVC syndrome. Thanks for your consultation.
• 2023-07-01 Thoracic Surgery
  • Q
    • Productive cough and orthopnea for 2 months
    • Face edema was told by daughter
    • Past history: anxiety, HTN
    • Allergy: NKA
    • Surgical hx: thyroid s/p OP now under eltroxin
  • A
    • The patient had dyspnea. CT scan showed huge mediastininal tumor with SVC compression
    • Lymphoma, small cell lung cancer was suspected
    • Please consult oncologist for treatment

==========

2023-07-03

• As per the PharmaCloud database, this patient frequently visits RenJi Hospital (last visit on 2023-06-19) and routinely refills his prescription at a local pharmacy. The prescription includes sennoside, ubidecarenone, bisoprolol, valsartan, pitavastatin, levothyroxine, alprazolam, carbinoxamine, and dextromethorphan.

• Except for carbinoxamine (a first-generation antihistamine used to treat allergic rhinitis and vasomotor rhinitis), all other drugs are included in the active medication list. However, no current diagnosis or active medical problems relating to allergic rhinitis or vasomotor rhinitis have been identified. Thus, there is no evidence of discrepancies in medication reconciliation.

701067842

230703

[exam findings]

• 2023-06-12, -06-12 Body fluid cytology - ascites
  • Negative
• 2023-05-25, -05-23 Body fluid cytology - ascites
  • Suspicious malignancy
• 2023-04-21 Patho - uterus with or without SO non-neoplastic/prolapse
  • PATHOLOGIC DIAGNOSIS
    • Ovaries, bilateral, BSO — Clear cell carcinoma
    • Uterus, ATH — Parametrium involved by carcinoma
    • Cul-de sac, debulking — Involv ed by carcinoma
    • Omentum, infracolic omentectomy — Involved by carcinoma
    • Peritoneal mass, debulking — Involved by carcinoma
      
    • Lymph nodes, pelvic and para-aortic, bilateral, BPLND — Negative for malignancy (0/34)
    • AJCC 8 th edition, Pathology stage: pT3cN0; stage IIIC; FIGO stage IIIC
  • MACROSCOPIC EXAMINATION
    • Procedure: ATH + BSO + omentectomy + BPLND + para-aortic LN dissection + Cul-de sac and peritoneal tumor excision
    • Specimen Size:
      • Five pieces, up to 5.5 x 5.0 x 3.2 cm (Lt ovary, received for frozen section), four pieces up to 4.9 x 3.2 x 2.9 cm (Lt ovary), 3.5 x 0.6 cm (Lt tube), four pieces, up to 9.3 x 7.8 x 2.5 cm (Rt ovary), 4.0 x 0.6 cm (Rt tube), 7.1 x 6.0 x 3.8 cm and 95 gm (uterus), four pieces up to 1.8 x 1.5 x 0.5 cm (Cul-de sac), five pieces up to 3.6 x 0.8 x 0.4 cm (peritoneal mass), 28.5 x 8.8 x 1.5 cm (omentum)
    • Specimen Integrity
      • Right ovary: Capsule ruptured
      • Left ovary: Capsule ruptured
      • Right fallopian tube: Serosa intact
      • Left fallopian tube: Serosa intact
    • Tumor Site: Bilateral ovaries
    • Ovarian Surface Involvement: Present
    • Fallopian tube Surface Involvement: Absent
    • Tumor Size: Can not be assessed because of fragmented tumor tissue
    • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic
    • Representative parts are taken for section and labeled as: F2023-00181FSA1, FSA2, A1-A6= left ovary. S2023-07635A= left iliac LNs, B= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E= left para-aortic, F= right para-aortic LNs, G1-G2= left ovary, G3= left fallopian tube, H1-H3= right ovary, H4= right fallopian tube, I1= cervix, I2-I3= uterine corpus, I4-I6= parametrium, J= Cul-de sac, K1-K2= omentum, L= peritoneal mass.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Clear cell carcinoma
    • Histologic grade: High grade
    • Implants: Present
    • Other Tissue/Organ Involvement: Parametrial involvement
    • Peritoneal Fluid: Positive for malignant cells
    • Regional Lymph Nodes: All lymph nodes are negative for tumor cells
      • number of lymph node examined: 8 (left iliac), 7 (left obturator), 1 (right iliac), 5 (right obturator), 6 (left para-aortic) and 7 (right para-aortic)
      • number with metastases >10 mm: 0
      • number with metastases 10mm or less: 0
      • number with isolated tumor cells (<=0.2mm): 0
    • Cul-de sac: Involved by carcinoma
    • Peritoneal mass: Involved by carcinoma
    • Omentum: Involved by carcinoma
    • Pathologic Stage
      • Primary Tumor: pT3c (macroscopic peritoneal metastasis beyond the pelvis and > 2cm in size)
      • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
      • Distant Metastasis: Not applicable
    • FIGO Stage: Stage IIIC
    • Lymphovascular invasion: Absent
    • Perineural invasion: Absent
    • Additional Pathologic Findings:
      • Cervix: Chronic cervicitis with Nabothian cysts and squamous metaplasia
      • Endometrium: Proliferative phase
      • Myometrium: Adenomyosis
      • Ovary, left: Endometrosis
      • Fallopian tube, right: Para-tubal cyst
    • IHC, tumor cells reveal: WT1(-), Napsin A(+), ER(-), and p53(no aberrant expression)
• 2023-04-21 Body fluid cytology - ascites
  • 40 cc, pink, turbid — Malignancy
  • Smears show several clusters of atypical hyperchromatic and pelomorphic cells. Malignancy is favored. Please correlate with the clinical presentation.
• 2023-04-20 Frozen Section
  • Ovary, left, frozen section — Malignant (carcinoma)
• 2023-04-17 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Massive ascites is found.
    • Cystic change at bilateral ovaries measuring 11.7cm at right ovary and 5.4cm at left side is found. Some solid component is also found. Ovarian cancer is considered.
    • Tiny enhanced dots at mesentery is found. Mesenterric meta is favored.
    • The liver, spleen, pancreas, both kidneys and adrenals are intact.
    • There is no evidence of paraarotic LAPs.
    • Normal heart size.
    • The lung fields are clear.
    • No pleural effusion is found.
  • Imp:
    • Bilateral ovarian cystic tumors with largest one at right side msm 11.7cm. Ovarian cancer is considered.
    • Peritoneal seeding is also found.
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-04-07 Gynecologic ultrasonography
  • R/O RT Ovarian mass: 109 x 85 (septum RI: 0.42)
  • Asites(+)
• 2023-01-04 CT - abdomen
  • Indication
    • LMP: 2022-12-27, sex(+), dysmenorrhea sometimes, duration: 6 days
      • CA-125: 37.71
    • 20230104 sono: A cystic mass 7.3 x 5.4 cm in right adnexa with solid mural nodule 3.1 cm. R/O right ovarian mass.
      • Left ovarian cyst 2 cm.
    • 20230104 CA125, CEA, and CA199: normal
  • Findings:
    • There is a well-defined cystic lesion in right adnexa 7 cm in size (the largest dimension) with central solid mural nodule (2.6 cm in size).
      • The differential diagnosis include cystic adenoma and cystic adenocarcinoma.
    • There is a cystic lesion with wall thickening at left adnexa, measuring 4 x 2.4 cm in size.
  • Impression:
    • A cystic lesion with mural nodule at right adnexa, nature?
    • The differential diagnosis include cystic adenoma and cystic adenocarcinoma.
• 2023-01-04 Gynecologic ultrasonography
  • R/O Lt Ovarian cyst
  • R/O RT Ovarian mass (septum RI: 0.63)

[surgical operation]

• 2023-04-20
  • Surgery
    • Diagnosis: Huge ovarian mass, bilateral
      • Frozen section: malignant, suspect carcinom
    • Operation:
      • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy (BY GENERAL SURGEON))   - Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder, peritoneum and bilateral adnexa due to the tumor burden. Multiple papillary mass was noted over anterior wall.
    • Adnexa:
      • LOV: huge ovarian mass about 10 X 10 X 8 cm in size, with heterogeneous and rough surface, partial rupture with hemorrhagic content
      • ROV: ovarian mass about 6 X 5 X 5 cm in size
      • Fallopian tube: tensely connected to the bowel and adjacent tissues due to adhesion
    • CDS: massive ascites
    • Ascites: light yellowish, at least 4000 mL
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(+)
    • Omentum: multiple hard, variable nodules noted; infracolic omentectomy was done by general surgeon.
    • Optimal debulking was achieved, Residual tumor:R0.
    • Estimated blood loss: 850 mL
    • Blood transfusion: LpRBC 2U
    • Complication: nil
• 2023-04-20
  • Operation
    • Excision of intraabdominal tumor: pelvic peritoneum + omentectomy
    • Tenckhoff tube insertion
  • Finding
    • Several tumor seedins in pelvic peritoneum with massive ascites
    • Tenckhoff tube: over RLQ
  • Procedure
    • Under ETGA, GYN performed operation at first. Made omentectomy. Excised the seeding tumor in pelvic peritoneum. Inserted a Tenckhoff tube over RLQ. Finally, GYN commenced further operation.

[chemotherapy]

• 2023-06-30 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-06-12 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-05-22 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr + NS 500mL 1hr (before chemotherapy) + NS 500mL 1hr (after chemotherapy)
  • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL

==========

2023-07-03

• As per the PharmaCloud database and our in-house HIS5 records, our institution has been the sole provider of medical services to this patient over the past three months. In addition to our Hematology-Oncology department, the patient also attended appointments in our Metabolism and Endocrinology department on 2023-06-05 and our Obstetrics and Gynecology department on 2023-05-04. However, no prescriptions were issued by these two departments. All current medications were prescribed by our Hematology-Oncology department, with no medication reconciliation discrepancies detected.

701031265

230630

[present illness] - 2023-03-20 admission note

• This 92-year-old male had history of
  • Benign prostate hyperplasia
  • Hypothyroidism
  • Hypertension
  • status post left total knee replacement about 10 years ago
  • Adenocarcinoma of ascending colon, pT2N0M0 stage I status post Single-incision laparoscopic right hemicolectomy on 2021/11/03
• He was under regular follow up at CRS/Meta/Uro OPD.
• Liver metastasis after RFA on 2023/02/03. On 2023/03/04 whole abdominal CT showed suspect of three new liver metastasis.
• Under the impreession of colon cancer with liver metastases, he was admitted for port-A and palliative chemotherapy after further advanced evalaution on 2023/03/20.

[past history]

• Benign prostate hyperplasia
• Hypothyroidism
• Hypertension
• status post left total knee replacement about 10 years ago
• Adenocarcinoma of ascending colon, pT2N0M0 stage I status post Single-incision laparoscopic right hemicolectomy on 2021/11/03
• Liver metastasis after RFA on 2023/02/03         

[allergy]

• NKDA     

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-05-15, -03-24, -03-20 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Enlargement of cardiac silhouette.
  • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
• 2023-04-26 KUB + L-spine Lat
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4 and L4-5 (more severe on L4-5).
  • Spondylolisthesis of L5-S1 (< Grade I) is noted.
• 2023-03-23 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (133 - 36) / 133 = 72.93%
    • M-mode (Teichholz) = 72
  • Conclusion:
    • Borderline dilated LV; Adequate LV systolic function with normal resting wall motion
    • Dilated aortic root; mild to moderate AR
    • Trivial MR, mild to moderate TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
• 2023-03-22 Spirometry
  • normal lung volume and ventilatory function
• 2023-03-20 ECG
  • Normal sinus rhythm
  • Voltage criteria for left ventricular hypertrophy
• 2023-03-04 CT - abdomen
  • Indication: refer from CRS a case of colon cancer R/O single liver metss/p RFA on 2023-02-03 no AE. now CT 1 m F/U
  • With and without contrast enhancement CT of abdomen shows:
    • Colon CA, s/p operation. No local recurrent tumor.
    • No enlarged lymph nodes in para-aortic and pelvic regions.
    • Right posterior segment liver metastasis, s/p RFA. Three poor enhancing lesions in right hepatic lobes: 1.4cm in S7, 0.8cm and 1.0cm in S5.
    • No ascites, nor extraluminal free air.
    • No bony destructive lesion on these images.
  • Impression
    • Colon CA, s/p operation
    • Suspect three new liver metastasis. Suggest sonography correlation.
• 2023-02-03 RFA
  • Indication: colon ca with single mets for RFA
  • Procedure
    • Metastatic liver tumor (1.8 cm) s/p RFA (2 sessions; 2 cm active tip)
  • Course
    • By sono-guided, RFA probe was inserted to the tumor (stop after 3 pauses; 2 sessions). The patient tolerated the procedure. Iv anesthesia was performed during the procedure.
  • Findings
    • A 1.8 cm mass at rt post seg near liver surface.
• 2023-02-02 ECG
  • Normal sinus rhythm
  • Moderate voltage criteria for LVH, may be normal variant
  • Borderline ECG
• 2023-01-11 ENT Hearing Test
  • Reliabilty Fair
  • PTA
    • R’t : 71 dB HL
    • L’t : 66 dB HL
    • Bil mild to profound SNHL.
• 2022-12-28 SONO - abdomen
  • Diagnosis
    • Chronic liver parenchymal disease
    • Hepatic tumor C/W single metastatic tumor
    • Calcified spot of liver
    • Liver cyst
  • Suggestion
    • RFA if needed
• 2022-12-21 ENT Hearning Test
  • Tymp:
    • Bil type B.
  • ART:
    • Bil absent.
  • PTA
    • Reliability FAIR
    • Average RE >101 dB HL; LE 70 dB HL.
    • RE moderately severe to profound MHL.
    • LE moderate to profound SNHL. (BC masking dilemma)
• 2022-11-28 CT - abdomen
  • A colon cancer s/p SILS right hemicolectomyp T2N0M0 on 20211103
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Abdominal CT with and without enhancement revealed:
    • s/p RAR.
    • Low density lesion at S6 of liver up to 1.1cm is found. In comparison with CT dated on 2021-10-09, the lesion is new. New liver meta is suspected.
    • Enlarged prostate up to 5.9cm is found.
    • Ground glass opacity over right lower lobe is found.
  • IMp:
    • s/p RAR.
    • new low density lesion at S6 of liver. 1.1cm, suspected liver meta.
• 2022-09-28 Nerve Conduction Velocity, NCV
  • Findings
    • Decreased amplitudes and slowed NCVs in bilateral peroneal and tibial CMAP.
    • Decreasd amplitudes and slowed NCVs in bilateral sural SNAPs.
    • Prologed F-wave latencies followed bilateral peroneal and tibial nerve stimulations.
    • Prolonged H-reflex latencies followed right tibial nerve stimulations.
  • Conclusion
    • This abnormal NCV study suggested mix-type sensorimotor polyneuropathy may superimposed polyradiculopathy
      • note ChatGPT: Polyneuropathy refers to damage or disease affecting multiple peripheral nerves throughout the body. Sensorimotor polyneuropathy involves both sensory and motor nerves, which can cause symptoms such as numbness, tingling, weakness, and pain. Polyradiculopathy refers to damage or disease affecting multiple spinal nerve roots, which can cause similar symptoms.
• 2022-05-19 SONO - abdomen
  • Diagnosis
    • Suspected liver cyst,right
    • Suspected liver calcification,right
    • Pancreas not shown
    • Suboptimal examination of liver due to poor echo window
  • Suggestion
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
    • Because of poor echo window,infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
• 2022-04-23 Bladder Sonography
  • PVR: 23.89 mL
• 2022-04-23 Uroflowmetry
  • Q max: low
  • flow pattern: obstructive
• 2021-11-03 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Large intestine, ascending colon, laparoscopic right hemicolectomy — Adenocarcinoma, well differentiated, arising from tubulovillous adenoma
      
    • Resection margins: free
      
    • Lymph node, mesocolic, dissection — Negative for malignancy (0/22)
      
    • Lymph node, IMA / SMA, dissection — N/A.
      
    • Terminal ileum, laparoscopic right hemicolectomy — Negative for malignancy
      
    • Appendix, appendectomy — Negative for malignancy
      
    • Pathology stage: pT2N0(if cM0); AJCC stage I
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: laparoscopic right hemicolectomy
      
    • Specimen site: ascending colon
      
    • Specimen size: colon: 30 cm in length ; Terminal ileum: 8 cm
      
    • Tumor size: 11x 8x 5 cm
      
    • Tumor location: 12 cm away from the closest resection margin
      
    • Depth of invasion grossly: muscularis propria
      
    • Mucosa elsewhere: Not remarkable
      
    • Representative sections and labeled: A1:appendix, A2-3:bilateral marfins, A4-7:LNs, A8:non-tumor part, A9-15:tumor
      
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
    • Histology Grade: well differentiated
      
    • Depth of invasion: muscularis propria
      
    • Angiolymphatic invasion: Not identified
      
    • Perineural invasion: Not identified.
      
    • Discontinuous extramural tumor extension: Not identified.
      
    • Circumferential (radial) margin of rectum: Serosal margin status of colon: Uninvolved
      
    • Lymph node metastasis, mesocolic: 0 / 22
      
    • Lymph node metastasis,, IMA / SMA: N/A.
      
    • Extranodal involvement: N/A.
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT)
        • pT2: Tumor invades the muscularis propria
          
      • Regional Lymph Nodes (pN)
        • pN0: No regional lymph node metastasis
          
      • Distant Metastasis (pM)
        
    • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
      
    • Additional pathologic findings: None identified.
      
    • TNM descriptors: N/A
      
    • Tumor regression grading S/P CCRT: N/A.
      
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2021-10-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (133 - 36) / 133 = 72.93%
    • M-mode (Teichholz) = 72
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH without outflow tract obstruction; impaired LV relaxation.
    • Normal RV systolic function.
    • Aortic valve sclerosis with no AS, mild to moderate AR; mild MR; mild TR; mild PR.
    • Atherosclerosis of aorta with mildly diated aortic root and ascending aorta.
• 2021-10-19 Patho - colon biopsy
  • Clinical Finding
    • One huge tumor with partial obstruction was noted A-colon, s/p biopsy
  • PATHOLOGIC DIAGNOSIS
    • Colon tumor, ascending colon, biopsy — Villotubular adenoma with high grade dysplasia
      
  • MICROSCOPIC EXAMINATION
    • Microscopically, the sections show a picture of villotubular adenoma, composed of colonic mucosal tissue with atypical glands lined by low grade dysplastic columnar cells, in tubular, fused glandular or cribriform arrangement. No convincing stromal invasion present in the limited specimen. Repeat biopsy is advised for further evaluation is advised, if malignancy is suspected clinically. Closely follow up
• 2021-10-19 Colonoscopy
  • Diagnosis
    • Highly suspect colon cancer with partial obstruction, A-colon, s/p biopsy
    • Mixed hemorrhoids
  • Suggestion
    • F/U pathology report
  • Complication
    • No immediate complication
• 2021-10-14 Bronchodilator Test
  • probably normal screening
  • negative BDT
  • Inadequate tracing
• 2021-10-09 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Huge soft tissue mass up to 7.69cm in largest dimension at ascending colon with dilatation of the cecum is found. Colon cancer is favored. Two tiny lymph nodes are found.
      
    • Mild consolidation over right lower lobe and left lower lobe is found.
    • Borderline heart size is found.
    • Tiny subpleural nodule at right middle lobe up to 0.cm, in largest dimension is found.
    • Bula formation at bilateral upper chest is found.
    • Hepatic cyst at S6 of liver up to 1.25cm in largest dimension is found. S (CVP line placement Im63).
    • Very enlarged prostate up to 5.67cm in largest dimension is found.
  • Imp:
    • Suspected huge Colon cancer at ascending colon.
    • Consolidation over bilataral basal lungs.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T2(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2021-07-10 Bladder Sonography
  • PVR: 8.32 mL
• 2018-07-20 Renal Echo
  • Bilateral parenchymal renal disease
  • Calcification lesion, left kidney
  • Enlarged prostate
• 2018-03-22 Pure Tone Audiometry & Tymanometry
  • Tymp: bil type A.
  • PTA:
    • reliability: fair
    • R’t mild to severe SNHL, average 66 dB HL.
    • L’t mild to profound SNHL, average 60 dB HL.
    • Audiogram: bil BC 2k and 4k Hz at 70 dB HL NR.
• 2017-11-09 Barium Enema Double Contrast study of LGI series
  • Findings:
    • The contrast medium passage from anus to the cecum smoothly without obstruction.
    • Normal contour, haustration and peristalsis of the colon.
    • Redundant of sigmoid colon.
  • IMP:
    • Redundant of sigmoid colon.
      • note ChatGPT: “Redundancy of sigmoid colon” is a condition in which the sigmoid colon, which is the last part of the large intestine, is abnormally long and twisted. This results in the sigmoid colon being bunched up or looped on itself, which can cause constipation, bloating, and abdominal pain.

[consultation]

• 2021-10-12 Dermatology
  • A
    • This patient suffered from multiple erythematous papules on trunk and limbs for months
    • Imp: Asteatotic dermatitis
    • Suggestion:
      • Zaditen 1 / Bid
      • Clobetasol x 6 tubes/bid

[surgical operation]

• 2021-11-03
  • Surgery
    • SILS right hemicolectomy        
  • Finding
    • Villotubular adenoma with high grade dysplasia of ascending colon, cT2N1M0
    • Anastomosis by GIA 75/4.8mm x2
    • One JP drain in pelvic area
    • Close abdomen by surgical assister

[chemotherapy]

• 2023-05-15 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 760mg NS 250mL 2hr + fluorouracil 2800mg/m2 3735mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 775mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[note]

Refillable prescriptions for patients with chronic illnesses - ref: https://www.nhi.gov.tw/Glossary/Glossary.aspx?page=6

==========

2023-06-30

• Our Urology department issued refillable prescriptions for the patient with chronic illnesses for Betmiga (mirabegron), Eurodin (estazolam), Harnalidge (tamsulosin), Minirin (desmopressin), Norvasc (amlodipine), and Uretropic (furosemide), on 2023-04-08. These medications have been accurately incorporated into the current medication list, hence no issues were encountered during the medication reconciliation process.

2023-06-08

• The patient has exclusively sought medical care at our hospital, with the exception of a visit to a local clinic for low back pain on 2023-04-28, where he was prescribed mephenoxalone for a duration of 5 days. Since low back pain isn’t mentioned in the admission note or in the current list of medical problems, there appear to be no medication reconciliation issues.

2023-05-16

• Subclinical hypothyroidism is biochemically characterized by a normal serum free thyroxine (T4) concentration along with an elevated serum thyroid-stimulating hormone (TSH) concentration. Our endocrinologist has previously prescribed a refillable dose of Eltroxin (levothyroxine). This drug is currently listed in the patient’s active medication regimen. However, the patient continues to have normal free T3 and free T4 levels, while there is a significant increase in TSH levels (approximately doubled every 2 months this year). Therefore, it may be prudent to consult with the endocrinologist to determine if an adjustment in levothyroxine dose is necessary.
  • 2023-05-05 TSH 35.330 uIU/mL
    
  • 2023-03-21 TSH 19.587 uIU/mL
    
  • 2023-01-12 TSH 9.573 uIU/mL
    
  • 2022-09-12 TSH 7.507 uIU/mL
    
  • 2023-03-22 Free T3 2.5 pg/mL
    
  • 2023-03-22 Free T4 1.085 ng/dl

2023-03-25

[assessment]

• The FOLFOX regimen has been adjusted by reducing the dose of oxaliplatin and fluorouracil by 30% due to the patient’s advanced age.
• According to the TPR panel, the patient’s blood pressure and serum glucose levels are well controlled with the appropriate medications based on his age.
• No issues have been identified with the patient’s active prescriptions.

700523705

230629

[exam findings]

• 2023-06-28 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Increase soft tissue density of the left lower neck is suspected. Please correlate with sonography or CT for further evaluation.
  • Several Compression fracture of the T-spine S/P vertebroplasty.
• 2023-06-28 ECG
  • Normal sinus rhythm
  • CCWR
  • Minimal voltage criteria for LVH, may be normal variant
  • T wave abnormality, consider anterior ischemia
• 2023-06-22 T-spine AP + Lat
  • S/P VP.
  • Compression fracture of spine.
• 2023-06-22 KUB + L-spine Lat
  • S/P VP.
  • Non-specific small bowel and colon gas pattern.
  • A calcification at pelvic cavity.
• 2023-06-07 Tc-99m MDP bone sccan with SPECT
  • No evidnece of bone lesion at the left shoulder and left scapula.
  • Suspected benign lesions in both rib cages, maxilla, sternum, some T- and L-spine, left sternoclavicular junction, bilateral shoulders, S-I joints, and hips.
• 2023-06-05 CXR
  • No active lung lesion
  • No pleural lesion
  • Borderline enlarged cardiac sihoutte
  • Tortuous thoracic aorta with intimal calcification
  • General osteoporosis
  • Multilevel compression fracture of T-L spine
• 2022-12-17 SONO - nephrology
  • Left borderline small kidney with chronic parenchymal changes.
• 2022-12-17 Bladder sonography
  • PVR: 10.1 ml
• 2022-10-15 Bladder sonography
  • PVR: 10.8 ml
• 2022-10-13, -07-21, -04-02 Gynecologic ultrasonography
  • Uterine myoma
• 2021-08-28 Bladder sonography
  • PVR: 1.52 ml
• 2019-07-13 Colonoscopy
  • Diagnosis
    • There was no abnormal mucosa or mass up to the ileocecal valve
    • Mixed hemorrhoids,minimal
  • Suggestion
    • CRS OPD follow up
    • Repeated colon scopy was suggested for follow-up in 1-2 yrs
    • Small lesion may be masked by semifluid like feces
• 2019-05-08 L-spine Lat (including sacrum)
  • Gr.I spondylolisthesis of L5/S1
  • Facet degeneration of lumbar spine
  • Disc space narrowing of L2-S1
• 2019-04-01 CTA - abdomen
  • No evidence of ischemic colitis.
• 2019-03-31 CXR
  • Increase bilateral lung markings.
  • Mild cardiomegaly.
  • Tortuous thoracic aorta with intimal calcification.

==========

2023-06-29

• According to PharmaCloud records, the patient had visited JingMei Hospital for a wedge compression fracture of the first lumbar vertebra on 2023-05-31. She was given short-term prescriptions for dexamethasone (1 day), tramadol (7 days), and mephenoxalone (7 days), all of which have now expired and are therefore invalid.
• Currently, intravenous formulations of Limadol (tramadol) and morphine have been prescribed for pain management since her admission date of 2023-06-28. Based on the information available, there are no apparent medication reconciliation issues found.

700013816

230628

[exam findings]

• 2023-06-12, -06-09 CXR
  • s/p PICC inserted via Lt arm, tip in SVC
  • extensive heterogeneous consolidation in both lungs in progression
  • moderate enlarged cardiac silhoutte
• 2023-06-07 Cardiac Catheterization
  • We perform PICC under the cath room and fluroscopy guiding
    • Left basilic vein was puncture by peripheral echo guiding. Terumo wire in basilic to axillary vein.
    • The sheath advanced to puncture site and
    • A peripherally inserted central catheter (PICC) was implanted to SVC under the fluroscopy guiding.
  • Conclsuion
    • PICC was implanted via left brachial vein successful.
• 2023-06-07 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Compatible with acute monoblast/monocytic leukemia
  • The sections show hypercellular marrow (85%). The marrow space is replaced by a population of medium to large-sized immature cells with round to oval, ocasional distorted nucleus, and abundant cytoplasm. Numerous mitotic figures can be found.
  • IHC: CD34 (<3% +), CD117(10% +), MPO(30%+), and CD68(70% +). The finding is compatible with acute monoblastic/monocytic leukemia. Suggest bone marrow smear, flow cytometry and clinic correlation.
• 2023-06-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (178 - 93) / 178 = 47.75%
    • 2D (M-simpson) = 48
  • Conclusion:
    • Dilated LV with hypokinesia of posterior wall, lateral wall; impaired LV systolic function.
    • Preserved RV systolic function.
    • Gr II LV diastolic dysfunction and impaired RV relaxation; moderately dilated LA.
    • Degenerative changes of mitral valve with severe MR; moderate TR; mild PR; dilated aortic root with mild AR.
    • Possible moderate to severe pulmonary hypertension (the estimated systolic PA pressure > 62 mmHg).
    • Mild aortic root calcification.
• 2023-06-06 CXR
  • S/P nasogastric tube insertion
  • S/P endotracheal intubation with the tip beyond the carina
  • extensive, multifocal consolidation, in both lungs
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2023-06-05 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2023-06-01 CXR
  • Ground glass opacity in LLL.
  • Atherosclerosis of the aorta.
• 2023-06-01 ECG
  • Sinus rhythm with Premature atrial complexes
  • Otherwise normal ECG

[MedRec]

• 2023-06-12 POMR Chest Medicine Progression Note
  • Problem List
    • R/I acute myeloid leukemia, Pending bone marrow biopsy
      • Assessment: serious
        • 20230608 HBsAg(-), Anti-HCV(-)
        • Hydroxyurea 1# QD (20230607 ~ 9)
        • 20230606 Bone marrow
      • Plan
        • BT with LPR 1U and LPRBC 2u on 20230612 for thrombocytopenia and anemia
        • Consider chemotherapy if Oncology suggest
        • Blood transfusion with LPRBC 2u and LRP 1PH on 20230612, s/p Lasix 0.5amp iv injection
    • Bilateral pneumonia, suspect leukemic lung with hypoxic respiratory failure post intubation on 2023-06-06
      • Extubation on 20230609
      • Assessment: serious
      • Plan
        • Nasal cannula supply
        • Antibiotics with Targocid plus Mepem (since 20230606) were prescribed
        • Anti-fungus agent with Mycamine (since 20230606)
        • Sevatrim oral form(IV form 20230606 ~ 10, since 20230610) for cover PJP
        • Kalimate 2pk qid was given for correct hyperkalemia (Baktar side effect)
        • Collect K qd
        • 20230605 Pending CMV and PJP result
    • EFrEF with vere MR
      • Assessment: serious
        • 20230607 Heart echo EF 48%, severe MR
      • Plan
        • Concor 1# BID
        • Diuretic with Lasix 0.5# PO QD
    • Type 2 Diabetes mellitus
      • Assessment
        • HbA1c 6.5% on 20230605
      • Plan
        • RI 14u SC TIDAC as sliding scale and Toujeo 10u SC HS
        • Tragenta 1# QD
    • Acute kidney injury and imbalance electrolyte
      • Assessment: impairment renal function
      • Plan:
        • Closely monitor renal function and electrolyte
        • Correct hypocalcemia with Calcium gluconate 1amp IVD QD
        • Add MgSO4 1amp iv infusion loading for correct hypo-Mg
  • Attending Physician’s Rounds Record and Comment
    • keep O2 support, closely monitor his respiratory pattern and O2 saturaiton
    • keep Targocid, Meropenem, Micafungin and oral Baktar for infection control, trace culture result
    • give PRBC and PLT transfusion to correct anemia and thrombocytopenia, regular hemogram f/u, if prograssive leukopenia (ANC < 500), may add G-CSF
    • keep Kalimate to correct hyperkalemia
    • because of CXR still showed pulmonary congestion, keep Diuretic used to keep I/O negative balance for CHF and severe MR
    • wait Bone marrow biopsy result
    • explained his condition to himself and his family
    • consult Hema doctor f/u, if possible, may let him transfer to Hema general ward
• 2023-06-01 SOAP Hemato-Oncology
  • S
    • Referred from clinic for WBC 72K, PLT 48K, HGB 6.9 (20230601)
    • fever in recent days for 1 month
    • Exertional shortness of breath (dyspnea on exertion) for 2 wks
  • A
    • Suspected acute leukemia with hyperviscosity
    • Suspected coexisting infection
  • P
    • Marked leukocytosis –> refer to ER for emergent treatment and admission

[consultation]

• 2023-06-08 Cardiology
  • Q
    • for severe MR
    • This is a 70 y/o male with type 2 DM without treatment. The impression of acute leukemia, he was admitted to Hema ward on 20230602. Due to acute hypoxic respiratopry failure, he received intubation then transffered to MICU on 20230606. At MICU, antibiotic with Targocid, Mepem, Sevatrim, Mycamine (since 20230606) for infection control. F/u Bone marrow on 20230606 (pending result), Oral chemotherapy with hydroxyurea was precribed. Arrange 2-D echo on 20230607 for heart function evaluation and which revealed EF 48%, severe MR. We really need your help for treatment suggestion, thank you!!
  • A
    • This is a 70 years old man with suspected acute leukemia, acute hypoxic respiratory failure. We were consulted for severe MR management.
    • Labs
      • Worsening renal function
    • Impression
      • Heart failure with mildly reduced EF, dilated LV with hypokinesia of posterior and lateral wall, with severe primary mitral regurgitation, with moderate to severe pulmonary HTN.
      • Acute respiratory failure with bilateral pneumonia r/o pulmonary congestion
      • Acute on chronic renal impairment, r/o prerenal type.
      • r/o acute leukemia;
    • Suggestion
      • Surgical intervention for MR is not suitable at present due to poor general condition (underlying hematolic malignancy + sepsis).
      • Keep lasix + concor use; may consider adding low dose candesarten if Cr < 2.0.
• 2023-06-06 Infectious Disease
  • A
    • 70-year-old DM male patient is a fresh case of AML, that bone marrow study not done yet.
      • Persistent fever is noted before and during hospitalization, that leukemic fever likely.
      • Serial CxR films showed rapid onset bilateal perihilar infiltrations, especially right lung, that leukemic lung is the first consideration.
      • Possibility of PJP infection also exist, that sputum PJP-PCR study necessary.
      • IV steroid is necessary, as well as intubation for severe hypoxemia.
    • Suggestion:
      • Continue the present Mepem, Targocid and Mycamine.
      • Decrease Sevatrim dosage to 2 vials iv q12h due to AKI.
      • Send sputum for bacterial culture, PJP-PCR.
      • Check cryptococcal/Aspergillus antigen, and CMV viral load too.

==========

2023-06-28

• Patient body weight 64.7kg => CrCl 27mL/min. Considering the patient’s CrCl falls within the range of 20 to 50 mL/min, the levofloxacin dosage should be adjusted. Instead of the initially intended daily dose of 750mg, it is recommended to administer 750mg of levofloxacin every other day.
  • 2023-06-28 BUN 81 mg/dL
    
  • 2023-06-28 Creatinine 2.20 mg/dL
    
  • 2023-06-28 eGFR 31.52
• Fluconazole in patients with CrCl ≤50 mL/minute: Reduce dose by 50%. 2# switch to 1# QD is recommended.

2023-06-12

• The patient’s renal function is showing signs of improvement, but still remains inadequate. The administration of furosemide should continue to ensure a net outflow in the fluid balance, thus helping to alleviate pulmonary congestion, congestive heart failure (CHF), and mitral regurgitation (MR). Please note that the oral bioavailability of furosemide varies greatly, but on average it’s around 50% of the intravenous (IV) dose.
  • 2023-06-12 Creatinine 2.17 mg/dL
    
  • 2023-06-10 Creatinine 2.51 mg/dL
    
  • 2023-06-09 Creatinine 2.90 mg/dL
    
  • 2023-06-07 Creatinine 3.14 mg/dL

2023-06-06

[tube feeding - Concor]

• The manufacturer’s instructions for Concor (bisoprolol 5mg/tab) advise that it should be swallowed with a drink of water and not be chewed. If the patient is receiving tube feeding, the Simple Suspension Method (SSM) may be used. In the simple suspension method, the packaged tablets can be dissolved in 55-degree Celsius water and left for 5-10 minutes, then can be flowed through a feeding tube. This method involves disintegrating tablets and capsules in warm water before suspending them for administration. This method could be applicable for administering Concor tablets through a feeding tube.

[assessment]

• Since the start of Hydrea (hydroxyurea) treatment on 2023-06-02, there has been a noticeable reduction in the patient’s WBC count from a peak of 105K/uL. However, along with this, It is also seen a concurrent suppression of the patient’s HGB and PLT levels, despite the administration of blood transfusions on 2023-06-01 and 2023-06-05.
  • 2023-06-06 WBC 66.82 x10^3/uL
    
  • 2023-06-05 WBC 99.17 x10^3/uL
    
  • 2023-06-04 WBC 105.86 x10^3/uL
    
  • 2023-06-03 WBC 105.55 x10^3/uL
    
  • 2023-06-02 WBC 100.28 x10^3/uL
    
  • 2023-06-01 WBC 75.10 x10^3/uL
    
  • 2023-06-06 HGB 7.8 g/dL
    
  • 2023-06-05 HGB 7.9 g/dL
    
  • 2023-06-04 HGB 6.9 g/dL
    
  • 2023-06-03 HGB 7.4 g/dL
    
  • 2023-06-02 HGB 7.0 g/dL
    
  • 2023-06-01 HGB 6.3 g/dL
    
  • 2023-06-06 PLT 44 x10^3/uL
    
  • 2023-06-05 PLT 62 x10^3/uL
    
  • 2023-06-04 PLT 37 x10^3/uL
    
  • 2023-06-03 PLT 43 x10^3/uL
    
  • 2023-06-02 PLT 47 x10^3/uL
    
  • 2023-06-01 PLT 63 x10^3/uL
• 2023-06-06 lab Cre 2.63mg/dL, eGFR 25.72, CrCl 27
  • Tarcocid (teicoplanin) for CrCl <30 mL/minute：
    • If the usual indication-specific dose is 6 mg/kg once daily：6 mg/kg every 72 hours or 2 mg/kg once daily
    • If the usual indication-specific dose is 10 mg/kg once daily：10 mg/kg every 72 hours or 3.3 mg/kg once daily
    • If the usual indication-specific dose is 12 mg/kg once daily：12 mg/kg every 72 hours or 4 mg/kg once daily
  • The maintenance dose, which stands at 700mg Q3D, is equivalent to 9.5 mg/kg. This is within the reasonable therapeutic range.

701319969

230628

{metastatic breast cancer}

[exam findings]

• 2023-05-26 MRI - brain
  • Indication: Breast cancer with brain and lung mets
  • Pre- and poat-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
    • Post-operation change at right parieto-occipital skull with localized CSF accumulation, and white matter edema in underlying arain parenchyma. Stationary as compared with MRI on 20230130.
    • A small rim-enhancing lesion, about 7 mm, with perifocal edema in left paramedial frontal lobe, indicating a metastatic lesion.
    • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
    • No remarkable finding of nasopharynx visible in these images.
  • IMP: A new metastatic lesion (7 mm) at left paramedial frontal lobe. Stationary of the post-operation change at right parieto-occipital lobe.
• 2023-05-04 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 2023/02/02, the the lesion in the right acetabulum is a little more evident. Bone metastasis in a little more progression should be considered.
  • The previous faint hot spot in the anterior aspect of left 3rd rib is slightly more evident.
  • Increased activity in the right parietal area of the skull, compatible with post-operative change.
  • Other bone lesions are possibly more benign in nature.
• 2023-05-03 CT - chest
  • Indication: Breast cancer with brain and lung mets
  • Comparison was made with previous CT dated on 2022/11/01
    • Lungs: interval stationary in size nodular lesions in both lungs as compared with CT on 2023/02/01
    • Mediastinum and hila: no enlarged LN or mass. the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: Ulcerative tumor at left breast and a smaller nodule at lateral anterior chest wall and two nodular lesions at right breast, stationary as compared with CT on 2023/2/1
    • Visible abdominal-pelvic contents:
      • moderate splenomegaly and hyperplasia of left adrenal gland, stable.
      • small residual hepatic metastatic tumors, stable.
      • enlarged uterus with many myomas.
      • normal appearance of gall bladder.
      • unremarkable of the Rt adrenal gland, pancreas, and both kidneys. bile ducts.
    • Visualized bones: unremarkable.
  • Impression:
    • advanced breast cancer with lung and liver metastases, stationary as compared with CT on 2023/02/01
• 2023-02-02 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 2022/11/17, no prominent chanhge is noted in the the lesion in the right acetabulum. Bone metastasis in stationary status may show this picture.
  • Increased activity in the right parietal area of the skull, compatible with post-operative change.
  • The faint hot spot in the anterior aspect of left 3rd rib is a little less evident and no prominent change is noted in other bone lesions, possibly more benign in nature.
• 2023-02-01 CT - chest
  • Impression: advanced breast cancer with lung and liver metastases, stationary and increase in size of left breast tumor compared with CT on 2022/11/01
• 2023-01-30 MRI - brain
  • Post OP at right parieto-occipital lobe and skull, no evidence of tumor recurrence.
• 2022-11-17 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 2022/08/05, the the lesion in the right acetabulum is a little less evident. Bone metastasis with some resolution may show this picture.
  • Increased activity in the right parietal area of the skull, compatible with post-operative change.
  • No prominent change is noted in other bone lesions, possibly more benign in nature.
• 2022-11-01 CT - chest
  • Indication: Breast adenocarcinoma with metastasis to right cerebral parietal lobe status post craniectomy for brain tumor excision and intracranial pressure monitoring on 2022/09/29.
  • Findings
    • Lungs: interval increase in size nodular lesions in both lungs compared with CT on 20220804.
      • mosaic attenuation changes with centrilobular micronoduels in both lower lobes.
    • Mediastinum and hila: no enlarged LN or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion.
    • Vessels:
      • the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
      • Chest wall and visible lower neck: Ulcerative tumor at left breast and a smaller nodule at lateral anterior chest wall, increase in size and stationary of two nodular lesions at right breast compared with CT on 8/4.
    • Visible abdominal-pelvic contents: moderate splenomegaly and hyperplasia of left adrenal gland, stable.
      • small residual hepatic metastatic tumors, stable.
      • enlarged uterus with many myomas.
      • normal appearance of gall bladder.
      • unremarkable of the Rt adrenal gland, pancreas, and both kidneys. bile ducts.
    • Visualized bones: unremarkable.
  • Impression:
    • CT of brain: s/p Rt parietal craniectomy with residual vasogenic edema and suspect residual metastatic tumor still present.
  • Impression: advanced breast cancer with lung, liver, and brain metastases, in progression of lung metastasis and increase in size of left breast tumors compared with CT on 20220928.
• 2022-09-30 Patho - brain/meninges (tumor)
  • Brain, right medial parietal, tumor excision — metastatic invasive carcinoma, compatible with breast origin
  • The specimen submitted consists of 5 tissues measuring up to 3x 2x 1.5 cm in size, in fixed state.
  • Microscopically, sections show invasive carcinoma composed of neoplastic nests in infiltrative growth pattern, arranged in solid architecture and foci of tumor necrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, and high N/C ratio.
  • Immunohistochemical study demonstrates ER (-), PR (-), Her2/neu: positive (3+), GATA3 (+), Ki-67 inedex: 30%.
• 2022-09-28 MRA - brain
  • indication: Left breast cancer with right breast, bilateral lung and liver meta
  • findings
    • decreased intraventricular and extraventricular CSF spaces; 13.7mm midline shift to the left side
    • rihgt parahippocampal hernia; a heterogeneous enhancing tumor, about 37mm xm38mm x 44mm, in the right parietal lobe with severe perifocal edema. The lesion revealed heterogeneous high SI on T2WI withfluid-fluid layrings and heterogeneous low SI on T1WI and several high density spots within it. Mass effect on the right lateral centricle was noted.
    • unremarkable change in the skull base
  • IMP: suspected a metastatic tumor or maligment glioma in the right parietal lobe, causing significant mass effect on the brain.
• 2022-09-28 CT - brain
  • History and indication: severe headache
  • Findings
    • Right brain metastases with calcifications, perifocal edema causing midline shift to left and right lateral ventricle compression.
    • No evidence of intracranial hemorrhage.
    • Intact bony structures.
    • Widening of cortical sulci and dilatation of ventricles.
  • IMP: Right brain metastases with mass effect.
• 2022-08-05 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 2022/05/06, the the lesion in the right acetabulum is slightly more evident. Bone metastasis in slight progression should be watched out.
  • No prominent change is noted in other bone lesions, possibly more benign in nature.
• 2022-08-04 CT - chest
  • Left breast cancer with right breast, bilateral lung and liver meta. Right axillary lymphadenopathy, these tumor size and extension are stationary.
• 2022-05-10 CT - chest
  • advanced Lt breast cancer with liver, lungs, and axillary LNs metastases, stationary as compared with CT on 20220210
• 2022-05-06 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 2022/02/07, no prominent change is noted in the the lesion in the right acetabulum, compatible with bone metastasis in stationary status.
  • The previous lesion in the left 3rd rib is less evident.
  • No prominent change is noted in other bone lesions, possibly more benign in nature.
• 2022-02-10 CT - chest
  • Left breast tumor with right breast subcutaneous meta. Stationary.
  • Lung meta, in regression.
• 2022-02-07 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 2021/11/11, the lesion in the right acetabulum is more evident, suspected bone metastasis in progression.
  • Increased tracer uptake at the left hip comes to more prominent also, and the nature is to be determined (metastasis, compensatory effect or other nature ?). Please correlate with other clinical findings for further evaluation.
    
  • No prominent change is noted in other bone lesions.
• 2021-11-11 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 2021/08/11, the lesion in the right acetabulum is a little more evident, compatible with bone metastasis in a little more progression.
  • A new hot spot in the anterior aspect of left 3rd rib. Either post-traumatic change or bone metastasis may show this picture. Please correlate with the clinical history and follow up bone scan for further evaluation.
  • The lesions in the upper L-spines and right S-I joint are slightly more evident. The nature is to be determined (early metastases? degenerative change in a little more severe status?). Please correlate with other clinical findings for further evaluation.
  • No prominent change is noted in other bone lesions.
• 2021-11-10 CT - chest
  • advanced Lt breast cancer with liver, lungs, and axillary LNs metastases, in progression of lung metastasis, but regression of hepatic metastasis and primary breast tumor as compared with CT on 20210810
• 2021-08-11 Tc-99m MDP whole body bone scan
  • Markedly increased activity in the right acetabulum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
  • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral shoulders, S-I joints, left hip, and knees.
• 2021-08-10 CT, lung/mediastinum/pleura:
  • advanced Lt breast cancer with liver, lungs, and axillary LNs metastases, in progression compared with CT on 6/24.
  • decreased size of Rt breast mass with axillary lymphadenopathy compared with CT on 6/24.
  • uterine myomas.
• 2021-08-10 SONO, breast:
  • left breast cancer, upper hemisphere.
  • suspicious right breast tumors at 4’ and 10’ (#2, #3), contralateral cancer cannot be excluded. suggest biopsy.
  • BI-RADS category 6, known Biopsy-proven malignancy. surgical excision should be considered when clinically appropriate.
• 2021-08-10 Doppler color flow mapping, 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 27) / 78 = 65.38%
    • M-mode (Teichholz) = 66
  • Normal LV systolic function with normal wall motion.
  • LV diastolic dysfunction Gr 2.
  • Normal RV systolic function.
  • Trivial MR; mild TR.
• 2021-07 right breast palpable mass with oozing and purulent discharge were noted.
  • left breast cancer, stage IV, with liver and right femoral bone metastasis? s/p 8 cycles chemotherapy and herceptin for 2-3 cycles at Taipei city hospital Fuyou branch, and hold since 2021-04.
  • hypertension.

[counsultation]

• 2022-10-06 Radiation Oncology
  • Q
    • She visited our ER due to headache, vomiting and general weakness for 3 days. CT showed right brain metastases with calcifications, perifocal edema causing midline shift to left and right lateral ventricle compression. MRI showed suspected a metastatic tumor or maligment glioma in the right parietal lobe, causing significant mass effect on the brain on 20220928. Concern of the mass effect by brain tumor, she agreed to undergo craniectomy for metastatic brain tumor excision on 20220929 . After operation, she was sent to ICU for intensive monitoring. She was sent to normal ward after her condition improved. During our ward, her condition was stable without ICP elevation or infection sign or loss of GCS. The pathology of brain tumor revealed breast tumor metastasis, and further management was needed.
    • We strongly need your expertise for radiotherapy arrangement and further advises for current breast cancer. Thank you very much.
  • A
    • Postoperative RT is indicated. CT-simulation will be arranged on 2022/10/12. Plan to deliver 18 Gy/ 6 fx to the whole brain. Then boost the preOP tumor bed to 36 Gy/ 12 fx. RT will start around 10/13 or 14. Thank you very much.
• 2022-09-28 Neurosurgery
  • A
    • 54 y/o female.
      • Left breast cancer with right breast, bilateral lung, and liver metastases.
      • c/o headache and nausea.
    • Head CT scan: R hemipheric edema.
    • IMP: breast ca with brain metastasis.
    • Rx: Brain MRI/MRA with/without contrast.
    • Admitted to ward if the patient and family consent to undergo craniotomy.
    • Poor prognosis.
• 2021-08-23 Rehabilitation
  • Q
    • For educating the patient learning to use mobility aids, such as walkers, canes, and also needs to learn how to turn over, get in and out of bed, get in and out of a wheelchair, and walk to alleviate pain.
    • This 53-year-old woman patient has suffered from left breast huge mass for one year and she visited our OPD for help. Left breast cancer was suspect after breast mammography and echo examination. Echo guide core needle biopsy was performed on 2020/06/09 and invasive ductal carcinoma was confirmed by pathology. After 4-8 courses Neo-adjuvant chemotherapy with AC-T for 8 cycles(AC x 4 and taxotere x 4) and herceptin for 2-3 cycles at FuYou Hospital (hold since 2021-04). Due to severe side effect of the chemotherapy, she was admitted for supportive treatment. She was refer to our oncologist of right palpable mass with oozing and purulent discharge without change. Ｃurrent stage is cT4cN1M1, Stage IV. Now, she was admitted to our ward for further treamtent.
  • A
    • Assessment
      • Left breast cancer with liver and right femoral bone metastasis ,cT4cN1M1, Stage IV
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation programs
      • Goal: recondition, improve endurance and muscle strength
• 2021-08-12 Radiation Oncology
  • Q
    • This 53-year-old woman patient is a case of Left breast cancer with liver and right femoral bone metastases, Stage IV. Right thigh pain developed in 2021/05. Whole body bone scan on 2021/08/11 showed right pelvis bone metastasis. Now, for evaluate palliative radiotherapy for pain control. Thank you.
  • A
    • Palliative RT is indicated. CT-simulationi will be arranged today. Plan to deliver 30 Gy/ 10 fx to the Rt hip joint region. RT will start on 2022/08/16. Thank you very much.

[immunochemotherapy]

• 2023-06-27 - Enhertu (trastuzumab deruxtecan) 5.4mg/m2 200mg D5W 100mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg D1-3
• 2023-06-06 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-05-16 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-03-28 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-02-21 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-01-31 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-01-03 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-12-13 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-11-23 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-10-31 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-08-18 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2022-07-27 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2022-07-06 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2022-06-15 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2022-05-25 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2022-05-04 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2022-03-30 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2022-03-02 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2022-02-09 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2022-01-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2021-12-15 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2021-11-24 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2021-11-03 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2021-10-13 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2021-09-22 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2021-09-02 - docetaxel 35mg/m2 60mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
• 2021-08-26 - docetaxel 35mg/m2 55mg NS 250mL 1hr
• 2021-08-12 - docetaxel 35mg/m2 55mg 1hr

==========

[underdose] (not posted)

Enhertu 5.4mg/kg

2023-06-28

[reconciliation]

• Currently, we are unable to access the patient’s PharmaCloud database, likely due to lack of authorization. However, after reviewing the medication records in HIS5, it’s apparent that all valid prescriptions have been issued by the Hemato-Oncology department. Therefore, we did not find any issues related to medication reconciliation.

[patient education]

• On this hospitalization, the patient is receiving Enhertu ADC for the first time. I visited the patient around 14:00 on 2023-06-28, carrying a leaflet explaining the possible side effects and precautions of this medication. During my visit, the patient’s younger sister arrived, and I also explained the details to her, especially emphasizing on the risk of Interstitial Lung Disease. I informed them that they should immediately notify the medical team if any suspected symptoms occur. The patient’s sister inquired about how to contact the doctor on regular days, to which I advised that she could call the hospital to reach the clinic or contact nurse practitioner Zheng for relay. I also provided the contact information of the Pharmacy Consultation Window for their future reference.

2022-11-23

• In terms of PFS and OS, trastuzumab deruxtecan outperforms trastuzumab emtansine (ref: Trastuzumab Deruxtecan versus Trastuzumab Emtansine for Breast Cancer. N Engl J Med. 2022;386(12):1143-1154. doi:10.1056/NEJMoa2115022), however trastuzumab deruxtecan remains unreimbursed by the National Health Insurance program.
• The patient has met the criteria (had received trastuzumab and a taxane) to apply for trastuzumab emtansine coverage under the National Health Insurance Program.
• Ado-trastuzumab emtansine for patients with breast cancer, metastatic, HER2+: IV 3.6 mg/kg every 3 weeks until disease progression or unacceptable toxicity.
• As long as trastuzumab emtansine is used, it is recommended to monitor any possible hepatotoxicity and cardiotoxicity on a regular basis.

2022-09-29

• Neurosurgery suggests craniotomy for the patient’s severe headache due to brain mets.
• Neratinib has been tested in combination with capecitabine in patients with HER2+ breast cancer brain metastases. Of the 37 patients, 89%, 22% and 14% were previously treated with trastuzumab, T-DM1 and another investigational HER2-directed agent, respectively, and most had received previous radiotherapy (65% WBRT and 32% SRS) and several chemotherapy agents. It is reported that 18 partial responses, with a brain metastasis volumetric response of 49%, 6-month PFS of 38% and a median time-to-brain-mets progression of 5.5 months. 51% of patients experienced grade 3 toxicities, of which 32% were gastrointestinal events, mostly diarrhoea, requiring specific prophylactic management.
  • ref: a phase II trial of neratinib and capecitabine for patients with human epidermal growth factor receptor 2-positive breast cancer and brain metastases. J. Clin. Oncol. 37, 1081–1089 (2019).
• The above result was supported by the NALA -randomised second-/third-line trial, including 130 patients with non-progressive BM at study entry. The overall cumulative incidence of intervention for BM was reduced from 29.2% with lapatinib–capecitabine to 22.8% with neratinib–capecitabine (P = 0.043).
  • ref: Neratinib + capecitabine versus lapatinib + capecitabine in patients with HER2+ metastatic breast cancer previously treated with >= 2 HER2-directed regimens: findings from the multinational, randomized, phase III NALA trial. J. Clin. Oncol. 37, 1002–1002 (2019).
• In an investigator-initiated prospective, open-label, single-arm phase II TUXEDO-1 study conducted among patients with newly diagnosed or progressive brain metastases from HER2-positive breast cancer, antibody drug conjugate trastuzumab deruxtecan yielded responses by response assessment in neuro-oncology brain metastases (RANO-BM) criteria in 11 of 15 patients with a response rate by central review of 73.3% in the intention-to-treat (ITT) population. Median progression-free survival (PFS) was 14 months, and median overall survival (OS) was not reached at a median follow-up of 12 months.
  • ref: Trastuzumab deruxtecan in HER2-positive breast cancer with brain metastases: a single-arm, phase 2 trial. Nat Med 28, 1840–1847 (2022).
• Trastuzumab deruxtecan is available as a ‘temporary purchase’ item in the inventory.

2021-08-12

• stage workup is renewing, continuing HTN management for the moment with patient-carried drugs
  • Adapine (nifedipine) 30mg PO QD
  • Diovan (valsartan) 80mg PO QD
  • Syntrend (carvedilol) 12.5mg PO QD
• brain and/or spine MRI with contrast should be indicated if CNS symptoms, back pain or symptoms of spinal cord compression.
  • bone scan or sodium fluoride PET/CT, if needed.
• all or some of ER, PR, HER2, BRCA, PIK3CA, PD-L1, NTRK, MSI-H/dMMR, TMB-H tests might have been done at Taipei city hospital Fuyou branch, order the tests for new biopsy if needed.
  • since the patient received herceptin before, HER2 should be positive.
• for preoperative/adjuvant therapy for HER2(+), options including:
  • paclitaxel/trastuzumab
  • docetaxel/carboplatin/trastuzumab
  • docetaxel/carboplatin/trastuzumab/pertuzumab
  • doxorubicin/cyclophosphamide followed by paclitaxel/trastuzumab
  • doxorubicin/cyclophosphamide followed by paclitaxel plus trastuzumab/pertuzumab

701474048

230628

[exam findings]

• 2023-04-18 PD-L1 (22C3)
  • Block No: S2023-04371
  • RESULTS：
    • Combined Positive Score (CPS) assessment: CPS >= and <10
    • Combined Positive Score (CPS): X
• 2023-04-01, -03-20 SONO - abdomen
  • moderate fatty liver (suboptimal exam of liver)
  • fatty infiltration of pancreas
  • suspected right renal cysts or focally dilated right renal pelvis
• 2023-03-21 MRI - breast
  • Clinical history: 72 y/o female patient with left breast cancer.
  • With and without enhancement MRI of breast (axial T1, T1FS, sagittal T2, T2FS, axial and sagittal T1FS contrast, dynamic study):
    • Large irregular tumor, up to 6cm in right subareolar region with periareolar skin thickening, prominent heteregeneous enhancement, c/w breast malignancy.
    • There are multiple enlarged lymph nodes in bilateral axillary regions (mainly in right side, up to 2.2cm), r/o lymph nodes metastasis.
  • IMP:
    • Right breast malignancy with skin invasion and bilateral axillary lymph nodes metastasis.
  • BI-RADS:
    • Category 6 - proven malignancy.
• 2023-03-20 ECG
  • Normal sinus rhythm
  • Increased R/S ratio in V1, consider early transition or posterior infarct
• 2023-03-13 PET
  • Glucose-hypermetabolism in the right breast with nipple and skin of the anterior chest wall involvement, in the right axillary lymph nodes, and in a right SCF lymph node, highly suspected breast cancer with regional lymph nodes metastases.
    
  • Increased FDG uptake in a level II lymph node of the right neck and in a left axillary lymph node, highly suspected cancer with distant metastases.
  • Right breast cancer, cT4N3cM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-03-10 Patho - lymphnode biopsy
  • Labeled as “right axillary lymph node”, core needle biopsy — invasive carcinoma.
  • Section shows lymph node with invasive carcinoma.
• 2023-03-10 Patho - breast biopsy
  • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • IHC stains: ER (-, 0%), PR(-, 0%), Her2/neu: negative(score=1+), Ki-67(25 %), p63 (-).
• 2023-03-10 SONO - breast
  • Right breast tumors with enlarged axillary lymph nodes, suggest biopsy.
  • BI-RADS: Category 5 - highly suggestive of malignancy - appropriate action should be taken.
• 2023-03-10 Mammography
  • Digital mammography of both breasts with MLO and CC views:
    • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
    • Diffuse increased density in right breast with periarolar skin thickening, r/o malignancy.
      
    • No periareolar skin thickening.
    • Enlarged right axillary lymph nodes.
  • Impression:
    • Dense breast. R/O right breast malignancy with lymph nodes metastasis, suggest biopsy.
  • BI-RADS: Category 5 - highly suggestive of malignancy - appropriate action should be taken.

[chemotherapy]

• 2023-06-21 - docetaxel 75mg/m2 120mg NS 250mL 1hr (D, Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-05-31 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 955mg NS 500mL 1hr (AC(lipo), Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + famotidine 20mg + NS 250mL
• 2023-05-03 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (AC(lipo), Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + famotidine 20mg + NS 250mL
• 2023-04-12 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (AC(lipo), Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-03-21 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (AC(lipo), Q3W)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

2023-06-27 G-CSF (filgrastim 150ug) SC ST 2023-06-21 Granocyte (lenograstim 250ug) SC QD 3D

==========

2023-06-28

• The pathology results from the breast biopsy performed on 2023-03-10 confirmed that the patient has triple-negative breast cancer (TNBC) with HER2-low characteristic (ER negative, PR negative, and Her2/neu score=1+).

• Following this diagnosis, the patient underwent four cycles of liposomal doxorubicin with cyclophosphamide (AC) on 2023-03-21, 2023-04-12, 2023-05-03, and 2023-05-31. Docetaxel was then administered on 2023-06-21.

• Leukopenia episodes were observed on the 20th day after the 3rd AC administration and the 6th day after the 1st docetaxel administration, with WBC levels marked with an asterisk (*) representing WBC < 2K/uL and double asterisks (**) representing WBC < 1K/uL.

  • 2023-06-27 WBC 0.93 x10^3/uL **
  • 2023-06-27 WBC 0.79 x10^3/uL **
  • 2023-06-20 WBC 3.02 x10^3/uL
  • 2023-05-30 WBC 5.99 x10^3/uL
  • 2023-05-23 WBC 1.74 x10^3/uL *
  • 2023-05-02 WBC 4.50 x10^3/uL
  • 2023-04-12 WBC 4.29 x10^3/uL
  • 2023-03-08 WBC 7.64 x10^3/uL

• To manage the episodes of leukopenia, filgrastim 150ug was given on 2023-06-27 and lenograstim 250ug was given consecutively for 3 days starting from 2023-06-21. Following these interventions, the patient’s WBC level has begun to show signs of improvement. Regular monitoring is essential to ensure this upward trend continues and to ensure the patient’s safety during further chemotherapy treatments.

• The NHI in Taiwan approves the use of G-CSF for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL after chemotherapy. As the patient meets these criteria, the use of G-CSF is covered by NHI.

• The patient received G-CSF with the chemotherapy regimen on 2023-06-21. For primary and secondary prophylaxis, G-CSF administration should typically begin 24 to 72 hours after completion of chemotherapy.

• If the current chemotherapy regimen becomes less effective, Enhertu (fam-trastuzumab deruxtecan-nxki) may be used. This medicine is indicated for adult patients with unresectable or metastatic HER2 low (IHC 1+ or IHC 2+/ISH-) breast cancer who have received prior chemotherapy in the metastatic setting or who have experienced disease recurrence within six months of completing adjuvant chemotherapy. However, Enhertu is currently not covered by NHI in Taiwan.

700769074

230627

[exam findings]

• 2023-06-05 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (135 - 54) / 135 = 60.00%
    • M-mode (Teichholz) = 60
  • Conclusion:
    • Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Mildly dilated LV with preserved LV and RV systolic function.
    • Mildly dilated aortic root.
• 2023-05-24 Patho - soft tissue debridement
  • PATHOLOGIC DIAGNOSIS
    • Breast, left, partial mastectomy — Invasive carcinoma of no special type, recurrent
    • Resection margin, breast, left, simple mastectomy — Free
    • Lymph node, left axilla sentinel, SLNB — Negative for malignancy (0/6)
    • AJCC 8 th edition, Pathology stage: rpT1c(m)N0(sn); Anatomic stage IA; Prognostic stage IA if cM0
    • Specimen labeled “capsule”, left breast, release constracture — Chronic inflammation, fibrosis and foreign body reaction
  • MACROSCOPIC EXAMINATION
    • Breast Size: 6.5 x 4.1 x 1.8 cm
    • Skin Size: 6.2 x 1.1 cm
    • Nipple: Not included
    • Tumor Size: Two tumors, 1.5 x 1.0 x 0.8 cm (9’ tumor) and 1.0 x 1.0 x 0.8 cm (8’ tumor) , respectively
    • Resection Margin: Free, 0.4 cm from the deep margin
    • Lymph node: Axilla sentinel
    • Specimen labeled “capsule, left breast”: two pieces, measuring up to 3.5 x 2.8 x 0.4 cm.
    • Representative parts are taken for section and labeled: F2023-00239FS A1= 12’ 3’, 6’’ margins, FSA2= 9’ and deep margins, FSB1-FSB2= left axilla sentinel lymph nodes, A= skin, A2-A4= 9’ tumor, A5-A6= 8’ tumor, A7= non-tumor. S2023-10135= capsule, left breast
  • MICROSCOPIC EXAMINATION
    • Histology
      • Histologic type: Invasive carcinoma of no special type (both 9’ and 8’ tumors)
      • Size of invasive carcinoma: 1.5 x 1.0 x 0.8 cm (9’ tumor) and 1.0 x .0 x 0.8 cm (8’ tumor)
        
      • Histologic grade (Nottingham histologic score): Grade 2 (score= 7, both tumors)
      • Skin involvement: Absent
      • Ductal carcinoma in situ: Absent
    • Margins: Negative, Closest margin ( 4 mm from deep margin)
    • Nodal status: Negative (0/6)
      • number of lymph node examined: 6 (sentinel)
      • number with macrometastases (> 2mm): 0
      • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
      • number with isolated tumor cells (<= 0.2mm and <= 200 cells): 0
    • Treatment Effect: Not applicable
    • Lymphovascular invasion: Absent
    • Perineural invasion: Absent
    • Specimen labeled “capsule, left breast”: Chronic inflammation, fibrosis, and foreign body granuloma
  • IMMUNOHISTOCHEMICAL STUDY (S2023-08643)
    • 8’ tumor, left breast
      • ER: Positive (+, 100%, strong intensity),
      • PR: Positive (+, 100%, strong intensity)
      • HER-2/Neu: Negative (score=1+)
      • Ki-67: 10%
    • 9’ tumor, left breast
      • ER: Positive (+, 80%, strong intensity)
      • PR: Positive (+, 80 %, strong intensity)
      • Her2/neu: Positive (score=3+)
      • Ki-67: 10 %
• 2023-05-22 MRI - breast
  • Clinical history: 45 y/o female patient with left breast cancer and right breast tumor.
  • With and without enhancement MRI of breast
    • S/P left breast mammoplasty.
      
    • There is spiculated tumor in 9’region of left breast, 2.4x2.2cm, around the implant, with prominent enhancement, malignancy considered.
    • Irregular tumor, 1.4cm in 8’region of left breast, malignancy considered.
    • Right subareolar oval shaped tumor, 1.3cm.
      
    • There are stipple enhancement in right breast, r/o fibrocystic disease.
    • No periareolar skin thickening.
    • There are bilateral axillary lymph nodes.
    • Prominent internal mammary lymph nodes, left side.
  • IMP:
    • S/P left breast mammoplasty, recurrent tumors (8’region and 9region).
    • Right subareolar tumor.
    • Bilateral axillary lymph nodes.
    • Prominent left internal mammary lymph nodes, metastasis?
  • BI-RADS:
    • Category 6 - proven malignancy.
• 2023-05-15 Tc-99m MDP bone scan
  • Two hot spots in the sternal body, the nature is to be determined (bone mets, post-traumatic change or other nature ?), suggesting PET scan for investigation and follow-up with bone scan in 3 months.
  • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, knees, and feet.
• 2023-05-05 Patho - breast biopsy (no need margin)
  • Breast, left, 8’clock, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR(+ , 100%, strong intensity), Her2/neu: negative(score=1+), Ki-67(10 %), E-cadherin (+).
  • Breast, left, 9’clock, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER (+, 80%, strong intensity), PR(+, 80 %, strong intensity), Her2/neu: positive(score=3+), Ki-67(10 %), E-cadherin (+).
• 2023-04-25 SONO - breast
  • Right breast subareolar tumor, suggest biopsy.
  • S/P left mammoplasty. Irregular hypoechoic lesion in left 9’region, post-op scar or recurrence. Suggest further study.
    
  • BI-RADS 4b

[consultation]

• 2023-05-23 Hemato-Oncology
  • Q
    • This is a 45 years old woman patient. Due to left breast cancer and right breast tumor, she was admitted for surgery of left partial mastectomy + SLNB and right tumor excision on 2023/05/23. However, Hb:5.6 was noted. Anemia over 3 years without follow up by this patient told. We need your help for anemia assessment. Thank you so much!!
  • A
    • This 45 year old woman is a case of Lt breast ca s/p op at Cathay General Hospital in 2010-12, Lt breast ca recurrence proved by CNB on 2023-05-05 and Rt intraductal papilloma. she was admitted for surgery of left partial mastectomy + SLNB and right tumor excision on 2023/05/23. We are consulted for anemia.
    • 2023-05-23 did not encounter the patient during visitation.
    • For microcytic anemia, please check Hb electrophoresis, Ferritin, Fe/TIBC, stool OB (if positive, please arrange colonoscopy and panendoscopy to rule out GI bleeding).
    • Please add Foliromin 1 tab QD (or HS) and increase vitamin C intake. Arrange our OPD after discharge. Thanks for your consultation.

[immunochemotherapy]

• 2023-06-27 - trastuzumab 600mg SC 5min + docetaxel 75mg/m2 132mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr (DCH)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-06-06 - trastuzumab 600mg SC 5min + docetaxel 75mg/m2 132mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr (DCH)
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Regimen Reference Order - BRST - DCH — ref: https://www.cancercare.mb.ca/export/sites/default/For-Health-Professionals/.galleries/files/treatment-guidelines-rro-files/regimen-reference-orders/breast/BRST-DCH.pdf — Updated: June 14, 2023

• Planned Course: DCH every 21 days for 6 cycles, followed by trastuzumab every 21 days for 12 cycles
• Indication for Use: Breast Cancer Adjuvant; HER2 positive

==========

2023-06-27

• The patient received two cycles of the DCH regimen on 2023-06-06 and 2023-06-27. However, lab data shows that there was already a noticeable decrease in HGB levels before the initiation of the regimen, with the lowest record on 2023-05-22 at 5.6g/dL. Subsequently, multiple blood transfusions were conducted on 2023-05-22, 2023-06-05, and 2023-06-27.

  • 2023-06-27 HGB 7.4 g/dL
    
  • 2023-06-12 HGB 9.2 g/dL
    
  • 2023-06-05 HGB 8.1 g/dL
    
  • 2023-05-24 HGB 6.8 g/dL
    
  • 2023-05-23 HGB 6.6 g/dL
    
  • 2023-05-22 HGB 5.6 g/dL

• Trastuzumab has been associated with a low occurrence of anemia, affecting approximately 4% of patients, with less than 1% experiencing a severe (grade 3) form, according to UpToDate. However, both docetaxel and carboplatin, which are part of the patient’s treatment regimen, are known to significantly increase the risk of anemia. Docetaxel can cause anemia in 65% to 97% of patients, with 8% to 9% experiencing severe anemia (grades 3/4). Carboplatin can cause anemia in a wide range of 21% to 90% of patients. Therefore, these drugs could be contributing to the patient’s current anemia.

• MCV is at the lower end of the normal limit, and both MCH and MCHC are below the lower limit of normal, suggesting possible iron deficiency. This is further supported by the ferritin level measured on 2023-05-24, which was significantly below the lower limit of normal. It may be necessary to further investigate and address this possible iron deficiency.

  • 2023-06-27 MCV 82.3 fL
    
  • 2023-06-27 MCH 21.8 pg
    
  • 2023-06-27 MCHC 26.5 g/dL
    
  • 2023-05-24 Ferritin 4.9 ng/mL

700402514

230626

[exam findings]

• 2023-05-09 Pure Tone Audiometry
  • PTA
  • Reliability FAIR
  • Average RE 24 dB HL; LE 19 dB HL.
  • RE normal to moderately severe SNHL.
  • LE normal to moderate SNHL.
• 2023-05-06 MRI - brain
  • Venous angioma in right frontal lobe. No evidence of brain metastases.
• 2023-05-05 Patho - colon biopsy
  • Colon, descending, 40 cm above anal verge, polypectomy — tubulovillous adenoma with low grade dysplasia
  • Colon, descending, 30 cm above anal verge, biopsy — tubular adenoma with low grade dysplasia
  • Colon, transverse, 50 cm above anal verge, polypectomy — Hyperplastic polyp
  • Colon, transverse, 60 cm above anal verge, biopsy — tubulovillous adenoma with low grade dysplasia
  • Colon, hepatic flexure, biopsy — Hyperplastic polyp
• 2023-05-05 Miniprobe endoscopy ultrasound
  • Indication: for staging
  • Symptoms: for staging
  • Pre-EUS diagnosis: Eso adeno Ca
  • Endoscopic findings
    • With white light endoscopy, a easily touch-bleeding elevated lesion was noted at EC junction. With NBI-ME, focal JES-IPCL B3 pattern. Chromoendoscopy was performed with lugol-solution and showed no LVLs above EC junction. A few sessile polyps were scattered at remnant stomach.
  • EUS findings
    • With UM-DP20-25R, it showed 6.5x7.7mm hypoechoic lesion, invading to 4th layer of esophageal wall. At least two hypoechoic lesions up to 4.3mm were noted at paraesophageal space.
  • Diagnosis
    • Esophageal adenocarcinoma, EC junction, EUS staging at least cT2N1
    • Gastric polyps, remnant stomach.
• 2023-05-04 Tc-99m MDP whole body bone scan
  • Mildly increased activity in the lower T-spines and some L-spines. Degenerative change is more likely.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, left wrist, bilateral hips, knees, ankles and feet, compatible with benign joint lesions.
• 2023-05-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (107 - 47) / 107 = 56.07%
    • M-mode (Teichholz) = 55
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy
    • Trivial MR and trivial TR
    • Preserved RV systolic function
• 2023-05-03 PET
  • Increased FDG uptake in the lower third of esophagus, near E-G junction, compatible with the primary esophageal cancer.
    
  • Increased FDG uptake in a focal soft tissue in the right supraclavicular fossa, the nature is to be determined (esophageal cancer with regional lymph nodes metastases, the other primary cancer, or other nature ?), suggesting biopsy for investigation.
    
  • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
  • Highly suspected lower esophageal cancer with regional lymph nodes metastases, cTxN1-2M0, stage IIIA-B (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-04-20 CT - chest
  • IMP: Esophageal tumor at EG junction. 1.6cm.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-04-10 Patho - stomach biopsy
  • Esophagus, EC junction, biopsy — Adenocarcinoma in situ, at least
  • Microscopically, it shows adenocarcinoma in situ composed of high-grade atypical neoplastic glands admixed with necrotic tissues and stromal fibrosis.
• 2023-04-10 Esophagogastroduodenoscopy, EGD
  • Gastric A2 ulcer, anastomosis site, s/p biopsy (A)
  • Esophageal erosion, EC junction, s/p biopsy (B)
  • Remnant gastritits
  • Post subtotal gastrectomy with Billroth II anastomosis
• 2023-05-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 24) / 79 = 69.62%
    • M-mode (Teichholz) = 69.9
  • Conclusion:
    • Normal chamber size
    • Septal hypertrophy
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Mild MR
    • No regional wall motion abnormalities
• 2021-03-31 Patho - appendix (non-incidental)
  • Appendix, L.A. — Early appendicitis and myxoid degeneration of appendix wall
• 2021-03-30 CT - abdomen
  • Mild dilatation of appendix, r/o acute appendicitis, suggest clinical correlation.
  • S/P gastrectomy.
  • Left renal cysts.
• 2020-05-25 ENT Hearing Test
  • Tymp: Bil type A.
  • ART:
    • R’t ipsi 4k Hz reduced, and contra 2-4k Hz elevated and absent.
    • L’t ipsi 4k Hz and contra 4k Hz absent.
  • PTA
    • Reliability: fair
    • Average: R’t 33 dB HL, L’t 25 dB HL.
    • Bil normal to moderately severe SNHL. (4k Hz notch)

[consultation]

• 2023-05-09 Radiation Oncology
  • A
    • This 46 years old male has history of subtotal gastrectomy, alcohol(+), smoke(+). He was admitted to our GI ward due to tarry stool. Biopsy at EC junction revealed adenocarcinoma in situ, at least. The PET revealed the right supraclavicular lymph node metastasis. PET and EUS clinical staging revealed at least cT2N1-2M0,stage IIIA-B.
    • Neoadjuvant CCRT is indicated. CT-simulation will be arranged on 2023/05/15. Plan to deliver 45 Gy/ 25 fx to the lower half esophagus, the adjacent lymphatic drainage area, and Rt SCF. Then boost the esophageal tumor, LAPs, and Rt SCF LAP to 50.4 Gy/ 28 fx. RT will start around 2023/05/17 or 18. Thank you very much.
• 2023-05-08 Hemato-Oncology
  • Q
    • For lower third esophageal maglignancy further evlauation and mangement.
    • This 46 years old male has history of subtotal gastrectomy, alcohol(+), smoke(+). He was admitted to our GI ward due to tarry stool. Panendoscope was done and tissue biopsy at anastomosis revealed ulcer,no H.pylori present. However, biopsy at EC junction revealed adenocarcinoma in situ, at least. Thus, he was admitted to our chest surgery ward for furteher cancer survey and pre-operative evaluation. However, the PET reported his right supraclavicular lymph node metastasis, PET and EUS clinical staging revealed at least cT2N1M0,stage IIIA-B.
    • Thus, we need your expertise for the patient’s further evaluation and further managment, thanks a lot!
  • A
    • This 46 year old man is a case of EG junction cancer, cT2N1M0,stage III, biopsy show adenocarcinoma in situ with initial presentation epogastric pain. He had history of HTN, GU, obesity s/p subtotal gastrectomy. He was admiited for cancer work up. We are consulted for pre-op CCRT.
    • Please arrange port A insertion. Please arrang auditory test and 24 urine CCR and check Anti HBc, Anti HBs, HBsAg, Anti HCV. We will arrange chemotherapy concurrent with RT. Please consult Radio-oncologist. Thanks for your consultation

[chemotherapy]

• 2023-06-23 - cisplatin 75mg/m2 150mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D1-4 (PF, CCRT, Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-22 - cisplatin 75mg/m2 150mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D1-4 (PF, CCRT, Q4W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-06-26

• According to the PharmaCloud database, our hospital is the sole provider of all medical services and medications required by the patient in recent months. Therefore, no medication reconciliation issues have been identified.

700856655

230621

[exam findings]

• 2023-06-05 SONO - abdomen
  • Hepatic hemangiomas, right lobe
  • Renal stone, RK
• 2023-06-02 Tc-99m MDP bone scan
  • No definite evidence of bone metastasis.
  • Increased activity in the lower L-spines. Degenerative change may show this picture.
  • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral hips and right foot, compatible with benign joint lesions.
• 2023-06-01 MRI - nasopharynx
  • Oralcavity
    • Impression (Imaging stage) : T:4a N:0 M:0 STAGE:
• 2023-05-17 Patho - gingival/oral mucosa biopsy
  • Oral cavity, left tongue, incisional biopsy — Squamous cell carcinoma, moderately differentiated
  • Section shows squamous mucosal tissue with infiltration of nests of neoplastic squamous cells.

[immunochemotherapy]

• 2023-06-19 - cetuximab 400mg/m2 600mg 2hr + docetaxel 40mg/m2 60mg NS 150mL 2hr + cisplatin 40mg/m2 60mg NS 500mL 3hr + fluorouracil 1000mg/m2 1600mg NS 1000mL 22hr + leucovorin 100mg/m2 160mg in 5-FU 22hr (longer infusion taxel and platin)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-06-09 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 1000mg/m2 1600mg NS 1000mL 22hr + leucovorin 100mg/m2 160mg in 5-FU 22hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

==========

2023-06-21

• The patient’s medical history, as recorded in the HIS5 database, shows previous episodes of leukopenia and thrombocytopenia in 2018-01. No chemotherapy was administered at that time.

• More recently, in mid to late May 2023, the patient was diagnosed with SCC of the left tongue margin. The patient then received TPF chemotherapy on 2023-06-09 and a combination of TPF and cetuximab on 2023-06-19. Leukopenia, defined here as a WBC count of less than 3K/uL, was observed on 2023-06-16. To treat this, 3 doses of Granocyte (lenograstim 250ug) were administered on 2023-06-16, 2023-06-17, and 2023-06-21.

  • 2023-06-19 WBC 5.80 x10^3/uL
    
  • 2023-06-16 WBC 2.26 x10^3/uL *
  • 2023-06-01 WBC 3.57 x10^3/uL

• Given that the WBC count prior to the 2nd dose of TPF was higher than that prior to the 1st dose, and given that G-CSF was administered 2023-06-21 morning, the likelihood of severe leukopenia following the 2nd round of chemotherapy is expected to be reduced. However, the patient’s blood counts should continue to be monitored closely.

[reconciliation]

• The patient regularly visits a local psychiatric clinic to manage her episodic paroxysmal anxiety. The prescribed medications for this condition are clonazepam, fludiazepam, estazolam, and escitalopram. These medications have all been integrated into the patient’s current medication list, and no reconciliation issues have been identified. Please ensure the patient is adhering to her psychiatric medication regimen, as disruptions could potentially exacerbate her anxiety symptoms.

700030422

230620

[diagnosis] - 2023-05-08 discharge note

• Sigmoid colon cancer with liver metastases, T3N1bM1a, stage IVA s/p chemotherapy with FOLFIRI from 2022/03/07 and Avastin from 2022/04/27
• Chronic viral hepatitis B without delta-agent
• Cachexia
• Essential (primary) hypertension
• Constipation, unspecified

[exam findings]

• 2023-05-05 CT - abdomen
  • Findings: Comparison: prior CT dated 2022/08/16.
    • Prior CT identified segmental asymmetrical wall thickening of the sigmoid colon is noted again, mild decreasing in size and enhancement.
      • Prior CT identified two enlarged nodes in the adjacent mesocolon are not noted again.
    • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size that are c/w liver metastases S/P C/T with progressive disease.
    • Prior CT identified two ovoid-shaped enlarged nodes in right inguinal area are noted again, stationary.
      • Benign reactive nodes are highly suspected.
    • The urinary bladder shows diffuse wall thickening and small size that may be chronic cystitis.
  • Impression:
    • Liver metastases S/P C/T show progressive disease.
• 2023-02-11 CT - abdomen
  • Findings
    • Sigmoid colon, s/p operation. No local recurrent tumor.
    • No enlarged lymph nodes in para-aortic and pelvic regions.
    • Several liver metastasis, mild in progression.
    • No ascites, nor extraluminal free air.
    • No bony destructive lesion on these images.
  • Impression
    • Sigmoid colon, s/p operation
    • Liver metastasis, mild in progression
    • Suggest clinical correlation and follow up evaluation
• 2022-11-09 MRI - brain
  • General brain atrophy. Leukoaraiosis. Mild intracranial artherosclerosis.
• 2022-08-16 CT - abdomen
  • Findings
    • Mild regression of S-colon cancer and bil. liver metastases (up to 4.0cm).
    • A small nodule (3.6mm) at RLL.
    • Some calcifications in prostate.
    • A nodule (1.9cm) at left buttock.
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • Mild regression of S-colon cancer and bil. liver metastases (up to 4.0cm).
• 2022-08-03 All-RAS + BRAF
  • There was no variant detected in the KRAS/NRAS gene.
  • There was no variant detected in the BRAF gene.
• 2022-05-24 CT - abdomen
  • Findings
    • Much regression of S-colon cancer and bil. liver metastases (up to 5.2cm).
    • A bullae (2.8cm) at LUL.
    • Some calcifications in prostate.
    • Some tiny nodules in bil. lungs.
    • A nodule (1.9cm) at left buttock.
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • Much regression of S-colon cancer and bil. liver metastases (up to 5.2cm).
    • A bullae (2.8cm) at LUL.
    • Some tiny nodules in bil. lungs.
• 2022-03-03 CT - chest
  • Indication: colon cancer with liver meta, favor lung meta
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Pneumatocele at left upper lobe up to 2.48cm in largest dimension is found.
      • Diffuse centrilobular Emphysematous change over both lungs is found.
      • Minimal atelectatic change at right middle lobe and left lingula lobe is found.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • No evidence of bilateral pleural effusion.
      • Calcified coronary arteries is found.
    • Visible abdomen:
      • Target like hepatic tumors are found at both lobes of liver up to 9.6cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-02-25, the lesion is stationary.
        
      • The spleen, pancreas, both kidneys and adrenals are intact.
  • Imp:
    • No evidence of pulmonary meta.
    • Diffuse centrilobular Emphysematous change over both lungs.
    • Liver meta. stationary as previous CT on 2022-02-25.
• 2022-02-25 Patho - colon biopsy (Y1)
  • Colon, sigmoid colon, 30cm from AV, s/p biopsy x6 — Adenocarcinoma.
  • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2022-02-25 CT - abdomen
  • History: 20220224 sono: Two huge 8.68x7.07cm and 7.68x6.43cm ill-defined hyperechoic lesion with scattered hyperechoic spot at left lobe and S5, Two 2.13cm and 1.5cm hyperechoic lesions with hypoechoic rim was noted at S5 and S6
  • Indication: Suspected HCCs or metastases
  • Findings:
    • There is segmental asymmetrical wall thickening of the sigmoid colon measuring 5 x 2.5 cm in size that may be adenocarcinoma.
      • In addition, there are two enlarged nodes in the adjacent mesocolon that may be metastatic nodes.
    • There are several lobulated well-defined poor enhancing masses on both hepatic lobes, the largest one measuring 9.2 cm in S2-3 of the liver. During dynamic study, all masses show poor enhancement in arterial phase, portal venous phase, and delayed phase images.
      • Metastases are highly suspected.
    • There is a well-defined enlarged node measuring 2.2 x 1.4 cm in hepatoduodenal ligament that may be benign reactive node.
      • The differential diagnosis include metastatic node.
    • There are two ovoid-shaped enlarged nodes in right inguinal area that may be benign reactice nodes.
    • There are two small soft tissue nodule in RML and RLL of the lung at lung window setting, nature? Please correlate with chest CT.
    • The urinary bladder shows diffuse wall thickening and small size that may be chronic cystitis.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression ( Imaging stage ): T:T3 (T_value) N:N1b (N_value) M:M1 (M_value) STAGE:IVA(Stage_value)

[consultation]

• 2022-03-02 Hemato-Oncology
  • A
    • Impression:
      • Sigmoid colon cancer with liver metastases, at least cT3N1bM1a, stage IVA, patho: Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Suggestion:
      • Already make appointment for family meeting in the morning on 2022-03-03
      • arrange chest CT with/without contrast r/o lung meta
      • consult CRS for operation evaluation
      • may add FOLFIRI +/- avastin
        
      • We wound like to take over this case, thanks for your consultation. If there is any problem, please feel free to let us known.
• 2022-03-02 Colorectal Surgery
  • A
    • S
      • This 74 year-old male patient was consulted CRS for colon cancer with liver metastases. he has the histories of 1) HBV but loss follow-up, 2) inguinal hernia s/p operation, 3) upper GI bleeging s/p micro invasive surgery. He denied any allergey, and family history.
      • He smoke 0.5 PPD for 60 years and no alcholism. He had body weight lost 8 Kgs (60 to 52 Kgs) and severe anorexia in the past 3 months.
      • He visited Postal Hospital for help. Hepatitis markers were checked and HBeAg, Anti-HBs, Anti-HBe, Anti-HBc, Anti-HCV were all negative, and HBsAg 3048.14 IU/mL. Tumor maker was checked and showed AFP 3.9 ng/mL; CEA 1993 ng/mL ; CA-199 555 ng/mL. Abdominal sonography was arranged on 2022/02/09 and revealed multiple liver tumors. He transferred to our GI OPD for help. He sufferred from anorexia, epigastric paresthesia, and tea color urine for days. He denied chillness or fever, nausea or vomiting, dizziness, headache, chest tightness or pain, diarrhea or constipation, dysuria or frequency found. No TOCC history was noted. COVID19 rapid test showed Negative. Lab data showed no leukocytosis and normal AST, ALT, bilirubin, r-GT. Elevated ALP 122 U/L. Under the impression of Liver tumor, R/O HCC or metastasis tumor, he was admitted to GI ward for cancer survey and further management.
      • After admission, colonscopy was done and the pathlogy showed adenocarcinoma
      • Abdominal CT with contrast was done that showed colon cancer with liver metastasis, T3N1bM1a, stage IVA..
      • Abdomen: soft, no distended, no tenderness
      • pass stool(+)
    • A: S-colon cancer with multiple liver metastases, T3N1bM1a, stage IVA.
    • P:
      • We will discuss with the patient and his son this afternoon
      • Suggest chemotherapy with target therapy first, then re-evaluate for possible colectomy+/-liver surgery
      • Check RAS gene status
      • We would like to follow this patient

[MedRec]

• 2022-11-08 SOAP Psychosomatic medicine
  • S
    • Recently found to have increasingly deteriorating memory, depressive symptoms, anxiety symptoms, fear symptoms, delusional symptoms (being stolen, being harmed, jealousy, being intruded, misidentification), hallucinations, behavioral disorders (irritability, aggression, wandering, gluttony, changes in eating, repetitive behavior, bizarre behavior, poor personal hygiene, inappropriate disorganization).
    • Screen dementia positive in the community by (elderly health check, care points, community health centers) with AD-8 test.
    • Past history of hypertension (+, -), DM (+, -), hyperlipidemia (+;-), arrhythmia (+,-), alcohol drink habit (+,-), head injury (+,-).
    • 1st time visiting comes with TZ volunteer, family (couple, son, daughter) due to poor memory, frequently showing forgetfulness for years.
    • Community memory screening AD8 > 2
    • Dementia warning signs assessment > 2
    • In the past few months, have family members mentioned (or have you discovered) that you seem to have the following conditions? Please mark (V) for yes and (X) for no.
      • ( v ) Memory decline affecting life:
      • ( v ) Difficulty planning or solving problems:
      • ( v ) Unable to handle familiar tasks
      • ( v ) Confusion about time and place:
      • ( v ) Difficulty understanding the relationship between visual images and space:
      • ( v ) Difficulty in verbal expression or writing:
      • ( v ) Things are misplaced and lose the ability to retrace steps:
      • ( v ) Poor or weakened judgment:
      • ( v ) Withdrawal from work or social activities:
      • ( v ) Changes in mood and personality:
      • Result: Mark (V) for a total of OO items.
  • O
    • Repeating the same questions, stories, and statements. Difficulty learning how to use tools, equipment, and small appliances. Forgetting the correct month and year. Difficulty remembering appointment times. Persistent problems with thinking and memory.
    • Result explanation:
      • Please check the items below according to the actual scores on the previous page (single choice):
        • AD8 total score >= 2 points
        • GDS total score >= 2 points
    • Patient meets the criteria for Alzheimer’s disorder
      • A: Multiple cognitive developmental impairments combined with the following A-1 and A-2 impairments:
        • A-1: Memory impairment (unable to learn new things or unable to recall previously learned things)
        • A-2: At least one of the following cognitive impairments:
          • Aphasia
          • Apraxia
          • Agnosia
    • Disturbance in executive functioning
      • B: Causing social or occupational difficulties, and a significant decline from the previous level of functioning
      • C: Cognitive decline is gradual and persistent
    • PSP: poor social function, disorientation to time and place, easily lost orientation to home
    • O: Vital sign: relatively stable
      • Physical and neurological examination: no significant abnormal findings were noticed during outpatient visiting
    • Mental Status Examination:
      • JOMAC: poor orientation, memory, and abstract thinking.
      • Insight: partial
      • Impression: Mild Cognitive Impairment
    • Plan to do:
      • Examinations for CBC, VDRL, BUN, Creatinine, GOT, GPT, T4, TSH, B12, and Folic acid.
      • MMSE or CDR cognitive test report.
      • Arrange brain CT or MRI if indicated
  • Diagnosis
    • Mild cognitive impairment of uncertain or unknown etiology G31.84
• 2022-08-31 SOAP Hemato-Oncology
  • S: 2022-08-03 All-RAS: Wildtype
  • O: 2022/08/16 CT: ABD - Mild regression of S-colon cancer and bil. liver metastases (up to 4.0cm).
• 2022-08-03 SOAP Hemato-Oncology
  • O: AE: anorexia - staionary
  • P: Avastin 10 - 2 = 8 on 2022-08-03
• 2022-07-20 SOAP Hemato-Oncology
  • O: AE: anorexia
• 2022-05-25 SOAP Hemato-Oncology
  • O: AE: Gr 1 constipation -> diarrhea
• 2022-04-27 SOAP Hemato-Oncology
  • O: AE Gr 1 constipation -> not improved
  • A/P:
    • Avastin 24 - 2 = 22
    • Already explain HTN, proteinuria, hollow organ perforation etc
    • Arrange Abd/Pelvis/Chest CT Q3M, next on 2022-05-24
• 2022-04-13 SOAP Hemato-Oncology
  • O: AE Gr 1 constipation
  • Prescription
    • Norvasc (amlodipine 5mg) 1# QD
    • Takepron (lansoprazole 30mg) 1# QDAC
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Through (sennoside 12mg) 2# HS
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • MgO 250mg 1# TID
    • Hepac Lock Flush (heparin sodium 100 USP units/mL 10mL) 10# ST IRRI (irrigation)
• 2022-03-31 SOAP Hemato-Oncology
  • O: Now on FOLFIRI, C1D1 on 2022-03-07
• 2022-03-17 SOAP Hemato-Oncology
  • S: Hx of sigmoid cancer s/p C/T, T3bN1aM1a, Stage IVA
• 2022-03-10 ~ 2022-03-10 POMR Hemato-Oncology
  • Discharge diagnosis
    • Sigmoid colon cancer with liver metastases, T3N1bM1a, stage IVA
    • Reflux esophagitis LA grade A
    • Gastric erosions, antrum and low body
    • Chronic viral hepatitis B without delta-agent
    • Constipation, unspecified
  • CC
    • anorexia, epigastric paresthesia, and tea color urine for days
  • Prescription
    • Promeran (metoclopramide 3.84mg) 1# TIDAC
    • Through (sennoside 12mg) 2# HS
    • Baraclude (entecavir 0.5mg) 1# QDAC
    • Takepron (lansoprazole 30mg) 1# QDAC
• 2022-02-23 SOAP Gastroenterology
  • S
    • Loss 8 Kgs (60 to 52 Kgs) and anorexia in the past 3 months.
    • Metastatic lesions were found in the liver with sky high tumor markers at a LMC on 2022-02-08.
    • So, he was referred to our hospital for evaluation.
  • O
    • PE: No icteric sclera, soft abdomen, no leg pitting edema.
    • 2022-02-07 CEA: 1993 (<5).
    • 2022-02-07 Ca19-9: 555. (at a LMC).
    • 2022-02-09 Abdo sono: Multiple liver tumors. (at a LMC).

[chemoimmunotherapy]

• 2023-06-19 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-06-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-05 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-22 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-18 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-04 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-14 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-23 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-02 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-09-21 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-09-07 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-08-24 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-08-03 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-07-20 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-07-06 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-06-22 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 120mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-06-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-05-25 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-05-11 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-04-27 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-04-13 - irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-04-01 - irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-03-18 - irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-03-07 - irinotecan 90mg/m2 135mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-06-20

• Based on the information retrieved from the PharmaCloud database, the patient visited a local clinic for nausea and vomiting on 2023-06-09. The last chemotherapy treatment took place from 2023-06-01 to 2023-06-03. Delayed nausea and vomiting, a common side effect of chemotherapy, usually begins more than 24 hours after treatment and may continue for several days after completion of therapy. Please monitor to see if the nausea and vomiting resolves.

• During this hospitalization, the patient started a new regimen of FOLFOX (previously on FOLFIRI). As oxaliplatin is a new component for the patient, a patient education visit was conducted at approximately 15:00 on 2023-06-20. However, at the time of the visit, the patient was resting with his eyes closed. In order not to disturb the patient’s rest, the oxaliplatin medication guide including information on side effects, precautions, and pharmacy contact information was left on the bedside table for the patient to review upon awakening.

2023-06-02

• The patient had appointments at a local clinic for chronic pharyngitis on 2023-04-03 and 2023-05-02. The medications prescribed during these visits have now expired. No issues were identified during the medication reconciliation process, provided the patient no longer has symptoms of pharyngitis.

2023-05-08

• On 2023-05-03, lab data showed essentially normal results except for an elevated tumor marker CEA. CEA initially decreased from 2204ng/mL on 2022-02-25 to 50ng/mL on 2022-10-12 after starting bevacizumab plus FOLFIRI treatment on 2022-03-07. However, during the course of treatment, the CEA level has then increased in an apparent trend and has reached 414ng/dL to date. During the same period, another tumor marker, CA199, has also increased, but at a slower rate. This might indicate that the disease has become more heterogeneous with increased resistance and/or that the current regimen may not be as effective as it was initially. Comparing the results of the two most recent CT scans (2023-05-05 and 2023-02-11), it is evident that the liver metastases are showing progressive disease.
  • 2023-05-03 CEA 414.57 ng/mL
    
  • 2023-04-11 CEA 337.63 ng/mL
    
  • 2023-03-01 CEA 193.51 ng/mL
    
  • 2023-02-11 CEA 213.84 ng/mL
    
  • 2023-02-08 CEA 193.49 ng/mL
    
  • 2022-11-02 CEA 78.00 ng/mL
    
  • 2022-10-12 CEA 50.71 ng/mL
    
  • 2022-09-21 CEA 52.31 ng/mL
    
  • 2022-08-17 CEA 60.72 ng/mL
    
  • 2022-07-20 CEA 94.15 ng/mL
    
  • 2022-06-22 CEA 146.05 ng/mL
    
  • 2022-06-08 CEA 176.80 ng/mL
    
  • 2022-05-25 CEA 265.53 ng/mL
    
  • 2022-05-11 CEA 419.31 ng/mL
    
  • 2022-04-27 CEA 448.30 ng/mL
    
  • 2022-04-01 CEA 1395.98 ng/mL
    
  • 2022-02-25 CEA 2204.47 ng/mL
    
  • 2023-05-03 CA199 21.68 U/mL
    
  • 2023-04-11 CA199 18.12 U/mL
    
  • 2023-03-01 CA199 16.28 U/mL
    
  • 2023-02-11 CA199 20.05 U/mL
    
  • 2023-02-08 CA199 14.93 U/mL
    
  • 2022-11-02 CA199 10.66 U/mL
    
  • 2022-10-12 CA199 12.81 U/mL
    
  • 2022-09-21 CA199 10.02 U/mL
    
  • 2022-08-17 CA199 10.98 U/mL
    
  • 2022-07-20 CA199 11.93 U/mL
    
  • 2022-06-22 CA199 12.26 U/mL
    
  • 2022-06-08 CA199 15.92 U/mL
    
  • 2022-05-25 CA199 19.70 U/mL
    
  • 2022-05-11 CA199 33.04 U/mL
    
  • 2022-04-27 CA199 36.93 U/mL
    
  • 2022-04-01 CA199 131.87 U/mL
    
  • 2022-02-25 CA199 592.71 U/mL
• No medication reconciliation issues have been identified for this patient.

700578300

230620

[diagnosis] - 2023-03-21 admission note

• Descending colon adenocarcinoma obstruction with peritoneal seeding, lung and liver metastases, cT4aN2bM1c, stage IVC, s/p T-loop colostomy excisional biopsy of omental seeding on 2022/11/21 and palliative chemotherapy with FOLFIRI from 2022/12/02 and Target therapy with Avastin from 2022/12/16
• Unspecified viral hepatitis B without hepatic coma
• Essential (primary) hypertension

[past history]

• The patient had hypertension for 10 years ago under regular medical control, and hyperlipidemia
• History of operation:
• Myoma, s/p total hysterectomy for 20 years ago in FuYou Hospital
• T-loop colostomy excisional biopsy of omental seeding on 2022/11/21

[allergy]

• NKDA             

[family history]

• Her mother had hypertension and DM, while her father had hemorrhagic stroke
• There is no family history of cancer, mental diseases or asthma.

[exam findings]

• 2023-03-23 CT - abdomen
  • History and indication:
    • D-colon adenocarcinoma obstruction with peritoneal seeding, lung and liver meta, cT4aN2bM1c, stage IVC
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Much regression of D-colon cancer, peritoneal seeding, LNs, lung and liver metastases.
    • Liver and renal cysts (upt o 9.0cm).
    • Gallbladder stones (up to 1.9cm).
  • IMP:
    • Much regression of D-colon cancer, peritoneal seeding, LNs, lung and liver metastases.
• 2023-01-30 KUB
  • There are three gallstones.
  • S/P colostomy at right lower abdomen?
  • Spondylosis of the L-spine is noted.
• 2022-11-22 All-RAS + BRAF
  • Cell Block: S2022-20638 A1
  • RESULTS：
    • There was no variant detect in the KRAS/NRAS gene.
    • There was no variant detect in the BRAF gene.
• 2022-11-22 Patho - omentum biopsy
  • Omentum, excisional biopsy — metastatic adenocarcinoma, colorectal origin
  • Microscopically, it shows adenocarcinoma composed of invasive neoplastic glands with tumor necrosis and stromal fibrosis. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • Immunohistochemical stain reveals CK7(-), CK20(+), EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2022-11-18 ECG
  • Sinus bradycardia
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2022-11-18 Flow Volumn Loop
  • Normal ventilation
• 2022-11-18 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (83 - 14) / 83 = 83.13%
    • M-mode (Teichholz) = 83
  • Conclusion:
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; trivial MR; mild TR.
    • Multiple liver cysts with variable sizes (the largest one up 8.8 cm).
• 2022-11-17 CT - abdomen
  • History and indication: Advanced D-colon cancer with obstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of D-colon with adjacent fat stranding and regional LAP.
    • Some soft tissues (up to 2.9cm) in peritoneal cavity.
    • Right thyroid nodule (0.8cm).
    • A nodule (0.9cm) at LUL.
    • Invisible uterus.
    • Liver and renal cysts (upt o 8.8cm). A poor enhancing tumor (2.4cm) in right hepatic lobe.
    • Gallbladder stones (up to 1.9cm).
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M1c(M_value) STAGE:IVC(Stage_value)

[surgical operation]

• 2022-11-21
  • Surgery
    • T-loop colostomy        
    • Excisional biopsy of omental seeding     
  • Finding
    • Carcinomatosis, omental seeding     
    • T-loop colostomy was created at RUQ area 

[immunochemotherapy]

• 2023-06-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI without bolus 5FU)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL Q12H D1-2 + aprepitant 125mg PO D1-3 + lorazepam 1mg Q12H D1-3
• 2023-05-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI without bolus 5FU)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-04 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-21 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-03 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-30 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-28 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-02 - + irinotecan 120mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-06-20

• The patient visited a local clinic on 2023-06-13 for her primary hypertension. She was prescribed Norvasc (amlodipine 5mg) to be taken once daily. This medication is now on the patient’s active medication list as a self-carried item with no reconciliation issues identified.

2023-05-05

• During this hospital stay, the patient has experienced vomiting 3 to 4 times while on metoclopramide. If the symptom persists, it may be worth considering prescribing prochlorperazine upon discharge.

2023-04-14

• On 2023-04-06, the patient’s lab data showed normal readings except for an elevated CEA of 6.38ng/mL. It seems that the patient is tolerating the treatment well.

2023-03-23

• On 2023-03-07, the patient was observed to have neutropenia. However, there was no administration of G-CSF and no reduction of the regimen dosage. Despite this, there have been no new episodes of neutropenia observed as of the present time.

  • 2023-03-16 WBC 6.12 x10^3/uL
    
  • 2023-03-07 WBC 2.92 x10^3/uL
    
  • 2023-03-02 WBC 6.36 x10^3/uL
    
  • 2023-02-14 WBC 4.11 x10^3/uL
    
  • 2023-03-16 Neutrophil 66.7 %
    
  • 2023-03-07 Neutrophil 39.1 %
    
  • 2023-03-02 Neutrophil 67.7 %
    
  • 2023-02-14 Neutrophil 63.0 %

• According to today’s (2023-03-23) CT results, there is a significant regression of D-colon cancer, peritoneal seeding, lymph nodes, lung, and liver metastases. These findings suggest that the Avastin + FOLFIRI regimen is still effective.

• The patient’s medical history indicates that her mother had DM. However, there is no record of the patient’s HbA1c test result in HIS 5, which is a recommended test to monitor and manage diabetes.

701243929

230620

{esophageal SCC moderately differentiated T3N2M1 with lung mets}

[exam findings]

• 2023-05-17, -04-17, -04-14, -02-23, -01-31 CXR
  • Multiple metastases on both lungs.
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
• 2023-04-14 Patho - lung wedge biopsy
  • Lung, left, CT-guide biopsy — squamous cell carcinoma, moderately differentiated, consistent with metastatic
  • Sections show dysplastic keratinized squamous cell carcinoma infiltrating in a fibrotic stroma. The morphology is consistent with metastatic squamous cell carcinoma. Please correlate with the clinical presentation.
• 2023-03-21 CT - chest
  • Indication: Esophageal cancer of squamous cell carcinoma, moderately differentiated T3N2M1 with lung mets progression, stage IV
  • Comparison was made with previous CT dated on 2022/12/08
    • post op change with staple lines in LLL. left upper lobe medial fibrotic change, related to treatment.
    • multiple randomly distributed nodules/masses of varing sizes in both lungs, increase in size and number of these lesions as compared with previous CT on2022/12/8. interlobular septal thickening in Rt lung and LUL.
    • Mediastinum and hila: s/p esophagectomy and gastric conduit in middle mediastinum, enlarged LNs in visceral space and Rt hilum.
    • mild pericardial effusion.
  • Impression
    • bilateral lung metastases and mediastinal and hilar metastatic LAP, in progression as compared with previous CT study on 2022/12/08
• 2022-12-08 CT - chest
  • Indication: Esophageal cancer of squamous cell carcinoma, moderately differentiated T3N2M1 with lung mets progression, stage IV
  • Chest CT with and without IV contrast ehnancement shows:
    • Soft tissue mass at both lungs up to 6.7cm at left lower lobe and right upper lobe up to 4.67cm is found. Lung mets is considered. In comparison with CT dated on 2022-08-17, the lesios enlarged.
    • S/p port-A placement with its tip at Superior vena cava.
    • s/p esophagectomy and gastric tube reconstruction.
  • Imp: Lung meta at both lungs. In progression.
• 2022-12-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (83 - 32) / 83 = 61.45%
    • M-mode (Teichholz) = 60
  • Adequate LV systolic function with normal resting wall motion
  • Trivial MR, trivial TR and trivial PR
  • Minimal pericardiac effusion
  • Preserved RV systolic function
  • left pleural effusion
• 2022-12-07 CXR
  • S/P port-A implantation.
  • Multiple metastases on both lungs.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
• 2022-08-17 CT - Lung/Mediastinum/Pleura
  • Findings
    • Lungs:
      • post op change with staple lines in LLL. left upper lobe medial fibrotic change, related to treatment.
      • multiple nodules in both lungs, some with intrinsic cavitations slightly inecrease in size of these nodules as compared with previous CT on 2022/5.17
    • Mediastinum and hila: s/p esophagectomy and gastric conduit in middle mediastinum, no enlarged LN or mass..
  • Impression
    • bilateral lung metastases, sligthly in progression as compared with previous CT study on 20220517
• 2022-05-17 CT - Lung/Mediastinum/Pleura
  • Findings
    • Lungs:
      • post op change with staple lines in LLL. left upper lobe medial fibrotic change, related to treatment.
      • multiple nodules in both lungs, some with intrinsic cavitations slightly decrease in size as compared with previous CT on 20220208
    • Mediastinum: s/p esophagectomy and gastric conduit in middle mediastinum, no enlarged LN or mass..
    • Hila: no enlarged LN.
    • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Pleura: minimal effusion.
    • Chest wall and visible lower neck: no LAP.
    • Visible abdominal-pelvic contents:
      • distended U-bladder filled with urine.
      • normal appearance of gallbladder. unremarkable of the liver, spleen, adrenal glands, pancreas, and kidneys. no enlarged lymph node. no ascite.
  • Impression:
    • bilateral lung metastases, sligthly in regression as compared with previous CT study on 2022-02-08
• 2022-02-08 CT - Lung/Mediastinum/Pleura
  • Impression: bilateral lung metastases, sligthly in regression as compared with previous CT study on 2021-12-08.
• 2021-12-08 CT - Lung/Mediastinum/Pleura
  • Impression: bilateral lung metastases, in progression as compared with previous CT study on 2021-08-20.
• 2021-02-08 Patho - Lung wedge biopsy
  • Diagnosis: Lung, left, upper lobe, wedge resection - Squamous cell carcinoma, moderately differentiated, consistent with metastatic esophageal tumor
  • The HER2/NEU In-Situ Hybridization Test is NEGATIVE. There is NO amplification of HER2 detected.
  • IHC: Her-2/neu (Ab) equivocal(2+).
• 2020-09-25 Patho - Esophageal biopsy
  • Esophagus, middle, 32cm to 34cm below incisor - squamous cell carcinoma, moderately differentiated
  • IHC: CK(+), p63(+)
• 2020-07-09 Patho - Esophageal biopsy
  • Esophagus, middle, 25cm below incisor - squamous cell carcinoma, moderately differentiated
  • IHC: p63(+), CD56(focal +)

[consultation]

• 2020-07-08 Radiation Oncology
  • A
    • History:
      • This 48 year-old male patient denied the systemic disease or specific medical history before. He has suffered from dysphagia and food stuck in the chest for 1-2 months. He can tolerate regular food now. Upper G- I panendoscopy showed esophageal ulcerative lesion, favor malignancy. Biopsy pathology showed squamous cell carcinoma. Esophageal cancer, middle to lower third, was diagnosed at the Yeezen General Hospital in TaoYuan. EUS on 2020078 and Chest CT on 20200709 were arranged for further survey.
      • Previous RT: denied.
      • Other disease: denied.
      • Family history: denied.
      • Habit: Alcohol, 1 bottle/day for 20 yr; smoking: 1/2 PPD for 20 yr; betel nuts: 20#/day for 20 yr.
      • Married, 3 sons (grade 5, kindergarten middle class, baby class). Caregiver: his wife. Job: worker and driver. Mild economic stress at least. Lives in XinWu Dist. TaoYuan City.
      • Language: Mandarin, Taiwanese.
      • Religion: Buddhism
    • Objective:
      • General Condition-ECOG: 1.
      • PE, 20200709: No palpable neck LNs.
      • Pathology, 202007: esophagus, squamous cell carcinoma.
        
      • Images:
        • Chest CT, 20200710: pending.
        • EUS, 20200710: pending.
        • CXR, liver echo, 20200706: negative.
    • Diagnosis: Esophageal cancer, middle to lower third, squamous cell carcinoma, fresh case, ECOG = 1.
    • Plan: Staging workup as your order. CCRT (5040cGy/28 fx) will be indicated if upfront surgery is not favored by the surgeon. Please contact us later to arrange CT simulation later. Diet education, psychological and spiritual support is given.

[surgical operation]

• 2021-02-05
  • Surgery
    • VATS, LUL wedge + LLL wedge resection
  • Finding
    • mutiple lung nodule suspected esophageal cancer metastasis s/p LUL wedge (a solid nodule about 6mm x1); LLL wedge (two soft nodules about 7mm and 4mm)
    • a 14 Fr. pigtail inserted in 7 ICS
    • blood loss: minimal
• 2020-10-05
  • Surgery
    • VATS esophagectomy + gastric tube reconstruction.
  • Finding
    • Esophageal tumor was noted over middle third esophagus, adhesion to left main bronchus, s/p CCRT.
    • One 28 Fr. straight chest tube was inserted via right 8th ICS.
    • 18 Fr. Foely catheter as jejunostomy tube.
• 2020-07-10
  • Surgery
    • Port-A + feeding jejunostomy
  • Finding
    • 18 Fr. Foley as jejunostomy tube
    • 8 Fr. polysite, left cephalic vein, cut-down method.

[radiotherapy]

• 2020-08 ~ 2020-08 CCRT 5040cGy/28fx

[chemotherapy]

• 2023-06-19 - oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 245mg NS 500mL 90min + leucovorin 400mg/m2 655mg NS 250mL 2hr + fluorouracil 2800mg 4590mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-05-18 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg NS 500mL 90min + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2800mg 4745mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-04-18 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg NS 500mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg 4765mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-03-20 - gemcitabine 1000mg/m2 1735mg NS 250mL 30min + leucovorin 200mg/m2 345mg NS 250mL 2hr + fluorouracil 2000mg/m2 3475mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-24 - gemcitabine 1000mg/m2 1775mg NS 250mL 30min + leucovorin 200mg/m2 355mg NS 250mL 2hr + fluorouracil 2000mg/m2 3550mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-01 - gemcitabine 1000mg/m2 1775mg NS 250mL 30min + leucovorin 200mg/m2 355mg NS 250mL 2hr + fluorouracil 2000mg/m2 3550mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-27 - gemcitabine 1000mg/m2 1775mg NS 250mL 30min + leucovorin 200mg/m2 355mg NS 250mL 2hr + fluorouracil 2000mg/m2 3550mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-05 - gemcitabine 1000mg/m2 1770mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3540mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-14 - gemcitabine 1000mg/m2 1800mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-10-24 - gemcitabine 900mg/m2 1600mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3570mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-09-29 - gemcitabine 900mg/m2 1600mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3570mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-09-07 - gemcitabine 900mg/m2 1400mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 1800mg/m2 3000mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-08-17 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-07-26 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-06-27 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-06-06 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-05-16 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-04-19 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-03-30 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-03-08 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-02-09 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-01-24 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-01-03 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2021-12-08 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2021-11-22 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
• 2021-11-08 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
• 2021-10-15 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
• 2021-09-16 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4700mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
• 2021-09-03 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4700mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-08-19 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4700mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-08-03 - oxaliplatin 85mg/m2 147mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4840mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-07-20 - oxaliplatin 85mg/m2 147mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4840mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-06-30 - oxaliplatin 85mg/m2 146mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-06-10 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-05-27 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4850mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-05-11 - oxaliplatin 60mg/m2 100mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4860mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-04-27 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 69mg 2hr + fluorouracil 2000mg/m2 3450mg 46hr
  • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-04-27 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3380mg 46hr
  • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-03-25 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3380mg 46hr
  • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-03-11 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3340mg 46hr
  • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2021-02-23 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3390mg 46hr
  • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2020-08-24 - cisplatin 50mg/m2 84mg 2hr + fluorouracil 1000mg/m2 1700mg 22hr D1-4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2020-07-27 - cisplatin 50mg/m2 87mg 2hr + fluorouracil 1000mg/m2 1750mg 22hr D1-4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

==========

2023-06-20

The patient has been prescribed Bafen (baclofen 5mg) 1# PRNQ12H for hiccups. Metoclopramide is also included in the active medication list. Both baclofen and metoclopramide are regarded as first-line therapy for hiccups. However, it’s advisable to note that there have been numerous cases reported in the literature indicating neurotoxicity due to oral baclofen accumulation in adult patients with varying levels of renal impairment. Additionally, abrupt discontinuation of oral baclofen has been linked to altered mental status. While the current dosage seems unlikely to cause these adverse reactions, it’s worth mentioning as a precaution.

2022-12-27

• The elevated serum uric acid level (8.1 mg/dL on 2022-11-22) has returned to normal levels (5.6 mg/dL on 2022-12-27).
• First-line chemotherapy for advanced esophageal squamous-cell carcinoma results in poor outcomes. The monoclonal antibody nivolumab has shown an overall survival benefit over chemotherapy in previously treated patients with advanced esophageal squamous-cell carcinoma (for PD-L1 expression of 1% or greater). ref: Doki Y, Ajani JA, Kato K, et al. Nivolumab Combination Therapy in Advanced Esophageal Squamous-Cell Carcinoma. N Engl J Med. 2022;386(5):449-462. doi:10.1056/NEJMoa2111380

2022-12-06

• CT scan on 2022-08-17 revealed bilateral lung metastases that were slightly in progress compared to previous CT scans on 20220517, after which the current regimen was initiated in September 2022. A CT update in this hospital stay has been arranged.

2022-06-07

• Using the current regimen since Dec 2021, consecutive CT images (2022-02, 2022-05) have shown bilateral lung mets slight regression.
• The creatinine level has risen in recent weeks (1.36mg/dL 2022-06-06, 1.41mg/dL 2022-05-16). In the event that the reading continues to rise, a lower dose of cisplatin might be considered, or carboplatin might be substituted for cisplatin if there are no clinical contraindications.
  • reference
    • https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2789153
    • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870131/

2022-05-17

• CT image might be updated. The progression was seen to have slowed in last CT dated on 2022-02-08, which implies that the present [5-FU + Cisplatin + Paclitaxel] regimen, which begins in December 2021, has had an effect.
• As of 2022-05-16, lab data showed that liver functions, serum electrolytes were generally normal. However, there were elevated blood creatinine 1.41 mg/dL, elevated Neutrophil 85% and decreased blood magnesium 1.3 mg/dL. Estimated creatinine clearance based on Cockcroft-Gault is 60 L/min. Kintzel 1995 recommended administration 75% of cisplatin dose for CrCl 46 to 60 mL/minute patients.
• On 2022-05-16, high stool frequency was observed (5 times). There has been a decline in blood magnesium levels over the last 12 months, which may be a result of diarrhea depleting magnesium levels. Magnesium sulfate has been prescribed. Some loperamide might also be helpful.

2022-04-20

• The progression was seen to have slowed in the most recent CT dated 2022-02-08, which implies that the present [5-FU + Cisplatin + Paclitaxel] regimen, which begins in December 2021, has had an effect.
• As of 2022-04-19, lab data showed that liver and kidney functions, serum electrolytes, and blood cell counts were grossly normal.
• No PD-L1, NTRK, MSI/MMR, TMB results found. HER2 overexpression is not evident, trastuzumab might not be applicable.
• There has been a slight decline in blood magnesium levels (<1.9mg/dL) that might be asymptomatic for at least 12 months. Magnesium depletion is more prevalent as a result of diarrhea than vomiting in general. The causal relationship could be further clarified if clinically needed.

2022-02-23

• the on going progression slightly slowed down according to CT findings on 2022-02-08, it seems that the current 5-FU + Cisplatin + Paclitaxel regimen since Dec 2021 showed certain effect.
• ANC ~ 1.23 x 0.85 (based on 2022-02-23 lab data) is just above 1 with fluctuation which should be monitored.

2022-01-25

• in progresstion, several subsequent therapies have been tried.
• HER2 overexpression is not evident, trastuzumab might not be applicable.
• PD-L1, NTRK, MSI/MMR, TMB test might be ordered optionally.
• no drug allergy recorded in database, no issue with current medication.

700096683

230619

[lab data]

2023-06-16 Anti-HBc Reactive
2023-06-16 Anti-HBc-Value 8.30 S/CO
2023-06-16 Anti-HBs 0.91 mIU/mL
2023-06-16 Anti-HCV Nonreactive
2023-06-16 Anti-HCV Value 0.10 S/CO
2023-06-16 HBsAg Nonreactive
2023-06-16 HBsAg (Value) 0.27 S/CO
2021-06-10 HBsAg (NM) Negative
2021-06-10 HBsAg Value (NM) 0.359
2021-06-10 Anti-HCV (NM) Negative
2021-06-10 Anti-HCV Value (NM) 0.00292

[exam findings]

• 2023-05-24 Patho - liver biopsy needle/wedge
  • Liver, needle biopsy — Metastatic colonic adenocarcinoma
  • The sections show a picture of metastastic colonic adenocarcinoma, composed of liver tissue with nests of columnar neoplastic cells arragned in cribriform pattern with dirty necrosis.
  • IHC, the neoplastic cells shows: CK7(-), CK20(+) and CDX2(+).
• 2023-05-22 SONO - abdomen
  • Diagnosis:
    • Hepatic hypoechoic lesion, S6/7, nature?
    • Fatty liver, moderate
  • Suggestion:
    • Lesion could be masked due to fatty liver background.
    • Correlated with triphase CT and tumor markers
• 2023-04-17 CT - abdomen
  • Indication: Adenocarcinoma of cecum status post single incision laparoscopic right hemicolectomy on 2021/06/10, pT2N0M0(0/12), stage I
  • Abdominal CT with and without enhancement revealed:
    • s/p single incision laparoscopic right hemicolectomy
    • Low density lesion at S6 of liver up to 0.93cm is found. In comparison with CT dated on 2022-05-16, the lesion is new. Metastatic tumor cannot be excluded.
    • The GB is well distended without soft tissue lesion
    • Enlarged prostate up to 5.3cm is found.
  • Imp:
    • Cecal cancer s/p operation.
    • New low density lesion at S6 of liver. 0.93cm, r/o meta.
    • Enlarged prostate.
• 2023-04-17 Colonoscopy
  • No definite mucosal lesion was seen.
• 2022-05-16 CT - abdomen
  • Cecal cancer s/p operation. No evidence of tumor recurrence.
• 2022-05-16 Colonoscopy
  • C/W colon cancer s/p right hemicolectomy
  • Internal hemorrhoid
• 2021-06-10 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Tumor, cecum, SILS R’t hemicoloectomy — Adenocarcinoma
      
    • Resection margins, bilateral, ditto — Free from tumor invasion
      
    • Lymph nodes, mesocolic, dissection — Free from metastasis (0/12)
      
    • Appendix, ditto — Free from tumor, periappendiceal congestion
      
    • AJCC pathologic stage — pT2N0, if cM0, stage I
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: SILS right hemicolectomy
      
    • Specimen site: ascending colon, terminal ileum and appendix
      
    • Specimen size: (a) A-colon: 10.5 cm in length, 3.2 cm in diameter, (b) Terminal ileum: 1.7 cm in length, 3.7 cm in diameter and (c) Appendix: 6.3 cm in length, 0.5 cm in diameter
      
    • Tumor size: 3.2 x 2.8 cm
      
    • Tumor location: 2.2 and 7.2 cm away from bilateral resection margins
      
    • Tumor appearance: elevated mass
      
    • Depth of invasion grossly: muscular propria
      
    • Representative sections as follows: A1: bilateral margins, A2: appendix, A3-A7: tumor, A8-A12: lymph nodes
      
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
      
    • Histology Grade: G2: moderately differentiated
    • Depth of invasion: muscular propria
      
    • Angiolymphatic invasion: present
      
    • Perineural invasion: present
      
    • Discontinuous extramural tumor extension: not present
      
    • Circumferential (radial) margin of rectosigmoid: not involved
      
    • Lymph node metastasis, mesocolic: free from metastasis (0/12)
      
    • Lymph node metastasis, IMA / SMA: N/A
      
    • Extranodal involvement: N/A
      
    • Pathological TNM Stage: pT2N0, stage I
      
    • Type of polyp in which invasive carcinoma arose: N/A
      
    • Additional pathologic findings: N/A
      
    • TNM descriptors: N/A
      
    • Tumor regression grading S/P CCRT: N/A
      
  • IMMUNOHISTOCHEMISTRY
    • SMA highlights muscle tissue
• 2021-05-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (96.3 - 24.1) / 96.3 = 74.97%
    • LVEF (%) = 80
    • M-mode (Teichholz) = 75.0
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with no MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
• 2021-05-06 CT - abdomen
  • History and indication: A flat and depressed 2cm tumor at cecum, R/O cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Focal wall thickening of cecum.
    • Grade 5 fatty liver.
    • Right renal cyst (6mm).
    • Enlargement of prostate.
    • Atherosclerosis of aorta, iliac arteries.
    • Several cysts (5-6mm) at RUL.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:I(Stage_value)
• 2021-05-03 Patho - colon biopsy
  • Large intestine, cecum, biopsy — Adenocarcinoma, moderately differentiated
    
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    
  • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2021-05-03 Colonoscopy
  • Suspect early colon cancer, cecum, s/p biopsy
  • Mixed hemorrhoid

[MedRec]

• 2023-06-01 SOAP Hemato-Oncology
  • P: Arrange Neoadjuvant chemtoehrapy with FOLFOX +/- targeted therapy
• 2021-06-09 ~ 2021-06-14 POMR Colorectal Surgery
  • Discharge diagnosis
    • Adenocarcinoma of cecum status post single incision laparoscopic right hemicolectomy on 110/06/10, pT2N0M0(0/12),G2, LVI(+), PNI(+), CRM(-), stage I
    • Malignant neoplasm of cecum
    • Type II diabetes mellitus
  • CC
    • for preoperative preparation and surgical treatment for cecal cancer.
  • Present illness
    • This 62 years old male patient has the history of 1) colon polyp s/p polypectomy at Wanfang Hospital in MK 102; 2) mixed hemorrhoids s/p hemorrhoidectomy on 2015-09-22; 3) DM under OHA control for 5-6 years.
    • He received health examination and FOBT revealed postive. He denied abdominal discomfort, bowel habit change, bloody stool passage and body weight loss. He visited CRS for help and colonoscopy revealed suspect early colon cancer, cecum, s/p biopsy. Pathology proved adenocarcinoma. Abdominal CT revealed cecal ctumor, cT2N0M0, stage: I. This time, he admitted to our ward for preoperative preparation and surgical treatment.
  • Course of inpatient treatment
    • After admission with ward routine and pre-op study were done. After well explain the risk of surgery including heart, lung complications and risk of leakage. Operation of SILS right hemicolectomy under general anesthesia were performed on 2021-06-10. NPO and adequate IV fluid supplement. His wound pain is acceptable by Dynastat. Early activity is encouraged. Chewing cookies, toast, rice with gum was started at op day. The wound healing well and no erythema change. He had flatus passage and abdominal wound pain subsided. So he started to take oral diet well and no abdominal discomfort after meal. He had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. Drain is clear ascites and removal of JP drain at post-op day 4. His abdominal wound pain had got much better. In stable condition, he was discharged on 2021/06/14 and will receive OPD follow up next week.

[surgical operation]

• 2021-06-10
  • Surgery
    • SILS Right-hemicolectomy        
  • Finding
    • Cecal tumor, cT2N0M0 stage I
    • Anastomosis by GIA 75/4.8mm x2
    • TISSEL 4ml at anastomosis site and wound clot
    • One 15# JP drain at Morison’s pouch

==========

2023-06-19

• There’s no available data from PharmaCloud, possibly due to the patient not providing consent for access.

• Based on the records from our hospital, the patient has visited the departments of Colorectal Surgery, General and Digestive Surgery, and Hematology-Oncology in the past three months. No prescriptions were issued by the first two departments, hence, no medication reconciliation issues were found.

• Several data points have indicated that the patient’s fasting plasma glucose levels are exceeding 200mg/dL, even while being under medication with Januvia (sitagliptin 100mg) 0.5# BID and Uformin (metformin 500mg) 1# BID. There are no HbA1c readings available in the HIS5 data. It is recommended to obtain an HbA1c reading to get an understanding of the average blood glucose levels over the past two to three months.

• Additionally, the patient has also been prescribed Zulitor (pitavastatin 4mg) 0.5# QD, an HMG-CoA reductase inhibitor used to lower lipid levels and reduce the risk of cardiovascular disease. However, there are no diagnoses, medical problems, or lab data related to dyslipidemia. The status of the patient’s dyslipidemia might need to be checked and clarified.

700421458

230619

==========

2023-06-19

• Vitacal (CaCl2) 120mL IVD ST is just prescribed. It is recommended in HIS5 not to exceed 100mL in each administration. The most recent lab data on 2023-05-15 showed normal calcium and chloride readings. It is prudent to check the use of CaCl 120mL.
• This patient is a stem cell donor. If calcium supplementation is required, particularly during hematopoietic stem cell (HSC) harvesting where citrate-based regional anticoagulation is used, it might be advisable to utilize a sliding scale for the continuous infusion of calcium chloride. This would help maintain systemic ionized calcium levels between approximately 3.6 to 5.2 mg/dL (~0.9 to 1.3 mmol/L). Regular monitoring of systemic ionized calcium levels, ideally every 6 hours or more frequently when necessary, is also recommended under these circumstances.

In continuation of the previous pharmacist note.

• I just had a phone conversation with the patient’s nurse practitioner. She indicated that for the HSC harvesting procedure, 120mL of CaCl2 is commonly used, and calcium levels are regularly monitored both before and after the procedure. Therefore, it doesn’t seem to present any issues at present.

700761500

230619

[lab data]

2023-06-19 JAK2 single site mutation Undetectable
2023-06-14 HBsAg (NM) Negative
2023-06-14 HBsAg Value (NM) 0.392
2023-06-14 Anti-HCV (NM) Negative
2023-06-14 Anti-HCV Value (NM) 0.047
2023-06-14 Anti-HBc (NM) Positive
2023-06-14 Anti-HBc Value (NM) 0.009
2023-06-14 Anti-HBs (NM) Negative
2023-06-14 Anti-HBs value (NM) 4.930 mIU/mL
2023-03-13 CK 14 U/L
2023-03-03 Zinc,Zn 648 ug/L
2023-02-16 ANA Homogeneous 1:1280; Speckled 1:1280
2023-02-15 Anti-ds DNA Antibody 5.6 IU/ml
2023-02-15 Anti-ENA(Jo-1) EliA U/ml
2023-02-15 Anti Jo-1 antibody 0.3 EliA U/ml
2023-02-15 Anti-ENA (Scl-70) EliA U/ml
2023-02-15 Anti-ENA Scl-70 Ab 2.0 EliA U/ml
2023-02-14 ESR 31 mm/hr
2023-02-09 CK 10 U/L
2021-05-15 ESR 45 mm/hr
2021-03-17 LA1 52.8 sec
2021-03-17 LA2 38.0 sec
2021-03-17 LA1/LA2 ratio 1.1
2021-03-13 ESR 33 mm/hr
2020-07-04 Ferritin 101.9 ng/mL
2020-05-20 ESR 44 mm/hr
2020-05-14 Aspergillus Ag Negative
2020-05-14 Aspergillus Ag Value 0.13 Ratio
2020-05-06 LA1 51.4 sec
2020-05-06 LA2 39.4 sec
2020-05-06 LA1/LA2 ratio 1.1
2020-05-05 Anti-beta2-glycoprotein-I Ab 3.5 U/mL
2020-05-05 Anti-cardiolipin-IgM 3.0 MPL U/mL
2020-05-05 Anti-cardiolipin IgG GPL-U/mL
2020-05-05 Anti-Cardiolopin 8.0 GPL-U/mL
2020-05-05 Anti-ENA Sm 7.0 EliA U/ml
2020-05-05 Anti-ENA RNP 2.4 EliA U/ml
2020-05-05 Anti-ds DNA Antibody 14 IU/ml
2020-05-05 C4 30.4 mg/dL
2020-05-05 C3 102.8 mg/dL
2020-04-20 Aspergillus Ag Positive
2020-04-20 Aspergillus Ag Value 0.5 Ratio
2020-04-20 Anti-ENA SS-A (Ro) >2400 EliA U/ml
2020-04-20 Anti-ENA SS-B (La) >3200 EliA U/ml
2020-04-20 ANA Homogeneous ; 1:1280
2020-04-17 Cryptococcus Ag Negative
2020-04-17 Antibody Identification Anti-M
2020-04-15 Anti-ENA Sm 7.5 EliA U/ml
2020-04-15 Anti-ENA RNP 2.4 EliA U/ml
2020-04-15 Anti-ds DNA Antibody 14 IU/ml

[exam findings]

• 2023-06-09 CXR
  • reticular and hazy areas of increased opacities over Rt and Lt lower lung zones, due to fibrosis
  • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
  • partial atelectasis of inferior lingular segment and RML
  • Minimal dextroscoliosis of the T-spine
    
  • marginal spurs of multiple vertebral bodies
• 2023-06-09 SONO - abdomen
  • Liver cysts
  • Splenomegaly with heterogenous parenchyma.
• 2023-05-08 Spirometry
  • There is mild restrictive lung defect.
  • The bronchodilator test is negative.
• 2023-04-08 CT - chest
  • Bronchiectatic change over right middle lobe and left lingula lobe.
  • The pneumonic patch resolved.
  • Splenomegaly with heterogenous appearance of the splenic parenchyma. Suggest contrast enhanced study.
• 2023-02-08, -01-20, -01-06, 2022-12-26, -12-19 CXR
  • Consolidation and volume reduce over Rt and Lt lower lung zones, further in progression
  • mild enlarged cardiac silhoutte due to dilated cardiac chamber (LAD) and prominent cardiophrenic angle mediastinal fat pad
  • partial atelectasis of inferior lingular segment and RML
• 2023-02-08 SONO - chest
  • Pleural thickening and subpleural consolidation, bilateral
• 2022-12-15 SONO - chest
  • Bilateral lower lobes pneumonia with airbronchogram inside, 3x4 cm in size, bilaterally.
  • Only trivial amounts of plerual effusion, bil.
  • High risk of chest tapping.
• 2022-12-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 35) / 89 = 60.67%
    • M-mode(Teichholz) = 60
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA
    • Mild MR, mild TR and mild PR
    • Mild pulmonary hypertension
    • Preserved RV systolic function
• 2022-12-14 CT - chest
  • consolidation in the lower lobes of the bilateral lung.
• 2022-09-05 CT - Temporal Bone HRCT
  • Noncontrast high resolution CT (HRCT) of bilateral temporal bones in thin axial cut and with coronal reformation shows:
    • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
    • Soft tissue within right middle ear.
    • No obvious bone erosion.
  • IMP: Osteitis media with soft tissue within right middle ear.
• 2022-08-01 ENT Hearing Test
  • Tymp:
    • R’t grommet inserted (ECV 1.0 was noted); L’t type A.
  • ART:
    • R’t ipsi CNT and contra absent.
    • L’t ipsi absent and contra CNT.
  • PTA
    • Reliability FAIR
    • Average RE 65 dB HL; LE 49 dB HL.
    • R’t moderate to profound mixed type HL.
    • L’t mild to profound mixed type HL.
• 2022-02-05 MRI - C-spine
  • herniated disc in the C5/6 disc.
• 2021-10-02 ENT Hearing Test
  • Tymp:
    • R’t type B; L’t type A.
  • ART:
    • Bil absent.
  • PTA
    • Reliability FAIR
    • Average RE 73 dB HL; LE 44 dB HL.
    • R’t moderate to profound mixed type HL.
    • L’t normal to severe SNHL with 15 dB ABG at 4k Hz.
• 2021-04-06 Ga-67 whole body inflammation scan with SPECT
  • The whole-body gallium-67 inflammation scan with SPECT was performed at the 24th and the 48th hour after injecting 6 mCi of Ga-67 to the patient. The images showed relatively increased radiotracer uptake in the liver, spleen, and bilateral shoulders. In addition, there was increased radiotracer accumulation in the colon.
  • IMPRESSION:
    • Relatively increased radiotracer uptake in the liver and spleen, the nature is to be determined. Please correlate with other clinical findings for further evaluation.
    • Mildly increased radiotracer uptake in bilateral shopulders, mild inflammation may show this picture.
    • Increased Ga-67 accumulation in the colon, physiological accumulation of Ga-67 may show this picture.
• 2021-03-17 SONO - chest
  • Pleural effusion, minimal, left
  • Consolidation, LLL, minimal
• 2021-03-15 CT - chest
  • post inflammatory fibrosis in LLL and RLL, stationary.
  • splenomegaly
  • hyperplastic LNs in both axillary region, stationary.
  • new left pleural effusion.
• 2021-03-15 Spirometry
  • mild restrictive ventilatory impairment, FVC 74%, FEV1 75%
• 2020-09-22 CT - chest
  • post inflammatory fibrosis in LLL and RLL.
  • splenomegaly with poorly enhanced foci.
  • regression of hyperplastic LNs in both axillary compared with CT on 2020/04/06
• 2020-07-09 Bronchodilator Test
  • mild restricitve ventilatiory impairemnt
• 2020-04-30 Bronchodilator Test
  • mild restrictive ventilatory impairment, FEV1/FVC = 86%, FVC = 70%, FEV1 = 74%
  • without significant reversibility
• 2020-04-07 SONO - chest
  • Bilateral thorax: minimal amount pleural effusion (thoracocentesis was not performed).
• 2020-04-06 CT - chest
  • nonspecific inflammation r/o infection in lower lungs with pleural effusion. splenomegaly and LAPs in both axillae, hematological disorder?, suggest further correlation with lab. data.
• 2019-12-04 Acoustic Radiation Force Impulse, AFRI
  • CC: For measurement of fibrosis stage
  • Diagnosis: ARFI = F0
  • Suggestion
    • V median = 1.31
    • V IQR/median = 13.4%
• 2019-12-04 SONO - abdomen
  • Liver cysts, three
  • Splenomegaly, mild
• 2018-08-16 Flow Volume Curve
  • Mild restriction
• 2018-08-16 SONO - abdomen
  • Multiple (>20) splenic hemangiomas up to 1.4cm.
• 2017-01-12 SONO - abdomen
  • splenic tumors, C/W hemangioma (by prior study)
  • liver cysts

[MedRec]

• 2023-03-27 SOAP Rheumatology and Immunology
  • Prescription
    • Plaquenil (hydroxychloroquine 200mg) 1# QDCC
    • Celebrex (celecoxib 200mg) 1# QD
    • Evoxac (cevimeline 30mg) 1# BID
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNHS
• 2023-02-25 SOAP Dermatology
  • S
    • hair loss for months,acute exacer bated
    • enlarged neck (+)
    • malar rash on face for months
  • Prescription
    • Topsym (fluocinonide 0.05%) HS TOPI
    • Zinga (zinc gluconate 78mg) 1# QD
• 2020-05-07 SOAP Rheumatology and Immunology
  • A
    • Sjogren syndrome
    • r/o fibromyalgia
  • Prescription
    • Hydroquine (hydroxychloroquine 200mg) 1# QDCC
    • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# HS
    • Bokey (aspirin 100mg) 1# QD
    • LacTam (acetaminophen 500mg) 1# PRNBID
    • Compesolon (prednisolone 5mg) 1# QD

==========

2023-06-19

• Based on the PharmaCloud database, our hospital is the sole medical provider for the patient in the past 3 months. No issues related to medication reconciliation have been identified.

• Cyclophosphamide is a potential therapeutic option for severe, refractory cases of dermatomyositis/polymyositis, and it is often administered as an adjunctive treatment. The recommended oral dose typically ranges from 1.5 to 2 mg/kg/day (ref: UpToDate). As of 2023-06-18, the patient’s body weight is 53.3kg, and the current prescription of cyclophosphamide at 50mg QD is below the suggested dosage range. Please continue to monitor the treatment’s effectiveness and consider whether a dose adjustment might be required.

701097074

230619

[MedRec]

• 2022-02-18 ~ 2022-05-10 POMR Hemato-Oncology
  • Discharge diagnosis
    • Multiple myeloma, IgG kappa, ISS stage IIIA
    • Type 1 diabetes mellitus with unspecified complications
    • Nausea with vomiting, unspecified
    • Diabetes mellitus without mention of complication, Type I [insulin dependent type] [IDDM] [juvenile type], not stated as uncontrolled
  • CC
    • Nausea with vomit for 2 days, right shoulder and back pain over month    
  • Present illness
    • This 53-year-old female has history of
      • Type 1 diabetes mellitus since age of 19
      • Hypertension
      • Secondary hypoparathyroidism
      • Sacrum and right ilium fracture after fell down in 2021/06
      • Osteoporosis with BMD: T score -4.2.
      • Right Scapula fracture
    • This time, she suffered from persistent back pain for over one month and nausea with vomit for 2 days. According to the patient’s statement, she had been to our Ortho. OPD for help on 2021/12/15, when KUB + L-spine Lat was revealed compression fractures at L5, L4, L2, L1 and T12 vertebral bodies, mild decreased disc spaces in the upper L-spine discs.
    • Due to above symptoms, she came to our ER for help. At ER, tachycardia with BP 153/73 were noted. Physical examination showed tenderness at bilateral flank and T-L spinal process. Laboratory data revealed hypercalcemia of Calcium: 3.17 mmol/L. T-L spine X-ray revealed compression fracture of L1 and L2. Under the impression of 1) Hypercalcemia, 2) Right Scapula and back pain, she was admitted for pain control and further management on 2022/02/18.    
  • Course of inpatient treatment
    • This 53 y/o female has history of type 1 diabetes mellitus since age of 19, anemia, hypertension, secondary hypoparathyroidism, sacrum and right ilium fracture after fell down in 2021/06, osteoporosis with BMD: T score -4.2, and retinal hemorrhage OU s/p OP. She suffered from persistent back pain for about one month. Under the impression of T7, T8 compression fracture and old compression frature of T12, L1/2/4/5, the patient was admitted.
    • After admitted, she received pain killer and IV fluid supplement for compression fracture pain control. During hospitalization, she had nausea with vomit and hyperglycemia with diabetic ketoacidosis were noted on 2022/02/21. The laboratory data revealed hyponatremia, favor hyperglycemia related. The endocrinologist was consulted, RI pump (2/21~22), 0.298 KCL were perscribed and titrate insulin dose. The Oncologist was consulted for hypercalcemia with low PTH, suspect multiple myeloma. Blood test and urine Protein EP/IFE/Free Light Chain κ/λ were performed by Oncologist advice and they arrange bone marrow examination on 3/2. She will transfer to oncologist ward for further management.
    • Due to bone marrow report showed MM IgG kappa, stage IIIB. Major illness and family conference were done this week. RT was consulted and positioning on 3/8. Feburic F.C 80mg 1# qd for hyperuricemia and rechecked level decerased well. This week, the bone marrow for FISH test was done and we gave Thalidomide 2# qn and dexamethasome 40mg qw. Painful condition got improvement. Sugar poor control and we comfirm Meta for adjust Apidra and Tresiba. RT (2022-03-10 ~ 2022-03-23): 2000cGy/10 fractions (6MV photon) of the upper T spine and peripheral area. Chemotherapy as VTd (C1 Velcade since 2022/3/29, weekly) and XGEVA on 2022/3/30. Hypocalcemia and Hypomagnesemia were correct during hospitalization. Nutritional assessment for DM diet with energy and protein requirement during hospitalization. RT again for bilateral hip pain (2022-4-12 ~): at 600cGy/3 fractions (6MV photon) of the right hip to upper femur.
    • Under the stable condition, VTD (C1 on 2022/3/29, C2 on 4/6, C3 on 4/13, C4 on 4/20, C5 on 4/27, C6 on 5/4, C7 on 5/9). Pain control with Neurontin 100mg/cap (Gabapentin) 1# bid, Celebrex 200mg/cap (Celecoxib) 1# q12h,Muaction 100 mg/SR tab (Tramadol) 1# hs.
    • With the relatively stable condition,she was discharged on 2022/05/10 and will OPD follow up later
    • VTD regimen
      • Days 1,8,15,22: Bortezomib 1.3mg/m2 subcutaneous
      • Days 1-21: Thalidomide 50-200mg (usual dose range) orally once daily at bedtime
      • Days 1-2, 8-9, 15-16, 22-23: Dexamethasone 40mg orally once daily
      • Repeat cycle every 3 weeks
  • Discharge prescription
    • Limeson (dexamethasone 4mg) 5# QN 5/9-5/10
    • Thado (thalidomide 50mg) 2# QN 5/9-30, take 3 weeks, skip 1 week
    • Muaction (tramadol 100 mg) 1# HS
    • Concor (bisoprolol 1.25mg) 1# QD      
    • Tresiba FlexTouch 16 Unit QD SC (If F/S HS < 140, eat something before go to bed, Tresiba should not be stopped)
    • Apidra 8 Unit TIDAC SC (As correction scales)
    • Celebrex (celecoxib 200mg) 1# Q12H
    • Neurontin (gabapentin 100mg) 1# BID
    • Stogamet (cimetidine 300mg) 1# TID
    • Through (sennoside 12mg) 2# HS
    • Pentop (pentoxifylline 400mg) 1# BID

[chemotherapy]

• 2023-04-28 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2023-04-21 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2023-04-14 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2023-04-07 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2023-03-03 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2023-02-23 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2023-02-17 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2023-02-10 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2023-02-03 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2023-01-27 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2023-01-06 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-12-30 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2023-12-23 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-12-16 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-12-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-12-02 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-11-11 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-11-04 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-10-28 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-10-21 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-10-14 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-10-07 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-09-30 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-09-23 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-09-16 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-09-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-09-02 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-08-26 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-08-19 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-08-12 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-08-05 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-07-29 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-07-15 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-07-08 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-07-01 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-07-24 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-06-17 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-06-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-06-02 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-05-26 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-05-19 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-05-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-05-04 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-04-25 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-04-19 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-04-13 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-04-06 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
• 2022-03-29 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC

==========

2023-06-19

• The patient had an appointment at TaiAn Hospital on 2023-05-16, where she was prescribed oral Pentop (pentoxifylline) and several eye drops for a 28-day course, which has now concluded. If the patient continues to experience eye symptoms, it might be advisable to consult our ophthalmologist for reevaluation.

700394537

230616

[exam findings]

• 2023-06-07 MRI - brain
  • no evidence of brain metastasis.
• 2023-06-06 Tc-99m MDP bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in multiple C-, T- and L-spines, sternum, bilateral multiple ribs, left scapula, pelvic bones, right humerus, and left femur.
  • IMPRESSION: As compared with the previous study on 2023-02-15, some of the previous bone lesions are a little more evident, suggesting multiple bone metastases in a little more progression.
• 2023-06-05 CXR
  • Osteoblastic metastasis in spine
• 2023-06-05 CT - chest
  • Indication: Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis
    • Malignant neoplasm of upper lobe, right bronchus or lung
  • Comparison was made with previous CT dated on 2023/02/13
    • Lungs: the small spiculated nodule at posterior RUL is still visible. interval regression of miliary and small nodules in both lungs, and resolution of septal thickening and peribronchovascular bundle thickening as compared with CT on 2023/2/13
    • Mediastinum and hila: no more enlarged LNs.
    • Vessels: the great vessels in the hila and mediastinum are normal in caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: minimal residual bilateral effusions
    • Chest wall and visible lower neck: no enlarged LNs at supraclavicular fossae
    • Visible abdominal contents: distended gallbladder. unremarkable of the spleen, liver, adrenal glands, pancreas, and both kidneys. no enlarged lymph node
    • Visualized bones:
      • multiple marginal spurs of vertebrae.
      • blastic metastatic change spine and sternum.
  • Impression: RUL cancer T4M1c, in regression as compared with CT on 2023/02/13
• 2023-03-22 Shoulder Lt
  • Narrowed joint or discal space with bony sclerosis but without acute fracture, bone destruction or dislocation.
  • A small focal hyperdense osteoblastic metastasis at medial humeral neck?
• 2023-03-22 MRI - C-spine
  • spinal canal stenosis at the imddle and lower C-spine
  • herniated discs in the C4/5 and C5/6 discs.
  • multiple bone metastasis in the visible T-spine and L-spine.
• 2023-02-23 MRI - brain
  • no evidence of brain metastasis.
• 2023-02-21 EGFR
  • Two mutations were detected at exon 19 (Del) and exon 20 (T790M) of EGFR gene in this specimen.
• 2023-02-16 Patho - lung transbronchial biopsy
  • Lung, side ?, CT-guide biopsy —adenocarcinoma, moderately differentiated
  • Sections show acinar, papillary, and micropapillary tumor cells infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal TTF-1(+), Napsin A(focal +), and CD56(-). The results are supportive for the diagnosis.
• 2023-02-15 Tc-99m MDP bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in multiple C-, T- and L-spine, sternum, bilateral multiple ribs, left scapula, bilateral multiple pelvic bones, right humerus, and right acetabulum.
  • IMPRESSION: Some of above-mentioned bone lesions including sternum, several T-spine, and left rib cage come to more evident, while other lesions such as left scapula, left iliac bone and right acetabulum become less prominent compared with the previous study on 2022-11-30, indicating dissociated response to current therapy.
• 2023-02-13 CT - chest
  • Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis, ECOG 1
  • Comparison was made with previous CT dated on 2022/11/21
    • Lungs: the smallm spiculated nodule at posterior RUL is readily identified. miliary and small nodules throughout both lungs, and septal thickening and peribronchovascular bundle thickening visible, due to lung to lung metastases. dependent atelectasis over both lower lobes.
    • Mediastinum and hila: residual small and enlarged LNs in visceral and left anterior perivascular spaces.
    • Vessels: the great vessels in the hila and mediastinum are normal in caliber. minimal left pericardial effusion.
    • Heart: normal in size of cardiac chambers.
    • Pleura: small bilateral effusions, increase in volume.
    • Chest wall and visible lower neck: no enlarged LNs at supraclavicular fossae
    • Visible abdominal contents: distended gallbladder. unremarkable of the spleen, liver, adrenal glands, pancreas, and both kidneys. no enlarged lymph node
    • Visualized bones: multiple marginal spurs of vertebrae. blastic metastatic change spine and sternum, .
    • CECT of brain shows no brain metastasis
  • Impression: RUL cancer T4M1cN2, in progression as compared with CT on 2022/12/21
• 2022-11-30 Tc-99m MDP bone scan
  • All of above-mentioned bone lesions are old and most of them show less evident compared with the previous study on 2022-7-14, indicating partial response to current therapy.
• 2022-11-21 CT - chest
  • Impression: RUL cancer T4M1c, stationary as compared with CT on 2022/8/8
• 2022-10-27 Cardiopulmonary Exercise Testing
  • Conclusion
    • maximal exercise
    • low exercise capacity (VO2 39%, WR 51%)
    • normal stroke volume response during exercise
    • normal ventilatory function (FEV1/FVC 78 , FVC 81%, FEV1 77%)
    • low expiratory muscle strength (MIP 100%, MEP 50%)
    • Health-related quality of life, CAT= 4
  • Suggestions:
    • treat underlying condition
    • suggest exercise training
• 2022-08-08 CT - chest
  • Impression: RUL cancer T4N3M1c, with new bony metastasis as compared with CT on 2022/03/01 and resolution of patchy consolidations in both lungs compared with CT on 2022-04-28
• 2022-07-14 Tc-99m MDP bone scan
  • The scintigraphic findings suggest multiple bone metastases. In comparison with the previous study on 2022/03/07, some new bone lesions are noted and some previous bone lesions are more evident. However, some previous bone lesions in the lower L-spines, sacrum and bilateral S-I joints are a little less evident.
• 2022-04-28 CT - chest
  • Pneumonic patch at both lungs with bilateral pleural effusion.
• 2022-04-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (96.3 - 25.8) / 96.3 = 73.21%
    • M-mode (Teichholz) = 73
  • Conclusion:
    • Mild dilated aortic root
    • Septal hypertrophy
    • Adequate LV and RV systolic function
    • Mild MR, AR, TR and PR
    • No regional wall motion abnormalities
• 2022-03-18 Spirometry
  • mild obstructive combine restrictive lung defect with significant reversibility
  • FEV1/FVC=81%, FVC= 70% FEV1= 69%
  • small airway disease FEF25-75% = 44%
• 2022-03-09 Patho - pleural/pericardial biopsy
  • Lymph node, right neck, dissection — adenocarcinoma, moderately differentiated, metastatic, consistent with lung origin (8/10)
  • Sections show 10 lymph nodes with metastatic acinar and papillary glandular tumor cells in 8 lymph nodes. Extranodal extension is seen. The morphology is consistent with metastatic adenocarcinoma from lung.
• 2022-03-09 CXR
  • Diffuse miliary lesions in both hypoinflated lungs due to lung to lung metastases
  • superior mediastinal widening due to lymph node enlargement,
  • Blunting of left costophrenic angle, pleural effusion?
• 2022-03-07 PD-L1 (SP142)
  • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • S2022-3466
    • Tumor type: adenocarcinoma
    • Tumor location: supraclavicular fossa lymph node
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark XT
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: Pass,
      
    • Adequate tumor cells present (>=50 viable tumor cells): Yes,
  • Result:
    • Tumor cell (TC) staining assessment: TC category: TC < 1%
    • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
      
  • Note:
    • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
    • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2023-03-07 Tc-99m MDP bone scan
  • Highly suspected cancer with multiple bone metastases in multiple C-, T- and L-spine, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, S-I joints, right humerus, and left femur.
• 2023-03-07 MRI - brain
  • No evidence of brain metastasis.
• 2023-03-04 PET
  • Glucose hypermetabolism in a focal area in the upper lobe of right lung. Primary lung malignancy may show this picture. Please correlate with other clinical findings.
  • Glucose hypermetabolism in the right lower neck lymph nodes, bilateral supraclavicular lymph nodes, right axillary lymph nodes, bilateral pulmonary lymph nodes and bilateral mediastinal lymph nodes, compatible with metastatic lymph nodes.
  • Glucose hypermetabolism in some small focal areas in bilateral lung fields, in some small focal area in the liver and in multipe bones as mentioned above, suggesting lung to lung metastases and multiple liver and bone metastases.
• 2022-03-03 Patho - lymphnode biopsy
  • Soft tissue, supraclavicular fossa lymph node, sono-guiding biopsy — Metastatic adenocarcinoma, consistent with lung origin
  • Sections show solid nests and acinar glandular tumor cells infiltrating in a fibrotic stroma. No lymphoid tissue is seen. The morphology is consistent with S2022-3326. The immunohistochemical stains are done in S2022-3326.
• 2022-03-02 Patho - bone marrow biopsy
  • Bone marrow, iliac crest, biopsy — Metastatic adenocarcinoma, consistent with lung origin
  • Sections show 20-30 % cellularity. The M/E ratio is about 3/1 - 4/1. Megakaryocytes are found about 2-8/HPF. No increase of blasts is noted. There are no granulomas. Nests of papillary and acinar tumor cells are seen.
  • The immunohistochemical stains reveal CK(+) and TTF-1(+). The results are consistent with metastatic adenocarcinoma from lung. Please correlate with the clinical presentation and image study.
• 2022-03-01 CT - chest
  • Imaging Report Form for Lung Carcinoma
• 2022-02-21 MRI - L-spine
  • History
    • PH: no DM; no HTN
    • OP hx: nil
    • 20220215: LBP, esp ant banding; buttock/ thigh radiaiton for 2 months; walk level < 30 mins; ineffective to L-traction/ hot packing/ pain killer for 1 month; relief by lying down
  • Thoraco-lumbar spine (including sagittal T2WI of cervical spine) MRI without IV Gd-DTPA administration shows:
    • Multiple bone destructing lesions in TL spine, esp. at L1-2-3 levels, including posterior parts of L2-3.
    • Multiple bone destructions at bil. pelvic bones.
    • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression.
    • Normal cord size and signal intensity.
  • IMP: Multiple bone metastases, or multiple myelomas?
    • C-spine: Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression.
• 2022-02-21 KUB + L-spine Lat
  • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.

[consultation] (not completed)

• 2023-06-05 Dermatology
  • Q
    • for herpus around anus and abdominal
    • This 49-year-old man who with past history of gastric ulcer. 1) Gastric ulcer. 2) Right upper lung cancer, adenocarcinoma, T4N3M1c, stage IVB with  lung to lung, liver, bone metastasis, ECOG 1, NGS LAPs: EGFR - amplification, exon 19 deletion (E746_A750del).
      • The lung cancer treatment regimen as below:
        • First TKI with Giotrif 30mg on 2022-03-18 to 2023-03-08, changed to Tagrisso on 2023-03-08.
        • Angiogenesis inhibitor C1 Ramucirumab since 2022-03-22.
        • Radiotherapy 3000cGy/10 fx to T12-sacrum, SI, Rt iliac crest 2022/03/08 to 2022/03/02
        • Radiotherapy 3000cGy/10 fractions (6 MV photon) to left upper femur, 2022/06/08 to 2022/06/21.
        • Radiotherapy 3500cGy/10 fractions (6 MV photon) to Lt sternum, scapula and Lt humerus, 2022/12/15 to 2022/12/28; 2450cGy/7 fractions (6 MV photon) to Rt iliac and ischial bone; 1050cGy/3 fractions (6 MV photon) to Rt iliac bone, 2022/12/29 to 2023/01/06.
      • Tracing back the past history, his complained low back pain since 2021-11, especially anterior banding, buttock, and thigh radiaiton, he can only walk less than 30 minutes, relief by lying down.
        • He first went to the clinic to receive anti-inflammatory and pain-relieving injections and oral medication, which were ineffective; then he was transferred to the orthopaedic clinic, where suggested rehabilitation.
        • He received rehabilitation treatment with traction and hot packing for about a month, but it was also ineffective, then he was referred to our neurosurgery clinic in 2022-02. Neurosurgery Clinic on 2022/02/15, the neurological assessment revealed consciousness E4V5M6, JOMAC and cranial nerves examinatin were intact, pupil right 3.0(+), left 3.0(+), muscle power upper limbs 5+, lower limbs 5-, deep tendon reflex upper limbs 2-3+, right lower limb 2+, left lower limb +, negative result of Hoffmann sign and Spurling sign, there were left shoulder pain and suspect numbness, and bilateral thigh hypesthesdia, limited of gait, normal coordination and finger-nose-finger test, continence of sphincter.
        • The impression was cervical and lumbar spine spondylosis. Pain-killers with Celebrex and Sketa were prescribed to him back home, a magnetic resonance imaging of lumbar spine was arranged and it revealed multiple bone destructing lesions in TL spine, especially at L1-2-3 levels, including posterior parts of L2-3, multiple bone destructions at bil. pelvic bones, bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression, and bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression. Suspect metastasis?
        • He was was referred to the Department of Hematology and Oncology for follow-up survey. He is hospitalized on 2022/02/28. After admission, check tumor marker CEA=20.78ng/ml, kept pain-killer for symptoms relief, arranged Chest CT on 2022/03/01, which revealed a 13 mm spiculated solid nodule at posterior RUL consistent with a primary lung cancer, with innumerable small nodules and miliary nodules randomly distributed throughout both lungs due to lung to lung metastases. Mediastinum and hila: extensive metastatic lymphadenopathy in the visceral aand anterior prevascular spaces. Impression: RUL cancer T4N3M1c.
        • Arranged bone marrow and biopsy was done and smoothly on 2022/03/02 and show Metastatic adenocarcinoma, consistent with lung origin. Due to primary lung cancer, sona guide biopsy was done that reveal metastatic adenocarcinoma, consistent with lung origin. Sent EGFR, PD-LI and ALK, that report EGFR mutation Exon 19 detect. Painless of endoscopy was complete that show Reflux esophagitis LA grade A. Superficial gastritis. Gastric erosions, mid body, LC and GC, s/p biopsy. Pursue pathology report. Check sputum and TB culture data in negative finding. Brain MRI reveal no evidence of brain metastasis. Bone scan was complete that show highly suspected cancer with multiple bone metastases in multiple C-, T- and L-spine, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, S-I joints, right humerus, and left femur.
        • Consult oncology of radiotherapy that suggest radiotherapy to L1-2 and pelvic bone metastasis for 3000cGy/10 fractions is suggested for pain control. Possible treatment toxicity is told. CT simulation was arranged on March 07 08:30 and treatment will be started after pathological proof is available. Xgeva 120mg was administrated. PET disclose 1.Glucose hypermetabolism in a focal area in the upper lobe of right lung. 2.Glucose hypermetabolism in the right lower neck lymph nodes, bilateral supraclavicular lymph nodes, right axillary lymph nodes, bilateral pulmonary lymph nodes and bilateral mediastinal lymph nodes, compatible with metastatic lymph nodes. 3.Glucose hypermetabolism in some small focal areas in bilateral lung fields, in some small focal area in the liver and in multipe bones as mentioned above, suggesting lung to lung metastases and multiple liver and bone metastases.
        • Vemidy was prescribed for Hepatitis B and abd echo was done that reveal Fatty liver, mild hepatic tumor, S5, r/o metastatic lesion. Neck lymphnode dissection and a minivac in placed on 2022-03-09 post consult CS. TKI with Giotrif 30mg was presribed on 2022-03-18. Arrange agiogenesis inhibitor C1 Cyramza 500mg on 2022-03-22 was done smoothly. This time he was admitted to our ward on 20230530 for C15-3 Ramu 500, C2 Durva (1+1) CEA, BT with PLT 2ph.
    • We sincerely need your professional assistance!!!
  • A
    • This patient suffered from multiple grouped vesicles on L’t trunk for days and graulation on R’t thumb for days.
    • Imp:
      • Herpes Zoster
      • Pyogenic granuloma
    • Suggestion:
      • Lyrica x1 /bid
      • Serenel x1 /hs
      • ZnO x1 tube/bid
      • Arrange He-Na laser
      • Liq N2
• 2023-02-17 Radiation Oncology
  • A
    • Diagnosis: Lung cancer, RUL, adenocarcinoma, with military lung to lung & multiple bone metastasis, cT4N3M1c; EGFR mutation: L858R(-), exon 19(+), under Afatinib since 2022/03/12, Ramicurimab since 2022/3/22 & multiple RT course to bone, last on 2023/01/13 with disease progression; ECOG:1.
    • Plan: RT to T3-11 spines and possible left scapula for 3000cGy/10 fractions is suggested for pain control. Possible treatment toxicity is told. CT simulation was arranged on Feb 20 14:30 and treatment will be started on Feb 22 or 23. Diet education & psychological support is done.
• 2022-06-07 Dermatology
  • Q
    • A 48-year-old man with a past medical history of 1) asthma, 2) gastric ulcer, 3) Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis, ECOG 1, under TKI with Giotirf, chemotherapy and radiotherapy treatment.
    • Due to left hand erythematous rash, so we sincerely need your help for evaluation. Thanks a lot!!!
  • A
    • This patient suffered from erytheamtous papules-with scaling for wks
    • Imp: Subacute dermatitis
    • Sugestion:
      • please check ANA, TSH, IgE
      • Xyzal x 1 /Hs
      • Topsym cream x 5 tubes/bid
• 2022-05-05 Psychosomatic Medicine
  • Q
    • this consultation is for depression management.
    • This 48-year-old man had past history of gout. He was diagnosed with lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis on March, 2022. Since then he became depressed and need hypnotic agent. He was admitted to our ICU for desaturation noted at chest ward. He had extubation on 2022/05/02 and he had no SOB under n/c use. We planned to transfer him back to chest ward on 2022/05/05. However, he claimed that he became more depressed and had insomnia. No suicidal ideation or decreased appetite were noted. Due to above reason, we sincerely need your expertise for depression management. Thanks!
  • A
    • Impression: Major depressive disorder
    • Clincial course and symptoms:
      • This is a 48-year-old man had past history of gout. No psychiatric history.
      • He was diagnosed with lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis on March, 2022. We were consulted for his depression and insomnia recently.
      • Upon visit, he said he had depressed mood, insomina, negative thought, decreased appetite, lack of reward sensation, since 2022/03, and he kept crying during the interview, intermittent suicide ideation was noted.
      • The patient has been diagnosed with cancer after this March, and recently he has often crying and feeling down, with insomnia. He has lost 5kg in 2 months. He feels guilty and apologetic to his family. In the past few days, he has had suicidal thoughts, but currently, he is not planning to commit suicide due to his daughter.
      • And he had no depresive episode or psychiatric history before.
    • Suggestion:
      • Use mirtazapine 15mg HS firstly for his depression, if no oversedation tomorrow, please tirtrated to 30mg HS
      • please arrange our OPD follow up after he dsicahrge.
• 2022-05-03 Dermatology
  • Q
    • Dear doctor, this consultation is for skin lesion management.
    • This 48-year-old man had past history of
      • Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis.
      • asthma
      • gastric ulcer
    • He was admitted to ICU due to OHCA and acute respiratory failure s/p ETT s/p extubation 2022/05/02.
    • A skin lesion over his left knee was noted. We ever prescribed biomycin but in vain. He denied painful sensation. There was no swelling or discharge from the wound. Due to above reason, we sincerely need your expertise for skin lesion management. Thanks!
  • A
    • This patient suffered from ulceration w’d on L’t thigh for months.
    • Imp: Chronic wound
    • Suggestion:
      • ZnO x1 tube/bid
      • Fucidin cream x2 tubes/bid

[immunochemotherapy] (not completed with small molecular targeted therapeutics)

• 2023-06-06 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-05-02 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr + durvalumab 240mg NS 100mL 1.5hr D2
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-04-06 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-02-14 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2023-01-16 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2022-12-19 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2022-11-21 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2022-10-24 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2022-09-26 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2022-08-09 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2022-07-10 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2022-06-06 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2022-04-18 - ramucirumab 10mg/kg 500mg NS 250mL 90min
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
• 2022-03-22 - ramucirumab 10mg/kg 500mg NS 250mL 90min
  • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

==========

2023-06-16

• This year, there have only been 2 episodes of leukopenia with a WBC count less than 3K/uL, occurring on 2023-01-14 and 2023-04-06. The injectable Cyramza (ramucirumab) has been used since 2022-03-22. Oral TKI treatment was divided at 2023-03-15: before this date, the patient was taking Giotrif (afatinib), and after this date, the patient was taking Tagrisso (osimertinib). The relationship between the usage of these drugs and the WBC level is shown in the table below, with asterisks indicating the dates when the WBC count was less than 3K/uL.

  • 2023-06-05 WBC 3.33 x10^3/uL 2023-05-02 ramucirumab osimertinib
  • 2023-04-27 WBC 4.95 x10^3/uL osimertinib
  • 2023-04-06 WBC 2.88 x10^3/uL * 2023-04-06 ramucirumab osimertinib
  • 2023-04-03 WBC 3.35 x10^3/uL osimertinib
  • 2023-03-30 WBC 3.72 x10^3/uL 2023-02-14 ramucirumab osimertinib
  • 2023-02-11 WBC 6.33 x10^3/uL 2023-01-16 ramucirumab afatinib
  • 2023-01-14 WBC 2.88 x10^3/uL * afatinib
  • 2022-12-19 WBC 4.24 x10^3/uL 2022-12-19 ramucirumab afatinib
  • 2022-11-21 WBC 5.87 x10^3/uL 2022-11-21 ramucirumab afatinib
  • 2022-10-24 WBC 6.04 x10^3/uL 2022-10-24 ramucirumab afatinib
  • 2022-09-26 WBC 6.75 x10^3/uL afatinib

• The administration time of ramucirumab does not appear to directly correlate with the episodes of leukopenia. However, all three drugs mentioned above have been reported to be associated with leukopenia. For ramucirumab, neutropenia has been reported in 5% to 24% of patients, with grade >=3: 8%. Afatinib has been associated with lymphocytopenia in 38% of patients, with grades 3/4: 9%, and decreased white blood cell count in 12% of patients, with grades 3/4: 1%. Osimertinib has been reported to cause leukopenia in 54% of patients, neutropenia in 26% to 41% of patients, with grades 3/4: <= 3%. (ref: UpToDate)

• In conclusion, it is difficult to determine whether leukopenia is caused by a specific drug or a combined effect of all drugs.

• As per the reimbursement guidelines of Taiwan’s NHI, the administration of G-CSF is approved for patients with non-hematological malignancies who demonstrate a WBC count of less than 1000/uL or an ANC of less than 500/uL following chemotherapy. In this particular patient’s case, the specific criteria are not fulfilled, which means that the use of G-CSF is not covered by the NHI, if G-CSF is desirable.

700532802

230616

[diagnosis]

• 2023-04-23 discharge note
  • Metachronous adenocarcinoma transverse colon cancer with lung metastasis, cT4aN1bM1a stage IVA, status post right hemicolectomy on 2022/12/21, pT3N2aM0, stage IIIB, s/p chemothearpy with FOLFOX from 2023/02/21
  • Chronic viral hepatitis B without delta-agent
  • Tuberculosis of lung
  • Insomnia, unspecified
  • Idiopathic gout, unspecified site
• 2023-02-20 admission note
  • Malignant neoplasm of transverse colon
  • Chronic persistent hepatitis, not elsewhere classified
  • Tuberculosis of lung
  • Functional dyspepsia
• 2023-01-03 discharge note
  • Metachronous transverse colon cancer with lung nodule suspect metastasis status post right hemicolectomy on 2022/12/21, pT3N2aif cM0, stage IIIB.
  • Left lung nodule status post video-assisted thoracoscopic surgery left lower lobe and left upper lobe wedge lymph node dissection on 2022/12/21.
  • Chronic persistent hepatitis

[past history]

• The patient had no systemic diseases, including endocrine, CNS, CV, and infection
• Tuberculosis of lung under treatment from 2023/01/13 (AKuriT-4 (RIF 150mg/INH 75mg/PZA 400mg/EMB 275mg)/tab)
• History of operation: Ascending colon s/p right hemi 15 years ago.
• Denied recent traveling history
• Blood transfusion history: NIL
• Occupational function (premorbid): OK。
• Regular medications or herb: no  

[allergy]

• NKDA

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings] (not completed)

• 2023-03-10 CXR
  • Atherosclerotic change of aortic arch
  • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
• 2023-03-01 SONO - abdomen
  • Liver cirrhosis
  • GB polyp
  • Splenomegaly, mild
• 2023-02-09 CXR
  • Tortous aorta with calcification is noted.
  • Faint aveolar opacity over left central lung is found.
  • Emphysematous change over both lungs.
• 2023-01-02 Cepheid Xpert MTB/ RIF Test
  • Result: Positive
• 2022-12-23 CXR
  • Ground glass opacity in LLL.
• 2022-12-22 Patho - lung wedge biopsy
  • Diagnosis
    • A: Lung, LUL, wedge resection —- fibrotic nodules with surrounding granulomatous inflammation
    • B: Lung, LLL, wedge resection —- necrotizing granulomatous inflammation
    • C: Lymph node, left, group 7, dissection —- negative for malignancy (0/3)
    • D: Lymph node, left, group 9, dissection —- negative for malignancy (0/1)
    • E: Lymph node, left, group 10, dissection —- negative for malignancy (0/3)
    • F2022-00622 Lung, LLL, biopsy —- necrotizing granulomatous inflammation
• 2022-12-22 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, transverse colon, anastomosis of small intestine and colon, colectomy —- Adenocarcinoma, moderately differentiated
      • Omentum, omentectomy —- Negative for malignancy
      • Peritoneum ?, excision —- Negative for malignancy
    • Resection margins: free
    • Lymph node, mesocolic, dissection —- Adenocarcinoma, metastatic (4/17)
    • Lymph node, IMA / SMA, dissection —- Not received
    • AJCC 8th edition Pathology stage: pStage IIIB, pT3N2a(if cM0) or pStage IVA, pT3N2a(if cM1a)
      
  • Gross Description:
    • Operation procedure: colectomy, s/p right hemicolectomy
    • Specimen site: transverse (anastomosis of small intestine and colon)
      
    • Specimen size: small intestine and colon: 15.5 cm in length; omentum: 21 x 8 x 1.5 cm; peritoneum ?: 1.7 x 0.7 cm
      
    • Tumor size: 6.5 x 4 cm, annularly ulcerated
    • Tumor location: 6.5 cm and 2.5 cm away from the two resection margins
    • Depth of invasion grossly: mesocolic soft tissue
      
    • Mucosa elsewhere: congestion
    • Macroscopic Tumor Perforation: Not identified
    • Sections are taken and labeled as: A1-2: bilateral resection margin; A3: colon, non-tumor; A4: omentum; A5-8: tumor (A5 and A8 with peritoneum ?); A9-12: lymph node, mesocolic.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Uninvolved, Distance of tumor from margin: 1 mm
        
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Present
    • Tumor Budding: Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: not applicable
      
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes: 4/17
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN): pN2a: Four to six regional lymph nodes are positive
        • Distant Metastasis (pM): if cM0 or cM1
    • Additional Pathologic Findings (select all that apply): None identified
• 2022-12-14 CT - abdomen
  • History: A-Colon cancer, s/p right hemicolectomy. now 1 yr F/U, Hb 8.2,
    • 20221130 colonoscopy:One huge ulcerative mucosa lesion, probable at transverse colon to hepatic flexure, s/p biopsy
  • Findings:
    • S/P right hemicolectomy.
      • There is asymmetrical wall thickening at the proximal transverse colon with irregular fuzzy contour that is c/w newly-developed adencarcinoma (T4a).
      • In addition, three enlarged nodes in the adjacent mesocolon are noted that are c/w metastatic nodes (N1b).
    • There are three soft tissue nodules in LLL of the lung that are c/w lung metastases (M1a).
    • There are several calcification in LUL of the lung that are c/w old granulomas.
    • Several hepatic cysts in both lobes are noted and the largest one 0.8 cm in size at S2/3.
    • There is minimal ascites in the cul-de-sac.
• 2022-12-01 Patho - colon biopsy
  • Colorectum, probable at transverse colon to hepatic flexure, biopsy — Adenocarcinoma.
  • IHC stains: CK20 (+), CD56 (-), EGFR (+); PMS2 (-), MSH6 (+), MSH2(+), MLH1 (-).
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
• 2022-11-30 Colonoscopy
  • Highly suspect colon cancer, probable transverse colon to hepatic flexure, s/p biopsy
• 2022-10-19 SONO - abdomen
  • Diagnosis
    • Liver cirrhosis
    • GB polyp
    • Splenomegaly, mild
    • R/O colon leison
  • Suggestion
    • suggest colonoscopy

[MedRec]

• 2023-03-07 SOAP Hemato-Oncology
  • A/P
    • Check TB PCR first -> If negative, then C/T with FOLFOX. -> Because the lung nodules are TB, the stage would be pT3N2aM0, Stage IIIB -> Adjuvant FOLFOX would be given.
    • Port-A insertion on 2023-02-14
    • Admission on 2023-02-20.
• 2023-02-02 SOAP Gastroenterology and Hepatology
  • Prescription: Baraclude (entecavir 0.5mg) 1# QDAC 28 days
• 2023-01-13 SOAP Infectious Disease
  • Diagnosis: A15.0 Tuberculosis of lung, confirmed by sputum microscopy with or without culture or confirmed molecularly.
  • A/P; check blood tests, begin anti-TB regimen
  • Prescription
    • AKuriT-4 (RIF 150mg + INH 75mg + PZA 400mg + EMB 274mg) 4# QDAC 14 days
    • Vit B6 (pyridoxine 50mg) 1# QD 14 days
• 2023-01-10 SOAP Hemato-Oncology
  • A/P:
    • Check TB PCR first -> If negative, then C/T with FOLFOX
    • Refer to GS for Port-A insertion
    • RTC 3 weeks
• 2023-01-09 SOAP Infectious Disease
  • A/P: collect sputum for TB
• 2023-01-09 SOAP Colorectal Surgery
  • S
    • Colon cancer, A colon. s/p. OP, 200712
    • Loss follow up for years and then a newly found tumor at T-colon
    • 20221221 Right hemicolectomy, Colon cancer, metachronous pT3N2aM0
    • Lung nodule: necrotizing granulomatous inflammation
  • A/P
    • Suggest post-op chemotherapy
    • Refer to Infection due to R/O TB
• 2022-12-20 ~ 2023-01-03 POMR Colorectal Surgery
  • Discharge Diagnosis
    • Metachronous transverse colon cancer with lung nodule suspect metastasis status post right hemicolectomy on 2022/12/21, pT3N2a if cM0, stage IIIB.
    • Left lung nodule status post video-assisted thoracoscopic surgery left lower lobe and left upper lobe wedge lymph node dissection on 2022/12/21.
    • Chronic persistent hepatitis
  • CC: Accidentally finding of local recurrence of ascending colon carcinoma during OPD follow up.
• 2022-12-15 SOAP Thoracic Surgery
  • S: for consultation about lung nodules.
  • O:
    • 20221214 Abd CT showed LUL and LLL nodules,
    • suggest VATS for tissue proof and culture.
    • 20221221 VATS LLL wedge followed by CRS
• 2022-12-15 SOAP Colorectal Surgery
  • O
    • 20221214 Abd CT done
  • A/P
    • Enhanced Recovery After Surgery, ERAS
• 2022-12-08 SOAP Gastroenterology and Hepatology
  • S
    • colon cancer, recurrence
    • Hb 8.2
    • refer for CRS
• 2022-11-30 SOAP Gastroenterology and Hepatology
  • S
    • colonoscopy R/O colon cancer
    • dizziness R/O anemia
• 2022-11-03 SOAP Gastroenterology and Hepatology
  • S
    • Colon cancer, A colon. s/p. now 1 yr F/U
    • CH-B. LC. HBeAg (-).
    • start ETV on 20110421
    • Now ETV tx for 12 yrs 7 m. HBV DNA (-) (1 yr, 3 yr, 4 yr, 7, 8 yrs). normal AFP.
  • O
    • US 20221019:
      • Liver cirrhosis, GB polyp, Splenomegaly, mild
      • R/O colon leison
  • Diagnosis
    • Malignant rectosigmoid junction neoplasm [C19]
    • Chronic persistent hepatitis [K73.0]
• 2017-03-01 SOAP Gastroenterology and Hepatology
  • S
    • Colon cancer, A colon.
    • CH-B. LC. HBeAg (-). anti-HBe (+). Splenomegaly mild. check HBV DNA 1.21E+4 IU/mL (20110413)
    • start ETV on 20110421 (ETV = Endoscopic Third Ventriculostomy)
    • Now ETV tx for 6 yrs 4 m. HBV DNA (-) (1yr, 3 yr, 4 yr). normal AFP.
  • Diagnosis
    • Malignant rectosigmoid junction neoplasm [C19]
    • Chronic persistent hepatitis [K73.0]
    • Dyspepsia & other specified disorders of function of stomach [K30]
    • Acute upper respiratory infection, unspecified [J06.9]

[surgical operation]

• 2022-12-21
  • Surgery
    • Right hemicolectomy        
  • Finding
    • Metachronous T-colon cancer
• 2022-12-21
  • Surgery
    • 3D VATS LLL and LUL wedge + LND.
  • Finding
    • Multiple solid lung nodules over LUL and LLL, size about 0.7 to 1.0cm.
    • Frozen section: benign
    • One 24 Fr. straight chest tube was inserted via left 8th ICS.

[chemotherapy]

• 2023-06-15 - oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2000mg 3000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL D1-3 + aprepitant 125mg PO D1-3 + lorazepam 1mg IVD D1-3
• 2023-05-26 - oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2000mg 3000mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-24 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-31 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX, lower Oxa, skip 5FU bolus)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-10 - oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX, lower Oxa and LV, skip 5FU bolus)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-21 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-06-16

• On 2023-06-15, the patient commenced the 6th cycle of FOLFOX chemotherapy. In this cycle, the dosage of oxaliplatin was reduced to 65mg/m2, leucovorin to 300mg/m2, and infusional 5-FU to 2000mg/m2. This dosage reduction was a continuation from the 5th cycle (2023-05-26). It’s also worth noting that the bolus 5-FU was excluded from the regimen from the 2nd cycle (2023-03-10) onwards.
  • 2023-06-15 WBC 2.58 x10^3/uL *
    
  • 2023-06-07 WBC 4.31 x10^3/uL
    
  • 2023-05-26 WBC 3.76 x10^3/uL
    
  • 2023-05-04 WBC 3.23 x10^3/uL
    
  • 2023-04-12 WBC 3.56 x10^3/uL
    
  • 2023-03-28 WBC 3.39 x10^3/uL
    
  • 2023-03-10 WBC 2.38 x10^3/uL *
    
  • 2023-02-20 WBC 3.89 x10^3/uL
    
  • 2023-02-09 WBC 4.43 x10^3/uL
    
  • 2023-01-13 WBC 5.21 x10^3/uL
• The patient’s WBC level does not yet meet the criteria for G-CSF reimbursement under Taiwan’s NHI rules. However, considering that the WBC level was already below the LLN just before the administration of this regimen cycle, it might be beneficial to administer G-CSF on a self-pay basis. The G-CSF administration is recommended to be started at least 24 to 72 hours after the end of this regimen cycle.

[optional addition of antiemetics]

• Even though premedication with palonosetron and aprepitant was administered prior to the dose-reduced FOLFOX regimen, the patient is still experiencing grade 2 vomiting (3-5 instances within 24 hours) today. If the administration of Imperan (metoclopramide) PRNQ6H is found to be ineffective, it might be worth considering the addition of olanzapine or prochlorperazine. However, this would require careful monitoring for signs of extrapyramidal reactions or neuroleptic malignant syndrome. (Dexamethasone is already in use.)

2023-04-25

• Vital signs are relatively stable during this hospitalization, and the most recent lab data on 2023-04-12 showed grossly normal readings.
• On 2023-03-10, the patient’s WBC level was at 2.38K/uL, which led to a reduction of oxaliplatin from 85mg/m2 to 65mg/m2 and the skipping of the 5-FU bolus in the FOLFOX regimen. Oxaliplatin has since been titrated back to the standard dose, and no instances of WBC levels below 3K/uL have been observed up to this point.
• Underlying conditions including HBV and TB are properly managed with Baraclude (entecavir), Epbutol (ethambutol) and Rina (rifampicin, isoniazid).

700556004

230616

2023-06-13 Anti-HBs 0.00 mIU/mL
2023-06-13 HBsAg Reactive
2023-06-13 HBsAg (Value) 6203.60 S/CO
2023-06-13 Anti-HCV Nonreactive
2023-06-13 Anti-HCV Value 0.17 S/CO
2023-05-23 HBeAg Nonreactive
2023-05-23 HBeAg (Value) 0.949 S/CO
2023-05-23 HBsAg Reactive
2023-05-23 HBsAg (Value) 5353.06 S/CO

2023-05-02 P.jiroveci DNA-Sp Undetectable
2023-05-02 CMV viral load assay <35 IU/mL
2023-05-02 EBV DNA PCR Not deteceted copies/mL

2023-04-29 Gamma 25.9 %
2023-04-28 B2-Microglobulin 6183 ng/mL

2023-04-27 HIV Ab-EIA Nonreactive
2023-04-27 Anti-HIV Value 0.04 S/CO

2023-04-27 LDH 344 U/L

[exam findings]

• 2023-06-13, -05-17, -05-11 CXR
  • Multiple nodules at bil. lungs.
• 2023-05-08, -05-05, -05-02, -04-27, -04-24, -04-20 CXR
  • Multiple nodules in both lungs due to metastases.
• 2023-04-25 Esophagogastroduodenoscopy, EGD
  • Diagnosis:
    • Reflux esophagitis LA Classification grade A
    • Mild oozing lesion, antrum, GC, s/p hemostasis with argon plasma coagulation
  • Suggestion:
    • High dose PPI use
    • Coagulopathy correction
    • 2nd look maybe indicated, if active bleeding present
• 2023-04-24 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Hypercellularity
  • Immunohistochemical stains:
    • MPO: positive for myeloid series
    • CD71: positive for erythroid series
    • CD61: positive for megakaryocytes
    • CD34 & CD117: positive for blast
    • CD138: positive for plasma cells
    • Kappa & lambda light chain: polyclonality
    • CK: negative for carcinoma cell
  • Microscopically, the section shows pictures as follows:
    • Hypercellularity for her age, 70%
    • M/E ratio > 10, hyperplasia of myeloid series and marked hypoplasia of erythroid series
    • Adequate megakaryocytes with focal mononucleation and hyposegmentation
    • No increase of blast
    • Increase of plasma cells (about 10%) with polyclonality of kappa and lambda light chains
  • According to above histopathologic findings, it maybe either therapeutic effect or myelodysplastic syndrome. Please correlate with clinical finding and bone marrow smear for conclusive diagnosis.
• 2023-04-17 CXR
  • Multiple nodules of variable sizes in both hypoinflated lungs due to metastases.
• 2023-04-17 SONO - chest
  • Findings
    • Left-side of thorax:
      • There was no pleural effusion in the left hemithorax. The pleural gliding and diaphragm excursion were adequate.
    • Right-side of thorax:
      • There was no pleural effusion in the right hemithorax. The pleural gliding and diaphragm excursion were adequate. Large amount of ascites was also noted in the abdominal cavity. We tried echo-assisted ascites tapping first but failed because of too thick of skin and soft tissue to approach ascites. We then performed echo-assisted pig-tail insertion from RLQ for ascites tapping under her son’s agreement. After local anaesthesia, Fr 10 pig-tail was inserted smoothly and total 1000cc yellowish turbid fluid was drained immediately. The specimen was submitted for routine, biochemistry, TB, bacterial culture and cell block. The whole procedure was smoothly.
  • Special Procedure
    • Insertion of pig-tail catheter fr.10 through the RLQ abdomen
  • Echo diagnosis
    • No pleural effusion.
    • Massive ascites post pig-tail insertion for ascites drainage.
• 2023-04-15 Gynecologic ultrasonography
  • Findings
    • Uterus Position : AVF
      • Myoma: Myoma: 11 x 8 mm ,
        
    • Endometrium:
      • Thickness: 15.7 mm
    • CUL-DE-SAC: with fluid
      
    • Other: Asites >1000ml
  • IMP:
    • EM: 15.7mm, blood clot
    • Ascites
• 2023-04-06 CT - abdomen
  • History and indication: Sepsis
  • Non-contrast CT of abdomen-pelvis revealed:
    • Left breast cancer (4.0cm) with calcification.
    • Multiple nodules at bilateral basal lungs.
    • Liver cirrhosis with splenomegaly.
    • Some calcifications in uterus.
    • S/P foley catheter indwelling. S/P Port-A infusion catheter insertion.
  • IMP: Left breast cancer with lung metastases. Liver cirrhosis with splenomegaly.
• 2023-04-05 CT - brain
  • Brain atrophy.
• 2023-04-05 ECG
  • Sinus tachycardia
  • Poor wave progression
  • Abnormal ECG
• 2023-02-17 SONO - abdomen
  • Liver cirrhosis with suspected muliple regeneration noules
• 2023-02-15 PET
  • Glucose-hypermetabolism in the left breast and several left axillary lymph nodes, compatible with the primary left breast cancer with regional lymph nodes metastases.
    
  • Glucose-hypermetabolism in bilateral lung fields and the left 1st rib, highly suspected cancer with distant metastases.
    
  • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    
  • Left breast cancer with regional lymph nodes, bilateral lungs and left 1st rib metastases, cTxN2M1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-02-14 ECG
  • Normal sinus rhythm
  • Low voltage QRS
  • Inferior infarct, age undetermined
• 2023-02-14 Spirometry
  • mild restrictive impairment
• 2023-02-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (68 - 17) / 68 = 75%
    • M-mode (Teichholz) = 75
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
    • Trivial TR
• 2023-02-06 CT - chest
  • Indication: Left breast palpable tumor noted for several days. Left breast heterogenous hypoechoic lesion under the nipple, size: 5.0x5.0cm
  • MDCT (256-detector rows, GE Revolution, was performed with 0.625 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Lungs: multiple randomly distributed pulmonary nodules of varying sizes due to metastases. mosaic attenuation changes in both lower lobes may be due to obstructive airway disease
    • Mediastinum and hila: no enlarged LN or mass.
    • Aorta: normal caliber, mild atherosclerotic change of aortic arch.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: no effusion or nodule.
    • Chest wall and visible lower neck: an ill-defined large soft-tissue tumor (52mm in longest dimension) with areas of cystic or necrotic change, and thickening of overlying skin, and with multiple metastaic LAP at left axilla.
    • Visible abdominal contents: appearance of liver cirrhosis and moderate splenomegaly. normal appearance of gall bladder. unremarkable of the, both adrenal glands, pancreas, and both kidneys. no enlarged lympode.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression: Lt breast cancer T3N2M1
• 2023-02-03 Patho - breast biopsy
  • Breast tumor, left, core needle biopsy — Invasive carcinoma of no special type
  • Microscopically, the sections show a picture of invasive carcinoma of no special type characterized by tumor nests infiltrating in the sclerotic stroma with tumor necrosis.
  • Immunohistochemistry shows P63(-), ER(80%, 2~3+), PR(50%, 2+), Her2/neu(+, Dako score 3+) and Ki-67: 70% for tumor.
• 2023-02-02 Mammography
  • Impression:
    • R/O left breast malignancy with axillary lymph nodes metastasis.
    • Group hetergeneous calcifications in UIQ of right breast (posterior third portion). Malignancy?
  • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
• 2021-04-16 Nerve Conduction Velocity, NCV
  • Findings
    • The results of NCV study showed (1) prolonged distal motor latency and decreased sensory nerve conduction velocity in bilateral median nerves, (2) decreased motor nerve conduction velocity in left median nerve, (3) reduced CMAP amplitude in left peroneal nerve.
    • The results of F-wave and H-reflex studies were within normal limits.
    • The thermal QST study showed normal cold and warm threshold in upper and lower limbs.
  • Conclusion
    • The above findings suggest (1) bilateral median distal neuropathy, more severe in the left side, (2) left peroneal neuropathy. Advise clinical correlation.

[immunochemmotherapy]

• 2023-06-13 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr

• 2023-03-29 - epirubicin 90mg/m2 157mg NS 100mL 30min + cyclophosphamide 600mg/m2 1044mg NS 500mL 1hr (EC(90) Q3W)

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL + Granocyte (lenograstim 250ug) SC

• 2023-02-17 - epirubicin 90mg/m2 155mg NS 100mL 30min + cyclophosphamide 600mg/m2 1033mg NS 500mL 1hr (EC(90) Q3W)

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

• 2023-05-23 ~ Femara (letrozole)

• 2023-05-19 ~ 2023-05-24 - Cytotec (misoprostol)

==========

2023-06-16

• The chronological data for the patient’s WBC levels is organized in the following table, with asterisks (*) denoting instances when the WBC count fell below 3K/uL. According to the available HIS5 data, there were three episodes of leukopenia, where the WBC count fell below 3K/uL. These instances occurred in late Feb to early Mar, early Apr, and late Apr. The first two episodes could potentially be attributed to the chemotherapy regimen of epirubicin and cyclophosphamide. However, the cause of the third episode is less certain as there was a full recovery between the second and third episode, and no chemotherapy treatment was administered during this period.
  • 2023-06-13 WBC 4.68 x10^3/uL 2023-06-13 trastuzumab + pertuzumab
  • 2023-05-17 WBC 3.88 x10^3/uL
  • 2023-05-12 WBC 4.74 x10^3/uL
  • 2023-05-11 WBC 3.52 x10^3/uL
  • 2023-05-10 WBC 3.95 x10^3/uL
  • 2023-05-08 WBC 5.11 x10^3/uL
  • 2023-05-05 WBC 7.37 x10^3/uL
  • 2023-05-02 WBC 8.82 x10^3/uL
  • 2023-04-29 WBC 5.39 x10^3/uL
  • 2023-04-27 WBC 4.56 x10^3/uL
  • 2023-04-26 WBC 4.85 x10^3/uL
  • 2023-04-25 WBC 6.28 x10^3/uL
  • 2023-04-24 WBC 1.81 x10^3/uL * cause unknown
  • 2023-04-20 WBC 1.51 x10^3/uL * cause unknown
  • 2023-04-17 WBC 3.36 x10^3/uL
  • 2023-04-13 WBC 7.86 x10^3/uL
  • 2023-04-10 WBC 1.37 x10^3/uL *
  • 2023-04-08 WBC 0.13 x10^3/uL *
  • 2023-04-05 WBC 0.06 x10^3/uL *
  • 2023-03-29 WBC 7.28 x10^3/uL 2023-03-29 chemo
  • 2023-03-16 WBC 5.07 x10^3/uL
  • 2023-03-09 WBC 6.67 x10^3/uL
  • 2023-03-05 WBC 13.05 x10^3/uL
  • 2023-03-03 WBC 1.87 x10^3/uL *
  • 2023-03-02 WBC 0.48 x10^3/uL *
  • 2023-02-23 WBC 2.32 x10^3/uL *
  • 2023-02-16 WBC 3.66 x10^3/uL 2023-02-17 chemo
  • 2023-02-14 WBC 3.86 x10^3/uL

In continuation of the previous pharmacist note.

• According to Taiwan’s NHI reimbursement guidelines, the administration of G-CSF is approved for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL after chemotherapy. In this specific case of the patient, these criteria have been met, suggesting that if the use of G-CSF is deemed beneficial, it will be covered by the NHI.
• Granocyte (lenograstim) was administered concurrently with the chemotherapy regimen on 2023-03-29. It’s recommended for primary and secondary prophylaxis that G-CSF administration typically starts 24 to 72 hours after the end of chemotherapy treatment (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation). ref(1): Delayed Granulocyte Colony-Stimulating Factor (G-CSF) Administration after Chemotherapy Reduces Total G-CSF Doses without Affecting Neutrophil Recovery in a Randomized Clinical Study in Children with Solid Tumors. Pediatr Hematol Oncol. 2020;37(8):665-675. ref(2): Efficacy of delayed administration of post-chemotherapy granulocyte colony-stimulating factor: evidence from murine studies of bone marrow cell kinetics. Exp Hematol. 2008;36(1):9-16.

[not posted]

• Lab 2023-05-23 HBsAg showed reactive. Individuals who are HBsAg positive are at greater risk for HBV reactivation associated with immunosuppressive therapy compared with those who are HBsAg negative. HBsAg-positive individuals who are hepatitis B e antigen (HBeAg) positive and/or have high baseline levels of HBV DNA may be at highest risk. Vemlidy (tenofovir alafenamide 25mg) 1# QDCC was in use from 2023-02-14 to 2023-05-18.

700209819

230615

• 2023-06-13 Patho - esophageal biopsy
  • Esophagus, lower, 33 cm to 37 cm belwo incisors, biopsy — Squamous cell carcinoma, moderately differentiated
  • The sections of a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Rare keratin formation is noted.
• 2023-06-10 CT - brain
  • CC: General weakness for daysDizziness and headache. Cough, throat pain, abdominal pain, nausea.
  • Cranial CT scans without IV contrast medium enhancement was performed smoothly and show:
    • Extensive encephalomalacic change in left frontal and temporal lobes.
    • Diffusely prominent cerebral fissures, cisterns & sulci.
    • Moderate dilated lateral & 3rd ventricles most severe on Lt.
    • Atrophy of the left cerebral peduncle and anterolateral of pons.
    • No evidence of acute intracranial hemorrhage.
    • Hypodensity in the periventricular white matter of bilateral frontal and parietal lobes.
    • No mid-line structure deviation.
    • s/p large Lt and Rt craniotomies.
  • IMP:
    • No evidence of intracranial hemorrhage.
    • Moderate brain atrophy. Extensive encephalomalacic change in left frontal and temporal lobes. Wallerian degeneration of brain stem,
• 2023-06-10 CXR
  • focal increased opacity over Lt lower lung zone with obscuring costophrenic angle
  • old fracture of Rt distal clavicle
• 2023-06-10 KUB
  • large amount of fecal material filled nondilated colon
  • fracture of left pubic rami old
• 2019-04-12 EEG
  • Normal, no focal cortical dysfunction or epileptic form discharges were recorded.
• 2017-10-06 CT - brain
  • Clinical history: 39 y/o
    • 2017-09-18_TBI s/p op (Left F-T-P craniotomy) in Dec 2016 at Hua-Lien TCH. Alcoholism. Facial abrasions. Two episodes of convulsions and upward gaze. Unsteady gait. Poor memory.
    • 2010_right traumatic SDH s∕p craniotomy, double vision.
  • Without enhancement CT of brain:
    • Encephalomalacic change in left temporal lobe.
    • Soft tissue swelling over right periorbital region.

==========

2023-06-15

• Upon reviewing the PharmaCloud database, no issues with medication reconciliation were found.

• According to the records from the neurosurgery OPD, this patient has a long history of alcohol use. The patient also has a history of epilepsy, which is currently managed with Depakine (valproate). This medication is not typically recommended for use in patients with hepatic disease because its clearance is reduced in liver impairment. Therefore, it might be prudent to order comprehensive LFTs for further assessment.

701187733

230615

[past history] - 2023-03-23 admission note

• ovarian cancer, pT2a N1a cM0, pStage: IIIA s/p ATH and BSO on 2019-07-31 and s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Feb 2020 & recurrent tumor in the abd wall in June 2021 s/p 2nd line palliative C/T wt Avastin/Taxotere/Carboplatin IV Q3W x 6 ceased in Oct 2021        
  • ChatGPT: The patient has a history of ovarian cancer with the pathological stage of pT2a N1a cM0, resulting in a pStage of IIIA. The patient underwent abdominal total hysterectomy (ATH) and bilateral salpingo-oophorectomy (BSO) on 2019-07-31. Post-operatively, the patient received adjuvant chemotherapy with Taxol and carboplatin intravenously every 3 weeks for a total of 6 cycles, which was completed in February 2020. The patient had a recurrent tumor in the abdominal wall in June 2021 and underwent second-line palliative chemotherapy with Avastin, Taxotere, and Carboplatin intravenously every 3 weeks for a total of 6 cycles, which was discontinued in October 2021.

[allergy]

• NKDA         

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.    

[exam findings]

• 2023-06-14 CXR
  • Several nodular opacity projecting in the both lung show stationary.
  • Spondylosis of the T-spine
• 2023-03-24 CT - abdomen
  • Clinical history: Ovarian CA s/p Op on 7/31 19 by Pro Huang SiCheng. Papillary serous adenocarcinoma. pT2a N1a cM0, pStage: IIIA
    
  • IMP:
    • S/P HIPEC catheter implantation
    • Mild ascites in left subphrenic space, right subhepatic space and right paracolic gutter space is noted.
    • In addition, there are soft tissue nodules in the omentum that may be carcinomatosis.
• 2023-01-19 Patho - soft tissue tumor, extensive resection
  • PATHOLOGIC DIAGNOSIS
    • Tumor, midline abdominal wall, excision — Metastatic carcinoma
    • Peritoneum, RLQ, ditto — Metastatic carcinoma
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consisted of (A) one piece of tumor tissue measuring 9.8 x 6.5 x 2.8 cm in size without skin and (B) multiple small pieces of peritoneum tumor tissue measuring up to 6.5 x 3.3 x 1.7 cm in size respectively, fixed in formalin. Representatively embedded for sections as A1-A4: abdominal wall tumor and B1-B2: peritoneum tumor.
  • MICROSCOPIC EXAMINATION
    • Microscopically, the sections show pictures as follows:
      • Midline abdominal wall tumor: a poorly-differentiated carcinoma arranged in nest or papillary pattern with necrosis and tumor emboli, compatible with metastaic carcinoma.
      • Peritoneum tumor: metastatic carcinoma
    • Immunohistochemistry (S2023-01270A2) show PAX-8(+), WT-1(+), CK7(+), TTF-1(-) and CDX-2(-), compatible with metastatic ovarian serous carcinoma
• 2023-01-18 ECG
  • Septal infarct, age undetermined
• 2022-11-07 CT - abdomen
  • Indication
    • Malignant neoplasm of left ovary
    • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
  • Imp:
    • Herniation with intestines at anterior abdominal wall is found. In comparison with CT dated on 2022-02-22, the lesion is stationary in extension.
    • s/p ATH and BSO. No evidence of recurrent/residual tumor in the study.
• 2022-02-22 CT - abdomen
  • s/p ATH and BSO. No evidence of recurrent/residual tumor in the study.
• 2022-02-14, 2021-11-22 CT - abdomen
  • S/P hysterectomy. No evidence of tumor recurrence.
  • Ventral hernia.
• 2021-06-01 CT - abdomen
  • Clinical history: 52 y/o female patient with CA 125:592.
  • With and without contrast enhancement CT of abdomen–whole:
    • S/P bilateral oophorectomy.
    • Irregular soft tissue (1.8x1.5cm) in the abdominal wall (surgical scar region), r/o abdominal wall recurrence.
    • Outpouching lesion in ascending colon, suggesting ascending colon diverticulum.
    • Presence of ascites in the pelvic cavity.
  • Impression:
    • S/P hysterectomy and oophorectomy.
    • R/O recurrent tumor in the abdominal wall (surgical scar region).
    • Ascites in the pelvic cavity, progression.
• 2021-02-16 CT - abdomen
  • s/p ATH and BSO. No evidence of abnormal soft tissue mass in the study.
• 2020-09-02 CT - abdomen
  • Clinical history: Ovarian CA s/p Op on 7/31 19. Papillary serous adenocarcinoma. pT2a N1a cM0, pStage: IIIA
    
  • IMP: S/P hysterectomy. There is no evidence of tumor recurrence.
• 2020-04-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (95.4 - 23.0) / 95.4 = 75.89%
    • M-mode (Teichholz) = 75.9
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with mild MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, trivial TR, normal IVC size
• 2019-07-31 Surgical pathology Level VI
  • PATHOLOGIC DIAGNOSIS
    • Ovary, left, salpingo-oophorectomy — Papillary serous adenocarcinoma.
      • IHC stains: ER +, 90%, strong intensity); PR: (+, 80%, strong intensity), WT-1 (+), PAX-8 (+), Napsin-A (-).
    • Ovary, right, salpingo-oophorectomy — Free.
    • Fallopian tube, left, salpingectomy — Free.
    • Fallopian tube, right, salpingectomy — Seeding.
    • Uterus, corpus, total hysterectomy — Atrophic endometrium and myomas
    • Uterus, cervix, total hysterectomy — Free.
    • Omentume, omentectomy — Free.
    • Lymph node, bilateral pelvic and paro-aortic, dissection — Metastatic adenocarcinoma (1/27)
    • Appendix, appendectomy —- Not received.
    • pT2a N1a (if cM0); pStage: IIIA1i
  • MICROSCOPIC EXAMINATION
    • Histologic type: papillary serous adenocarcinoma.
      
    • Histologic grade: high grade
    • Contralateral ovary involvement: absent
    • Tumor side ovarian surface involvement: absent
    • Contralateral ovary surface involvement: absent
    • Right tube involvement: present (in peri-tubal soft tissue)
    • Left tube involvement: absent
    • In situ adenocarcinoma in right &/or left fallopian tube: absent
    • Right adnexa soft tissue involvement: present
    • Left adnexa soft tissue involvement: absent
    • Pelvic soft tissue involvement: absent
    • Uterine serosa involvement: absent
    • Omentum involvement: absent
    • Uterine Cervix involvement: absent
    • Endometrium involvement: absent
    • Myometrium involvement: absent
    • Appendix involvement: not received
    • Largest Extrapelvic Peritoneal Focus : abscent
    • Peritoneal/Ascitic Fluid: see N2019-2801Results pending
    • Regional Lymph Nodes: A1-2: left external iliac LNs (0/7); B: left obturator lymph nodes (0/4); C: right iliac lymph nodes (1/3); D1-2: right obturator lymph nodes (0/6); E: left para-aortic lymph nodes (0/3); F: right para-aortic lymph nodes (0/4).
      • No lymph nodes submitted or found: 27
      • Positive for metastasis: 1, see above. (size: 0.5 x 0.1 cm)
      • Negative for metastasis: 27 see above
    • Other organs or specimens involvement: absent

[MedRec]

• 2021-10-04 SOAP Hemato-Oncology
  • S: 52 y/o female, a pt of Ovarian CA, pT2a N1a cM0, pStage: IIIA s/p Op on 7/31 19 by Pro Huang SiCheng & s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Feb 2020 & recurrent tumor in the abd wall in June 2021 s/p 2nd line palliative C/T wt Avastin/Taxotere/Cisplatin IV Q3W x 6 since 6/11 21.
• 2020-02-25 SOAP Hemato-Oncology
  • S: 50 y/o female, a pt of Ovarian CA, pT2a N1a cM0, pStage: IIIA s/p Op on 7/31 19 by Pro Huang SiCheng & s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Feb 2020.
• 2019-07-25 SOAP Obstetrics and Gynecology
  • O
    • 2019-07-25 sona
      • EM 5.5 mm, Pelvis mass: 311 x 137 mm, RI: 0.26
    • R/O OV tumor
  • Diagnosis
    • Abdominal pain, unspecified site [R10.9]
    • Irregular menstruation, unspecified [N92.6]
    • Malignant neoplasm of right ovary [C56.1]

[MultiTeam]

• 2023-04-25 Social Services
  • Consultation Date: 2023-04-24
  • Reason for Consultation: Other: Low-income household
  • Case Status: No Case Opened
  • Reason for not opening case: 2023.04.24 - Conversation with client and review of past case records
  • Family Situation:
    • The client is 54 years old, an ethnic Chinese from Indonesia, divorced with three sons, and has been unemployed in recent years due to illness. The client is registered as a low-income family in Taipei City but does not receive any subsidies. The client has no labor insurance or private medical insurance.
    • The eldest son is 28 years old, unmarried with a daughter (11 years old), and recently returned to vocational high school (weekend classes), thus only engaging in part-time work; the second son is 24 years old, studying at Chung Hua University in the Department of Multimedia and working as a part-time employee in a health food store, earning over 20,000 NTD per month; the youngest son is 22 years old, currently working as a mobile phone tester. The sons are now jointly helping to cover the family’s expenses.
    • The granddaughter, 11 years old, has been raised by the client since childhood. The client stated that because the sons have found jobs recently, the family now qualifies as a low-income household, and the granddaughter receives a monthly subsidy of over 4,000 NTD.
    • The family lives in Nangang social housing with a monthly rent of 11,000 NTD.
    • The client’s parents have passed away, and they have seven sisters and four brothers, with the client being the ninth child. The eldest sister is deceased, the younger sister and brother have both moved to Taiwan, and the remaining family members still live in Indonesia. Both the younger sister and brother are married with two children each and have occasional contact with the client.
  • Assessment and treatment:
    • The client is automatically referred as a low-income family in Taipei City, exempt from part of the health insurance burden and able to bear medical expenses independently. This time, the client was provided with related welfare consultation, but the client stated that the sons are currently employed, so they may not meet the application criteria. However, the family’s current living situation is still manageable. Additionally, the client expressed concern about the impact of her treatment on her granddaughter and was provided with emotional support by the social worker. It was also suggested that the client seek resources such as the school counseling office for the granddaughter, which the client accepted.
    • This consultation provided the above treatment, and it was noted that the client has experienced discomfort and vomiting after chemotherapy in the past. The team is advised to pay attention to this issue.

[surgical operation]

• 2023-01-19
  • Surgery
    • excision of intraabdominal tumor, malignancy
    • excision of abdomianl wall tumor, malignancy
  • Finding
    • firm mass over lower abdominal wall, favor malignancy
    • multiple seeding tumors over whole peritoneal cavity, total PCI: 26/39
    • UOQ 3
    • epigastria 1
    • LUQ 1
    • right flank 1
    • central 3
    • left flank 0
    • RLQ 3
    • inferior 3
    • LLQ 3
    • small bowel PCI: 1 + 2 + 2 + 3 = 8
• 2019-07-31
  • PreOP Dx: Malignant neoplasm of ovary and other uterine adnexa
  • PostOP Dx: Malignant neoplasm of ovary and other uterine adnexa
  • PCS code: 80418B
  • Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, small military nodules over right vesicouterine fold
    • Adnexa:
      • LOV: 30x20 cm, capsule intact, intra-op rupture(-)
      • ROV: 4x3 cm, capsule intact,
      • Fallopian tube: bilateral grossly normal
    • CDS: no adhesion
    • Ascites: yellowish and clear, about 200 ml
    • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
    • Omentum: no nodules noted
    • Liver: grossly normal & smooth
    • Bilateral peritonium: miliary tumor seeding(+), bean sized
    • Appendix: grosslt normal.
    • After the operation, optimal debulking surgery was achieved.
    • Residue tumor: multiple tumors, maximal diameter smaller then 1 cm, over peritoneal wall and bladder base
  • Estimated blood loss: 300ml
  • Blood transfusion: nil
  • Complication: nil

[chemoimmunotherapy]

• 2023-06-14 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + topotecan 0.35mg/m2 0.6mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-04-24 - topotecan 0.35mg/m2 0.5mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-03-23 - topotecan 0.35mg/m2 0.5mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-02-17 - topotecan 0.35mg/m2 0.5mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-10-25 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-10-04 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-09-06 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-08-02 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-07-08 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 60mg/m2 100mg NS 250mL 1hr + NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 2hr + NS 500mL (after cisplatin) 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-06-11 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 60mg/m2 100mg NS 250mL 1hr + NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 2hr + NS 500mL (after cisplatin) 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2020-02-13 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 3 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + acetaminophen 500mg PO
• 2020-01-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 3 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + acetaminophen 500mg PO
• 2019-12-19 - ditto
• 2019-11-26 - ditto
• 2019-11-05 - ditto
• 2019-10-15 - ditto

==========

2023-07-13

• For the past three months, this patient has used only the outpatient and inpatient hemato-oncology services at our hospital. No medication reconciliation issues have been identified.

2023-06-15

• According to the PharmaCloud database, all of this patient’s prescribed medications for the past 3 months have been provided exclusively by our hospital’s hemato-oncology department. There are no identified medication reconciliation issues.

2023-04-25

• Since the last episode of leukopenia (2.81K/uL) on 2023-03-10, the patient’s WBC count has remained consistently above 4K/uL. However, the patient has experienced post-chemotherapy discomfort with the feeling of wanting to vomit. A short-term prescription of Emend (aprepitant) at 1# QD may help alleviate these symptoms.

2023-03-24

• On 2023-01-19, the patient underwent surgery to remove malignant intra-abdominal and abdominal wall tumors and subsequently began receiving the topotecan/cisplatin regimen on 2023-02-17. Approximately 2 weeks after starting the regimen, an episode of leukopenia was observed with a WBC count of 2.81K/uL on 2023-03-10. It is recommended that the patient’s blood counts continue to be monitored as usual.

701474917

230615

[exam findings]

• 2023-03-28 Peropheral Vascular Test: AV fistula
  • Result:Intra-operative sonography finding: Adequate size of LIJV
• 2023-03-27 Patho - gingival/oral mucosa biopsy
  • Diagnosis
    • Right buccal mucosa, incisional biopsy (frozen section) — Moderately differentiated squamous cell carcinoma
    • Skin, right, incisional biopsy — Moderately differentiated squamous cell carcinoma
    • Right posterior molar area, right, incisional biopsy — Moderately differentiated squamous cell carcinoma
    • Soft palate, right, incisional biopsy — Moderately differentiated squamous cell carcinoma
    • Buccal mucosa, right, incisional biopsy — Moderately differentiated squamous cell carcinoma
  • Microscopically, sections shows moderately differentiated squamous cell carcinoma consisting of nests of tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
  • Immunohistochemical stain reveals p16: negative (patchy immunoreactive, < 70%), and P40: positive.
• 2023-03-27 Frozen Section
  • FROZEN SECTION INITIAL DIAGNOSIS: Oral cavity, right buccal mucosa, frozen section — squamous cell carcinoma
• 2023-03-27 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade A
    • Esophageal papilloma, upper esophagus
    • Gastric ulcer, shallow, antrum, LC
    • Gastritis, antrum and body
    • Hiatal hernia
    • Duodenal ulcer scar with deformed bulb.
  • Suggestion
    • consider PPI Rx
    • consider HP eradication at GI OPD.
• 2023-03-24 Tc-99m MDP bone scan
  • IMPRESSION:
    • Increased activity in the right aspect of the mandible. Malignancy with local bone invasion may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the right and left aspects of the maxilla. The nature is to be determined (dental problem? other nature?). Please correlate with other clinical findings for further evaluation.
    • A hot spot in the anterior aspect of left 4th rib. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips, knee and feet, compatible with benign joint lesions.
• 2023-03-24 MRI - nasopharynx
  • Oralcavity: Impression (Imaging stage) : T:4b N:2b M:0 STAGE:IVB
• 2023-03-23 SONO - abdomen
  • Gallbladder polyps
  • Cholecystopathy
• 2023-03-14 Patho - gingival/oral mucosa biopsy (Y1)
  • Ulcerative tumor, right cheek, incisional biopsy — Ulcer with high grade dysplasia, at least
  • Microscopically, the sections show a picture of ulcer with high grade (moderate at least) dysplasia characterized by enlarged atypical cells with prominent nucleoli, occasional mitoses and focal dyskeratosis. However, early stromal budding or invasion can not be excluded entirely due to interface inflammation and fibrosis. Closely follow up.

[consultation]

• 2023-04-26 Vascular Surgery
  • Q
    • This is 66 y/o male patient had squamous cell carcinoma of right buccal mucosa extending to right masticator space and encasement of right carotid artery, cT4bN2bM0, Stage IVB.
      
    • For port-A wound redness with pus, suspect infection, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • I have had the pleasure of involving with the patient’s care. In brief, He is a 67 year old male seen in consultation for opinion regarding treatment options for port-A wound suspected infection
    • The pt’s hx/Dx was noted for
      • Squamous cell carcinoma of right buccal mucosa extending to right masticator space and encasement of right carotid artery, cT4bN2bM0, Stage IVb
      • Inflammatory conditions of jaws
      • Gallbladder polyps
      • Reflux esophagitis LA Classification grade A
      • Chronic viral hepatitis B without delta-agent
    • Lab/CXR reviewed, noted for leukocytosis, the pt appeared easy looking, denied febrile/chillness. b/c sent. results pending
    • I personally examined the wound, there was no frank pus, yet there was deshiscnce ~ 0.3cm defect, and port-A was exposed
    • SUGGESTION & PLAN:
      • wound debridement will be arranged on 4/28 8AM under local anesthesia.
      • If primary team w’d like to alternate C/T access, we can put in CVC or PICC if needed.
• 2023-03-30 Hemato-Oncology
  • Q
    • Dx: Squamous cell carcinoma of right buccal mucosa, cT4bN2bM0
    • According to NCCN guideline, the tumor was unresectable or the patient was unfit for the surgery due to encasement of right carotid artery and involvement of right masticator space.
    • We strongly suggest induction chemotherapy followed by CCRT in accordance with NCCN guideline after the family meeting.
    • Thus we need your help for chemotherapy. Thank you for your help
  • A
    • This 68 year old man is a case of right buccal cancer, SCC, cT4bN2b M0 stage IVB, we are consulted for induction chemotherapy follow by CCRT.
    • We will discuss with patient (Induction with TPF). Transfer to 11A on Dr Xia. Thanks for your consultation.
• 2023-03-28 Family Medicine
  • Q
    • This is a 68-year-old man who noticed a ulcerative mass on his right cheek but was unwilling to receive treatment until this month. After thorough examination, malignancy of right buccal mucosa was highly suspected. Incisional biopsy revealed high-grade dysplasia but malignancy was still suspected. Incisional biopsy under general anesthesia was done and left subclavian Port-A implantation was done on 2023/03/27 after a series of tumor work-up.
    • Dx: Squamous cell carcinoma of right buccal mucosa, cT4bN2bM0
    • According to NCCN guideline, the tumor was unresectable or the patient was unfit for the surgery due to encasement of right carotid artery and involvement of right masticator space.
    • We strongly suggest induction chemotherapy followed by CCRT in accordance with NCCN guideline after the family meeting (20230328). We need your help, Thanks!
  • A
    • 68-year-old male, Squamous cell carcinoma of right buccal mucosa, cT4bN2bM0
    • Consciousness alert, ECOG 3
    • We will arrange hospice combined care and follow up his condition (20230328 family meeting, the patient and family members agreed to accept cancer treatment.)
    • Indication: Right buccal SCC
    • Plan: Hospice combined care
• 2023-03-28 Gastroenterology
  • Q
    • This is 66 y/o male patient had suffered from SCC of right buccal mucosa and right retromolar area, cT4bN2bM0, cstage IVb. We will arrange chemotherapy with Taxotere, Cisplatin and 5-Fu for him. However, his laboratory showed AFP 1.4 ng/mL , serum Anti-HBc (+) , Anti-HBs (+) were found.  Gastroscopy showed 1) Reflux esophagitis LA Classification grade A 2) Esophageal papilloma, upper esophagus and CLO test (+) were found. We need your further evaluation and suggestion. Thanks !!
  • A
    • We are consulted for pre-chemotherapy evaluation.
    • Lab
      • 2023-03-27 HBsAg Nonreactive
        
      • 2023-03-27 HBsAg (Value) 0.51 S/CO
        
      • 2023-03-27 Anti-HBs 60.07 mIU/mL
        
      • 2023-03-27 Anti-HBc Reactive
        
      • 2023-03-27 Anti-HBc-Value 3.71 S/CO
        
      • 2023-03-27 Anti-HCV Nonreactive
        
      • 2023-03-27 Anti-HCV Value 0.13 S/CO
        
      • 2023-03-27 Creatinine 0.71 mg/dL
        
      • 2023-03-22 APTT 29.6 sec
        
      • 2023-03-22 PT 10.5 sec
        
      • 2023-03-22 INR 1.02
        
    • A
      • Pre-chemotherapy evaluation
      • CLO test positive
    • P
      • Check CBC, AST/ALT, PT, ALB, T.BIL, AFP, HbeAg, Anti-Hbe Ab, Anti-Hbc IgM Ab, Anti-Hbc Ab, HBV DNA
      • Arrange abdominal sonography
      • Baraclude 0.5mg (GFR >50 QD, GFR 30-49 QOD, GFR 15-29 Q3D, GFR <15 or HD QW)
        • NHI reimbursement: HBV carrier (HbsAg(+) or HbsAg(-) but anti-Hbc ab(+)) (Anti-HBc on 2023/03/27 showed Reactive)
          • Coverage begins 1 week prior to chemotherapy and continues for 6 months after completion of chemotherapy.
      • GI OPD follow up

[surgical operation]

• 2023-03-27
  • Surgery
    • Port-A insertion (LIJV approach, B Braun 8.5Fr)        
    • Intra-op venogram    
  • Finding
    • Intra-operative sonography finding: Adequate size of LIJV, yet difficult wiring into SVC occurred, which aided by 5 Fr sheath, venogram guided, .35” terumo wire, finally we were able to wiring into desired position.  
• 2023-03-27
  • Surgery: Incisional biopsy
  • Finding: ulcerative mass on the right buccal mucosa more than 4cm in size with skin perforation.

[chemotherapy]

• 2023-06-14 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D2-5 (TPF)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-05-19 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-04-26 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-03-30 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
  • dexamethasone 4mg IVD D1 + dexamethasone 8mg BID PO D1-3 + palonosetron 250ug D1 + aprepitant 125mg D1-3 + NS 250mL D1 + NS 2000mL D1-5

Neoadjuvant Chemotherapy regimen in In-hospital “Prescription Collection of Chemotherapy for Head and Neck Cancer” protocol (dated 2022-02-11).

• TPF
  • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
  • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
  • 5-FU 750~1000 mg/m2 IVD (24 hs) D1-2, D8-9
  • Q3W for 1~3 cycles
  • H&N Committee suggestion
  • References: Modified from Posner MRI et al. N.Engl.J.Med.357 (2007):1705-1715.
• PF +/- Docetaxel
  • Docetaxel 50~75 mg/m2 IVD (1 hs) D1
  • Cisplatin 70~100 mg/m2 IVD (2 hs) D1
  • 5-FU 1000 mg/m2 IVD (24 hs) D1-3 +/- D4
  • Q3W for 1~3 cycles
  • H&N Committee suggestion
  • References
    • Modified from Posner MRI et al. N.Engl.J.Med.357 (2007):1705-1715.
    • Modified from Van Cutsem E et al. NEJM 2007;357(17):1695-1704.
• Induction Chemotherapy modified with TPF
  • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
  • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
  • 5-FU + Leucovorin, 1000mg/m2 + 100mg/m2 IVD (24 hs) D2, 9
  • Q3 week x 3cycles (Q1W, Q2W, Q3W: rest)
  • H&N Committee suggestion
  • References: Modified from Jérôme Fayette et al. Oncotarget 2016；7(24):37297-37304

Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438&topicKey=ONC%2F85694

• Cycle length: Every 21 days for three cycles.

• Regimen

  • Docetaxel
    • 75 mg/m2 IV
    • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
    • Day 1
  • Cisplatin
    • 100 mg/m2 IV
    • Dilute in 250 mL NS and administer over 30 minutes to three hours. Do not administer with aluminum needles or IV sets.
    • Day 1
  • Fluorouracil (FU)
    • 1000 mg/m2/day IV
    • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
    • Days 1 through 4

Docetaxel, cisplatin, and fluorouracil induction chemotherapy followed by radiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX323) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F72461&topicKey=ONC%2F85694

• Cycle length: Every 21 days for four cycles.

• Regimen

  • Docetaxel
    • 75 mg/m2 IV
    • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
    • Day 1
  • Cisplatin
    • 75 mg/m2 IV
    • Dilute in 250 mL NS and administer over 60 minutes. Do not administer with aluminum needles or IV sets.
    • Day 1
  • Fluorouracil (FU)
    • 750 mg/m2/day IV
    • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
    • Days 1 through 5

==========

2023-06-15

• According to the PharmaCloud database, all of this patient’s prescribed medications for the past 3 months have been provided exclusively by our hospital. There are no identified medication reconciliation issues.

• The leukocytosis seems to be improving as the patient’s WBC count is nearing ULN. The medications recently used, which include esomeprazole, entecavir, and megestrol, have been reviewed, but none of them are known to significantly affect the WBC count. At the moment, there don’t seem to be any medication-related problems associated with this issue.

  • 2023-06-14 WBC 13.43 x10^3/uL
    
  • 2023-06-06 WBC 32.62 x10^3/uL

• Hypomagnesemia has been noted. This might be due to the use of the TPF regimen, which contains cisplatin, and/or the PPI, esomeprazole. During the regimen administration and hospital stay, the patient receives magnesium supplements. Given that hypomagnesemia has been persistent for several months, it may be beneficial to consider magnesium supplementation upon discharge.

  • 2023-06-14 Mg (Magnesium) 1.5 mg/dL
    
  • 2023-06-06 Mg (Magnesium) 1.4 mg/dL
    
  • 2023-05-18 Mg (Magnesium) 2.7 mg/dL
    
  • 2023-05-14 Mg (Magnesium) 1.8 mg/dL
    
  • 2023-04-18 Mg (Magnesium) 1.7 mg/dL
    
  • 2023-03-22 Mg (Magnesium) 2.1 mg/dL

2023-04-27

• The patient started receiving “PF +/- Docetaxel” regimen on 2023-03-30 and lab showed obvious decrease in SCC reading.
  • 2023-04-18 SCC 2.6 ng/mL
    
  • 2023-03-29 SCC (NM) 9.14 ng/mL
• The 2nd dose of the regimen has been postponed due to the development of signs of infection such as redness and pus at the port-A wound site. Pus culture is currently pending. The patient is being treated with the empiric antibiotic Sintrix (ceftriaxone) 2000mg QD since 2023-04-26, and there have been no issues with this treatment to date.

700154194

230614

[lab data]

• 2020-12-17 ROS1 Not detected
  
• 2020-12-11 EGFR G719X Not detected
  
• 2020-12-11 EGFR Exon19 Del Detected
  
• 2020-12-11 EGFR S768I Not detected
  
• 2020-12-11 EGFR T790M Detected
  
• 2020-12-11 EGFR Exon20 Ins Not detected
  
• 2020-12-11 EGFR L858R Not detected
  
• 2020-12-11 EGFR L861Q Not detected
  
• 2020-12-11 ALK IHC Negative
  
• 2020-12-09 PD-L1 (22C3) TPS <1%

[exam findings]

• 2023-06-08 MRI - L-spine

  • The lumbar spine shows spondylosis and disk space degeneration at the L2/3 through L5/S1 levels.
  • Scoliosis of L-spine.
  • Spondylolisthesis of L5 on S1, grade I.
  • Severe narrowing of right L5/S1 neural foramen, caused by protusion disc. Compression of right L5 nerve root.

• 2023-05-20 MRI - brain

  • no evidence of brain metastasis.

• 2023-05-19 CXR

  • LUL atelectasis with increased density with obliteration of the hilum and adjacent mediastinal border, and compensatory overflation of LLL, with elevated hemidiaphgram and left shift of heart.

• 2023-05-19 ECG

  • Unusual P axis, possible ectopic atrial tachycardia
  • Abnormal ECG

• 2023-04-24 Patho - colon biopsy

  • Colorectum, sigmoid colon, (15 cm from anal verge) , Specimen: A — HIGH grade dysplasia.
  • Section shows fragment(s) of polypoid colonic mucosal tissue with proliferative tubular mucinous glands lined by cells containing hyperchromatic, elongated nuclei with HIGH grade dysplasia. The possibility of a more advanced lesion cannot be excluded.

• 2023-04-21 Patho - soft tissue nontumor/mass/lipoma/debridement (Y2)

  • Labeled as “left shoulder”, core needle biopsy — carcinoma, poorly differentiated.
  • Section shows soft tissue infiltrated by andulated irregular nests of carcinoma.
  • IHC stains: WT-1(-), Napsin-A (-), TTF-1 (-), GATA-3 (+), TRPS-1 (-), CK20 (-), vimentin (+).

• 2023-04-21 CT - abdomen

  • History: LUL lung adenocarcinoma, cT4N2M1, stage: IV.
    • 20200613 CT: Mass in Lt pelvis, 6.1cm with left hydronephrosis. S/P left pelvic mass resection and left ureteronephrectomy.
      • Patho: metastases (endometrioid cancer) with ureter invasion
    • 20210908 CT: Few metastases in left pelvis retroperitoneal space?
      • S/P CT guided biopsy: metastatic adenocarcinoma
    • 20210908 CT: multiple liver tumors, R/O mets. B (-), C (-), s/p biopsy. patho: adenocarcinoma. refer back to chest doctor.
      • R/O lung ca with liver mets or multiple CCC
    • 20210802 tumor marker: SCC:7.23 ng/ml (normal: < 2.7),
      • CA125: 55.55 U/ml (normal: < 35), CEA and CA199: normal
  • Findings: Comparison prior chest CT dated 2022/07/08.
    • Prior CT identified several poor enhancing lesions on both hepatic lobes are noted again, increasing in size that is c/w Metastases S/P C/T with progressive disease.
    • There are two newly developed soft tissue mass 1.1 cm and 2.2 cm in the retroperitoneal space of left lower abdomen and left upper pelvis that are c/w metastasis.
      • In addition, there is a third newly developed rim enhancing soft tissue mass 2.1 cm in the mesentery of right upper pelvis that is also c/w metastasis.
    • S/P left nephrectomy.
    • S/P hysterectomy
  • Impression:
    • Prior CT identified several poor enhancing lesions on both hepatic lobes are noted again, increasing in size that is c/w Metastases S/P C/T with progressive disease.
    • Two Metastasis in the retroperitoneal space of left lower abdomen and left upper pelvis, and one metastasis in the mesentery of right upper pelvis.

• 2023-04-21 Bone densitometry - spine + hip

  • L-spines BMD performed by DXA revealed:
    • AP L-spines, BMD of L1-4 1.175 gms/cm2, about 1.2 SD above the peak bone mass (112%) and 3.0 SD above the mean of age-matched people (162%).
  • Hip BMD performed by DXA revealed:
    • Left hip, BMD is 0.582 gms/cm2, about 2.4 SD below the peak bone mass (69%) and 0.2 SD above the mean of age-matched people (102%).
  • Impression
    • Osteopenia

• 2023-04-17 CT - chest

  • LUL cancer T4M1c, stationary of primary tumor and hepatic metastases as compared with previous CT on 2023/01/07

• 2023-03-14 Whole body PET scan

  • Glucose hypermetabolism in the anterior aspect of the upper lobe of left lung. Residual or recurrent malignancy may show this picture. Please correlate with other clinical findings for further evaluation.
  • Multiple glucose hypermetabolic lesions in the pelvic cavity, compatible with metastatic lesions.
  • Glucose hypermetabolism in some lymph nodes in the right aspect of the mediastinum, compatible with metastatic lymph nodes.
  • Glucose hypermetabolism in the posterior aspect of right 4th rib, in a focal area in the soft tissue in the anterior aspect of proximal portion of left humeral shaft, in multiple focal areas in the right lobe of the liver and in a focal area in the left buttock. Metastatic lesions in the bone, liver and soft tissues may show this picture.

• 2023-02-08 Tc-99m MDP

  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed a faint hot area in the post. aspect of the right 4th rib, and increased activity in the maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips, and knees in whole body survey.
  • IMPRESSION:
    • A faint hot area in the post. aspect of the right 4th rib is new compared with the previous study on 2022-03-28; the nature is to be determined (post-traumatic change or other nature?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in the maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips, and knees.

• 2023-01-17 MRI - upper abdomen

  • History and indication:
    • Endometrial cancer with liver mets
    • Lung cancer
  • IMP:
    • Poor enhancing tumors (up to 1.4cm) in right hepatic lobe.
    • Absence of left kidney.
    • Partial consolidation at left lingual lung.

• 2023-01-07 CT - chest

  • Indication: reuse Tagrisso (osimertinib) due to the liver lesion was endometrial cancer with liver meta (not from lung after pathologist revision)
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Left hilar mass with encasing left lobe bronchus, causing collapsed left lingula lobe is found. In comparison with CT dated on 2022-07-08, the lesion is stationary.
      • Enlarged lymph nodes at left axillary region are ofund.
      • S/p port-A placement with its tip at Superior vena cava.
      • Enlarged lymph nodes are found at right anterior chest wall is found.
    • Visible abdomen:
      • Hepatic cystic lesion at right lobe of liver are found. Stable.
      • Aortic wall thickening is found.
      • Scoliotic alignment of the thoracolumbar spine is noted.
  • Imp: Left hilar lung cancer with collapsed left lingula lobe, chest wall lymphadenopathy and probably liver lesions. Stationary.

• 2022-11-09, -09-07 CXR

  • LUL atelectasis with increased density with obliteration of the hilum and adjacent mediastinal border, and compensatory overflation of LLL, with elevated hemidiaphgram and left shift of heart

• 2022-07-08 CT - chest

  • Indication: Endometrioid carcinoma with ureter invasion with etastatic pulmonary adenocarcinoma, T3N0Mx, stage IIIB
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Consolidation over left upper lobe with air-bronchogram is found. In comparison with CT dated on 2022-03-25, the lesion is stationary in size.
      • Mild pericardial effusion is found.
    • Visible abdomen:
      • Low density lesions are found at both lobes of liver up to 1.32cm in largest dimension. These lesions are stationary in size and numbers.
      • s/p left nephrectomy.
  • IMp:
    • Left upper lobe lung cancer, stationary in size.
    • Hepatic metastatic tumors at both lobes liver, stable.

• 2022-05-18 Pure Tone Audiometry, PTA

  • Reliability FAIR
  • Average RE 31 dB HL // LE 41 dB HL
  • RE normal to moderately sevre SNHL
  • LE normal to severe SNHL

• 2022-05-11 Pure Tone Audiometry, PTA

  • Tymp: Bil type C.
  • ART: Bil absent.
  • PTA
    • Reliability FAIR
    • Average RE 35 dB HL; LE 51 dB HL.
    • R’t normal to severe SNHL.
    • L’t normal to severe mixed type HL.

• 2022-04-27, 2022-04-20 CXR

  • LUL atelectasis with increased density with obliteration of the hilum and adjacent mediastinal border, and compensatory overflation of LLL, with elevated hemidiaphgram and left shift of heart.
  • Port-A catheter inserted into cavo-atrial junction via right subclavian vein.

• 2022-03-28, 2021-12-22 Tc-99m MDP whole body bone scan

  • No strong evidence of bone metastasis.
  • Suspected benign lesions in the left 7th rib, maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips, and knees.

• 2021-12-20 KUB

  • Compression fracture of L2 vertebral body
  • moderate dextroscoliosis of the L-spine
    
  • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, L-spine.
  • significant amount of fecal material filled nondilated colon

• 2021-12-09 CT - lung/mediastinum/pleura

  • Left upper lobe lung cancer with stationary size.
  • Liver meta, in enlargement.

• 2021-10-25 Patho - soft tissue biopsy, simple excision, non lipoma

  • left pelvic - Adenocarcinoma, metastatic.
  • IHC: CK7(focal positive), CK20(-), PAX8(+), PR(+), TTF-1(-), Napsin A(-), p40(-), and CD56(-).
  • The morphology and immunohistochemical stains are consistent with S2020-8600 (Endometrioid carcinoma).

• 2021-10-21 CT - whhole abdomen, pelvis

  • Partial consolidation at left lingual region.
  • Tumors in liver, prevertebral region and LLQ tumor metastases.

• 2021-09-08 CT - lung/mediastinum/pleura

  • LUL cancer T4M1c, in progression of primary tumor and hepatic metastases as compared with previous CT study on 2021-06-02

• 2021-09-08 CT - liver, spleen, biliary duct, pancreas

  • Metastases are highly suspected.
  • Multiple Cholangiocarcinomas are less likely.

• 2021-07-16 Patho - liver biopsy

  • IHC: CK7(+), CK20(-), TTF1(-), Napsin A(-), and p40(focal + in squamous component).
  • Primary liver adenocarcinoma (cholangiocarcinoma) can not be completely excluded.
  • Metastatic pulmonary adenocarcinoma is less likely in IHC result.
  • Additional IHC: ER(focal +), PAX8(focal +)
  • Comment: The IHC finding is compatible with metastatic endometroid carcinoma.

• 2021-07-07 Tc-99m MDP whole body bone scan

  • A faint hot spot in the lateral aspect of the left 7th rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3-6 months for investigation.
  • Suspected benign lesions in the maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips and knees.

• 2020-12-17 ROS1 FISH not detected

• 2020-12-11 EGFR, ALK IHC, PD-L1(22C3) S2020-18026 (bronchus biopsy)

  • EGFR
    • G719X (-)
    • Exon19 deletion (+)
    • S768I (-)
    • T790M (+)
    • Exon20 insertion (-)
    • L858R (-)
    • L861Q (-)
  • ALK IHC (-)
  • PD-L1 Tumor proportion score TPS < 1%

• 2020-11-25 Patho - bronchus biopsy

  • CT-guide biopsy - adenocarcinoma, moderately differentiated
  • IHC: TTF-1(+).
  • The result is supportive for the diagnosis of malignant neoplasm of left bronchus or lung.

• 2020-11-13 CT - lung/mediastinum/pleura

  • left upper lobe lung cancer with probably right lung meta. the primary left upper lobe lung cancer progressed.

• 2020-08-12 CT - lung/mediastinum/pleura

  • LUL tumor involving mediastinum and hilum and Rt lung metastasis, in progression as compared with previous CT study on 20200320.

• 2020-06-30 Patho - Ureter resection

  • pathologic diagnosis
    • Ureter, left, frozen section + open nephroureterectomy - Endometrioid carcinoma with ureter invasion
    • Kidney, left, ditto - Chronic pyelonephritis
  • IHC for tumor cells: CK7(+); CK20 (-); ER(+); GATA-3(-), TTF-1(-), WT-1(-), PAX-8(+), P63(-) and CDX-2(+, focal) for tumor cells

• 2020-06-29 Patho

  • Tumor, urinary tract?, frozen section - Adenocarcinoma, uncertain origin

• 2020-06-13 CT - whole abdomen, pelvis

  • S/P hysterectomy.
  • Malignant tumors in the pelvic cavity, up to 6.1cm in left side with left hydronephrosis. Probably metastasis(TCC? GYN or GI tract). Suggest tissue study.

• 2020-03-30 CT - lung/mediastinum/pleura

  • LUL tumor involving mediastinum and hilum, stationary as compared with previous CT study on 20191230.

• 2019-12-30 CT - lung/pleura

  • LUL tumor involving mediastinum and hilum, stationary as compared with previous CT study on 20190918.

• 2019-09-18 CT - lung/pleura

  • LUL tumor involving mediastinum and hilum, stationary as compared with previous CT study on 20190612.

• 2019-06-12 CT - lung/pleura

  • LUL tumor involving mediastinum and hilum, in regression as compared with previous CT study on 20190312.

• 2019-04-11 MRI - L-spine

  • Lumbar spondylosis, canal stenosis and small L1/2 HIVD. No tumor or metastasis found.

• 2019-03-15 MRI - brain

  • No evidence of brian metastasis.
  • Mild ventriculomegaly.

• 2019-03-14 Surgical pathology Level IV

  • indication: Malignant bronchus and lung neoplasm, NOS;
  • diagnosis: Lung, ? side, needle biopsy - adenocarcinoma, moderately differentiated
  • IHC: TTF-1(+), Napsin A(+), and p63(-). The results are supportive for the diagnosis.

• 2019-03-12 CT - lung/pleura

  • Progression of LUL lesion (6.1x7.1cm) with mediastinal LAP. TNM: T4N2Mx
  • Right tiny renal stones (1-2mm). Left hydronephrosis.

• 2019-03-02 CT - brain

  • No brain lesion.
  • A 6.4mm dense calcification at left parasagittal region, calcified meningioma or benign parafalcal calcification.

• 2018-06-06 Surgical pathology Level IV

  • indication: bilateral lung nodules
  • diagnosis: Lung, ? side, needle biopsy - Interstitial fibrosis with atypical pneumocytes
  • Sections show alveolar lung tissue with interstitial fibrosis and atypical pneumocytes proliferating along the alveolar wall. No stromal invasion is seen. The immunohistochemical stain of CK reveals no invasive tumor. The TTF-1 is positive. Please correlate with the clinical presentation and further examination is suggested.

• 2018-05-31 Low-dose CT - lung cancer screening

  • A spiculated mass (4.2x6.1cm) at LUL suspected cancer.

[MedRec] (not completed)

• 2022-02-09 SOAP Hemato-Oncology
  • A/P
    • On 2022-02-09. C/O Toxicity of C/T, e.g., four limbs numbness, especially left upper limb; decreased acuity of eye; fatigue and weakness. Already told the worse of prgnosis. Options are given e.g., change C/T regimen to NHI re-imbursement; rest for one week; continue current regiemen and C/T on 2022-02-09. They dedicde continue current C/T on 20220-02-09.
    • Admission 3rd course of C/T on 2022-02-09
    • Due to acnefirom skin rash over face, order clindaymicin gel.
    • Already told the C/T-irelated neuropathy, patient would like to try one more time on 2022-02-09. If not tolerated, may chnage to other regimen
• 2022-01-05 SOAP Hemato-Oncology
  • O
    • Now on palliative C/T with TP, C1D1 on 2021-12-29
    • AEs: Fatigue
• 2021-11-11 SOAP Chest Medicine
  • Prescription (part)
    • Navelbine (vinorelbine 20mg) 3# QW
• 2021-11-05 SOAP Hemato-Oncology
  • A/P: She is receiving IO and navelbine for her lung ca by Dr Wu. (20211105)
• 2021-09-01 SOAP Chest Medicine
  • Prescription
    • Tagrisso (osimertinib 80mg) 1# QD
• 2021-07-13 SOAP Hemato-Oncology
  • A
    • s/p local radiotherapy after operation for Lt nephrectomy and endometrioid ca with ureter invasion
    • Liver metastases noted in CT abdomen (20210713)
  • P
    • Suggest liver biopsy
• 2021-06-04 SOAP Chest Medicine
  • A/P
    • 2021/05/28 chest CT with/without contrast suspected MET and/or c797 metastasis
    • biopsy of LUL by CS
    • She refused and hope to use qd Tagrisso
• 2020-12-23 SOAP Chest Medicine
  • Prescription
    • Tagrisso (osimertinib 80mg) 1# QD (change)
    • Romicon-A 1# TID
    • Through (sennoside 12mg) 2# HS
    • Sketa 1# TID
• 2020-10-14 SOAP Chest Medicine
  • Prescription
    • Iressa (gefitinib 250mg) 1# Q3D
    • codeine phosphate 15mg 1# BID
    • Zalain External Gel (sertaconazole 2%) Q3D EXT
• 2020-09-16 SOAP Chest Medicine
  • A/P
    • we discuss with patient and final decision was shifted to Iressa 1# Q3D
  • Prescription
    • Iressa (gefitinib 250mg) 1# Q3D (longer interval)
    • Topsym (fluocinonide 0.05%) BID TOPI
• 2020-08-19 SOAP Chest Medicine
  • A/P
    • we discuss with patient and final decision was shifted to Iressa 1# QOD => If after 3 months, on improve => Arrange rebiopsy
  • Prescription
    • Iressa (gefitinib 250mg) 1# QOD (shorter interval)
• 2020-07-22 SOAP Chest Medicine
  • A/P
    • Iressa 1# Q3D
    • prepare to receive RT and C/T for endometrial ca
  • Prescription
    • Iressa (gefitinib 250mg) 1# Q3D
    • Allegra (fexofenadine 60mg) 1# BID
• 2020-04-16 SOAP Radiation Oncology
  • Plan
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 1200cGy/3 fractions to vaginal cuff mucosa surface by IVRT.
• 2020-07-16 SOAP Obstetrics and Gynecology
  • Objective
    • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2021-07-16
      • Cancer staging: rypT3bNx(cM0), stage IIIB.
      • Treatment: Radiotherapy followed by Chemotherapy.
    • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2021-07-09
      • Wait for the pathology report to confirm if the primary cancer is endometrial cancer or cervical cancer.
      • Hematology doctor: Since the patient is old (70 years old) and has lung cancer (Lung adenocarcinoma, T4N0M1, stage IV, post Iressa since 2019-03), the significance of chemotherapy is not high. Suggest initial Local Radiotherapy.
• 2020-02-04 SOAP Chest Medicine
  • Diagnosis
    • Lung cacer with adenocarcinoma, T4N0M1bx, ECOG 0. [C34.90]
    • Cellulitis and abscess other specified sites [L02.811]
  • Prescription
    • Iressa (gefitinib 250mg) 1# Q3D (even longer interval)
    • Allegra (fexofenadine 60mg) 1# BID
    • Mosflow (moxifloxacin 400mg) 1# QDAC
• 2019-06-25 SOAP Chest Medicine
  • Prescription
    • Iressa (gefitinib 250mg) 1# QOD (longer interval)
• 2019-06-11 SOAP Dermatology
  • S
    • Multiple painful erythematous papule-nodules on face, trunk and 4-limbs
    • Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching
  • Diagnosis
    • Lung cacer with adenocarcinoma, T4N0M1bx, ECOG 0. [C34.90]
    • Acne varioliformis [L70.2]
    • Other erythematosquamous dermatosis [L30.3]
    • Seborrheic dermatitis, unspecified [L21.9]
    • Type 2 diabetes mellitus without complications [E11.9]
    • Right eye hypertropia [H50.21]
  • Prescription
    • doxycycline 100mg 1# BID
    • Kefen (ketotifen fumarate 1mg) 1# BID
    • Mycomb BID TOPI
• 2019-06-11 SOAP Chest Medicine
  • Plan:
    • change to Iressa due to severe adverse effect of giotrif, but adverse effect persist, so hold Iressa 2 weeks and wait CT result
• 2019-05-28 SOAP Chest Medicine
  • Objective
    • Assessment of Side Effects of Cancer Treatment (2019-05-28)
      • Skin rash: G2: Moderate rash, or single moist desquamation, mostly in skin folds and moderate edema
      • Oral mucositis: G2: Moderate pain, can eat, need to adjust diet
  • Plan
    • change to Iressa due to severe adverse effect of giotrif
  • Prescription
    • Iressa (gefitinib 250mg) 1# QD (new)
    • Ulstop (famotidine 20mg) 1# BID
    • Allegra (fexofenadine 60mg) 1# BID
    • Mycomb Cream BID TOPI
• 2019-05-14 SOAP Chest Medicine
  • Objective
    • Assessment of Side Effects of Cancer Treatment (2019-05-14)
      • Skin rash: G1: Superficial rash or dry scales
      • Hand-foot syndrome: G3: Skin changes with pain, affecting daily life
      • Oral mucositis: G1: No lesions
  • Prescription
    • same as 2019-04-30
• 2019-04-30 SOAP Chest Medicine
  • Objective
    • Assessment of Side Effects of Cancer Treatment (2019-04-30)
      • Diarrhea: G1: Up to 4 times per day
      • Skin rash: G2: Moderate rash, or single moist desquamation, mostly in skin folds and moderate edema
      • Oral mucositis: G2: Moderate pain, can eat, need to adjust diet
  • Prescription
    • Giotrif (afatinib 30mg) 1# QDAC (lower dose)
    • Ulstop (famotidine 20mg) 1# BID
    • Allegra (fexofenadine 60mg) 1# BID
    • Mycomb Cream BID TOPI
• 2019-04-24 SOAP Chest Medicine
  • Objective
    • Conclusion of the Multidisciplinary Team Meeting for Cancer, Meeting Date: 20190326): Check PD-L1, EGFR and ALK status, if positive mutation is found, then initiate targeted therapy.
    • EGFR Exon 19 Del, PD-L1 5%, ALK negative
  • Prescription
    • Giotrif (afatinib 40mg) 1# QDAC
    • Ulstop (famotidine 20mg) 1# BID
    • Allegra (fexofenadine 60mg) 1# BID
    • Imolex (loperamide 2mg) 1# BID
• 2019-03-27 SOAP Chest Medicine
  • Diagnosis
    • Lung cacer with adenocarcinoma, T4N0M1bx, ECOG 0. [C34.90]
    • Type 2 diabetes mellitus without complications [E11.9]
    • Right eye hypertropia [H50.21]
    • constipation [K59.00]
  • Prescription
    • Navelbine (vinorelbine 20mg) #3 QW
    • Sketa (acetaminophen 300mg + chlorzoxazone 250mg) 1# TID
    • Through (sennosides 12mg) 1# HS
• 2019-03-08 SOAP Ophthalmology
  • Diagnosis
    • Senile cataract, unspecified [H25.9]
  • Prescription
    • ONSD (neostigmine methylsulfate) 0.01% 10mL eye drop BID
• 2019-03-01 SOAP Neurology
  • Diagnosis
    • Disorder of binocular vision, unspecified [H53.30]
    • Sixth or abducens nerve palsy [H49.22]
  • Prescription
    • Compesolon (prednisolone 5mg) 1# BID
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
• 2018-06-01 SOAP Chest Medicine
  • Dx: bilateral lung nodules
• 2017-03-24 SOAP Family Medicine
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Gout, unspecified [M10.9]
    • Urinary calculus, unspecified [N20.9]
    • Mixed hyperlipidemia [E78.2]
    • Constipation [K59.00]
  • Prescription
    • Uformin (metformin 500mg) 1# QD
    • Lipanthyl (fenofibrate 160mg) 1# QOD
    • Euricon (benzbromarone 50mg) 0.5# QOD

[consultation]

• 2023-05-22 Oral and Maxillofacial Surgery
  • Q
    • She would like to receive Xgeva (denosumab)
    • We need your expertise and evaluation for her jaw because of propable MRONJ
  • A
    • After intraoral dental examination, no dental decay or mobile teeth was noticed.
    • Xgeva could be used safely.
• 2023-05-22 Radiation Oncology
  • Q
    • This 72-year-old woman with underlying histories of
      • LUL adenocarcinoma, Stage= T4N2M1 stage IV with probably right lung metastasis
      • Malignant tumors in the pelvic cavity, up to 6.1cm in left side with left hydronephrosis. Probably metastasis (endometrioid cancer)。
      • DM
      • hyperuricemia
      • Endometrioma sp ATH+BSO 2011
      • Abdominal benign mass lesion sp surgical removal x3 many years ago.
        
    • This time, she was admitted to ward for restaging of Brain MRI (no meta) and NGS evaluation.
    • The patient complaint about her left arm pain and liver meta. She would like to receive radiotherapy
    • We need your expertise and evaluation for her treatment and symptoms control
  • A
    • History: This 72-year-old woman suffers from LUL adenocarcinoma, cT4N2M1 stage IV with probably right lung metastasis s/p Durvalumab and navelbine s/p Taxol/Carboplatin for 3 cycles in 2022/07 under Tagrisso now;
    • This time, she was admitted to ward for restaging of Brain MRI (no meta) and NGS evaluation. The patient complaint about left shoulder pain with movement limitation and progressive liver metastasis noted by CT on 2023/04/21.
    • Previous RT: Endometrial carcinoma of the uterus, s/p hysterectomy and BSO at ZhongShan Hospital in 2011, with recurrence and left ureter invasion, s/p operation (Nephrourterectomy with bladder cuff resection, left (open); Excision of retroperitoneal tumor, retrorectal tumor, left exteranl iliac LAP on 2020/07/06; stage rypT3bNx (cM0), stage IIIB, s/p adjuvant RT on 2020/09/11; RT to Rt posterior 4th rib for 3500cGy/10 fx on 2023/4/06.
      
    • Diagnosis: Metastatic soft tissue tumor over left shoulder (origin from lung cancer or endometrial cancer?); ECOG =1.
    • Plan: RT to left shoulder for 4000cGy/10 fx is suggested for pain control. Possible radiation toxicity (radiation dermatitis) is told to her. CT simulation will be arranged on May 30, 10:30.
• 2021-12-21 Hemato-Oncology
  • Q
    • This 70 y.o female was a case with past history of (1) Endometrioid carcinoma with ureter invasion with Metastatic pulmonary adenocarcinoma is less likely in IHC result (2) DM.
  • A
    • This 70 year old woman had history of
      • s/p Hystectomy & BSO due to endometriosis in 2011 at ZhongShan Hospital.
      • LUL tumor involving mediastinum and hilum and Rt lung metastasis, NSCLC T4N0M1 stageIV adenocarcinoma, moderately differentiated s/p navelbine since 2019/03/27, Exon 19 Del, PD-L1 5%, ALK negative s/p afatinib since 2019/04/24, change to Iressa due to severe adverse effect of Giotrif (afatinib) since 2019/05, 2020/11 re biopsy, t790m mutation, shift to osimertinib 2020/12/23, 2021/02 CT: left upper lobe lung cancer with probably liver meta, s/p C1 Alimta 600mg on 2021/09/14 and C1 Durvalumab 240mg(1+1) on 2021/09/15.
      • Endometrioid carcinoma with ureter invasion status post retroperitoneal tumor s/p 1.excision of retroperitoneal tumor, LN. with enterolysis, 2.debulking, 3.ureterorenoscopic exam and DBJ insertion pT3N0M0 stage III on 2020-06-29: CK7(+); CK20 (-); ER(+); GATA-3(-), TTF-1(-), WT-1(-), PAX-8(+), P63(-) and CDX-2(+, focal) for tumor cells
      • 2021/07/16 liver biopsy: Adenocarcinoma with focal squamous differentiation, IHC shows following features: CK7(+), CK20(-), TTF1(-), Napsin A(-), and p40(focal + in squamous component). Primary liver adenocarcinoma (cholangiocarcinoma) can not be completely excluded. Metastatic pulmonary adenocarcinoma is less likely in IHC result. 2021-09-08 CT: 1. LUL cancer T4M1c, in progression of primary tumor and hepatic metastases as compared with previous CT study on 2021/06/02 2. There are multiple well-defined ring-enhancing masses on both heatic lobes, the largest one 3 cm in S7/8, at arterial phase images and contrast washout in portal and delayed phase images. Several larger lesions show central tunor necrosis. Metastases are highly suspected. Multiple Cholangiocarcinomas are less likely.
      • LLQ tumor seen in 2021/10/21 CT, biopsy:adenocarcinoma, metastatic, The morphology and immunohistochemical stains are consistent with S2020-8600 (Endometrioid carcinoma).
    • Impression:
      • Recurrent Endometrioid carcinoma (left lower quadrate mass biopsy result)
      • Lung adenocarcioma, EGFR mutation, cT4N2M1c, cStage IVb, s/p afatinib, s/p Gefitinib, s/p osimertinib, now under durvalumab
      • Liver lesions r/o lung meta or endometrioid meta, primary Cholangiocarcinomas are less likely
    • Suggestion:
      • Please contact pathologist for more IHC stain of liver biopsy to differentiate the possible origin from endometrioid cancer; in addition, may request pathologist to perform MMR, regarding the MSI-H or not.
      • As for the chemotherapy regimen, may consider palictaxel plus platinum to cover lung cancer and endometriroid cancer, if the final result of the possible cholangiocarcinoma is not coming out.
• 2021-10-18 Gastroenterology
  • Q
    • This was a 70 y/o female with lung adenocarcinoma stage IVb, and she was admitted for immunotherapy (durvalumab). She complaint of constipation for long time. So MgO TID and sennoside 2 tab HS was given. Her constipation was relieved but she started to have LLQ pain since 20211014. So we stopped MgO and keep sennoside 1 tab HS. But she still have intermittant LLQ pain. The pain always exacerbated at night and could be relieved by Tramacet. Her colonscopy showed brownish pigmentation of mucosa on 2021/08/10. No bloody stool and watery diarrhea was noted.
  • A
    • 70F Phx:
      • Lung adenocarcioma, EGFR mutation, cT4N2M1c, cStage IVb, s/p Gefitinib, s/p osimertinib, now under durvalumab
      • Endometrial carcinoma of the uterus, s/p total hysterectomy with BSO 9 years ago
      • Pelvic malignancy tumor with left ureter invasion, s/p nephrourterectomy and tumor resction 1 year ago, followed by RT 4500cGy
      • DM, controlled with sitagliptin
    • S:
      • LLQ abdominal pain, raidating to LUQ and back since 2021/10/15. (Last durvalumab course)
      • Quality: dull with intermittent bloating
      • Do not relief after defecation nor flatulence
        
      • The pain would be precipitated at walking
      • Pain score: 3-5
    • O:
      • Abdomen:
        • soft and flat with multiple OP Scar
        • marked tenderness over LLQ, mild rebound tenderness, percussion tenderness (+)
        • knocking tenderness at left lower back
    • A
      • Acute LLQ abdominal pain,
      • r/o intraperitoneal or retroperitoneal inflammatory process
      • r/o colitis (immunotherapy related?)
    • P
      • Arrange KUB (standing)
      • Arrange abdominal echo
      • Check stool routine and urinanlysis
      • Consider CT scan if the aforementioned examinations are inconclusive
• 2020-07-01 Infectious Disease
  • Q
    • This 69-year-old female wtih a known history of
      • Lung Ca s/p CM since March 2019
      • s/p Hystectomy & BSO due to endometriosis    
    • This time, she had Retroperitoneal tumor. Thus, excision of retroperitoneal tumor, retrorectal tumor, LN. with enterolysis were performed on 20200629. However, we found pneumonia, abdominal pain and leucocytosis (WBC 18680, CRP 9.38). We need your expertised for further evaluation and management. Thank you!!
  • A
    • Consultation for Tienam antibiotic.
      • 69-year-old lung cancer female patient received retroperitoneal tumor surgery two days ago.
      • There is post-operative fever that white count up to 18680 thismorning, with CRP level 9.38.
      • Mild elevated serum PCT level also noted.
      • CxR film this morning shows newly-developed infiltration patches over BLL and LUL, that postoperative pneumonia is the first impression.
      • Tienam is prescrbed.
    • Suggestion:
      • Continue Tienam for five days first.
      • Check blood and sputum culture report.

[surgical operation]

• 2020-06-29
  • Operation
    • Excision of retroperitoneal tumor
    • Excision of retrorectal tumor
    • Ex of left exteranl iliac LN
    • Adhesionolysis
  • Finding
    • Moderate adhesion of small bowel and omentum of lower abdomen, no gross peritoneal seedings
    • A bulky tumor in pelvic retroperitoneal space and adjacent to left external iliac vessels and encasing left ureter
    • A rectal submucosa tumor in upper rectum, 3cm in diameter
    • Drain: 19Fr Blake drain x 2 in left retroperitoneal space
    • Washing cytology: 100cc normal saline irrigation for peritoneal cavity
    • Wound: treated with New Epi 5cc
• 2020-06-09
  • Surgery
    • Nephrourterectomy with bladder cuff resection, left (open)
  • Finding
    • EBL: 1500cc
    • 300 cc during bladder cuff
    • 600 cc at renal pedicule
    • 6cm stone hard tumor at middle ureter –> after explanation of risk and alternative treatment, family member agreed nephroureterectomy
    • Frozen section: adenocarcinoma

[chemotherapy]

• 2022-07-07 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-06-15 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-05-27 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-03-29 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-02-09 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-01-19 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-12-28 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 250mg D5W 250mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-11-25 - durvalumab 240mg NS 250mL
  • none
• 2021-11-03 - durvalumab 240mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + NS 50mL
• 2021-10-12 - durvalumab 240mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + NS 50mL
• 2021-09-15 - durvalumab 240mg NS 250mL
  • none
• 2021-09-14 - pemetrexed 600mg NS 100mL
  • dexamethasone 4mg + hydroxocobalamin 1mg + NS 50mL
• 2021-11 ~ 2021-12 - vinorelbine
• 2020-12 ~ ongoing - osimertinib (for NSCLC)
• 2019-05 ~ 2020-11 - gefitinib
• 2019-04 ~ 2019-05 - afatinib
• 2019-03 ~ 2019-04 - vinorelbine

NCCN Non-Small Cell Lung Cancer Evidence Block 20220316 p89 — targeted therapy or immunotherapy for advanced or metastatic NSCLC

• EGFR Exon 19 Deletion or L858R
  • First-line therapy -Afatinib -Erlotinib -Dacomitinib -Gefitinib -Osimertinib -Erlotinib + ramucirumab -Erlotinib + bevacizumabc (nonsquamous)
  • Subsequent therapy -Osimertinib9

-EGFR S768I, L861Q, and/or G719X - First-line therapy -Afatinib -Erlotinib -Dacomitinib -Gefitinib -Osimertinib - Subsequent therapy -Osimertinib9

• EGFR Exon 20 Insertion Mutation Positive
  • Subsequent therapy -Amivantamab-vmjw -Mobocertinib
• KRAS G12C Mutation Positive
  • Subsequent therapy -Sotorasib
• ALK Rearrangement Positive
  • First-line therapy -Alectinib -Brigatinib -Ceritinib -Crizotinib -Lorlatinib
  • Subsequent therapy -Alectinib -Brigatinib -Ceritinib -Lorlatinib
• ROS1 Rearrangement Positive
  • First-line therapy -Ceritinib -Crizotinib -Entrectinib
  • Subsequent therapy -Lorlatinib -Entrectinib
• BRAF V600E Mutation Positive
  • First-line therapy -Dabrafenib/trametinib -Dabrafenib -Vemurafenib
  • Subsequent therapy -Dabrafenib/trametinib
• NTRK1/2/3 Gene Fusion Positive
  • First-line/Subsequent therapy -Larotrectinib -Entrectinib
• MET Exon 14 Skipping Mutation
  • First-line therapy/Subsequent therapy -Capmatinib -Crizotinib -Tepotinib
• RET Rearrangement Positive
  • First-line therapy/Subsequent therapy -Selpercatinib -Pralsetinib -Cabozantinib
• PD-L1 >=1%
  • First-line therapy -Pembrolizumab -(Carboplatin or cisplatin)/pemetrexed/pembrolizumab (nonsquamous) -Carboplatin/paclitaxel/bevacizumab/atezolizumab (nonsquamous) -Carboplatin/(paclitaxel or albumin-bound paclitaxel)/pembrolizumab (squamous) -Carboplatin/albumin-bound paclitaxel/atezolizumab (nonsquamous) -Nivolumab/ipilimumab -Nivolumab/ipilimumab/pemetrexed/ (carboplatin or cisplatin) (nonsquamous) -Nivolumab/ipilimumab/paclitaxel/carboplatin (squamous)
• PD-L1 >=50% (in addition to above)
  • First-line therapy -Atezolizumab -Cemiplimab-rwlc

==========

2023-06-14

• For the past 3 months, the patient has been receiving exclusive medical services, both outpatient and inpatient, from our hospital, in particular, from our departments of thoracic medicine and hemato-oncology. On 2023-06-02, our thoracic specialist prescribed a 14-day medication regimen that included acetaminophen, bisoprolol, megestrol, cortisone, osimertinib, sennoside, fentanyl patch, rabeprazole, and Romicon-A. These medications are accurately listed on the active prescription with no reconciliation issues identified.

2022-06-16

• Audiometric test of pure tones indicated recovery to some degree in hearing loss (2022-05-18 Average RE 31 dB HL and LE 41 dB HL <- 2022-05-11 Average RE 35 dB HL and LE 51 dB HL).

2022-01-20

• drug allergy: alimta (pemetrexed) moderate skin rash recorded in database as from 2021-12-20.
• HER2 test might be tried to opt-in Trastuzumab as a backup candidate.

700223701

230614

[past history]

• Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa
• Hypertension    

[allergy]

• NKDA

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.  

[exam findings]

• 2023-05-12 Sonography for peripheral vessel
  • Peripheral Vascular Test: Vein, lower limbs
  • Conclusion:
    • No evidence of deep vein thrombosis at bilateral common femoral, femoral and popliteal veins (by color flow filling, direct compression, and distal augmentation response)
    • Left thigh swelling and inguinal lymphadenopathy, consider more proximal vein problem or external compression
• 2023-05-09 CT - abdomen
  • With and without contrast enhancement CT of abdomen - whole:
    • Wall thickening at rectum and anus, regression.
    • Left adrenal tumor, 1cm. Stationary.
    • Liver cyst, 0.5cm in S4.
    • Regression of left inguinal lymph nodes.
  • Impression:
    • Rectal malignancy and left inguinal lymph nodes with regression.
    • Left adrenal tumor, stationary.
    • Liver cyst.
• 2023-05-04 Knee Bilat
  • Both knee AP/Lat view: Swelling of left lower extremity.
• 2023-03-13 CXR
  • Enlargement of cardiac silhouette.
• 2023-03-10 CXR
  • Cardiomegaly is noted.
  • Scoliotic alignment of the thoracolumbar spine is noted.
  • Tortous aorta with calcification is noted.
  • S/p port-A placement with its tip at Superior vena cava.
• 2023-02-03 CXR
  • Borderline cardiomegaly
  • Increased lung markings on left lower lung are noted. Please correlate with clinical condition.
• 2023-01-31 24hr portable ECG
  • Baseline was sinus rhythm
  • Frequent isolated VPCs / VPC couplets (burden 2%)
  • 1 episode VPC salvo / idioventricular rhythm (3 beats, 81 bpm)
  • Rare isolated APCs / APC couplet
  • No long pause
• 2023-01-31 Ankle-Brachial Index
  • both lower limbs normal
• 2023-01-31 Neurosonology
  • Minimal atherosclerosis in right subclavian artery.
  • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
• 2023-01-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 37) / 105 = 64.76%
    • M-mode (Teichholz) = 64
• 2023-01-24 MRA - brain
  • Right MCA occlusion at M2 segment with right MCA territory infarct.
• 2023-01-24 CT - brain
  • Low attenuations in right parietal and temporal regions suspected infarcts.
• 2023-01-24 ECG
  • Normal sinus rhythm
  • Cannot rule out Inferior infarct, age undetermined
  • T wave abnormality, consider anterior ischemia
• 2023-01-17 Patho - soft tissue biopsy/simple excision (non lipoma)
  • Labeled as “left neck mass”, SONO guided biopsy — poorly differentiated.
  • IHC stains: CK20 (+), TTF-1 (-).
  • Section shows lymph node with poorly differentiated carcinoma.
• 2023-01-09 Whole body PET scan
  • There was increased FDG uptake in the anorectal region (SUVmax early: 17.21, delay: 21.74), in bilateral lower pelvis lymph nodes (SUVmax early: 8.94, delay: 12.81), bilateral inguinal lymph nodes (SUVmax early: 11.70, delay: 15.82), bilateral para-aortic lymph nodes (SUVmax early: 8.61, delay: 13.92), gastrohepatic lymph nodes (SUVmax early: 5.44, delay: 6.64), and left mediastinal lymph nodes (SUVmax early: 5.29, delay: 8.80). In addition, increased FDG uptake was also noted in the left adrenal region (SUVmax early: 8.77, delay: 14.81), left lobe of the thyroid gland (SUVmax early: 9.57, delay: 11.41), and left several level V cervical lymph nodes (SUVmax early: 6.06, delay: 8.71).
  • IMPRESSION:
    • Glucose hypermetabolism in the anorectal region, compatible with the primary anorectal cancer.
      
    • Glucose hypermetabolism in bilateral lower pelvis lymph nodes, bilateral inguinal lymph nodes, bilateral para-aortic lymph nodes, and gastrohepatic lymph nodes, highly suspected anorectal cancer with regional and distant lymph nodes metastases.
    • Glucose hypermetabolism in the left mediastinal lymph nodes, the nature is to be determined (reactive or metastatic nodes, or other nature ?), suggesting follow-up with PET scan for investigation.
    • Increased FDG uptake in the left adrenal region, probably a functioning tumor in the left adrenal gland, suggesting further investigation.
      
    • Increased FDG uptake in the left lobe of the thyroid gland and left several level V cervical lymph nodes, highly suspected another primary thyroid cancer with regional lymph nodes metastases, suggesting biopsy for investigation.
      
    • Anorectal cancer with regional and distant lymph nodes metastases, cTxN2bM1b, stage IVB (AJCC 8th ed.); highly suspected left thyroid cancer with left cervical lymph nodes metastases, by this F-18 FDG PET scan.
• 2023-01-03 Patho - colon biopsy
  • Colorectum, rectum, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2023-01-02 CT - abdomen
  • History and indication: Anorectal cancer
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of anus and rectum with adjacent fat stranding and regional LAP.
    • Enlarged LNs at left neck, retroperitoneum and left inguinal region.
    • Enlargement of left adnexa (3.0cm) with calcification.
    • Enlargement of left adrenal gland.
    • Left liver cysts (up to 7mm).
• 2022-12-30 Anoscopy
  • Impression:
    • Buttock & perianal region: No discharge, no abscess or fistula
    • DRE/Anoscopy: normal anal tonicity; mixed hemorrhoids with congestion, tumor mass like lesion at low rectum!
• 2022-12-30 Sigmoidoscopy
  • Suspected anorectal cancer with impending obstruction

[MedRec]

• 2023-06-08 MultiTeam
  • Multi-team Recommendations
    • Medical Team Discussion
      • Dr. He Jingliang: Briefly described the patient’s condition and current treatment direction. Currently, the pain control is mainly morphine, and oral chemotherapy drugs are used to control metastatic skin tumors.
      • Dr. Chang Youkang: Attempted to do radiotherapy positioning on Tuesday, but it failed due to severe lower back pain. Maybe we can try using oral chemotherapy for a week. If the effect is limited, we can move towards palliative care.
      • Psychologist: The patient has actively asked about palliative care and actively expressed a desire to be as comfortable as possible at the end of life.
      • Palliative Care Nurse: Discussed with the family about the advance medical directive and palliative care.
      • Discharge Preparation Center: Recommended hospice care.
      • Social Worker: Will continue to care about the economic situation and contact available resources.
      • Disability Handbook: The functional recovery after the stroke does not meet the rules for issuing the handbook.
      • Patient’s Sister: Respect the patient’s wish to be comfortable and hope that the social worker can help find available financial resources.
      • Patient’s Son: Asked about dyspnea, bowel movement, and left lower limb edema issues.
        • The current shortness of breath is not a lung problem (5/31 CHEST CT: no lung meta.) It might be caused by pain.
        • Bowel movement problem: The lower frequency of bowel movements is due to the lower food intake, but medication can assist treatment.
        • Left lower limb edema: Due to lymph node metastasis and after radiotherapy, causing lymphatic damage and blockage, currently can only symptomatic treatment, cannot fully recover.
  • Conclusion
    • Try a week of oral chemotherapy drugs and then palliative care.
    • Refer to the family medicine department to discuss subsequent advance medical directives and palliative care.
• 2023-02-10 SOAP Hemato-Oncology
  • Objective
    • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2023-01-10
      • Arrange for a neck tumor biopsy first to plan for thyroid cancer.
• 2023-02-10 SOAP Neurology
  • Impression
    • Acute ischemic stroke in right MCA territory, onset on 2023/01/23, r/o cancer related hypercoagulability (TOAST:5. Undetermined etiology - conflict date)
    • Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema
    • Malignant neoplasm of rectum
    • Unspecified viral hepatitis B without hepatic coma
    • Modified ranking scale 2
    • Hyperlipidemia, unspecified
    • Essential (primary) hypertension
    • Contusion of unspecified part of head, initial encounter
    • Laceration without foreign body of left eyelid and periocular area, initial encounter
  • Plan
    • Keep Bokey, Crestor, Diovan
  • Prescription
    • Diovan (valsartan 160mg) 1# QD
    • Bokey (aspirin 100mg) 1# QD
    • Crestor (rosuvastatin) 1# QD

[consultation]

• 2023-01-30 Rehabilitation
  • Q
    • We sincerely need your help for arrange rehab. program.
  • A
    • Rehabilitation programs: GYM PT, OT rehabilitation programs
    • Goal: Ambulation with/without device ID, BADL ID
• 2023-01-27 Hemato-Oncology
  • Q
    • This is a 57-year-old woman with history of
      • Hypertension
      • Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema, s/p neoadjuvant chemotherapy and radiotherapy,
      • Thyroid papillary carcinoma.
    • The patient was arrnged to accept chemotherapy and radiotherapy for her Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa as schedule. But unfortunately, she had acute ischemic stroke with right MCA infarction. Now the patient was in our ward for stroke therapy.
    • Acue ischemic stroke for right MCA infarction
    • Assessment
      • MRA showed acute infarct in
        • Right temporo-parietal area,
        • Right MCA posterior M2 occlusion
        • subacute small infarct in left parietal lobe.
      • CT showed low attenuations in right parietal and temporal regions suspected infarcts.
      • NE showed
        • Left side central type fascial palsy
        • MP: Upper limbs-> Rt:5, Lt:4+ , Lower limbs-> Rt:5, Lt:4
        • Rombers test : unstable, Tanden gait : unstable
    • Plan
      • Antiplatelet therapy: Bokey 1# QD
      • Hypolipidemic agents: Crestor 1# QD
      • Anti-dizziness drugs: Diphenidol 1# BID
      • Stress ulcer prevention: ULSTOP 1# BID
    • We hope your visit to evaluate her adenocarcinoma of anorectum radiotherapy and chemotherapy condition.
  • A
    • This 57 year old woman is a case of Anorectal cancer with regional and distant lymph nodes metastases, cT4N2bM1b, stage IVB. She was admiited to neuro ward due to acute ischemia stroke (Right MCA occlusion at M2 segment with right MCA territory infarct). For cancer treatment, we are consulted.
    • CCRT for down staging is suggested at tumor board. Please send All-RAS (sample number S2023-00082) for further cancer work up.
    • However, due to the patient’s stroke condition (right MCA infarction) and it sequela that might be, chemotherapy may not change much. If the family still consider aggressive treatment,
    • After stroke condition stable, we may take over this case in the next week if you agree.
• 2023-01-24 Neurology
  • A
    • S
      • This is a 57-year-old woman with history of hypertension and adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema, s/p neoadjuvant chemotherapy and radiotherapy, and thyroid papillary carcinoma. She still could walk and speak without any difficulty before the noon on 2023/01/23. She presented with slower speech and slurred speech at night. Her family found she had a laceration wound in the left forehead and left upper eyelid in the midnight (00:30) on 2023/01/24. Thus, she was sent to our ED.
      • Non-contrast brain CT showed hypodensity in right MCA territory.
    • O
      • NE Consciousness: E4V5M6, alert
      • EOM: full and free, preferential gaze to left side
      • left side hemianopia
      • pupil 3/3, light reflex +/+
      • left central facial palsy
      • mild intelligible dysarthria
      • MP: right upper 5, right lower 5
      • left upper 4+, left lower 4+
      • FNF and HKS: no dysmetria
      • Sensation: anesthesia in the left limbs
      • NIHSS: 8 (000 111 1010 02010)
    • Assessment
      • Acute ischemic stroke in right MCA territory, onset on 2023/01/23, suspected cancer related hypercoagulability
      • HTN
      • Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa
    • Suggestion
      • Please arrange brain MRA with/without contrast to clarify large vessel occlusion and to exclude brain metastasis
      • Keep Aspirin 100mg QD.
      • Keep adequate hydration with normal saline at 40 ml/hr.
      • keep BP < 220/120 mmHg.
      • Arrange admission to NEURO ward. Thanks. (Stroke survey in the NEURO ward: check D-dimer, lipid profile, HbA1C, carotid duplex+TCD, cardiac echo, Holter EKG)
• 2023-01-16 Radiation Oncology
  • A
    • Diagnosis: Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction, left inguinal, pelvis, paraaortic LAP metastasis and lympoedema of left lower limb; ECOG =1.
    • Plan: CCRT to anorectal tumor, pelvic and paraaortic LAPs for 5040cGy/28 fx is suggested for locoregional control. CT simulation was arranged on 2023/01/17, 08:30am. Treatment will be started on 2023/01/27.
• 2023-01-16 Hemato-Oncology
  • Q
    • This is a 57 years old female with hypertension and asthma suffers from constipation, distended pain of low abdomen for 1-2 month. Progressive swelling of the left lower extremity for one month.
    • 2022-12-30 sigmoidoscopy: R/O Anorectal cancer with impending obstruction
    • 2023-01-02 CT showed wall thickening of anus and rectum with adjacent fat stranding and regional LAP, enlarged LNs at left neck, retroperitoneum and left inguinal region.
    • CEA:149
    • Colorectum, rectum, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Under impression of adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema, she was admitted for port-A, biopsy of neck mass and further survey
    • We would like to consult for your expertise, thank you.
  • A
    • This 57 year old woman is a case of Anorectal cancer with regional and distant lymph nodes metastases, cT4N2bM1b, stage IVB and highly suspected left thyroid cancer with left cervical lymph nodes metastases.
    • CCRT for down staging is suggested at tumor board. Pending neck biopsy result. In addition, please send All-RAS (S2023-00082) for further work up. We may take over this case if you agree.

[chemotherapy]

• 2023-02-03 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 2hr + fluorouracil 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-06-14

• Lab data indicate a deterioration in renal function, accompanied by rising levels of CRP and WBC. - Lab data indicate a deterioration in renal function, accompanied by rising levels of CRP and WBC. Please keep a close eye on the patient for any indicators of an escalating infection.
  • 2023-06-05 Creatinine 0.60 mg/dL
    
  • 2023-06-12 BUN 37 mg/dL
    
  • 2023-06-05 BUN 16 mg/dL
    
  • 2023-06-12 CRP 11.7 mg/dL
    
  • 2023-06-05 CRP 6.2 mg/dL
    
  • 2023-06-12 WBC 23.30 x10^3/uL
    
  • 2023-06-05 WBC 10.59 x10^3/uL
• Valsartan, an ARB, can indeed be associated with increases in serum Cre levels and/or AKI, particularly in patients who have renal artery stenosis or who are volume depleted. Typically, the increase in serum Cre levels due to ARBs is expected to stabilize within a range of 20% to 30% above baseline levels. However, in this patient’s case, Diovan (valsartan 160mg) has been prescribed by our neurologist since 2023-02-10 and has been used for several months. This long-term use makes it less likely that valsartan is the cause of the recent worsening in renal function.

2023-05-24

• The D-dimer levels in this patient have remained elevated for nearly one month. Elevated plasma D-dimer levels indicate that coagulation has been activated, fibrin clot has formed, and clot degradation by plasmin has occurred. A long-lasting high D-dimer level could be a sign of an ongoing or chronic medical condition that is associated with increased blood clotting or fibrinolysis (breakdown of blood clots).
  • 2023-02-21 D-dimer 7638.09 ng/mL(FEU)
    
  • 2023-01-30 D-dimer 7283.81 ng/mL(FEU)
    
  • 2023-01-25 D-dimer 8056.38 ng/mL(FEU)

2023-02-22

• The patient was admitted to the hospital yesterday (2023-02-21), and the admission note indicates that she just experienced abdominal distension and watery diarrhea up to 10 times per day according to the review of systems. Nevertheless, the patient has been prescribed sennoside and lactulose, and she is currently taking these medications. Please verify the patient’s current bowel movement status.
• If the patient’s heavy diarrhea is related to chemotherapy, it might be beneficial to consider omitting the 400mg/m2 5-FU bolus and adjusting the 5-FU infusion dose to 2800mg/m2 from 2400mg/m2 to keep the dose unchanged in the FOLFOX regimen.

700514981

230614

[exam findings]

• 2023-03-29 Tc-99m MDP bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a faint hot spot in the lateral aspect of the left rib cage, and increased activity in the maxilla, some T- and L-spine, sacrum, bilateral shoulders, hips, and knees, in whole body survey.
  • IMPRESSION:
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the left rib cage, maxilla, some T- and L-spine, sacrum, bilateral shoulders, hips, and knees.
• 2023-03-28, -02-13 ECG
  • Normal sinus rhythm
  • Low voltage QRS
  • Borderline ECG
• 2023-01-02 Patho - breast mastectomy with regional lymph nodes
  • PATHOLOGIC DIAGNOSIS
    • Tumor, L’t breast, frozen + partial mastectomy — Invasive carcinoma of no special type
    • Resection margins, frozen — Tumor involved at above tumor, others are free
      • Margin, above tumor recut, frozen — Free of tumor invasion
    • L’t axillary sentinel lymph nodes, frozen — Tumor metastasis (2/5) without extracapsular extension (0/2)
      • L’t axillary non-sentinel lymph nodes, ditto — Free of tumor metastasis (0/4)
    • AJCC Pathologic Anatomic Stage — pT1cN1a, if cM0, stage IIA; Prognostic Stage — Stage IIA
• 2022-12-30 Lymphoscintigraphy
  • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the left axilla.
  • IMPRESSION: Probably a sentinel lymph node at the left axillary region.
• 2022-12-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 23) / 81 = 71.60%
    • M-mode (Teichholz) = 70
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Mild MR, mild TR and trivial PR
    • Preserved RV systolic function
• 2022-12-28 CT - chest
  • Indication: Left breast cancer
  • Findings
    • Lungs: mild fibrosis at both apical lung regions.
      • normal appearance of both lower lobes and RML.
    • Mediastinum and hila: no enlarged LN or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion.
    • Vessels:
      • well opacification of proximal segments of the LAD, and LCX, and right coronary arteries.
    • Aorta: normal caliber, mild atherosclerotic change of aortic arch.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: a small enhancing nodule in Lt breast (15cm) and enlarged LNs in left axilla
    • Visible abdominal contents:
      • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.no enlarged lymph node. no ascites..
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • Lt breast cancer with axillary LAP
• 2022-12-20 Patho - breast biopsy
  • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • IHC stains: ER (-, 0%), PR(-), Her2/neu: positive (score=3+), Ki-67(30 %), E-cadherin (+).
• 2017-11-15 Thyroid Ultrasound
  • Autoimmune thyroid disease

[surgical operation]

• 2022-12-30
  • Surgery
    • Left partial mastectomy and Left axillary lymph node dissection
    • Right subclavian vein port-a implantation
  • Finding
    • Left breast invasive ductal carcinoma at 3/3cm, size: [su2.15x2.00cm, invasive ductal carcinoma, cT2N1M0, ER(-), PR(-), HER-2(3+). (1/8)

[immunochemotherapy]

• 2023-06-12 - trastuzumab 600mg SC 5min (Herceptin)

• 2023-05-17 - cyclophosphamide 300mg/m2 457mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr (AC(lipo) Endoxan 50%)

  •                    betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-04-25 - cyclophosphamide 600mg/m2 970mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 57mg D5W 250mL 2hr (AC(lipo))

  • lenograstim 250ug SC + betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO

• 2023-03-28 - cyclophosphamide 600mg/m2 996mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(lipo))

  • lenograstim 250ug SC + betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO

• 2023-02-13 - cyclophosphamide 600mg/m2 992mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(lipo))

  •                    betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO

==========

2023-06-14

• On 2023-01-02, breast mastectomy with regional lymph node pathology revealed the disease to be pT1cN1a; if cM0, stage IIA. Adjuvant chemotherapy with trastuzumab is indicated for this disease.

• The dose-dense AC regimen (cyclophosphamide 600mg/m2, original doxorubicin 60mg/m2 replaced by liposomal doxorubicin 35mg/m2) was administered on 2023-02-13, 2023-03-28, 2023-04-25, 2023-05-17, with cyclophosphamide at 50% of the planned dose on the last administration.

• The timeline of the patient’s WBC level is organized in the following table, with asterisks indicating instances where the WBC count was less than 2K/uL. The lowest WBC values occurred 2 to 4 weeks after administration of the adjusted AC regimen, suggesting a prolonged nadir or slow recovery of the white blood cells given the dosage and frequency at that time, even G-CSF was administered.

  • 2023-06-12 WBC 1.74 x10^3/uL * trastuzumab 06-12
  • 2023-06-05 WBC 1.07 x10^3/uL *
    
  • 2023-05-22 WBC 2.28 x10^3/uL
    
  • 2023-05-17 WBC 2.73 x10^3/uL CT 05-17
    
  • 2023-05-03 WBC 1.25 x10^3/uL * CT 04-25
    
  • 2023-04-24 WBC 2.35 x10^3/uL
    
  • 2023-04-17 WBC 1.33 x10^3/uL *
    
  • 2023-04-03 WBC 2.81 x10^3/uL CT 03-28
    
  • 2023-03-27 WBC 2.70 x10^3/uL
    
  • 2023-03-13 WBC 3.29 x10^3/uL
    
  • 2023-03-06 WBC 1.74 x10^3/uL *
    
  • 2023-02-13 WBC 4.35 x10^3/uL CT 02-13
  • 2022-12-28 WBC 3.81 x10^3/uL
    
  • 2018-11-14 WBC 4.65 x10^3/uL

• According to Taiwan’s NHI reimbursement rules, the use of G-CSF is permitted for patients with non-hematological malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL post-chemotherapy. In this patient’s case, the criteria are not met, so G-CSF is not covered by the NHI.

• Granocyte (lenograstim) was administered concurrently with the adjusted AC regimen on 2023-03-28, 2023-04-25, and 2023-05-17. It’s recommended for primary and secondary prophylaxis that G-CSF administration typically starts 24 to 72 hours after the end of chemotherapy treatment (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation). ref(1): Delayed Granulocyte Colony-Stimulating Factor (G-CSF) Administration after Chemotherapy Reduces Total G-CSF Doses without Affecting Neutrophil Recovery in a Randomized Clinical Study in Children with Solid Tumors. Pediatr Hematol Oncol. 2020;37(8):665-675. ref(2): Efficacy of delayed administration of post-chemotherapy granulocyte colony-stimulating factor: evidence from murine studies of bone marrow cell kinetics. Exp Hematol. 2008;36(1):9-16.

700928067

230614

[diagnosis]

• Rectal cancer, adenocarcinoma, 10 cm from anal verge, cT4aN2M0, stage IIIC.

[exam findings]

• 2023-06-17 Nasopharyngoscopy
  • right buccal leukoplakia, smooth NPx, OPx, HPx
• 2023-04-28 CT - abdomen
  • History and indication:
    • 20230103 colonoscopy: Rectal cancer at right lateral wall, 8 cm from AV
    • 20230103 CT: rectal cancer, invades the visceral peritoneum, cT4aN0M0, stage IIB
  • Findings:
    • Prior CT identified mild focal wall thickening at right lateral aspect of the rectum is not noted again.
      • Please correlate with colonoscopy.
    • S/P resection of S5, S6, and S7 of the liver.
    • Gallbladder stone (3mm).
    • Prior CT identified several nodular soft tissue lesions in the pre-sacral space are noted again, stationary. Benign process is suspected.
  • Impression:
    • Prior CT identified mild focal wall thickening at right lateral aspect of the rectum is not noted again.
    • Please correlate with colonoscopy.
• 2023-01-13 MRI - pelvis
  • CC: Bloody stool passage
    • Rectal cancer, 10cm from AV Dx at TSGH, CCRT was arranged
    • 20230103 colonoscopy: Rectal cancer at right lateral wall, 8 cm from AV.
    • 20230103 CT：Rectal cancer, cT4aN0M0, cSTAGE:IIB
  • Findings - Comparison: prior CT dated 2020/12/04 and 2021/06/18.
    • There is a soft tissue mass measuring 2 x 1.5 cm in right lateral wall of the rectum that is c/w adenocarcinoma.
      • In addition, There are few engorged vascular structure at the right lateral perirectal tumor space that may be extramural vascular invasion (EMVI) (T4a).
    • There are five enlarged nodes in right perirectal space and right superior rectal space (N2a).
    • S/P near total right hepatectomy and S/P cholecystectomy. (E1)
    • Prior CT identified several nodular lesions in pre-sacral space are noted again, stable in size and feature.
      • All lesions show enhancement in portal venous phase images.
      • Benign vascular lesions are highly suspected.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
• 2023-01-03 Patho - colorectal polyp
  • Colorectum, proximal transverse colon, suspect previous polypectomy site, Biopsy, Specimen: A — chronic inflammation.
    • Section shows piece(s) of benign colon mucosa with chronic inflammation. Cryptitis or crypt abscess is not present.
  • Colorectum, D-colon, 40 cm ＆ 25cm , suspect previous polypectomy sites, biopsy was done at 40cm sites, Specimen: B — ulcer with acute and chronic inflammation.
    • Section shows piece(s) of benign colon mucosa with ulcer, acute and chronic inflammation. Cryptitis or crypt abscess is not present.
  • Colorectum, rectum, right lateral wall, 8 cm from AV, Biopsy Specimen: C — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2023-01-03 CT - abdomen
  • History and indication: Rectal cancer, 10cm from AV
  • Findings
    • Focal wall thickening of rectum with adjacent fat stranding.
    • S/P liver operation.
    • Gallbladder stone (3mm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N0(N_value) M:M0(M_value) STAGE:IIB(Stage_value)
• 2022-09-17 L-spine AP + Lat. (including sacrum):
  • Disc space narrowing at L2-3 level.
  • Lumbar spondylosis.
• 2021-06-18 CT - abdomen
  • History and indication: Diffuse abdominal pain. suspect peritionitis
  • Findings
    • S/P liver operation.
    • A patchy density (1.9cm) at RLL.
    • Distention of gallbladder. Mild dilatation of IHD.
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
  • IMP:
    • S/P liver operation.
    • A patchy density (1.9cm) at RLL.
    • Distention of gallbladder. Mild dilatation of IHD.
• 2021-06-03 KUB
  • S/P operation with retention of surgical clips.
  • Degeneration and spondylosis of L-S spine.
  • Stool retention in the bowel.
• 2020-12-04 CT - abdomen
  • History and indication: RUQ tender, suspected cholecystitis
  • IMP: Distention of gallbladder. R/O distal CBD stone (6mm).
• 2020-01-20 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Fish bone misswallowing s/p endoscopic foreign body extraction.
    • Reflux esophagitis LA Classification grade A
    • Gastric erosion, antrum.
  • Suggestion
    • PPI and Sucralfate use.

[radiotherapy]

• 2022-01-13 ~ undergoing - 5040cGy/28 fx, preoperative CCRT

[chemotherapy]

• 2023-07-03 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

• 2023-06-13

• 2023-05-23

• 2023-04-28

• 2023-04-06

• 2023-03-24

• 2023-03-14

• 2023-03-23

• 2023-02-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

• 2023-01-13 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)

  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-07-04

The medications Janumet (sitagliptin, metformin), Kentamin (B1, B6, B12), Diovan (valsartan), and Livalo (pitavastatin) were prescribed at Tri-Service General Hospital on 2023-06-10 and recently refilled on 2023-06-30. However, none of these drugs are currently included in the active medication list. Please verify whether these medications are still required for the patient’s current condition.

2023-06-14

• This patient recently visited Tri-Service General Hospital for his primary diagnosis of malignant neoplasm of the rectum. The medications prescribed during this visit were sitagliptin, thiamine, valsartan, pitavastatin, ambroxol, and glycyrrhiza extract. These medications, or their equivalent therapeutic classes, are already included in the current active prescription. No issues with medication reconciliation were identified.

700325303

230613

[lab data]

2023-05-10 Blood gas (Vein) 2023-05-10 PH 7.499
2023-05-10 PCO2 39.6 mmHg
2023-05-10 PO2 82.5 mmHg
2023-05-10 HCO3 30.1 mmol/L
2023-05-10 ctCO2 31.3 mmol/L
2023-05-10 Base Excess 7.1 mmol/L
2023-05-10 BEecf 6.9 mmol/L
2023-05-10 SBC 29.7 mmol/L
2023-05-10 O2 Saturation 97.2 ％

2023-05-10 Blood Osmolality 291 mOsm/Kg

2023-05-08 Blood gas (Vein) 2023-05-08 PH 7.488
2023-05-08 PCO2 47.6 mmHg
2023-05-08 PO2 47.9 mmHg
2023-05-08 HCO3 35.3 mmol/L
2023-05-08 ctCO2 36.7 mmol/L
2023-05-08 Base Excess 10.6 mmol/L
2023-05-08 BEecf 11.9 mmol/L
2023-05-08 SBC 33.0 mmol/L
2023-05-08 O2 Saturation 87.9 ％

2023-05-08 Free Light Chain κ/λ (blood) ratio 2023-05-08 FKLC 8.6 mg/L
2023-05-08 FLLC 10900.0 mg/L
2023-05-08 FK/FL ratio <0.01 ratio

2023-05-02 Protein EP 2023-05-02 Protein, total 6.1 g/dL
2023-05-02 Albumin 59.6 %
2023-05-02 Alpha-1 3.2 %
2023-05-02 Alpha-2 16.6 %
2023-05-02 Beta 11.1 %
2023-05-02 Gamma 9.5 %
2023-05-02 M-peak Negative
2023-05-02 A/G Ratio 1.50

2023-04-29 B2-Microglobulin 13021 ng/mL
2023-04-28 IgG (blood) 687 mg/dL
2023-04-27 Ca (Calcium) 2.89 mmol/L
2023-04-27 LDH 706 U/L

2023-03-17 CD45+Total leukocyte 149733 /uL
2023-03-17 %CD34+ 0.56 %
2023-03-17 CD34+ Count 846 /uL

2023-03-17 HPC Ratio 0.15 %
2023-03-17 HPC# 0.029 10^3/ul

2023-03-16 CD45+Total leukocyte 127292 /uL
2023-03-16 %CD34+ 0.67 %
2023-03-16 CD34+ Count 848 /uL

2023-03-16 HPC Ratio 0.25 %
2023-03-16 HPC# 0.036 10^3/ul

2023-03-15 CD45+Total leukocyte 117620 /uL
2023-03-15 %CD34+ 0.78 %
2023-03-15 CD34+ Count 915 /uL
2023-03-15 HPC Ratio 0.47 %
2023-03-15 HPC# 0.038 10^3/ul

2023-03-15 Ca (Calcium) 2.21 mmol/L
2023-03-15 Alkaline phosphatase 74 U/L
2023-03-15 LDH 235 U/L

2023-03-10 Ca (Calcium) 2.18 mmol/L
2023-03-10 Alkaline phosphatase 69 U/L
2023-03-10 LDH 183 U/L

2023-03-05 Alkaline phosphatase 74 U/L
2023-03-05 LDH 197 U/L

2023-03-05 Total protein 6.3 g/dL

2023-03-05 PT 10.4 sec
2023-03-05 INR 1.01
2023-03-05 APTT 26.7 sec

2023-02-20 Free Light Chain κ/λ (blood) ratio
2023-02-20 FKLC 13.3 mg/L
2023-02-20 FLLC 101 mg/L
2023-02-20 FK/FL ratio 0.13 ratio

2023-02-17 Protein EP 2023-02-17 Protein, total 5.4 g/dL
2023-02-17 Albumin 58.3 %
2023-02-17 Alpha-1 3.1 %
2023-02-17 Alpha-2 11.8 %
2023-02-17 Beta 13.1 %
2023-02-17 Gamma 13.7 %
2023-02-17 M-peak Negative
2023-02-17 A/G Ratio 1.40

2023-02-16 B2-Microglobulin 2245 ng/mL
2023-02-15 IgG (blood) 588 mg/dL

2023-02-15 HBsAg Nonreactive
2023-02-15 HBsAg (Value) 0.29 S/CO

2023-02-15 Anti-HBc Nonreactive
2023-02-15 Anti-HBc-Value 0.09 S/CO

2023-02-15 Anti-HCV Nonreactive
2023-02-15 Anti-HCV Value 0.06 S/CO

2023-02-15 Total protein 5.7 g/dL
2023-02-15 Ca (Calcium) 2.22 mmol/L
2023-02-15 LDH 206 U/L

• 2022-12-12 (at Cardinal Tien Hospital)
  • IgG: 5288mg/dl
  • IgA: 34mg/dl
  • IgM: 29mg/dl
  • IgD: <46.7IU/ml
  • B2-Microglobulin: 3241ng/ml

[exam findings]

• 2023-05-08 ECG
  • Sinus rhythm with 1st degree A-V block
  • Left atrial enlargement
• 2023-05-08 CXR
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • Dilation of central pulmonary arteries pulmonary trunk
  • Moderate enlarged cardiac silhoutte
  • Clean lung fields based on plain image
  • Normal appearance of both hila
• 2023-05-02 Patho - bone marrow biopsy
  • Bone marrow, ilium, biopsy — Plasma cell myeloma
    • NOTE: Correlation of bone mrrow smear, peripheral blood data, molecular genetic study, flow cytometery and clinical findings is recommended.
  • Microscopically, it shows hypercellularity (>90%) and marked proliferation of plasm cells. Blast-like cells highlighted by CD117 is seen (<=2%). Megakaryocytes are present in normal in numbers (1 per HPF) and demonstate no significant morphologic abnormalities.
  • Immunohisotchemical stain reveals CD34(-), Kappa ligh chain(-), Lambda light chain (diffuse+), CD138 (diffuse+), MPO(focal +, <=2%), CD71(<1%).
• 2023-04-28 CT - abdomen
  • Indication: Multiple myeloma not having achieved remission
  • Findings:
    • Both kidneys show several ill-defined wedge-shaped poor-enhancing areas that may be acute pyelonephritis.
      • The differential diagnosis includes infiltrative lesions.
      • Please correlate with urine routine.
    • A hepatic cyst 2 cm in S7 is noted.
    • There is an ill-defined poor enhancing lesion 6 mm in the spleen. Follow up is indicated.
  • Impression:
    • Acute pyelonephritis of both kidney is highly suspected. The differential diagnosis includes infiltrative lesions. Please correlate with urine routine.
• 2022-07-20 Patho - bone marrow biopsy (at Cardinal Tien Hospital)
  • C/W Plasma cell myeloma, IgG/Lambda type
  • Immunostatins: CD138 +++, Kappa light chain -, Lambda light chain ++, CD34 Focally +, CD71 ++.
• 2022-07 MRI - right femur (at Cardinal Tien Hospital)
  • suspect multiple bone metastasis.
• 2022-03 CT - chest (at Cardinal Tien Hospital)
  • hepatic cyst in segment 7 of right lobe liver.

[consultation]

• 2023-05-09 Oral and Maxillofacial Surgery
  • Q
    • Today, she was admitted for short of breathing, hyperkalemia on 2023/05/09, and plan to receive Xgeva treatment, so we need your help for oral health assessment, thanks a lot!!
  • A
    • After intraoral dental examination, no dental decay or mobile teeth was noticed.
    • Xgeva could be used safely.

[MedRec]

• 2023-05-04 SOAP Nephrology
  • S
    • Hypokalemia was detected during admission
    • Hypercalcemia was also detected
    • Urine K 22.4
    • DM (+) for 10 years.
    • Actos 1# qd, metformin 1# bid, Diamicron 1# qd
  • O
    • BP: 145/66; HR: 87;
    • leg edema (-)
    • CVA knocking pain (-)
    • 2023-05-02 Creatinine 1.21 mg/dL
      
    • 2023-04-27 Creatinine 1.60 mg/dL
      
    • 2023-03-15 Creatinine 0.44 mg/dL
      
    • 2023-02-15 Creatinine 0.64 mg/dL
      
  • A
    • Suspected poor oral intake with hypercalcemia (diuresis) related hypokalemia.
• 2023-04-07 ~ 2023-05-04 POMR Hemato-Oncology
  • Course of Inpatient Treatment
    • After admission, owing to blood test showd Balst: 5%, R/O multiple myeloma change to AML. We check total protine, Alb, IgG, B2-Microglobulin, AML+ALL/Myeloid, Protein EP, Free Light Chain κ/λ on 4/27 23 and report showed B2-Microglobulin: 13021 ng/mL, IgG: 687mg/dl, total protine: 6.5g/dl, Alb: 3.8g/dl, protine EP: total protine: 6.1, Alpha-1: 3.2, Alpha-2: 3.2. Beta: 11.1, Gamma: 9.5, M-peak: negative, A/G Ratio: 1.50.
    • Bone marrow on 5/2 23 for further diagnosis and pathology (5/5 23) proved Plasma cell myeloma, hypercellularity (> 90%) and marked proliferation of plasm cells. Blast-like cells highlighted by CD117 is seen (<= 2%). Megakaryocytes are present in normal in numbers (1 per HPF) and demonstate no significant morphologic abnormalities. Immunohisotchemical stain reveals CD34(-), Kappa ligh chain(-), Lambda light chain (diffuse +), CD138 (diffuse +), MPO(focal +, <= 2%), CD71(< 1%).
    • LYRICA 75mg 1# po hs, Deflam-K 25mg 1# po bidprn was added for neuropathic pain due to herpes zoter related.
    • Intervenous KCL 500ml qd, MgSo4 1amp in N/S 100ml IVF 1hr qd, Miacalcic 100 unit q12h were given for hypokalemia, hypomagnesemia and hypercalcemia.
    • The abdominal CT (4/28 23) shwoed Acute pyelonephritis of both kidney is highly suspected. The differential diagnosis includes infiltrative lesions. Septic work-up was performed and antibiotic with Seforce 400mg ivd q12h since 4/28 23. She felt bilateral flanks pain much better.
  • Prescription
    • Const-K (potassium chloride 750mg/10mEq) 1# QD
    • MgO 250mg 1# TID
    • Cinolone (ciprofloxacin 250mg) 2# BIDAC
• 2023-03-31 SOAP Hemato-Oncology
  • O: 2023/03/17 CD45+ Total leukocyte = 149733/uL
• 2023-03-05 ~ 2023-03-17 POMR Hemato-Oncology
  • Discharge diagnosis
    • Multiple myeloma not having achieved remission, Bone marrow biopsy (2022/7/20) proved C/W Plasma cell myeloma, IgG/Lambda type, immunostatins: CD138+++, Kappa light chain -, LAmbda light chain ++, CD34 Focally +, CD71 ++. The laboratory showed IgG: 5288mg/dl, IgA:34mg/dl, IgM:29mg/dl, IgD:<46.7IU/ml, B2-Microglobulin :3241ng/ml on 2022-12-12. C1 chemotherapy with Endoxan on 3/6, 3/15, 3/16, 3/17 collect PBSC
    • Endometrium cancer stage I S/P operation on 2013-04
    • Diabetes mellitus due to underlying condition without complications
    • Anemia due to antineoplastic chemotherapy
  • Present Illness
    • This 64-yeasr-old woman, a patient of multiple myeloma, IgG, ISS stage II, S/P VRD therapy X 6 with very good partial response at Cardinal Tien Hospital, suffered from right thight pain when walking June 2022 then visited to Cardinal Tien Hospital for survey and treatment.
    • Image study with right femur MRI (2022/07) showed suspect multiple bone metastasis. Chest CT (2022/07) shwoed negative and abdominal CT (2022/03) revealed hepatic cyst in segment 7 of right lobe liver.
    • Bone marrow biopsy (2022/07/20) proved C/W Plasma cell myeloma, IgG/Lambda type, immunostatins: CD138 +++, Kappa light chain -, Lambda light chain ++, CD34 Focally +, CD71 ++. The laboratory showed IgG: 5288mg/dl, IgA: 34mg/dl, IgM: 29mg/dl, IgD: <46.7IU/ml, B2-Microglobulin: 3241ng/ml on 2022-12-12.
    • She received chemotherapy with VRD (VELCADE / Revlimid / Dexamethasone 20mg) Q3W x 6 since 2022/08/17 to 2022/12/29 finished.
  • CC: for C1 chemotherapy with Cycolphosphamide/Mesna & collect stem cells
  • Course of Inpatient Treatment
    • After admission, chemotherapy with Cyclophosphamide/Mesna was given on 3/6 23 & Mesna 0.6g/m2 from Endox for 4hrs start/from Endox for 8hrs start/from Endox for 12hrs start on 3/6 23, smoothly without obvious side effect.
    • Lenograstim 500mcg & G-CSF 150mcg total 650mcg sc qd was administered post C/T 24hrs given on 3/7 to 3/17 23. right neck double Lumen Catheter was inserted and collect stem cells on 3/15, 3/16, 3/17 23 was done and Vitacal was added for symptom relief of hypocalcemia. Mild bone pain was told due to Lenograstim related and NSAID was given for pain control. Blood transfusion with LPRBC 2U was given on 3/16 23.
• 2023-02-15 SOAP Hemato-Oncology
  • Plan
    • recheck the disease status
    • prepare for chemotherapy at 2023-03-06, and collection of the stem cell at 2023-03-15.
• 2023-01-04 SOAP Hemato-Oncology
  • S: She was referred on account of multiple myeloma, IgG, ISS stage II, S/P VRD therapy X 6 with very good partial response, for discussion about auto_HSCT
    • Review the referring sheet and system review.
    • Past history: Nothing in particular.
    • Family history: No systemic disease in the family members.
    • Personal history:
    • Smoking (no), alcohol consumption (no), betel nut chowing (no)
    • Allergy: NKA.
    • Travel history: No traveling history within one month.
    • Occupation: Salesperson
  • Assessment: multiple myeloma, IgG, ISS stage II, S/P VRD therapy X 6 with very good partial response, for discussion about auto_HSCT
  • Plan: discussion about auto-HSCT
  • Diagnosis: Multiple myeloma not having achieved remission C90.00

[chemotherapy]

• 2023-06-13 - bortezomib 1.3mg/m2 2.0mg SC 0.5min D1 + daratumumab 16mg/kg 900mg NS 500mL 6hr D1
  • dexamethasone 20mg PO + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL
• 2023-05-23 - bortezomib 1.3mg/m2 2.3mg SC 0.5min D1
• 2023-05-15 - bortezomib 1.3mg/m2 2.3mg SC 0.5min D1
  • dexamethasone 20mg PO D1-2
• 2023-05-12 - bortezomib 1.3mg/m2 2.0mg SC 0.5min D1 + daratumumab 16mg/kg 1000mg NS 1000mL 6hr D1
  • dexamethasone 20mg PO D1-2
• 2023-03-06 - cyclophosphamide 2000mg/m2 3400mg NS 500mL 60min + mesna 0.6mg/m2 1000mg NS 500mL 60min (Y-sited Endoxan) and 3 times (each 30min at 4, 8, 12hr after Endoxan)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
• 2022-08-17 ~ 2022-12-29 - VRd

Bortezomib (Velcade), lenalidomide (Revlimid), and “low dose” dexamethasone (VRd) for multiple myeloma 2023-05-10 https://www.uptodate.com/contents/image?imageKey=ONC%2F91054&topicKey=HEME%2F6647

• Cycle length: 21 days.

• Regimen

  • Bortezomib
    • 1.3 mg/m2 SC
    • Given as a single SC injection.
    • Days 1, 8, and 15
  • Lenalidomide
    • 25 mg by mouth
    • Administer with water. Swallow capsule whole; do not break, open, or chew.
    • Daily, on days 1 through 14
  • Dexamethasone
    • 40 mg by mouth
    • Take with food (after meals or with food or milk) in the morning.
    • Days 1, 8, and 15

• Pretreatment considerations:

  • Emesis risk
    • MINIMAL TO LOW.
  • Prophylaxis for infusion reactions
    • Routine premedication is not indicated. If a hypersensitivity reaction (not including local reactions) occurs with bortezomib or lenalidomide, then neither drug should be readministered.
  • Antithrombotic prophylaxis
    • Routine antithrombotic prophylaxis is warranted. Thromboembolism was reported in 2 to 6% of patients in clinical trials receiving VRd despite antithrombotic prophylaxis.
    • The risk of thromboembolism was over 10% with another lenalidomide and high-dose dexamethasone (RD) regimen.
  • Infection prophylaxis
    • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia.
    • Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VRd.
    • Some clinicians also administer prophylactic trimethoprim-sulfamethoxazole (eg, one double-strength tablet once daily on Mondays, Wednesdays, and Fridays) during treatment.
    • Primary prophylaxis with G-CSF is not indicated.
  • Vesicant/irritant properties
    • Bortezomib is an irritant.
  • Dose adjustment for baseline liver or renal dysfunction
    • Bortezomib: No dosage adjustment for bortezomib secondary to renal insufficiency is necessary.[6] For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the ULN) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
    • Lenalidomide: Patients with renal insufficiency experience more neutropenia with lenalidomide.[7] Dose adjustment is recommended for patients with CrCl <60 mL/min.[8] At this time, studies have not been conducted in patients with hepatic impairment.

• Monitoring parameters:

  • Assess CBC with differential, electrolytes, renal function, and liver function prior to starting each cycle. A CBC should also be performed prior to the day 8 and 15 doses of bortezomib during induction therapy.
  • Weekly assessment for peripheral neuropathy and/or neuropathic pain.
  • Monitor for hypotension during bortezomib therapy; adjustment of antihypertensives and/or administration of IV hydration may be needed.

• Suggested dose modifications for toxicity:

  • Myelotoxicity
    • A cycle of VRd should not be started unless the ANC is >=1000/microL and the platelet count is >=70,000/microL. If platelets are <50,000/microL or the ANC is <1000/microL on day 15, hold day 15 bortezomib dose. If several doses are held, reduce bortezomib dose by one level (from 1.5 mg/m2 to 1.3 mg/m2 or from 1.3 mg/m2 to 1 mg/m2 or from 1 mg/m2 to 0.7 mg/m2) and decrease the daily dose of lenalidomide by 5 mg. Growth factor support can be given on day 8 of the second and subsequent cycles for ANC <500/m2 lasting >7 days or for an episode of febrile neutropenia.
  • Neuropathy
    • Dose adjustment guidelines for bortezomib in patients who develop peripheral neuropathy or neuropathic pain are available:
      • Grade 1 (asymptomatic, loss of deep tendon reflexes or paresthesia without pain or loss of function): No action required.
      • Grade 1 (with pain) or Grade 2 (interfering with function but not activities of daily living): Reduce by one level (from 1.5 mg/m2 to 1.3 mg/m2; or from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2).
      • Grade 2 (with pain) or Grade 3 (interfering with activities of daily living): Hold until resolution, may reinitiate at 0.7 mg/m2 once weekly.
      • Grade 4 (life-threatening, disabling, eg, paralysis): Discontinue.
    • Rarely, bortezomib has been associated with RPLS, which can present with seizures, hypertension, headache, lethargy, confusion, blindness, or as other visual or neurological disturbances. Bortezomib should be discontinued if the diagnosis of RPLS is confirmed on brain MRI.
  • Thrombotic microangiopathy
    • Rarely, bortezomib has been associated with TMA, which can present with Coombs-negative hemolysis, thrombocytopenia, renal failure, and/or neurologic findings.[6] If TMA is suspected, stop bortezomib and evaluate.
  • Other nonhematologic toxicity
    • For grade 3 or 4 nonhematologic toxicity other than neuropathy, hold lenalidomide and bortezomib. Once symptoms have resolved to grade 1 or baseline, reinitiate therapy with lower doses. Reduce dexamethasone dose for grade 2 muscle weakness, grade 3 gastrointestinal tract toxicity, hyperglycemia, confusion, or mood alterations.
  • If there is a change in body weight of at least 10%, doses should be recalculated.

DVd (Daratumumab + Velcade (bortezomib) + dexamethasone) is a Chemotherapy Regimen for Multiple Myeloma (MM) 2023-05-10 https://www.chemoexperts.com/dvd-daratumumab-velcade-bortezomib-dexamethasone.html

• How does DVd work?
  • Each of the medications in the DVd (Daratumumab, Velcade, dexamethasone) regimen is designed to kill or slow the growth of myeloma cells.
• Regimen
  • D - Daratumumab (Darzalex)
  • V - Velcade (bortezomib)
  • d - dexamethasone (dex)
• Goals of therapy:
  • DVd is not given to cure multiple myeloma, but rather to slow the progression of the disease and to decrease symptoms.
• Schedule
  • Drugs
    • Daratumumab intravenous (I.V.) infusion or subcutaneous (SubQ) injection (Darzalex Faspro) on Days 1, 8, and 15 of Cycles 1, 2, and 3; then Day 1 only of Cycles 4, 5, 6, 7, and 8, then once monthly (every 28 days) thereafter. The time of infusion varies depending upon the tolerability and number of previous infusions.
    • Bortezomib subcutaneous (S.Q.) injection on Days 1, 4, 8 and 11 of Cycles 1, 2, 3, 4, 5, 6, 7, and 8
    • Dexamethasone 20 mg (five 4 mg tablets) by mouth on Days 1, 2, then Days 4, 5, then Days 8, 9, then Days 11, 12 of Cycles 1 through 8.
  • Cycles 1 through 8 are repeated every 21 days.
• Estimated total infusion time for this treatment:
  • For daratumumab, Cycle 1 Day 1 may take up to 8 hours because of the possibility of experiencing infusion reactions. If you do not experience any with the first infusion, Cycle 1 Day 8 may be reduced to 6 hours. If you do not experience any infusion reactions during the first two daratumumab doses, it may only take up to 4 hours after that. There is also a 90-minute rapid infusion option if it is well tolerated.
  • If daratumumab is given by subcutaneous injection (Darzalex Faspro), there may be an observation time of up to 6 hours after the first dose to observe for reactions. If no reactions are seen, the observation times for future doses may be much shorter or not needed at all.
  • On days that only bortezomib and dexamethasone are given, infusion time may be as little as 1 hour
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time.
  • DVd is usually given in an outpatient infusion center, allowing the person to go home afterwards. It is repeated every 21 days. This is known as one Cycle. Each cycle may be repeated up to eight times and then ONLY daratumumab is given (no Velcade or dexamethasone) until daratumumab no longer works or until unacceptable side effects occur.
• Side Effects
  • In clinical studies, the most commonly reported DVd (daratumumab + Velcade + dexamethasone) side effects are shown here:
    • Increased bleeding risk [low platelet count; thrombocytopenia] (59%)
    • Pins-and-needles feeling in fingers and toes (47%)
    • Diarrhea (32%)
    • Anemia [low red blood cell count] (26%)
    • Sinus infection (25%)
    • Cough (24%)
    • Fatigue (21%)
    • Constipation (20%)
    • Shortness of breath (19%)
    • Low white blood cells (18%)
    • Trouble sleeping (17%)
    • Fluid retention (17%)
    • Fever (16%)
    • Pneumonia (12%)
    • Weakness (9%)
    • High blood pressure (9%)
• Monitoring
  • How often is monitoring needed?
    • Labs (blood tests) may be checked before treatment and periodically during treatment. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), serum protein electrophoresis (SPEP), urine protein electrophoresis (UPEP), serum free light chains (FLC), quantitative immunoglobulins, plus any others your doctor may order.
  • How often is imaging needed?
    • Imaging may be checked during treatment. Imaging may include: bone scans, computerized tomography (CT) scans, or magnetic resonance imaging (MRI).
  • How might blood test results/imaging affect treatment?
    • Depending upon the results, your doctor may advise to continue DVd as planned, reduce the dose of future treatments, delay the next dose until the side effect goes away, or switch to an alternative therapy.

NHS - Chemotherapy Protocol - Myeloma - DVd (Weekly) Bortezomib-Daratumumab-Dexamethasone (cycles 1 to 8) https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Myeloma/DVd-Weekly-Daratumumab-Bortezomib-Dexamethasone-Cycles-1-to-8.pdf

==========

2023-06-21

2023-06-13

The DVd regimen (Daratumumab + Velcade (bortezomib) + dexamethasone) was initiated on 2023-05-12. Pancytopenia was observed, but it’s important to note that bicytopenia (anemia and thrombocytopenia) was already present even before the regimen started. Furthermore, the fluctuations in HGB and PLT levels are smaller than those in the WBC count. This can be attributed to the fact that the patient has received multiple blood transfusions at our hospital (on 2023-03-16, 2023-04-28, 2023-05-09, 2023-05-15, 2023-05-19, 2023-05-26, 2023-05-31, 2023-06-08, 2023-06-13), which have helped replenish red blood cells and platelets.

• 2023-06-13 PLT 45 x10^3/uL
  

• 2023-06-11 PLT 10 x10^3/uL
  

• 2023-06-08 PLT 51 x10^3/uL
  

• 2023-06-05 PLT 24 x10^3/uL
  

• 2023-06-02 PLT 34 x10^3/uL
  

• 2023-05-31 PLT 14 x10^3/uL
  

• 2023-05-29 PLT 54 x10^3/uL
  

• 2023-05-28 PLT 89 x10^3/uL
  

• 2023-05-26 PLT 8 x10^3/uL
  

• 2023-05-24 PLT 33 x10^3/uL
  

• 2023-05-23 PLT 57 x10^3/uL
  

• 2023-05-22 PLT 19 x10^3/uL
  

• 2023-05-19 PLT 78 x10^3/uL
  

• 2023-05-17 PLT 25 x10^3/uL
  

• 2023-05-15 PLT 58 x10^3/uL
  

• 2023-05-12 PLT 15 x10^3/uL
  

• 2023-05-10 PLT 49 x10^3/uL
  

• 2023-05-08 PLT 23 x10^3/uL

• 2023-06-13 HGB 7.7 g/dL
  

• 2023-06-11 HGB 7.5 g/dL
  

• 2023-06-08 HGB 6.7 g/dL
  

• 2023-06-05 HGB 7.4 g/dL
  

• 2023-06-02 HGB 8.7 g/dL
  

• 2023-05-31 HGB 7.5 g/dL
  

• 2023-05-29 HGB 8.5 g/dL
  

• 2023-05-28 HGB 8.1 g/dL
  

• 2023-05-26 HGB 8.9 g/dL
  

• 2023-05-24 HGB 9.4 g/dL
  

• 2023-05-23 HGB 8.5 g/dL
  

• 2023-05-22 HGB 7.6 g/dL
  

• 2023-05-19 HGB 8.4 g/dL
  

• 2023-05-17 HGB 9.0 g/dL
  

• 2023-05-15 HGB 6.8 g/dL
  

• 2023-05-12 HGB 8.8 g/dL
  

• 2023-05-10 HGB 8.2 g/dL
  

• 2023-05-08 HGB 8.0 g/dL

Since the VRd (bortezomib, lenalidomide, dexamethasone) regimen has already been utilized from 2022-08-17 to 2022-12-29, and the DVd regimen is preferred in patients who are refractory to full doses of lenalidomide or a lenalidomide-containing triplet, the choice of DVd regimen is reasonable in this case. The major toxicities of the DVd regimen include peripheral neuropathy, transient cytopenias, acute or delayed hypersensitivity reaction, fatigue, and nausea. At present, the WBC count has exceeded the upper limit of normal, reversing the previous leukopenia and presenting as a problem of leukocytosis.

• 2023-06-13 WBC 16.35 x10^3/uL
  
• 2023-06-11 WBC 11.96 x10^3/uL
  
• 2023-06-08 WBC 8.48 x10^3/uL
  
• 2023-06-05 WBC 5.33 x10^3/uL
  
• 2023-06-02 WBC 2.48 x10^3/uL
  
• 2023-05-31 WBC 1.32 x10^3/uL
  
• 2023-05-29 WBC 0.90 x10^3/uL
  
• 2023-05-28 WBC 0.73 x10^3/uL
  
• 2023-05-26 WBC 0.68 x10^3/uL
  
• 2023-05-24 WBC 0.41 x10^3/uL
  
• 2023-05-23 WBC 0.39 x10^3/uL
  
• 2023-05-22 WBC 0.36 x10^3/uL
  
• 2023-05-19 WBC 0.42 x10^3/uL
  
• 2023-05-17 WBC 0.64 x10^3/uL
  
• 2023-05-15 WBC 2.06 x10^3/uL
  
• 2023-05-12 WBC 21.19 x10^3/uL
  
• 2023-05-10 WBC 28.72 x10^3/uL
  
• 2023-05-08 WBC 34.88 x10^3/uL

[DVd regimen renal dosing checked]

The recent lab data indicates that the patient’s renal function has stopped deteriorating and shows signs of slight recovery.

• 2023-06-13 Creatinine 1.86 mg/dL
  
• 2023-06-11 Creatinine 1.92 mg/dL
  
• 2023-06-08 Creatinine 1.99 mg/dL
  
• 2023-06-05 Creatinine 1.86 mg/dL
  
• 2023-06-02 Creatinine 1.60 mg/dL
  
• 2023-05-31 Creatinine 1.45 mg/dL
  
• 2023-05-29 Creatinine 1.51 mg/dL
  
• 2023-05-28 Creatinine 1.56 mg/dL
  
• 2023-05-26 Creatinine 1.45 mg/dL
  
• 2023-05-24 Creatinine 1.25 mg/dL
  
• 2023-05-23 Creatinine 1.11 mg/dL
  
• 2023-06-13 BUN 31 mg/dL
  
• 2023-06-11 BUN 38 mg/dL
  
• 2023-06-08 BUN 41 mg/dL
  
• 2023-06-02 BUN 21 mg/dL
  
• 2023-05-31 BUN 18 mg/dL
  
• 2023-05-29 BUN 16 mg/dL
  
• 2023-05-28 BUN 18 mg/dL
  
• 2023-05-26 BUN 22 mg/dL
  
• 2023-05-24 BUN 16 mg/dL
  
• 2023-05-23 BUN 16 mg/dL

For patients with CrCl between 15 to 89 mL/minute, there are no dosage adjustments provided in the daratumumab manufacturer’s labeling. Studies show that this range of renal function does not significantly affect the pharmacokinetics of daratumumab. Additionally, no dosage adjustment is necessary for bortezomib in patients with renal insufficiency. For the current treatment regimen of multiple myeloma, there is no need for dosage adjustment.

2023-05-15

[tube feeding]

• As of 2023-05-15, the patient’s serum potassium level has been measured at 3.7 mmol/L, which falls within the normal range. Therefore, it may be less necessary to continue potassium supplementation, unless there’s clear evidence of ongoing potassium loss.
  • 2023-05-15 K(Potassium) 3.7 mmol/L
    
  • 2023-05-12 K(Potassium) 3.3 mmol/L
    
  • 2023-05-11 K(Potassium) 3.0 mmol/L
    
  • 2023-05-10 K(Potassium) 2.6 mmol/L
• Currently, Const-K is the only oral potassium supplement available in this hospital. If intravenous potassium supplementation is not the preferred method, it’s recommended to crush the Const-K tablet into particles small enough to pass through the feeding tube and administer the supplement with sufficient water. It’s preferable to give this medication with meals due to its original extended-release design.

2023-05-10

• Based on the PharmaCloud database, the patient has been diagnosed with “Other postherpetic nervous system involvement - B02.29”. The patient has an active, refillable prescription, including medications diclofenac, chlorzoxazone, and pregabalin. At present, the corresponding symptoms are being managed with these medications, or with others that have similar pharmacological effects. Therefore, no issues with medication reconciliation have been identified at this time.
• The patient’s MM was previously treated with the VRd regimen (Velcade (bortezomib), Revlimid (lenalidomide) and dexamethasone) from mid-Aug to late Dec 2022 at Cardinal Tien Hospital. The DVd regimen (Darzalex (daratumumab), Velcade (bortezomib) and dexamethasone) is being considered as a new therapeutic strategy in the face of disease relapse.
• If the DVd regimen is ultimately chosen, the first dose of daratumumab on Cycle 1 Day 1 may take up to 8 hours due to the potential infusion reactions. If the patient does not experience any reactions with the first infusion, the infusion time on Cycle 1 Day 8 can be reduced to 6 hours. If no infusion reactions occur during the first two doses of daratumumab, subsequent infusions may be shortened to around 4 hours.
• By the way, daratumumab is no longer in stock at this time (and isatuximab remains unavailable).

700472307

230612

[lab data]

• 2023-02-10 HBsAg Nonreactive
  
• 2023-02-10 HBsAg (Value) 0.36 S/CO
  
• 2023-02-10 Anti-HBc Nonreactive
  
• 2023-02-10 Anti-HBc-Value 0.05 S/CO
  
• 2023-02-10 Anti-HCV Nonreactive
  
• 2023-02-10 Anti-HCV Value 0.06 S/CO

[exam findings]

• 2023-06-10 KUB
  • Degeneration of bony structures.
• 2023-06-10 CXR
  • Ground glass opacity in bilateral lower lungs.
• 2023-06-02 CT - abdomen
  • CC: nausea and poor appetite for 1 month. Persist poor intake due to pain after intake. BW loss 7-8 kgs since 2023-01
    • 20230129 CT: Wall thickening of stomach & regional LAP r/o malignancy.
    • 20230130 gastroscopy: Diffuse ulcerative lesions with blood clot on surface were noted at antrum, body, fundus and cardia, s/p biopsy.
      • Pathology: Gastric lymphoma.
  • Findings: Comparison prior CT dated 2023/01/29.
    • Prior CT identified diffuse wall thickening of the stomach and regional LAP is noted again, mild decreasing in wall thickness and lymph nodes size that is c/w gastric lymphoma S/P C/T with partial response.
    • There is splenomegaly and the greatest anterior-posterior dimension measuring about 14.8 cm.
  • Impression:
    • Gastric lymphoma S/P C/T show partial response.
• 2023-04-03, -03-06 CXR
  • Increased lung markings on both lower lung are noted.
• 2023-02-28 CXR
  • Ground glass opacity in bilateral lower lungs.
• 2023-02-15 CXR
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2023-02-14 CT - chest
  • Indication: Large B cell lymphoma, non-geminal center type, Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +). C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-).
  • MDCT (128-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
  • Comparison was made with previous abdomimal CT dated on 2023/01/29
    • Lungs:
      • Linear band subsegmental atelectasis at both lower lobes,
        • inferior lingular segment, and RML.
        • mosaic attenuation changes in both lower lobes too.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal-pelvic contents:
      • large region infiltrative lesion and wall thickening of the stomach, with ulceration at antral, body, and fundal regions. small LNs at perigastric region.
      • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • enlarged prostate.
    • Visualized bones:marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • no LAP or mass in the chest and visible lower neck.
    • gastric lypmhoma with perigastric LAP.
• 2023-02-13 Whole body PET scan
  • There was increased FDG uptake in the gastric region (SUVmax early: 33.94, delay: 41.31), and lymph nodes in bilateral thigh regions (SUVmax early: 4.37). In addition, diffusely increased FDG uptake was also noted in bone marrow including sternum, both rib cags, scapulae, spines, sacrum, pelvic bones, humeri and femurs.
  • IMPRESSION:
    • Glucose-hypermetabolism in the gastric region (Deauville score 5), compatible with large B-cell lymphoma.
      
    • Glucose-hypermetabolism in lymph nodes in bilateral thigh regions (Deauville score 4), highly suspected lymphoma with involvement of lymph node regions.
      
    • Diffusely increased FDG uptake in bone marrow including sternum, both rib cags, scapulae, spines, sacrum, pelvic bones, humeri and femurs, probably severe anemia. However, lymphoma with involvement of bone marrow may be excluded, suggesting follow-up.
      
    • Large B-cell lymphoma with involvement of stomach and lymph nodes in bilateral thigh regions, by this F-18 FDG PET scan.
• 2023-02-10 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 24) / 104 = 76.92%
    • M-mode (Teichholz) = 77.2
  • Dilated LA
  • Adequate LV, RV systolic function with normal wall motion
  • LV hypertrophy, Impaired LV relaxation
  • Mild AR (aortic regurgitation is the diastolic flow of blood from the aorta into the left ventricle)
• 2023-01-31 Patho - stomach biopsy
  • Stomach, body, biopsy — Lymphoma, B cell type, diffuse pattern. High grade.
  • IHC stains: CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +).
  • Addtional IHC stains: C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-). Diffuse large B cell lymphoma, non-geminal center type is considered.
  • Section shows gastric glandular mucosal tissue with diffuse infiltration by round blue neoplastic cells.
• 2023-01-30 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Diffuse ulcerative lesions, antrum, body, fundus and cardia, highly suspected malignancy, suspected lymphoma, s/p biopsy
    • Reflux esophagitis LA Classification grade A
• 2023-01-29 CT - abdomen
  • History and indication: abdominal pain
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of stomach with regional LAP r/o malignancy.
    • Normal appearance of liver, spleen, pancreas, adrenals and kidneys.
    • Normal appearance of gallbladder.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • No abnormal density at bilateral basal lungs.
  • IMP:
    • Wall thickening of stomach with regional LAP suspected malignancy.
• 2023-01-08 CT - abdomen
  • Normal appearance of the appendix.
  • The both kidneys show normal contrast excretion, size, and contour without evidence of renal stone or tumors.
  • The liver parenchyma reveals no evidence of focal lesion.
  • The gallbladder is normal in size and wall thickness.
  • The pancreas & spleen appears normal in size and contour.
  • No evidence of ascites or intra-abdominal fluid collection.
  • No evidence of paraaortic or pericaval lymphadenopathy in this study.

[surgical operation]

• 2022-01-04
  • Surgery
    • Hemorrhoidectomy        
  • Finding
    • Prolasped hemorrhoids at 3,7,11 o’clock        
  • Procedure
    • Under IVGA, Patient was placed on modified Jack-Knife position
    • Tap anus apart
    • Disinfected perianal area with aqueous Beta-Iodine and draped perianal area as usual
    • Local anesthesia applied with mixture of 20ml Marcaine 0.5% and 1% Xylocaine 20ml + E
    • Expose anal canal retractor and identified of hemorrhoid
    • Skin incision was made longitudinally the sites as figure to just above the level of internal sphincter
    • Elevate all tissue above sphincter plant. Turn it over and trimmed away hemorrhoid plexuses
    • Check bleeders and suture mucosa and skin back to sphincter with 4-0 Vicryl
    • Identical procedures were done as figure below
    • Wash anal canal and apply Neomycine ointment
    • Pack wound with gauze 

[chemoimmunotherapy]

• 2023-05-30 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2
• 2023-04-03 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2
• 2023-03-09 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2
• 2023-02-17 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2

==========

2023-06-12

• The patient has been regularly visiting a local healthcare provider primarily for the management of his hypertension. The most recent consultation was on 2023-06-06, during which the patient was prescribed bisoprolol, valsartan, atorvastatin, and febuxostat. The current active medication list includes Concor (bisoprolol), Feburic (febuxostat), Atozet (ezetimibe + atorvastatin), and Exforge (amlodipine + valsartan). So far during this hospitalization, there have been no observations of elevated blood pressure readings. No discrepancies have been identified in the medication reconciliation process.

• Leukopenia was detected with the lowest WBC count dropping to 420/uL on 2023-06-10, 11 days after the last R-CHOP regimen was initiated on 2023-05-30. To address this, G-CSF (filgrastim 150ug) was administered for 3 consecutive days beginning on 2023-06-10, which led to a noticeable increase in WBC count by 2023-06-12.

  • 2023-06-12 WBC 0.69 x10^3/uL
    
  • 2023-06-10 WBC 0.42 x10^3/uL
    
  • 2023-06-06 WBC 6.74 x10^3/uL
    
  • 2023-05-30 WBC 3.68 x10^3/uL
    
  • 2023-05-16 WBC 8.06 x10^3/uL

• Possible leukopenia-related bilateral ground-glass opacity in the lower lungs was revealed in the CXR performed on 2023-06-10, potentially indicating respiratory infections. This might also be substantiated by an elevated CRP level of 8.9mg/dL and a fever of 39.2°C recorded on the same day. Following the initiation of Cefim (cefepime 2000mg every 8 hours), the patient’s fever seems to have been managed effectively.

• Recent lab results have shown that the patient’s hs-Troponin I, total bilirubin, and BUN levels have exceeded the upper limit of normal. The root causes of these elevated levels might require further investigation.

  • 2023-06-10 hs-Troponin I 17.7 pg/mL
    
  • 2023-06-10 Bilirubin total 1.24 mg/dL
    
  • 2023-06-06 Bilirubin total 0.67 mg/dL
    
  • 2023-06-06 BUN 34 mg/dL
    
  • 2023-05-30 BUN 22 mg/dL

2023-03-06

• Since 2023-02-28, the patient has been receiving consecutive doses of Granocyte (lenograstim 250ug) for several days and no leukopenia is observed now.
  • 2023-03-06 WBC 10.64 x10^3/uL
    
  • 2023-03-04 WBC 15.66 x10^3/uL
    
  • 2023-03-02 WBC 1.44 x10^3/uL
    
  • 2023-02-28 WBC 0.51 x10^3/uL
    
  • 2023-02-22 WBC 5.49 x10^3/uL
    
  • 2023-02-20 WBC 7.31 x10^3/uL
    
  • 2023-02-19 WBC 9.48 x10^3/uL
    
  • 2023-02-17 WBC 9.66 x10^3/uL
    
  • 2023-02-16 WBC 11.02 x10^3/uL
• The patient received blood transfusions on 2023-02-16 ~ 19 and 2023-03-02 ~ 03, and the latest record shows that the hemoglobin level is close to normal.
  • 2023-03-06 HGB 10.5 g/dL
    
  • 2023-03-04 HGB 11.8 g/dL
    
  • 2023-03-02 HGB 7.8 g/dL
    
  • 2023-02-28 HGB 9.9 g/dL
    
  • 2023-02-22 HGB 9.4 g/dL
    
  • 2023-02-20 HGB 9.7 g/dL
    
  • 2023-02-19 HGB 8.6 g/dL
    
  • 2023-02-17 HGB 7.8 g/dL
    
  • 2023-02-16 HGB 5.9 g/dL
• Currently, the platelet count is within the normal range.
  • 2023-03-06 PLT 212 x10^3/uL
    
  • 2023-03-04 PLT 216 x10^3/uL
    
  • 2023-03-02 PLT 112 x10^3/uL
    
  • 2023-02-28 PLT 114 x10^3/uL
    
  • 2023-02-22 PLT 239 x10^3/uL
    
  • 2023-02-20 PLT 248 x10^3/uL
    
  • 2023-02-19 PLT 267 x10^3/uL
    
  • 2023-02-17 PLT 265 x10^3/uL
    
  • 2023-02-16 PLT 320 x10^3/uL
• The patient seems to be prone to developing pancytopenia after the first R-CHOP treatment from 2023-02-17. The lowest blood counts were observed one to two weeks after treatment according to the data. Therefore, measures such as G-CSF might be prepared ahead of the next chemotherapy.

2023-03-02

• Lab data
  • 2023-03-02 Procalcitonin(PCT) 3.75 ng/mL
    
  • 2023-03-02 WBC 1.44 x10^3/uL
    
  • 2023-02-28 WBC 0.51 x10^3/uL
    
  • 2023-02-22 WBC 5.49 x10^3/uL
    
  • 2023-02-19 WBC 9.48 x10^3/uL
    
  • 2023-02-16 WBC 11.02 x10^3/uL
• The patient’s temperature has not exceeded 37.3 degrees Celsius since 2023-03-02, following the administration of piperacillin and tazobactam and Granocyte (lenograstim), indicating initial control of febrile neutropenia.
• According to the current National Health Insurance drug reimbursement regulations, short-acting injection of granulocyte-colony stimulating factor (G-CSF) such as filgrastim and lenograstim can be used for patients with hematological malignancies after receiving intravenous chemotherapy.
• The patient has B cell lymphoma and started his first cycle of R-CHOP on 2023-02-17. Leukopenia was observed on 2023-02-28, and the aforementioned national health insurance drug reimbursement regulations could be applied.

2023-02-13

• The patient was unable to take in a sufficient amount of food due to pain after intake. As a result of the poor response to acetaminophen and the development of anorexia following use of Nexium, Pariet has been prescribed. In the event that poor intake persists in this patient, Tramacet 2 hrs before prandial might be considered.
• As a PPI, Panzolec (pantoprazole) is duplicated by self-carried Pariet (rabeprazole). If two PPIs are necessary, please confirm.

701254669

230612

[diagnosis] - 2023-04-01 admission note

• Epilepsy, unspecified, not intractable, without status epilepticus
• Malignant neoplasm of unspecified site of left female breast
• Constipation, unspecified
• Pleural effusion in other conditions classified elsewhere
• Chronic viral hepatitis B without delta-agent
• Cachexia

[past history]

• Breast ca with brain meta, lung meta with bilateral pleural effusion
• HBV

[allergy]

• NKDA

[family history]

• Deny any family history

[exam findings]

• 2023-06-10 CXR
  • Bilateral pleural effusion.
  • Compression fracture of T12. R/O bone lesions at right clavicle and right 5th rib.
• 2023-05-09 KUB
  • Bilateral pleural effusion.
  • Compression fracture of T12-L1.
• 2023-04-12 SONO - chest
  • Pleural effusion, moderate, bilateral, left>right, organizing
  • Atelectasis, LLL, RLL
  • Pleural thickening, irregular, bilateral
• 2023-05-24, -05-05, -04-17, -04-11, -04-07, -03-29, -03-15, …, -01 CXR
  • Bilateral Pleura effusion
  • S/P port-A implantation.
  • S/P partial left Mastectomy?
  • Compression fracture of T12 and L1 vertebral body.
  • Old fracture of right clavicle?
• 2023-04-07 KUB
  • Fecal material store in the colon.
  • Compression fracture of T12 and L1 vertebral body.
• 2023-04-01 KUB
  • Stool retention in the bowel.
• 2023-04-01 CXR
  • R/O bony metastases at right clavicle and right ribs.
  • Bilateral pleural effusion.
• 2023-04-01 CT - brain
  • Findings
    • Minimal SAH at right frontal region.
    • No midline shift.
    • No abnormal low attenuation lesion in the brain parenchyma.
    • Widening of cortical sulci and dilatation of ventricles.
    • Degeneration and spondylosis of C-spine. Compression fracture of 4-6.
  • IMP:
    • Minimal SAH at right frontal region.
    • Brain atrophy.
• 2023-01-17 Cell block
  • 50 cc yellow turbid pleural effusion — Atypia
  • The smears show lymphocytes, reactive mesothelial cells and scant atypical cell clusters show hyperchromasia and degenerative quality.
• 2023-01-17 SONO - chest
  • Bilateral large amount pleural effusion s/p insertion of right side, 14 Fr. pig-tail catheter and fixed at 18cm.
• 2023-01-16 ECG
  • Sinus tachycardia
  • Low voltage QRS
  • Borderline ECG
• 2022-12-22 SONO - chest
  • pleural effusion
  • Chest echography was performed first. The suitable intercostal space was selected and located.
  • Catheter was inserted with negative pressure smoothly.
  • Right/Left side pleural effusion was drawn smoothly.
  • Watch out BP after tapping.
  • Send left side pleural effusion for examination about cytology (cell block),
  • biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR.
• 2022-12-12 MRA - brain
  • Findings
    • Extradural dura-based lobulated tumors (15 mm and 38 mm) with diffusion restriction and vivid enhancement at right frontal convexity, associating with white matter edema beneath the larger one. Meningiomas are first considered. Pachymeningeal metasatses are less likely.
  • IMP: -Right frontal extra-axial tumors (15 mm and 38 mm). Meningiomas are first considered. D/D: metastases.
• 2022-12-12 CT - brain
  • Indication:
    • 05:30 Wake up
    • 07:00 Dizziness started, no weakness.
    • Dizziness and left face twitchness.
    • PHx: breast ca with pleural effusion and bone metastasis
    • NKDA
  • Cranial CT scans without IV contrast medium enhancement was performed smoothly and show:
    • A hyperdense right frontal dural based tumor (meningioma)? with white matter edema, up to 35 mm, infarct seems less likely.
    • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • The interhemispheric fissure is centered on the midline.
    • The basal ganglia, internal capsule, corpus callosum, and thalamus appear normal.
    • Sella and pituitary are normal, parasellar structures are unremarkable.
    • There are no abnormalities in the cerebellopontine angle areas on both sides.
    • There are no abnormalities in the calvarium.
  • Imp:
    • suspected a right frontal dural based tumor (meningioma) with white matter edema, infarct seems less likely.
• 2022-12-12, -11-26 ECG
  • Sinus tachycardia
  • Low voltage QRS
• 2022-09-19 CT - chest
  • Comparison was made with previous CT dated on 2022/05/31
    • moderate to massiave bilateral pleural effusions, increase in volume and parietal pleural thickening.
    • lungs: mild dependent atelectasis of LLL and RLL.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels: normal caliber of thoracic aorta and central pulmonary arteries
    • Heart: normal in size of cardiac chambers.
    • Chest wall and visible lower neck: irregular soft tissue tumor with stippled calcifications and surrouding nodules at left breast, aasociated diffuse thickening over the overlying skin. small LNs at left axilla
    • Visible abdominal contents: normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node.
    • Visualized bones: lytic or blastic change in bony structures still visible.
  • Impression:
    • advanced Lt breast cancer with skin involvement, bony metastasis, stationary, and increase in volume of pleural effusion, as compared with CT on 2022/05/31
• 2022-09-13 SONO - chest
  • Right thorax: moderate amount pleural effusion s/p drainage of 700cc, yellowish pleural effusion.
  • Left thorax: small amount pleural effusion.
• 2022-08-01 SONO - chest
  • Bilateral pleural effusion (Left: small and Right: small to moderate), post bilateral therapeutic thoracentesis.
• 2022-05-31 CT - chest
  • Comparison was made with previous CT dated on 2022/03/03
    • moderate bilateral pleural effusions, stationary.
    • lungs: mild dependent atelectasis of LLL and RLL.
    • Chest wall and visible lower neck: irregular soft tissue tumor (at least 43 mm in longest dimesion with surrouding nodules at left breast, aasociated diffuse thickening over overlying skin. small LNs at left axilla
    • Visualized bones: lytic or blastic change in bony structures still visible.
  • Impression:
    • advanced Lt breast cancer with skin involvement, bony metastasis, and moderate pleural effusion, seem stationary.
• 2022-03-03 CT - chest
  • Findings
    • Soft tissue lesion at left breast up to 2.26cm in largest dimension. The lesion decreased minimally as compared with previous CT on 2021-11-25.
    • There is bilateral pleural effusion. r/o pleural meta. sdtationary.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
  • Imp:
    • Left breast cancer with bone meta and pleural meta. The primary tumor regressed minimally.
• 2021-11-26 Tc-99m MDP bone scan with SPECT
  • In comparison with the previous study on 2020/12/24, some of the previous bone lesions are a little more evident, suggesting multiple bone metastases in a little more progression.
• 2021-11-25 CT - chest
  • Indication: left breast cancer with pleural & bone mets
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Loculated, modereate right pleural effusion is found.
      • s/p pigtail placement at left hemithorax. Minimal left pleural effusion is found.
      • Soft tissue mass at left breast up to 2.67cm in largest dimension. In comparison with CT dated on 2021-05-06, mild progression is found.
      • Tiny nodular lesion at left lower lobe is found. Lung meta is considered.
      • S/p port-A placement with its tip at Superior vena cava.
        
    • Visible abdomen:
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • The GB is well distended without soft tissue lesion
      • There is no evidence of paraarotic LAPs.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
  • Imp:
    • Left breast cancer with left lung and bone meta. Bilateral pleural effsuion. The main mass increased in size slightly
• 2021-11-22 Cell block
  • 50 cc yellow turbid pleural effusion — Positive for malignancy
    
  • The smears and cell block show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
• 2021-11-22 SONO - chest
  • Bilateral pleural effusion (Left: massive and Right: moderate), s/p left diagnostic thoracentesis plus pig-tail insertion and right therapeutic thoracentesis.
• 2021-05-06 CT - chest
  • Indication: breast ca for further staging
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Soft tissue nodule at left breast up to 2.34*1.79cm in largest dimension. Breast cancer is favored. In comparison with CT dated on 2020-10-01, the lesion regressed.
      • There is moderate bilateral pleural effusion.
      • The lung fields are clear.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
    • Visible brain
      • Marked prominent sulci, fissue and dilated ventricles indicate brain atrophy.
      • No evidence of space occupying lesion in the brain parenchyma is found.
  • Imp:
    • Left breast cancer, in regression.
    • Bilateral pleural effusion.
    • Spine meta. Please correlate with bone scan for treatment respoonse.
• 2020-12-24 Tc-99m MDP bone scan with SPECT
  • In comparison with the previous study on 2020/10/05, some new bone lesions are noted and some of the previous bone lesions are more evident, suggesting multiple bone metastases in progression.
• 2020-10-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 32) / 93 = 65.59%
    • M-mode (Teichholz) = 65
  • Conclusion:
    • Adequate LV,RV systolic function with normal wall motion
    • Thick LVPW, Impaired LV relaxation
    • Poor echo window
• 2020-10-07 SONO - chest
  • Pleural effusion, massive, left
  • No pleural effusion, right
• 2020-10-06 Patho - breast biopsy
  • Unspecified site, Labeled as “Left breast tumor with bone metastasis”, biopsy — carcinoma.
  • Section shows pieece of fibroadipose tissue with carcinoma highlighted by IHC stain of CK (+).
• 2020-10-05 Tc-99m MDP bone scan
  • The scintigraphy suggests skeletal metastasis in skull, spine, rib cages, sternum, scapulae, clavicles, bilateral pelvic bones, and left femur.
• 2020-10-03 MRI - brain
  • No brain nodule found.
  • Right skull metastases was highly suspected.
• 2020-10-02 Cell block
  • 50 cc red turbid pleural effusion — Positive for malignancy
  • The smears and cell block show lymphocytes, reactive mesothelial cells and many atypical epithelial cell clusters.
  • Immunocytochemistry shows TTF-1(-), GATA-3(+), ER(1+, 50-60%), PR(3+, 10-20%) and Her2/neu(-, Dako score 1+) for tumor cells. According to clinical information and cytomorphologic findings, it is compatible with metastatic carcinoma of breast origin.
• 2020-10-01 CT - chest
  • History and indication: PLEURAL EFFUSION, BILATERAL
  • Non-contrast CT of chest revealed:
    • A soft tissue tumor (4.3cm) at left breast with adjacent skin thickening and bil. neck and axillary LAP.
    • Osteolytic lesions at L1 and L4.
    • Bil. pleural effusion with adjacent lung collapse.
    • Some LNs at mediastinum.
    • A tumor (3.9cm) at uterus r/o myoma.
  • IMP:
    • In favor of left breast cancer with multiple LNs and spine metastases.
    • Bil. pleural effusion with adjacent lung collapse.
• 2020-10-01 CXR
  • Bilateral pleural effusion.

[MedRec]

• 2023-03-15 SOAP Hemato-Oncology
  • Xgeva 120mg
• 2023-02-15 SOAP Hemato-Oncology
  • Xgeva 120mg
• 2023-01-06 SOAP Radiation Oncology
  • 2022/12/27~ - RT to the whole brain: 18 Gy/ 6 fx. The metastatic brain tumor: 27 Gy/ 9 fx.
• 2022-12-30 SOAP Radiation Oncology
  • Plan to deliver 18 Gy/ 6 fx to the whole brain. Then boost the Rt convexity metastases to 36 Gy/ 12 fx.

[consultation]

• 2023-02-02 Family Medicine
  • Q
    • for share care or hospice care
    • Owing to disease progression noted and we explained her poor condition to her family and DNR was consented. We need expertise to evaluate her condition thanks!
  • A
    • S: 56-year-old female, left breast cancer with bones metastasis & possible pleural metastasis with massive pleural effusion and brain metastasis, stage IV.
    • O:
      • Now under bilateral pig-tail drainage
      • Consciousness alert, ECOG 2
      • Patient herself prefer continuation of chemotherapy
      • We will arrange hospice combine care and follow her condition
      • Indication: Left breast cancer
    • Plan
      • Combined Hospice Care
• 2023-01-24 Infectious Disease
  • Q
    • Suspect hopital acquired pneumonia
    • Will de-escalate when culture results are available
  • A
    • Consultation for IV Zyvox antibiotic
    • 56-year-old breast cancer female patient, who has both-lung effusion with pigtail drainage, has newly developed pneumonia of both lower lobes.
    • Besides Brosym and Cravit, iv Zyvox is added for coverage of possible MRSA infection.
    • Since patient can take oral medications, oral Zyvox is preferred in this case.
    • Please cancel iv Zyvox and add oral Zyvox for 3 days first.
    • Check blood and sputum culture report for further antibiotic adjustment.
• 2022-12-14 Radiation Oncology
  • A
    • This 56 y/o female was diagnosed left breast cancer with pleura and bone meta. Bilateral pleura effusion was noted.
    • This time, she sufferred from seziure attack. She came to our ER for help. Brain CT and MRA showed suspect right convexity metastasis with leptomeningeal seeding, tumor perifocal edema.
    • Palliative radiothearpy is indicated. CT-simulation will be arranged on 2022/12/20. Plan to deliver 18 Gy/ 6 fx to the whole brain. Then boost the Rt convexity metastases to 36 Gy/ 12 fx. RT will start around 2022/12/21 or 22. Thank you very much.
• 2022-12-12 Neurosurgery
  • Q
    • 05:30 Wake up
    • 07:00 Dizziness started, no weakness.
    • Dizziness and left face twitchness.
    • PHx: breast ca with pleural effusion and bone metastasis
    • NKDA
  • A
    • O
      • at present,
        • E4V5M6
        • pupil: 3+/3+
        • MP R L
        • UE 5 4+
        • LE 5 5
      • ct/MRI: suspect right convexity metastasis with leptomeningeal seeding, tumor perifocal edema
    • Plan:
      • please admit to my service
      • give AED and dexan iv
• 2022-12-12 Neurology
  • Q
    • 05:30 Wake up
    • 07:00 Dizziness started, no weakness.
    • Dizziness and left face twitchness.
    • PHx: breast ca with pleural effusion and bone metastasis
    • NKDA
  • A
    • S: This 56 y/o patient with terminal breast CA presented with left face twiching for 8 mins
    • O
      • GCS: E4V5M6
      • MP: RU:4 RL:4 LU:4 LL:4
      • Brain MRA with contrast: Right frontal extra-axial tumors, suspected meningioma
    • Imp:
      • Focal onset aware seizures, might due to right frontal extra-axial tumors
    • Suggestion:
      • Keppra 1000mg ST and 500mg #1 BID
      • Consult NS for right frontal extra-axial tumors
• 2020-11-12 Dermatology
  • Q
    • for left leg skin rash & icthing for half year ago
    • This 54-year-old woman, a patient of left breast cancer with bone mets S/P C/T. She was admitted for chemotherapy. She complained of left leg skin rash & icthing for half year ago. We need expertise to evaluate her condition thanks!
  • A
    • Skin finding: annular erythematous patches with scalings on left lower leg
    • Imp: tinea corporis
    • Plan: exelderm cream BID topical used

[radiotherapy]

[chemotherapy]

• 2023-06-07 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-05-27 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-05-05 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-04-18 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-03-29 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-03-15 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-03-01 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-02-15 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-11-08 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-10-25 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-10-11 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-09-26 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-09-12 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-08-29 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-08-15 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-07-11 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-07-04 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-05-30 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-05-23 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-05-09 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-05-02 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-04-18 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-04-11 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-03-21 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-03-14 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-03-01 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-02-21 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-02-07 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-01-24 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-01-10 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-01-03 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2021-12-20 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2021-12-13 - eribulin 1.4mg/m2 2mg NS 50mL 10min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2021-04-23 - docetaxel 75mg/m2 110mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2021-04-01 - docetaxel 75mg/m2 110mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2021-03-11 - docetaxel 75mg/m2 117mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2021-02-18 - docetaxel 60mg/m2 90mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2021-01-14 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2020-12-24 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2020-11-12 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2020-10-22 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Xgeva (denosumab 120mg) CXGEV01

• 2023-05-05 OPD
• 2023-03-15 OPD
• 2023-02-15 OPD
• 2022-10-25 OPD
• 2022-09-26 OPD
• 2022-06-20 OPD
• 2022-05-09 OPD
• 2022-04-11 OPD
• 2022-03-01 OPD
• 2022-01-10 OPD
• 2021-11-09 IPD
• 2021-05-04 OPD
• 2021-04-01 IPD
• 2021-01-26 OPD
• 2020-12-24 IPD
• 2020-11-12 IPD
• 2020-10-01 IPD

==========

2023-06-12

• According to the PharmaCloud database, this patient has been exclusively seeking medical services from our hospital, specifically from the hemato-oncology department and the emergency room, for the past three months. No issues related to medication reconciliation have been identified.
• The patient’s CRP level was recorded as 11mg/dL on 2023-06-10 and bilateral pleural effusion was observed in a chest X-ray. As a response, Brosym (cefoperazone + sulbactam) 4000mg was administered Q12H starting from 2023-06-11. Following the treatment, the patient’s body temperature, which was previously elevated, decreased to under 37°C from 2023-06-11 and has consistently remained below that level since then.
• The medication Keppra (levetiracetam) is generally prescribed for the management of focal (partial) onset seizures and generalized onset seizures. The usual immediate release oral dosage starts at 500 mg twice daily and can be increased every two weeks by 500 mg per dose, based on the patient’s response and the medication’s tolerability. The maximum recommended dose is 1.5 g twice daily. Considering the patient’s liver and kidney functions are within normal limits, if the current dose of Keppra (500mg daily) appears to be ineffective, there might be a scope to increase the dosage.
• Xgeva (denosumab 120mg) is typically used to prevent skeletal-related events in patients with bone metastases from solid tumors, and it is usually administered Q4W. Given that the patient’s last administration of this medication was on 2023-05-05 in an outpatient setting, it appears that more than a month has passed. Therefore, it may be appropriate to administer another dose. Denosumab is covered by National Health Insurance for patients with multiple myeloma and patients with breast cancer, prostate cancer, and lung cancer with osteolytic bone metastases.

701460623

230612

[exam findings]

• 2023-04-14 CT - abdomen
  • Findings:
    • S/P hysterectomy
    • Presence of gallbladder stones.
    • Prior CT identified an ovoid-shaped Lymph node, 1.1cm (long axis) in left obturator region is noted again, stationary.
      • Benign reactive node is highly suspected.
    • Fatty liver, grade 4, is noted.
    • Prior CT identified RML nodule, 0.2cm, is noted again, stationary. Benign process is highly suspected. suggest follow up.
    • S/P subtotal gastrectomy.
  • Impression:
    • S/P hysterectomy
    • There is no evidence of tumor recurrence.
• 2023-03-27 Gynecologic ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2022-12-14 Patho - soft tissue tumor, extensive resection
  • Diagnosis:
    • Ovary, right, debulking surgery — Serous borderline tumor with microinvasive low-grade serous carcinoma
    • Ovary, left, debulking surgery — Positive for tumor
    • Fallopina tube, bilateral, debulking surgery — Negative for malignancy
    • Uterus, myometrium, debulking surgery — Positive for tumor and intramural myoma
    • Uterus, endometrium, debulking surgery — Endometrial polyp
    • Uterus, cervix, debulking surgery — Nabothian cyst
    • Labeled as “Pelvic tumor”, excision — Positive for tumor
    • AJCC 8th edition pathology stage: pT2bNx (if cM0); FIGO stage IIB; AJCC stage IIB
  • Gross description:
    • Procedure (select all that apply)
      • debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + pelvic tumor excision)
        • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
    • Specimen Integrity
      • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.
        • Specimen Integrity of Right Ovary (if applicable) Capsule intact
        • Specimen Integrity of Left Ovary (if applicable) Capsule intact
        • Specimen Integrity of Right Fallopian Tube (if applicable) Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable) Serosa intact
    • Tumor Site:
      • Note: Please select the primary tumor site only
        • Right ovary
    • Ovarian Surface Involvement (required only if applicable)
      • Present ( Left)
    • Fallopian Tube Surface Involvement (required only if applicable)
      • Absent
    • Tumor Size
      • Note: For bilateral tumors, please report maximum dimension for each primary tumor, specifying by laterality.
        • Greatest dimension (centimeters): < 0.5 cm of microinvasive serous carcinoma; 12x 7 cm of serous borderline tumor
          
    • Sections are taken and labeled as: F2022-601FSA1-2 & 601A1-9:right ovary, F2022-601A10:right tube, A1-2:left adnexae, A3-4:myometrium, A5-6:endometrium, A7:myoma, A8:cervix
  • Microscopic Description:
    • Histologic Type: Serous borderline tumor with microinvasive low-grade serous carcinoma
    • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
      • Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.
      • WHO Grading System
        • Two-Tier Grading System (required for immature teratomas only)
          • Low grade
    • Implants (required for advanced stage serous/seromucinous borderline tumors only)
      • Note: Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.
        • Present (specify sites): left ovary, uterine serosa
    • Other Tissue/ Organ Involvement (select all that apply): Pelvic
    • Largest Extrapelvic Peritoneal Focus (required only if applicable) Not applicable
    • Peritoneal/Ascitic Fluid
      • suspicious (explain): N2022-04613
        
    • Regional Lymph Nodes: No lymph nodes submitted
      
    • Additional Pathologic Findings
      • Intramural myoma
      • Endometrial polyp
    • Comment(s): None
    • Immunohistochemical stain reveals p53 (wild-tyep), WT-1(+)
• 2022-11-14 Cell block
  • SMEARS and CELLBLOCK: highly suspicious for malignancy
  • IHC stains: PAX-8 (+), calretinin (-), suggestive of ovarian origin.
    
  • Many clusters of suspicious cells with high nuclear cytoplasmic ratio present.
• 2022-11-12 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Large soft tissue tumor, 10cm in the pelvic cavity, with cystic and solid component, r/o right ovarian malignancy.
    • Presence of gallbladder stones.
    • Uterine tumor, 2.4cm in anterior wall of the uterus, r/o uterine myoma.
    • Lymph node, 1.1cm in left obturator region, reactive or metastasis?
    • Gereralized low density over liver parenchyma, suggesting fatty liver.
    • Presence of ascites.
    • RML nodule, 0.2cm, suggest follow up study.
    • S/P subtotal gastrectomy.
  • Impression:
    • R/O right ovarian malignancy with massive ascites.
    • Lymph node, 1.1cm in left obturator region, reactive or metastasis?
    • Uterine tumor, r/o myoma.
    • GB stones.
    • Fatty liver.
    • RML nodule, 0.2cm, suggest follow up study.
    • S/P subtotal gastrectomy.
  • Addendum:
    • Post-op: Ovary, right, debulking surgery — Serous borderline tumor with microinvasive low-grade serous carcinoma
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T: T2b(T_value) N: N0(N_value) M: M0(M_value) STAGE: IIB(Stage_value)
• 2022-11-12 Gynecologic ultrasonography
  • pelvic mass: 80x63mm
  • IMP
    • uterine myoma
    • pelvic mass, nature? GYN origin less likely.

[surgical operation]

• 2022-12-13
  • Surgery
    • debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + pelvic tumor excision) + enterolysis
  • Finding
    • right ovary and tube (during surgery, it did not rupture, and it was only cut open after being completely removed from the body.)
      • ROV – 9x9cm, multiple papillary mass inside with brown, chocolate-like fluid 1200c.c in tumor, suspected LOV cancer
      • Frozen report of ROV – berderline malignanacy
      • right tube – np
    • uerus and LOV + tube –
      • uterus corpus – myoma 3x3cm
      • EM – np
      • cervix – adhesion, seemed free of cancer invasion
      • post uterine surface – has also some papillary mass, similar to those noted in ROV tumor, tumor seeding??
      • LOV and tube – surface has also some papillary mass, similar to those noted in ROV tumor, tumor seeding??
    • omentum: absent, excised during previous gastrectomy?
    • pelvic tumor on Doughlas pouch (CDS) and rectum surface – multiple papillary mass, 0.5cm for each; similar to those noted in ROV tumor, tumor seeding??
    • appendix, liver surface and bowels – seemed free of tuumor invasion
    • Optimal debulking was done.

[chemotherapy]

• 2023-06-09 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2023-05-12 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2023-04-13 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2023-03-17 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2023-02-24 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
• 2023-02-01 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL

==========

2023-06-12 (not posted yet)

• This patient’s serum uric acid levels are oscillating around the upper limit of the normal range, sometimes exceeding it, and sometimes at the upper edge. This could potentially trigger gout, chronic kidney disease, or nephrolithiasis. It is advisable to encourage the patient to increase her water intake. If hyperuricemia persists, the addition of benzbromarone or febuxostat might be considered.
  • 2023-06-09 Uric Acid 7.8 mg/dL
  • 2023-05-12 Uric Acid 6.4 mg/dL
  • 2023-04-13 Uric Acid 6.0 mg/dL
  • 2023-04-12 Uric Acid 7.3 mg/dL
    
  • 2023-03-17 Uric Acid 4.8 mg/dL
  • 2023-03-16 Uric Acid 6.8 mg/dL
    
  • 2023-02-25 Uric Acid 5.4 mg/dL
    
  • 2023-02-24 Uric Acid 7.9 mg/dL
    
  • 2023-01-30 Uric Acid 6.5 mg/dL
    
  • 2022-12-12 Uric Acid 6.0 mg/dL

700857239

230609

[exam findings]

• 2023-06-08 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • There is no evidence of destructive bone lesion.
  • Pleural effusion over left side is found.
• 2023-02-21 SONO - nephrology
  • Chronic renal parenchymal disease
• 2022-05-25 Neurosonology
  • Minimal atherosclerosis in left distal CCA and bilateral proximal ICAs.
  • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
  • Poor bilateral temporal windows for transcranial insonation.
• 2022-05-24 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (95 - 34) / 95 = 64.21%
    • LVEF (%) = 64
    • M-mode (Teichholz) = 64
  • Conclusion:
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated ascending aorta; LV diastolic dysfunction Gr 1.
    • Normal RV systolic function.
    • Trivial AR; mild to moderate MR; mild TR; mild PR.
    • Mininmal pericardial effusion.
• 2022-05-23 MRA - brain
  • Indication
    • Triage level: 3, Stroke symptoms (sudden dysarthria/unilateral limb sensory abnormalities/sudden visual abnormalities) > Symptoms onset time > 4.5 hours or already alleviated. Refer to Neurology OPD. The symptoms of right limb weakness began on 2022-05-21.
    • PH: THROMBOCYTOPENIA, SLE
    • NKDA
    • COVID 19 VACCINATION: NONE
  • MRI of the brain in multiplanar projections, multisequences imaging acquisition without IV Gd-DTPA administration shows:
    • Acute left cerebellum, left corona radiata, bilateral thalamus infarcts. Old bilateral basal ganglia, left corona radiata, left cerebellar lacunar brain infarcts also were noted.
    • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
  • The MRA study shows mild arteriosclerosis of the neck and intracranial vessels with irregular outline but without focal severe stenosis or complete occlusion.
  • Imp: Acute left cerebellum, left corona radiata, bilateral thalamus infarcts. Old bilateral basal ganglia, left corona radiata, left cerebellar lacunar brain infarcts also were noted.
• 2022-05-23 CXR
  • s/p bilateral shoulder arthroplasty
  • mild enlarged cardiac silhoutte
• 2022-05-23 CT - brain
  • Brain atrophy with multiple old bilateral basal ganglia, corona radiata, left thalamus, left cerebellar lacunar brain infarcts.
• 2021-03-23 Patho - lymphnode biopsy
  • Lymph node, left axillary, core needle biopsy — lymphoid hyperplasia
    
  • Section shows cores of reactive lymphoid tissue without malignancy.
    
  • The immunohistochemical stain of CK is negative. The immunohistochemical stains of CD3 and CD20 show relatively preserved lymphoid architecture. Please correlate with the clinical presentation.
• 2020-06-18 Patho - synovium
  • Labeled as “right knee OA, SLE synovitis”, “open” — Synovial tissue with acute and chronic inflammtion, calcification, as well as panniculitis.
    
  • Section shows 1 piece(s) of synovial tissue with acute and chronic inflammtion, calcification, as well as panniculitis.
• 2020-05-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 19) / 89 = 78.65%
    • M-mode (Teichholz) = 79
  • Conclusion:
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Trivial MR; trivial TR; mild PR

==========

2023-06-09

• The two medications, Plaquenil (hydroxychloroquine) and dipyridamole, which were prescribed by our Rheumatology and Immunology OPD on 2023-05-15, are correctly listed on the active medication list. No issues with medication reconciliation were identified.

• Given that hematemesis was just added to the patient’s medical problem list on 2023-06-08, the inclusion of tranexamic acid could be beneficial in reducing gastrointestinal bleeding.

701471389

230609

==========

2023-06-09

[IVIG usage]

According to UpToDate, immune globulin can be used for acute disseminated encephalomyelitis, IV: 400 mg/kg once daily for 5 days.

Based on the patient’s body weight of 80kg and Privigen at 5gm per vial, a dosage schedule of 7-7-6-6-6 vials over 5 days appears to fulfill the recommended dosage.

While the package insert doesn’t specify a need for dilution, if dilution is preferred, D5W can be used as the solvent.

Infusions should ideally begin at a rate of 0.5 to 1 mL/kg/hour for the first 15 to 30 minutes. If no adverse reactions occur, the rate can be incrementally increased every 15 to 30 minutes to a maximum of 3 to 6 mL/kg/hour. This information is referenced from https://www.ncbi.nlm.nih.gov/books/NBK554446/. An alternative infusion rate reference can be found at https://www.gov.nl.ca/hcs/files/bloodservices-resources-pdf-adult-invig-inf-table.pdf.

700022241

230608

[exam findings]

• 2023-06-02 CT - chest
  • Indication: gastric cancer favor lung metastasis
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Lobulated calcified mass at right lower lobe measuring 2.8cm in largest dimension is found. Old insult is considered.
      • Small lymph nodes are found at paratracheal region.
    • Visible abdomen:
      • Huge mass lesion at gastric body measuring 11.6cm with liver invasion is found. Gastric cancer is considered. Some lymph nodes are found around the gastric body.
      • s/p biliary stent placement.
      • Dilated IHDs and CBD is found.
      • Mild pneumobilia is found.
  • Imp:
    • Huge gastric cancer with biliary tree obstruction s/p biliary stent placement.
    • Right lower lobe calcified mass. Old insult is considered.
• 2023-05-31 Patho - stomach biopsy
  • Stomach, antrum, biopsy — Signet-ring cell carcinoma
  • Section shows fragments of gastric tissue infiltrated by signet-ring cells.
  • The immunohistochemical stains reveal CK(+) and Her-2/neu (Ab): Negative (0).
• 2023-05-31 Endoscopic Retrograde Cholangiopancreatography, ERCP
  • Indication: Gastric cancer, obstructive jaundice, rule out metastic tumor with hepatic hilar compression
  • Symptoms: Jaundice
  • Premedication: Buscopan IV + Gascon po
  • Anesthesia: IV anesthesia
  • Findings
    • Duodenum
      • Since advanced gastric cancer involve gastric body and antrum had been known from previous study, upper GI endoscopic GIF-H260 was used before ERCP to exam the route from gastric body to 2nd portion. A huge ulcerative mass was noted from lower body to pyloric ring. Juxtapapillary diverticulum (type 2) was noted.
    • Common bile duct
      • Cholangiogram showed dilated proximal CBD measured 1.5 cm in max diameter. About 2.5 cm stricture was noted middle CBD
  • Management during examination
    • Unintended pancreatic duct guide wire cannulation happened on initial cannulation. After 45 minute trial to stanadard cannulation, needle knief precut fistulotomy (Boston) was applied followed by successful bile duct cannulation. About 10 ml yellowish bile was aspirated. ERBD (Boston, Advenix,8.5 Fr. 9 cm) was inserted with good bile drainage
  • Diagnosis
    • Middle common bile duct stricture, status post needle knife precut fistulotomy + ERBD
    • Non-visualized GB
    • Juxtapapillary diveritculum
    • Advanced gastric cancer, type IV, lower body to pylorus
  • Suggestion
    • NSAID (Voltaren 100mg supp) was used to post ERCP pancreatitis prevention
• 2023-05-30 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Gastric lesion, suspect gastric cancer, Borrmann type IV (infiltration type), s/p biopsy
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
  • Suggestion
    • Pursue pathology report
    • PPI use
• 2023-05-29 CT - abdomen
  • History and indication: favor a tumor in upper abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of stomach (low body and antrum) with adjacent liver, pancreas, CBD, hepatic artery, portal vein and SMV invasion causing biliary dilatation. Some LNs around stomach. Some soft tissue in peritoneal cavity.
    • Nodules (6.4mm, 7.2mm) at RLL.
    • Liver and renal cysts (up to 2.8cm).
    • Distention of gallbladder.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • In favor of gastric cancer with adjacent structures invasion, peritoenal seeding, LNs and lung metastases.
• 2023-05-29 CXR
  • Multiple nodules at bil. lower lung zones.
• 2023-05-27 SONO - abdomen
  • Diagnosis
    • favor a tumor in upper abdomen (origin to be determined: pancreas or stomach?)
    • suspected liver parenchymal disease
    • gallbladder distention, dilatation of CBD and bilateral IHD
    • gallbladder sludge, sludge in left IHD
    • bilateral renal cysts
  • Suggestion
    • 4 phase CT scan

[chemotherapy]

• 2023-06-08 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-06-09

• Trastuzumab is recommended to be included in the first-line chemotherapy for advanced gastric adenocarcinoma with HER2 overexpression. The National Health Insurance (NHI) covers the use of trastuzumab (specifically the IV formulation) in metastatic gastric cancer when used in conjunction with capecitabine (or 5-fluorouracil) and cisplatin for the treatment of HER2 overexpressing (IHC3+ or FISH+) metastatic gastric adenocarcinoma that hasn’t been previously treated with chemotherapy.
• However, the patient’s stomach biopsy pathology dated 2023-05-31 showed negative results for Her-2/neu(Ab)(0). Therefore, this patient does not meet the criteria for the use of trastuzumab covered by NHI.
• The patient has begun his initial dose of the FOLFOX regimen today, without a bolus of 5-FU and with a reduced dosage of oxaliplatin. As of the current moment, there have been no complaints of adverse reactions. The patient’s TPR readings are stable, and there are no concerns with the currently active prescription.

2023-06-08

[patient education]

After attending a family meeting with the patient’s relatives at 11:00 this morning, I visited the patient at 12:30. At that time, the patient and his wife had left the bed to walk nearby, only the patient’s daughter was present. I told the patient’s daughter that if immunotherapy is to be used, it is better to use it sooner rather than later. The patient’s daughter also asked about the possible prognosis of the disease and the possible side effects of the drugs. I elaborated based on the content of this morning’s family meeting. The patient’s daughter indicated that she will decide whether to use immunotherapy in the near future.

701453808

230607

[diagnosis] - 2023-03-27 admission note

• Acute interstitial pneumonitis
• Malignant neoplasm of hypopharynx, unspecified

[past history]

• squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0 stage IVB post TPF (2022/08/25) and Pembrolizumab（2022/08/31）at Cathay Hospital        

[allergy]

• NKDA     

[family history]

• There is no family history of cancer, hypertension

[lab data]

• 2022-10-06 HBsAg Negative
  
• 2022-10-06 HBsAg Value 0.412
  
• 2022-10-06 Anti-HCV Negative
  
• 2022-10-06 Anti-HCV Value 0.0392
  
• 2022-10-06 Anti-HBc Positive
  
• 2022-10-06 Anti-HBc Value 0.00682
  
• 2022-10-06 Anti-HBs Negative
  
• 2022-10-06 Anti-HBs value 5.16

[exam findings]

• 2023-04-14 Electromyography, EMG
  • Findings
    • No pick-up on right facial stimulation.
    • Abcense of right R1, R2 and right R2’ latencies on blink reflex study.
  • Conclusion
    • The above finding may suggest right facial nerve neuropathy. Advice clinical correlation
• 2023-04-07 Nasopharyngoscopy
  • Findings: tube in place
  • Conclusion: right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0 stage IVB post CCRT
• 2023-03-28 CT - neck
  • Findings:
    • Lobulated mass lesion over laryngeal space and hypopharyngeal space with involvement of A-E folds, vocal cords and right thyroid cartilage. Favor malignancy.
    • One huge lobulated necrotic lesion (8.0cm in size) over right parotid space and level II, favor a malignant node.
    • S/P tracheostomy.
• 2023-03-24, -03-03 CXR
  • S/P tracheostomy
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
• 2023-03-13 Nasopharyngoscopy
  • Findings
    • several mucosal injuries within trachea, beyond tracheostomy level. smooth nasopharynx. much saliva accumulated in oropharynx and hypopharynx, poor visualization.
  • Conclusion
    • mucosal injury of trachea
• 2023-02-20 CXR
  • Cardiomegaly is noted.
  • S/p port-A placement with its tip at Superior vena cava.
  • Bronchiectatic change over left lower lobe is found.
  • Senile fibrotic change is noted at lung fields.
  • Osteopenia of the bony structure is noted.
• 2023-02-06 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • S/p port-A placement with its tip at Superior vena cava.
  • Faint aveolar opacity over left lower lobe is found.
  • S/p tracheal tube placement with its tip in place.
• 2023-01-31, -01-16, -01-09, -01-04, 2022-12-05, -11-29 CXR
  • S/P tracheostomy
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
• 2022-12-10 MRA - brain
  • Indication: squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0) stage IVB post TPF (2022/08/25) and Pembrolizumab（2022/08/31）left leg weakness
  • With- and without-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial FLAIR images and axial DWI; using 4 mm thickness for sagittal section and 5 mm thickness for the others) revealed
    • mild dilated intraventricular and extraventricular CSF spaces
    • punctate white matter gliosis in the supratentorial brain; atrophic change in the right frontal lobe.
    • unremarkable change in the skull base
    • multiple foci with low SI change on T1WI in the skull bones.
    • a heterogeneous enhancing lesion, about 69mm, in the right parotid gland and right posterior cervical space.
  • IMP:
    • no evidence of brain metastasis
    • multiple low SI lesions on T1WI in the skull bones
    • a large mass lesion in the right parotid gland and right posterior cervical space
• 2022-12-07 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
  • Findings
    • prolonged motor DLs on left peroneal n. with lower CMAP ampltidues and normal NCVs.
    • prolonged sensory DLs on bil. median and ulnar n. with lower SNAP amplitudes on right median n. and slowed NCVs.
    • the F-wave latencies of bil. median, ulnar, peroneal and tibial n. were normal
    • the H-reflex study of bil. tibial n. were normal.
  • Conclusion:
    • bil. median and ulnar sensory neuropathies at distal region.
• 2022-11-29 CT - chest
  • Indication: squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0) stage IVB post TPF (2022/08/25) and Pembrolizumab（2022/08/31）suspect insterstitial lung disease
  • MDCT (256-detector rows, GE Revolution, was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the neck, chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • large necrotic tumor (metsatatic lymphadenopathy, 64x82mm axial dimensions) at Rt neck and infiltrative mass at Rt hypopharyngeal region.
    • lungs: extensive centrilobular emphysema with extensive inhomogeneous opacities at both upper lobes (Rt greater than Lt), lingula, and RML.
      • there is subpleural reticulation and ground-glass opacity, with areas of consolidation at both lower lobes
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels: moderate calcified plaques of the LAD and LCX coronary arteries.
    • Aorta: normal caliber, mild atherosclerotic change of aortic arch.
    • Central pulmonary arteries: normal caliber.
    • Heart: dilated LV; old myocardial infarction at cardiac apex and anterior interventricular septum (with calcification and low attenuated appearance).
    • Pleura: no effusion
    • Visible abdominal-pelvic contents: normal appearance of gall bladder.
      • unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node.
      • mild atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • interstirial lung disease (NSIP), drug toxicity?
    • emphysema with area or infection or edema at upper lobes?
    • moderate 2V-CAD and old AMI in LAD teritrory.
    • Rt hypopharygeal cancer with Rt neck LNs metastasis
• 2022-11-22 Nasopharyngoscopy
  • Findings
    • right hypopharynx bulging with larynx airway compression (vocal cord not clearly seen, left false cord normal), left pyriform sinus visible and smooth mucosa; trachea ok
  • Diagnosis/conclusion
    • hypopharyngeal cancer under chemotherapy
• 2022-10-24, -10-14 CXR
  • S/P tracheostomy
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
• 2022-10-11 Neck soft tissue
  • S/P tracheostomy in place.
  • S/P Port-A infusion catheter insertion.
  • Thickening of retropharyngeal tissue.
• 2022-08-30 CT (Cathay Hospital)
  • A large right laryngea tumor or cancer with superior extension through right supraglottis to vallecula and direct invasion through the right thyroid cartilage.
  • A large regional enlarged lymph node (50mm) with extrapsular invasion at right cervical levels II and III.
  • Multifocal centrilobular emphysema in bilateral upper lobes of lungs and pulmonary fibrotic change in both lungs.
  • Bilateral pleural effusions and partial atelectasis at RLL of lungs.
  • Cardiomegaly and atherosclerosis of aorta and coronary arteries.
  • Several small hepatic cysts.
  • Suspicious annular wall thickening at the ascending colon.
  • Mild scoliosis and marked osteoarthritis of the visible thoracolumbar spine.
• 2022-08-19 Pathology (Cathay Hospital)
  • Hypopharynx, right, direct laryngoscopic biopsy, — squamous cell carcinoma
  • The specimen submitted consists of two tissue fragments measuring up to 0.9 x 0.6 x 0.3 cm in size, fixed in formalin. Grossly, they are gray to tan and firm. All for section.
  • Tumor type: Squamous cell carcinoma
  • Histological grade: Moderately differentiated (grade 2)
  • Histological pattern: Neoplastic squamous epithelial cells growing in confluent solid sheets
  • Nuclear pleomorphism: Moderate
  • Keratin pearl formation: Focally present
  • Tumor necrosis: Present
  • Subepithelial stroma: Included, with desmoplastic change
  • Lymphocytic response: Absent
• 2022-08-15 CT (Cathay Hospital)
  • A 7.6cm tumor at right piriform sinus, right aryepiglotic fold, bilateral posterior wall of hypopharynx, extending superiorly right posterior wall oropharynx and laterally the right thyroid cartilage and adjacent right strap muscle (T4a).
  • A 8.3x7.0cm abnormal enlarged necrotic LN with extracapsular extention at right level II/III, probably invasion adjacent right SCM muscle, encasement/occlusion of adjacent right IJV, and compression on adjacent right ICA.(N3b)
  • Suspect a small round LAP at right III area.

[consultation]

• 2023-03-13 Ear Nose Throat
  • Q
    • Bloody sputum and bloody clot was noted after replacement of tracheostomy on 2023/03/12, we need your expertise for further management
  • A
    • Scope: several mucosal injuries within trachea, beyond tracheostomy level. smooth nasopharynx. much saliva accumulated in oropharynx and hypopharynx, poor visualization.
    • Impression: mucosal injury of trachea, probably due to suction.
    • Plan: May provide inhalation for mucolysis.
• 2023-03-11 Ear Nose Throat
  • Q
    • This time,he was admitted for scheduled chemotherapy.
    • Now, his Tr. tube slip off , so we need tour help for re on Tr. tube, thanks a lot!!
  • A
    • S
      • tracheostomy dislodge
      • fair breathing pattern and saturation (SaPO2: 97-98% when visiting)
    • O
      • Potable scope: visible tracheal ring and carina after tracheostomy replacement
    • A
      • tracheostomy dislodge, s/p replacement
    • P
      • replacement of tracheostomy smoothly
• 2023-03-07 Infectious Disease
  • A
    • This is a case of A squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0) stage IVB under chemotherapy and immunotherapy.
    • blood culture yielded Staphylococcus caprae.
    • Agree with the use of Zyvox (linezolid).
    • Please adjust antibiotic according to culture results and clinical conditions.
• 2023-03-01 Ear Nose Throat
  • Q
    • We need your expertise for changing tracheostomy (11fr.), thanks
  • A
    • New Teflon #11 inserted smoothly
    • Scope: smooth NPx,
    • swelling epiglottis, larynx and hypopharynx can’t be clearly seen
    • saliva pooling
• 2023-01-09 Infectious Disease
  • Q
    • This time, he had suffered from fever for one day and was brought to our ER. Laboratory test revealed leukopenia, impaired liver and renal function.
    • Chest film disclosed no specific penumonia patch. Empiric antibiotics with Tapimycin was adminiustered. Under the impression of fever, cause unknown. He was admitted for further management
    • After admissoin, empiric antibiotics with Tapimycin was administered on 2022/12/27~2023/01/09, blood culture yielded negative. selfpaid of weekly Taxotere was administered on 2022/12/30.
    • Radiotherapy was complete on 2023/01/02. keep Baktar 2tab QD for prevent pjp infection. Ganciclovir 250mg q12h was administered from 2023/01/03 due to Cytomegaloviral reactivation.
    • However, spiking fever was noted this morning and laboratory test revealed elevated CRP and PCT level. Empiric antibiotics with Targocid and Culin were administered.
    • We need your expertise for further management, thanks
  • A
    • Assessment
      • Persistent fever is noted in the past few days and lab data showed higher CRP and PCT levels.
      • Bacterial infection is considered first.
      • Serial CXR films showed no definite newly-developed pneumonia and urinalysis showed no UTI picture.
      • Previous Cravit is replaced by Culin and Targocid today.
      • There was detectable CMV viral load on 2022-12-28, that patient has received 6-day Cymevene till now, since 2023-01-03.
      • Further work up is necessary, including repeated blood culture, check Port-A site, fungus and TB studies.
    • Suggestion
      • Check blood Aspergillus antigen again and cryptococcal antigen, send sputum for TB-PCR.
      • Continue the present antibiotic regimen.
      • Check blood culture report.
• 2022-12-16 ENT
  • Q
    • We need your expertise for changing tracheostomy (11fr.), thanks
  • A
    • The tracheostomy tube was replaced smoothly.
    • In addition, mucosal erosion with whitish exudative coating was noted in oropharynx.
    • If not contraindicated, please give Nystatin for oral gargling and swallowing, along with pain killer.
• 2022-12-05 Neurology
  • Q
    • He complained of left leg weakness in recent days. We need your expertise for further management, thanks
  • A
    • S: left arm weakness followed by left leg weakness in recent days
    • NE: aware, fluent speech, normal cranial nerves, no visual field defect
      • decreased dexterity on left hand as well as left leg, and equivocal Babinski signs
    • Impression:
      • Suspected tumor encasing on right carotid artery
      • Suspected polyneuropathies
    • Suggest:
      • brain MRA with contrast might be considered if tolerable
      • nerve conduction study (motor + sensory NCS, upper and lower limbs) might be arranged
• 2022-12-01 Chest Medicine
  • Q
    • This time, he had suffered from dyspnea with stinky sputum for one week then came to our OPD for help. Laboratory test revealed anemia and hypoalbuminemia.
    • Chest film disclosed suspect instertitial lung pneumonitis. Under the impression of acute instertitial pneumonitis, suspect immunotherapy related. He was admitted for further management
      
    • After admission, CT revealed interstirial lung disease (NSIP), drug toxicity? emphysema with area or infection or edema at upper lobes? moderate 2V-CAD and old AMI in LAD teritrory. Rt hypopharygeal cancer with Rt neck LNs metastasis.
    • Dexamethasone and empiric Cravit, Baktar were administered. We need your expertise for further management, thanks
  • A
    • Diagnosis
      • Acute interstitial pneumonitis; suspect immunotherapy related
      • Malignant neoplasm of hypopharynx, unspecified
    • Suggestion
      • Keep Dexamethasone 4mg Q12H for 1 week and shifted to oral form
      • Empiric antibiotics with Cravit
      • Keep adequate oxygenation
• 2022-11-30 Infectious Disease
  • Q
    • After admission, CT revealed interstirial lung disease (NSIP), drug toxicity? emphysema with area or infection or edema at upper lobes? moderate 2V-CAD and old AMI in LAD teritrory. Rt hypopharygeal cancer with Rt neck LNs metastasis.
    • Dexamethasone and empiric Cravit, Baktar were administered. We need your expertise for further management, thanks
  • A
    • Assessment
      • 62-year-old stage 4 hypopharyngel cancer male patient, who contracted recent Covid-19 infection on 2022-11-03, has interstitial lung with right lung secondary infection now.
      • No fever, but tachypnea and desaturation noted.
      • There was Stenotrophomonas isolate from sputum culture on 2022-11-04, which should be selected by previous broad spectrum antibiotic use since the mid-October, including Tienam (imipenem + cilastatin).
      • Secondary bacterial infection is still the first considration, Aspergillus possibility exists, but CMV or PJP not very likely.
      • Patient is receiving Cravit and Baktar now, that change of antibiotic regimen seems not necessary.
      • Further work up necessary.
    • Suggestion:
      • Continue Cravit and Baktar
      • Send sputum for PJP-PCR, TB-PCR
      • Check serum Aspergillus antigen, CMV viral load too.
• 2022-10-27 Oral & Maxillofacial surgery
  • Q
    • RT was consulted for further radiotherapy. We need your expertise for dental examination before RT simulation, thanks
  • A
    • Dear doctor, we are consulted for dental evaluation prior the radiotherapy for squamous cell carcinoma from right hypopharynx cancer
    • Dental findigns:
      • Dental panoramic film showed multiple retained root and full mouth tooth attrition caused by betul nut chewing
      • Retained root 21,22
      • Extraction wound of tooth of 34 and 35 with stitches
      • Extra-oral
        • A large neck mass more than 6 cm with skin color change and peeling was noticed.
    • Problem:
      • Retained root 21, 22 with poor prognosis
    • Plan:
      • Explain the findings to the patient and her caregiver
      • Complicated extraction of tooth 21 and 22 under local anesthesia
      • Removal stitches of extraction wound tooth of 34 and 35
      • Suggest follow up for the wound condition next week
      • Antibiotic for infection control.
• 2022-10-17 Oral & Maxillofacial surgery
  • Q
    • RT was consulted for further radiotherapy. We need your expertise for dental examination before RT simulation, thanks
  • A
    • Dear doctor, we are consulted for dental evaluation prior the radiotherapy for squamous cell carcinoma from right hypopharynx cancer
    • Dental findigns:
      • Dental panoramic film showed multiple retained root and full mouth tooth attrition caused by betul nut chewing
      • Retained root 21,22,34,35,44
      • Extra-oral
        • A large neck mass more than 6 cm with skin color change and peeling was noticed.
    • Problem:
      • Retained root 21, 22, 34, 35, 44 with poor prognosis
    • Plan:
      • Explain the findings to the patient and her caregiver
      • Suggest extraction of tooth 21, 22, 34, 35, 44 prior to radiotherapy (Fractured teeth may cause local cellulitis. To avoid possible osteonecrosis of the jaw after future radiation therapy, it is important to prevent tooth extraction.)
• 2022-10-14 Radiation Oncology
  • A
    • A: Squamous cel carcinoma of the hypopharynx, stage cT4aN3bM0 (stage IVB), s/p induction chemotherapy (TPF regimen) and pembrolizumab.
    • P: Radiotherapy is indicated for this patient with the following indicators: stage cT4aN3bM0 (stage IVB)
      • Goal: pallaition
      • Treatment target and volume: hypopharyngeal tumor, peripheral, to bilateral neck
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the hypopharyngeal tumor, peripheral, to bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor and right neck involved nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2022-10-19.
      • Please consult Dental department for pre-RT dental evaluation and management.
• 2022-10-13 Dermatology
  • Q
    • This 62-year-old male was diagnosed of hypopharynx cancer with right LN mass metastasis (cT4N3bM0) stage IVB post TPF and C1 Pembrolizumab on 2022/08/31 at Cathay hospital.
      
    • He has psoriasis for several years and skin rash over whole body was noted after the immunotherapy. We need your expertise for further management, thanks
  • A
    • The patient had sufferred from hypopharynx cancer undr PD-L1 therapy and post-herpestic neurogenia with residual wound.
      
    • Under the impression of replasing psoriasis.
      
    • The following sugeetion:
      • Belolin onit. (clobetasol) 4 tube topcial QD use and Xamiol gel (calcipotriol hydrate + betamethasone dipropionate) 1 tube topical QN use over psoriatic lesions.
        
      • Sinphraderm 2 tube topical QN use after body wash for enhance mositurization.

[radiotherapy]

• 2022-11-14 ~ undergoing - at 5000cGy/25 fractions(6MV photon) of the hypopharyngeal tumor, peripheral, to bilateral neck, and 5800cGy/29 fractions of the hypopharyngeal tumor and right neck involved nodal lesions.

[chemoimmunotherapy]

• 2023-04-29 - docetaxel 35mg/m2 60mg NS 100mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-28 - pembrolizumab 100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-04-14 - docetaxel 35mg/m2 60mg NS 100mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-30 - docetaxel 35mg/m2 60mg NS 100mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-29 - pembrolizumab 100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-03-02 - docetaxel 35mg/m2 60mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-01 - pembrolizumab 100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-01-31 - pembrolizumab 100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-12-30 - docetaxel 35mg/m2 60mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-16 - pembrolizumab 100mg NS 100mL 30min + docetaxel 35mg/m2 60mg NS 100mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-18 - pembrolizumab 100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-11-02 - docetaxel 35mg/m2 60mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-10-26 - docetaxel 35mg/m2 60mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-10-21 - pembrolizumab 100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2023-06-07

[tube feeding]

According to the package insert of Valcyte (valganciclovir), once ingested, it rapidly converts to ganciclovir, which has been shown in animal studies to be mutagenic, teratogenic, and carcinogenic. This morning I called the drug supplier (YuLi Co., Ltd.), who advised against direct contact with the drug substance on the mucous membranes to avoid exposure, so they don’t recommend crushing or splitting the pill by hand. However, they suggested that the pill could be broken into smaller pieces without the operator’s hands directly touching it, dissolved in an appropriate amount of drinking water, and then administered with food via tube feeding.

2023-05-02

• It appeared that the SCC readings were dropping slowly. However, the 2023-03-28 neck CT findings indicated the presence of two malignant lesions. The first is a lobulated mass in the laryngeal and hypopharyngeal space, involving the aryepiglottic folds, vocal cords, and right thyroid cartilage. The second is a large (8.0 cm) lobulated necrotic lesion in the right parotid space and level II, likely representing a malignant lymph node.
  • 2023-04-24 SCC, Squamous cell carcinoma antigen (nuclear medicine) 41.60 ng/mL
    
  • 2023-04-19 SCC, Squamous cell carcinoma antigen (nuclear medicine) 43.40 ng/mL
    
  • 2023-04-07 SCC, Squamous cell carcinoma antigen (nuclear medicine) 54.90 ng/mL
    
  • 2023-03-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 48.20 ng/mL
• No medication reconciliation issues were identified during this hospitalization.

2023-03-28

• Lab data from early Feb 2023 showed a short trough. However, recent results indicate that the SCC antigen has doubled compared to late Dec 2022.

  • 2023-03-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 48.20 ng/mL
    
  • 2023-02-09 SCC, Squamous cell carcinoma antigen (nuclear medicine) 9.02 ng/mL
    
  • 2022-12-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 20.10 ng/mL

• The patient is currently being treated with Valcyte (valganciclovir), Morcasin (sulfamethoxazole/trimethoprim), and Mycostatin (nystatin) for suspected respiratory infections.

• During this hospital stay, no issues with medication reconciliation were identified, and the drugs recently prescribed and listed in the NHI PharmaCloud System were properly prescribed as self-carried items to address the patient’s underlying conditions.

2023-03-01

• 2023-02-27 lab results indicated that the CMV viral load was not detected, which is a positive indication. Additionally, the reading for squamous cell carcinoma antigen (SCC) has shown a trend of decreasing levels.
  • 2023-02-09 SCC, Squamous cell carcinoma antigen (nuclear medicine) 9.02 ng/mL
    
  • 2022-12-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 20.1 ng/mL
• Morcasin (sulfamethoxazole, trimethoprim) is appropriately prescribed to treat Pneumocystis pneumonia since 2023-02-07. Typically, treatment for Pneumocystis jirovecii pneumonia lasts for 14 to 21 days. It is suggested to monitor symptoms and response to determine if a longer course of treatment is necessary.

2023-01-11

There is no specific pharmacist shift handover to follow in this patient.

[Zavicefta 2g/0.5g powder for concentrate for solution for infusion - Usage and Precautions ] for the patient’s primary nurse

• Compatibilities (ref: MicroMedex)
  • D5W (Dextrose 5% in water)
  • NS (Normal saline (Sodium chloride 0.9%))
  • Lactated Ringer’s Injection
  • Dextrose 2.5% in sodium chloride 0.45%

2022-10-12

• It has been reported that fungitech (terbinafine) itself may cause the following dermatologic adverse reactions: pruritus (3%), rash (6%), and urticaria (1%).

700173157

230606

[exam findings]

• 2023-06-05 CXR
  • Bilateral pleural effusion.
  • Multiple nodules at bil. lungs.
• 2023-06-05 ECG
  • Normal sinus rhythm
  • Low voltage QRS
  • Cannot rule out Inferior infarct, age undetermined

[consultation]

• 2023-06-05 Family Medicine
  • Q
    • Chief Complaints: SOB for a long time, more severe recently
    • no fever, no URI s/s
    • Past History: malignant tumor of right submandibular gland? with pleural metastases, pleural effusion and pericardial effusion
    • Drug allergy: NKDA
    • 2023/04/21 NTU Cancer Center - Neck + Lung CT: Right suprahyoid neck lymphadenopathy; Progressive bilateral lung and left pleural metastases; Right pleural effusion and pericardial effusion; Indeterminate hepatic lesions at left medial segment;
  • A
    • 52 y/o lady Malignant tumor of right submandibular gland? with pleural metastases, Dyspnea
    • CXR Bilateral pleural effusion. Multiple nodules at bil. lungs.
    • BEd full
    • Our share care would follow up.

==========

2023-06-06

• This patient has recently been visiting the NTU Cancer Center and Cheng Hsin Hospital for her malignant neoplasm of the pleura (at least since April). The medications prescribed during these visits are already included in her current active prescription list, with no discrepancies identified during the medication reconciliation process.

700790807

230606

{gastric cancer with peritoneal seeding, pT4aN2M1, stage IV, (poorly cohesive carcinoma, signet-ring cell type) s/p total gastrectomy with D2 LN dissection & CCRT}

• past history
  • gastric cancer with peritoneal seeding, pT4aN2M1, stage IV, (poorly cohesive carcinoma, signet-ring cell type),
    • s/p total gastrectomy with D2 LN dissection IP C/T wt Mitomycin-C on 20211004,
    • s/p port-A implantation on 20211020,
    • under post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-Op adjuvant C/T wt Oxaliplatin / HDFL IV Q2W x 12 (since 20211026)
  • open cholecystectomy
  • operation for left kidney staghorn stone
• exam findings
  • 2022-09-26 CXR
    • Patchy consolidation projecting at right middle lung show near complete resolving.
  • 2022-09-22 CXR
    • Patchy consolidation projecting at right middle lung is noted. Please correlate with clinical condition and CT to rule out Bronchopneumonia.
  • 2022-08-17 CT - abdomen
    • Findings
      • S/P total gastrectomy.
      • Mild ascites is highly suspected. Please correlate with sonography.
      • Prior CT identified two tiny nodule at RUL are noted again, stationary. Prior CT identified small amount left pleural effusion and Small amount pericardial effusion are noted again, stationary.
      • Prior CT identified few ground-glass opacity at bil. basal lungs are not noted again.
      • Prior CT identified A vesical stone (1.8cm) shows stationary.
      • There are few poor enhancing lesions in the spleen at portal venous phase images and homogeneous enhancement in delayed phase images that may be hemangiomas. Please correlate with sonography.
    • Impression
      • S/P total gastrectomy.
      • Mild ascites is highly suspected. Please correlate with sonography.
  • 2022-05-17 CT - abdomen
    • History and indication:
      • gastric cancer with peritoneal seeding, pT4aN2M1, stage IV
    • Findings
      • S/P gastric operation. Moderate amount ascites.
      • A tiny nodule at RUL. Some patchy densities at bil. basal lungs. Bil. pleural effusion. Small amount pericardial effusion.
      • Left renal stone (up to 4mm). A stone (1.8cm) in urinary bladder.
      • General subcutaneous edema.
    • IMP:
      • S/P gastric operation. Moderate amount ascites.
      • A tiny nodule at RUL r/o metastases. Some patchy densities at bil. basal lungs. Bil. pleural effusion. Small amount pericardial effusion.
      • Left renal stone (up to 4mm). A stone (1.8cm) in urinary bladder.
  • 2021-10-08 Upper GI series
    • Indication:
      • gastric cancer s/p total gastrectomy on 2021/10/04
    • Impression
      • There is no leakage of the contrast medium from esophagus into small intestines.
      • The peristasis of the esophagus and small intestines are intact.
  • 2021-10-05 Patho - Stomach
    • Stomach, total gastrectomy - Poorly cohesive carcinoma, signet-ring cell type
      
    • Margins, total gastrectomy - Radial margin is involved by tumor
      
    • Lymph nodes, D2 LN dissection - Metastatic carcinoma (3/55)
      
    • AJCC Pathologic staging - pT4aN2M1, stage IV
  • 2021-09-27 Patho - Stomach, low body, biopsy
    • Adenocarcinoma, poorly differentiated
      
    • IHC: CK(+), CDX2(+), and Her-2/neu(Ab): Negative(0).
• surgical operation
  • 2021-10-04
    • Surgery
      • total gastrectomy with LN 1-9,11,12,14v dissection
      • cholecystectomy
      • IPCT with normotemperature with Mitomycin C 15mg/m2 (30mg) fo 90 mins
    • Finding
      • distal gastric tumor with complete gastric outlet obstruction cT4aN3M1
      • Frozen section: lesser curvature stomach serosa 3 cm below EG junction. positive tumor seeding(+)
• radiotherapy
  • 2021-11-05 ~ 2021-12-09 - 4500cGy/25 fractions (15MV photon) of the gastric tumor bed, peripheral, and regional lymphatic area.
• chemotherapy
  • 2022-10-06 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4700mg 46hr
  • 2022-09-21 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4700mg 46hr
  • 2022-08-29 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4720mg 46hr
  • 2022-07-27 - oxaliplatin 75mg/m2 120mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • 2022-07-07 - oxaliplatin 75mg/m2 120mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4600mg 46hr
  • 2022-06-22 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4600mg 46hr
  • 2022-05-16 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4750mg 46hr
  • 2022-04-26 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4780mg 46hr
  • 2022-03-22 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
  • 2022-03-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
  • 2022-02-21 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4990mg 46hr
  • 2022-02-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
  • 2022-01-24 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
  • 2022-01-13 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
  • 2021-11-29 - fluorouracil 200mg/m2 380mg 24hr D1-5 (CCRT)
  • 2021-11-22 - fluorouracil 200mg/m2 380mg 24hr D1-5 (CCRT)
  • 2021-11-18 - fluorouracil 200mg/m2 380mg 24hr D1-2 (CCRT)
  • 2021-10-06 - fluorouracil 750mg 1hr IP D1-5 + gentamicin 40mg IP D1-5 + sodium bicarbonate 2800mg IP D1-5
  • 2021-10-04 - mitomycin-c 15mg/m2 30mg 90min IP + gentamycin 40mg IP + sodium bicarbonate 4200mg IP

==========

2023-06-06

[compatibility]

There is no compatibility information available in Micromedex for concurrent administration of Nako No.5 and Oliclinomel N4-550E.

Nako No.5 injection contains: - sodium chloride - sodium acetate anhydrous - potassium acetate - magnesium chloride 6H2O - potassium phosphate monobasic - dextrose monohydrate

Oliclinomel N4-550E Emulsion for Infusion contains: - sodium acetate 3H2O - sodium glycerophosphate 5H20 - potassium chloride - magnesium chloride 6H2O - glucose monohydrate - calcium chloride 2H2O

The electrolyte components in both Nako No.5 and Oliclinomel N4-550E share a high degree of similarity, which suggests that they are unlikely to be incompatible when administered concurrently through a Y-line immediately prior to administration.

2022-10-07

• A HGB level of 6.6g/dL (CTCAE v5 grade 3 anemia) was detected on 2022-10-06, as well as dizziness and mild fatigue. The myelosuppressive chemotherapy might be put on hold for a while if no other consideration.

2022-03-23

• According to lab data reported on 2022-03-22, serum potassium, magnesium and HGB were low (2.6 mmol/L, 1.4 mg/dL, 6.7 g/dL respectively).
• KCl (IV), potassium gluconate (PO), MgSO4 (IV), MgO (PO) are prescribed and blood products are ordered.

2022-02-08

• HER2 tested negative, trastuzumab might not be indicated.
• PD-L1, microsatellite testing outcome not found, not sure nivolumab should be applicable.
• Over 95% of gastric cancers are adenocarcinomas, which are typically classified based on anatomic location (cardia/proximal or noncardia/distal) and histologic type (diffuse or intestinal). The diffuse type, which is characterized by poorly differentiated and discohesive tumor cells with a signet-ring or non-signet-ring morphology diffusely infiltrating the gastric wall in a desmoplastic stroma, is more prevalent in low-risk areas and is mostly associated with heritable genetic abnormalities.
  • according the patient’s pedigree chart, he has 3 direct descendants alive, who should be aware of suspected higher risk of gastric cancer.
• no drug allergy recorded in database, no issue found in active medication.

700051397

230605

{SCC of esophagus, lower third, with mediastinal & SCF LAPs and multiple brain metastases, stage IV}

[diagnosis] - 20230110 admisstion note

• Malignant neoplasm of lower third of esophagus
• Squamous cell carcinoma of lower third esophagea with multiple brain metastases, ypT3N1M1, ypStage IVB, mediastinal lymph node and aorta invasion s/p immunity therapy with Nivolumab/chemotherapy with FOLFOX6 from 2022/12/01
• Hypothyroidism, unspecified
• Ulcer of esophagus without bleeding
• Secondary malignant neoplasm of mediastinum
• Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
• Secondary malignant neoplasm of brain
• Hypokalemia

[past history]

• Esophageal cancer, SqCC, L/3, with mediastinal & SCF LAPs, s/p port-A insertion and feeding jejunostomy on 20210707, neoadjuvant CCRT (3600 cGy/12 fx) for brain metastases from 2021/07/08 ~ -07/23, neoadjuvant CCRT (5040 cGy/28 fx) for primary tumor from 2021/07/26 ~ 09/01, with FOLFOX from 2021/07 ~ 2021/11, s/p VATS esophagectomy and gastric tube reconstruction on 2022/07/04

[family history]

• Mother has colon cancer
• Denied DM, H/T, HCVD or CAD history in his family

[exam findings]

• 2023-04-11 CXR
  • Atherosclerosis of the aorta.
  • Ground glass opacities in bil. lungs.
  • Bilateral pleural effusion.
• 2023-04-11 ECG
  • Sinus tachycardia
  • Low voltage QRS
  • Nonspecific T wave abnormality
• 2023-04-03 SONO - chest
  • Left
    • LEft side trivial pleural effusion, risk of tapping -> suggest closely follow up
      • if progression of pleurale ffusion -> arrange Chest echo again
  • Right
    • Right side trivial pleural effusion, RLL consolidation
• 2023-03-29 CXR
  • Lt pleural effusion with loculation and nodular metastasis
  • Rt pleural effusion and partial atelectasis of RLL
  • Rt-sided convexity of the Rt hilum and Rt upper cardiac border with narrowing of Rt main bronchus and increased density over mediasttinum, lower tracheal level to lower mediastinum due to large tumor
  • s/p EVAR in Descending thoracic aorta (EVAR: endovascular aneurysm repair)
  • Multiple nodules in both lungs and Rt pleural nodularity due to metastases
• 2023-03-13, -03-09, -03-06 CXR
  • Left pleura effusion.
    
  • S/P metalic stent implantation at the descending thoracic aorta.
  • Few nodular opacities on both lungs are noted that are c/w metastases after correlate with CT.
  • Patchy consolidation of the left middle and lower lung is noted. Please correlate with clinical condition to rule out inflammatory process.
• 2023-02-16 CT - chest
  • Indication: Malignant neoplasm of lower third of esophagusdyspnea RULING OUT BRONCHIAL OBSTRUCTION, PARTIAL
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Necrotic mass at lower third esophagus with consolidation over right lower lobe is found. In comparison with CT dated on 2022-11-03, the lesion enlarged.
      • s/p gastric tube reconstruction.
      • s/p aortic stent placement.
      • Enlarged mass anterior to right heart border measuring 4.08cm in largest dimension, in progression.
      • One soft tissue mass at left heart border about 2.82cm is found.
      • Left mild pleural effusion is found.
    • Visible abdomen:
      • Low density lesions are found at left lobe liver up to 4.2cm in largest dimension. In enlargement.
      • The GB is well distended without soft tissue lesion
      • The spleen, pancreas, both kidneys and adrenals are intact.
  • Imp:
    • Lower third esophageal cancer with probably tumor rupture, causing right lower lobe conoslidation. The primary tumor enlarged.
    • Mediastinal lymphadenopathy, in progression.
    • Liver meta, in enlargement.
• 2023-02-10 CXR
  • Port-A catheter inserted into SVC via left subclavian vein.
  • Lt pleural effusion with loculation and nodular metastasis
  • Rt pleural effusion and partial atelectasis of RLL
  • Rt-sided convexity of the Rt hilum and Rt upper cardiac border with narrowing of Rt main bronchus and increased density over mediasttinum lower tracheal level to lower mediastinum due to tumor
  • s/p EVAR in Descending thoracic aorta
  • Multiple nodules in both lungs and Rt pleural nodularity due to metastases
• 2023-02-01, -01-19, -01-10, -01-03 CXR
  • Left pleura effusion.
    
  • S/P metalic stent implantation at the esophagus or descending thoracic aorta?
  • Few nodular opacities on both lung are noted.
• 2022-12-22, -12-05, -11-30 CXR
  • Left pleura effusion S/P pigtail catheter implantation.
    
  • S/P metalic stent implantation at the esophagus or descending thoracic aorta?
  • Enlargement of cardiac silhouette.
• 2022-11-25, -11-15, -11-05 CXR
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
• 2022-11-18 Chest Decubitus Bilat
  • Pleura effusion of left costal-phrenic angle.
  • Peri-bronchial wall thickening of the RML of the lung is suspected? Please correlate with clinical condition or CT.
• 2022-11-18 Cell block
  • Negative
• 2022-11-18 SONO - chest
  • left side small amount of loculated and septated pleural effusion, 60cc serosangious fluid was aspirated for analysis.
• 2022-11-10 Stroboscopy
  • right vocal cord palsy
  • left vocal fold compensation
• 2022-11-04 Cell block
  • Negative
• 2022-11-04 SONO - chest
  • left side small amount of pleural effusion, 550cc serosangious fluid was aspirated for analysis.
• 2022-11-03 CT - chest
  • Indication: Esopageal cancer s/p OP f/u (LLL pleural effusion)
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Soft tissue mass at lower third esohpagus about 6.6cm in largest dimension. In comparison with CT dated on 2022-05-19, the lesion enlarged.
      • Consolidation over right lower lobe is found.
      • There is moderate bilateral pleural effusion.
      • s/p gastric tube reconstruction at anterior mediastinum is found.
    • Visible abdomen:
      • Low density lesion at left lobe liver about 1.7cm in largest dimension. Liver meta is favored.
      • The GB is well distended without soft tissue lesion
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Esophageal cancer at lower third s/p gastric tube reconstruction. The primary tumor enlarged.
    • New liver meta.
    • Bilateral pleural effusion.
• 2022-11-02 CXR
  • Lung markings: opacification in the left lower lung field.
  • blurred left hemidiaphram
• 2022-07-22 Upper GI series
  • UGI series was done partially due to very frequent aspirtion and shows
  • Contrast medium stasis at pyriform sinus with leakage into trachea easily
  • post op. of the esophagus is found.
  • Oral intact is not suggested in the current status.
• 2022-07-18 MRI - brain
  • Indication: brain meta re-follow up
  • History: The 46-y/o man has esophageal cancer, SqCC, L/3, with medastinal & SCF (supraclavicular fossa) LAPs and multiple brain metastases. He has suffered from progressive dysphagia for 2 years. SCC of esophagus, lower third, stage II was diagnosed by other hospital in 2019/10 but only Chinese medicine was done by decision of patient.
  • MRI of the brain in multiplanar projections, multisequences imaging acquisition with and without IV Gd-DTPA administration shows:
    • comparison: 2021/10/08, 2022/01/07 MRI
    • Normal cisterns and sulcal systems.
    • Normal bilateral ventricular size and shapes.
    • Normal appearance of bilateral cochlear and vestibular nerves complexes.
    • No evidence of severe mass effect or midline structural deviation.
    • Small poor enhancing nodules in left frontal and right occipital lobes,stationary.
      
  • Imp:
    • Small poor enhancing nodules in left frontal and right occipital lobes, regressed and stationary.
    • Regressed size and edema of left occipital nodule, stationary.
• 2022-07-11, -07-05 CXR, Portable supine chest AP view shows:

  • Port-A catheter inserted into SVC via left subclavian vein.

  • approriately positioned endotracheal tube in place

  • s/p VATS esophagectomy and gastric tube reconstruction with gastric tube inserted

  • Right internal jugular central venous catheter with tip in the SVC

  • s/p right chest tube in place, its tip directed superomedially, projecting over Rt upper hemithorax

  • s/p left chest tube in place, its tip directed superomedially, projecting over 6th rib

  • extensive increased opacity over Rt lung field

  • Lung volume reduction and increased opacity over RLL

  • Subcutaneous emphysema in the right neck and chest wall

  • 2022-07-15 Patho - esophagus subtotal/total resection

    • Diagnosis
      • Esophagus, lower third, VATS McKeown esophagectomy —- Squamous cell carcinoma, moderately differentiated, s/p CCRT
        • Stomach, cardia, partial gastrectomy —- Negative for malignancy
        • Azygous vein, excision —- Negative for malignancy
        • Thoracic duct, excision —- Negative for malignancy
      • Resection margin: Circumferential resection margin: involved
      • Lymph node
        • Lymph node, peri-gastric, specimen 1, dissection — Negative for malignancy (0/10)
        • Lymph node, right, group 2, dissection —- Negative for malignancy (0/1)
        • Lymph node, right, group 3, dissection —- Negative for malignancy (0/1)
          
        • Lymph node, right, group 4, dissection —- Negative for malignancy (0/1)
        • Lymph node, right, group 7, dissection —- Metastatic squamous cell carcinoma (2/2)
        • Lymph node, upper para-esophageal, dissection —- Negative for malignancy (0/0)
        • Lymph node, middle para-esophageal, dissection —- Negative for malignancy (0/0)
        • Lymph node, lower para-esophageal, dissection —- Negative for malignancy (0/1)
      • AJCC 8 th edition pT N M Pathology stage: ypStage IVB, ypT3N1 (if cM1)
    • Gross Description:
      • Procedure: VATS McKeown esophagectomy; Size: Esophagus: 2 segments, the upper segment measuring 6.7 cm in length, the lower segment measuirng 6.2 cm in length with a portion of gastric tissue measuring 3.2 cm in length.
      • Tumor Site: Distal esophagus (low thoracic esophagus)
      • Relationship of Tumor to Esophagogastric Junction: Tumor midpoint lies in the distal esophagus and tumor involves the esophagogastric junction
      • Tumor Size: annularly involving the lower esophagus and measuring 7.5 cm in length
      • Proximal cut end, azygous vein (2.6 cm in length and 0.4 cm in diameter), thoracic duct (5.5 cm in length and 0.3 cm in diameter), group 2, 3, 4, 7, 10, and upper para-esophageal, middle para-esophageal, and lower para-esophageal lymph nodes are received in the another bottles.
      • Sections are taken and labeled as: A1-2: distal gastric resection margin; A3: stomach, non-tumor; A4: esophagus, non-tumor; A5: middle para-esophageal tissue; A6: tumor, upper segment; A7-12: tumor (A7-9: the same level), lower segment; B: lymph node, group 2; C: lymph node, group 3; D: lymph node, group 4; E: lymph node, group 7; F: lymph node, upper paraesophageal; G: lymph node, middle paraesophageal; H1-3: lymph node, lower paraesophageal; I: azygous vein; J: thoracic duct; K: proximal cut.
        
    • Microscopic Description:
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades adventitia
      • Margins
        • Margin(s) involved by invasive carcinoma
        • Specify involved margin: circumferential
        • Proximal resection margin: 5.5 cm
        • Distal resection margin: 3.2 cm
      • Treatment Effect: Absent: Extensive residual cancer with no evident tumor regression (poor or no response, score 3)
        
      • Lymphovascular Invasion: Present
        
      • Perineural Invasion: Present
        
      • Regional Lymph Nodes: please see diagnosis
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors: y (posttreatment)
          • Primary Tumor (pT): pT3: Tumor invades adventitia
          • Regional Lymph Nodes (pN): pN1: Metastasis in one or two regional lymph nodes
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM1
      • Additional Pathologic Findings: The azygous vein and thoracic duct are free of malignancy.

  • 2022-07-01 Pulmonary Flow Volume Loop

    • Mild restrictive ventilatory impairment, possibly due to small airway obstruction
    • Please consult chest specialist

  • 2022-06-27 CXR

    • Patchy infiltration with air-bronchogram projecting at right infrahilum and right lower medial lung zone is noted.

  • 2022-06-01 Patho - bronchus biopsy

    • Labeled as “right lower lobe”, bronchoscopic biopsy — benign respiratory epithelium lined lung tissue with focal fibrosis and focal mild chronic inflammation.

  • 2022-05-19 CT - chest

    • Indication: Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • Soft tissue mass encircling lower third esophagus is found. The tumor causes a fistula connecting right posterolateral esophageal wall to RLL lung. Consolidation over right lower lobe and right middle lobe and left lower lobe is found.
        • Some lymph nodes are found at bilateral paratracheal region.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Right renal stone is found.
    • Imp:
      • Esophageal cancer at lower third esophagus and mediastinal lymph nodes.
      • Tumor invasion causes fistula at the right posterolateral esophageal wall, and resulting in RLL pneumonia.

  • 2022-03-10 Patho - esophageal biopsy

    • Esophagus, 30 cm below the incisor, biopsy - Compatible with squamous cell carcinoma
    • IHC: CK(+); P16(-), P63(+) and P53 (+, focal) for atypical cells.
    • According to histopathologic finding and past history, it is compatible with poorly-differentiated squamous cell carcinoma, although no convincing stromal invasion.

  • 2022-03-01 Esophagography

    • Severe stenosis at middle esophagus

  • 2022-01-17 MRI - brain

    • Small poor enhancing nodules in left frontal and right occipital lobes, regressed. Regressed size and edema of left occipital nodule.

  • 2022-01-14 CT - lung/mediastinum/pleura

    • Compatible with middle third esophageal cancer and mediastinal lymph nodes, in regression.

  • 2021-10-11 CT - lung/mediastinum/pleura

    • Esophageal cancer with mediastinal lymph nodes metastasis, in regression post CCRT, but a suspect new RLL nodular metastasis and inflammation or infection in LLL of lungs, compared with CT on 20210428.

  • 2021-10-08 CT - brain

    • Multiple brain metastases, size slightly smaller as compared to that in previous CT done on 20210705.

  • 2021-04-28 Whole body PET scan

    • A glucose-hypermetabolic lesion in the esophagus, L/3, compatible with the primary esophageal cancer.
      
    • Glucose-hypermetabolic lesions in bilateral mediastinal lymph nodes, probably cancer with regional lymph nodes involvement.
      
    • Glucose-hypermetabolic lesions in the right lower lung, probably benign in nature.
      
    • Increased FDG uptake in the colon, probably physiological uptake of FDG.
      
    • Esophageal cancer, cTxN3M0, by this F-18 FDG PET scan.

  • 2021-04-28 CT - lung/mediastinum/pleura

    • lower third esophageal cancer T3N3M0 IVA

[consultation]

• 2023-03-03 Family Medicine
  • Q
    • For further hospice care
    • Follow up in this year showed disease progression despite chemotherapy and immunotherapy. Poor prognosis was told, the patient signed Advance Care Directive (ACD). We need your expertise for hospice care, thank you!
  • A
    • When I visited, the patient sit on the bed and his caregiver stood by him. His consciousness was clear, and his ECOG was 4. After discussion, I decided to arrange hospice combine care for this patient. Thanks for your consultation.
    • Indication for hospice combine care: Esophageal cancer
    • Plan: Hospice combined care.
• 2023-03-03 Radiation Oncology
  • A
    • Objective:
      • General Condition-ECOG: 2.
      • PE, 2023/3/03: No palpable neck LNs.
      • Images:
        • Chest CT, 2022/02/16: Lower third esophageal cancer with probably tumor rupture, causing right lower lobe consolidation s/p bypass surgery with gastric tube. The primary tumor & pleural metastasis enlarged. Mediastinal lymphadenopathy, in progression. Liver meta, in enlargement. Thin body fat, c/w cachexia.
        • CXR, 2023/03/02: new LLL consolidation due to pneumonia & lung metastasis; RLL consolidation due to broncho-esophageal fistula. Small nodular lesions in the bilateral lung fields.
    • Diagnosis: Esophageal cancer, SqCC, L/3, diagnosed in 2019/10 without treatment (Chinese Medicine only) with mediastinal & SCF LAPs and multiple brain metastases s/p RT (3600 cGy/12 fx) for brain metastases from 2021/7/8-7/23, neoadjuvant CCRT (5040 cGy/28 fx) for primary tumor from 2021/7/26-9/1, s/p C/T with FOLFOX, PF, s/p VATS esophagectomy and gastric tube reconstruction on 2022/7/4 for esophageal cancer and fistula, s/p TEVAR stent placement on 2022/11/29, Zone III TEVAR (Medtronic VALIANT), s/p immunotherapy with Opdivo & FOLOFX6 with disease progression (pleural, lung and liver metastasis); ECOG = 2.
    • Plan: RT is not suggested due to disease progression, cachexia and active infectious process. If he recovers from pneumonia, immunotherapy with R/T may be considered.
  • 2022-11-28 Anesthesiology
    • Q
      • For aorta invasion -> TEVAR (thoracic endovascular aortic/aneurysm repair) stent placement on 2022/11/29, due to poor condition, we need your anesthesia consultation for evaluation. Thanks a lot!!!
    • A
      • To doctor or nurse practitioner, We were consulted for pre-op anesthesia evaluation.
      • Pt: 47 y/o M
      • Op: TEVAR
      • Past hx:
        • VATS esophagectomy and gastric tube reconstruction on 2022/7/4
      • GCS: 456
      • Vitals: stable
      • EKG: sinus tachy
      • CXR: blunting of left CP angle
      • 2D-echo:
        • EF54%
        • Trivial AR
      • Lab:
        • Hb10.3
      • PLAN
        • ASA II
        • EtGA
        • Post-ICU care if needed
        • We have informed the risks of anesthesia and the possible complications to the patient and the patient’s family.
  • 2022-11-28 Family Medicine
    • Q
      • This 47 y/o man is a case of SqCC of the lower third esophagus diagnosed at FuJen Catholic University Hospital in 2019/10 who went to National Taiwan University Hospital for second opinion in 2019/12. He refused chemotherapy and received only chinese medicine. With progression, his current disease status was esophageal cancer, SqCC, L/3, with mediastinal & SCF LAPs and multiple brain metastases, s/p port-A insertion and feeding jejunostomy on 20210707, neoadjuvant CCRT (3600 cGy/12 fx) for brain metastases from 2021-07-08 ~ -07-23, neoadjuvant CCRT (5040 cGy/28 fx) for primary tumor from 2021-07-26 ~ -09-01, with FOLFOX from 2021-07 ~ 2021-11 (9 cycles). He also received chemotherapy with PF (Cisplatin + 5-Fu) since 2021-12-07 to 2022-04-23 (8cycles). He has received VATS esophagectomy and gastric tube reconstruction on 2022-07-04 for esophageal cancer and fistula. This time, he suffered from progressive dyspnea for at least one month.
      • For Combined Hospice Care, thanks
    • A
      • 47-year-old male, esophageal cancer with mediastinal & SCF lymphadenopathy and multiple brain metastases
        • s/p neoadjuvant CCRT, s/p FOLFOX, s/p VATS esophagectomy and gastric tube reconstruction for esophageal cancer with fistula
        • Suffer from exertional short of breath
        • Consciousness alert, ECOG 2
      • We will arrange hospice combine care and follow his condition
        • Indication: Esophageal cancer
        • Plan: Combined Hospice Care
  • 2022-11-26 Cardiac Surgery
    • Q
      • Chest CT on 20221103 showed new liver metastasis and CXR on 20221115 still showed left pleural effusion.
      • For tumor recurrence with aorta invasion, we need your consultation for evaluation. Thanks a lot!
    • A
      • I have had the pleasure of involving with the patient’s care. In brief, He is a 47 year old male seen in consultation for opinion regarding treatment options for Squamous cell carcinoma of lower third esophagea
      • Prophylatic TEVAR (thoracic endovascular aortic/aneurysm repair) is scheduled on 20221130 yet this time the pt was admitted and c/o (complaint of) SOB, not sure if such was caused by airway compression or large amount of pleural effuion
      • SUGGESTION & PLAN:
        • TEVAR stent placement can be brought forward to tuesday 20221129 ETGA, on call, pigtail/chest tube insertion may be performed as combined procedure to relieve his resp. distress.
  • 2022-05-26 Chest Medicine
    • Q
      • The 45 y/o male he has Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV. This time, he was admitted for fever and cough, the CXR showed pmeumonia over RLL, so we need your help. Thank you.
    • A
      • S: short of breath with exertion
      • O:
        • The chest CT showed RLL consoildation. The CXR showed RLL consolidation in progression.
        • According to the patient’s self-report, the taste of sputum after coughing is the same as that of drinks he has had.
      • A:
        • Suspected tracheo-esophageal fistula [T-E fistula]
        • right lower lung pneumonia
        • Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV
      • P:
        • consider gastroscopy if possible for diagnosis of T-E fistula
        • suggest bronchoscopy for diagnosis of T-E fistula, however having undergone a bronchoscopy previously, the patient would be more breathless following the procedure. In order to proceed, the patient desired to wait for his condition to stabilize.
        • if T-E fistula is proved, please consult Thoracic Surgery to evaluate esophageal stent or tracheal stent
        • check sputum culture and adjusted antibiotics for pneumonia
        • check sputum TB x3
        • check serum aspergillus antigen
  • 2022-05-23 Infectious Disease
    • Q
      • The 47 y/o man has Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV. This time, he sufferes from cough, SOB and high fever since 20220513. We gave antibiotic as Tapimycin for RLL pneumonia treatment, but condition progress and repeat CXR showed significant patch noted, so we need your help for management. Thanks!
    • A
      • O
        • 20220518 WBC: 4070
        • 20220519 S/C: Group F streptococci and mixed flora
      • A
        • Lobar pneumonia, RLL is impressed.
      • Suggestion:
        • Recheck CBC and CRP level
        • Antibiotics with cravit 750mg iv st and qd is suggested
  • 2022-05-19 Chest Medicine
    • Q
      • The 47 y/o man has esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV. Due to fever, cough with sputum since 20220513. RLL pneumonia noted and CT was done today. We need your help for management.
    • A
      • Lab:
        • WBC:4070, band:11%, Hb:10.8, PLT:171K, BUN:28, Cr:0.66, Na:141, K:3.3, AST:45, ALT:41, PCT:0.27
      • Chest CT:
        • Esophageal cancer at lower third esophagus and mediastinal lymph nodes with stationary considition.
        • Consolidation over right lower lobe , probably due to aspiration pneumonia.
          
      • Impression:
        • Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV.
        • Suspected Aspiration pneumonia
      • Suggestion
        • Change to Tapimycin or avelox for covering anaerobic pathogen
        • Tracing all culture
        • F/U CXR
          
        • Moniter fever and respiratory pattern
  • 2022-01-25 Oral and Maxillofacial Surgery
    • A
      • S
        • This 47 year old male patient had SqCC of the esophagus and mediastinal lymph nodes invasion.
        • He complained swelling discomfort of his right upper jaw for 4 days.
      • O
        • The mouth finding showed chronic periodontitis. Swelling of 21 palate side were noted.
      • Plan:
        • Oral hygiene.
        • Pain control.
        • Add antibiotic agent with Amoxicllin 500mg q8h were prescribed.
        • Explained to patient home care.
  • 2021-07-06 Radiation Oncology
    • Q
      • The 46 y/o man has Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastases, we need your help for brain RT management. Thanks!
    • A
      • Diagnosis: Esophageal cancer, SqCC, L/3, diagnosed in 2019/10 without treatment (Chinese Medicine only) with mediastinal & SCF LAPs and multiple brain metastases; ECOG = 2.
      • Suggest: Radiotherapy.
      • Goal: Palliative.
      • RT Plan:
        • Target & Volume: Brain metastasis (and esophageal tumors/LAPs).
        • Technique: IMRT & VMAT by linear accelerator.
        • Dose & Fractionation: 3600cGy/12 fractions to brain metastasis (3600cGy/12 fractions to esophageal tumor if feasible).
      • Plan: Brain RT is suggested for tumor control. Possible radiation effects (malaise, IICP, dermatitis) is told. CT simulation is arranged on July 06 16:10 2021. Treatment will be started 1-2 days later. Dexamethasone and mannitol may be prescribed to control the IICP during brain R/T. RT to esophageal tumors/LAPs may be arranged if his condition is stable.

[surgical operation]

• 2022-11-29
  • Surgery
    • Zone III TEVAR (Medtronic VALIANT)     
    • Left pleural pigtail insertion     - Finding
    • Pre-OP / Post-op diagnosis: advanced esophageal cancer with DsAo adventitia invasion
    • Operative Indications:
      • The patient is a 47 year old male with history of advanced esophageal cancer with DsAo adventitia invasion; he presented with worsening SOB, CT demonstrated aortic encasement by the tumor at low thoracic DsAO; He desired to proceed with prophylactic TEVAR.   
  • Operative Findings:
    • Medtronic VALIANT VAMF2222C100 & VAMF2626C100 were sequentially deployed. (Via RCFA)
    • Left pleral effusion was subseqeuntly drained by a pigtail.
• 2022-07-04
  • Surgery
    • VATS McKeown esophagectomy gastric tube reconstruction + decortication
  • Finding
    • previous ruptured malignant esophagus with abscess formation and severe orgainzed adjacent tissue s/p esophagectomy + decortication
    • thick mediastinum pleural, dilated and bulky esophagus, subcarina lymphnode necrosis, and main tumor stiffness with partial necrosis were noted
    • severe adhesion of necrotic main tumor to left main bronchus
    • remove azygus vein and thoracic duct abide with esophagus
    • gastric tube reconstruction via retrosternal route, esophagogastric anastomosis at left neck, hand-sewn
    • chest tube insertion: righ pleural cavity: 28Fr; left: 24 Fr.

[radiotherapy]

• 2021-07-26 ~ 2021-08-30 - 5040cGy/28 fractions (15 MV photon) to esophageeal tumor and LAPs
• 2021-07-08 ~ 2021-07-23 - 3600cGy/12 fractions (6 MV photon) to brain metastasis

[chemotherapy]

• 2023-05-17 - nivolumab 3mg/kg 180mg NS 100mL 30min D1
• 2023-05-08 - docetaxel 35mg/m2 60mg NS 100mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-05-02 - docetaxel 35mg/m2 60mg NS 100mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-21 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + docetaxel 35mg/m2 60mg NS 100mL 1hr D2
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D2
• 2023-04-12 - docetaxel 35mg/m2 60mg NS 100mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-03 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + docetaxel 35mg/m2 60mg NS 100mL 1hr D2
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D2
• 2023-02-21 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + oxaliplatin 85mg/m2 148mg D5W 500mL 2hr D2 + leucovorin 400mg/m2 680mg NS 250mL 2hr D2 + fluorouracil 2800mg/m2 4800mg NS 500mL 44hr D2 (Opdivo/FOLFOX6 Q2W)
  • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2 + NS 250mL D2
• 2023-01-30 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + oxaliplatin 85mg/m2 148mg D5W 500mL 2hr D2 + leucovorin 400mg/m2 680mg NS 250mL 2hr D2 + fluorouracil 2800mg/m2 4800mg NS 500mL 44hr D2 (Opdivo/FOLFOX6 Q2W)
  • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2 + NS 250mL D2
• 2023-01-10 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + oxaliplatin 85mg/m2 148mg D5W 500mL 2hr D2 + leucovorin 400mg/m2 680mg NS 250mL 2hr D2 + fluorouracil 2800mg/m2 4800mg NS 500mL 44hr D2 (Opdivo/FOLFOX6 Q2W)

  • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2 + NS 250mL D2

  • 2022-12-21 - nivolumab 3mg/kg 200mg 30min D1 + oxaliplatin 85mg/m2 145mg 2hr D2 + leucovorin 400mg/m2 700mg 2hr D2 + fluorouracil 2800mg/m2 4800mg 44hr D2 (Opdivo/FOLFOX6 Q2W)

    • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2

  • 2022-12-01 - nivolumab 3mg/kg 180mg 30min D1 + oxaliplatin 85mg/m2 148mg 2hr D2 + leucovorin 400mg/m2 680mg 2hr D2 + fluorouracil 2800mg/m2 4800mg 44hr D2 (Opdivo/FOLFOX6 Q2W)

    • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2

  • 2022-04-22 - cisplatin 40mg/m2 77mg 4hr + leucovorin 400mg/m2 775mg 2hr + fluorouracil 2800mg/m2 5430mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

  • 2022-03-29 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

  • 2022-03-14 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

  • 2022-02-15 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

  • 2022-01-24 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

  • 2022-01-11 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

  • 2021-12-22 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

  • 2021-12-07 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

  • 2021-11-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

  • 2021-11-02 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

  • 2021-10-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5435mg 46hr (FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

  • 2021-09-29 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5435mg 46hr (FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

  • 2021-08-24 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

  • 2021-08-10 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

  • 2021-07-27 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

  • 2021-07-14 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

==========

2023-04-12

• After reviewing PharmaCloud, which showed that the recent patient’s medications were all prescribed at our hospital, no medication reconciliation issue was identified.
• Combined hospice care was arranged due to progression after trying several chemoimmunotherapy regimens.

2023-02-21

• During this hospital stay, the drugs recently prescribed and disclosed in the NHI PharmaCloud System have been correctly prescribed as self-carried items currently with no medication reconciliation issues found in the patient.

2023-01-11

• A combined hospice care arrangement has been made for this patient since 2022-11.
• Medications (ROMICON-A, Pulmicort Nebulising Susp INHL) already prescribed to relieve respiratory symptoms.
• Underlying conditions hypothyroidism and hypokalemia are appropriately managed with Eltroxin (levothyroxine) and Radi-K (potassium gluconate), respectively.

2022-03-29

• Nexium (esomeprazole) must not be ground. Instead, it should be dissolved in adequate drinking water prior to tube feeding.

700507760

230605

[exam findings]

• 2023-05-23 CXR
  • Enlarged heart shadow with tortuous aorta.
  • Placement of right subclavian port-A catheter.
  • Peribronchial thickening at bilateral lower lung field.
  • Bilateral clear costophrenic angles.
  • Degenerative change of the spine with marginal spur formation.
  • Surgical implant fixation at lumbar spine.
• 2023-05-23 ECG
  • Normal sinus rhythm
  • Septal infarct, age undetermined
• 2023-04-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (165 - 31) / 165 = 81.21%
    • M-mode (Teichholz) = 81
  • Conclusion:
    • Dilated LA and LV; Adequate LV systolic function with normal resting wall motion
    • Moderate to severe MR, moderate TR, mild AR
    • Impaired LV relexation
    • Preserved RV systolic function
• 2023-04-11 CXR
  • S/P CVP line insertion from right jugular vein and the tip located at SVC.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • A mass-like opacity projecting in the left lower medial lung shows stationary that is c/w hiatal hernia after correlate with CT.
• 2023-03-18 CT - chest
  • Rt L4 radiculopathy since 202207. History of melanoma post operation at Cardinal Tien Hospital in Apr 2021 and path revealed Lt femoral LN (20/27) melanoma, metastatic.
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Lobulated nodule at left lingula lobe is found.
      • Subcarina lymph node is found. Meta is considered.
      • Hiatus hernia is found.
      • No evidence of bilateral pleural effusion.
      • Senile fibrotic change is noted at lung fields.
    • Visible abdomen:
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Scoliotic alignment of the thoracolumbar spine is noted.
      • The GB is well distended without soft tissue lesion
  • Imp:
    • left lingula lobe nodule. 1.5cm.
    • Hiatus hernia
    • Mediastinal lymphadenopathy
    • Bone meta.
• 2023-02-09 KUB + L-spine Lat
  • s/p PI, PD, and PLF at L2-3-4
  • Disc space narrowing at L1/2 and L4/5
• 2022-12-28 KUB + L-spine Lat
  • post-OP change from L2 to L4
  • severe decreased disc space in the L4/5 disc.
  • mild anterior spur formation at the L-spine
  • compression fractures at L1 and T12 vertebral bodies.
• 2022-12-27 Spinal angiography
  • The spinal angiograms were done via right femoral approach and show:
    • Tortuous abdominal aorta.
    • Prominent tumor stain with engored tumor feeding vessels were found in right L3 segmental artery.
• 2022-12-26 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Septal infarct, age undetermined
• 2022-12-02 MRI - L-spine
  • Indication: Melanoma with mediastinal lymph nodes, left upper lung, and L3 spine metastases at least
  • MRI of lumbar spine without/with Gadolinium-based contrast enhancement shows:
    • abnormal bone marrow signal lesion with contrast enhancement at the L3 vertebral body, with a heterogeneously enhancing bone mass protruding laterally to the right side, obliterating right L3-4 neuroforamen and compressing or involving right L3 nerve root. Bone metastasis is compatible.
    • marked degenerative change of the spine with marginal spur formation and dehydrated discs at multiple levels.
    • severe right L5-S1 neuroforaminal narrowing.
    • no evidence of abnormal signal lesion in visible spinal cord.
  • Impression:
    • Bone metastasis at L3 vertebral body, with bone mass protruding laterally to right side, obliterating right L3-4 neuroforamen and compressing or involving right L3 nerve root.
    • Degenerative spinal and disc disease.
    • Severe right L5-S1 neuroforaminal narrowing.
• 2022-10-24 PET scan
  • Increased FDG uptake at the L3 spine, compatible with the pathological findings of metastatic melanoma.
  • Glucose hypermetabolic lesions in mediastinal lymph nodes and in a nodular lesion in the left upper lung, highly suspected melanoma with distant metastases.
    
  • Glucose hypermetabolic lesions in the right lobe of the thyroid gland and in the left SCF lymph nodes, the nature is to be determined, suggesting biopsy for further investigation.
    
  • Increased FDG uptake in bilateral knees, the nature is to be determined also (post-traumatic change, melanoma, or other nature ?), suggesting further investigation.
    
  • Increased FDG uptake in bilateral palatine tonsils, probably a chronic inflammation process.
  • Increased FDG uptake in the colon, probably physiological uptake of FDG.
    
  • Melanoma with mediastinal lymph nodes, left upper lung, and L3 spine metastases at least, c-stage IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2022-10-14 Tc-99m MDP bone scan
  • Prominently increased activity in the L3-5 spines. The nature is to be determined (malignancy/metastases? other nature?). Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the middle C-spine and middle T-spines. Degenerative change may show this picture. However, please keep follow up to rule out other possibilities.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, knees and left foot, compatible with benign joint lesions.
• 2022-10-13 Patho - bone biopsy/curetting
  • Vertebral body, L3, CT-guided biopsy — Melanoma, metastatic
  • The sections show a picture of melanoma, metastatic, composed of sheets of large epitheloid neoplastic cells with pleomorphic nuclei and abundant cytoplasm. Small amount of melanin pigment deposition can be found.
  • IHC: CK(-), S100(+), Melan A(+) and SOX10(+).
• 2022-10-11 ECG
  • Sinus bradycardia
  • Poor wave progression
• 2022-09-27 MRI - L-spine
  • The lumbar spine shows spondylosis and disk space degeneration at the L2/3 through L5/S1 levels.
  • Scoliosis of L-spine.
  • One large lobulated mass lesion (5.1cm) over right-side of the L3 vertebral body with destruction of bone cortex. Suggest check enhanced MRI or tissue proof to rule out malignancy.
  • Narrowing of right L5/S1 neural foramen.
• 2022-09-08 KUB + L-spine Lat
  • Facet degeneration of lower lumbar spine
  • Disc space narrowing at L2-3-4-5-S1
  • General osteoporosis
  • Concave vertebrae of T-L spine
• 2022-09-08 Merchant view (patella 45 0) Bil
  • No lateral subluxation or lateral tilting of the patella
  • s/p bilateral total knee replacements
• 2022-09-08 Knee Bilat. standing AP and Lat views:
  • S/P total knee arthroplasty, Bil
  • Good alignment without prosthesis loosening

[MedRec]

• 2023-04-09 ~ 2023-04-14 POMR Hemato-Oncology
  • Discharge diagnosis
    • Melanoma with mediastinal lymph nodes, left upper lung and L3 spine metastases, cstage IV, status post L3 posterior decompression + L2-4 posterior instrumentation and fusion on 2022/12/28
    • Atherosclerotic heart disease of native coronary artery without angina pectoris
    • Hypertensive heart disease without heart failure
• 2022-11-24 ~ 2022-12-02 POMR Hemato-Oncology
  • Discharge diagnosis
    • Malignant melanoma of left lower limb, including hip
    • Melanoma with mediastinal lymph nodes, left upper lung and L3 spine metastases at least, cstage IV
    • Secondary malignant neoplasm of bone
    • Osteoarthritis of knee, unspecified
    • Other spondylosis, lumbar region
    • Radiculopathy, site unspecified
    • Constipation, unspecified
• 2022-11-22 SOAP Hemato-Oncology
  • Objective: no V600E mutation (dabrafenib not indicated)
• 2022-10-28 SOAP Hemato-Oncology
  • Plan to apply Tafinlar (dabrafenib) if V600E mutation is documented
    • Note: as monotherapy, dabrafenib is indicated to treat unresectable or metastatic melanoma with BRAF V600E mutation

[chemotherapy]

• 2023-05-12 - Nab-paclitaxel 150mg/m2 200mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-05-05 - Nab-paclitaxel 150mg/m2 200mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-04-20 - Nab-paclitaxel 150mg/m2 200mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-04-13 - Nab-paclitaxel 150mg/m2 200mg 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Nanoparticle albumin bound paclitaxel (nab-paclitaxel) 2023-05-24 https://www.uptodate.com/contents/nanoparticle-albumin-bound-paclitaxel-nabpaclitaxel-drug-information

• Melanoma, metastatic (off-label use):
  • Previously treated patients: IV: 100 mg/m2 on days 1, 8, and 15 of a 28-day cycle; if tolerated, may increase dose by 25 mg/m2 in cycle 2 and beyond; continue until disease progression or unacceptable toxicity.
  • Previously untreated patients: IV: 150 mg/m2 on days 1, 8, and 15 of a 28-day cycle; continue until disease progression or unacceptable toxicity.

==========

2023-06-05

• The patient was prescribed famotidine, sennosides, clopidogrel, isosorbide dinitrate, nicorandil, bisoprolol, valsartan, rosuvastatin, and alprazolam by WanFang Hospital for the primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris on 2023-04-27. The patient refilled these medications at a local pharmacy on 2023-05-24. Among these, alprazolam and sennosides are not included in the current active medication list. These medications may be excluded if there’s no ongoing indication. All the cardiovascular drugs prescribed are properly integrated into the active medication list without any medication reconciliation issues.
• It has been noted that the disease does not possess the BRAF V600E mutation; however, the status of the V600K mutation is currently undocumented (not found). If the presence of a V600K mutation is confirmed, the combined therapy of dabrafenib and trametinib might be also considered as a treatment option.

2023-05-24

• The patient made a visit to WanFang Hospital on 2023-04-27, where several medications were prescribed for a duration of 28 days to manage her atherosclerotic heart disease. It appears that clopidogrel, one of the prescribed medications, is not currently listed on the active medication list. If there are no contraindications or other clinical concerns, it might be beneficial to add clopidogrel back into the patient’s regimen to maintain an accurate and up-to-date medication reconciliation.
• The patient, who has metastatic melanoma, is currently receiving off-label treatment with nab-paclitaxel at a dose of 150mg/m2 on days 1, 8 and 15 of a 28-day cycle. Targocid (teicoplanin) and tapimycin (piperacillin + tazobactam) are currently used to treat cellulitis with pus formation over the port-a-wound. There is no issue with the active prescription.

701001983

230605

[diagnosis] - 2023-03-20 admission note

• Malignant neoplasm of gallbladder
• Encounter for antineoplastic chemotherapy
• Insomnia, unspecified
• Unspecified viral hepatitis B without hepatic coma
• Constipation, unspecified

[past history]

• Left multiple lower neck LAP with cystic like change at level III, IV, Vb
• Left thyroid tumor, small, favor benign.            

[allergy]

• NKDA             

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-05-09, -04-10, -04-06 Abdomen - Standing (Diaphragm)
  • S/P plastic stent implantation from right lobe IHD to duodenum.
• 2023-04-13 Patho - stomach biopsy
  • Stomach, body, biopsy — Non-atrophic chronic gastritis
  • The sections show gastric body mucosal tissue with congestion, edema, mild chronic inflammatory cell infiltration, no neutrophil infiltration, no intestinal metaplasia, no gastric atrophy, and no Helicobacter pylori colonization.
• 2023-04-13 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis, lower esophagus, LA classification, grade A
  • Superfical gastritis, antrum
  • Gastric polyp, multiple, body, s/p biopsy
  • Post ERBD
• 2023-04-12 CT - abdomen
  • History: 20230110 MRI: gallbladder cancer with cystic duct, CHD extension, LNs and liver metastases.
  • Findings:
    • Prior CT identified a mass lesion (3.8x7.5cm) in gallbladder is noted again, marked decreasing in size that is c/w gallbladder cancer S/P C/T with partial response.
    • Prior CT identified several metastatic LNs at hepatic hilar region are noted again, marked decreasing in size that is c/w metastatic LNs S/P C/T with partial response to near complete response.
    • Prior CT identified several metastases in both hepatic lobes are noted again, decreasing in size that is c/w liver metastases S/P C/T with partial response.
    • Prior CT identified a nodule (1.3cm) at right breast is noted again, stationary.
    • There is an ill-defined faint poor enhancing area in S4-8 of the liver, nature? Follow up is indicated.
    • S/P plastic stent implantation in between right lobe IHD and duodenum. However, mild dilatation of IHDs is still noted.
  • Impression:
    • Gallbladder cancer with liver and LNs metastases S/P C/T show partial response.
• 2023-03-22 CT - brain
  • Indication: Gallbladder cancer with Common bile duct compression and multiple liver metastases, cT3N2M1, stage IV
  • IMP: no evidence of brain tumors.
• 2023-03-20 CXR
  • Mild Scoliosis of the T-spine with convex to right side.
  • Atherosclerotic change of aortic arch
• 2023-03-06 CXR
  • Scoliosis of the T-spine with convex to right side.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2023-01-16 Patho - lymphnode biopsy
  • Labeled as “subclavian lymph node, left”, biopsy — metastatic adenocarcinoma with neuroendocrine feature.
  • Section shows lymph node almost completely replaced by metastatic adenocarcinoma, demonstrating glands and short papillary structure.
  • IHC stains: CK7 (diffuse +), CK20 (-), TTF-1 (focal +), CK19 (diffuse +), PAX-8 (focal +), thyroglobulin (equivocal), Napsin-A (-), CD56 (focal +), synaptophysin (focal +). Extranodal extension is not present.
• 2023-01-11 SONO - breast
  • A round right breast tumor (#2).
  • Enlarged left axillary lymph nodes, suspect lymphadenopathy.
  • BI-RADS category 4, Suspicious abnormality. Biopsy should be considered.
• 2023-01-11 Endoscopic Retrograde CholangioPancreatography, ERCP
  • Diagnosis
    • Middle CBD stricture, s/p plastic stent placement (8.5 Fr. 9 cm )
    • Chronic cholangitis
    • Reflux esophagitis, Gr. A
  • Suggestion:
    • f/u amylase & lipase
• 2023-01-10 MR Cholangiography, MRCP
  • History and indication: Acute cholecystitis
  • IMP: In favor of gallbladder cancer with cystic duct, CHD and CHD extension, LNs and liver metastases. Right breast tumor.
• 2023-01-09 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Poorly differentiated carcinoma with marked neuroendocrine differentiation
  • The sections show a picture of sheets of poorly differentiated neoplastic cells with marked tumor necrosis, embedded in fibrous stroma. No definite glandular formation can be identified.
  • IHC shows: CK(+), CK7(+), CK20(-), CD56(+), and Synaptophysin(+). Either neuroendocrine carcinoma or mixed carcinoma with marked neuroendocrine differentiation should be considered.
• 2023-01-08 CT - abdomen
  • Lobulated mass-like lesions within the gallbladder with heterogeneous enhancement. Suspected malignancy.
  • Several hypoperfusion nodular lesions over right hepatic lobe, may be metastatic lesions.
  • Dilated CBD and IHDs.
    
  • S/P hystorectomy.
  • Suspect confluent lobulated nodes over hepatic hilum.

[consultation]

• 2023-01-17 Radiation Oncology
  • A
    • A: Poorly differentiated carcinoma with marked neuroendocrine differentiation of the gallbladder, with liver metastasis.
    • P: Radiotherapy is indicated for this patient with the following indicators: tumor with metastasis and pain
      • Goal: palliation
      • Treatment target and volume: gallbladder tumor, peripheral involved, to metastatic liver tumor
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the gallbladder tumor, peripheral involved, to metastatic liver tumor
      • The treatment planning of radiotherapy will be started at 0830, 2023-02-06.
• 2023-01-12 Hemato-Oncology
  • Q
    • for chemotherapy
    • This is a 64 yesr old female patient. Under impressed of gallbladder cancer with liver metastases. We need your professional evaluation for this patient. Thank you so much!!
  • A
    • This 64 year old woman is a case of gall bladder cancer with liver metastasis (liver biopsy: Poorly differentiated carcinoma with marked neuroendocrine differentiation). We are consulted for chemotherapy.
    • Please arrange port A insertion and check HbsAg, Anti Hbc, Anti HCV. We will discuss with patient about further palliative chemotherapy (regimen such as cisplatin + etoposide). Please arrange our OPD after discharge.
• 2023-01-12 Ophthalmology
  • Q
    • This time she felt headache due to high intraocular pressure at night. We need your help for professional assessment. Thank you so much!!
  • A
    • S
      • Left eyelid twitching and mild fullness
    • O
      • denied bv ou, headache occasionally
      • denied past hx
      • denied oph hx
      • nka
      • VAcNC od 20/70 os 20/70
      • IC 13/14mmHg
      • Pupil 3/3 +/+
      • Conj np ou
      • K clear ou
      • AC shallow / clear ou
      • Lens ns+++
    • A
      • no acute ocular problem at present
    • P
      • Inform the red flags, if worsen vision, come back asap
      • suggest oph opd f/u for prophylatic LI ou
      • opd f/u

[radiotherapy]

• 2023-02-14 ~ 2023-03-30 - 1800cGy/10 fractions of the gallbladder tumor, peripheral involved, to metastatic liver tumor, and 4500cGy/25 fractions of the gallbladder tumor, peripheral involved area.

[chemotherapy]

• 2023-06-02 - etoposide 70mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 70mg/m2 110mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-05-09 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-03-20 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 115mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-02-10 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-01-16 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-03-21

• High-grade neuroendocrine carcinomas (NEC) with poor differentiation tend to have a high likelihood of developing distant metastases and a concerning prognosis, even when they appear to be clinically localized. For the treatment of metastatic gastrointestinal and pancreatic NEC, it is often recommended to use a two-drug platinum-based regimen, usually consisting of cisplatin or carboplatin combined with etoposide.

• The ideal treatment duration remains undetermined. Generally, the goal is to administer 4 to 6 cycles of therapy. However, if a patient continues to respond positively to the treatment and experiences minimal side effects, it may be suitable to extend chemotherapy until the maximum possible response is achieved. ref: UpToDate. https://www.uptodate.com/contents/high-grade-gastroenteropancreatic-neuroendocrine-neoplasms

• Neuroendocrine tumors, metastatic carcinoma

  • etoposide
    • 100 mg/m2 on days 1, 2, and 3 every 4 weeks (in combination with cisplatin) until disease progression or unacceptable toxicity. ref: https://pubmed.ncbi.nlm.nih.gov/11571721/
    • 130 mg/m2 as a continuous infusion on days 1, 2, and 3 every 4 weeks (in combination with cisplatin) until disease progression or unacceptable toxicity. ref: https://pubmed.ncbi.nlm.nih.gov/1712661/
    • 100 mg/m2 on days 1, 2, and 3 every 3 weeks (in combination with cisplatin) for up to 6 cycles. ref: https://pubmed.ncbi.nlm.nih.gov/23406729/
  • cisplatin
    • 45 mg/m2/day as a continuous infusion on days 2 and 3 every 4 weeks (in combination with etoposide) until disease progression or unacceptable toxicity. ref: https://pubmed.ncbi.nlm.nih.gov/11571721/ https://pubmed.ncbi.nlm.nih.gov/1712661/
    • 80 mg/m2 over 30 minutes on day 1 every 3 weeks (in combination with etoposide) for up to 6 cycles. ref: https://pubmed.ncbi.nlm.nih.gov/23406729/

• The patient’s current etoposide and cisplatin regimen does not exceed the mentioned dosage, making it suitable and not necessitating any dosage adjustments.

700335981

230602

[exam findings]

• 2023-05-11, -04-20 CXR
  • Atherosclerotic change of aortic arch
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2023-03-22 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 28 dB HL; LE 59 dB HL.
  • RE normal to severe SNHL. (BC masking dilemma at 4k Hz)
  • LE moderate to profound mixed type HL.
• 2023-03-16 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasopharynx, right, biopsy — Lymphoid hyperplasia
  • Section shows a piece of respiratory epithelium lined tissue with lymphoid hyperplasia.
  • The immunohistochemical stain of CK reveals no invasive tumor. The immunohistochemical stains of CD3 and CD20 show relatively preserved lymphoid architecture. The immunohistochemical stain of CD56 is negative.
• 2023-03-16 Nasopharyngoscopy
  • Bx of R NP PET + lesion
  • smooth bulging
  • CT-guided Bx = L poor diff ca, favor small cell ca
• 2023-03-06 PET
  • Glucose hypermetabolism in the left lower lung with left pulmonary lymph nodes involvement, highly suspected the primary lung cancer with regional lymph nodes metastases. Some small nodular lesions in the right lower lung, however, show no increased FDG uptake.
    
  • Increased FDG uptake in bilateral mediastinal and right pulmonary hilar lymph nodes, probably reactive or metastatic nodes, suggesting further evaluation.
  • Increased FDG uptake in the in the post. wall (submucosa layrer ?) of the right nasopharynx, the nature is to be determined (another NPC, inflammation process or other nature ?), suggesting biopsy for investigation.
  • Increased FDG uptake in soft tissue of bilateral buccal regions, inflammation process may show this picture.
  • Decreased FDG uptake in the left fronto-parieto-temporal regions of the cerebral cortex, compatible with cerebral infarction.
    
  • Left lower lung cancer, cTxN1-3M0 (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-02-13 Portable 24hr ECG
  • Baseline was sinus rhythm with paroxysmal AFIB
  • 2 episodes of sustained pAFIB noted (13~16PM, 8~12AM)
  • Rare isolated VPCs / VPC couplet
  • Frequent isolated APCs / APC couplets (Burden 2%)
  • 19 episodes of short-run AT, max 6 beats
• 2023-02-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (95 - 25) / 95 = 73.68%
    • M-mode (Teichholz) = 73
• 2023-02-10 Tc-99m MDP bone scan
  • Increased activity in some L-spines and sacrum. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Some hot and faint hot spots in the posterior aspect of bilateral rib cages and increased activity in the left frontal area of the skull and left tibia. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions and knees, compatible with benign joint lesions.
• 2023-02-06 CXR
  • Lung markings: a nodular lesion in the left perihilar lung field
• 2023-02-06 Patho - lung transbronchial biopsy
  • Lung, left, CT-guide biopsy — poorly differentiated carcinoma, in favor of small cell carcinoma
  • Sections show large nests of small hyperchromatic tumor cells with scanty cytoplasm and crushing artifact.
  • The immunohistochemical stains reveal CK(+), CK7(focal +), CK20(-), CD56(focal +), Synaptophysin(-), Chromogranin A(-), TTF-1(-), Napsin A(-), p40(-), GATA3(-), and CDX2(-). The Ki-67 is about 80%. The results and morphology are in favor of small cell carcinoma. Please correlate with the clinical presentation and image study.
• 2023-01-31 CT - abdomen
  • With and without contrast enhancement CT of abdomen:
    • Presence of gallbladder stone.
    • Left upper lung tumor (3.1cm), r/o lung malignancy.
    • Right lower lung nodule, r/o lung to lung metastasis.
    • Emphysematous change of lungs.
  • Impression:
    • GB stone.
    • Left upper lung tumor, r/o lung malignancy.
    • RLL nodule, r/o lung to lung metastasis.
    • Emphysematous change of lungs.
• 2023-01-31 Electroencephalography, EEG
  • This EEG study recorded background alpha rhythm (8-9) and beta activity with intermittent transient diffuse slow waves. more on the left.
  • No epileptiform discharges.
  • Please correlate with clinical features.
• 2023-01-28 CT - chest
  • Indication: for left lung nodular?
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Moderate to severe Emphysematous change over both lungs is found.
      • Mass like lesion at left upper lobe measuring 3.33cm in largest dimension. r/o lung cancer.
      • Minimal peribronchial opacity oveer right lower lobe and left lower lobe is found.
      • Some lymph nodes are found at bialteral paratracheal region.
    • Visible abdomen:
      • There is stone at dependent portion of GB. GB stone(s) are noted.
  • IMP:
    • COPD with one mass at left upper lobe measuring 3.33cm. Lung cancer is suspected.
    • Mediatinal lymphadenopathy
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-01-27 Neurosonology
  • Occlusion in R proximal CCA to CCA bifurcation; tight stenosis with trace flow in R ICA; reversed R ECA flow; mild atheromatous lesions in L CCA bifurcation and ICA.
  • Normal extracranial L carotid, vertebral, and intracranial vertebral, basilar arterial flows.
  • Poor bilateral temporal windows for transcranial insonation.
  • Reversed R ophthalmic arterial flows.
  • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
• 2023-01-26 MRA - brain
  • Subacute infarcts involving left frontotemporal lobe and basal ganglion as described. Stenosis of right ICA. Mild general brain atrophy.
• 2023-01-23, -01-19 CXR
  • Lung markings: a nodular lesion in the left perihilar lung field

[MedRec]

• 2023-05-25 SOAP Psychosomatic Medicine
  • S: The patient comes with son and wife. Less anxiety, less dysphoria, and more speech. It seems response to the additional sertraline.
• 2023-05-11 SOAP Psychosomatic Medicine
  • S: MAJOR ILLNESS CARD: [Diagnostic interview 45085] C.C. & P.I.: The first time visit, the patient comes with wife and son. He initilally focus on left lower leg and ankle area. He then hesitately to talk about something wrong, about his wife and son. left cerebral stroke. In addition, lung cancer diagnosis at the same time. Low self-esteem, hypotalkativeness.
• 2023-02-23 SOAP Chest Medicine
  • A/P
    • visit for asking about cancer Tx, for his stage III and poor performance, surgey was not suggested, refer to Oncology for possible clinical trial of IO
    • Tx COPD with Mx,
    • P: ultibro, xanthium, medicon
  • Prescription
    • Xanthium (theophylline 200mg) 1# QD
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Ultibro Breezhaler (indacaterol 100ug, glycopyrronium 50ug) 1# QD INHL

[consultation]

• 2023-02-02 Diagnostic Radiology
  • A: This 74-year-old patient is a case of LLL lung mass, r/o malignancy. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
• 2023-01-30 Chest Medicine
  • Q
    • This 74 y/o man has a history of HTN and hyperuricemia. He was normal at 6pm when going to toilet but was found lying on the ground with speechlessness at 6:30pm. He denied of any aura, urinary or faecal incontinence, history of recent URI symptoms, headaceh, taking OC pills, unknown medications, similar disease in family history. He was sent to our ER for help. Arrival our ER around 19PM. Initail GCS E4V2M6. Physical examination shoed right limb weakness (muscle power 0), left gaze deviation, right hemianopia and right central facial palsy. Brain CT was performed revealed suspect hyperdensity at left distal ICA and proximal MCA. The neurology was consulted. Who suggest r-tPA was indication. After Brain CTA was performed revealed occlusion of left ICA and proximal MCA, r/o ICA dissectio and suspect occlusion of right CCA. Impression of left distal ICA and left MCA occlusion with infarction s/p r-tPA + IA thrombectomy then admission to SICU for neurologicalo monitor.
    • After admission, the brain CT was follow-up on 2023-01-15, it revealed No definite intracranial hemorrhage, acute infarct in left insular cortex and frontal lobe. The Plavix was added at that time. After general condition stable, he will transfer to ward on 2023/01/19. at ward, his conscious E4VA(dysarthria + breathy sound)M6. motor aphasia, MP general 4-5. s/p NG with Foley and remove sucess. the bronchdilator for wheezing.
    • Brain MRA showed Subacute infarcts involving left frontotemporal lobe and basal ganglion as described. Stenosis of right ICA. Mild general brain atrophy. For chest x-ray found a nodular lesion in the left perihilar region. chest CT was done and showed COPD with one mass at left upper lobe measuring 3.33cm. Lung cancer is suspected. Mediatinal lymphadenopathy. we arranged Abdomen CT+C afternoon, so your was consulted.
  • A
    • For his CT scan with emphysema with one mass at left upper lobe measuring 3.33cm. Lung cancer is suspected. Suggested to perform CT guided biospy. If he is proved to be case of lung cancer, further study of brain MRI and bone scan should be done.
    • For his emphysema, Spiolto inhaler is suggested.
    • I will like to follow this case if pathology available.
• 2023-01-14 Neurology
  • Q
    • CVA Call
    • Triage Level: 2, Limb Weakness > Symptom onset time <4.5 hours. At 18 PM, patient was normally using the toilet. At 18:30 PM, patient was unable to move in the toilet, exhibiting right side limb weakness and both eyes looking to the left. Fasting sugar is 74 mg/dL by EMT. Denies TOCC (Time of onset, Characteristics, Circumstances).
  • A1
    • This 74 y/o man has a history of HTN and hyperuricemia. He was normal at 6pm when going to toilet but was found lying on the ground with speechlessness at 6:30pm.
    • NE E4VaM5 aphasia
      • CNs:
        • left gaze deviation, right hemianopia
        • right central facial palsy
      • MP upper 0/5 lower 2-3 /5
      • sensation: poor response of right limbs
      • NIHSS 022 111 0402 01320 (18) at 19:25
    • brain CT: no ICH, left dense MCA sign
    • impression: acute left MCA territory infarct
    • suggestion:
      • rt-PA therapy was indicated (71.2kg, 0.9mg/kg, total 64mg, loading 6.4mg)
      • arrange CTA to rule out LVO and consider EVT if indicated
      • neurology ICU admission
  • A2 2023-01-14 20:46:44
    • s/p rt-PA therapy (loading at 19:53)
    • NIHSS 122 111 0302 01220 (18) at 20:40
    • brain CTA: left ICA/MCA occlusion; right CCA occlusion
    • EVT is indicated after discussion with intervention radiologist
    • explained to the family about the EVT and the family agreed
    • tight control BP and arrange EVT

[chemotherapy]

• 2023-06-01 - etoposide 100mg/m2 135mg NS 500mL 2hr D1-3 + carboplatin AUC 5 300mg NS 250mL 2hr D1 (VP16 80mg/m2, Carbo AUC 4) (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-27 - etoposide 100mg/m2 135mg NS 500mL 2hr D1-3 + carboplatin AUC 5 300mg NS 250mL 2hr D1 (VP16 80mg/m2, Carbo AUC 4) (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

Carboplatin plus etoposide for chemotherapy-naïve extensive-stage small cell lung cancer 2023-06-02 https://www.uptodate.com/contents/image?topicKey=ONC%2F4633&imageKey=ONC%2F75586

• Cycle length: 21 days, for a maximum of six cycles.

• Regimen

  • Carboplatin
    • AUC = 5 mg/mL × min IV (AUC is converted to a patient-specific carboplatin dose (in mg) according to renal function by using the Calvert formula. The Calvert formula is total dose (mg) = (target AUC) × (GFR + 25). If using measured serum creatinine, limit the maximal GFR for the calculation to 125 mL/min)
    • Dilute in 250 mL NS and administer over 30 minutes.
    • Day 1
  • Etoposide
    • 100 mg/m2 IV
    • Dilute in 500 mL NS or D5W to final concentration <0.4 mg/mL. Infuse over 30 to 60 minutes; if infused more rapidly, severe hypotension may occur.
    • Days 1, 2, and 3

• Pretreatment considerations:

  • Emesis risk
    • MODERATE on day 1 and LOW on days 2 and 3.
  • Vesicant/irritant properties
    • Carboplatin and etoposide are irritants.
  • Infection prophylaxis
    • Routine primary prophylaxis with hematopoietic growth factors is not recommended (incidence of febrile neutropenia is about 5%).
  • Dose adjustment for baseline liver or renal dysfunction
    • Each carboplatin dose should be calculated based upon renal function by use of the Calvert formula. A lower starting dose of etoposide may be needed for patients with renal or liver impairment.

• Monitoring parameters:

  • CBC with differential and platelet count weekly during treatment.
  • Electrolytes and liver and renal function prior to each cycle of chemotherapy.

• Suggested dose modifications for toxicity:

  • Myelotoxicity
    • Dose adjustment based on myelotoxicity was not reported in the final publication. Per protocol, cycles were delayed for up to 42 days to allow neutrophils to return to >=1500/microL and platelets to >=100,000/microL. However, the United States Prescribing Information recommends that the dose of carboplatin be reduced by 25% if platelets are <50,000/microL and/or ANC is <500/microL.
  • Nonhematologic toxicity
    • Chemotherapy should be held for grade 3 and 4 nonhematologic toxicities (except for neurotoxicity) and is only restarted after the toxicity has resolved to patient’s baseline.
  • Hepatotoxicity
    • No formal etoposide dosing recommendations were reported in this publication. However, accepted dose reductions per product information may be found in the literature.
  • Nephrotoxicity
    • Alterations in renal function during therapy may require a recalculation of the carboplatin dose.
  • If there is a change in body weight of at least 10%, doses should be recalculated.

==========

2023-06-02

• The patient visited our Psychosomatic Medicine OPD on 2023-05-11 and 2023-05-25, where he was prescribed Zoloft (sertraline), which was duly added to the list of active medications. In addition, the patient has a refillable prescription for Lixiana (edoxaban) from our Neurology OPD dated 2023-04-13, which also appears on the active medication list.

• It’s advised to note that selective serotonin reuptake inhibitors (SSRIs), such as sertraline, can potentially increase the risk of bleeding, especially when used with antiplatelet and/or anticoagulant medications. There have been several observational studies linking the use of SSRIs to a variety of bleeding complications, ranging from minor problems such as bruising, hematoma, petechiae, and purpura to more serious conditions such as stroke, upper gastrointestinal bleeding, intracranial hemorrhage, postpartum hemorrhage, and perioperative bleeding. In light of this, it is prudent to monitor this patient closely for any signs of bleeding.

• The liver-associated enzymes ALT and AST, particularly ALT, have both shown an increasing trend in this patient. The patient is currently being treated with Baogan (silymarin) and Baraclude (entecavir), which are appropriate given the patient’s liver status and HBV carrier state.

  • 2023-06-01 S-GPT/ALT 116 U/L
    
  • 2023-05-04 S-GPT/ALT 140 U/L
    
  • 2023-04-20 S-GPT/ALT 75 U/L
    
  • 2023-04-06 S-GPT/ALT 51 U/L
    
  • 2023-03-27 S-GPT/ALT 20 U/L
    
  • 2023-03-22 S-GPT/ALT 31 U/L
    
  • 2023-02-06 S-GPT/ALT 30 U/L
    
  • 2023-06-01 S-GOT/AST 46 U/L
    
  • 2023-05-18 S-GOT/AST 64 U/L
    
  • 2023-05-11 S-GOT/AST 62 U/L
    
  • 2023-05-04 S-GOT/AST 60 U/L
    
  • 2023-04-27 S-GOT/AST 49 U/L
    
  • 2023-04-13 S-GOT/AST 40 U/L
    
  • 2023-02-06 S-GOT/AST 26 U/L
    
  • 2023-02-01 S-GOT/AST 22 U/L

• Etoposide has been associated with hepatotoxicity, but the incidence is low (<= 3%) and therefore it is less likely to be the primary cause of the elevated liver enzymes. On the other hand, carboplatin is reported to be associated with increased serum alkaline phosphatase (24% to 37%) and increased serum aspartate aminotransferase (15% to 19%). This suggests that carboplatin might be a more likely cause of the observed liver enzyme elevation.

• Given that the patient’s current regimen has already been dose-reduced since initiation (etoposide from 100mg/m2 to 80mg/m2, carboplatin from AUC 5 to AUC 4), it may not be necessary to further reduce the dose immediately unless the liver enzymes rapidly increase.

701469284

230602

[exam findings]

• 2023-02-10 MRI - nasopharynx
  • Indication: SCC of right buccal mucosa.
  • Past history: He is an oral cancer patient and has received operations in TSGH in 2011.
  • Neck MRI without/with Gadolinium-based contrast enhancement shows:
    • status post previous surgery with old intraoral flap at the right mandibular gingiva.
    • a large well-enhancing mass (largest diameter about 5.3cm) at right buccal region with direct invasion and destruction of right maxilla and right hard palate, with mass protruding medially into oral cavity. The fat plane between the tumor and inferior portion of medial/lateral pterygoid and temporalis muscles is blurred, with interstitial edema of the masticator space, tumor invasion to masticator space is suspected. T4b disease is favored.
    • slightly enlarged lymph nodes at right retropharyngeal space, bilateral level Ib and II, largest diameter about 1.7cm. N2c disease is suspected.
    • bilateral symmetric pharyngeal mucosa.
    • abnormal high signal change of left mandibular bone marrow with enhancement. However this lesion do not show hot spot in bone scan. Nature is to be determined.
  • Impression:
    • Advanced right buccal cancer, image staging favor AJCC T4bN2c.
    • Bone marrow signal change at left mandible, nature to be determined.
  • Oralcavity
    • Impression (Imaging stage) : T:4b N:2c M:0 STAGE:IVB
• 2023-02-09, -02-06 CXR
  • Normal heart size. No mediastinal widening. No active lung lesion. Intact bony thorax. S/P Port-A. S/P CVP line from left? Surgical clips at right side of the neck.
• 2023-02-08 Tc-99m MDP bone scan
  • Hot spots in the right aspect of the maxilla, the nature is to be determined (advanced oral cancer or other nature ?), suggesting PET scan for further evaluation.
  • Suspected benign lesions in some T- and L-spine, right sternoclvicular junction, bilateral shoulders, S-I joints, and knees.
• 2023-02-07 SONO - abdomen
  • Possible small liver cyst, left lobe
• 2023-02-06 ECG
  • Sinus bradycardia
  • Voltage criteria for left ventricular hypertrophy
  • ST elevation, consider early repolarization, pericarditis, or injury
• 2023-01-27 Patho - gingival/oral mucosa biopsy
  • Labeled as “right maxillary gingiva”, biopsy — squamous cell carcinoma.
  • IHC stain: p16 (-).

[consultation]

• 2023-05-26 Family Medicine
  • Q: This 52-year-old male suffered from an aggressive malignant tumor at his right maxillary gingiva, buccal and palate mucosa with bone destruction since few months ago. His SCC at the right buccal mucosa , maxillary gingiva, and palatal mucosa was classified as cT4bN2cM0, cStage IVB with terminal stage. We need your End-of-life co-care
  • A: 52-year-old male, Squamous cell carcinoma of right maxillary ginvia, buccal mucosa and platal mucosa with bone destruction, cT4bN2cM0, cstage IVB
    • This time suffer from disease progression, in process of induction chemotherapy
    • Consciousness E4V5M6, ECOG 2
    • We will arrange hospice combine care and follow up his condition
    • Indication: upper gum SCC (Major: Malignant neoplasm of upper gum)
    • Plan: Hospice combined care
• 2023-05-23 Radiation Oncology
  • A: Squamous cell carcinoma of the right upper gingivobuccal mucosa and hard palate, AJCC stage cT4bN2cMo, s/p induction chemotherapy with progression.
  • P: Radiotherapy is indicated for this patient with the following indicators: stage cT4bN2cMo, s/p induction chemotherapy with progression
    • Goal: palliation
    • Treatment target and volume: the right upper gingivobuccal mucosa and hard palate tumor, peripheral involved, to bilateral neck.
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 5000cGy/25 fractions of the right upper gingivobuccal mucosa and hard palate tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the right upper gingivobuccal mucosa and hard palate tumor and involved nodal lesions.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-5-31.
    • Please complete pre-RT dental evaluation and management.
• 2023-02-10 Gastroenterology
  • Q
    • This 52 year old male suffered from an aggressive malignant tumor of right maxillary and mandibular gingiva, buccal mucosa and palate for a few months. SCC of right buccal mucosa, maxillary gingiva, and palatal mucosa which combined with bone destruction, cT4aN0M0. We will arrange induction chemotherapy with Taxotere, Cisplatin, 5-Fu for him.
    • However, his data showed HbsAg (-), Anti-HBc (-) , Anti-Hbs (+) and Anti-HCV (+). We need your further evaluation and suggestion. Thanks !!
  • A
    • The patient is not in the ward, and has no plans to return to the ward after being contacted. I’ve explained to him over the phone, and he has expressed understanding.
      • Blood Draw: DAA medication pre-examination items (no need to redraw if previously done).
        • ALT, AST, Albumin, BUN, Creatinine, Bil(D), Bil(T), HbsAg, a-Fetoprotein, HCV RNA PCR, CBC, PT
    • Well explained to the patient low incidnece of HCV reactivation during or after chemotherapy according to previous reports
    • GI OPD f/u for treatment and echo

[chemotherapy]

• 2023-05-24 - docetaxel 36mg/m2 50mg NS 100mL 1hr D1 + cisplatin 36mg/m2 50mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-05-17 - docetaxel 36mg/m2 60mg NS 100mL 1hr D1 + cisplatin 36mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-04-28 - docetaxel 36mg/m2 60mg NS 100mL 1hr D1 + cisplatin 36mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-04-21 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-04-06 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-03-13 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-03-06 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-02-20 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-02-13 - docetaxel 40mg/m2 60mg NS 100mL 1hr D1 + cisplatin 40mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-03-28 ~ 2023-04-04 UFT (tegafur 100mg + uracil 224mg) 2# BID

==========

2023-06-02

• As the chemotherapy regimen has been ongoing since 2023-02-13, the patient’s WBC level remained within an acceptable range until April. However, a leukopenia event was observed following the most recent treatment cycle which began on 2023-05-24, as evident from the data on 2023-05-29. The patient was discharged on 2023-05-31, and it was noted in the discharge summary that “Filgrastim (G-CSF) 150mcg SC QD (self-paid) was prescribed for the prevention of neutropenia.” Nonetheless, the list of discharge prescriptions - loperamide, metoclopramide, zinc gluconate, and acetaminophen - does not include G-CSF. G-CSF is a reasonable medication in this context.
  • 2023-05-29 WBC 1.58 x10^3/uL
    
  • 2023-05-24 WBC 2.78 x10^3/uL
    
  • 2023-05-15 WBC 4.61 x10^3/uL
    
  • 2023-05-01 WBC 2.54 x10^3/uL
    
  • 2023-04-26 WBC 3.19 x10^3/uL
    
  • 2023-04-19 WBC 3.57 x10^3/uL
    
  • 2023-04-11 WBC 5.17 x10^3/uL
    
  • 2023-04-06 WBC 5.11 x10^3/uL
    
  • 2023-03-27 WBC 3.48 x10^3/uL
    
  • 2023-03-20 WBC 6.35 x10^3/uL
    
  • 2023-03-15 WBC 4.22 x10^3/uL
    
  • 2023-03-13 WBC 3.39 x10^3/uL
    
  • 2023-03-06 WBC 5.74 x10^3/uL
    
  • 2023-02-24 WBC 3.62 x10^3/uL
    
  • 2023-02-20 WBC 8.05 x10^3/uL
    
  • 2023-02-06 WBC 5.55 x10^3/uL
• For non-hematological malignancy patients who have experienced leukopenia of less than 1000/uL, or an absolute neutrophil count (ANC) less than 500/uL following chemotherapy, national health insurance covers the use of filgrastim and lenograstim. However, the patient’s WBC count does not yet meet this criterion, hence the need for self-payment. Please confirm the prescription status of Filgrastim.

701482774

230601

[exam findings]

• 2023-06-01 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 29 dB HL; LE 26 dB HL.
  • RE normal to moderate SNHL.
  • LE normal to mild SNHL.
• 2023-06-01 SONO - abdomen
  • Diagnosis
    • Fatty liver, mild
    • Suspected fatty infiltration of pancreas
    • Small GB
    • Splenomegaly, mild
    • Suboptimal examination of liver,especially the subcostal view due to poor echo window
  • Suggestion
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2023-05-30 Nasopharyngoscopy
  • left arytenoid swelling, blood clots over larynx and hypopharynx, penetration and impending aspiration
  • bulging tongue tumor, airway compromised+
• 2023-05-25 CT - chest
  • Submental and right submandibular lymphadenopathy
  • COPD. Moderate.
  • Diffuse Swelling of the gastric wall is found. Suggest endoscopy.
• 2023-05-18 MRI - larynx
  • Oralcavity
    • Impression (Imaging stage) : T:4b N:3b M:0 STAGE:IVB
• 2023-05-17 CXR
  • Multifocal opacities of left lung. Increased infiltration over both lungs. May be active infection.
• 2023-05-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (79.0 - 23.2) / 79.0 = 70.63%
    • M-mode (Teichholz) = 70.6
    • 2D (M-simpson) = 71.0
  • Conclusion:
    • Normal AV/MV with mild MR
    • Concentric LVH, normal LV wall motion
    • Preserved LV and RV systolic function
    • No PR, no TR, normal IVC size
• 2023-05-15 Patho - tongue biopsy (Y1)
  • Tongue, right lateral, biopsy— well differentiated squamous cell carcinoma
  • Microscopically, section shows well differentiated squamous cell carcinoma consisting of squamous tumor nests in infiltrative growth pattern and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, nuclear pleomorphism, hyperchromasia, and mitiotic activity.
  • HC stain— p16(-)
• 2023-05-15 ECG
  • Normal sinus rhythm
  • Increased R/S ratio in V1, consider early transition or posterior infarct
  • Prolonged QT
• 2023-05-13 Nasopharyngoscopy
  • granular tumor right tongue border, whitish lesion over left hard palate, smooth NPx, protuding of right tongue base with yellowish discharge, sputum pooling over HPx, fair vocal cord movement

[MedRec]

• 2023-05-24 SOAP Hemato-Oncology
  • Arrange admission for PET-CT, Chest CT (including whole body if possibile), EGD, Abdominla sonography and Port-A implantation
  • Refer to CS for Port-A implantation
• 2023-05-23 SOAP Ear Nose Throat
  • A: Tongue cancer, stage IVb
  • Treatment plan: induction CT + CCRT, referred to Hema

[consultation]

• 2023-05-30 Anesthesiology
  • Q
    • Injury Severity Score: 3 Difficulty Swallowing > Acute Central Moderate Pain (4-7) Tongue cancer, tongue bleeding for 1 week, significant bleeding today, the patient expresses desire for DNR (Do Not Resuscitate)
    • 5/18 ENT (Ear, Nose, and Throat) discharge diagnosis
      • Right deep neck infection status post right deep neck incision & drainage on 2023-5-14.
      • Right lateral tongue cancer status post biopsy (squamous cell carcinoma) on 2023-5-14.
      • Localized swelling, mass and lump, neck
      • Hypertension
      • Type II diabetes mellitus
  • A
    • Visited the patient in the emergency department
    • The patient was not using any oxygen assistance at the time
    • If the ENT doctor indicates that the patient may have a risk of airway loss at any time
    • Please have the emergency tracheotomy on standby for intubation in the operating room, or directly proceed with a tracheostomy
    • The patient had previously been treated for difficult airway in the operating room, and a direct tracheostomy should be considered.
• 2023-05-30 Ear Nose Throat
  • A1
    • S:
      • intermittent oral bleeding for 1 week, progressed today
      • the patient complained dyspnea and can’t lying down
      • Deep neck infection s/p I+D and right lateral tongue biopsy
      • Right tongue cancer. T4bN3BM0, Stage IVB
    • O:
      • Scope:
        • left arytenoid swelling, blood clots over larynx and hypopharynx, penetration and impending aspiration
        • bulging tongue tumor, airway compromised+
    • Plan:
      • Suggest tracheostomy, but the patient strongly refused
      • Well explanation to the patient and his family about the risk of active bleeding and airway obstruction with possible death
      • Well education: if bleeding again, sit up with mouth open and head downward to prevent aspiration
      • ENT OPD f/u
  • A2 2023/05/30 16:50
    • We were informed that the patient agreed to receive tracheostomy
    • We will arrange tracheostomy under ETGA on 2023/6/1
    • OA to oncology, if active bleeding or respiratory failure -> intubation
  • A3 2023-05-30 18:00:58
    • We will arrange tracheostomy operation today for airway protection.
    • Keep NPO and finish preOP survey
  • A4 2023-05-30 22:09:46
    • staus post tracheostomy (shiley 6 #)
    • adequate pain control and antibiotics
    • f/u CXR to check tracheostomy position
    • hemoclot and bosmin gauze prn for oral tumor bleeding
    • suction prn carefully (The tumor is located on the right rear side, do not poke too deep.)
• 2023-05-14 Cardiology
  • Q
    • This 53-year-old male has histories of HTN, D.M, type II and hyperlipidemia. This time, he was admitted to ENT ward for under impression of deep neck infection on May 13, 2023. He underwent 1. Incision and drainage of right deep neck infection 2. Biopsy of right lateral tongue and left soft palate tumor on May 14, 2023. But, acute respiratory failure at POR, re-intubation with ventialtor support was performed on May 14, 2023, and he was transferred to our SICU for intensive care today. Due to ST depression by 12 leads EKG, and elevated of hs Tropnin I (from 179.4 tp 308.4 pg/mL), We need your expertise for suspect acute coronary syndrome evaluation. Thanks a lot!!
  • A
    • We were consulted for diffuse STD and elevated hs-troponin I
    • The STT change was noted while the routine screening of his cardiac enzyme and ECG. Since this patinet was clear consciousness, he could inform us that he had no subjective symptom.
    • S:
      • patient is clear conscious under ventilator support.
      • Denied of chest pain, chest tightness right now and in the past.
    • O:
      • Clear breathing sounds
      • No pitting edema
      • EKG:
        • 20230513 - Q wave in inferior leads, and T wave invertion at anterolateral leads
        • 20230514 - diffuse STD from V2-V6
      • Labs
        • 20230514 - hsTrop I 180 -> 300
      • Bedside echo: adequate EF and no abnormal wall motion, poor echo window.
    • Impression
      • R/o demand ischemia
      • Deep neck infection
    • Suggestion
      • ST EKG V1-V6 + V7-V9 showing recovery of STD changes (spontaneous recovery)
      • F/u hs-Trop and EKG 2hr later.
      • Might consider plavix 1# QD if no bleeding tendency and secure hemostasis at OP site.
      • F/u electrolytes ( Mg, Ca, Ip, Na/K), CAD risk factors including lipid profile, HbA1c and uric acid.
      • Arrange 2D cardioechography. CV OPD follow up
• 2023-05-13 Ear Nose Throat
  • Q
    • Chief Complaints:
      • left neck pain for one week
      • dysphagia
    • Past History: Nil
    • Surgical history: Denied
    • Drug allergy: Denied
  • A
    • S
      • Right neck pain for one week
      • Previous R tongue border leukoplakia s/p biopsy = benign in 2023/01.
      • Hx of DM, HTN
    • O
      • Local findings: granular tumor over right tongue border, whitish lesion over left hard palate
      • Scope: smooth NPx, protuding of right tongue base, yellowish discharge pooling over HPx, mild airway compromized
    • A
      • Impression: Highly suspect Oral ca with deep neck infection
    • P
      • OA to ENT, continue IV anti, pain control
      • Arrange I&D on 2023/05/14

==========

2023-06-01

This patient visited a local clinic on 2023-05-11 for his primary hypertension (PharmaCloud only reveals one main diagnosis, there should be also diabetes diagnosed) and be prescribed with amlodipine, losartan and glimepiride. Currently Norvasc (amlodipine), Amepiride (glimepiride) and 與 losartan 同藥理作用的 Olmetec (olmesartan) are shown in the active medication list, no reconciliation issue identified.

2023-05-19 anaerobic culture for deep neck wound/pus showed peptostreptoccus spp. 3+

701267240

230531

[exam findings]

• 2023-05-22 Laryngoscopy
  • Findings
    • flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge), size stable favor granulation; saliva accumulation at bi hypopharynx and on pharyngeal wall
  • Diagnosis/conclusion
    • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
    • Swallowing dysfunction, under swallowing rehabilitation
• 2023-05-08 Laryngoscopy
  • Findings
    • flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge), favor granulation
  • Diagnosis/conclusion
    • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
    • Swallowing dysfunction, under swallowing rehabilitation
• 2023-04-27 Laryngoscopy
  • Findings
    • Scope: flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge)
    • FEES: soft diet: premature leak +, residual + at vallecula and pyriform sinus, penetration +
  • Diagnosis/conclusion
    • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
    • Swallowing dysfunction, under swallowing rehabilitation
• 2023-04-20 Patho - nasopharyngeal/oropharyngeal biopsy
  • Right nasopharyngeal lesion, biopsy — Necrotic ulcer debris, acute inflammatory exudates, and granulation tissue only.
• 2023-04-20 Nasopharyngoscopy
  • Findings
    • Scope: flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge), size increase >>> biopsy done
  • Diagnosis/conclusion
    • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
    • Right nasopharyngeal lesion, biopsy done
• 2023-04-06 Laryngoscopy
  • Findings
    • Scope: flap at right oropharynx and hypopharynx, right vocal paresis, glottic closure fair; flap upper edge swelling, granulation, r/o tumor
    • FEES:
      • liquid diet: premature leak +, residual + at vallecula and pyriform sinus, penetration +, aspiration +
      • soft diet: premature leak -, residual + at vallecula and pyriform sinus, penetration +
  • Diagnosis/conclusion
    • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
    • Swallowing dysfunction
• 2023-03-24 PD-L1 (SP142)
  • Pathologic Report for PD-L1 (SP142) Assay (Ventana) S2023-3886 G1
    • Tumor type: squamous cell carcinoma
    • Tumor location: Oropharynx
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark XT
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: Pass,
    • Adequate tumor cells present (>=50 viable tumor cells): Yes,
  • Result:
    • Tumor cell (TC) staining assessment:
      • TC category: TC >=1% and <5%
      • Percentage of PD-L1 expressing tumor cells (%TC): 3%
    • Tumor-infiltrating immune cell (IC) staining assessment:
      • IC category: IC >= 10%
      • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 15%
  • Note:
    • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
    • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2023-03-24 PD-L1 IHC
  • Tissue blocks/unstained slides received labeled as: S2023-03886 G1
    • Tumor type: Labeled H&N cancer
    • Testing assay: 28-8 pharmDx Assay (Agilent/Dako)
  • RESULT：
    • Tumor cell (TC) staining assessment: TC < 1%
• 2023-03-24 PD-L1 22C3
  • Unstained slides received labeled as: S2023-03886 G1
    • Tumor type: oral cancer
    • Testing assay: 22C3 pharmDx Assay (Agilent/Dako)
  • RESULTS：
    • Tumor Proportion Score (TPS) assessment: TPS >=1% and <50%
      • Tumor Proportion Score (TPS): 1%
    • Combined Positive Score(CPS) assessment: CPS >=1 and <10
      • Combined Positive Score (CPS): 5
• 2023-03-06 Patho - oral cancer (wide excision + lymph node)
  • Diagnosis:
    • Oropharynx, right, wide excision —- Squamous cell carcinoma, moderately differentiated, AJCC 8th edition: pStage IVB, pT4bN0(if cM0); The immunohistochemical stain of p16 is negative.
    • Lymph node, right neck, level III, selective neck dissection—- Negative for malignancy (0/9)
    • Lymph node, right neck, level IIb, selective neck dissection —- Negative for malignancy (0/2)
    • Lymph node, right neck, level IIa, selective neck dissection —- Negative for malignancy (0/7)
    • Lymph node, right neck, level I, selective neck dissection —- Negative for malignancy (0/5)
    • Submandibular gland, right, excision —- Negative for malignancy
    • Sublingual gland, right, excision —- Negative for malignancy
    • Parapharyngeal space tissue, right, excision —- Negative for malignancy
    • Lymph node, parapharyngeal space tissue, right, excision —- Negative for malignancy (0/1)
    • Prevertebral fascia and muscle, right, excision —- Negative for malignancy
    • Tissue close to skull base, right, excision —- Squamous cell carcinoma
    • Carotid sheath close to skull base, right, excision —- Squamous cell carcinoma
    • Prevertebral tissue close to carotid artery, right, excision —- Squamous cell carcinoma
    • F2023-00085
      • FsA: Carotid sheath, biopsy — Negative for malignancy
      • FsB: Superior margin, biopsy — Negative for malignancy
      • FsC: Medial margin, biopsy — Negative for malignancy
      • FsD: Inferior margin, biopsy — Negative for malignancy
      • FsE: Deep margin, biopsy — Squamous cell carcinoma
      • FsF: Carotid sheath close to skull base, biopsy — Squamous cell carcinoma
  • Macroscopic examination
    • Surgical Procedure(s): wide excision
    • Specimen Type:
      • Main location: oropharynx
      • Other part(s) included: Sublingual gland, Parapharyngeal space tissue, Prevertebral fascia and muscle, Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
      • Lymph node dissection: yes, (specify) III, IIb, IIa, I
    • Specimen Integrity: intact
      
    • Specimen Size: Greatest dimensions: 3.0 x 2.5 x 2.2 cm
      • Additional dimensions (if more than one part): Sublingual gland: a piece, 2.6 x 2.0 x 1.0 cm; Parapharyngeal space tissue: a piece, 3.3 x 2.6 x 1.4 cm; Prevertebral fascia and muscle: 7 pieces, measuring up to 2.2 x 2.0 x 0.3 cm; Tissue close to skull base: 8 pieces, measuring up to 1.4 x 1.0 x 0.5 cm; Carotid sheath close to skull base: 4 pieces, measuring up to 1.5 x 0.4 x 0.2 cm; Prevertebral tissue close to carotid artery: multiple pieces, measuring up to 1.5 x 0.9 x 0.7 cm
    • Depth of invasion: 6 mm
    • Tumor Site: oropharynx

      • Laterality: right  

    • Tumor Focality: single focus with involving several areas, (specify) Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
      
    • Tumor Size: Greatest dimension: 1.8 x 1.0 cm
      • Additional dimensions (if available): not applicable
    • Mucosal Surface: Intact
      
    • Gross Tumor Extension: (specify) Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
      
    • Representative sections are taken and labeled as: A: lymph node, level III; B: lymph node, level IIb; C: lymph node, level IIa; D1: submandibular gland; D2-3: lymph node, level I; E: sublingual gland; F1-2: Parapharyngeal space tissue; G1-2: through section from superior (ink green) to inferior (ink blue); G3: anterior margin; G4: posterior margin; H: Prevertebral fascia and muscle; I: Tissue close to skull base; J: Carotid sheath close to skull base; K: Prevertebral tissue close to carotid artery.
      • F2023-00085
        • A: Specimen submitted in fresh and labeled as “Carotid sheath” consists of 2 pieces of tan, irregular tissue measuring up to 0.5 x 0.4 x 0.3 cm. All for section in one cassette FsA1.
        • B: Specimen submitted in fresh and labeled as “Superior margin” consists of a piece of tan, irregular tissue measuring 1.4 x 0.6 x 0.3 cm. All for section and inked green in one cassette FsA1.
        • C: Specimen submitted in fresh and labeled as “Medial margin” consists of a piece of tan, irregular tissue measuring 2.1 x 1.3 x 0.4 cm. All for section and inked purple in one cassette FsA1.
        • D: Specimen submitted in fresh and labeled as “Inferior margin” consists of a piece of tan, irregular tissue measuring 1.4 x 0.5 x 0.3 cm. All for section in one cassette FsA2.
        • E: Specimen submitted in fresh and labeled as “Deep margin” consists of a piece of tan, irregular tissue measuring 1.6 x 0.6 x 0.3 cm. All for section and inked green in one cassette FsA2.
        • F: Specimen submitted in fresh and labeled as “Carotid sheath close to skull base” consists of several pieces of tan, irregular tissue measuring up to 0.4 x 0.2 x 0.2 cm. All for section and inked purple in one cassette FsA2.
  • Microscopic examination
    • Histologic Type: Squamous cell carcinoma, The immunohistochemical stain of p16 is negative.
    • Histologic Grade: G2: Moderately differentiated,
    • Microscopic Tumor Extension: (specify) Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
      
    • Margins (obtained from the main resection specimen):
      • F2023-00085: Deep margin involved by invasive carcinoma
      • S2023-03886: Anterior resection margin: 1.2 cm; Posterior resection margin: 0.2 cm; Superior resection margin: 0.4 cm; Inferior resection margin: 0.2 cm
        
    • Lymph-Vascular Invasion: present
      
    • Perineural Invasion: not identified
      
    • Neck Lymph Nodes: please see diagnosis
      • Ipsilateral: Number examined: 24; Number involved: 0
      • Contralateral (if available): not received
      • Size (greatest dimension) of largest metastatic deposit: not identified
      • Extranodal extension: not identified
        
    • F2023-00085
      • Sections of specimens A, B, C and D are free of malignnacy. Sections of specimens E and F show invasive squamous cell carcinoma.
• 2023-03-03 Frozen section
  • Preliminary diagnosis:
    • FsA: Carotid sheath, biopsy — Negative for malignancy
    • FsB: Superior margin, biopsy — Negative for malignancy
    • FsC: Medial margin, biopsy — Negative for malignancy
    • FsD: Inferior margin, biopsy — Negative for malignancy
    • FsE: Deep margin, biopsy — Squamous cell carcinoma
    • FsF: Carotid sheath close to skull base, biopsy — Squamous cell carcinoma
• 2023-01-16 Patho - larynx biopsy
  • PATHOLOGIC DIAGNOSIS
    • R’t pyriform sinus, anterior wall, LMS — Benign squamous epithelium
    • Tumor, right posterior oropharyngeal wall, excision — Squamous cell carcinoma
  • MICROSCOPIC EXAMINATION
    • R’t pyriform sinus anterior wall: benign squamous epithelium without underlying stromal tissue included
    • Right posterior oropharyngeal wall tumor: squamous cell carcinoma with moderate differentiation characterized by solid tumor nests infiltration with focal keratin formation, perineural invasion, tumor emboli and ulceration. Besides, unlabelled peripheral margin and deep margin are involved by tumor. Follow up
• 2023-01-11 PET scan
  • The right oropharynx wall lesion shown on the previous larynx MRI reveals glucose hypermetabolism, indicating highly suspected tumor recurrence. Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in the left lower lung, probably inflammation precess, suggesting follow-up.
  • Glucose hypermetabolism in bilateral pulmonaty hilar lymph nodes, and right mediastinal lymph nodes, probably reactive nodes.
  • Increased FDG uptake at bilateral shoulders, probably benign in nature.
  • Increased FDG accumulation in both kidneys and colon, probably physiological uptake of FDG.
  • Right pyriform sinus cancer s/p treatment with highly suspected tumor recurrence in the lateral wall of the right oropharynx, rcTxN0M0, by this F-18 FDG PET scan.
• 2023-01-09 MRI - larynx
  • Comparison: 2022/10/04, 2022/06/28, 2021/01/25 Neck CT, 2021/0929 MRI
    • No obvious local recurrent right hypopharynx mass or nodule. -Highly suspected tumor recurrence in right oropharynx wall, and recrurent LAP at right carotid space with well post contrast enhancement.
      -No obvious right hypopharynx mass or nodule. -Post OP at right submandiublar gland and LNs. -Small left level I-II LNs. -Dental caries? in left low jaw with signal intensity change of the mandible bone, stationary.
      -A small right maxillary sinus retention cyst or mucocele, stationary.
  • IMP:
    • No obvious local recurrent right hypopharynx mass or nodule.
    • Highly suspected tumor recurrence in right oropharynx wall, and recrurent LAP at right carotid space.
• 2023-01-07 CT - chest
  • Indication: pyriform sinus cancer s/p OP and CCRT
  • Chest CT with and without IV contrast ehnancement shows:
    • s/p left lower lobe op.
    • Calcified coronary arteries is found.
    • Subpleural nodular lesion at left upper lobe measuring 0.89cm is found. In comparison with CT dated on 2022-07-07, the lesion is stationary. Smaller lesion at left upper lobe measuring 0.4cm is found.
    • Calcified dot at right upper lobe measuring 0.3cm is found.
  • Imp:
    • Left upper lobe nodules. 0.4cm to 0.89cm, stationary.
    • Right upper lobe calcified dot.
    • s/p left lower lobe op.
• 2022-10-11 CT - chest
  • two LLL solid nodules (up to 9mm) stationary.
  • RUL granuloma 3mm.
• 2022-10-04 MRI - larynx
  • No obvious right hypopharynx mass or nodule. No evidence of tumor recurrence. No neck LAP.
• 2022-08-03 Patho - larynx biopsy
  • Labeled as “superior part of lesion, right”, Oral tumor or oropharynx excision — ulcer with benign squamous mucosa.
  • Labeled as “inferior part of lesion, right”, Oral tumor or oropharynx excision — fibrotic necrotic tissue.
• 2022-07-20 Patho - larynx biopsy (Y1)
  • Labeled as “right pyriform sinus”, excision with frozen section for margins (F2022-336FSA) — squamous cell carcinoma. 1 mm from all margins. IHC stain: p16 (-).
• 2022-07-07 CT - chest
  • Left upper lobe perifissural nodule. 1.04cm, aolid nodule. 3mm, these two nodules are stationary.
• 2022-06-28 MRI - larynx
  • The current study was compared to the prior one obtained on 2022/04/01.
  • Known a case of right pyriform sinus cancer S/P CCRT. Still effacement of right pyriform sinus with mild mucosal thickening. Suggest clinical correlation.
• 2022-04-01 MRI - larynx
  • No obvious recurrent hypopharyngeal tumor in this study.
  • A 1.0cm enhancing lesion at the left mandible, stationary. Dental problem or other etiology? Suggest close follow up.
• 2022-01-05 CT - chest
  • two solid nodules in LLL (9 mm, 4 mm) and a LUL solid nodule 3 mm, suggest f/u at 6-12 months later.
  • RUL granuloma 3 mm.
• 2021-12-30 MRI - larynx
  • No obvious right hypopharynx mass or nodule.
  • Post OP at right submandiublar gland and LNs.
• 2021-10-20 Patho - lung wedge biopsy
  • Lung, left lower lobe, VATS LLL wedge — Lymphoid hyperplasia
  • IHC stain — CK(-)
• 2021-10-06 CT - chest
  • RUL tiny granuloma. Two LLL solid nodules 9 mm and 4 mm. suggest f/u at 6 months with CT.
• 2021-09-29 MRI - larynx
  • a heterogeneous enhancing lesion at the left mandibular alveolar region, stationary.
• 2021-09-03 CT - brain
  • Brain atrophy.
  • Chronic maxillary sinusitis.
• 2021-09-03 ECG
  • Normal sinus rhythm with sinus arrhythmia
  • T wave abnormality, consider inferior ischemia
  • Abnormal ECG
• 2021-06-09 MRI - larynx
  • a heterogeneous enhancing lesion at the left mandibular alveolar region.
• 2021-04-28 Endoscopic radiofrequency ablation
  • Indication: Esophageal high grade dysplasia
  • Anesthesia: Dormicum + alfentanil + propofol titrated given
  • Procedure: Endoscopic radiofrequency ablation with catheter type RFA catheter
  • Course:
    • Radiofrequency Ablation is performed with TTS type 90 RFA catheter. After Lugol soln (1.5%) spraying, leopard spots scattering at the whole esophagus was noted. Three Lugol-voiding lesions needed to be ablated.
    • Three lesions are localized at the 37 cm, 30cm and 25 cm.
    • The procedure is done with ablation -ablation-clean- ablation-ablation mode with energy 12 jouls delivered.
  • Other finding
    • Short mucosal breaks noticed at the lower esophagus.
  • Diagnosis
    • Esophageal carcinoma in situ s/p RFA
    • Reflux esophagitis Gr.A
  • Suggestion
    • PPI & sucrafate use
  • Complication
    • No immediate complication
• 2021-04-09 Tc-99m MDP bone scan
  • Increased activity in the lower C-spine. Degenerative change may show this picture.
  • Increased activity in the maxilla and left aspect of mandible. The nature is to be determined (dental problem? other nature?). Please correlate with other clinical findings for further evaluation.
  • Some hot and faint hot spots in the skull. The nature is to be determined (post-traumatic change? other nature?). Please correlate with the clinical history and follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
• 2021-04-06 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 24 dB HL; LE 20 dB HL.
  • R’t normal to severe SNHL.
  • L’t normal to moderate SNHL
• 2021-03-23 MRI - larynx
  • Comparison: 2021/01/25 Neck CT
    • Poor defined right hypopharynx mass or nodule.
    • Post OP at right submandiublar gland and LNs.
    • Small left level I-II LNs.
    • Dental caries? in left low jaw with signal intensity change of the mandible bone.
    • A small left oropharynx wall LN?
    • Suggest clinical correlation.
• 2021-03-17 Patho - larynx biopsy
  • Labeled as “right AE fold”, biopsy — squamous cell carcinoma.
  • IHC stains: CK5/6 (+), p40 (+), p16 (-)
• 2021-02-26 PET
  • A prominent glucose hypermetabolic lesion in the left aspect of mandible. Either dental problem or malignancy may show this picture. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the right aspect of the hypopharynx, right aspect of the soft palate, right tonsil, some bilateral neck level II lymph nodes and a left submandibular lymph node. The nature is to be determined (inflammatory process? other nature?). Please also correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the right submandibular area, compatible with post-operative inflammation.
  • Increased FDG accumulation in both kidneys and colon. Physiological FDG accumulation is more likely.
• 2021-02-19 Patho - salivary gland resection
  • Lymph nodes, submandibular gland, right, excision — Squamous cell carcinoma, metastatic; p16(-)
    
  • The sections show a picture of squamous cell carcinoma, metastatic, composed of nests of moderately differentiated neoplastic squamous cells in lymphoid tissue. Keratin formation, focal tumor necrosis, and extranodal extension are evident. The surgical margin is free of carcinoma.
  • IHC: p16(-).
• 2021-01-25 CT - neck
  • IMP: An ill-defined tumor mass in middle posterior part of right submandibular gland, at least, up to 3.1 cm.
  • Imaging Report Form for major salivary gland malignancy
  • Impression (Imaging stage): T:T2(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IVA (Stage_value)

[MedRec]

• 2023-04-13 SOAP Hemato-Oncology
  • Waiting for the result of PD-L1 -> Consider IO-based Tx -> Due to trail started since 2023-07, already suggest patient start PF. But patient would like to get better performance status.
• 2023-03-23 SOAP Hemato-Oncology
  • Waiting for the result of PD-L1 -> Consider IO-based Tx
• 2021-03-23 SOAP Hemato-Oncology
  • Conclusions of the Multidisciplinary Cancer Team Meeting, meeting date 20210305
    • It is recommended to arrange an MRI examination.
    • Seek the opinion of the original ENT doctor.
    • Further search for the primary (source of cancer).

[consultation]

• 2023-03-18 Hemato-Oncology
  • Q
    • for chemotherapy
    • This 54 y/o man had history of DM and hypopharyngeal cancer s/p op + CCRT in 2021. Under the impression of right oropharyngeal cancer, he was admitted and received tumor excision + right neck disection + tracheostomy + flap reconstruction on 20230303 to 20230304. He was tranfered to SICU for intensive care on 2023/03/04 to 2023/03/06. After wound condition stable, he was transferred to our service on 20230309. Tracheostomy removed on 20230313. Remove neck suture wound on 20230317. Today, tumor board meeting discussion, which suggest chemotherapy. We need yor help for further evaluation and management. Thank you very much!!
  • A
    • Due to RT treatment history, the dose of RT in the patient is limitation. Systemic therapy is indicated in the patient (Ex: immuno, chemo…). We will also discuss with patient about clinical trial (head and neck cancer with IO naive). Please arrange our OPD after discharge. Thanks for your consultation.
• 2023-03-16 Dermatology
  • Q
    • for right face some rash with itching
    • This 54 y/o man had history of DM and hypopharyngeal cancer s/p op + CCRT in 2021. Under the impression of right oropharyngeal cancer, he was admitted and received tumor excision + right neck disection + tracheostomy + flap reconstruction on 20230303 to 20230304. He was tranfered to SICU for intensive care on 2023/03/04 to 2023/03/06. After wound condition stable, he was transferred to our service on 20230309. Tracheostomy removed on 20230313, and keep neck wound care. Right face some rash with itching was found on 20230315. We need yor help for further evaluation and management. Thank you very much!!
  • A
    • The patient had sufferred from erythematous plaques with fine scales over face and chin
      
    • Under the impression of seborrheic dermatitis over face.
    • The following sugeetion:
      • Betason-N onit 1 tube topical bid use first on the wound and curst lesions first.
      • Mycomb cream 1tube topical bid use over large erytheamtous papules and plaques area on the face.
      • If still itchy or spreading erythema, consider Rinderon cream 1 tube topical QN use (depends on the situation, only needed on areas with red and scaly skin, strengthen locally).
• 2021-05-28 Radiation Oncology
  • A: Squamous cell carcinoma of right hypopharynx (pyriform sinus), , p16 (-), stage cT2N2bM0 (IVA), s/p induction chemotherapy.
  • P: Radiotherapy is indicated for this patient with the following indicators: hypopharygeal cancer, stage cT2N2bM0 (IVA)
    • Goal: curative
    • Treatment target and volume: right hypopharyngeal cancer to bilateral neck,
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 5000cGy/25 fractions of the bilateral neck, and 7000cGy/35 fractions of the right hypopharyngeal tumor bed to involved neck nodal lesions.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy. The treatment planning of radiotherapy will be started at 10AM, 2021-6-2.

[chemotherapy]

• 2023-05-30 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y site 5-FU) + [magnesium sulfate 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL D1-4
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-05-30 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y site 5-FU) + [magnesium sulfate 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL D1-4
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-07-27 - carboplatin AUC 2 150mg D5W 250mL 2hr + NS 1000mL (Y site carboplatin)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-07-20 - carboplatin AUC 2 150mg D5W 250mL 2hr + NS 1000mL (Y site carboplatin)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-07-13 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-07-06 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-06-29 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-06-22 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-06-15 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-05-27 - docetaxel 75mg/m2 130mg NS 250mL 1hr + cisplatin 75mg/m2 130mg NS 500mL 24hr (Y site 5-FU) + fluorouracil 750mg/m2 1300mg NS 500mL 24hr D1-5
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-05-03 - docetaxel 75mg/m2 130mg NS 250mL 1hr + cisplatin 75mg/m2 130mg NS 500mL 24hr (Y site 5-FU) + fluorouracil 750mg/m2 1300mg NS 500mL 24hr D1-5
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-04-10 - docetaxel 75mg/m2 130mg NS 250mL 1hr + cisplatin 75mg/m2 130mg NS 500mL 24hr (Y site 5-FU) + fluorouracil 750mg/m2 1300mg NS 500mL 24hr D1-5
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-05-31

Based on the PharmaCloud database, this patient has only sought medical care at our hospital in the past three months. On 2023-05-27, our metabolic physician recently prescribed refillable medications including Uformin (metformin), Trajenta (linagliptin), Lipanthyl (fenofibrate), and Zulitor (pitavastatin). These drugs have been correctly integrated into the current active medication list without any issues in medication reconciliation.

700647993

230530

[exam findings]

• 2023-05-29 CT - abdomen
  • Clinical information: 1) High grade serous carcinoma of fallopian tube with peritoneal metastasis and pleural effusion with positive cytology, cT3N0M1 stage IV, post debulking surgery + Hyperthermic Intraperitoneal Chemotherapy on 2023/04/24. 2) GERD. 3) HTN
  • The CT scan of the whole abdomen was performed without/with IV contrast medium enhancement and revealed that:
    • Known a case of fallopain tube cancer with peritoneal carcinomatosis S/P operation and chemotherapy. No presence of recurrent or residual tumor.
    • The both kidneys show normal contrast excretion, size, and contour without evidence of renal stone or tumors.
    • The liver parenchyma reveals no evidence of focal lesion.
    • The gallbladder is normal in size and wall thickness.
    • The pancreas & spleen appears normal in size and contour.
    • There is fecal materials impaction in the sigmoid colon and rectum.
• 2023-04-26 CXR
  • Bilateral parahilar infiltrates with blunting of left costophrenic angle, r/o lung edema. Progression as compare with CXR on 2023-04-24. suggest clinical correlation.
  • Mild cardiomegaly.
• 2023-04-25 Patho - uterus (with or without SO) neoplastic
  • Diagnosis:
    • Ovary, bilateral, oophorectomy —- high grade serous carcinoma, metastatic
    • Fallopian tube, right, salpingectomy —- high grade serous carcinoma, metastatic, tumor seeding on serosa
    • Fallopian tube, left, residual, salpingectomy —- high grade serous carcinoma, metastatic, tumor seeding on serosa, s/p salpingectomy (S2023-01126)
    • Uterus, corpus, total hysterectomy —- negative for malignancy
    • Uterus, cervix, total hysterectomy —- negative for malignancy
    • Lymph node, left external ilaic, dissection —- high grade serous carcinoma, metastatic (1/8)
    • Lymph node, left obturator, dissection —- high grade serous carcinoma, metastatic (1/11)
    • Lymph node, right external ilaic, dissection —- high grade serous carcinoma, metastatic (1/9)
    • Lymph node, right obturator, dissection —- negative for malignancy (0/13)
    • Lymph node, left para-aortic, dissection —- high grade serous carcinoma, metastatic (2/20)
    • Lymph node, right para-aortic, dissection —- high grade serous carcinoma, metastatic (1/7)
    • Soft tissue on intestine, excision —- high grade serous carcinoma, metastatic
    • Omentum, omentectomy —- high grade serous carcinoma, metastatic
    • AJCC 8th edition: ypStage IIIC, ypT3cN1a(if cM0), FIGO Stage IIIAIi or ypStage IVA, ypT3cN1aM1a (pleural effusion with positive cytology), FIGO Stage: IVA; please correlate with the clinical presentation and image study.
  • Gross description:
    • Procedure (select all that apply): Debulking surgery (ATH + BSO + Cytoreduction surgery + bilateral pelvic ＆ paraaortic lymphadectomy + infracolic omentectomy); No appendix is received
      
  • Microscopic Description:
    • Histologic Type: High-grade serous carcinoma
    • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors): not applicable
      
    • Implants (required for advanced stage serous/seromucinous borderline tumors only)
      • Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.: Present (specify sites): soft tissue on intestine and omentum
    • Other Tissue/ Organ Involvement (select all that apply): bilateral ovary, bilateral fallopian tube, soft tissue on intestine and Omentum
    • Largest Extrapelvic Peritoneal Focus (required only if applicable): Macroscopic (greater than 2 cm) (omentum)
    • Peritoneal/Ascitic Fluid: N2023-01554: Atypical
      
    • Regional Lymph Nodes: please see diagnosis;
      
    • Additional Pathologic Findings: endometrial polyp, adenomyoma and leiomyomas are seen.
• 2023-04-20 CT - abdomen
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A tumor (3.6cm) at uterur. Some soft tissues in peritoneal cavity. A cystic lesion (3.1x6.1cm) at pelvic cavity.
    • Bil. pleural effusions.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • Peritoneal carcinomatosis.
    • A tumor (3.6cm) at uterus. A cystic lesion (3.1x6.1cm) at pelvic cavity.
    • Bil. pleural effusions.
• 2023-03-27 CXR
  • Right Pleura effusion.
• 2023-02-03 CXR
  • Bilateral Pleura effusion.
• 2023-01-26, -01-23, -01-19 CXR
  • S/P port-A implantation.
  • Bilateral Pleura effusion S/P pigtail catheter implantation at right CP angle.
  • Borderline cardiomegaly
  • Hypoinflation of both lung is noted.
• 2023-01-20 SONO - breast
  • diagnosis: no mass lesion
  • BI-RADS: 1. negative
• 2023-01-17 Patho - fallopian tube biopsy
  • Peritoneum, biopsy — high grade serous carcinoma, metastatic, consistent with fallopian tube origin
  • Section shows fibrous tissue with metastatic high grade serous carcinoma.
  • The immunohistochemical stains reveal PAX8(+), WT-1(focal +), p53(aberrant expression present), PR(-), CD56(focal +), p40(-).
  • The results are consistent with metastatic high grade serous carcinoma from fallopian tube. Focal neuroendocrine feature can not be excluded.
• 2023-01-17 Patho - fallopian tube biopsy
  • Fallopian tube, left, salpingectomy — high grade serous carcinoma
  • Section shows fallopian tube with high grade serous carcinoma arising from fimbriae.
  • The immunohistochemical stains reveal CK(+) and PAX8(focal +).
  • Tumor seedings on serosa are seen.
• 2023-01-16 Body fluid cytology - ascites
  • cell block cytology: Malignancy
  • The immunohistochemical stains reveal CK(+), CK7(+), CK20(-), TTF-1(-), Napsin A(-), Calretinin(-), GATA3(-), CDX2(-), and PAX8(equivocal). There are no conclusive results. Please correlate with the clinical presentation for tumor origin.
    
  • Smears and cell block show clusters of pleomorphic tumor cells and focal glandular pattern. Metastatic adenocarcinoma is favored.
• 2023-01-12 MRI - brain
  • NO evidence of brain metastasis.
• 2023-01-11 Whole body PET scan
  • Glucose hypermetabolism in the T-colon, the nature is to be determined (benign or malignant neoplasm, s/p colon fibroscopy change or other nature ?), suggesting further investigation.
    
  • Glucose hypermetabolism in the right lobe of the liver and in some right subphrenic lymph nodes, malignnacy with distant metastases should be considered.
    
  • Glucose hypermetabolism in the spleen, the nature is to be determined also, suggesting further investigation.
  • Increased FDG uptake in the uterus, malignancy should be considered, suggesting pelvis CT or MRI for further investigation.
    
  • No prominent abnormal focal FDG uptake is noted elsewhere.
• 2023-01-10 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the lower L-spines, L5-sacrum junction, bilateral shoulders, hips and feet in whole body survey.
  • IMPRESSION:
    • Increased activity in the lower L-spines and L5-sacrum junction. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips and feet, compatible with benign joint lesions.
• 2023-01-10 Patho - stomach biopsy
  • Stomach, body, biopsy — Hyperplastic polyp
• 2023-01-10 Patho - colon biopsy
  • Colorectum, rectum. Cold snaring polypectomy (A) — Tubular adenoma with low grade dysplasia
  • Colorectum, descending colon. Cold snaring polypectomy (B) — Tubular adenoma with low grade dysplasia
• 2023-01-09 CT - chest
  • favor peritonei carcinomatosis, cause and origin to determined.
  • no lung nodule or mass.
• 2023-01-05 Body fluid cytology - ascites
  • The immunohistochemical stains reveal CK(+), CK7(+), CK20(-), TTF-1(-), Napsin A(-), Calretinin(-), GATA3(-), CDX2(-), and PAX8(equivocal). There are no conclusive results. Please correlate with the clinical presentation for tumor origin.
    
  • Smears and cell block show clusters of pleomorphic tumor cells and focal glandular pattern. Metastatic adenocarcinoma is favored.

[surgical operation]

• 2023-01-17
  • Surgery
    • Diagnosis: peritoneal cacinomatosis
    • Operation: SILS left salpingectomy     
  • Finding
    • Uterus: AVF, adhesion to uterus, with mural mass on the surface
    • Adnexae: adhesion to pelvix wall, with mural mass on the surface of tube
    • Bil ovary : graossly normal
    • Cul-de-sac: with ascites, about 3000ml
    • peritoneal carcinomatosis noted, multiple tumors between omentum and bowels
    • Estimated blood loss: minimal
    • Blood transfusion: nil
    • Complication: nil  

[chemotherapy]

• 2023-05-16 - paclitaxel 135mg/m2 260mg NS 300mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr + [paclitaxel 40mg/m2 77mg + cisplatin 30mg/m2 58mg + gentamicin 40mg + sodium bicarbonate 2800mg NS 800mL] IP 1hr

  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + NS 500mL pre-C/T + NS 500mL post-C/T

• 2023-04-23 - [Liposome doxorubicin 30mg/m2 60mg D5W 250mL 90min + carboplatin AUC 5 700mg NS 250mL] IP (HIPEC)

• 2023-03-28 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr

  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2023-03-07 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr

  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2023-02-09 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr

  • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2023-01-20 - paclitaxel 175mg/m2 360mg NS 300mL 1hr + carboplatin AUC 5 740mg NS 250mL 2hr

  • dexamethasone 8mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

701182498

230530

[exam findings]

• 2023-05-29 CXR
  • There are few nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
  • Borderline cardiomegaly
• 2023-04-19 CT - abdomen
  • History and indication: Endometrial CA s/p TAH + BSO + BPLND and para-aortic LND on 20190612, pT2N1a(cM0), stage III & s/p CCRT.
    • 20230104 chest CT: bilateral pulmonary metastases and mediastinal and hilar LNs metastases, in progression as compared with CT on 2022/11/10
  • MD CT (Revolution) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images with axial and coronal reformatted isotropic images were obtained in non-contrast scan and portal venous phase scan after IV contrast injection.
  • FINDINGS: Comparison: prior chest CT dated 2023/01/04.
    • Prior CT identified bilateral pulmonary metastases are noted again, decreasing in size that is c/w lung metastases S/P C/T with partial response.
      • In addition, Prior CT identified mediastinal and hilar LNs metastases are noted again, decreasing in size that is c/w mediastinal and hilar LNs metastases S/P C/T with partial response.
    • S/P hysterectomy
    • Left renal angiomyolipoma 1.3 cm is noted.
    • Few small gallstones are noted.
  • IMP:
    • Lung metastases S/P C/T show partial response.
      
    • Mediastinal and hilar LNs metastases S/P C/T show partial response.
• 2023-03-19 CXR
  • One nodular opacity over right middle lung zone.
• 2023-02-06 CXR
  • There are few nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
• 2023-01-04 CT - chest
  • Indication: endometrioid adenocarcinoma, pTNM: pT2N1a(cM0), stage III s/p TAH + BSO + BPLND and para-aortic LND, recurrent lung mets
  • Comparison was made with previous CT dated on 2022/11/10
    • Lungs:
      • s/p op change in left upper and lower lobes.
      • multiple solid nodules in bilateral lungs up to 23mm at RLL
      • consistent with metastatic tumors.
    • Mediastinum and hila: metastatic LAP at Lt hilum and Lt
    • Pleura: unremarkable.
    • Visible abdominal contents: a left renal angiomyolipoma (7 mm) and a few tiny stone in the gallbladder. unremarkable of the liver, spleen, adrenal glands, pancreas, and Rt kidney. no enlarged lymph node.
    • Visualized bones: unremarkable.
  • Impression:
    • bilateral pulmonary metastases and mediastinal and hilar LNs metastases, in progression as compared with CT on 2022/11/10
• 2023-01-03 CXR
  • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
• 2022-11-28 CXR
  • Solitary pulmonary nodule at bil. lungs.
• 2022-11-10 CT - chest
  • Indication: Malignant neoplasm of endometrium; Sleep disorder, unspecified
  • Chest:
    • Nodular lesions are found at both lungs up to 1.84cm in largest dimension. In comparison with CT dated on 2022-04-07, the lesions are enlarged.
    • No evidence of bilateral pleural effusion.
  • Visible abdomen:
    • There is stone at dependent portion of GB. GB stone(s) are noted.
    • Fat containing tumor at middle zone of left kidney up to 1.0cm in largest dimension. Angiomyolipoma.
  • Imp: Nodular lesions are found at both lungs. In enlargement. Lung meta is favored.
• 2022-11-01 CT - abdomen
  • Clinical history: 42 y/o female patient with endometrioid adenocarcinoma, pTNM: pT2N1a(cM0), stage III s/p TAH + BSO + BPLND and para-aortic LND on 6/12 19 s/p CCRT
  • With and without contrast enhancement CT of abdomen–whole:
    • S/P hysterectomy.
    • Fatty content tumor, 1.5cm in left kidney, r/o renal AML.
    • Presence of gallbladder stones.
    • Bilateral lower lung tumors, up to 1.5cm in left lower lung, r/o lung metastasis.
  • Impression:
    • S/P hysterectomy.
    • Left renal AML.
    • Gallbladder stones.
    • Bilateral lung tumors, r/o lung metastasis.
• 2022-08-09 SONO - abdomen
  • Few gallstones are noted and the size < 1 cm.
  • Angiomyolipoma 1.37 cm in left kidney middle pole.
• 2022-04-07 CT - chest
  • Left renal angiomyolipoma.
  • s/p right upper lobe and left lower lobe op.
  • There is no evidence of recurrent/residual tumor in the study.
• 2022-03-08 CT - abdomen
  • S/P hysterectomy. A nodule (4mm) at left lower lung. R/O left renal angiomyolipoma (9mm). Small gallbladder stones (2-4mm).
• 2021-12-17 CT - abdomen
  • S/P hysterectomy. There is no evidence of tumor recurrence.
• 2021-09-03 CT - abdomen
  • S/P hysterectomy. There is no evidence of tumor recurrence.
    
  • Prior CT identified few small nodules in bilateral lower lung are not noted in the current CT. Follow up chest CT 3 months later is indicated.
• 2021-07-27 CT - chest
  • endometrial CA recurrence wt lung mets s/p C/T.
  • Comparison made with previous CT dated on 2021/6/12
    • Lungs:
      • s/p op change in left upper and lower lobes.
      • multiple solid nodules in bilateral lungs up to 10 mm at LLL
      • consistent with metastatic tumors.
    • Mediastinum: no enlarged LN or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion.
    • Hila: unremarkable.
    • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Chest wall: unremarkable.
    • Visible abdominal contents: a left renal angiomyolipoma (7 mm) and a few tiny stone in the gallbladder. unremarkable of the liver, spleen, adrenal glands, pancreas, and Rt kidney. no enlarged lymph node.
    • Visualized bones: unremarkable.
  • Impression:
    • bilateral pulmonary metastases are still visible.
• 2021-06-12 CT - chest
  • Indication: Endometrioid adenocarcinoma, Grade 2, pTNM: pT2N1a(cM0), FIGO stage IIIC1 s/p TAH + BSO + BPLND and recurrent lung mets S/P op
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
      • s/p left upper lobe and left lower lobe op.
      • Minimal fobritc like change at right upper lobe is found. In comparison with CT dated on 2021-01-06, the lesion regressed markedly.
        
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • s/p ATH and BSO.
      • There is no ascites accumulation at abdominal cavity.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
  • Imp:
    • s/p ATH and BSO.
    • s/p left upper lobe and left lower lobe op.
    • Regression of right upper lobe and right middle lobe nodules.
• 2021-01-26 Patho - lung wedge biopsy
  • Lung, left, lower lobe, wedge resection —- Consistent with metastatic endometrioid adenocarcinoma
  • Lung, left, upper lobe, wedge resection —- Consistent with metastatic endometrioid adenocarcinoma
  • Histologic Type (select all that apply): Consistent with metastatic endometrioid adenocarcinoma
  • The immunohistocehmical stains reveal CK7(focal +), CK20(-), PAX8(+), PR(-), and TTF-1(-).
    
  • Histologic Grade: G2: Moderately differentiated
• 2021-01-25 CXR
  • nodules in both lungs due to metastasis.
  • s/p left chest tube in place, its tip directed superiorly
• 2021-01-06 CT - chest
  • Findings: multiple solid nodules in bilateral lungs up to 12 mm in LLL, consistent with metastatic tumors.
  • Impression: consistent bilateral pulmonary metastases.
• 2020-12-17 CT - abdomen
  • Findings
    • Small nodules (4-8mm) at bil. lower lungs.
    • R/O left renal angiomyolipoma (9mm).
    • Small gallbladder stone (4mm).
  • Impression:
    • S/P hysterectomy. Small nodules (4-8mm) at bil. lower lungs r/o metastases.
• 2020-09-24 SONO - abdomen
  • Sonography of hepatobiliary system revealed:
    • Gallbladder stone (0.61cm).
    • R/O left renal angiomyolipoma (0.94x1.05cm).
  • IMP: gall stone and left renal angiomyolipoma.
• 2020-05-15 CT - abdomen
  • S/P hysterectomy. There is no evidence of tumor recurrence.
• 2020-04-10 Treadmill exercise test, TET
  • Resting ECG : Normal
  • ST changes during TET : No significant ST changes
  • Interpretation : negative for ischemia
• 2020-04-10 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 22.5) / 81.3 = 72.32%
    • M-mode (Teichholz) = 72.3
  • Conclusion:
    • Normal AV with no AR
    • Thickened MV with mild MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, mild TR, normal IVC size
• 2019-12-18 CT - abdomen
  • S/P hysterectomy. No evidence of tumor recurrence.
• 2019-06-19 Phleborheograph (PRG) & Perivasculary doppler flowmetry
  • Doppler study: (N= Normal, A= Abnormal, T= Thrombus)
    • Lower limbs R-CFV R-SFV R-PV R-PTV R-SV L-CFV L-SFV L-PV L-PTV L-SV
    • Spontaneous signal A A A A A A A A A A
    • Respiratory changes N N N N N N N N N N
    • Cough response N N N N N N N N N N
    • Compression study N N N N N N N N N N
  • Findings
    • Thrombus ：None
    • Varicose vein ：None
  • Conclusion
    • No evidence of DVT, bilateral lower legs
    • Biateral CFV contiunce flow pattern, etiology; upstream stenosis could not be rule out.
• 2019-06-17 CT - pelvis
  • S/P operation. Some fluid and air collection in pelvic cavity (s/p drainage) and left posterior pararenal space. R/O left renal angiomyolipoma (9mm). Bil. pleural effusion. General subcutaneous edema.
• 2019-06-12 Surgical pathology Level VI
  • PATHOLOGIC DIAGNOSIS:
    • Uterus, endometrium, total abdominal hysterectomy — endometrioid adenocarcinoma, Grade 2 — pTNM: pT2N1a(cM0) , FIGO stage: IIIC1, pStage IIIC1
    • Uterus, myometrium, total abdominal hysterectomy — involved by endometrioid adenocarcinoma (> 1/2 thickness)
    • Uterus, cervix, otal abdominal hysterectomy — involved by endometrioid adenocarcinoma (stromal connective tissue involvement) — free of lower cervical margin
    • Fallopian tube, bilateral, salpingectomy — negative for malignancy
      
    • Ovary, bilateral, oophorectomy — negative for malignancy
      
    • Lymph node, left iliac, dissection — negative for malignancy ( 0 / 1 )
    • Lymph node, left obturator, dissection — positive for malignancy ( 2 / 7 )
    • Lymph node, right iliac, dissection — positive for malignancy ( 2 / 10 )
    • Lymph node, right obturator, dissection — positive for malignancy ( 1 / 4 )
    • Lymph node, left para-aortic, dissection — negative for malignancy ( 0 / 4 )
    • Lymph node, rightt para-aortic, dissection — negative for malignancy ( 0 / 4 )
    • Pathology stage:pTNM: — pTNM: pTNM: pT2N1a(cM0), FIGO stage: IIIC1, pStage IIIC1
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: total abdominal hysterectomy, LN dissection
    • Specimens include: uterus with bilateral adnexae,regional LNs,
    • Tumor site: upper and lower body, fundus and cervix
      
    • Tumor size: 9x 6 cm
    • The myometrium: Tumor invades more than one-half of myometrium (2 cm)
    • The cervix: free of tumor (0.5 cm away from margin)
    • Adnexa: unremarkable
    • Lymph node: bilateral iliac, obturator and para-aortic LNs are received.
  • MICROSCOPIC EXAMINATION
    • Histology type: endometrioid adenocarcinoma
    • Histology grade: grade 2
      
    • Depth of invasion: Tumor invades more than one-half of myometrium (2 cm)
      
    • Lymphovascular invasion: Present
    • The cervical stromal connective involvement: Present
    • Resection margins of the cervix (or vagina): free (0.5 cm)
    • Additional pathologic findings:
      • Endometrial hyperplasia: Absent
      • (squamous) metaplasia: Present
      • adenomyosis: Absent
    • Bilateral adnexa: free of tumor
      
    • Lymph node metastasis
      • Group as specified No. Positive / No. Total
      • Left iliac ( 0 / 1 )
      • Left obturator ( 2 / 7 )
      • Right iliac ( 2 / 10 )
      • Right obturator ( 1 / 4 )
      • Left para-aortic ( 0 / 4 )
      • Right para-aortic ( 0 / 4 )
      • over all 5 / 30
    • IHC stain — ER(-), PR(-), TTF-1(-), CK20(-), PAX-5(-)
• 2019-06-10 Surgical pathology Level IV
  • Uterus, endometrium, D&C — Adenocarcinoma
  • Uterus, cervix, biopsy — Adenocarcinoma.
  • IHC stains: (S2019-9114) ER (-, 0%), PR (-, 0%); vimentin (+++), p16 (equivocal 20-60%), CK (+).
• 2019-06-06 MRI - pelvis
  • Clinical history: 39 y/o female patient with huge cervical mass, R/O myoma or malignancy.
  • WITHOUT enhancement MRI pelvis:
    • There is huge soft tissue tumor (12cm), extention from uterine cavity into the cervical area, can’t rule out malignancy.
    • Minimal ascites.
    • No enlarged lymph node in the pelvic cavity and paraaortic region.
    • Cystic lesion, 1.5cm in right pelvic cavity, r/o lymphocele.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression:
      • Huge soft tissue tumor(12cm), extention from uterine cavity into the cervical area, can’t rule out malignancy.
      • R/O lymphocele in right pelvic cavity, 1.5cm.
    • Clinical proven endometrial malignancy, cstage T2N0Mx.
• 2019-06-06 Gynecologic ultrasonography
  • R/O Huge cervical mass (58mmx71mm)

[chemotherapy]

• 2023-04-18 - topotecan 0.6mg/m2 1mg NS 100mL 30min D1-3 + cisplatin 40mg/m2 68mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-06 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + topotecan 0.6mg/m2 1mg NS 100mL 30min D1-3 + cisplatin 40mg/m2 68mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-04 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + topotecan 0.6mg/m2 1mg NS 100mL 30min D1-3 + cisplatin 40mg/m2 68mg NS 500mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-12-03 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg
• 2021-11-10 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg
• 2021-10-19 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg
• 2021-09-28 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg
• 2021-09-03 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg
• 2021-08-04 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg
• 2021-07-13 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-06-11 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-05-03 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-04-08 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-03-15 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 75mg/m2 126mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-02-23 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2020-02-10 - paclitaxel 175mg/m2 210mg D5W 250mL 3hr + carboplatin AUC 4 250mg 4hr mannitol 20% 80mL NS 250mL 4hr
  • dexamethasone 5mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2020-01-03 - paclitaxel 175mg/m2 210mg D5W 250mL 3hr + carboplatin AUC 4 250mg 4hr mannitol 20% 80mL NS 250mL 4hr
  • dexamethasone 5mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

[note]

Systemic Therapy for Endometrial Carcinoma - Endometrial Carcinoma - NCCN Clinical Practice Guidelines in Oncology - NCCN Evidence Blocks - Version 2.2023 - April 28, 2023 - ENDO-D

Primary or Adjuvant Therapy (Stage I-IV)

• Chemoradiation Therapy
  • Preferred Regimens
    • Cisplatin plus RT followed by carboplatin/paclitaxel
• Systemic Therapy
  • Preferred Regimens
    • Carboplatin/paclitaxel
    • Carboplatin/paclitaxel/pembrolizumab (for stage III-IV tumors, except for carcinosarcoma) (category 1)
    • Carboplatin/paclitaxel/dostarlimab-gxly (for stage III-IV tumors) (category 1)
    • Carboplatin/paclitaxel/trastuzumab (for stage III/IV HER2-positive uterine serous carcinoma)
    • Carboplatin/paclitaxel/trastuzumab (for stage III/IV HER2-positive carcinosarcoma) (category 2B)

Recurrent Disease

• First-Line Therapy for Recurrent Diseaseh
  • Preferred
    • Carboplatin/paclitaxel (category 1 for carcinosarcoma)
    • Carboplatin/paclitaxel/pembrolizumab (except for carcinosarcoma) (category 1)
    • Carboplatin/paclitaxel/dostarlimab-gxly (category 1)
    • Carboplatin/paclitaxel/trastuzumab (for HER2-positive uterine serous carcinoma)
    • Carboplatin/paclitaxel/trastuzumab (for HER2-positive carcinosarcoma) (category 2B)
  • Other Recommended Regimens
    • Carboplatin/docetaxel
    • Carboplatin/paclitaxel/bevacizumab
  • Useful in Certain Circumstances (Biomarker directed: after prior platinum-based therapy including neoadjuvant and adjuvant)
    • Lenvatinib/pembrolizumab (category 1) for mismatch repair proficient (pMMR) tumors
    • Pembrolizumab for TMB-H or MSI-H/dMMRm tumors
    • Dostarlimab-gxly for dMMR/MSI-H tumors
• Second-Line or Subsequent Therapy
  • Other Recommended Regimens
    • Cisplatin/doxorubicin
    • Cisplatin/doxorubicin/paclitaxel
    • Cisplatin
    • Carboplatin
    • Doxorubicin
    • Liposomal doxorubicin
    • Paclitaxel
    • Albumin-bound paclitaxel
    • Topotecan
    • Bevacizumab
    • Temsirolimus
    • Cabozantinib
    • Docetaxelf (category 2B)
    • Ifosfamide (for carcinosarcoma)
    • Ifosfamide/paclitaxel (for carcinosarcoma)
    • Cisplatin/ifosfamide (for carcinosarcoma)
  • Useful in Certain Circumstances (Biomarker directed therapy)
    • Lenvatinib/pembrolizumab (category 1) for mismatch repair proficient (pMMR) tumors
    • Pembrolizumabb for TMB-H or MSI-H/dMMR tumors
    • Dostarlimab-gxly for dMMR/MSI-H tumors
    • Larotrectinib or entrectinib for NTRK gene fusion-positive tumors (category 2B)
    • Avelumab for dMMR/MSI-H tumors
    • Nivolumab for dMMR/MSI-H tumors
• Hormonal Therapy for Recurrent or Metastatic Endometrial Carcinoma
  • Preferred Regimens
    • Megestrol acetate/tamoxifen (alternating)
    • Everolimus/letrozole
  • Other Recommended Regimens
    • Medroxyprogesterone acetate/tamoxifen (alternating)
    • Progestational agents
      • Medroxyprogesterone acetate
      • Megestrol acetate
    • Aromatase inhibitors
    • Tamoxifen
    • Fulvestrant
• Hormonal Therapy for Uterine Limited Disease Not Suitable for Primary Surgery
  • Preferred Regimens
    • Progestational agents
      • Medroxyprogesterone acetate
      • Megestrol acetate
  • Useful in Certain Circumstances
    • Levonorgestrel intrauterine device (IUD)

==========

2023-05-30

• According to the PharmaCloud database, the patient has visited a local clinic in Xindian for an unspecified acute upper respiratory infection 4 times in the past 3 months, beginning on 2023-03-15. The patient’s most recent visit was yesterday, on 2023-05-29, during which ibuprofen, dextromethorphan, and pseudoephedrine were prescribed. None of these medications are present on the current active medication list, and the acute upper respiratory infection is not listed in the clinical problem list. Please confirm whether the respiratory symptoms are still present. Thank you!

700529576

230529

[diagnosis] - 2023-03-27 discharge note

• Malignant neoplasm of extrahepatic bile duct
• Urinary tract infection, site not specified

[past history]

• Type 2 DM
• Hypertension
• Dyslipidemia

        

[allergy]

• NKDA         

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-04-23 CXR

  • Boderline cardiomegaly
  • Tortuosity of the aorta with atherosclerotic change.
  • Increased lung markings over both lungs.
  • Degenerative joint disease of T-spine with marginal osteophytes.

• 2023-04-18 SONO - abdomen

  • liver cyst, both lobe
  • post cholestectomy
  • post stenting to bilateral IHD

• 2023-04-13 CXR

  • Ground glass opacity in bilateral lower lungs.
  • S/P operation with retention of surgical clips.
  • S/P CBD stenting.

• 2023-04-11 CXR

  • Ground glass opacity in LLL.

• 2023-03-24, -03-17 CXR

  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.

• 2023-03-21 CT - abdomen

  • History and indication: Klatskin tumor (Cancer that forms in the area where the left and right hepatic ducts join just outside the liver and form the common hepatic duct. Bile ducts carry bile from the liver and gallbladder to the small intestine. Klatskin tumor is a type of extrahepatic bile duct cancer. Also called perihilar bile duct cancer and perihilar cholangiocarcinoma. 2023-04-14 https://www.cancer.gov/publications/dictionaries/cancer-terms/def/klatskin-tumor)
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction. With and without-contrast CT of abdomen-pelvis revealed:
    • S/P CBD stenting. Dilatation of bil. IHD and distention of gallbladder.
    • Mild enlargement of left thyroid gland. Minimal ascites.
    • Mild bronchiectasis at LLL.
    • R/O right renal cyst (2.5cm).
    • Normal appearance of spleen, pancreas, adrenals.
    • Degeneration and spondylosis of L-S spine.
    • No enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • S/P Port-A infusion catheter insertion.
    • S/P foley catheter indwelling.
  • IMP:
    • S/P CBD stenting. Dilatation of bil. IHD and distention of gallbladder.
    • Mild bronchiectasis at LLL.

• 2023-03-17 KUB

  • S/P plastic stent implantation in between the IHDs and duodenum
  • S/P Foley’s catheter insertion at the urinary bladder.
  • Fecal material store in the colon.
  • Spondylosis of the L-spine is noted.

• 2023-03-15, -03-12 CXR

  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Widening of the upper mediastinum is noted, which may be innominate vessel or tumor. Please correlate with standing p-a view or CT.

• 2023-02-12 ECG

  • Sinus tachycardia
  • Possible Left atrial enlargement
  • Left axis deviation
  • Abnormal ECG

• 2023-01-09 Nasopharyngoscopy

  • via right nasal cavity: patent right nose, patent right E tube orifice, NPx seemed smooth

• 2022-12-28 Cholangiography

  • Cholangiography via bil. PTCD catheters administration revealed:
    • Patency of the catheters. Mild migration of right PTCD catheter.
    • Obstruction of left proximal IHD.
    • Partial obstruction of right proximal IHD.
    • S/P operation with retention of surgical clips.

• 2022-12-28 Endoscopic Retrograde CholangioPancreatography, ERCP

  • diagnosis:
    • Klatskin tumor, post bilateral PTCD, status post bilateral stricture balloon dilation and stenting to right anterior branch and right IHDs
    • Non-visualized GB
  • suggestion:
    • Please keep antibiotics treatment for high post ERCP cholangitis risk

• 2022-12-26 Percutaneous Transhepatic Cholangio-Drainage, PTCD

• 2022-12-23 Patho - gallbladder (benign lesion)

  • A: Gallbladder, cholecystectomy — chronic cholecystitis
    
  • B: Lymph node, group 12a, excision — negative for malignancy (0/1)
  • C: Lymph node, group 12c, excision — negative for malignancy (0/1)
  • F2022-00624 - Lymph node, zone 12 and 8, excision — Negative for malignancy (0/2)

• 2022-12-12 Percutaneous Transhepatic Cholangio-Drainage, PTCD

• 2022-12-12 SONO - abdomen

  • C/W hilar tumor with left IHD and right IHD branch (B6) dilation
  • Renal cysts, RK
  • Hepatic cysts, both lobe

• 2022-12-11, -11-08 CXR

  • Atherosclerosis of the aorta.
  • Enlargement of right hilum.

• 2022-11-11 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (77.3 - 24.4) / 77.3 = 68.43%
    • M-mode (Teichholz) = 68.4
    • 2D (M-simpson) = 64.4
  • Normal AV with mild AR
  • Normal MV with trivial MR
  • Normal LV chamber size and wall thickness
  • Preserved LV and RV systolic function
  • Mild PR, trivial TR, normal IVC size

• 2022-11-22 Flow volume chart

  • mild obstructive ventilatory impairment

• 2022-11-21 SONO - abdomen

  • C/W hilar tumor with left IHD and right IHD branch (B6) dilation
  • ERBD in situ (ERBD: Endoscopic Retrograde Biliary Drainage)
  • Renal cysts, RK

• 2022-11-17 CT - abdomen

  • S/P CBD stenting.
  • Dilatation of bil. IHD and distention of gallbladder.
  • Mild bronchiectasis at LLL.

• 2022-11-12 MRI - MR Cholangiography, MRCP

  • History and indication: Jaundice
  • IMP: In favor of Klatskin tumor with bil. proximal IHD invasion. Some LNs at hepatic hilar region.

• 2022-11-11 Patho - liver biopsy needle/wedge

  • Bile duct, tip of cytoplogy brush, ERCP — Negative for malignancy

• 2022-11-10 Endoscopic Retrograde CholangioPancreatography, ERCP

  • Diagnosis
    • Klastin tumor with obstructive jaundice, suspicious Bismuth-Corlette classification type I, s/p EPBD + brush cytology + ERBD (right IHD)
    • Duodenal ulcer, shallow, bulb
    • Duodenitis, bulb
  • Suggestion
    • On NPO except water tonight
    • f/u Hb, serum AST/ALT, T-bil, lipase on the next morning (11/11)
    • PPI Rx.

• 2022-11-09 CT - abdomen

  • History and Indication: obstructive jaundice.
    • 20221108 CA199:811 U/mL (<35), CEA and AFP:normal.
  • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is a soft tissue mass in the trifurcation of both lobe IHDs and CHD, measuring 1.5 cm in size, causing IHDs dilatation and this mass directly attached the S4 liver.
      • Klatskin tumor (T2b) is highly suspected.
      • In addition, There are four enlarged nodes in the hepatoduodenal ligament (N2).
    • There are several enlarged nodes in gastrohepatic ligament, para-aortic space and para-cava space that may be non-regional lymph nodes metastases (M1).
    • There is linear calcification in the gallbladder fossa. please correlate with clinical condition.
    • There are several renal cysts on both kidney and the largest one measuring 2.4 cm in size at right upper pole.
    • Others
      • There is no focal abnormality in the pancreas, spleen & both kidney.
        
      • There is no ascites.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
    • IMP:
      • Klatskin tumor is highly suspected.
      • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for perihilar CCC: T2b N2 M1, stage:IVB

• 2021-04-13 Bone densitometry - hip

  • Hip BMD performed by DXA revealed:
  • Hip, BMD is 0.637 gms/cm2, about 1.9 SD below the peak bone mass (75 %) and 0.4 SD above the mean of age-matched people (108%).
  • IMP: osteopenia

[consultation]

• 2023-01-09 Ear Nose Throat
  • Q
    • For left ear tinnitus
    • This 81 y/o female was a case of Klastin tumor with obstructive jaundice, T2bN2M1, stage:IVB, s/p ERBD on 2022/11/10. This time, she was admitted for further operation. However, TBI showed 15.21 was noted. Abdomen echo was performed which showed C/W hilar tumor with left IHD and right IHD branch (B6) dilation. Right side PTCD insertion was done smoothly on 2022/12/12. Operation was perfomred which revaled CHD tumor with direct bification and right portal vein invasion and severe fatty liver was noted, then no further operation is proceed due to high risk of hepatic failure. Due to persisted of TBI > 6, left side PTCD was inserted on 2022/12/26. In recent, she felt left ear tinnitus for 2 days. No other cold side were noted in recently. We need your help for further assessment for this patient. Thanks for your time!!
  • A
    • S:
      • Left tinnitus for 2 days, high frequency, especially when talking? Autophony?
      • hearing loss-, aural fullness-, dizziness-
      • NO-, Rhinorrhea+, Sneezing+
    • O:
      • Bil TM intact, EAC clean
      • Bil TM atrophic scar
      • Scope:
        • via right nasal cavity: patent right nose, patent right E tube orifice, NPx seemed smooth
        • the patient can’t tolerate the nasopharyngoscopy and refused further exam
      • Hearing exam:
      • Rinne test: Bil AC > BC
      • Weber: no lateralization
    • A:
      • Left tinnitus, cause?
      • DDx: patulous E tube
    • Plan:
      • may try kentamin if no contraindication
      • The patient refused further exam currently (PTA/typanometry or complete nasopharyngoscopy)
      • The patulous E tube may be improved by lying down or lower the head
      • Please arrange ENT OPD f/u
• 2022-12-23 Radiation Oncology
  • A:
    • A: Klatskin tumor with bil. proximal IHD and portal vein invasion, s/p open cholecystectomy. LN 8,12, dissection.
    • P: Radiotherapy is indicated for this patient with the following indicators: unresectable Klatskin tumor
      • Goal: palliation
      • Treatment target and volume: Klatskin tumor and peripheral involved nodal lesions.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the Klatskin tumor and peripheral involved nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2023-01-19.

[surgical operation]

• 2022-12-22
  • Surgery
    • open cholecystectomy
    • LN 8,12, dissection
  • Finding
    • CHD tumor with direct bification and right portal vein invasion
    • regional LN8 and 12 enlarge
    • severe fatty liver

[MedRec]

• 2023-05-24 SOAP Hemato-Oncology
  • S: supportive treatment with oral UFT
  • Prescription
    • UFT (tegafur 100mg, uracil 224mg) 1# BID 7D
• 2023-05-17 SOAP Hemato-Oncology
  • Plan
    • explain the clinical condition to patient’s daugther
    • suggest oral chemotherapy with UFUR
  • Prescription
    • UFT (tegafur 100mg, uracil 224mg) 1# BID 7D
• 2023-01-30 SOAP Hemato-Oncology
  • explain to pt & her son about the indication & risk / benefit of palliative CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T

[radiotherapy]

• 2023-01-19 ~ undergoing - 3960cGy/22 fractions (15 MV photon) of the Klatskin tumor and peripheral involved nodal lesions.

[chemotherapy]

• 2023-05-17 ~ undergoing - UFT (tegafur 100mg, uracil 224mg) 1# BID

• 2023-02-06 - fluorouracil 200mg/m2 300mg NS 500mL 24hr D1-5

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

• 2023-02-02 - fluorouracil 200mg/m2 300mg NS 500mL 24hr D1-2

  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

[note]

Principles of Systemic Therapy — NCCN Clinical Practice Guidelines in Oncology - Biliary Tract Cancers - Version 2.2023 - May 10, 2023 - BIL-C

• Neoadjuvant Therapy
  • Preferred Regimens
    • None
  • Other Recommended Regimens
    • FOLFOX
    • Capecitabine + oxaliplatin
    • Gemcitabine + capecitabine
    • Gemcitabine + cisplatin
    • Durvalumab + gemcitabine + cisplatin
    • Gemcitabine + cisplatin + albumin-bound paclitaxel (category 2B)
  • Useful in Certain Circumstances
    • None
• Adjuvant Therapy
  • Preferred Regimens
    • Capecitabine (category 1)
  • Other Recommended Regimens
    • FOLFOX
    • Capecitabine + oxaliplatin
    • Gemcitabine + capecitabine
    • Gemcitabine + cisplatin
    • Capecitabine + cisplatin (category 3)
    • Single agents:
      • 5-fluorouracil
      • Gemcitabine
  • Useful in Certain Circumstances
    • None
• Agents Used with Concurrent Radiation
  • 5-fluorouracil
  • Capecitabine
• Primary Treatment for Unresectable and Metastatic Disease
  • Preferred Regimens
    • Durvalumab + gemcitabine + cisplatin (category 1)
  • Other Recommended Regimens
    • Gemcitabine + cisplatin (category 1)
    • FOLFOX
    • Capecitabine + oxaliplatin
    • Gemcitabine + albumin-bound paclitaxel
    • Gemcitabine + capecitabine
    • Gemcitabine + oxaliplatin
    • Gemcitabine + cisplatin + albumin-bound paclitaxel (category 2B)
    • Single agents:
      • 5-fluorouracil
      • Capecitabine
      • Gemcitabine
  • Useful in Certain Circumstances
    • Targeted therapy
      • For NTRK gene fusion-positive tumors:
        • Entrectinib
        • Larotrectinib
      • For MSI-H/dMMR tumors:
        • Pembrolizumab
      • For TMB-H tumors:
        • Nivolumab + ipilimumab (category 2B)
      • For RET gene fusion-positive tumors:
        • Pralsetinib (category 2B)
        • Selpercatinib for CCA (category 2B)
• Subsequent-Line Therapy for Biliary Tract Cancers if Disease Progression
  • Preferred Regimens
    • FOLFOX
  • Other Recommended Regimens
    • FOLFIRI (category 2B)
    • Regorafenib (category 2B)
    • Liposomal irinotecan + fluorouracil + leucovorin (category 2B)
    • See also: Preferred and Other Recommended Regimens for Unresectable and Metastatic Disease above
  • Useful in Certain Circumstances
    • Nivolumab (category 2B)
    • Lenvatinib + pembrolizumab (category 2B)
    • Targeted therapy
      • For NTRK gene fusion-positive tumors:
        • Entrectinib
        • Larotrectinib
      • For MSI-H/dMMR tumors:
        • Pembrolizumab
        • Dostarlimab-gxly (category 2B)
      • For TMB-H tumors:
        • Nivolumab + ipilimumab
        • Pembrolizumab
      • For BRAF V600E-mutated tumors:
        • Dabrafenib + trametinib
      • For CCA with FGFR2 fusions or rearrangements:
        • Futibatinib
        • Pemigatinib
      • For CCA with IDH1 mutations
        • Ivosidenib (category 1)
      • For HER2-positive tumors:
        • Trastuzumabk + pertuzumab
      • For RET gene fusion-positive tumors:
        • Selpercatinib for CCA
        • Pralsetinib (category 2B)

Principles of Systemic Therapy — NCCN Clinical Practice Guidelines in Oncology - Hepatocellular Carcinoma - Version 1.2023 - March 10, 2023 - HCC-G

• First-Line Systemic Therapy
  • Preferred Regimens
    • Atezolizumab + bevacizumab (Child-Pugh Class A only) (category 1)
    • Tremelimumab-actl + durvalumab (category 1)
  • Other Recommended Regimens
    • Sorafenib (Child-Pugh Class A [category 1] or B7)
    • Lenvatinib (Child-Pugh Class A only) (category 1)
    • Durvalumab (category 1)
    • Pembrolizumab (category 2B)
  • Useful in Certain Circumstances
    • Nivolumab (Child-Pugh Class B only)
    • Atezolizumab + bevacizumab (Child-Pugh Class B only)
    • For TMB-H tumors:
      • Nivolumab + ipilimumab (category 2B)
• Subsequent-Line Systemic Therapy if Disease Progression
  • Options
    • Regorafenib (Child-Pugh Class A only) (category 1)
    • Cabozantinib (Child-Pugh Class A only) (category 1)
    • Lenvatinib (Child-Pugh Class A only)
    • Sorafenib (Child-Pugh Class A or B7)
  • Other Recommended Regimens
    • Nivolumab + ipilimumab (Child-Pugh Class A only)
    • Pembrolizumab (Child-Pugh Class A only)
  • Useful in Certain Circumstances
    • Ramucirumab (AFP >=400 ng/mL and Child-Pugh Class A only) (category 1)
    • Nivolumab (Child-Pugh Class B only)
    • For MSI-H/dMMR tumors -Dostarlimab-gxly (category 2B)
    • For RET gene fusion-positive tumors:
      • Selpercatinib (category 2B)
    • For TMB-H tumors:
      • Nivolumab + ipilimumab (category 2B)

==========

2023-05-29

• The patient’s treatment was changed to UFT (a combination of Tegafur and Uracil) on 2023-05-17. There is limited data on the tolerability of UFT in older adults. However, in a study with a control group of 39 patients over 70 years of age who had undergone resection for colorectal cancer and received UFT alone, adverse events were rare and all were grade 2 or less (Reference: Cancer Biother Radiopharm. 2009;24(1):35-40). Given the patient’s advanced age, the chosen drug appears to be appropriate.

• The drug UFT is approved in Taiwan and other countries, but is not approved by the FDA, Health Canada, or the European Medicines Agency (EMA), and is therefore not recommended by the NCCN guidelines. UFT consists of a 1:4 molar combination of tegafur (a prodrug of 5-FU) and uracil (which competitively inhibits the degradation of 5-FU, resulting in sustained plasma and intratumoral concentrations). As tegafur is a prodrug of 5-FU, which has already been used in this patient in concurrent chemoradiotherapy (CCRT), the efficacy of this approach should be continuously monitored as always.

2023-04-14

• Amsulber (ampicillin, sulbactam) is used due to 2023-04-13 CRP 2.1mg/dL and CXR showed ground glass opacities in bilateral lower lungs.

• Baogan (silymarin) is being used for the patient’s elevated AST and ALT.

2023-03-13

• PharmaCloud database indicates that the medications prescribed within the last 3 months are currently being used properly with no reconciliation issues.

700762682

230529

[exam findings]

• 2022-04-13 CT - abdomen, pelvis
  • S/P segmental small intestine resection and side-to-side duodenojejunostomy.
  • There is marked dilatation from the stomach to duodenum.
• 2021-12-03 Patho - small intestine resection for tumor
  • pathologic diagnosis
    • Jejunum, proximal, segmental resection – Adenocarcinoma, well differentiated
      
    • Resection margins, segmental resection – Free
      
    • Lymph nodes, regional and group 12, segmental resection and LN dissection — Negative for malignancy
      
    • Pathology stage: pT4N0; Stage IIB if cM0
      
  • microscopic examination
    • Histology: Adenocarcinoma
      
    • Histology Grade: well differentiated
      
    • Depth of invasion: To serosa
    • Angiolymphatic invasion: Not identified
      
    • Perineural invasion: Present
      
    • Tumor cell budding: intermediate
      
    • Circumferential (radial) margin: Uninvolved, 5 mm from the margin
      
    • Lymph node metastasis, mesenteric (11) and LN 12(1): Negative (0/12)
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition) pT4N0, if cM0
    • Type of polyp in which invasive carcinoma arose: Tubular adenoma
      
    • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2021-11-25 Patho - small intestine biopsy
  • Tumor, possibly proximal jejunum, biopsy — Villotubular adenoma with high grade dysplasia
• 2021-11-23 MRI - liver, spleen
  • Bil. liver hemangiomas (up to 15.5cm). Inviaible left portal vein.
• 2021-11-17 CT - abdomen, pelvis
  • Huge Hemangioma in S2-3 of the liver with central fibrosis and cystic degeneration is highly suspected.
  • Hemangioma in S4 liver is also suspected.
  • Left lobe portal vein shows small size that may be tumor compression? This feature is relative unusual.
  • Please correlate with MRI to R/O angiosarcoma.
• 2021-05-20 CT - abdomen, pelvis
  • Left liver hemangioma (15.3cm).
  • S/P hysterectomy? Bil. ovary cysts (up to 3.2cm).
• 2021-05-12 Peripheral Vascular Test - Vein, lower limbs
  • Conclusion:
    • No evidene of DVT, bilateral lower legs
    • Both LSV and SSV without reflux
    • Right CFV, LSV and DFV, venous pulstile flow pattern, etiology?
    • Both leg MVO/SVC is related low
  • Suggestion:
    • Because of low MVO/SVC and venous pulstile flow pattern; maybe follow up CT to rule out upstream lesion.

[MedRec]

• 2023-03-28 SOAP Hemato-Oncology
  • O
    • 2023/03/15 Tc-99m MDP whole body bone scan
      • Hot spots in the L4-5 spines, the nature is to be determined (severe DJD or others?), suggesting follow-up with bone scna in 3-6 months for investigation.
      • Suspected benign lesions in both rib cages, maxilla, some lower T-spine, bilateral shoulders, S-I joints, and hips.
    • 2023/03/10 PATHO - peritoneum biopsy
      • R’t ovary tumor, frozen section + RSO — Metastatic adenocarcinoma
      • Pelvic peritoneum, Exp.Lap. — Metastatic adenocarcinoma
  • P
    • Admission for C/T with DFL
• 2021-12-25 SOAP Hemato-Oncology
  • small bowel adenocarcinoma, pT4N0 cM0, Stage IIB, s/p Op on 20211202.
• 2019-04-20 SOAP Cardiology
  • Diagnosis
    • Other forms of angina pectoris [I20.8]
    • Heart failure, unspecified [I50.9]
    • Other pulmonary embolism and infarction [I26.99]
    • Autoimmune disease not eleswhere classified [D89.89]
  • Prescription
    • Coxine (isosorbide-5-mononitrate 20mg) 0.5# PRNQD
• 2019-02-20 SOAP Rheumatology
  • Diagnosis
    • Autoimmune disease not eleswhere classified [D89.89]
    • Arterial embolism and thrombosis of lower extremity [I74.3]
  • Prescription
    • Bokey (aspirin 100mg) 1# QD
    • Plaquenil (hydroxychloroquine 200mg) 1# QD
• 2019-01-22 SOAP Rheumatology
  • S
    • persistent R’t lower leg swelling pain & soreness
  • Diagnosis
    • Autoimmune disease not eleswhere classified [D89.89]
    • Arterial embolism and thrombosis of lower extremity [I74.3]
• 2019-01-15 SOAP Rheumatology
  • S
    • Limb swelling & stiffness sensation, high D-dimer was detected in LMC after mycoplasma infection.
    • Family Hx: SLE (her daughter)
    • Allergy: amoxicillin
  • O
    • maculopapules over bilateral palms
  • Diagnosis
    • Autoimmune disease not eleswhere classified [D89.89]

[consultation]

• 2023-05-25 Diagnostic Radiology
  • Q: This 50-year-old woman patient is a case of Small bowel adenocarcinoma, pT4N0cM0, Stage IIB, s/p left hepatectomy, segmental small intestine resection and side-to-side duodenojejunostomy reconstruction and cholecystectomy on 2021/12/02, s/p adjuvant chemotherapy with FOLFOX finishing in 2022/07/25 (2022/01/03 to 2022/07/25), pelvic cavity metastasis, s/p cytoreductive surgery HIPEC with oxaliplatin, right salpingo-oophorectomy and bilateral ureteral catheterization on 2023/03/09, pT4N0M1, Stage IV s/p palliative chemotherapy with DFL from 2023/04/21. She was admitted for chemotherapy. This time, for Port-A catheter obstruct. Now, for evaluate Antegrade Venograghy. Thank you.
  • A: According to the clinical condition and imaging findings, venography is indicated.
• 2023-03-07 Urology
  • Q: On 2022/11/15 following abdomen CT showed soft tissue tumor, 3.9cm in right pelvic cavity, r/o metastasis. On 11/25 arrange PET revealed a mild glucose hypermetabolic lesion in the right pelvic cavity. The nature is to be determined (a metastatic lesion of low FDG uptake? other nature?). However, she suffered from RLQ dull pain since 2023/02/08, nausea since yesterday. She also had tenesmus, denied of appetite change, no body weight loss, no tarry nor bloody stool. Abdomen CT was performed which revealed a large tumor (10.2cm) in pelvic cavity r/o tumor seeding on 2023/02/14. Physical examination showed abdomen soft and ovoid, mild tenderness over lower abdominal, no palpable mass. Under impression of pelvic tumor suspect small bowel cancer recurrent, she admitted for surgical intervention. She will receive exploratory laparotomy with pelvic tumor excision +- HIPEC on 2023/03/09. We need your expertise for ureteral catheter insertion. Thanks for your times.
  • A: I will arrange catheter insertion
• 2023-02-17 Colorectal Surgery
  • Q: Abdomen CT was performed which revealed a large tumor (10.2cm) in pelvic cavity r/o tumor seeding on 02/14. We need your expertise for pelvic tumor evaluation for colonscopy or sigmoidoscopy.
  • A: please arrange colonoscopy (booking time with 3F GI room), thanks a lot!
• 2023-02-17 Obstetrics and Gynecology
  • Q: On 2022/11/15 following abdomen CT showed soft tissue tumor, 3.9cm in right pelvic cavity, r/o metastasis. On 11/25 arrange PET revealed a mild glucose hypermetabolic lesion in the right pelvic cavity. The nature is to be determined (a metastatic lesion of low FDG uptake? other nature?). However, she suffered from RLQ dull pain since 2023/02/08, nausea since yesterday. She also had tenesmus, denied of appetite change, no body weight loss, no tarry nor bloody stool. Abdomen CT was performed which revealed a large tumor (10.2cm) in pelvic cavity r/o tumor seeding on 02/14. We need your expertise for pelvic tumor for GYN sono evaluation. Thanks for your times.
  • A
    • S
      • This 50 y/o female: 1) Sjogren syndrome; 2) small bowel cancer, pT4N0M0 Stage IIB s/p segmental small intestine resection and side-to-side duodenijejunostomy reconstruction on 2021/12/02 and s/p chemotherapy on 2022/01/03 to 2022/07/05; 3) GYN history of left salpingectomy on 1995, Uterine myoma s/p laparoscopic assisted vaginal hysterectomy on 2017/08/25.
      • She had RLQ pain since 2023/02/08, she denied vaginal bleeding or discharge
      • Pap smear done this year and normal finding was told
    • O
      • 2022/11/15 abdomen CT: soft tissue tumor, 3.9cm in right pelvic cavity, r/o metastasis.
      • 2023/02/14 abdomen CT: A large tumor (10.2cm) in pelvic cavity r/o tumor seeding.
      • 2022/11/25 PET revealed a mild glucose hypermetabolic lesion in the right pelvic cavity
      • Lab:
        • CEA 5ng/mL (2022/11/09)
        • 2023/02/15 WBC 8460, CRP 2.31, Hb 15.6
      • Sono:
        • s/p ATH
        • pelvic mass 113*75mm
        • CDS minimal fluid
    • A
      • Impression: Huge pelvic mass (size 113*75mm), malignancy suspected, tumor seeding cannot be rule out
    • P
      • Suggestion:
        • please f/u tumor marker: CEA, CA199, CA125
        • if operation decided and GYN problem noted, fell free to contact us
• 2021-12-15 Hemato-Oncology
  • Q
    • For further chemotherapy evaluation
    • This 49 years old female has underlying of (1) autoimmune disease under AIR OPD follow and medication control, (2) liver hamengioma was noted for 3years. According to her statement, body weight loss 20kg within 6 months and anemia (Hb: 12 -> 9g/dL) was noted on Sep 2021. Denied of nausea or vomiting, dysphgia, no diarrhea or constipation, no tarry or bloody stool, no abdomen pain. On 2021/09/28 arrange UGI pendoscopy at a local clinic which showed reflux erosive esophagitis, LA grade A, healing GU s/p biopsy, gastric polyp s/p biopsy, chronic superficial gastritis. The pathology revealed chronic gastritis consistent with healed ulcer and polyp. Colonscopy was done and showed mixed hemorrhoids, rectal polyp, s/p biopsy, patholegy revealed hyperplastic polyp.
    • After UGI scopy examination, she suffered from nausea with vomiting postprandial frequently and easy abdomen fullness. Therefore, she visited to our GI OPD on Nov. Abdomen echo was done which revealed (1) liver hemangioma of left lobe, (2) suspicious GB stone, (3) suspicious SMA syndrome. Abdomen CT was arranged and showed huge hemangioma in S2-3 of the liver with central fibrosis and cystic degeneration is highly suspected. However, pertise of symptoms, she went to our ER for help on 2021/11/22. Admitted for further survey and jejuunum tumor s/p biopsy was done. The pathology revealed Villotubular adenoma with high grade dysplasia. She underwent left hepatectomy, segmental small intestine resection and side-to-side duodenijejunostomy reconstruction and cholecystectomy on 2021/12/02. The final pathology showed adenocarcinoma, well differentiated, lymph node with metastesis, pT4N0; Stage IIB if cM0. We need your expertise for further chemotherapy evaluation. Thanks for your times.
  • A
    • The further Tx for the pt wt small bowel adenocarcinoma, pT4N0 cM0, Stage IIB, s/p Op is to be proposed.
    • PH:
      • autoimmune disease under AIR OPD follow and medication control
      • liver hamengioma was noted for 3years.
    • Lab:
      • Jejunum, proximal, segmental resection (2021/12/02): AdenoCA, WD
      • Resection margins, segmental resection – Free
      • LNs, regional and group 12, seg. Resection & LN dissection: Negative for malignancy
    • Pathology stage: pT4N0; Stage IIB if cM0
      • Histology: Adenocarcinoma
        
      • Histology Grade: well differentiated
        
      • Depth of invasion: To serosa
        
      • Perineural invasion: Present
        
      • Tumor cell budding: intermediate
        
      • Circumferential (radial) margin: Uninvolved, 5 mm from the margin
        
      • LN metastasis, mesenteric (11) and LN 12(1): Negative (0/12) (No. Positive / No. Total)
        
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        
      • Primary Tumor (pT): pT4 (Tumor invades serosa)
        
      • Regional Lymph Nodes (pN): pN0 (No regional LN metastasis)
        
      • Distant Metastasis (pM): Not applicable
        
      • Type of polyp in which invasive carcinoma arose: Tubular adenoma
        
      • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
        
      • Tumor, possibly proximal jejunum, biopsy (11/25 21): Villotubular adenoma with high grade dysplasia
        
  • Image study:
    • UGI series (11/24 21): Luminal narrowing of proximal jejunum.
    • EGD (11/24 21)
      • Proximal jejunal tumor, with obstruction, s/p biopsy
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • Bile reflux in stomach
    • CXR (12/11 21):
      • S/P operation.
      • Right CVP inserted to SVC in position.
      • S/P NG tube indwelling.
      • Pneumoperitoneum.
      • Normal appearance of trachea and bil. main bronchus.
      • Normal size of heart
    • Abd CT (11/17 21):
      • Huge Hemangioma in S2-3 of the liver with central fibrosis and cystic degeneration is highly suspected.
        
      • Hemangioma in S4 liver is also suspected.
      • Left lobe portal vein shows small size that may be tumor compression? This feature is relative unusual.
    • Liver MRI (11/23 21):
      • Bil. liver hemangiomas (up to 15.5cm). Inviaible left portal vein.
  • Medical advice:
    • Small bowel adenocarcinoma ( SBA ) is rare cancer that has been treated similarly to colorectal cancer in the advanced setting. Few studies have been published to help guide management of this dz, and resectable and advanced SBA have been primarily treated as an extensin of CRC.
      • Despite SBA being treated as a large intestinal cancer, pt outcomes are inferior.
      • SBA tends to be diagnosed at a later stage compared wt CRC.
        • 33.7% of pt wt SBA ( excluding duodenal ) were diangosed wt stage I-II Dz compared wt 52.3 % of those wt colon cancer.
        • 32.1% of pt wt SBA diagnosed wt distant mets compared wt 15.6% of those wt CRC, from SEER-Medicare database.
      • Molecular biology progress had expanded understanding of SBA.
        • Several hereditary cancer syndromes can predispose individuals to developing SBA. Hereditary nonpolyposis CRC (HNPCC) or Lynch syndrome is an autosomal dominant inheritance of germline mutations in DNA mismatch repair (MMR) genes, including MLH1, MSH2, MSH6, and PMS2, and rarely EPCAM and PMS1.
      • IHC staining of small bowel adenoCA of this pt showed normal MLH1, MSH2, MSH6, and PMS2.
      • The lifetime risk of developing SBA in Lynch-affected individuals remains low at about 1%, according to European registry studies, and therefore no small bowel screening recommendations currently exist.
        • routinely assessing all SBA tumors for deficient MMR (dMMR) gene expression or high microsatellite instability (MSI-H) is indicated and may help predict better therapies, including immune checkpoint therapy, for these patients.
      • Molecular Alterations
        • Recent studies have made major strides in understanding the molecular drivers of SBA and demonstrated SBA to represent a unique molecular entity with distinct differences between both CRC and gastric cancer.
        • APC (26.8% vs 75.9%; P,.001), TP53 (58.4% vs 75%; P,.001), and CDKN2A (14.5% vs 2.6%; P,.001), showed statistically different molecular alterations between SBA and CRC.
    • By NCCN guideline 2021 for small bowel adenocarcinoma, T3, N0,M0 wt high risk features or T4,N0,M0 (MMS or pMMR) , observation or FOLFOX or CAPEOX (3~6 mo) or 5-FU/LV or capecitabine (6 mo) was recommended.
    • The pt is relatively young & pMMR, post-Op adjuvant C/T wt FOLFOX or CAPEOX is recommended.
• 2021-11-22 General and Gastroenterological Surgery
  • assessment:
    • BW loss since 2021-05, 10kg in 4 months (2021-05 ~ 2021-09)
    • frequent abdominal fullness and vominting since 2021-09, BW loss 13kg in 2 months
    • liver tumor over left lobe, favor hemangioma, size stationary
  • impression:
    • dyspepsia, not related to liver tumor, SMA syndrom related?
    • liver tumor over left lobe, favor hemangioma, less likely hemangiosarcoma
  • suggest:
    • admit for UGI series survey
    • PPN support
    • MRI survey

[surgical operation]

• 2021-12-02
  • Surgery
    • left hepatectomy
    • segmental small intestine resection and side-to-side duodenijejunostomy reconstruction
    • cholecystectomy
  • Finding
    • huge hemangioma over left lobe of liver
    • suspect small bowel cancer over proximal jejunum, 10cm distal to the Treiz ligament, no significant LAP
    • no peritoneal seeeding
    • one small gallstone
• 2017-08-25 Laparoscopy hysterectomy
  • Diagnosis
    • adenomyosis
  • Finding
    • Uterus: enlarged, 15x12x5cm, 235gm, adenomyosis-like
    • EM – thickened, endometrial hyperplasia?
    • cervix eroded, dysplasia?
    • bil adnexa: normal-looking
    • CDS: no fluid but pelvic endometriosis and pelvic adhesion were noted between post uterus, bil US ligaments, pelvic walls and bowels s/p laparoscopic fulguration of pelvic endometriosis and lysis

[chemoimmunotherapy]

• 2023-05-25 - docetaxel 60mg/m2 100mg NS 250mL 1hr + leucovorin 300mg/m2 520mg NS 250mL 2hr + fluorouracil 300mg/m2 520mg NS 250mL 10min + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2023-04-21 - docetaxel 60mg/m2 100mg NS 250mL 1hr + leucovorin 300mg/m2 520mg NS 250mL 2hr + fluorouracil 300mg/m2 520mg NS 250mL 10min + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

• 2023-03-09 - [oxaliplatin 300mg/m2 530mg D5W 3000mL + sodium bicarbonate 4200mg + gentamicin] IP 30min

• 2022-07-25 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-07-05 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-06-21 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4790mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-06-08 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4770mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-05-11 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4750mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-04-19 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4790mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-03-28 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-03-14 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-02-24 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-02-11 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-01-19 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-01-03 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-05-29

• The patient received two cycles of the docetaxel and fluorouracil regimen on 2023-04-21 and 2023-05-25. The lowest WBC count (nadir) was observed on 2023-05-02, 11 days after the first dose.
  • 2023-05-25 WBC 4.57 x10^3/uL
    
  • 2023-05-09 WBC 5.74 x10^3/uL
    
  • 2023-05-02 WBC 1.03 x10^3/uL (nadir, Granocyte (lenograstim 250ug) QD 5/2 ~ 5/4)
  • 2023-04-20 WBC 5.36 x10^3/uL
• Since the second dose was the same as the first, the patient is likely to experience leukopenia again. To prevent severe leukopenia, it is recommended that G-CSF be prepared and administered approximately one week after the second cycle of chemotherapy.

2023-05-26

• Based on the PharmaCloud data, this patient has exclusively sought medical care at our hospital. The drug Plaquenil (hydroxychloroquine), as prescribed by our attending rheumatologist, has been included in the active medication regimen for the patient. There were no discrepancies or issues identified in the medication reconciliation process for this patient.

2022-05-12

• This patient has stage IIB small bowel adenocarcinoma s/p segmental small intestine resection on 2021-12-02, and has been receiving Folfox since 2022-01-03.
• CT images on 2022-04-13 CT showed a marked dilatation from stomach to duodenum, however, it is not symptomatic to be enrolled as an active problem.
• Lab data on 2022-05-11 indicated generally normal readings.

700823721

230529

[past history]

• Hypertension for 10 years with regular medication control.
  • Norvasc 1# PRNQD
• Type 2 diabetes mellitus for 15+ years with regular OHA control.
  • Relinide 1mg 0.5# po TIDAC
  • Januvia 100mg 1# po QD
  • Uformin 500mg 1# po TIDCC
• Hyperlipidemia for 15+ years with regular medication control.
  • Crestor 10mg 0.5# po QD
  • Dipyridamole 25mg 1# po BID
• Operation history: PHACO + PCIOL OD on 2015/07/21
  • ChatGPT:
    • “PHACO + PCIOL OD” is a term used in ophthalmology and it refers to a type of eye surgery.
      • PHACO: Stands for “Phacoemulsification,” which is a modern cataract surgery in which the eye’s internal lens is emulsified with an ultrasonic handpiece and aspirated from the eye.
      • PCIOL: Stands for “Posterior Chamber Intraocular Lens,” which is an artificial lens that is implanted in the eye to replace the natural lens that was removed during cataract surgery.
      • OD: Stands for “Oculus Dexter,” which is Latin for “right eye”.
    • So, “PHACO + PCIOL OD” means the patient underwent phacoemulsification cataract surgery with posterior chamber intraocular lens implantation in the right eye.

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-05-22 CT - chest
  • Indication: Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck s/p C/T
  • Comparison was made with previous CT
    • Lungs: several subpleural nodular opacities at LLL.
    • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine.
    • Mediastinum and hila: multiple small LNs in the visceral space and left anterior prevascular space
    • Vessels: extensive calcified plaques of the LAD, and LCX, and right coronary arteries.
    • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: dilated LA and concentric LVH. mild calcified aortic valves
    • Pleura: no effusion.
    • Chest wall and visible lower neck: marked enlarged thyroid gland with calcifications extending to superior mediastinum, and with mass effects on the trachea calcification.
    • Visible abdominal-pelvic contents: normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
    • Extensive atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
  • Impression:
    • nodular lesions in LLL of lung, recurrent lymphoma in lung or other pathology?
    • extensive 3V-CAD.
    • thyroid goiter with mediastinal extension.
• 2023-04-10 Nasopharyngoscopy
  • NP lymphoma
  • PND (postnasal drip), mucopus
• 2023-03-06 Nasopharyngoscopy
  • NP mass smaller
  • neck mass smaller after C/T
  • nasal mucopus
• 2023-02-19 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Low voltage QRS
• 2023-02-17 CXR
  • Widening of the upper mediastinum is noted, which may be due to torturous innominate vessel or tumor. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2023-02-17 MRI - nasopharynx
  • Indication: Right nasopharynx diffuse large B cell lymphoma, non-gernimal cell type
  • Findings
    • Diffuse mucosal thickening at nasopharynx.
    • Numeorus enlarged lymph nodes at both sides of the neck, including bilateral retrophayrngeal lymph nodes, and bilateral levels II, III, IV and V, and in visible superior mediastinum. The largest one, about 50 mm, confluent with necrotic change at left level V.
    • Severe enlargement of bilateral thyroid glands, with diffuse heterogeneous intensity, protruding into mediastinum, encasing trachea and compressin on great vessels.
    • A soft tissue intensity lesion, about 30 mm x 15 mm x 16 mm, with vivid enhacnement in right nasal cavity (mainly middle meatus).
  • IMP
    • C/W lymphoma involving nasopharynx, lymph nodes of both sides of neck, superior mediastinum and suspiciouly right nasal cavity.
• 2023-02-16 CT
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Some enhanced lymph nodes are found at bilateral neck, epiglottic, pharyngeal space, axillary, bilateral paratracheal region.
      • Enlarged thyroid tissue at both lobes with calcification is found.
      • No evidence of bilateral pleural effusion.
      • Patent airway is found.
      • Calcified coronary arteries is found.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Lymphadenopathy at bialteral neck, pharyngeal space, bilateral axillary and mediastinal region.
      • Enlarged bilateral thyoid glands.
      • Calcified coronary arteries is found.
• 2023-02-15 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
• 2023-02-14 ENT Hearing Test, PTA:
  • Reliability FAIR
  • Average RE 70 dB HL; LE 69 dB HL
  • RE moderately severe SNHL
  • LE moderately severe to severe SNHL
• 2023-02-14 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 22) / 91 = 75.82%
    • M-mode (Teichholz) = 75
  • Preserved LV and RV systolic function with normal wall motion
  • Dilated LA, grade 1 LV diastolic dysfunction
  • Mild MR, PR, trivial TR
• 2023-02-01 Whole body PET scan
  • The [F-18] Fluorodeoxyglucose (FDG) PET scan from head to upper thigh regions was performed at 40 minutes after i.v. injection 218 MBq of FDG on a GE Discovery ST PET-CT system. Fasting for at least 6 hours was required prior to this examination. Images were reconstructed iteratively with CT scan attenuation correction.
  • There was increased FDG uptake in bilateral N-P regions and right nasal cavity (SUVmax early: 28.95, delay: 41.80), bilateral cercial and SCF lymph nodes (SUVmax early: 30.05, delay: 32.62), bilateral axillary lymph nodes (SUVmax early: 7.85, delay: 10.53), left mediastinal and pulmonary hilar lymph nodes (SUVmax early: 7.87, delay: 15.17), right mediastinal and pulmonary hilar lymph nodes (SUVmax early: 4.76, delay: 8.86), and lymph nodes in the abdomen, pelvis, bilateral inguinal and upper thigh regions (SUVmax early: 12.35, delay: 9.02). In addition, increased FDG uptake was also noted in the left adrenal gland (SUVmax early: 4.24, delay: 7.76), bilateral kidneys and colon.
  • IMPRESSION:
    • Glucose-hypermetabolism in bilateral N-P regions and right nasal cavity (Deauville score 5), compatible with B-cell lymphoma.
      
    • Glucose-hypermetabolism in bilateral cercial and SCF lymph nodes, bilateral axillary lymph nodes, bilateral mediastinal and pulmonary hilar lymph nodes, and lymph nodes in the abdomen, pelvis, bilateral inguinal and upper thigh regions (Deauville score 5), highly suspected B-cell lymphoma with involvement of lymph node regions.
      
    • Increased FDG uptake in the left adrenal gland, probably a functing or non-functing benign tumor of the left adrenal gland, suggesting further investigation.
    • Increased FDG uptake in bilateral kidneys and colon, probably physiological uptake of FDG.
    • Diffuse large B-cell lymphoma with involvement of bilateral N-P regions, right nasal cavity and lymph node regions on both sides of the diaphragm, by this F-18 FDG PET scan.
• 2023-01-31 SONO - abdomen
  • A cystic lesion 1.88 x 0.74 cm in S5 of the liver, near the gallbladder, is noted. Follow up is indicated.
• 2023-01-30 Patho - nasopharyngeal/oropharyngeal biopsy
  • Labeled as “right nasopharynx”, biopsy — diffuse large B cell lymphoma, non-gernimal cell type. High grade.
  • IHC stains: CK (-), CD3 and CD20: a predominant B cell sub-population.
    • Bcl-2 (+, 90%), Bcl-6 (+, 90%), CD10 (<5%), C-myc: (+, 30-40%), Ki-67: (95%), MUM-1: (+, 90%), cyclin-D1 (-), CD23 (-). P16 (-), EBV (-).
• 2023-01-30, 2022-06-10 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Abnormal ECG
• 2023-01-30 Nasopharyngoscopy
  • Findings:
    • R NP tumor with yellowish crust coating; epiglottis lingual side tumor with patent airway; smooth HPx.
  • Diagnosis/Conclusion:
    • Nasopharyngeal and oropharyngeal tumor, suspect malignancy.
• 2022-06-22 Electroencephalography
  • This EEG study recorded background alpha rhythm (9-10Hz) and beta activity with transient diffuse slow waves.
  • No epileptiform discharge.
  • Please correlate with clinical features.
• 2022-06-22 Brainstem Auditory Evoked Potential, BAEP
  • Normal waveforms, amplitudes, peak latencies, interpeak intervals following click stimulation to each ear.
  • This is a normal BAEP study.
  • Please correlate with clinical features.
• 2018-08-10 Flow Volume Curve
  • Mild restriction
• 2018-08-10 Bone densitometry - hip
  • Hip BMD performed by DXA revealed:
    • Left hip, BMD is 0.539 gms/cm2, about 2.5 SD below the peak bone mass (67%) and 0.0 SD below the mean of age-matched people (100%).
  • IMP: Osteoporosis

[MedRec]

• 2023-05-25 SOAP Hemato-Oncology
  • P
    • Already mention the lesion over LLL of lung. Will discuss with family for options
      • Biopsy, or
      • PET-CT, or
      • Observation.
• 2023-05-04 SOAP Gastroenterology
  • Diagnosis
    • Gastro-esophageal reflux disease with esophagitis K21.0
    • Constipation, unspecified K59.00
    • Generalized anxiety disorder F41.1
    • Type 2 diabetes mellitus without complications E11.9
  • Prescription (refillable)
    • Spasmotin (hyoscyamine sulfate 0.125mg) 1# TID
    • Strocain (oxethazaine, polymigel 5mg) 1# TIDAC
    • Alpraline (alprazolam 0.5mg) 1# PRNHS
    • MgO 250mg 2# TID
• 2023-04-28 SOAP Metabolism and Endocrinology
  • Diagnosis - same as 2023-03-03
  • Prescription (refillable)
    • dipyridamole 25mg 1 tab BID
    • Crestor (rosuvastatin 10mg) 0.5 tab QD
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1 tab BID
    • Norvasc (amlodipine 5mg) 1 tab PRNQD
    • Relinide (repaglinide 1mg) 1 tab TIDAC
    • Uformin (metformin 500mg) 1 tab BIDCC
    • Tresiba FlexTouch (insulin degludec) 6 unit QN (during steroid used)
• 2023-03-03 SOAP Metabolism and Endocrinology
  • Diagnosis
    • Type 2 diabetes mellitus without complications E11.9
    • Mixed hyperlipidemia E78.2
    • Nontoxic multinodular goiter E04.2
    • Chronic kidney disease, stage 2 (mild) N18.2
    • Anemia, unspecified D64.9
    • Atherosclerosis of other arteries I70.8
  • Prescription (refillable)
    • Crestor (rosuvastatin 10mg) 0.5# QD
    • Norvasc (amlodipine 5mg) 1# PRNQD
    • Relinide (repaglinide 1mg) 1# ASORDER (0.5# TIDAC, 1# TIDAC if ACD > 180)
    • Uformin (metformin 500mg) 1# BIDCC
    • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
• 2023-03-02 SOAP Hemato-Oncology
  • O: AE Leukopenia Gr 1 3000~4000/mm3
• 2023-03-02 SOAP Dermatology
  • S
    • Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching.
    • fissuriform wound formaiton.
  • O
    • seborrhic dermatitis on scalp and face and trunk for yrs,
    • Generalized eczeam (+)
    • Polytar liquid for shampooing QOD
    • PHx:
      • sea food allergy (+-)
      • allergic rhinitis (+)
    • Travel histry: denied
    • fissuriform wound formaiton. -> hand eczema.
  • Plan:
    • education about drug side effec and explain
    • strongly suggested OPD f/u
  • Diagnosis
    • Seborrhoeic dermatitis, unspecified - L21.9
    • Infective dermatitis - L30.3
  • Prescription
    • Zalain External Gel (sertaconazole 2%) Q3D EXT
    • Topsym (fluocinonide 0.05%) BID TOPI
    • Asthan (ketotifen 1mg) 1# QN PO
    • Biomycin (neomycin, tyrothricin) BID TOPI
• 2023-02-13 ~ 2023-02-25 POMR Hemato-Oncology
  • Discharge diagnosis
    • Diffuse large B-cell lymphoma with involvement of bilateral nasopharynx regions, right nasal cavity and lymph node, non-gernimal cell type. High grade. IHC stains: CK (-), CD3 and CD20: a predominant B cell sub-population. Bcl-2 (+, 90%), Bcl-6 (+, 90%), CD10 (＜5%), C-myc: (+, 30-40%), Ki-67: (95%), MUM-1: (+, 90%), cyclin-D1 (-), CD23 (-). P16 (-), EBV (-)
    • Type 2 diabetes mellitus without complications
    • Mixed hyperlipidemia
    • Gastro-esophageal reflux disease with esophagitis
    • Osteoarthritis of knee, unspecified
    • Essential (primary) hypertension
    • Insomnia, unspecified
    • Sensorineural hearing loss, bilateral
    • Constipation, unspecified
    • Oral mucositis (ulcerative), unspecified
  • Prescription
    • Alpraline (alprazolam 0.5mg) 1# HS
    • Crestor (rosuvastatin 10mg) 0.5# QD
    • dipyridamole 25mg 1# BID
    • MgO 250mg 2# TID
    • Spasmotin (hyoscyamine sulfate 0.125mg) 1# TID
    • Uformin (metformin 500mg) 1# TIDCC
    • Relinide (repaglinide 1mg) 0.5# TIDAC
    • Norvasc (amlodipine 5mg) 1# QD
    • Januvia (sitagliptin 100mg) 1# QD
    • diphenidol 25mg 1# TID
    • Arcoxia (etoricoxib 60mg) 1# QD
• 2023-02-07 SOAP Hemato-Oncology
  • S
    • 2022/08/29 Free-T4 = 0.74 ng/dL; TSH = 0.165 uIU/mL
    • 2023/01/30 HGB = 10.2 g/dL; HbA1c = 7.3 %;
    • 2023/01/30 fiber: large R NP tumor with downward extension, Bx done, L tonsil: uneven, bil huge epiglottic mass (smooth surface)
    • 2023/01/30 SCC/CRP (-)
      • SCC (NM) = 1.37 ng/mL; SCC = 1.4 ng/mL, CRP = 0.69 mg/dL
    • 2023/02/03 EBV DNA PCR <120 copies/mL
    • 2023/02/06 NP: diffuse large B-cell lymphoma + bil NM
    • Referred from Dr. Gao at BanQiao LMC due to bilateral neck mass.
    • Poor appetite and BW loss 1-2 kg in recent 2 months
  • O
    • History: lipid, DM, HT at Meta, GERD, OA knee
    • Living alone with her husband, four sons take turns to care for her.
  • P
    • Arrange admission for HN MRI, Chest/Abd/Pelvis CT and bone marrow study (aspiration, biopsy, chromosome study), cardiac echography, C/T with R-COP or R-CHOP.

[chemotherapy]

• 2023-05-09 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 900mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-04-11 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-03-15 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-02-20 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[note: R-COP, R-mini-CHOP, R-CHOP21, EPOCH-R, daEPOCH]

R-CVP 2023-05-19 https://www.cancer.gov/about-cancer/treatment/drugs/r-cvp

• Drugs in the R-CVP combination:
  • R = Rituximab
  • C = Cyclophosphamide
  • V = Vincristine Sulfate
  • P = Prednisone
• R-CVP is used to treat: Non-Hodgkin lymphoma (NHL) that is indolent (slow-growing).
  • ChatGPT - Indolent NHL
    • “Indolent NHL” refers to a type of non-Hodgkin lymphoma that grows and spreads slowly. Non-Hodgkin lymphoma (NHL) is a group of blood cancers that includes all types of lymphomas, except Hodgkin’s lymphomas.
    • Examples of indolent NHL include follicular lymphoma, marginal zone lymphoma, and small lymphocytic lymphoma. Indolent lymphomas are typically associated with a relatively good prognosis, but they are usually not curable in advanced clinical stages.
    • It’s important to note that the term “indolent” doesn’t mean the disease is not serious. It’s still a type of cancer and requires treatment, but generally, it progresses more slowly than other types of lymphoma.

Initial treatment of advanced stage diffuse large B cell lymphoma 2023-05-19 https://www.uptodate.com/contents/initial-treatment-of-advanced-stage-diffuse-large-b-cell-lymphoma

• R-mini-CHOP - SPECIAL SCENARIOS - Older adults

  • Older patients with DLBCL generally have a worse prognosis compared to younger patients due, in part, to more comorbid conditions and lower treatment tolerance.
  • For patients >80 years with adequate heart, kidney, and liver function and for patients 60 to 80 years with modest impairments, we generally treat with R-mini-CHOP to reduce adverse effects (AE) associated with more intensive regimens.

• Pretreatment evaluation

  • For older patients, a comprehensive geriatric assessment can aid assessment of comorbid conditions and functional status and facilitate formulation of an appropriate, individualized treatment plan. Special considerations for the use of chemotherapy in older patients are discussed separately

• R-mini-CHOP Treatment

  • rituximab 375 mg/m2 D1
  • cyclophosphamide 400 mg/m2 D1
  • doxorubicin 25 mg/m2 D1
  • vincristine 1 mg D1
  • prednisone 40 mg/m2 D1-5

• A pre-treatment phase of a systemic steroid, with or without rituximab, may improve the patient’s performance status (PS) and facilitate treatment with R-mini-CHOP.

• Frail patients who require symptom palliation but cannot tolerate R-mini-CHOP may benefit from a systemic steroid (with or without rituximab) or single chemotherapeutic agents.

Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP21) for non-Hodgkin lymphoma 2023-05-19 https://www.uptodate.com/contents/image?topicKey=HEME%2F4729&imageKey=ONC%2F63586

• Cycle length: 21 days.

• Regimen

  • Rituximab
    • 375 mg/m2 IV
    • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated.[2] For subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count ≥5000/microL. Day 1
  • Cyclophosphamide
    • 750 mg/m2 IV
    • Dilute in 250 mL NS or D5W and administer over 30 minutes.
    • Day 1
  • Doxorubicin
    • 50 mg/m2 IV
    • Dilute in 50 mL NS or D5W and administer over three to five minutes.
    • Day 1
  • Vincristine
    • 1.4 mg/m2 IV (max dose 2 mg)
    • Dilute in 50 mL NS or D5W and administer over 15 to 20 minutes.
    • Day 1
  • Prednisone
    • 100 mg orally
    • Administer 30 minutes prior to chemotherapy on day 1, then every 24 hours on days 2 to 5. Days 1 to 5

Infusional etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for non-Hodgkin lymphoma 2023-05-19 https://www.uptodate.com/contents/image?topicKey=HEME%2F4729&imageKey=ONC%2F88411

• Cycle length: 21 days.

• Regimen

  • Rituximab
    • 375 mg/m2 IV
    • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. In the absence of an initial infusion reaction, for subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count >=5000/microL.
    • Day 0 or 1
  • Etoposide
    • 50 mg/m2 per day IV
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Doxorubicin
    • 10 mg/m2 per day IV
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Vincristine
    • 0.4 mg/m2 per day IV (dose not capped)
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Cyclophosphamide
    • 750 mg/m2 IV
    • Dilute with 250 mL NS or D5W and administer over 30 minutes.
    • Day 5
  • Prednisone
    • 60 mg/m2 orally twice daily
    • Administer first dose 30 minutes prior to chemotherapy on day 1.
    • Days 1 to 5
  • Granulocyte colony stimulating factor (G-CSF)
    • Start day 6

Chemotherapy regimens for non-Hodgkin lymphoma: Dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (daEPOCH) 2023-05-19 https://www.uptodate.com/contents/image?topicKey=ONC%2F85686&imageKey=ONC%2F105216

• Cycle length: 21 days.
• Regimen
  • Etoposide
    • 50 mg/m2 per day IV
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Doxorubicin
    • 10 mg/m2 per day IV
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Vincristine
    • 0.4 mg/m2 per day IV (dose not capped)
    • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
    • Days 1 to 4 (96 hours)
  • Cyclophosphamide
    • 750 mg/m2 IV
    • Dilute with 250 mL NS or D5W and administer over 30 minutes.
    • Day 5
  • Prednisone
    • 60 mg/m2 orally twice daily
    • Administer first dose 30 minutes prior to chemotherapy on day 1.
    • Days 1 to 5
  • Granulocyte colony-stimulating factor
    • Start day 6

==========

(not posted)

• Because chemotherapy-induced immunosuppression can potentially lead to HBV reactivation, which can result in discontinuation of cancer treatment, fulminant hepatitis, liver failure, and even death, proactive measures should be taken. The patient’s lab data from 2023-02-08 shows anti-HBc reactivity and an anti-HBc level of 5.18 S/CO. As a preventive measure, it is recommended that the patient be prescribed either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD.

2023-05-10

• The patient’s current active medication list correctly reflects the refillable prescriptions provided by our gastroenterologist and endocrinologist. These medications include Spasmotin (hyoscyamine), Strocain (oxethazaine), Alpraline (alprazolam), MgO from the gastroenterologist, and Crestor (rosuvastatin), Galvus Met (vildagliptin, metformin), Norvasc (amlodipine), Relinide (repaglinide), Uformin (metformin), Tresiba FlexTouch (insulin degludec), and dipyridamole from the endocrinologist. As such, there are no identified medication reconciliation issues at this time.

• Hyoscyamine, a tropane alkaloid and the levo-isomer of atropine, is often employed to manage acute episodes of gastric secretion, visceral spasm, hypermotility in spastic colitis, pylorospasm, and associated abdominal cramps. Additionally, it can serve as adjunctive therapy in the treatment of peptic ulcers. However, considering the patient’s constipation (in the clinical problem list), and the fact that metoclopramide is concomitantly prescribed to mitigate potential nausea and vomiting effects caused by the R-COP regimen, it might be advisable to temporarily withhold hyoscyamine during the chemoimmunotherapy sessions.

• The HbA1c level, which reflects the average blood glucose level over the past two to three months, has reached a record high of 8.1%. This suggests that the patient’s current diabetes management plan may not be effectively controlling her blood sugar levels.

  • 2023-04-22 HbA1c 8.1 %
    
  • 2023-02-13 HbA1c 6.9 %

• Despite the patient’s current use of antidiabetic agents Galvus Met (vildagliptin, metformin), Relinide (repaglinide), Uformin (metformin), and Tresiba FlexTouch (insulin degludec), recent blood glucose readings have exceeded 200mg/dL (187mg/dL at 17:03 2023-05-09, 204mg/dL 20:25 2023-05-09 and 202mg/dL at 06:13 2023-05-10). This suggests that the patient’s glycemic control is currently suboptimal. An adjustment to the patient’s insulin regimen may be needed. It is recommended that the dose of insulin degludec be increased to 7 or 8 units, with close monitoring of the patient’s blood glucose levels. This adjustment should be particularly considered during periods when the patient is receiving steroids (as part of the R-COP regimen).

2023-03-16

• Due to the patient’s senior age, R-COP was selected over R-CHOP as the regimen. The patient is currently admitted for the second cycle of this chemoimmunotherapy.

• According to the available data from the past 6 months, there have been no instances of leukopenia or thrombocytopenia observed. However, there has been a slight presence of anemia during this time period, which is unlikely to be caused by the R-COP regimen since it was present even before the start of treatment.

• Please ensure that the patient is adequately hydrated and monitor her BUN readings, which have been trending upward, while serum creatinine remains normal.

  • 2023-03-14 BUN 38 mg/dL
    
  • 2023-03-02 BUN 40 mg/dL
    
  • 2023-02-17 BUN 28 mg/dL
    
  • 2023-02-07 BUN 20 mg/dL

• This patient has a history of diabetes, and despite taking Uformin (metformin 500mg) 1# BID, Galvus Met (vildagliptin 50mg + metformin 500mg) 1# BID, and Relinide (repaglinide 1mg) total 2# daily (the daily dose of metformin has already reached 2g and should not be increased further), her blood sugar levels range from 284 to 301mg/dL. R-COP chemotherapy regimen includes high doses of prednisolone, which can contribute to hyperglycemia. Similar to the management of type 2 diabetes, stepwise intensification of antihyperglycemic therapy and frequent re-evaluation should be considered in cases of steroid-induced hyperglycemia. ref: A Practical Guide for the Management of Steroid Induced Hyperglycaemia in the Hospital. J Clin Med. 2021;10(10):2154. Published 2021 May 16. doi:10.3390/jcm10102154

• The addition of a rapid-acting insulin (RI) may be beneficial for controlling hyperglycemia in this patient. However, careful monitoring of blood glucose levels and titration of insulin dose are necessary to prevent hypoglycemia. It is also important to continue evaluating and adjusting the patient’s antihyperglycemic therapy as needed.

2023-02-21

• The patient’s HGB reading has decreased by more than 10%, which should be monitored closely. It may be necessary to investigate for any potential underlying bleeding.
  • 2023-02-17 HGB 9.1 g/dL
    
  • 2023-02-13 HGB 9.1 g/dL
    
  • 2023-02-07 HGB 10.6 g/dL
• 2023-02-14 cardiac sonography reveals normal wall motion and preserved systolic function in both the left and right ventricles, with a LVEF of 75%. 2023-02-19 ECG showed a normal sinus rhythm, left axis deviation, and low voltage QRS. Started R-COP (R-CVP) on 2023-02-20. No dose adjustment is needed based on grossly normal 2023-02-17 lab data except for a slightly high BUN (28mg/dL), which warrants monitoring.
• Patients with high white cell count or bulky disease are at an increased risk of developing tumor lysis syndrome and reacting to Rituximab. As the patient’s WBC count was 4.52K/uL on 2023-02-17, it is less likely for her to develop tumor lysis syndrome.
• Patients should be advised that cyclophosphamide can irritate the bladder mucosa, and it is important to maintain a fluid intake of at least 3 liters a day for the next few days.
• Given that this patient is more than 70 years old but not immunosuppressed prior to chemotherapy, primary prophylaxis with G-CSF may not be absolutely necessary.
• (ref: https://nssg.oxford-haematology.org.uk/lymphoma/documents/lymphoma-chemo-protocols/L-82-r-cvp.pdf)

2023-02-14

• This patient is diagnosed with high grade DLBCL (2023-01-30 patho IHC (not FISH): MYC + 30-40%, BCL2 + 90%, BCL6 + 90%; triple hit)

• International Prognostic Index = 3 => Risk Group: High-intermediate, 5-yr OS 43% (ref: UpToDate)

  • (+) Age >60 : 81
  • (-) Serum lactate dehydrogenase concentration above normal : 148U/L 2023-02-07
  • (-) ECOG performance status >=2 : score = 1, 2023-02-13
  • (+) Ann Arbor stage III or IV : PET 2023-02-01 both sides of the diaphragm
  • (+) Number of extranodal disease sites >1

• Considering the patient is elderly, R-CHOP might be an alternative to R-DA-EPOCH. It might be necessary to perform a cardiac ultrasound prior to the treatment in order to establish a baseline. A lumbar puncture may be necessary if the CNS is involved.

[drug identification]

• We did not receive the drugs awaiting identification that day. The next day, we contacted the nurse by phone, who explained that the medication was too fragmented, so only the in-house medication was used instead.

701393260

230529

[diagnosis] - 2022-12-15 admission note

• Right breast cancer - invasive carcinoma of no special type, Immunohistochemical study demonstrates ER(-), PR(-), Her2/neu: positve(3+), p53(patchy+, weak to moderate, wild-type), p63(-), Ki-67 inedex: 30%, CK5/6(-), stage IV, with multiple liver and lymph nodes metastases.
• Diffuse bone metastases involving C2-C7, T1-T4 spine, with left C1, C2 lateral mass tumors encasing left vertebral artery.
• epatomegaly
• poor liver function
• hyperbilirubinemia

[exam findings]

• 2023-05-19 MRI - brain
  • History and indication: Speaking unclearly, there are multiple metastases of breast cancer.
  • With and without-contrast multiplannar and multisequences MRI of brain revealed:
    • Multiple enhancing nodules in brain parenchyma.
• 2023-04-20, -03, 24, -02-02 CXR
  • Borderline cardiomegaly
  • Enlargement of cardiac silhouette.
• 2023-02-13 CT - abdomen
  • History and indication:
    • Right breast cancer - invasive carcinoma of no special type, stage IV, with multiple liver and lymph nodes metastases.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Much regression of right breast cancer. Necrosis and regression of liver metastases.
    • Left ovary cyst (4.6cm) with minimal hemorrhage. Minimal ascites.
    • Multiple bony metastases.
  • IMP:
    • Much regression of right breast cancer. Necrosis and regression of liver metastases.
    • Left ovary cyst (4.6cm) with minimal hemorrhage. Minimal ascites.
    • Multiple bony metastases.
• 2022-12-15, -12-02, -11-23 CXR
  • Borderline cardiomegaly
  • Enlargement of cardiac silhouette.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
• 2022-11-25 Gynecologic ultrasonography
  • Ascites
  • EM: 7.7mm
• 2022-11-14 CT - abdomen
  • Indication
    • Right breast cancer–invasive carcinoma of no special type
    • Secondary malignant neoplasm of liver and intrahepatic bile duct
    • Secondary malignant neoplasm of bone
    • Diffuse bone metastases
  • Findings
    • Massive ascites is found. Several confluent low density lesions are found at both lobes of liver up to 12.4cm at right lobe liver. Liver meta is considered. In comparison with CT dated on 2022-08-03, the lesions become necrotic. Chemotherapy effect is considered.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Mild enhancement of the peritoneum at pelvis is found. Cancerous peritonitis is suspected.
    • No evidence of abnormal soft tissue mass at pelvic cavity.
    • No definite inguinal or pelvic sidewall LAP
    • Soft tissue mass at right lateral breast is found about 2.5cm. In comparison with CT dated on 2022-08-03, the lesion is decreased in size.
    • Right massive pleural effusion is found.
    • Suggest clinical correlation
  • Imp:
    • Right breast cancer with liver meta with primary tumor regression and liver tumors necrosis. Chemotherapy effect is considered.
    • Bone meta, please correlate with bone scan study.
    • Massive ascites and right pleural effsuion. suspected cancerous peritonitis.
• 2022-11-11 CXR
  • Enlargement of cardiac silhouette.
  • Right Pleura effusion is noted.
  • Few nodular opacity projecting in the left lung are suspected. Follow up is indicated. Otherwise, Please correlate with CT.
• 2022-11-02, -10-20, -10-17, -10-10, -10-06 CXR
  • Bilateral Pleura effusion with more severe on right side.
  • Few nodular opacity projecting in the left lung are suspected. Follow up is indicated. Otherwise, Please correlate with CT.
• 2022-10-28 SONO - chest
  • Echo diagnosis:
    • left side trivial amount of pleural effusion
    • right side moderate amount of pleural effusion, 750cc serosangious fluid was aspirated for analysis.
• 2022-10-20, -09-26 Ascites tapping
  • After echo localization, local anesthesia was performed at RLQ and 2000ml straw-colored ascites was drained out with 18Fr catheter.
  • Moderate clear ascites was noted.
• 2022-10-17 SONO - chest
  • Echo diagnosis:
    • Bilateral pleural effusion (Left: trivial and Right: small to moderate), post right diagnostic and therapeutic thoracentesis.
    • Abdominal ascites
• 2022-10-11 SONO - chest
  • Echo diagnosis:
    • Right thorax: large amount pleural effusion s/p drainage of 910cc, yellowish pleural effusion
    • Left thorax: no pleural effusion.
• 2022-10-04 SONO - chest
  • Echo diagnosis:
    • Left thorax: no pleural effusion.
    • Right thorax: moderate amount pleural effusion s/p drainage of 960 cc, yellowish pleural effusion.
• 2022-10-03 Ascites tapping
  • The RLQ of the abdomen was prepped and draped in a sterile fashion using chlorhexidine scrub. The paracentesis catheter was inserted and advanced with negative pressure until STRAW colored fluid was aspirated
• 2022-09-26 SONO - chest
  • Echo diagnosis:
    • Right thorax: moderate amount pleural effusion s/p drainage of 600 cc, yellowish pleural effusion.
    • Left thorax: minimal amount pleural effusion
• 2022-09-21 SONO - chest
  • Echo diagnosis:
    • Pleural effusion, moderate, right
    • Pleural effusion, minimal, left
    • Atelectasis, RLL
• 2022-08-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (60.8 - 19.1) / 60.8 = 68.59%
    • M-mode (Teichholz) = 68.6
  • Adequate LV,RV systolic function with normal wall motion
  • Thick IVS, Impaired LV relaxation
  • Left pleural effusion
• 2022-08-18, -08-15, -08-12, -08-09, -08-08 CXR
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • Enlargement of cardiac silhouette.
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
• 2022-08-09 Patho - breast biopsy (no need margin)
  • Breast, right, core biopsy — Invasive carcinoma of no special type
  • The specimen submitted consists of 4 tissue cores measuring up to 1.7x0.1x 0.1 cm in size, in fixed state. Grossly, they are tan and elastic.
  • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid to ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
  • Immunohistochemical study demonstrates ER(-), PR(-), Her2/neu: positve(3+), p53(patchy+, weak to moderate, wild-type), p63(-), Ki-67 inedex: 30%, CK5/6(-).
• 2022-08-09 Tc-99m MDP whole body bone scan with SPECT
  • The scintigraphic findings suggest multiple bone metastases.
• 2022-08-09 SONO - chest
  • Echo diagnosis:
    • Bilateral thorax:
      • minimal amount pleural effusion;
      • bilateral lower lung consolidation (+);
      • thoracocentesis was not performed.
• 2022-08-08 Breast Ultrasound in Operation
  • Diagnosis: Highly suspicious of malignancy, with sonographic negative axillary LNs
  • Treatment: Core-needle biopsy
  • Suggestion and Plan:
    • Arrange core biopsy with 18 guage puncture needle
    • BI-RADS: 5-Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken
• 2022-08-05 MRI - C-spine
  • Indication: breast tumor with liver and C-spine meta
  • Findings
    • diffuse enhancing bone masses involving C2-C7, T1-T4 spine, compatible with bone metastases. There is pathological compression fracture at C5, C7 vertebral bodies. Exophytic masses at left C1, C2 lateral masses and transverse processes causing encasement of left vertebral artery (VA) is noted.
    • enlarged bilateral cervical lymph nodes, suspect lymphadenopathy.
    • no evidence of abnormal signal lesion and pathological enhancement in visible spinal cord.
  • Impression:
    • Diffuse bone metastases involving C2-C7, T1-T4 spine, with left C1, C2 lateral mass tumors encasing left VA.
• 2022-08-05 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Metastatic invasive carcinoma, consistent with breast primary
  • The specimen submitted consists of two strips of yellow gray soft tissue, labeled liver, measuring up to 2.0 x 0.1 x 0.1 cm.
  • The sections show metastastic invasive carcinoma of no special type, breast primary, composed of nests and cords of large pleomorphic neoplastic cells in fibrous stroma. Focal ductal differentiation and tumor necrosis are present.
  • IHC shows following features:
    • ER (Ab): Negative
    • PR (Ab): Negative
    • HER-2/Neu (Ab): Positive (score= 3+)
    • Ki-67 index: 30%
    • GATA3: Positive
• 2022-08-03 MRI - brain
  • a heterogeneous enhancing tumor in the left C1 vertebral body
• 2022-08-03 CT - abdomen
  • History: epigastric protruding sensation with fullness.
    • abnormal LFT: AST/ALT 62/100 GGT 83 (2022-04-20 at Taichung)
    • HBsAg non-reactive. HBsAb(anti-HBs) reactive
    • 20220801 echo: numerous liver tumors, suspected metastasses
    • AST/ALT 472/167: we’ve strongly suggested admission for supportive care and close observation and exam: but patient refused admission.
  • Findings:
    • There is a well-defined rim-enhancing soft tissue mass in right breast, measuring 3.4 cm. Breast cancer is suspected.
      • Please correlate with sonography and mammography.
    • There are multiple variable-sized poor enhancing tumors on both hepatic lobes that are c/w metastases.
      • In addition, There is hepatomegaly and the greatest cranial-caudal dimension measuring about 21.7 cm in length.
    • There are multiple enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space that are c/w metastatic nodes.
    • There is mild ascites in the cul-de-sac.
      • Please correlate with sonography.
    • Bilateral ovarian cysts are suspected.
      • Please correlate with GYN. sonography.
    • Others
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • Right breast cancer with multiple liver and lymph nodes metastases is highly suspected.
    • Please correlate with breast sonography and mammography.
• 2022-08-01 SONO - abdomen
  • Diagnosis
    • mild fatty liver
    • liver tumors, favor metastatic tumors
    • pancreas obscured
  • Suggestion
    • 4 phase CT scan

[body fluid]

• 2022-08-24 pleural effusion 720ml (orange, turbid)
• 2022-08-26 ascites 75ml (orange)
• 2022-08-30 pleural effusion 760ml (red, turbid)
• 2022-09-02 pleural effusion 600ml (orange, turbid)
• 2022-09-06 pleural effusion 630ml (red, turbid)
• 2022-09-08 pleural effusion 550ml
• 2022-09-15 pleural effusion 700ml (yellow, turbid)
• 2022-09-21 pleural effusion 600ml (yellow, turbid)
• 2022-09-26 ascites 2000ml
• 2022-09-27 pleural effusion 600ml (yellow, slight turbid)
• 2022-10-03 ascites 1750ml
• 2022-10-04 pleural effusion 960ml (yellowish)
• 2022-10-11 pleural effusion 910ml
• 2022-10-17 pleural effusion 860ml (yellowish, cloudy)
• 2022-10-21 ascites 2000ml

[MedRec]

• 2023-05-24 SOAP Radiation Oncology
  • A: Invasive carcinoma of no special type of the right breast with multiple including liver and bone metastases.
  • P: Radiotherapy is indicated for this patient with the following indicators: multiple brain metastases
    • Goal: palliation
    • Treatment target and volume: whole brain
    • Technique: 3D
    • Preliminary planning dose: 3000cGy/12 fractions of the whole brain.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2023-05-30.

[consultation]

• 2022-08-17 Rehabilitation
  • Q
    • For correct body posture and movement
  • A
    • Assessment
      • right breast tumor with liver, and C-spine metastasis
    • Conclusion
      • The patient refused to transfer or sit-up when I visited due to dyspnea, abominal fullness and severe discomfort. Please contact us if the patient get better and has willing to take rehab training.
• 2022-08-04 Radiation Oncology
  • Q
    • for C-spine radiotherapy evaluation
    • The 31-year-old female who denied having any past history, the she was getting the COVID-19 on June 25, 22.
    • This time, she suffered from stiff neck since end of April, then the symptoms intensify, so she went to our Chinese Medicine department for help, however, treatment was ineffective. And the liver index too high from health examination and epigastric protruding sensation with fullness, so she went to our GI OPD for help. The abdomen echo: numerous liver tumors: suspected metastatic tumors, the abdomen CT showed right side breast lesion with multiple liver metastasis, the brain MRI: C-spine metastasis, so we need your help, thanks a lot!!
  • A
    • S:
      • For radiotherapy due to suspicious metastatic lesion over left C1 vertebral body.
      • PI: The patient suffered from stiff neck since end of April, 2022. The symptoms intensify, so she went to our Chinese Medicine department for treatment but was ineffective. The abdomen echo showed numerous liver tumors: suspected metastatic tumors, the abdomen CT showed right side breast lesion with multiple liver metastasis, the brain MRI: C-spine metastasis.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM(-); HTN(-)
      • Previous RT Hx: (-)
    • O:
      • ECOG: 1
      • PE: neck and bil SCF: pain of the left upper neck.
      • Abd sono (2022-08-01): mild fatty liver; liver tumors, favor metastatic tumors; pancreas obscured.
      • MRI of brain (2022-08-03): a heterogeneous enhancing tumor in the left C1 vertebral body.
      • CT scan of abdomen (2022-08-03): pending.
    • A:
      • Suspicious right breast cancer with multiple including liver and bone metastases.
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: metastatic lesions in the left C1 vertebral body.
        
      • Goal: palliation
      • Treatment target and volume: possible the left C1 vertebral body.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 3000cGy/15 fractions
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family. Further work-up including tissue proven should be completed. The treatment planning of radiotherapy will be started after positive pathologic report available (please notify me).

[surgical operation]

• 2022-08-08
  • Surgery
    • Port-A insertion, L’t after L’t cephalic vein exploration        
    • Sonography guided R’t breast tumor core biopsy     
  • Finding
    • We explore and identify the L’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.        
    • A 5x2.72x1.78 cm hard tumor over R’t (1, 2).   

[chemoimmunotherapy]

• 2023-05-26 - Herceptin (trastuzumab) 6mg/kg 240mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 95mg 6hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-04-21 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 6hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-03-24 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 6hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-02-27 - Herceptin (trastuzumab) 6mg/kg 240mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 95mg 6hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-02-03 - Herceptin (trastuzumab) 6mg/kg 240mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 95mg 6hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-01-10 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 6hr (<- 3hr)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2022-12-15 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2022-11-23 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2022-11-03 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 80mg 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2022-10-12 - Herceptin (trastuzumab) 6mg/kg 280mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 60mg 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2022-09-21 - Herceptin (trastuzumab) 6mg/kg 280mg 90min + Perjeta (pertuzumab) 840mg 1hr + Intaxel (paclitaxel) 80mg/m2 20mg 3hr (pertuzumab loading dose)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2022-09-12 - Intaxel (paclitaxel) 80mg/m2 20mg 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2022-08-29 - Herceptin (trastuzumab) 6mg/kg 440mg 90min (loading)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[note]

PREVIOUSLY UNTREATED PATIENTS - Trastuzumab plus pertuzumab plus a taxane - 2022-11-24 UpToDate - https://www.uptodate.com/contents/systemic-treatment-for-her2-positive-metastatic-breast-cancer

• Preferred option
  • While there is no ideal strategy for the management of patients with HER2-positive metastatic breast cancer, one reasonable approach stratifies patients by whether or not they were previously treated with trastuzumab in the adjuvant setting. For previously untreated patients, we suggest trastuzumab, pertuzumab, and a taxane (docetaxel or paclitaxel). This regimen improves clinical outcomes compared with trastuzumab plus docetaxel. For most patients receiving treatment with trastuzumab or pertuzumab, we administer the HER2-directed agent along with chemotherapy. However, patients with hormone receptor- and HER2-positive metastatic breast cancer may receive HER2-directed therapy in combination with endocrine therapy, especially if their disease is not rapidly progressive or symptomatic, or is not characterized by significant visceral involvement (ie, multiorgan metastases). For women with hormone receptor-positive, HER2-positive disease, endocrine plus HER2-directed therapy may offer a less toxic approach compared with HER2 treatment combined with chemotherapy.
• Trastuzumab plus pertuzumab plus a taxane
  • For patients with untreated HER2-positive metastatic breast cancer who did not receive adjuvant therapy at the time of the initial diagnosis, we administer trastuzumab plus pertuzumab in combination with a taxane (docetaxel or paclitaxel). In our practice, we often use weekly paclitaxel rather than docetaxel with this combination as a less toxic and better tolerated taxane. However, other taxanes are appropriate in this setting. Alternatives to this regimen, and particular considerations for those with hormone receptor-positive disease, are discussed below.
  • The evidence to support the three-agent combination of trastuzumab plus pertuzumab and a taxane comes from the phase III CLEOPATRA trial, including 808 women with HER2-positive metastatic breast cancer who were treated with trastuzumab (8 mg/kg loading dose then 6 mg/kg intravenous [IV]) and docetaxel (75 mg/m2 IV) and then randomly assigned to treatment with pertuzumab (840 mg loading dose then 420 mg) or placebo. Treatment was administered every three weeks and continued until disease progression or intolerable side effects. Approximately 10 percent of these patients had previously received trastuzumab in the adjuvant or neoadjuvant setting. At a median follow-up of 19 months, the addition of pertuzumab to docetaxel plus trastuzumab resulted in (see “Treatment protocols for breast cancer”, section on ‘THP (docetaxel, trastuzumab, and pertuzumab)’ https://www.uptodate.com/contents/image?imageKey=ONC%2F96342&topicKey=ONC%2F85677):
    • Improvement in the overall response rate (ORR, 80 versus 69 percent).
    • Improvement in progression-free survival (PFS) compared with placebo (median, 19 versus 12 months; hazard ratio [HR] 0.62, 95% CI 0.51-0.75).
    • At over eight years of follow-up, the addition of pertuzumab resulted in: Improvement in overall survival (OS) compared with placebo (median, 57 versus 41 months without pertuzumab; eight-year survival rates of 37 versus 23 percent without pertuzumab; HR for death 0.69, 95% CI 0.58-0.82).
  • Trastuzumab, pertuzumab, and docetaxel is associated with higher rates of toxicity compared with trastuzumab and docetaxel. These included higher rates of diarrhea (67 versus 46 percent), neutropenia (53 versus 50 percent), rash (34 versus 24 percent), mucosal inflammation (27 versus 20 percent), dry skin (10 versus 4 percent), and serious (grade 3/4) febrile neutropenia (14 versus 8 percent). However, there was no increase in the rate of left ventricular dysfunction, which was very low in both arms (1 versus 2 percent).
  • Although the CLEOPATRA trial described above used docetaxel, we consider other taxanes to be acceptable alternatives to docetaxel in combination with trastuzumab and pertuzumab. In the first reporting from the PERUSE study, among 1436 patients with advanced HER2-positive breast cancer, median PFS was comparable between docetaxel, paclitaxel, and nanoparticle albumin-bound paclitaxel (nabpaclitaxel; 20, 23, and 18 months, respectively). Compared with docetaxel-containing therapy, paclitaxel-containing therapy was associated with more neuropathy (31 versus 16 percent), but less febrile neutropenia (1 versus 11 percent) and mucositis (14 versus 25 percent). A limitation in interpretation of these data, however, is that patients were not randomly assigned to different taxanes.
  • The addition of trastuzumab to chemotherapy has shown OS benefits in the adjuvant setting as well. (See “Adjuvant systemic therapy for HER2-positive breast cancer”, section on ‘Benefits’.)
• Formulations
  • Subcutaneous forms of trastuzumab as well as trastuzumab and pertuzumab have received approval by the US Food and Drug Administration based on similar pathologic complete response rates as the IV forms of these therapies when used with chemotherapy in the neoadjuvant setting. Either formulation may be used in the metastatic setting.

==========

2023-06-08

[tube feeding]

A grinding substitution method for Tykerb (lapatinib 250mg) tab

• Please prepare the medications to be given, a cup, chopsticks (for stirring), and room temperature drinking water.
• Put all the medications in the cup, add 20ml of room temperature drinking water.
• Let it sit for 5 to 10 minutes.
• Stir evenly with chopsticks to form a suspension, and then it can be given.
• Add another 20ml of room temperature drinking water to the cup to rinse the cup and then drink it. For patients with a nasogastric tube, the medication solution should be poured into a feeding syringe, and then add another 20ml of room temperature drinking water to the cup to rinse the cup.
• Then pour it into the feeding syringe again to flush into the nasogastric tube, which is used to rinse the tube wall.

2023-01-11

• After over 15 kg of weight loss between late August and early December in 2022, the patient’s weight has remained at approximately 41kg for one month, with no further noticeable decline in her weight.

• The elevated D-dimer readings are getting closer to the normal limits in a gradual manner. Given that the half-life of the D-dimer is only 15.8 (13.1 - 23.1) hours (ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693750/), could this slow decline be indicative of latent fibrin degradation?

  • 2022-12-23 D-dimer 3391.46 ng/mL(FEU)
    
  • 2022-12-15 D-dimer 4269.08 ng/mL(FEU)
    
  • 2022-12-02 D-dimer 5167.01 ng/mL(FEU)
    
  • 2022-11-11 D-dimer 6070.93 ng/mL(FEU)
    
  • 2022-10-28 D-dimer 6632.74 ng/mL(FEU)
    
  • 2022-09-26 D-dimer 9267.55 ng/mL(FEU)
    
  • 2022-08-29 D-dimer > 10000.00 ng/mL(FEU)

• It is advised to assess LVEF immediately prior to pertuzumab/trastuzumab initiation, every 3 months during pertuzumab/trastuzumab therapy, every 3 weeks if pertuzumab/trastuzumab is withheld for significant left ventricular cardiac dysfunction, and every 6 months for at least 2 years following completion of adjuvant pertuzumab/trastuzumab therapy. Pre-pertuzumab/trastuzumab 2D transthoracic echocardiography was performed on 2022-08-11, so it might be in need of updating. (Nov and Dec 2022 CXR showed borderline cardiomegaly and enlargement of cardiac silhouette.)

• Since bilirubin total was 0.95 mg/dL on 2023-01-11, there is no need to adjust the dose of paclitaxel.

2022-12-16

• Over 15 kg of body weight have been lost in the past four months (41.2kg 2022-12-15 <- 55.8kg 2022-08-24). It is possible that the serum creatinine level remains below LLN since August 2022 as a result of insufficient dietary intake or muscle mass loss (malnutrition, muscle wasting). It should be necessary to encourage the patient to consume more food and there may be benefits to prescirbe megestrol as an appetite stimulant.

• The presence of elevated plasma D-dimer concentrations indicates recent or ongoing intravascular coagulation and fibrinolysis. Although the reading remained high, it trended downward, a relatively positive sign. The metastatic liver lesion reduced clearance of fibrin degradation products?

  • 2022-12-15 D-dimer 4269.08 ng/mL(FEU)
    
  • 2022-12-02 D-dimer 5167.01 ng/mL(FEU)
    
  • 2022-11-11 D-dimer 6070.93 ng/mL(FEU)
    
  • 2022-10-28 D-dimer 6632.74 ng/mL(FEU)
    
  • 2022-09-26 D-dimer 9267.55 ng/mL(FEU)
    
  • 2022-08-29 D-dimer > 10000.00 ng/mL(FEU)

• According to the patient’s updated liver function lab results, paclitaxel dosage does not need to be adjusted.

2022-11-24

• 2022-11-23 AST 79 > 2x ULN(39), ALT 76 > 1.5x ULN(41), Bilirubin T 1.21 > 1x ULN(1.0), Bilirubin D 0.43 > 2x ULN(0.18). The dose of paclitaxel in this chemotherapy (3-hour infusion setting) does not need to be adjusted.

701466853

230529

[chemoimmunotherapy]

• 2023-05-26 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + docetaxel 75mg/m2 135mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-05-05 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 840mg NS 250mL 2hr + docetaxel 75mg/m2 135mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-04-14 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1075mg NS 500mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-03-24 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1073mg NS 500mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-03-01 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1075mg NS 500mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
• 2023-02-07 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1082mg NS 500mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-05-29

• Trastuzumab and Pertuzumab, both monoclonal antibodies utilized in the management of HER2-positive breast cancer, can lead to several dermatologic side effects.

• With Trastuzumab, patients may experience a skin rash in approximately 4% to 18% of cases.

• Our dermatologist has prescribed Mycomb (nystatin, neomycin, gramicidin, triamcinolone) TOPI and Exelderm (sulconazole nitrate) EXT for the symptom on 2023-05-15.

• In case of Grade 3 or higher paronychia - which is inflammation of the skin around the nails - the following approach is generally recommended aiming to manage the paronychia effectively while minimizing the impact on the patient’s overall cancer treatment plan. (ref: Prevention and management of dermatological toxicities related to anticancer agents: ESMO Clinical Practice Guidelines. Ann Oncol. 2021;32(2):157-170)

  • First, it’s crucial to interrupt the causative treatment until the severity of the paronychia has reduced to Grade 0 or 1. This will help to prevent exacerbation of the condition.
  • If there is suspicion of an underlying infection, bacterial, viral, and fungal cultures should be taken. This will help to determine the appropriate antimicrobial therapy, if necessary.
  • The ongoing management of the skin reaction should involve the use of topical treatments such as 2% povidone-iodine, topical beta-blocking agents, and topical antibiotics and corticosteroids. These can all help to reduce inflammation and prevent secondary infection.
  • Oral antibiotics can also be administered, particularly if there is concern about a more widespread infection.
  • After two weeks of this approach, the patient’s condition should be reassessed to evaluate the effectiveness of the intervention and to determine whether it’s safe to resume the original treatment.

700899684

230523

[diagnosis] - 2022-11-01 discharge note

• Adenocarcinoma of descending colon with impending obstruction, status post laparoscopic-assisted left hemicolectomy on 2022/08/11, pT3N1bM0(3/13), G2, LVI(+), PNI(-), stage IIIB s/p chemotherapy with FOLFOX from 2022/09/28
• Hyperlipidemia
• Type 2 diabetes mellitus
• Chronic viral hepatitis B without delta-agent
• Herniated Intervertebral Disc
• Diarrhea, unspecified

[past history]

• Type 2 diabetes mellitus, hyperlipidemia, and hypertension for 8 years under medications treatment and follow up at endocrinology & metabolism clinic.

• History of operation:

  • Liver abscess at right posterior lobe s/p needle aspiration on 2015/01/21.
  • CBD stone with cholangitis s/p laparoscopic cholecystectomy on 2015/07/09; and s/p EST and balloon lithotripsy on 2015/08/10.
  • T11, 12 compression fracture s/p T11, T12 vertebroplasty on 2018/03/23.

[Current Medication] - 20230220 admission note

• Kentamin (B1 50mg & B6 50mg & B12 500mcg) 1# PO BID
• Rivotril 0.5mg/tab (Clonazepam) 1# PO HS
• Nicametate citrate (saline) 50mg/tab 1# BID (2023/02/03 Hold)
• Uformin 500mg/tab (metformin) 1# PO BID
• Zulitor 4mg/tab (pitavastatin) 1# PO QN
• Kludone MR 60mg/tab (Gliclazide) 1# PO BID
• Canaglu 100mg/tab (canagliflozin) 1# PO QDAC                            

[allergy]

• NKDA

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-01-20 CT - abdomen
  • S/P segmental resection of the descending colon.
  • There is no evidence of tumor recurrence.
• 2022-12-27 CXR
  • S/P posterior longitudinal transpedicular screws and rods fixation.
  • Ground glass opacities in bil. lungs.
• 2022-12-27 ECG
  • Normal sinus rhythm
  • Inferior infarct, age undetermined
  • Anterior infarct, age undetermined
  • Prolonged QT
• 2022-12-19 Colonoscopy
  • not well prepare of colon
  • no obvious mucosal lesion is seen
• 2022-12-06 Pelvis & Rt. Hip Lat
  • S/P posterior instrumentation fixation from L4 To L5 and s/p cage implantation within the L4-5 disk space.
  • Atherosclerotic change of superficial femoral artery.
• 2022-09-27 CXR
  • Atherosclerotic change of aortic arch
• 2022-08-20 KUB
  • degenerative change of the bony structure with marginal osteophyte formation is identified.
  • s/p posterior fixation of the lumbar spine is found.
  • phlebolith at pelvic cavity is also found.
• 2022-08-12 All-RAS + BRAF mutations assay
  • All-RAS mutations assay
    • Detection range
      • KRAS codon 12, 13, 59, 61, 117, 146
      • NRAS codon 12, 13, 59, 61, 117, 146
    • Results
      • Detected (KRAS codon 12 GGT>GTT, p.G12D)
    • Interpretation
      • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • BRAF mutations assay
    • Detection range
      • BRAF codon 600
    • Results
      • There was no variant detected in the BRAF gene.
    • Interpretation
      • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
• 2022-08-11 Patho - colon segmental resection for tumor
  • Diagnosis:
    • Intestine, large, descending colon, laparoscopic-assisted left hemicolectomy — Moderately differentiated adenocarcinoma
    • Cut-end, proximal and distal, descending colon, laparoscopic-assisted left hemicolectomy — Free of tumor
    • Lymph node, regional, dissection — Metastatic adenocarcinoma (3/13)
    • AJCC 8th edition pathology stage:pT3N1b(if cM0); AJCC stage IIIB
  • Gross Description:
    • Procedure: laparoscopic-assisted left hemicolectomy
    • Tumor Site: Descending colon
    • Tumor Size: 5.4x 4.5 cm
      
    • Macroscopic Tumor Perforation: Not identified
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Uninvolved
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Not identified
    • Tumor Budding:
      • Number of tumor buds in 1 ‘hotspot’ field (specify total number in area = 0.785 mm2)
      • Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
    • Tumor Deposits: Not identified
      • Specify number of deposits: N/A
    • Regional Lymph Nodes:
      • Number of Lymph Nodes Involved/Examined: 3/13
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition):
      • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
      • Primary Tumor (pT)
        • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
      • Regional Lymph Nodes (pN):
        • pN1b: Two or three regional lymph nodes are positive
      • Distant Metastasis (pM):
        • N/A
    • Additional Pathologic Findings (select all that apply):
      • None identified
• 2022-08-09 Patho - colon biopsy
  • Intestine, large, descending colon, biopsy— adenocarcinoma
  • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, tumor necrosis and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
• 2022-08-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (73 - 15) / 73 = 79.45%
    • LVEF (%) = 80
    • M-mode (Teichholz) = 80
  • Normal LV systolic function with normal wall motion.
  • LV posterior wall thickening, dilated LA; LV diastolic dysfunction Gr 1.
  • Normal RV systolic function.
  • Aortic valve scleorsis with no AS and AR; posterior mitral annulus calcification with no MS, mild MR; mild TR; mild PR. - 2022-08-08 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Pulmonary disease pattern
  • Inferior infarct, age undetermined
  • Abnormal ECG
• 2022-08-08 Colonoscopy
  • colon cancer, descending colon, s/p biopsy
• 2022-08-05 CT - abdomen
  • History: LLQ pain for 1 month
    • Low abdomen pain and fever happened this morning
    • Past Hx of DM, liver abscess
  • Findings:
    • There is segmental wall thickening at the descending colon with irregular contour and lumen narrowing, measuring 1.7 cm in the maximal wall thickness that may be adenocarcinoma (T4a) with near complete obstruction. Please correlate with colonoscopy.
      • In addition, There are five enlarged nodes in the adjacent mesocolon (N2a).
    • S/P cholecystectomy.
      • There is dilatation and pneumobilia on IHDs, CHD, and CBD. Please correlate with serum alk-p and bilirubin level.
        
    • A renal cyst measuring 1.8 cm in left upper pole is noted.
  • Imaging Report Form for Colorectal Carcinoma
    • T:T4a (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC (Stage_value)
• 2022-07-28 SONO - abdomen
  • Diagnosis
    • Suspected pneumobilia,bil
    • S/p cholecystectomy
    • Suspected left renal cyst
    • Pancreas not shown
  • Suggestion
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• 2019-12-13 Pure Tone Audiometry
  • Tymp: Bil type A.
  • PTA
    • Reliability: fair
    • Average: R’t 19 dB HL, L’t 20 dB HL.
    • Bil high frequency mild SNHL.
• 2019-03-20 Echo for liver, gall bladder, pancreas, spleen
  • Postcholecystectomy
  • Fatty liver, moderate
  • Pneumobilia
• 2018-06-25 Doppler color flow mapping
  • LVEF = (LVEDV - LVESV) / LVEDV = (127 - 38) / 127 = 70.08%
    • M-mode (Teichholz) = 70
  • Mild septal hypertrophy with indeterminate LV filling pressure and impaired RV relaxation.
  • Normal LV and RV systolic function.
  • AV sclerosis and prominnet posterior mitral annulus calcification with trivial MR; trivial PR.
  • Mild aortic root calcification.
• 2018-04-02 Bone densitometry - Hip
  • Hip BMD performed by DXA revealed:
    • Left hip, BMD is 0.607 gms/cm2, about 1.8 SD below the peak bone mass (76%) and 0.5 SD above the mean of age-matched people (108%).
  • IMP: Osteopenia
• 2017-08-23 Echo for liver, gall bladder, pancreas, spleen
  • Postcholecystectomy
  • Pneumobilia
  • Renal cyst, left
  • Fatty liver, moderate

[MedRec]

• 2023-05-11 SOAP Neurology
  • S
    • P’t is a case of DM with regular F/U.
    • P’t suffered bilateral feet numbness for 1 year and hand cramping in recent days.
    • 20230216: Condition stationary, for medicine
    • 20230511: stationary, for medicine.
  • Diagnosis
    • DKA, NIDDM Type, adult-onset or unspecified type, not stated as uncontrolled [E11.65]
    • DM with neurological manifestation, NIDDM Type, adult-onset or unspecified type, not stated as [E11.40]
    • Displacement of lumbar intervertebral disc without myelopathy [M51.27]
  • Prescription
    • Rivotril (clonazepam 0.5mg) 1# HS
    • Saline (nicametate citrate 50mg) 1# BID
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
• 2023-05-03 SOAP Dermatology
  • S: severe itchy papules and plaques erupition over trunk after medication.
  • O
    • 1. urticaria/angioedema type
    • 2. maculopapular type
    • 3. urticaria-purpura type
         
  • A
    • hand-foot syndorme. r/o erythema mutiformis.
    • Suspect related medication: chemotherapy.
  • P
    • education about drug side effec and explain
    • strongly suggested OPD f/u
  • Diagnosis
    • Localized skin eruption due to drugs and medicaments taken internally L27.1
  • Prescription
    • Topsym cream (fluocinonide 0.05%) BID EXT
    • Compesolon (prednisolone 5mg) 2# PRNQD
    • tetracycline BID EXT
    • Sinpharderm cream (urea) QN TOPI
• 2023-04-25 SOAP Metabolism and Endocrinology
  • S: type 2 DM since 2013, hypertension, irregular Tx before, hyperlipidemia, hyperuricemia, poor control, family Hx of DM: (+)
    • patient refuse insulin injection
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension, benign [I10]
    • Mixed hyperlipidemia [E78.2]
    • Obesity, unspecified [E66.9]
  • Prescription
    • Uformin (metformin 500mg) 1# BID
    • Zulitor (pitavastatin 4mg) 1# QN
    • Kludone (gliclazide 60mg) 1# BID
    • Canaglu (canagliflozin 100mg) 1# QDAC

[consultation]

• 2022-12-06 Rehabiliation
  • A
    • Physical examination
      • Tenderness point: right lateral posterior lower back, near qudratus lumborum
        • Right lower back pain will exagerate when spine flexion and standing.
        • She denied pain over spine, SI joint or hip joint, muscle weakness or numbness.
        • suspected muscle strain or HIVD
      • L spine X ray: pending report
    • Assessment
      • Adenocarcinoma of descending colon with impending obstruction, status post laparoscopic-assisted left hemicolectomy on 2022/08/11, pT3N1bM0(3/13), G2, LVI(+), PNI(-), stage IIIB s/p chemotherapy with FOLFOX from 2022/09/28
      • Hyperlipidemia
      • Type 2 diabetes mellitus
      • Chronic viral hepatitis B without delta-agent
      • Herniated Intervertebral Disc s/p OP
      • Constipation
    • Plan
      • patient education for core-strengthening exercise, but the patient and her family refuse to do them.
      • keep current pain control medication;
        • NSAID or toricam could be considered if no contraindication
      • arrange rehab OPD follow up for further evaluation and treatment.
• 2022-09-28 Dermatology
  • Q
    • For skin itchy, and skin rash at back, four limbs
    • This 77 years old female patient was a case of type 2 diabetes mellitus, hyperlipidemia, and hypertension for 8 years under medications treatment.
    • She also had surgical history of 1) s/p needle aspiration of liver abscess at right posterior lobe in 2015; 2) CBD stone with cholangitis s/p laparoscopic cholecystectomy on 2015/07/09; and s/p EST and balloon lithotripsy on 2015/08/10; 3) s/p T11, T12 vertebroplasty in 2018.
    • According to patient statement, she suffered from left low abdominal dull pain while defecation was noted for one month; the LLQ pain was got worse with difficult defecation in recenyly days. The colon biopsy showed: adenocarcinoma, stage: pT3N1b(if cM0); AJCC stage IIIB. Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+). This time, she is admitted for chemotherapy with FOLFOX, and she denied having a fever, chillness, abdomen pain, or TOCC history.
    • She complaints skin itchy, and skin rash at back, four limbs since 2022/09/21, so we need your help, thanks a lot!!
  • A
    • The patient had sufferred from diffuse itchy papules over dry xerotic skin over back and upper limbs.
      
    • Under the impression of xerotic dermatitis over four limbs and eczema over back
    • The following sugeetion:
      • keep Allegra (fexofenadine) 1# bid po use and consider add ketotifen 1# bid po use.
      • consider shift Mycomb (nystatin, neomycin, triamcinolone, gramicidin) to Topysm cream (fluocinonide) 2 tube topical bid use for itchy papules over back/four limbs.
      • add Sinphraderm (urea, hydrocortisone) 1 tube topical QN use after body wash for skin mositurating enhancement, especially on the four limbs.
        
      • Keep patient’s back from becoming stuffy by avoiding prolonged bed rest.
• 2022-08-05 Colorectal Surgery
  • Q
    • LLQ pain for 1 month
    • Low abdomen pain and fever happened this morning
    • No vomiting, loose stool noted yesterday
    • Past Hx of DM, liver abscess
  • A
    • Abdomen: soft, mild tenderness at left, no distended
    • CT: Adenocarcinoma of the descending colon with near complete obstruction is highly suspected. Please correlate with colonoscopy.
      • According to American Joint Committee on Cancer(AJCC) staging system, 8th edition for colon cancer: T4a N2a M0, stage: IIIC
    • A: Tumor of D-colon, cT4aN2aM0
    • P: admission, nutrition support
      • we’ll arrange sigmoidoscopy next Monday for identification of colon lesion

[surgical operation]

• 2018-03-23 T11, 12 compression fracture s/p T11, T12 vertebroplasty
• 2015-08-10 EST and balloon lithotripsy (EST = endoscopic sphincterotomy)
• 2015-07-09 CBD stone with cholangitis s/p laparoscopic cholecystectomy
• 2015-01-21 Liver abscess at right posterior lobe s/p needle aspiration

[chemotherapy]

• 2023-05-22 - leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
  • dexamethasone 4mg + NS 250mL + aprepitant 125mg
• 2023-04-20 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-03-08 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-02-20 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-02-03 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Due to ANC 1262, Ox 85 -> 65, DC 5FU bolus)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-01-18 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-12-15 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-12-05 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-11-17 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-11-01 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-10-18 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-09-28 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

==========

2023-05-23

• Based on the PharmaCloud database, it appears that the patient has only been seen at our hospital for the past three months. No discrepancies or issues were identified in the medication reconciliation process for the patient upon admission this time.

• The CT scan performed on 2023-01-20 showed no evidence of tumor recurrence. In addition, on 2023-05-03, both tumor markers, CEA and CA199, fell into the normal range for the first time. This is an encouraging development in the patient’s condition to date.

• The patient experienced a severe eruption of pruritic papules and plaques over the trunk in early May 2023, probably in response to medication. The dermatologist has prescribed appropriate medications to treat this skin reaction. Please monitor closely for any recurrence of these symptoms.

• The patient’s serum glucose levels have remained high, exceeding 270 mg/dL for the past two days. All medications prescribed by our endocrinologist have been added to the active formulary, and the patient is unwilling to take insulin injections. This makes appropriate dietary control even more important. It may be beneficial to schedule a consultation with a dietitian during the patient’s hospitalization to provide guidance on dietary changes to manage blood glucose levels.

2023-04-21

• Blood glucose control becomes less effective, as evidenced by rising HbA1c levels.
  • 2023-04-12 HbA1c 8.0 %
    
  • 2023-01-11 HbA1c 6.8 %
    
  • 2022-10-12 HbA1c 6.0 %
    
  • 2022-07-11 HbA1c 5.8 %
• Since the patient has been taking at least 3 therapeutic categories of oral antihyperglycemic agents for a long time, it is recommended that injectable insulin be introduced to assist with glycemic control.

2023-03-09

• The patient has been receiving FOLFOX treatment since late Sep 2022. In early Feb 2023, the patient’s oxaliplatin dose was reduced from 85mg/m2 to 65mg/m2, and her 5FU bolus was skipped. Since then, there have been no further occurrences of severe leukopenia.
  • 2023-03-07 WBC 3.39 x10^3/uL
    
  • 2023-02-15 WBC 3.04 x10^3/uL
    
  • 2023-02-01 WBC 2.97 x10^3/uL
    
  • 2023-01-11 WBC 6.52 x10^3/uL
    
  • 2022-12-27 WBC 2.63 x10^3/uL
    
  • 2022-12-15 WBC 4.83 x10^3/uL
    
  • 2022-12-01 WBC 3.93 x10^3/uL
    
  • 2022-11-15 WBC 3.30 x10^3/uL
    
  • 2022-11-01 WBC 4.29 x10^3/uL
    
  • 2022-10-12 WBC 4.10 x10^3/uL
    
  • 2022-09-27 WBC 6.83 x10^3/uL
    
  • 2022-08-20 WBC 9.71 x10^3/uL
• The patient has poor blood sugar control, which has been observed across multiple recent hospital stays. Despite taking Uformin (metformin), Canaglu (canagliflozin), and Kludone (gliclazide), the patient’s blood sugar levels have been poorly controlled during her hospital stay, increasing from 214 to 339 to 333mg/dL. It might be necessary to consider insulin as an option to help manage her blood sugar levels.

2023-02-21

• The drugs that were recently prescribed at our Neurology, Metabolism & Endocrinology department and were disclosed in the NHI PharmaCloud System have been appropriately prescribed as self-carried items during this hospital stay. There have been no medication reconciliation issues found in the patient.
• The results of the finger prick blood glucose tests indicate high readings (304 <- 316 <- 351mg/dL) despite the current use of Uformin (metformin), Canaglu (canagliflozin), and Kludone (gliclazide).
• In consideration of the patient’s longstanding diabetes and development of neuropathy, retinopathy might need to be checked.
• Consideration can be given to adding basal insulin if the patient’s fasting plasma glucose levels continue to remain consistently above 300mg/dL.

2023-01-19

• The patient’s blood sugar level appears to have become less under control over the past half year. The results of finger prick blood glucose tests indicate that the readings are also high. (266 <- 296 <- 354mg/dL)
  • 2023-01-11 HbA1c 6.8 %
    
  • 2022-10-12 HbA1c 6.0 %
    
  • 2022-07-11 HbA1c 5.8 %
• In the absence of iodinated contrast imaging, Uformin (metformin 500mg/tab) 1# BID can be added to help improve blood glucose control as long as the patient’s creatinine level remains low (2023-01-11 0.72mg/dL).

2022-12-16

• The vital signs are stable and lab results on 2022-12-15 showed no extreme abnormalities. The control of blood sugar levels is better than it was during the last hospitalization.

2022-12-06

• The lab results (2022-12-01) were generally normal except for a low PLT reading (107 x10^3/uL).
• Despite treatment with metformin, gliclazide, and canagliflozain, the blood sugar level was still high at 205 mg/dL on 2022-12-06 06:09. An addition of DPP4 inhibitors, such as Trajenta (linagliptin), may be beneficial in lowering blood sugar levels.

2022-11-18

• The lab results (2022-11-15) were generally normal without extreme readings.
• There was a slight increase in blood pressure and blood sugar levels compared to normal. Please monitor on a regular basis.
• There are no issues with the scheduled chemotherapy and the current prescription.

2022-11-02

• A rise in pulse rate and drop in blood pressure were observed (2022-11-02 08:40 109/59, pulse 102), while SpO2 remained above 95%. Could it be caused by a lack of hydration?
• Diabetes is managed by oral hypoglycemic agents and ordered human insulin, however, blood glucose levels are volatile and maintained high. Please continue to monitor it on a regular basis.
• The active prescription is not subject to any issues.

2022-10-19

• The patient has a history of diabetes. Under self-carried metformin, gliclazide, and canagliflozin medication, fasting blood sugar levels were highly volatile (231mg/dL 2022-10-19 06:17 <- 102mg/dL 2022-10-18 16:39) and should be closely monitored.
• The most recent data on renal and liver function, serum electrolytes, CBC, WBC DC are dated 2022-10-12 and might be updated prior to chemotherapy.
• Please keep the patient’s back from becoming stuffy by avoiding prolonged bed rest. (skin itchy, and skin rash at back, four limbs were observed during last hospital stay)

2022-09-28

All-RAS + BRAF + IHC results were like 700811991’s.

• Using patient-carried antiglycemic agents Uformin (metformin), Kludone (gliclazide), and Canaglu (canagliflozin), the blood sugar level of the patient was acceptable.
• TPR and BP readings were stable. The results of the lab test on 2022-09-27 were grossly normal.
• No problems are identified that would make it inappropriate for the patient to receive the chemotherapy he is scheduled to receive.

700516200

230522

• 2023-05-19 SONO - chest
  • Echo diagnosis:
    • right side small amount of pleural effusion
    • left side moderate amount of pleural effusion, 600cc straw-color fluid was aspirated for analysis.
  • Special Procedure:
    • echo-assisted pleural tapping 18# needle Left side 600ml straw-color
• 2023-05-18 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
    
  • Enlargement of cardiac silhouette.
  • Massive bilateral Pleura effusion
• 2023-05-17 CXR
  • Sinus tachycardia
  • Left axis deviation
  • Low voltage QRS
  • T wave abnormality, consider anterior ischemia
  • Abnormal ECG
• 2023-05-11 Cell block cytology - pleural effusion, left side
  • 50 ml urbid — positive for malignancy
  • SMEARS and CELLBLOCK: Many red blood cells, lymphocytes, mesothelial cells, and neoplastic cells present.
• 2023-05-11 KUB
  • Spondylosis with scoliosis of the L-spine with convex to left side.
  • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
  • S/P CVP line insertion from right femoral vein and the tip located at IVC.
• 2023-05-11 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
    
  • Massive left Pleura effusion
• 2023-05-11 SONO - chest
  • Special Procedure:
    • Pleural tapping 16 #-needle Left side 500 ml straw-color
      • Chest echography was performed first. The suitable intercostal space was selected and located.
      • Catheter was inserted with negative pressure smoothly.
      • Left side pleural effusion was drawn smoothly.
      • Watch out BP after tapping.
  • Echo diagnosis:
    • Pleural effusion, left side.
  • Suggestion:
    • check BP for one hour. supine position for taking rest after tapping.
    • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR.
• 2023-05-10 Patho - esophageal biopsy
  • Esophagus, lower, biopsy — Esophageal ulcer
  • The sections show a picture of esophageal ulcer, composed of necrotic debris, inflammatory exudate and clusters of degenerative atypical cells.
  • IHC, the degenerative atypical cells reveal: CK(-), WT1(-) and Leukocyte common antigen (focal +). There is no evidence of carcinoma involvement in the sections examined.
• 2023-05-10 ECG
  • Sinus tachycardia
  • Low voltage QRS
  • Nonspecific T wave abnormality
• 2023-05-10 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Suboptimal survey, due to severe belching during exam
    • Reflux esophagitis LA Classification grade D
    • Esophageal ulcer, 25cm to 40cm below incisors
    • Superficial gastritis
    • Antral deformity
  • Suggestion
    • Suboptimal survey, due to severe belching during exam
    • PPI and sucralfate use
• 2023-04-06 Patho - stomach biopsy
  • Stomach, upper body, AW, Biopsy — Hyperplastic polyp
• 2023-04-06 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis, middle and lower esophagus, LA classification, grade D
    • Esophageal ulcer, middle and lower esophagus
    • Edematous change of gastric mucosa, body
    • Gastric polyp, upper body, AW, s/p biopsy
  • Suggestion
    • Please check albumin level
• 2023-04-03, -02-06 Abdomen - Standing (Diaphragm)
  • Rim gas shadow in the pelvis is noted. please correlate with clinical condition or CT.
  • Non-specific bowel gas pattern in right lower abdomen and pelvis is noted. please correlate with clinical condition. Follow up is indicated.
  • Spondylosis with scoliosis of the L-spine with convex to left side
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4.
  • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
• 2023-02-23 CT - abdomen
  • History and indication: ovarian ca
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Some fluid collection at left subhepatic region.
    • Atherosclerosis of aorta.
    • Disc space narrowing at L3/4.
  • IMP:
    • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Some fluid collection at left subhepatic region.
• 2022-11-22 Body fluid cytology - ascites
  • Finding: ovarian cancer with recurrence
  • 46 cc, orange, cloudy — Positive for carcinoma
  • Smears show clusters of carcinomatous cells with nuclear hyperchromasia, irregular contour and pleomorphism.
• 2022-11-17 CT - abdomen
  • Findings
    • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Large amount ascites.
    • Right liver cyst (7mm).
    • Atherosclerosis of aorta.
    • Disc space narrowing at L3/4.
  • IMP:
    • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Large amount ascites.
• 2022-09-03 CT - abdomen
  • s/p hysterectomy and salpingo oophorectomy
  • No evidence of tumor recurrence
  • Some soft tissue at abdominal wall, stationary
• 2022-05-06, -01-07 CT - abdomen
  • Prior CT mentioned Some soft tissues at abdominal wall are noted again, stationary. Benign process is highly suspected. Follow up is indicated.
• 2022-01-05 Nerve Conduction Velocity, NCV
  • Findings
    • normal motor DLs, CMAP amplitudes and NCVs of bil. median, ulnar, peroneal and tibial n.
    • prolonged sensory DLs on right median and bil. ulnar n. with slowed NCVs, otherwise normal SNAP amplitudes and NCVs of bil. sural n.
    • the F-wave latencies of bil. median, ulnar, peroneal and tibial n. were normal.
    • the H-reflex study of bil. tibial n. were normal.
  • Conclusion: left median and bil. ulnar sural sensory neuropathies at distal region
• 2022-01-04 Cerebral perfusion SPECT
  • There was no prominently abnormal focal radiotracer uptake in bilateral cerebral hemispheres. Please correlate with clinical findings for further evaluation.
• 2022-01-04 MRI - brain
  • Chronic bil. paranasal sinusitis, chronic left mastoiditis.
  • Brain atrophy. Mild Bilateral subcortical and periventricular white matter change (leukoaraiosis).
• 2021-12-28 CT - brain
  • No brain parenchymal lesion.
  • Intracranial ICAs and VAs atherosclerosis.
  • Brain atrophy.
  • Chronic left sphenoid-posterior ethmoid sinusitis and left mastoiditis.
• 2021-09-23 CT - abdomen
  • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding (stable). Stationary condition of anterior abdominal wall.
• 2021-03-18 CT - abdomen
  • S/P hysterectomy. Increased soft tissues at peritoneal cavity r/o tumor seeding. Small amount ascites.
  • Wall thickening of gallbladder.
• 2020-12-15 CT - abdomen
  • S/P hysterectomy. Increased soft tissues at right lower peritoneal cavity, r/o tumor seeding. Increased enhancement at anterior abdominal wall.
• 2020-08-07 CT - abdomen
  • Prior CT identified a cystic lesion at right adenxa 6.2 x 5.2 cm is noted again, mild increasing in size to 6.8 x 6.4 cm. Please correlate with clinical condition.
• 2020-08-04 Gynecologic ultrasonography
  • ATH + BSO
  • IMP: R/O Pelvis mass: (63mmx59mm), no blood flow
• 2020-06-09 Patho - peritoneum biopsy
  • Labeled as “pelvic tumor”, clinical history: “ovarian cancer s/p op”, excision biopsy — fibrosis
    
  • Section shows 1 piece(s) of fibrotic tissue. No maligmancy.
• 2020-04-27 CT - abdomen
  • S/P hysterectomy. Cystic lesions at bil. pelvic cavity.
• 2020-02-02 KUB
  • Non-specific bowel gas pattern in left lower abdomen is noted. please correlate with clinical condition or CT. Follow up is indicated.
  • Spondylosis with scoliosis of the L-spine with convex to left side .
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4.
  • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
• 2020-01-22 MRI - brain
  • no evidence of recent infarction.
• 2020-01-10 ECG
  • Normal sinus rhythm
  • Prolonged QT
  • Abnormal ECG
• 2020-01-07 Patho - soft tissue tumor, extensive resection
  • PATHOLOGIC DIAGNOSIS
    • Ovary, right, debulking — Serous adenocarcinoma, high grade.
      • IHC stains: ER (+), PR (-), WT-1 (+), PAX-8 (+): compatible with ovarian origin, vimentin (-): dis-favor endometrial origin.
        
    • Ovary, left, debulking — Serous adenocarcinoma, high grade
      
    • Fallopian tube, right, debulking — Serous adenocarcinoma, high grade
      
    • Fallopian tube, left, debulking — Serous adenocarcinoma, high grade
      
    • Uterus, corpus, total hysterectomy — Myomas; benign strophic endometrium.
      
    • Uterus, cervix, total hysterectomy — Free
      
    • Omentume, omentectomy (S20-289) — Serous adenocarcinoma, high grade
      
    • Lymph node, bilateral pelvic and para-aortic, dissection — Free
      
    • Urinary bladder, mass above bladder, excision — Transmural tumor invasion to bladder mucosa.
  • MICROSCOPIC EXAMINATION
    • Histologic type: serous carcinoma,
      
    • Histologic grade: high grade
      
    • Contralateral ovary involvement: present
      
    • Tumor side ovarian surface involvement: present
      
    • Contralateral ovary surface involvement: present
      
    • Right tube involvement: present (in parenchyma)
      
    • Left tube involvement: present (in parenchyma)
      
    • In situ adenocarcinoma in right ＆/or left fallopian tube: absent
      
    • Right adnexa soft tissue involvement: present
      
    • Left adnexa soft tissue involvement: present
      
    • Pelvic soft tissue involvement: present
      
    • Uterine serosa involvement: absent
      
    • Omentum involvement: present (invasive ) The largest tumor: 8 x 5 x 1.1 cm.
      
    • Uterine Cervix involvement: not received
      
    • Endometrium involvement: absent
      
    • Myometrium involvement: absent
      
    • Appendix involvement: not received
      
    • Largest Extrapelvic Peritoneal Focus Macroscopic (greater than 2 cm)
      
    • Peritoneal/Ascitic Fluid: N2019-05003 - Malignant (positive for malignancy)
      
    • Regional Lymph Nodes: Free (0/56)
      • left external iliac (0/9);
      • left obturator (0/12);
      • right external iliac (0/6);
      • right obturator (0/12);
      • left para-aortic (0/12);
      • right para-aortic (0/5).
        
    • Other organs or specimens involvement: N/A.
• 2020-01-07 Immunohistochemistry, IHC
  • Using block omental tissue S2020-289A1: IHC stains: ER (+), PR (-); WT-1 (+), PAX-8: (+): favor ovarian origin; vimentin (-): dis-favor endometrial origin.

[consultation]

• 2023-05-11 Family Medicine
  • Q
    • The 74y/o woman has left ovarian serous adenocarcinoma, stage IIIC /p chemo with Avastin + Topotecan on 20230319. She has can’t intake and vomit coffee ground, suspect disease progress, so we need your help for hospice share care. Thanks!
  • A
    • 74-year-old female, left ovarian serous adenocarcinoma, stage IIIC s/p chemotherapy
    • This time suffer from poor intake & coffee ground vomitus
    • Consciousness alert, ECOG 3
    • We will arrange hospice combine care and follow up her condition

[chemotherapy]

• 2023-03-20 - bevacizumab 15mg/kg 500mg NS 100mL 1.5hr + topotecan 3mg/m2 3.7mg NS 120mL 0.5hr (Avastin Q3W + topotecan D1,8,15)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-14 - topotecan 3mg/m2 3.7mg NS 120mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-06 - bevacizumab 15mg/kg 500mg NS 100mL 1.5hr + topotecan 3mg/m2 3.7mg NS 120mL 0.5hr (Avastin Q3W + topotecan D1,8,15)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-13 - topotecan 3mg/m2 3.8mg NS 120mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-06 - topotecan 3mg/m2 3.8mg NS 120mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-16 - topotecan 3mg/m2 3.8mg NS 120mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-06 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr + topotecan 4mg/m2 5.1mg NS 150mL 30min (Avastin Q3W + topotecan D1,8,15)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-11-05 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-09-28 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-08-20 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-07-20 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-06-29 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-06-01 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-05-11 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-04-20 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-04-07 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2020-05-26 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 500mL
• 2020-05-05 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 500mL
• 2020-04-14 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 500mL
• 2020-03-24 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 250mL
• 2020-03-03 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 250mL
• 2020-02-05 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 250mL
• 2020-01-05 - [liposome doxorubicin 30mg/m2 40mg D5W 100mL + carboplatin AUC 5 450mg NS 100mL] IP 2min

701451122

230522

[diagnosis] - 2023-04-09 admission note

• Multiple myeloma not having achieved remission

[exam findings]

• 2023-04-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (156 - 43) / 156 = 72.44%
    • M-mode (Teichholz) = 72.6
  • Conclusion
    • Adequate LV,RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Mild MR,TR,AR,PR
    • Calcified aortic valve
• 2023-04-06 MRI - L-spine
  • Intravenous injection of gadolinium was not given.
  • Findings:
    • The lumbar spine shows spondylosis and disk space degeneration at the L2/3 through L5/S1 levels.
    • Retrolisthesis of L3 on L4, grade I.
    • Spondylolisthesis of L5 on S1, grade I.
    • One low signal intensity nodular lesion within T11 vertebral body. May be secondary to multiple myeloma.
• 2022-09-05 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — plasma cell neoplasm (plasmacytoma or multiple myeloma).
  • Section shows piece(s) of bone marrow with 60-70% cellularity and M:E ratio of approximately 1:2. Three cell lineages are present with normal maturation of leukocytes and a predominant plasmacytoid subpopulation. Megakaryocytes are adequate in number.
  • IHC stains: CD138: 70%; Lambda and Kappa light chains: a predominant lambdsa light chain population, MPO: 10 %; CD71: 20% (of the nucleated cells). The findings are a pattern of plasmacytoma or multiple myeloma. Please correlate with image findings.

[MedRec]

• 2023-05-05 SOAP Neurosurgery
  • S - BMT soon (20230521); walk level > 10 mins; Rt LE soft/weakness told
  • Prescription
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
    • Saline (nicametate citrate 50mg) 1# QD
• 2023-04-07 SOAP Neurosurgery
  • S - respsone to neurotine; still bil legs soreenss; lying worser;
  • Prescription
    • Neurontin (gabapentin 100mg) #1 PRNBID
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
    • Saline (nicametate citrate 50mg) 1# BID
• 2023-03-17 SOAP Neurosurgery
  • S - LBP with Rt > Lt LE radiatioanl pain/ numbness to foot for months; Associated with Weakenss; Pitting edema; night pain
  • Prescription
    • Neurontin (gabapentin 100mg) #1 PRNBID
• 2022-09-29 SOAP Hemato-Oncology
  • O: 2022/09/27 Albumin = 2.8 g/dL
  • P:
    • NHI reimbursement - Bortezomib (such as Velcade) is limited to use in combination with other cancer treatment drugs for patients with multiple myeloma.
      • Maximum of 16 treatment cycles per person; Myzomib has a maximum of 8 treatment cycles per person.
      • Requires prior application before use, applying for 4 treatment cycles at a time.
      • After using 4 treatment cycles, it is necessary to confirm that paraprotein (M protein) has not increased after drug use (indicating response or stable status), or for some non-secretory type MM patients, the treatment effect is based on the ratio of plasma cells in bone marrow examination, only then can the treatment continue.
• 2022-09-27 SOAP Hemato-Oncology
  • S: He was diagnosed to have multiple myeloma presenting as normocytic anemia
  • O: 2022/09/17 IgA = 6539 mg/dL;
  • Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 20220926
    • Multiple myeloma IgA Lambda
    • ISS stage 2 at least
    • use VTD followed by autoPBSCT
• 2022-09-16 SOAP Hemato-Oncology
  • O
    • 2022/09/16 Free Light Chain κ/λ
      • FKLC = 7.44 mg/L;
      • FLLC = 155 mg/L;
    • 2022/09/13 Protein EP
      • M-peak = Positive;
• 2022-09-09 SOAP Hemato-Oncology
  • S: He was informed to have anemia since March 2022 and he received check up at HuaLien TzuChi Hospital
  • O:
    • 2022/09/09 Reticulocyte count = 6.340 %;
    • 2022/09/09 CBC
      • HGB = 7.2 g/dL;
      • MCV = 97.1 fL;
    • 20220909: BP 126/74; Pulse 74;
  • A:
    • Normocytic anemia requiring transfusion

[chemothereapy]

• 2023-04-14 - cyclophosphamide 3000mg/m2 5500mg NS 500mL 2hr (Endoxan for PBSC mobilization protocol)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + Uromitexan (mesna) NS 100mL 1hr + NS 250mL
• 2023-03-10 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
• 2023-02-09 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
• 2023-01-31 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1 (VTd)
• 2023-01-10 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
• 2022-12-27 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
• 2022-12-13 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
• 2022-11-29 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
• 2022-11-15 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
• 2022-11-01 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
• 2022-10-18 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
• 2023-10-11 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1 (VTd)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma 2023-05-22 https://www.uptodate.com/contents/image?imageKey=ONC%2F101205&topicKey=HEME%2F6647

• Cycle length: 28 days.
• Regimen
  • Bortezomib
    • 1.3 mg/m2 SC
    • Given as a single SC injection.
    • Days 1, 8, 15, and 22
  • Thalidomide
    • 100 mg for first 14 days then 200 mg per day thereafter by mouth
    • Take with water on an empty stomach at least one hour after the evening meal.
    • Daily, days 1 through 21
  • Dexamethasone (“low dose”)
    • 40 mg by mouth
    • Take with food (after meals or with food or milk) in the morning.
    • Days 1, 8, 15, and 22

[lab data]

prior to peripheral blood stem cell harvest

2023-04-17 CMV viral load assay Target not detecetedIU/mL
2023-04-17 EBV DNA quantitative amplification test <120 copies/mL
2023-04-13 EB VCA IgG Positive Ratio
2023-04-13 EB VCA IgG Value 5.3 Ratio
2023-04-12 EB VCA IgM Negative Index
2023-04-12 EB VCA IgM Value 0.0 Index
2023-04-10 RPR/VDRL Nonreactive
2023-04-10 CMV IgM Nonreactive
2023-04-10 CMV IgM Value 0.54 Index
2023-04-10 CMV_IgG Reactive
2023-04-10 CMV_IgG Value 834.1 AU/mL
2023-04-10 HIV Ab-EIA Nonreactive
2023-04-10 Anti-HIV Value 0.05 S/CO
2023-04-10 Anti-HBc Nonreactive
2023-04-10 Anti-HBc-Value 0.24 S/CO
2023-04-10 Anti-HCV Nonreactive
2023-04-10 Anti-HCV Value 0.06 S/CO
2023-04-10 HBsAg Nonreactive
2023-04-10 HBsAg (Value) 0.50 S/CO
2023-04-10 Anti HTLV I/II Nonreactive
2023-04-10 Anti HTLV I/II Value 0.05 S/CO

700901572

230518

[lab data]

• 2023-05-15 CMV_IgG Reactive
  
• 2023-05-15 CMV_IgG Value 628.6 AU/mL
  
• 2023-05-15 CMV IgM Nonreactive
  
• 2023-05-15 CMV IgM Value 0.16 Index

[exam findings]

• 2023-05-14 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • Linear infiltration over right and left lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
• 2023-02-20 Patho - bone marrow biopsy
  • Bone marrow, iliac reast, biopsy— Hypercellularity (near 100%) with presence of blasts (about 10%)
    • NOTE: Differential diagnosis includes chronic myeloid leukemia and myeloproliferative neoplasm. Correlation of CBC data, molecular cytogenetic study, BCR/ABL1 test and bone marrow smear is recommended.
  • Microscopically, it shows hypercellularity (near 100%) with myloid cell proliferation. Blasts highlighted by CD34 and CD117 are seen and about 10%. Megakaryocytes are increased.
  • Immunohistochemical stain reveals MPO(+), CD61(+), CD71( focal+), CD20(-), CD138(-), TdT(-).
• 2023-02-20 SONO - abdomen
  • Liver cysts
  • bilateral pleural effusion
  • right renal cyst
• 2023-02-17 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 35.9) / 116 = 69.05%
    • M-mode (Teichholz) = 69.1
  • Conclusion
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mild to moderate MR and TR, mild AR
    • Impaired LV relaxation
    • Dilated LA, thick IVS
• 2020-09-09 MRI - thyroid, parathyroid
  • Indication: L thyroid tumor
  • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed
    • a cystic lesion, about 24.76mm, in the left thyroid gland. NO obvious enhancement was noted.
    • no neck LAP.
    • unremarkable change in the skull base.
    • unremarkable change in the naspharynx, oropharynx, and hypopharynx
  • IMP:
    • a thyroid cystic lesion in the left thyroid gland.
• 2020-09-07 Nasopharyngoscopy
  • Findings: Lymphoid tissue noted in posterior pharyngeal wall
  • Conclusion: thyroid cyst, left
• 2020-06-18 Patho - intradermal nevus
  • Skin, face, excision biopsy — Seborrheic keratosis
    
  • Section shows piece(s) of hyperkeratosis, papillomatous skin with keratin cysts and interdigitation of epidermis and papillary dermis.

[MedRec]

• 2023-05-09 SOAP Hemato-Oncology
  • P
    • RTC 1 weeks -> Due to elevated WBC > 400K
    • Visit Dermatologist for skin induration
    • Visit Urologist for urine frequency
• 2023-03-30 SOAP Hemato-Oncology
  • A: Body weight loss might be related to poor dental condition
• 2023-03-16 SOAP Hemato-Oncology
  • S: 2022-03 Chromosome: 46~47,XX,+8[cp19]
  • O: 2023/03/09 JAK2 single site gene mutation = Undetectable
• 2023-03-02 SOAP Hemato-Oncology
  • O:
    • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date 20230227: waiting for JAK2 data
    • 2023/02/27 BCR/abl = Undetectable
• 2023-02-16 ~ 2023-02-24 POMR Hemato-Oncology
  • Discharge diagnosis
    • R/O Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
    • Gout, unspecified
  • CC
    • for higher WBC and PLT level
    • for SOB
  • Present illness
    • This 84 y/o female with dyslipidemia was admitted to our ward via ER due to abnormal leukocytosis during OPD examination.
    • According to the patient’s family, she started to cough and suffered from dyspnea, especially on exertion one week ago. She was brought to LMD for help, and came to our OPD today again for persisted symptoms. At our Family medicine OPD, her lab data showed leukocytosis with WBC level of 84810/uL, and thrombocytosis of 1118K. And the data was significantly different from last data in 2022/02, with WBC level of only 11070/uL. She was then refered to Hema OPD, and follow-up lab data showed even higher WBC count of 88170/uL, and metamyelocyte 19%, myelocyte 31.0 %, promyelocyte 2.0 %, blast 2%, PL 1118000/uL. Therefore, admission for further survey on 2023/02/17.
  • Course of inpatient treatment
    • After admission, she received NS hydration, Hydrea 2# qd (2/17-2/20), Feburic 0.5# qd and Bokey 1# qd for higher WBC and PLT. Critical condition for closely monitor. She will do the bone marrow, abd echo and echocardigraphy for general survey. Empiric antibiotic as Flumarin for low grade fever. Heart echo was done, LVEF 69%. Abd echo showed no splenomegaly. Bone marrow was done and no hematoma, report showed Hypercellularity (near 100%) with presence of blasts (about 10%) on 2023/2/23 and pending BCR-ABL. Norvasc 1# qd for hypertension, but lower limbs mild edema, so we shifted Olmetec and consult CV for assessment. After treatment, her WBC and PLT level decrease, so she can be discharged on 2023/02/24.
  • Prescription
    • Ulstop (famotidine 20mg) 1# QD
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
    • Olmetec (olmesartan medoxomil 20mg) 1# QD
    • Feburic (febuxostat 80mg) 0.5# QD
    • Bokey (aspirin 100mg) 1# QD
• 2023-02-16 SOAP Hemato-Oncology
  • Diagnosis
    • Chronic myeloid leukemia, BCR/ABL-positive C92.1
    • Dyspnea, unspecified R06.00
  • Prescription
    • Bokey (aspirin 100mg) 1# QD
    • Ulstop (famotidine 20mg) 1# QD
    • Hydrea (hydroxyurea 500mg) 2# QD
• 2023-02-16 SOAP Family Medicine
  • O
    • 2023/02/16 CBC
      • WBC = 84.81 x10^3/uL;
      • HGB = 11.4 g/dL;
      • PLT = 1118 x10^3/uL;
  • P: refer to hema OPD

[consultation]

• 2023-02-21 Cardiology
  • Q
    • The 84 y/o woman has hypertension without drug use. We gave Norvasc, but lower limbs pitting edema weak 1+. LVEF not dysfunction. We shift to ARB for control. We need your help for anti-hypertension agent assessment. Thanks!
  • A
    • Currently the patient’s blood BP is relatively stable.
    • Keep SBP 140-150 mmhg during admission with current medication.
    • CV OPD f/u.

==========

2023-05-18

[assessment]

• Based on the serial trend of WBC counts, it appears that hydroxyurea 1000mg daily might be excessively suppressing WBC levels, while 250mg or 500mg daily might not be sufficient. It might be worthwhile considering a daily dose of 750mg, using a combination of 500mg QD and 500mg QOD to achieve the desired therapeutic effect.
  • 2023-05-18 hydroxyurea 500mg 2# QD
  • 2023-05-17 WBC 57.14 x10^3/uL hydroxyurea 500mg 1# QD 1# ST
    
  • 2023-05-15 WBC 49.31 x10^3/uL hydroxyurea 500mg 1# QD
    
  • 2023-05-13 WBC 52.53 x10^3/uL hydroxyurea 500mg 1# QD
    
  • 2023-05-09 WBC 46.73 x10^3/uL hydroxyurea 500mg 1# QOD
    
  • 2023-04-26 WBC 11.91 x10^3/uL hydroxyurea 500mg 1# QOD
    
  • 2023-04-13 WBC 8.67 x10^3/uL hydroxyurea 500mg 1# QOD
    
  • 2023-03-30 WBC 12.58 x10^3/uL hydroxyurea 500mg 1# QOD
    
  • 2023-03-23 WBC 26.55 x10^3/uL hydroxyurea 500mg 1# QOD
    
  • 2023-03-16 WBC 59.00 x10^3/uL hydroxyurea 500mg 1# QOD
    
  • 2023-03-02 WBC 5.00 x10^3/uL
    
  • 2023-02-24 WBC 3.62 x10^3/uL
    
  • 2023-02-22 WBC 4.46 x10^3/uL hydroxyurea 500mg 2# QD
  • 2023-02-20 WBC 19.99 x10^3/uL hydroxyurea 500mg 2# QD
  • 2023-02-18 WBC 62.40 x10^3/uL hydroxyurea 500mg 2# QD
  • 2023-02-16 WBC 88.17 x10^3/uL hydroxyurea 500mg 2# QD
    
  • 2023-02-16 WBC 84.81 x10^3/uL hydroxyurea 500mg 2# QD 2# ST
• In addition, the PLT count is clearly in a downtrend, which would also be closely watched.
  • 2023-05-17 PLT 285 *10^3/uL
    
  • 2023-05-15 PLT 281 *10^3/uL
    
  • 2023-05-13 PLT 324 *10^3/uL
    
  • 2023-05-09 PLT 414 *10^3/uL
    
  • 2023-04-26 PLT 456 *10^3/uL
    
  • 2023-04-13 PLT 419 *10^3/uL
    
  • 2023-03-30 PLT 399 *10^3/uL
    
  • 2023-03-23 PLT 536 *10^3/uL
    
  • 2023-03-16 PLT 664 *10^3/uL
    
  • 2023-03-02 PLT 637 *10^3/uL
    
  • 2023-02-24 PLT 702 *10^3/uL
    
  • 2023-02-22 PLT 678 *10^3/uL
    
  • 2023-02-20 PLT 928 *10^3/uL
    
  • 2023-02-18 PLT 1102 *10^3/uL
    
  • 2023-02-16 PLT 1091 *10^3/uL
    
  • 2023-02-16 PLT 1118 *10^3/uL

Dacogen (decitabine)

• The drug candidate for the treatment of this patient, Dacogen (decitabine 50mg/vial), is currently being temporarily purchased by both Hualien General Hospital and Taipei Xindian Branch. The “temporary procurement” process for a drug usually takes about 1 to 2 months.
• The in-hospital unit prices for Dacogen (decitabine 50mg/vial) are TWD 14,280 for patients covered by NHI and TWD 16,422 for self-pay patients.
• Current “National Health Insurance Drug Reimbursement” for decitabine (2023-04-24 updated)
  • For patients with high-risk myelodysplastic syndromes: RA with excess blasts, RAEB; RAEB in transformation, RAEB-T; chronic myelomonocytic leukemia, CMMoL.
  • Pre-approval review is required for the initial application of this drug.
  • Continuation of this drug does not require pre-approval review, but the medical record should keep pathology or imaging diagnosis proofs, and clinical data related to the treatment. If the patient’s condition worsens to acute myeloid leukemia, the drug should be stopped.
  • Definition of acute myeloid leukemia: myeloblast count greater than 30%.
  • This drug and azacitidine can only be used alternatively. Except for intolerability, they should not be interchanged. If this drug is ineffective, azacitidine cannot be applied for again.

700561422

230517

[past history]

• Heart:(-)

• Chest:(-)

• Liver:(-)

• Kidney:(-)

• H/T:(-)

• DM:(-)

• Other medical:denied

• Surgical: s/p Peripheral glioma excision 20+ years ago

• Menstrual history: G4P2SA2, NSD x2

• Menarche at the age of 13 years old

• Menopaused at the age of 56 years old

• Menstrual cycle:Duration/Interval:4days/28days                 

[allergy]

• NKDA                 

[family history]

• Father: prostate cancer
• Mother: HTN, DM

[exam findings]

• 2023-04-28 Body fluid cytology - ascites
  • negative
• 2023-04-26 Body fluid cytology - ascites
  • negative
• 2023-03-23 Patho - uterus with or without SO non-neoplastic/prolapse
  • PATHOLOGIC DIAGNOSIS
    • Ovarian mass, bilateral, debulking surgery (s/p C/T) — Endometrioid carcinoma, grade 3
    • Fallopain tube, bilateral, ditto — Free of tumor invasion
    • Cervix, uterus, total hysterectomy — Free of tumor invasion
    • Endometrium, uterus, ditto — Endometrioid carcinoma, favor metastatic
    • Myometrium, uterus, ditto — Adenomyosis
    • Lymph node, left iliac, dissection — Free of tumor metastasis (0/4)
    • Lymph node, left obturator, ditto — Tumor metastasis (5/5) without extracapsular extension (0/5)
    • Lymph node, right iliac, ditto — Free of tumor metastasis (0/4)
    • Lymph node, right obturator, dissection — Tumor metastasis (2/10) without extracapsular extension (0/2)
    • Lymph node, left paraaortic, dissection — Free of tumor metastasis (0/5)
    • Lymph node, right paraaortic, dissection — Free of tumor metastasis (0/5)
    • Omentum, omentectomy — Metastatic adenocarcinoma
    • Bilateral parametria — Free of tumor invasion
    • AJCC Pathologic staging — ypT3cN1b, if cM0, stage IIIC
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: debulking surgery
    • Specimen type: uterus, R’t ovary mass, L’t ovary mass, pelvic and paraaortic LNs, and omentum
    • Specimen size:
      • L’t ovarian mass: 4.5 x 3.3 x 3.2 cm, solid mass with cystic change
      • L’t fallopian tube: 3.7 cm in length, 0.5 cm in diameter
        
      • R’t ovary mass: 7.2 x 7.2 x 4.1 cm, cystic mass with solid area and surface involvement
      • R’t fallopian tube: 6.2 cm in length, 0.4 cm in diameter
        
      • Uterus: 11 x 5.9 x 4.3 cm in size and 130 gm in weight. One yellow necrotic tumor mesured 1.2 x 0.5 cm within endometrium is seen, invades less than half the myometrium
        
      • Omentum: 34 x 13 x 2.2 cm with some firm masses
    • Tumor site: bilateral ovary and endometrium
    • Tumor size: (A) R’t ovary: 7.2 x 7.2 x 4.1 cm, (B) L’t ovary: 4.5 x 3.3 x 3.2 cm and (C) endometrium: 1.2 x 0.5 cm
    • Tumor appearance: (A) bilateral ovary: cystic tumor with solid area (B) endometrium: yellow necrotic tumor
    • Specimen integrity: intact, tumor on surface of right ovarian mass
    • Lymph node: pelvic and bilateral paraaortic LNs
    • Representative sections as: A: left iliac LNs, B: left obturator LNs, C: right iliac LNs, D: right obturator LNs, E: left paraaortic LNs, F: right paraaortic LNs, G1-G2: bilateral parametria, G3: cervix, G4: corpus, G5-G6: endometrial tumor, H1: L’t fallopian tube, H2-H6: L’t ovarian mass, I1: R’t F-tube, I2-I8: R’t ovarian mass, J1-J2: omentum
  • MICROSCOPIC EXAMINATION
    • Histologic type: Endometrioid carcinoma
      
    • Histologic grade: Grade 3
    • Contralateral ovary involvement: involved
    • Tumor side ovarian surface involvement: involved
    • Contralateral ovary surface involvement: Not involved
    • Right tube involvement: absent
    • Left tube involvement: absent
    • In situ adenocarcinoma in right ＆/or left fallopian tube: absent
    • Right adnexa soft tissue involvement: absent
    • Left adnexa soft tissue involvement: absent
    • Pelvic soft tissue involvement: N/A
    • Uterine serosa involvement: Not involved
    • Omentum involvement: tumor involved
    • Uterine Cervix involvement: absent, Nabothian cysts
    • Endometrium involvement: present
    • Myometrium involvement: present and adenomyosis
    • Lymph nodes metastasis: tumor metastasis (7/33) without extracapsular extension (0/7) in total number
    • Immunohistochemistry: PAX-8(+), ER(+), WT-1(-), PR (+) and P53(wild type)
    • Ascites: positive for tumor metastasis
• 2023-03-23 Cytology - ascites
  • 32 cc red turbid ascites — Positive for malignancy
  • The smears show lymphocytes, reactive mesothelial cells and some hyperchromatic atypical epithelial clusters, compatible with metastatic carcinoma. Clinical correlation is advised.
• 2023-03-22 CXR
  • Increased bilateral lung markings.
  • Borderline cardiomegaly.
  • Thoracic spondylosis.
• 2023-03-08 CT - abdomen
  • Indication
    • 20221215 sono: ascites, cause unknown. One hyperechoic lesion in the peritoneal cavity. Probable thickened omentum.
    • 20221221 CT: cystic adenocarcinoma of bilateral ovary is suspected. cT3cN1bM, STAGE: IIIC
  • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
  • Findings:
    • Prior CT identified massive ascites and omentum cake is noted again, marked decreasing in size that is c/w carcinomatosis S/P C/T with partial response.
    • Prior CT identified two multilocular cystic mass with some septa and enhancing mural nodules in right and left lower abdomen and pelvis, measuring 11.5 cm (right) and 10.4 cm (left) in size (the largest dimension), are noted again, marked decreasing in size to 6.8 cm (right) and 5.2 cm (left).
      • Cystic adenocarcinoma of bilateral ovary S/P C/T show partial response.
    • Prior CT identified several kissing enlarged nodes in left para-aortic space, left common iliac chain, left internal iliac chain, and left external iliac chain are noted again, marked decreasing in size that are c/w metastatic nodes S/P C/T with near complete response.
    • Prior CT identified few poor enhancing lesions in the uterus are not noted again.
    • Others
      • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidneys.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery.
  • Impression:
    • Carcinomatosis S/P C/T show partial response.
    • Cystic adenocarcinoma of bilateral ovary S/P C/T show partial response.
    • Metastatic lymph nodes S/P C/T show near complete response.
• 2023-01-10 Cytology - ascites
  • 42 cc orange turbid ascites — Atypia
  • The smears show some lymphocytes, neutrophils, reactive mesothelial cells and only one atypical cell cluster show hyperchromatic nuclei with vacuolated cytoplasm. Follow up.
• 2022-12-27 Cell block cytology
  • 40 cc, red, cloudy — Adenocarcinoma
  • Smears and cell block show dense clusters of atypical cells admixed with lymphoplasmcytes, leukocytes and mesothelial cells.
  • IHC stain— CK7(+), CK20(-), PXA-8(+), WT-1(focal+).
• 2022-12-22 Gynecologic ultrasonography
  • Ascites
  • Bilateral Ovarian mass, malignancy cannot be ruled out
  • Endometrial hyperplasia
• 2022-12-21 CT - abdomen
  • Indication: 20221215 sono: Acites, cause unknown. One hyperechoic lesion in the peritoeal cavity. Propable thickened omentum.
  • Findings:
    • There is massive ascites and omentum cake that is c/w carcinomatosis.
    • There are two multilocular cystic mass with some septa and enhancing mural nodules in right and left lower abdomen and pelvis, measuring 11.5 cm (right) and 10.4 cm (left) in size (the largest dimension).
      • Cystic adenocarcinoma of bilateral ovary （T3c) is suspected. Please correlate with CA125 and ascites cytology.
    • There are several kissing enlarged nodes in left para-aortic space, left common iliac chain, left interal iliac chain, and left external iliac chain that are c/w metastatic nodes.
      • The largest node in left common iliac chain measuring 2 cm in the largest dimension (N1b).
    • There are few poor enhancing lesions in the uterus that may be myomas. Please correlate with GYN. sonography.
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
• 2022-12-16 Patho - stomach biopsy
  • Stomach, cardia, biopsy — Helicobacter-associated non-atrophic chronic gastritis
  • Stomach, antrum, biopsy — Helicobacter-associated non-atrophic chronic gastritis
• 2022-12-15 SONO - abdomen
  • Fatty liver, mild
  • Suspected fatty infiltration of pancreas
  • Small amount ascites
  • One hyperechoic lesion in the peritoeal cavity. Propable thickened omentum

[surgical operation]

• 2023-03-22
  • Surgery
    • Operation
      • Excision of intraabdominal malignant tumor
      • HIPEC
      • Tenckhoff tube insertion
  • Finding
    • s/p neoadjuvant chemotherapy
    • PCI: total = 0 (PCI = Peritoneal Cancer Index)
      • [#] region – score
      • [0] central – 0
      • [1] RU – 0
      • [2] epigastrium – 0
      • [3] LU – 0
      • [4] left flank – 0
      • [5] LL – 0
      • [6] pelvis – 0
      • [7] RL – 0
      • [8] right flank – 0
      • [9] upper jejunum – 0
      • [10] lower jejunum – 0
      • [11] upper ileum – 0
      • [12] lower ileum – 0
    • HIPEC regimen: Lipo-dox 35mg/m2 + Carboplatin AUC 5
    • Drain: 15 Fr J-VAC x2 in the pelvic cavity
• 2023-03-22
  • Surgery
    • Diagnosis: Ovarian cancer
    • Frozen: Debulking surgery (hysterectomy + bil. salpingo-oopherectomy + BPLND + omentectomy)
  • Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder
    • Adnexa:
      • LOV: 5x4x4 cm, with enlarged mass
      • ROV: 8x8x8 cm, with papillary tumor growth
      • Fallopian tube: bilateral grossly normal
    • CDS: adhesion band to the bowel (+)
    • Ascites: bloody, about 50 ml
    • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
    • Omentum: grossly normal, infracolic omentectomy completed
    • After the operation, suboptimal debulking surgery was achieved.
    • Estimated blood loss: 850 mL
    • Blood transfusion: 2U pRBC
    • Complication: nil
• 2023-03-22
  • Surgery
    • bilateral ureter catheterization
  • Finding
    • grossly no tumor in bladder, no external compression
    • bilateral UO clean urine jet

[chemotherapy]

• 2023-05-16 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2023-04-25 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2023-03-21 - liposome doxorubicin 35mg/m2 60mg D5W 250mL IP 90min + carboplatin AUC 5 600mg NS 250mL IP 90min (for HIPEC in operation)

• 2023-02-23 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2023-01-31 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

• 2023-01-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1100mg NS 250mL 2hr

  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

==========

2023-05-17

• The patient’s vital signs are stable, labs are largely within normal limits, and no significant adverse reactions have been reported. A review of the PharmaCloud database shows that all of the patient’s recent medications were prescribed by our hospital, and no medication reconciliation issues were identified.

2023-04-26

[assessment]

• On 2023-04-26, lab results showed normal blood cell counts, electrolytes, liver, and kidney function levels, as well as stable vital signs on the TPR panel since this hospitalization.
• The patient experienced no significant discomfort other than mild abdominal distension following normal saline infusion via the IP tube. Naproxen was administered to relieve the abdominal pain in the IP wound area.
• The patient’s underlying condition of hepatitis B (anti-HBc positive) is being adequately treated with Vemlidy (tenofovir alafenamide).
• According to the PharmaCloud database, all recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

700757059

230517

[exam findings]

• 2023-04-21 CXR
  • Lung markings: emphysematous change in the bilateral lung fields
  • mild blunting bilateral costophrenic angles
  • fractures at the right ribs and left lower ribs
• 2023-04-21 KUB
  • compression fractures at L1, L2 and L3 vertebral bodies; compression fracture at L5 vertebral body.
  • s/p right THR at right hip
• 2023-04-21 ECG
  • Normal sinus rhythm
  • Nonspecific ST and T wave abnormality
  • Prolonged QT
  • Abnormal ECG
• 2023-03-06, 2022-12-12, -11-28 CXR
  • linear high density structures over over Rt infrahilum, lower lung zone and left lung, may be pulmonary foreign bodies embolic priop vertebroplasty
  • reticulonodular opacities over left lung too
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    
  • enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad/supine position
  • compression fracture of multiple vertebral bodies
  • priop vertebroplasty in many levels
  • Osteoporotic change of spine and bones of both shoulder regions
  • old fracture of multiple Lt and Rt ribs
  • Avascular necrosis of Rt humeral head, with marginal spurs
• 2023-01-17 Clinical Dementia Rating
  • CDR score: 2
• 2023-01-17 Mini-Mental State Examination
  • MMSE score: 13
• 2022-12-09 MRA - brain
  • Indication:
    • suspect Multiple myeloma, DM. unknown dementia history
    • can communicate 1.5 months ago. marked cognitive decline and disorientation after admission 1 month ago.
  • Impression:
    • Brain atrophy and leukoaraiosis.
    • No evidence of recent infarct.
    • A 0.6cm enhancing bone nodule in dens, nature to be determined.
• 2022-12-01 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Plasma cell myeloma
  • The sections show normocellular marrow (25%). The marrow space is largely replaced by a population of medium-sized immature and mature CD138+ plasma cells, constitue 80% of marrow cells. The plasma cells also shows lambda light chain restriction and negative for kappa light chain .
• 2022-11-15 Electroencephalography, EEG
  • This EEG were composed by continuous diffuse theta wave with 5-6 Hz, 10-20 uv in bilateral hemisphere. There were no obvious photic driving response. This EEG suggest moderate diffuse cortical dysfunction. Advise clinical correlation.
• 2022-11-10 MRI - T-spine
  • Multiple compression fracture of thoracic vertebrae.
  • S/P vertebroplasty of T7.
• 2022-11-08 MRI - L-spine
  • Acute compression fracture of L4 vertebral body.
  • Severe old compression fracture of T12, L1 and L3 vertebrae.
  • Moderate spinal stenosis at L3/4 level, caused by posteriorly displaced bony component.
  • S/P veretebroplasty, L1-3 and T7.
• 2022-11-07 CXR
  • Bilateral parahilar infiltrates with pleural effusion, r/o lung edema. Mild regression.
  • Deformity of right proximal humerus.
  • S/P vertebroplasty at T-L spine.
  • Diffuse osteoporosis of the bones.
  • Fractures at bilateral ribs.
• 2022-11-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (60 - 16) / 60 = 73.33%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Normal LV filling pressure; impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis.
    • Degenerative changes of mitral valve and mild mitral annulus calcification with trivial MR; mild TR.
    • Sinus tachycardia.
• 2022-06-27 SONO - nephrology
  • Chronic parenchymal renal disease

[consultation]

• 2022-11-16 Hemato-Oncology
  • Q
    • This 74y/o female with past history of compression fracture was admitted due to UTI,
    • lab data showed Hb:8.7 g/dL, M-peak positive
    • we need your expertise for better her condition!
  • A
    • The 74 y/o female showed M-peak (+) in serum protein electrophoresis & anemia, MM or some other myeloma related Dz is highly suspected.
    • Lab:
      • Serum protein eletrophoresis (11/9 22): positive.
      • TP (11/7 22):5.8, A/G: 3.2/ 2.6.
      • IgG, IgM, IgA (11/7 22): WNL.
      • Free light chain assay (11/10 22): FLLC / KLLC ratio: 451 ( 8487.5 / 18.8 )
      • b-2 microglobulin (11/8 22): 6172, LDH:296
      • BUN / Cre (11/14 22): 23 / 0.98, Ca: 2.26
      • Hb (11/7 22):8.6, MCV:97.2, MCHC:31.5, plt:313K, WBC:7210
      • NT-proBNP (10/31 22): 1785.
    • Dx: Anemia & M-peak (+), hypoalbuminemia.
      • R/I Lambda light chain amyloidosis
      • R/I Multiple myeloma ( MM ).
      • monoclonal gammopathy of undetermined significance
        • (M-protein in serum < 3 g/dL, < 10% clonal plasma cell on BM Bx, no end organ damage).
      • Smoldering myeloma
        • (M-protein in serum > 3 g/dL, > 10% clonal plasma cell on BM Bx, no end organ damage ).
    • Medical advice:
      • Owing to IgG, IgM, IgA (11/7 22): WNL, Free light chain assay (11/10 22): FLLC / KLLC ratio: 451 ( 8487.5 / 18.8 ), Lambda light chain amyloidosis is highly suspected.
        • In light chain disease, 50% did not show SPEP M-protein (+). but serum free light chain ( FLC ) assay may show abnormality of kappa or lambda chains & kappa / lambda ratio.
        • May do 24-h urine for total protein. Urin protein electrophoresis (UPEP), urine immunofixation electrophoresis ( UIFE).
        • Will do Unilateral bone marrow aspirate + biopsy & Congo red staining for amyloid.
        • The percentage of clonal bone marrow plasma cells (≥10%) is a major criterion for the diagnosis of MM or some other myeloma related Dz.
      • Identification of light chains in the serum or urine without confirmation of the amyloid composition in tissue is not adequate, as patients with other forms of amyloidosis may have an unrelated monoclonal gammopathy of undetermined significance (MGUS).
        • Will try biopsy of organ involvement of amyloidosis
          
      • Kidney:
        • 24-h urine protein >0.5 g/d, predominantly albumin.
        • Mx: may do 24 hr urine collection for protein loss evaluation.
      • Nerve:
        • Peripheral: clinical; symmetric lower extremity sensorimotor peripheral neuropathy
      • Autonomic: gastric-emptying disorder, pseudo-obstruction, voiding dysfunction not related to direct organ infiltration
        • Mx: may consult neurologist to R/I peripheral neuropathy & may do electromyography (EMG) ( if clinically significant peripheral neuropathy) / nerve conduction studies.
      • Soft tissue:
        • Tongue enlargement, clinical
        • Arthropathy
        • Claudication, presumed vascular amyloid Skin
        • Myopathy by biopsy or pseudohypertrophy
        • Lymph node (may be localized)
        • Carpal tunnel syndrome
          • Mx: If tongue enlargement, may do tonue biopsy. May try abdominal fat pad sampling to confirm amyloid deposit.
      • Liver:
        • Total liver span >15 cm in the absence of heart failure or alkaline
        • phosphatase >1.5 times institutional upper limit of normal
        • Mx: if gastroparesis present, may do Gastric emptying scan.
        • May do abd ultrasound or abd CT scan to document craniocaudal liver span.
      • Heart:
        • Echo: mean wall thickness >12 mm, no other cardiac cause or an elevated
        • NT-proBNP (>332 ng/L) in the absence of renal failure or atrial fibrillation
        • the pt has higher NT-ProBNP ( 1785 ), suggestive of heart failure. R/I light chain amylodosis related.
        • Mx: may do cardiac echo.
      • LDH and beta-2 microglobulin levels reflect tumor cell characteristics.
      • Higher b2-micoglobulin ( b2M ) means larger tumor load ( but renal failure will make b2-microglobulin accumulate. This pt has poor renal function ).
      • Higher LDH may suggest MM tumor aggression.
      • If light chain amyloidosis is confirmed, preferred Regimen:
        • Daratumumab and hyaluronidase fihj / bortezomib / cyclophosphamide / dexamethasone
        • Bortezomib ± dexamethasone
        • Bortezomib/cyclophosphamide/dexamethasone
        • Bortezomib/lenalidomide/dexamethasone
        • Bortezomib/melphalan/dexamethasone (if ineligible for HCT)
• 2022-11-12 Neurology
  • Q
    • For cognitive function assessment, is there dementia or ??? (Patient reports urinary and fecal incontinence without sensation, but sometimes says she feel bowel movements and other times says she does not feel them)
    • This 74 y/o woman is a case of type 2 DM, CKD stage 3 and anemia, cause to be determined. Operation history of
      • post lumbar spine surgery due to HIVD about 40 years ago at Gengshen Hospital
      • Pancreatic duct tumor with p-duct dilatation s/p Whipple’s operation (PPPD) in 2014
      • LUL lung nodule s/p thoracoscopic wedge resection and LN dissections in 2015
      • Right hip fracture s/p bipolar hemiarthroplasty in 2020
      • Multiple compression fracture post vertebroplasty at L3 in 2021, and vertebroplasty at L1 and L2 on 2022/04/07 at Tzu Chi H.
    • She was discharged from our isolation ward due to Covid-19 infection on 10/19, and admission again on 2022/10/31 due to urosepsis with drowsy consciousness, right lung infiltration with dyspnea, and hypokalemia.
    • After admission, she received KCL in fusion for correct hypokalemia, and antibiotics as sintrix treatment since 11/01 to 11/03, and change to Brosym 4.0 gm IVD Q12H since 11/03 for urine culture grew Escherichia coli. Improve of infection of urine and the consciousness return to near clear. Right lung edema improve after lasix use. Due to lumbar pain, paresthesia over both legs? light touch decrease at lateral aspect of lower leg and dorsum of foot? and incontinence? The T-L spine MRI was performed, showed multiple T-L compression fracture and Moderate spinal stenosis at L3/4 level, caused by posteriorly displaced bony component. Posterior decompression of L3 to L5 maybe is indication, but this moment, the patient complained incontinence condition improve? seems to feel sensation when stool output (But the words are inconsistent, sometimes says they feel bowel movements, sometimes says they don’t feel them, no sensation during urination, rectal examination: no relaxation of the anal sphincter).
    • Now, we need your help for evaluation about cognitive function assessment, whether there is dementia or other problem. Thanks.
  • A
    • the patient complainted incontinence condition improve ? seems to feel sensation when stool output
    • E4M6V4
    • Cranial nerve: intact
    • motor: all＞3
    • Imp: may have dementia+ delirium
    • P: Check BUN, Crea, CBC, ALT, AST, Ca, Na, Mg, TSH free T4, ammonia
      • Arrange EEG
      • Neurology OPD f/u after this acute illness for diagnosis of dementia
• 2022-11-07 Orthopedics
  • A
    • The 74 y/o women had T7 compression fracture post vertebroplasty on 2022/04/28
    • L1-2 compression fracture status post L1, L2 vertebroplasty on 2022/04/07.
    • Patient complain urination and defication incontinence for one week
    • She also complain numbness over anal area
    • X-ray: mutiple compression fracture
    • => transfer to our ward and arrange MRI
• 2022-11-05 Chest Medicine
  • Q
    • The 74 y/o women had COVID 19 2 weeks ago
    • She was admited to our weard due to dyspnea and back pain and UTI
    • Pleural effusion arrange aspiration today
    • Diuretic use for r/o pulmonary edema
    • We need your help for progress dyspnea, Thanks!
  • A
    • The pleural effusion was bilaterally symmetric, CT density favor transudate, possible due to:
      • long term malnutrition with hypoalbuminemia (the albumin level was pseudo-high due to severe intravascular volume depletion)
      • bed-ridden with lung atelectasis
      • chronic hypoxic lung disease (bed-ridden related) with right side CHF
      • Repeated infection (aspiration pneumonia and UTI and recently COVID-19 infection) with SIRS
    • Suggestion:
      • May repeat chest echo at next W3AM or W4 AM for possible diagnostic tapping
      • Lung expansion therapy
      • Increase intravascular volume (including hydrostatic and oncotid fluid)
      • Keep Hb not less than 10.0
      • choking was noted, NG feeding and totally avoid oral feeding/intake is suggested
      • keep present anti
      • check thyroid and adrenal function
      • Thanks and f/u prn.

[MedRec]

• 2023-04-07 SOAP Hemato-Oncology
  • Anemia, unspecified [D64.9]
  • Muliple myeloma, Light chain
    • #1 Velcade 1.5mg/m2 ( give 2.5mg ) SC D1 & D4, D8, D11 Q4W x 4 plus Dexa on 1/3 23. ( fee )
    • #2 on 02/06 23.
    • #3 on 03/17
    • #4 on 04/07
• 2023-01-03 SOAP Hemato-Oncology
  • #1 Velcade 1.5mg/m2 ( give 2.5mg ) SC D1 & D4, DD8, D11 Q4W x 4 plus Dexa on 1/3 23. ( fee )
  • RTC 1wk later on 1/9 23 for #2 Bortezomib / cyclophosphamide / dexa.
• 2022-11-28 SOAP Hemato-Oncology
  • Lab
    • 2022/11/17 U-TP(24hr) = 2200.5 mg/day;
    • 2022/11/10 Free Light Chain κ/λ (blood)
      • FKLC = 18.8 mg/L;
      • FLLC = 8487.5 mg/L;
      • FK/FL ratio = 0.002215 ratio;
    • 2022/11/09 M-peak = Positive;
    • 2022/11/08 B2-Microglobulin = 6172 ng/mL;
    • 2022/11/07 IgG (blood) = 687 mg/dL;
    • 2022/11/07 IgM = 31.0 mg/dL;
    • 2022/11/07 IgA = 39 mg/dL;
    • 2022/11/07 LDH = 296 U/L;
  • Light chain Dz, lambda, ISS stage ? is highly suspected (11/28 22).
  • will do BM biopsy on 12/1 22 (11/26 22).
  • If light chain amyloidosis is confirmed, preferred Regimen:
    • Daratumumab and hyaluronidase / bortezomib / cyclophosphamide / dexa.
    • Bortezomib ± dexamethasone
    • Bortezomib/cyclophosphamide/dexamethasone
    • Bortezomib/lenalidomide/dexamethasone
  • will apply Bortezomib / cyclophosphamide / dexa (11/28 22).
  • RTC 1wk later on 12/5 22 for possible #1 Bortezomib / cyclophosphamide / dexa.
  • Diagnosis C90.0 Multiple myeloma
• 2022-09-19 SOAP Hemato-Oncology
  • 73 y/o female was noted to have anemia (Hb:5.6) in Sep 2022 even poor renal function improves.
  • Lab 2022/09/14
    • Ferritin = 361.5 ng/mL;
    • Fe (Iron-bound) = 74 ug/dL;
    • TIBC = 237 ug/dL;
  • R/I
    • IDA
    • thalassemia
      
    • Vit B12 & folic acid deficiency related.
    • anemia due to chronic liver dz
    • anemia due to malnutirtion
    • anemia of chronic inflamnmation / infection ( eg: DM ).
    • hematologic dz ( eg MDS, pure red cell aplasia )
    • Viral infection related
    • hemolysis
  • will do CBC & DC, reticulocyte, RBC morphology, RF, ANA, Ferritin, Haptoglobin, LDH, BilT/D, Direct & Indirect Coombs test & abd sono R/I splenomegaly. (9/19 22).
  • will do CBC & DC, Ferritin, Fe/TIBC, SOB, LFT, RFT (9/19 22).
  • give P-RBC 2U (9/19 22).
  • SBP: 190+ mmHg noted at daycare before P-RBC, give Norvasc (9/19 22).
  • If definitive Dx is not made, will do BM biopsy (9/19 22).
  • RTC 1 wk later on 5/4 20 for IDA report.

[chemotherapy]

• 2023-04-07 - bortezomib 1.5mg/m2 2.0mg SC 5min D1,4,8,11
• 2023-03-17 - bortezomib 1.5mg/m2 2.0mg SC 5min D1,4,8,11
• 2023-02-06 - bortezomib 1.5mg/m2 1.9mg SC 5min D1,5,8,12
• 2023-01-09 - bortezomib 1.5mg/m2 1.9mg SC 5min D1,5
• 2023-01-03 - bortezomib 1.5mg/m2 1.9mg SC 5min D1,4

[note]

Bortezomib (Velcade) plus cyclophosphamide and dexamethasone (VCD or CyBorD) for multiple myeloma 2023-04-24 https://www.uptodate.com/contents/image?topicKey=ONC%2F85687&sectionRank=1&imageKey=ONC%2F50061

• Cycle length: 28 days.

• Regimen

  • Bortezomib
    • 1.5 mg/m2 SC or IV
    • Given subcutaneously or as a rapid IV bolus over three to five seconds.
    • Days 1, 8, 15, and 22
  • Cyclophosphamide
    • 300 mg/m2 by mouth, once weekly
    • Dose rounding to the nearest 50 mg. Do not cut or crush. Take during or after meal in the morning.
    • Days 1, 8, 15, and 22
  • Dexamethasone
    • 40 mg by mouth, once weekly
    • Take with food (after meals or with food or milk) in the morning.
    • Days 1, 8, 15, and 22

• Pretreatment considerations:

  • Hydration
    • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day during administration and for one to two days thereafter) and void every two to three hours to reduce the risk of hemorrhagic cystitis. Risk of bladder irritation is also decreased by avoiding bedtime administration.
  • Emesis risk
    • LOW or VERY LOW.
  • Prophylaxis for infusion reactions
    • Routine premedication is not indicated. If a hypersensitivity reaction occurs with cyclophosphamide, then neither oral nor IV cyclophosphamide should be readministered.
  • Infection prophylaxis
    • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VCD/CyBorD. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on Mondays, Wednesdays, and Fridays during treatment. Primary prophylaxis with G-CSF is not indicated.
  • Antithrombotic prophylaxis
    • While patients with multiple myeloma have an increased risk of thrombosis, the risk of thrombosis with the VCD/CyBorD regimen was ≤7% in two trials. Routine antithrombotic prophylaxis is not warranted.
  • Dose adjustment for baseline liver or kidney dysfunction
    • Bortezomib: No dosage adjustment for bortezomib secondary to kidney impairment is necessary. For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the upper limit of normal) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
    • Cyclophosphamide: For patients with preexisting hepatic impairment, dose adjustments in cyclophosphamide dose may be needed. The need for cyclophosphamide dose reduction in patients with kidney impairment is controversial; some suggest dose reduction if the creatinine clearance is <30 mL/minute.

• Monitoring parameters:

  • Assess CBC with differential, electrolytes, kidney function, liver function, and M protein prior to starting each cycle. A CBC should also be performed prior to the day 15 dose of bortezomib.
  • Weekly assessment for peripheral neuropathy and/or neuropathic pain.
  • Monitor for hypotension during therapy; adjustment of antihypertensives and/or administration of IV hydration may be needed.

• Suggested dose modifications for toxicity:

  • Myelotoxicity
    • If platelets are <50,000/microL or the absolute neutrophil count is <1000/microL on day 15, hold bortezomib and cyclophosphamide. If several doses are held, reduce bortezomib dose by one level (from 1.5 mg/m2 to 1.3 mg/m2; or from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2) and decrease the number of doses of cyclophosphamide given each cycle by one level (serial levels are: Days 1, 8, 15, and 22; days 1, 8, and 15; days 1 and 8; day 1 only).
  • Neuropathy
    • Dose adjustment guidelines for bortezomib in patients who develop peripheral neuropathy or neuropathic pain are available:
      • Grade 1 (asymptomatic, loss of deep tendon reflexes or paresthesia without pain or loss of function): No action required.
      • Grade 1 (with pain) or Grade 2 (interfering function but not activities of daily living): Reduce by one level (from 1.5 mg/m2 to 1.3 mg/m2; or from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2).
      • Grade 2 (with pain) or Grade 3 (interfering with activities of daily living): Hold until resolution, may reinitiate at 0.7 mg/m2 once weekly.
      • Grade 4 (life-threatening, disabling, eg, paralysis): Discontinue.
    • Rarely, bortezomib has been associated with RPLS, which can present with seizures, hypertension, headache, lethargy, confusion, blindness, or as other visual or neurological disturbances. Bortezomib should be discontinued if the diagnosis of RPLS is confirmed on brain MRI.
  • Cystitis
    • For grades 1 or 2 cystitis (minor symptoms responding to outpatient management), decrease the number of doses of cyclophosphamide given each cycle by one level (serial levels are: Days 1, 8, 15, and 22; days 1, 8, and 15; days 1 and 8; day 1 only). Cyclophosphamide should be discontinued if cystitis symptoms are distressing or affect lifestyle (grade 3 or 4).
  • Thrombotic microangiopathy
    • Rarely, bortezomib has been associated with TMA, which can present with Coombs-negative hemolysis, thrombocytopenia, kidney failure, and/or neurologic findings. If TMA is suspected, stop bortezomib and evaluate.
  • Other nonhematologic toxicity
    • For grade 3 or 4 nonhematologic toxicity other than neuropathy, bortezomib should be held. Once symptoms have resolved to grade 1 or baseline, bortezomib may be reinitiated with one dose level reduction (from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2). Dexamethasone dose should be reduced for grade 2 muscle weakness, grade 3 gastrointestinal tract toxicity, hyperglycemia, confusion or mood alterations.
  • If there is a change in body weight of at least 10%, doses should be recalculated.

Treatment of Clostridioides difficile infection (CDI) in adults 2023-05-17 https://www.uptodate.com/contents/image?topicKey=ID%2F2698&imageKey=ID%2F53273

• Nonfulminant disease
  • Initial episode (nonsevere or severe disease) - Management of an initial CDI episode consists of treatment with an antibiotic regimen.
    • Nonsevere disease is supported by the following clinical data: White blood cell count <=15,000 cells/mL and serum creatinine level <1.5 mg/dL
    • Severe disease is supported by the following clinical data: White blood cell count >15,000 cells/mL and/or serum creatinine level >=1.5 mg/dL
    • Antibiotic regimens:
      • Fidaxomicin 200 mg orally twice daily for 10 days
      • Vancomycin 125 mg orally 4 times daily for 10 days
      • For nonsevere disease, alternative regimen if above agents are unavailable:
        • Metronidazole◊ 500 mg orally 3 times daily for 10 to 14 days
  • Recurrent episode - Management of a recurrent CDI episode consists of treatment with an antibiotic regimen, in addition to adjunctive bezlotoxumab¶ if feasible.
    • First recurrence
      • Antibiotic regimens:
        • Fidaxomicin
          • 200 mg orally twice daily for 10 days, OR
          • 200 mg orally twice daily for 5 days, followed by once every other day for 20 days
        • Vancomycin in a tapered and pulsed regimen, for example:
          • 125 mg orally 4 times daily for 10 to 14 days, then
          • 125 mg orally 2 times daily for 7 days, then
          • 125 mg orally once daily for 7 days, then
          • 125 mg orally every 2 to 3 days for 2 to 8 weeks
        • Vancomycin 125 mg orally 4 times daily for 10 days
      • Adjunctive treatment:
        • Bezlotoxumab 10 mg/kg intravenously, given once during administration of standard antibiotic regimen.
    • Second or subsequent recurrence
      • Antibiotic regimens:
        • Fidaxomicin
          • 200 mg orally twice daily for 10 days, OR
          • 200 mg orally twice daily for 5 days, followed by once every other day for 20 days
        • Vancomycin in a tapered and pulsed regimen (example as above)
        • Vancomycin followed by rifaximin:
          • Vancomycin 125 mg orally 4 times daily by mouth for 10 days, then
          • Rifaximin 400 mg orally 3 times daily for 20 days
      • Adjunctive treatment:
        • Bezlotoxumab 10 mg/kg intravenously, given once during administration of standard antibiotic regimen.
      • Role of fecal microbiota transplantation (FMT):
        • For patients who have received appropriate antibiotic treatment for at least 3 CDI episodes (ie, initial episode plus 2 recurrences), who subsequently present with a fourth or further CDI episode (third or subsequent recurrence), we favor FMT in regions where available. Pending referral for FMT, we treat with an antibiotic regimen as outlined above.
• Fulminant disease
  • Fulminant disease is supported by the following clinical data: Hypotension or shock, ileus, megacolon
    • Absence of ileus: Enteric vancomycin plus parenteral metronidazole:
      • Vancomycin 500 mg orally or via nasogastric tube 4 times daily, AND
      • Metronidazole 500 mg intravenously every 8 hours
    • If ileus is present, additional considerations include:
      • FMT (administered rectally) OR
      • Rectal vancomycin (administered as a retention enema 500 mg in 100 mL normal saline per rectum; retained for as long as possible and readministered every 6 hours)
• The standard course of treatment for an initial episode of CDI is 10 days. Some patients, particularly those treated with metronidazole or with severe disease, may have a delayed response; in such circumstances, treatment may be extended to 14 days. For patients with inflammatory bowel disease, an extended duration of 14 days is also appropriate. If continuation of antibiotic(s) for a primary infection is essential, we continue CDI treatment for one week after completion of other antibiotics.
• The criteria proposed for defining severe or fulminant CDI are based on expert opinion and may need to be reviewed upon publication of prospectively validated severity scores for patients with CDI. Patients with severe or fulminant CDI also warrant assessment for surgical indications; refer to UpToDate topic on treatment of CDI for further discussion.
• For patients with nonfulminant disease, we suggest a fidaxomicin-based regimen over a vancomycin-based regimen. In addition, for patients with nonfulminant recurrent disease and prior CDI in the last 6 months, we suggest adjunctive bezlotoxumab. Use of fidaxomicin or bezlotoxumab have each been associated with a small benefit with respect to CDI recurrence rates (10 to 15% decrease). In the setting of cost constraints, we prioritize use of these agents for patients at greatest risk for CDI recurrence (age >=65 years, severe CDI, or immunosuppression). Vancomycin remains an acceptable agent for treatment of initial and recurrent CDI.
• Systemic absorption of enteral vancomycin can occur in patients with mucosal disruption due to severe or fulminant colitis; this consideration is particularly important for patients with kidney insufficiency (creatinine clearance <10 mL/minute). Therefore, monitoring serum vancomycin levels is warranted for patients with kidney failure who have severe or fulminant colitis and require a prolonged course (>10 days) of enteral vancomycin therapy.
• Metronidazole should be avoided in patients who are frail, age >65 years, or who develop CDI in association with inflammatory bowel disease. Caution is also warranted during pregnancy and lactation.
• The approach to antibiotic management of nonfulminant recurrent CDI is the same regardless of severity, but varies depending on the number of recurrences, as outlined above. For patients with a recurrent episode of CDI that is severe, refer to UpToDate topic on treatment of CDI for further discussion.
• The bezlotoxumab prescribing information in the United States warns that in patients with a history of congestive heart failure, the drug should be reserved for use when the benefit outweighs the risk, given reports of increased heart failure exacerbations and associated deaths in such patients. In addition, data for use of bezlotoxumab combined with fidaxomicin are limited.
• In contrast to the above approach, some favor FMT for patients who have received antibiotic treatment for at least 2 CDI episodes (ie, initial episode plus one recurrence), who subsequently present with a third or further CDI episode (second or subsequent recurrence).
• Continue dosing for 10 days. If recovery is delayed, treatment can be extended to 14 days.
• In the setting of ileus, we favor FMT over rectal vancomycin. However, such procedures are associated with risk of colonic perforation; therefore, they should be restricted to patients who are not responsive to standard therapy, and the procedure should be performed by personnel with appropriate expertise. Refer to the UpToDate topic on FMT for discussion of safety, efficacy, and delivery protocols.
• Rectal vancomycin may be administered as a retention enema, either in addition to oral vancomycin (if the ileus is partial) or in place of oral vancomycin (if the ileus is complete). Given potential risk of colonic perforation in setting of CDI, rectal vancomycin instillation should be performed by personnel with appropriate expertise.

==========

2023-05-17

• On 2023-05-14, the patient’s WBC was 7.37K/uL, creatinine was 1.01mg/dL, and stool occult blood was 2+. Stool culture obtained on 2023-05-15 was negative for Clostridioides difficile toxin A/B but positive for glutamate dehydrogenase (GDH). The patient had 9 and 8 bowel movements on 2023-05-15 and 2023-05-16, respectively. Therefore, the prescription of oral vancomycin at a dose of 125 mg 4 times daily is appropriate and unproblematic.

• Now that the pathogen has been identified, the previously prescribed and currently active medication, Metrozole (metronidazole) 500mg PO Q8H, could potentially be discontinued, assuming there are no hypotension or shock, ileus, megacolon and/or other ongoing infectious conditions.

• According to the HIS5 database, there have been no other culture reports on Clostridioides Difficile Infection (CDI) in the past 6 months. In the event of a recurrent infection, a tapered and pulsed regimen of vancomycin could be considered. Here is a possible schedule:

  • 125 mg orally four times daily for 10 to 14 days, followed by
  • 125 mg orally twice daily for 7 days, followed by
  • 125 mg orally once daily for 7 days, and then
  • 125 mg orally every 2 to 3 days for 2 to 8 weeks.

2023-04-24

[assessment]

• The patient has been diagnosed with Multiple Myeloma (MM) and was started on VCd regimen on 2023-01-03. All of the patient’s medications listed in PharmaCloud were prescribed by our hospital. No medication reconciliation issues were identified.

• After starting the VCd regimen, there was a decrease in the B2 microglobulin level. However, the most recent reading indicates that the level has nearly doubled from the previous low in approximately 1.5 months.

  • 2023-04-22 B2-Microglobulin 8692 ng/mL
    
  • 2023-03-04 B2-Microglobulin 4648 ng/mL
    
  • 2022-11-08 B2-Microglobulin 6172 ng/mL

• Currently, there is no evidence that the patient is developing thrombocytopenia, peripheral neuropathy or neuropathic pain.

701179622

230517

[exam findings]

• 2023-05-17 Sono-guide aspiration of right thyroid mass
  • IMP: right thyroid mass, s/p FNA
• 2023-04-20 Bronchodilator Test
  • mild obstructive ventilatory impairment, FEV1/FVC = 45%, FVC = 138%, FEV1 = 81%
  • without significant reversibility
• 2023-04-20 CT - chest
  • Indication
    • Chronic obstructive pulmonary disease, unspecified
    • Allergic rhinitis, unspecified
    • Unspecified asthma, uncomplicated
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Semi-solid nodule at left upper lobe measuring 1.6cm in largest dimension is found.
      • Moderate centrilobular Emphysematous change over both lungs is found.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • No evidence of bilateral pleural effusion.
      • Cystic lesion at right lobe thyroid with calcified wall measuring 3.7cm in largest dimension is found.
    • Visible abdomen:
      • Low density lesions at both lobes of liver is found up to 3.3cm at S7. r/o liver meta.
      • The spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
  • Imp:
    • Left upper lobe nodular lesion. 1.6cm
    • Right thyroid cystic lesion. 3.7cm, thyroid cancer?
    • Liver meta.
• 2023-02-02 CXR
  • Displacement of the tracheal axis to left at thoracic inlet and superior mediastinum probably due to enlarged thyroid gland or other mediastinal mass
  • a small nodular opacity (polylobular borders) over LUL,
  • suggest do CT study
  • Increased lung volume and areas of hyperlucency and decreased upper vascular markings due to emphysematous change of both lungs upper lung predominance
  • enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
• 2022-11-03, -02-24 CXR
  • Displacement of the tracheal axis to left at thoracic inlet and superior mediastinum probably due to enlarged thyroid gland and other mediastinal mass
  • Increased lung volume and areas of hyperlucency and decreased upper vascular markings due to emphysematous change of both lungs upper lung predominance
  • enlarged cardiac silhoutte due to prominent pericardial fat/ prominent cardiophrenic angle mediastinal fat pad
• 2022-02-24 Bronchodilator Test
  • moderate obstructive ventilatory impairment (FEV1/FVC: 46.4%, FVC:105%, FEV1: 62%)
  • without significant reversibility
• 2021-03-25 CXR
  • Displacement of the tracheal axis to left at thoracic inlet and superior mediastinum probably due to enlarged thyroid gland
  • Increased lung volume and areas of lucency due to emphysematous change of both lungs
  • prominent pericardial fat/cardiophrenic fat
• 2021-03-25 Bronchodilator Test
  • moderate obstructive ventilatory impairment, FEV1/FVC = 47%, FVC = 104%, FEV1 = 74%
  • without significant reversibility
• 2020-04-16 Bronchodilator Test
  • moderate obstructive ventilatory impairment, FEV1/FVC = 48%, FVC = 104%, FEV1 = 63%
  • without significant reversibility
• 2019-06-13 Bronchodilator Test
  • moderate obstructive ventilatory impairment, FEV1= 66 %
  • with significant reversibility
• 2019-05-16 CXR
  • Senile fibrotic change is noted at lung fields.

==========

2023-05-17

• The patient’s underlying conditions of COPD, asthma, HTN, and electrolyte imbalance are managed with appropriate medications on the active medication list. After reviewing PharmaCloud, no medication reconciliation issues were identified.

700818206

230516

[present illness] - 2023-02-23 admission note

• Radiotherapy for 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed from 2023/02/23~. Now, he was admitted to ward for concurrent chemoradiotherapy with 5FU(225mg/m2)(C1) from 2023/02/23.

[past history]

• Hypertension for 5 years under medication treatment.
  • Exforge F.C 5mg & 160mg 1# po QD
  • Concir 5mg 1# po QD
  • Lipanthyl Supra F.C 160mg 1# po QD
• HIVD (herniated intervertebral disc) post operation twice at 30-year-old and 40-year-old.
• Perianal tumor status post excision of perianal tumor on 2020/04.
• Grade IV hemorrhoids status post hemorrhoidectomy on 2020/04.
• Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L5-S1 by L-spine MRI on 2021/04/26.   
• Gastrorrhaphy, umbilical hernia repair and laparoscopy examination on 2021/11/10

[allergy]

• amoxicillin: Redness and swelling of the lips and oral mucosa

    

[family history]

• Denied any major disease or cancer history of his family member.

[exam findings]

• 2023-05-04 Colonoscopy
  • Rectal cancer s/p CCRT with partial response
• 2023-02-08 MRI - pelvis
  • History: Newly diagnosed rectal cancer at 8cm from AV
  • MR Imaging of the pelvis was performed on a 1.5 T superconducting magnet and phase arrayed body coil. Patient kept in supine position with field of view 28 cm, slice thickness 5 mm and gap 1 mm.
    
  • Scanning protocol:
    • Axial plane: spin echo T1WI, Non-Fat-saturation FSE T2WI, and HASTE T2WI, Diffusion weighted images
    • Coronal and sagittal plane: Non-Fat-saturation FSE T2WI
    • Dynamic study: Fat saturated T1WI with IV Gd-DTPA 0.1mmol/Kg and images were obtained at 70 second.
  • Findings:
    • There is asymmetrical wall thickening at left lateral aspect of the rectum, measuring 1.3 cm in wall thickness, that is c/w adenocarcinoma (T3).
      • In addition, There are two enlarged nodes in the presacral space that may be metastatic nodes (N1b).
    • There is a hyperintensity nodule 1.8 cm in right central zone of the prostate on both T2WI and DWI that is c/w hyperplasia.
    • There are several renal cysts on left kidney and the largest one measuring 3.3 cm in size at left middle pole.
    • A hepatic cyst measuring 0.5 cm in S2 is noted.
    • Abdominal aorta shows atherosclerosis and focal ectasia 2.1 cm at left lateral aspect.
    • Others
      • There is no focal abnormality in the seminal vesicle.
      • There is no focal abnormality in the urinary bladder.
      • There is no evidence of ascites.
      • The visible IVC are grossly unremarkable.
        
  • IMP:
    • Rectal cancer is highly suspected.
    • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T3 N1b M0, stage:IIIB
• 2023-02-03 CT - abdomen
  • CC: Hemorroidectomy at CRS on W2, Anal bleeding since then.
    • FOBT (+), External hemorrhoids
    • Anal protruding mass noted
    • Anal pain developed these days
    • Anal bleeding also noted occasionally
    • 20210202 colonoscopy: One mass in the rectum (8 cm AAV) Indication: Newly diagnosed rectal cancer for staging.
  • Findings:
    • There is asymmetrical wall thickening at left lateral aspect of the rectum, measuring 1.3 cm in wall thickness, that is c/w adenocarcinoma (T3).
      • In addition, There are three enlarged nodes in the perirecal space that may be metastatic nodes (N1b). Please correlate with MRI.
    • Abdominal aorta shows atherosclerosis and focal ectasia 2.1 cm at left lateral aspect.
    • There are several renal cysts on left kidney and the largest one measuring 3.3 cm in size at left middle pole.
    • A hepatic cyst measuring 0.5 cm in S2 is noted.
      • In addition, There is a poor enhancing lesion 1 cm in S8 of the liver dome subphrenic space or liver capsule area. Follow up is indicated.
    • There is no focal lesion in both lung and mediastinum.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
• 2023-02-03 ECG
  • Normal sinus rhythm
  • Minimal voltage criteria for LVH, may be normal variant
  • Borderline ECG
• 2023-02-03 Patho - colorectal polyp
  • Intestine, large, rectum, 8 cm from nal verge, biopsy— adenocarcinoma
  • Immunohistochemical stain— EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli,and high N/C ratio.
• 2023-02-03 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (123 - 29) / 123 = 76.42%
    • M-mode (Teichholz) = 76
  • Preserved LV and RV systolic function with normal wall motion
  • Grade 1 LV diastolic dysfunction
  • Mild AR, MR, and PR+
• 2023-02-03 Bronchodilator Test
  • normal ventilation; non-significant bronchodilator response
• 2023-02-02 Colonoscopy
  • D-colon polyp s/p polypectomy
  • Retcal cancer s/p biopsy
• 2022-11-18 SONO - nephrology
  • Chronic renal parenchymal disease, mild degree
  • Left renal cysts
• 2022-10-21 Knee BIL standing AP and Lat views
  • Mild to moderate osteoarthritis of both knees
  • Ahlback calcification: grade 2, 2
• 2022-10-21 Merchant view (patella 45 0) Bil :
  • Mild lateral subluxation of the patella
  • Patellofemoral osteoarthritis
  • Sperner classification: 2-3
• 2023-02-03 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (115 - 31) / 115 = 73.04%
    • M-mode (Teichholz) = 72.8
  • Normal chamber size
  • Thickening of IVS (interventricular septum) and LVPW (left ventricular posterior wall thickness)
  • Adequate LV and RV systolic function
  • Possibly impaired LV relaxation
  • AV (aortic valve) sclerosis with mild AR (aortic regurgitation), mild MR (mitral regurgitation), TR (tricuspid regurgitation) and PR (pulmonary regurgitation)
  • No regional wall motion abnormalities
• 2022-08-23 CXR
  • Atherosclerotic change of aortic arch
• 2022-03-02 Patho - stomach biopsy
  • Stomach, antrum, GC site, biopsy — chronic gastritis. No H.pylori present
  • Stomach, middle body, GC/AW site, biopsy — fundic gland polyp. No H.pylori present
• 2022-03-01 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA grade A(minimal)
    • Superficial gastritis
    • Gastric polyp, middle body, GC/AW site (A)
    • Gastric erosion, antrum, GC site, s/p biopsy (B)
    • C/W s/p gastrorrhaphy
  • Suggestion
    • Pursue biopsy result
• 2021-11-11 Patho - stomach biopsy
  • Stomach, antrum, midline laparotomy and repair of perforation — Ulcer with perforation, H pylori NOT present
• 2021-11-10 CT - abdomen
  • History and Indication: Abdominal pain for 3 days. INITIAL SHOULDER SORENESS AND COLD SWEATING, NO VOMITING, NO DIARRHEA
    • Allergy: amoxicillin
    • PHx: HTN, hyperlipidemia, NKDA
  • MD CT (256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
  • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
  • Findings:
    • There is ascites and free gas bubbles in peritoneal cavity (pneumoperitoneum) that is c/w hollow organ perforation.
      • In addition, focal fluid collection and gas bubbles in the gastrohepatic ligament is also noted.
    • Right side Pleura effusion and mild atelectasis in bilateral posterior basal lung are noted.
    • Two renal cyst 2.7 cm and 1 cm in left middle pole are noted.
    • Hyperplasia of right adrenal gland is noted.
    • Umbilical hernia with omentum fat herniation is noted.
    • Others
      • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & right kidney.
      • There is no lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
  • IMP: Hollow organ perforation is highly suspected.
• 2021-04-26 MRI - L-spine
  • Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L5-S1 (with right HIVD).
• 2021-03-15 Patho - skin cyst/tag/debridement
  • Eyelid mass, OS, excisional biopsy — Papillary squamous hyperplasia, compatible with papilloma
• 2000-04-15 Patho - hemorrhoids
  • Colon, rectum, hemorrhoidectomy — Hemorrhoid
  • Skin, peri-anal, excision — Epidermal inclusion cyst

[MedRec]

• 2023-05-04 SOAP Hemato-Oncology
  • P: During admission on 2023-05-04, consult dermatologist (for hand-foot syndorme) and reduce oxaliplatin to 75, DC bolus 5-FU.
• 2023-03-22 SOAP Hemato-Oncology
  • P: Encourage patient to continue the treatment
• 2023-02-09 SOAP Hemato-Oncology
  • O:
    • 2023/02/03 Abd CT: T3 N1b M0 STAGE:IIIB(Stage_value)
    • 2023/02/08 MRI Pelvis: Rectal cancer is highly suspected. According to AJCC staging system, 8th edition for colon cancer: T3 N1b M0, stage:IIIB
  • A/P
    • Suggest pre-op CCRT (Favor TNT) then OP
    • CCRT with FU followed by FOLFOX 12 16 weeks, then OP, the F/U

[consultation]

• 2023-03-28 Dermatology
  • Q
    • This 65-year-old man diagnosis was rectum cancer, T3N1bM0, stage IIIB under radiotherapy for 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed from 2023/02/23. He received concurrent chemoradiotherapy with 5FU(225mg/m2) from 2023/02/23-27(C1). Now, he was admitted to ward for concurrent chemoradiotherapy with 5FU(225mg/m2)(C2) from 2023/03/27.  
    • For skin lesion in palms of both hands, we need your further evaluation and management.
  • A
    • The patient had sufferred from dry, xerotic skin texture with fine excoriaiton scales.
      
    • Under the impression of hand-foot syndorme favor 5 FU related and xerotic dermatitis.
    • The following sugeetion:
      • add Tetracycline onit topical bid use. firts for wound.
        
      • enhance skin mositurization with body cream and add sinphraderm cream 1 tube topical QN use on the scaling lesions.
• 2021-11-10 General and Digestive Surgery
  • Q
    • Abd Pain for 3 days, INITIAL SHOULDER SORENESS AND COLD SWEATING
    • NO VOMITING, NO DIARRHEA
    • Allergy: amoxicillin
    • PHx: HTN, hyperlipidemia, NKDA
  • A
    • hollow organ perforation was impressed
    • PE: peritonitis sign
    • CT: minimal free air r/o colon perforation
    • suggest laparotomy

[surigcal operation]

• 2021-11-10
  • Surgery
    • gastrorrhaphy
    • umbilical hernia repair
    • laparoscopy examination
  • Finding
    • turbid ascites, with food debrides
    • one perforation at antrum, GC side, about 2cm in diameter, less likely malignancy
• 2021-03-22
  • Right L5 DRG PRF (right fifth lumbar dorsal root ganglion pulsed radiofrequency)
  • Right SI (sacroiliac) joint arthorgram and injection
• 2021-03-15
  • Surgery
    • excision biopsy (OS)
  • Finding
    • eyelid mass (OS)
• 2020-04-14
  • Surgery
    • Excision of perianal tumor
    • Hemorrhoidectomy        
  • Finding
    • Left anterior perianal tumor 1.5x1x1cm
    • Prolasped hemorrhoids at 3,7,11 o’clock 

[radiotherapy]

[chemotherapy]

• 2023-04-25 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFOX)

• 2023-03-27 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1-4 (CCRT)

• 2023-02-23 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1, 2, 5, 7 (excluding weekend and 2/28 holiday) (CCRT)

==========

2023-05-16

• According to the PharmaCloud database, all of the patient’s recent medications have been prescribed by our hospital, and no issues with medication reconciliation have been detected.

• On 2023-05-15, the patient’s WBC count was observed to be 1.89K/uL, indicating leukopenia. This was first noted in the HIS5 system 3 weeks after the last administration of FOLFOX on 2023-04-25. When this event became known, Granocyte (lenograstim) was administered for two consecutive days. The nadir may occur later than expected, or blood cell monitoring should be more frequent.

• This patient experienced hand-foot syndrome following the second dose of concurrent chemotherapy with 5-FU in late March 2023. The patient is currently undergoing FOLFOX treatment. If hand-foot syndrome reoccurs, it may be advisable to omit the 5-FU bolus.

• The patient has underlying kidney concerns, and the NSAID Celebrex (celecoxib) is currently prescribed as needed. If the primary purpose of using celecoxib is for pain management, considering an alternative like acetaminophen could be less harmful to the kidneys.

  • 2023-05-15 BUN 34 mg/dL
    
  • 2023-05-15 Creatinine 1.42 mg/dL
    
  • 2023-05-15 eGFR 53.18

2023-02-24

[assessment]

• No medication reconciliation issues were found during this hospital stay, and the recently prescribed drugs disclosed in the NHI PharmaCloud System have been accurately prescribed as self-carried items that cover the patient’s underlying conditions.

701346431

230512

{malignant neoplasm of unspecified site of left female breast, cT4aN3M1, stage IV}

[exam findings]

• 2023-01-17 Tc-99m MDP whole body bone scan with SPECT
  • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the skull, some T- and L-spines, sacrum, sternum, left scapula, bilateral multiple ribs, multiple pelvic bones, S-I joints, and femurs.
  • IMPRESSION:
    • In comparison with the previous study on 2021/11/08, most of the previous bone lesions are either less evident or disappeared. The scintigraphic findings suggest multiple bone metastases with some resolution.
• 2023-01-17, 2022-12-28, -12-07, -11-14, -10-24, -09-29, -08-29, -08-05, -07-11, -06-14 - CXR
  • A nodular opacity projecting in the left middle lung shows stationary. Follow up is indicated.
    
  • Left CP angle Pleura effusion or thickening.
  • Left hemi-diaphragm elevation is noted, which may be due to eventration or left lower lung volume decrease.
    
  • Spondylosis with scoliosis of the T-spine with convex to right side
  • S/P Mastectomy, left.
• 2022-11-16 CT - chest
  • Indication: Malignant neoplasm of unspecified site of left female breast
  • Findings - Comparison was made with previous CT dated on 20220713
    • Lungs:
      • There is interlobular septal thickening and ground-glass opacities in both lungs scatteredly, seem stationary.
      • Mediastinum and hila: a well-defined fluid density mass (33mm in longest dimension) at left thymic bed. no enlarged LN.
    • Vessels:
      • Aorta: normal caliber of thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LA and LV.
    • Pleura: minimla Rt and small Lt effusions.
    • Chest wall and visible lower neck: interval increase in size infiltrative bilateral breast tumors with overlying skin thickening as compared with previous CT.
      • two small thyroid cysts or nodules.
    • Visible abdominal-pelvic contents:
      • two small Rt hepatic cysts and an ill-defined hypodense lesion at S4 is still visible. a 5mm Lt renal cyst.
      • several small stones in gallbladder. unremarkable of the spleen, both adrenal glands, pancreas, and Rt kidney.
      • no enlarged lymph node.
    • Visualized bones: compression fracture of T7 and blastic metastasis in pedicle of T8.
  • Impression:
    • both breast cancers with pulmonary lymphangitic carcinomatosis and hepatic and bony metastases, in progression compared with CT on 20220713, a thymic cyst.
• 2022-07-13 CT - chest
  • both breast cancers, statiionary, with pulmonary lymphangitic carcinomatosis and hepatic and bony metastases, stationary, a thymic cyst.
• 2022-04-02 CT - chest
  • Breast cancer at both breast, in regression.
  • Diffuse intersitial change at both lungs. suspected lymphangitis carcinomatosis.
  • Bone meta and liver meta.
• 2022-01-19 Cell Block
  • Smears and cell blockshow lymphocytes, reactive mesothelial cells, and clusters of large, pleomorphic tumor cells.
  • IHC: CK(+), GATA3(+), and Calretinin(-).
  • The results are consistent with metastatic breast carcinoma.
• 2021-12-28 Pleural Effusion
  • 50 cc yellow cloudy pleural effusion
  • The smears show lymphocytes, reactive mesothelial cells and a few hyperchromatic atypical cell clusters, compatible with metastatic carcinoma.
• 2021-11-09 Patho - breast biopsy
  • pathologic diagnosis
    • Breast, right, biopsy - Invasive carcinoma of no special type
      
    • The sections show invasive carcinoma of no special type, composed of breast tissue with nests and cords of polygonal neoplastic cells, embedded in fibrous stroma.
    • IHC:
      • ER (Ab): Negative
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Positive (score= 3+)
      • Ki-67: 25%
• 2021-11-08 Tc-99m MDP whole body bone scan with SPECT
  • The scintigraphic findings suggest multiple bone metastases in the skull, some T- and L-spine, sacrum, sternum, left scapula, bilateral multiple ribs, multiple pelvic bones, S-I joints, and femurs.
  • Increased tracer uptake at bilateral shoulders, the nature is to be determined (bone mets, DJD, or other nature ?)
• 2021-11-08 SONO - Breast
  • Bilateral breast tumors with left axillary lymph node, suspected malignancy.
  • BI-RADS: Category 5 - highly suggestive of malignancy, appropriate action should be taken.
• 2021-11-04 Pleural Effusion
  • diagnosis: Adenocarcinoma
  • smears show tumr cells with large hyperchromatic nuclei, pleomorphism, prominent nucleoli and mitoses.

[surgical operation]

• 2021-11-09
  • Surgery
    • Port-A insertion, R’t after R’t cephalic vein exploration        
    • R’t breast tumor core biopsy under sonography guided       
  • Finding
    • We explore and identify the R’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.        
    • A 5x5x5 cm hard tumor over R’t subareolar region       

[chemoimmunotherapy]

• 2023-02-10 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2023-01-16 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 105mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-12-28 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-12-07 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-11-14 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-10-25 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-09-30 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-08-30 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 500mL
• 2022-08-05 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-07-12 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-06-15 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-05-20 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-04-21 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-03-31 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-03-08 - trastuzumab 8mg/kg 400mg NS 250mL 90min + pertuzumab 840mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr (loading)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-02-11 - docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + metoclopramide 10mg + NS 250mL
• 2022-01-20 - doxorubicin 60mg/m2 80mg NS 100mL 10min + cyclophosphamide 600mg/m2 800mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-12-28 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-12-03 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-11-12 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[blood WBC]

• 2023-02-10 WBC 7.41 *10^3/uL
  
• 2023-02-01 WBC 10.99 *10^3/uL
  
• 2023-01-15 WBC 12.72 *10^3/uL
  
• 2023-01-06 WBC 3.91 *10^3/uL
  
• 2022-12-28 WBC 9.28 *10^3/uL
  
• 2022-12-16 WBC 3.59 *10^3/uL
  
• 2022-12-07 WBC 8.85 *10^3/uL
  
• 2022-11-25 WBC 16.46 *10^3/uL
  
• 2022-11-14 WBC 7.13 *10^3/uL
  
• 2022-11-04 WBC 15.00 *10^3/uL
  
• 2022-10-26 WBC 4.23 *10^3/uL
  
• 2022-10-24 WBC 6.53 *10^3/uL
  
• 2022-10-07 WBC 2.24 *10^3/uL
  
• 2022-09-29 WBC 6.27 *10^3/uL
  
• 2022-09-09 WBC 7.98 *10^3/uL
  
• 2022-08-29 WBC 5.24 *10^3/uL
  
• 2022-08-17 WBC 14.06 *10^3/uL
  
• 2022-08-05 WBC 8.61 *10^3/uL
  
• 2022-07-27 WBC 9.02 *10^3/uL
  
• 2022-07-11 WBC 6.59 *10^3/uL
  
• 2022-06-24 WBC 6.87 *10^3/uL
  
• 2022-06-14 WBC 6.48 *10^3/uL
  
• 2022-05-27 WBC 2.86 *10^3/uL
  
• 2022-05-19 WBC 6.17 *10^3/uL
  
• 2022-04-29 WBC 2.90 *10^3/uL
  
• 2022-04-20 WBC 6.51 *10^3/uL
  
• 2022-04-08 WBC 5.58 *10^3/uL
  
• 2022-03-30 WBC 5.88 *10^3/uL
  
• 2022-03-16 WBC 1.72 *10^3/uL
  
• 2022-03-08 WBC 3.99 *10^3/uL
  
• 2022-02-18 WBC 0.84 *10^3/uL
  
• 2022-02-11 WBC 7.70 *10^3/uL
  
• 2022-02-04 WBC 5.58 *10^3/uL
  
• 2022-01-26 WBC 7.65 *10^3/uL
  
• 2022-01-24 WBC 2.41 *10^3/uL
  
• 2022-01-18 WBC 4.81 *10^3/uL
  
• 2022-01-07 WBC 0.60 *10^3/uL
  
• 2021-12-31 WBC 4.52 *10^3/uL
  
• 2021-12-27 WBC 11.22 *10^3/uL
  
• 2021-12-10 WBC 1.82 *10^3/uL
  
• 2021-12-03 WBC 8.73 *10^3/uL
  
• 2021-12-01 WBC 4.32 *10^3/uL
  
• 2021-11-27 WBC 25.99 *10^3/uL
  
• 2021-11-25 WBC 2.41 *10^3/uL
  
• 2021-11-23 WBC 0.75 *10^3/uL
  
• 2021-11-22 WBC 0.69 *10^3/uL
  
• 2021-11-19 WBC 1.92 *10^3/uL
  
• 2021-11-17 WBC 2.64 *10^3/uL
  
• 2021-11-12 WBC 5.80 *10^3/uL
  
• 2021-11-10 WBC 5.34 *10^3/uL
  
• 2021-11-08 WBC 7.80 *10^3/uL
  
• 2021-11-04 WBC 7.79 *10^3/uL

[G-CSF]

• Granocyte (lenograstim) CGRAN01
  • 2022-02-18 ~ 2022-02-20 250ug SC 2022-02-18 IPD
  • 2022-01-07 ~ 2022-01-09 250ug SC 2022-01-07 IPD
  • 2021-11-22 250ug SC 2021-11-04 IPD
• Neulasta (pegfilgrastim) CNEUL01
  • 2022-10-02 6mg SC 2022-09-29 IPD
  • 2022-08-08 6mg SC 2022-08-05 IPD
  • 2022-07-14 6mg SC 2022-07-11 IPD
  • 2022-04-02 6mg SC 2022-03-30 IPD
  • 2022-03-11 6mg SC 2022-03-08 IPD
  • 2022-01-24 6mg SC 2022-01-18 IPD

2023-05-12

[tube feeding]

As of 2023-05-12, the patient’s serum potassium level was measured at 3.2 mmol/L. Currently, Const-K is the only oral potassium supplement available in this hospital. If intravenous potassium supplementation is not the preferred method, it’s recommended to crush the Const-K tablet into small enough particles to pass through the feeding tube, and administer the supplement with sufficient water. It’s preferable to give this medication with meals due to its original extended-release design.

2023-02-13

[assessment]

• 2023-01-17 bone scan showed most of the previous bone lesions are either less evident or have disappeared in comparison with the previous study on 2021-11-08.
• According to the CT scan performed on 2022-11-16, both breast cancers had pulmonary lymphangitic carcinomatosis and hepatic and bony metastases that were in progression, as compared to the earlier CT scan performed on 2022-07-13.

2022-11-15

[assessment]

• 2022-11-16 CT scan suggested that the disease was progressing.
• Following the administration of AC-THP (doxorubicin and cyclophosphamide followed by docetaxel, trastuzumab, and pertuzumab) for one year (since November 2021), it seems that the disease has gradually developed resistance to these drugs.
• The subsequent line treatment options for the patients with HER2+ metastatic breast cancer might include trastuzumab emtansine or lapatinib, which are covered by NHI, and trastuzumab deruxtecan, which is not covered by NHI at this time.

2022-03-09

[assessment]

• The patient is diagnosed with breast cancer cT4aN3M1 stage IV and bone mets, and she is fitted with AC followed by docetaxelc + trastuzumab + pertuzumab regimen (the latter two drugs started on 2022-03-08).

230213

{malignant neoplasm of unspecified site of left female breast, cT4aN3M1, stage IV}

[exam findings]

• 2023-01-17 Tc-99m MDP whole body bone scan with SPECT
  • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the skull, some T- and L-spines, sacrum, sternum, left scapula, bilateral multiple ribs, multiple pelvic bones, S-I joints, and femurs.
  • IMPRESSION:
    • In comparison with the previous study on 2021/11/08, most of the previous bone lesions are either less evident or disappeared. The scintigraphic findings suggest multiple bone metastases with some resolution.
• 2023-01-17, 2022-12-28, -12-07, -11-14, -10-24, -09-29, -08-29, -08-05, -07-11, -06-14 - CXR
  • A nodular opacity projecting in the left middle lung shows stationary. Follow up is indicated.
    
  • Left CP angle Pleura effusion or thickening.
  • Left hemi-diaphragm elevation is noted, which may be due to eventration or left lower lung volume decrease.
    
  • Spondylosis with scoliosis of the T-spine with convex to right side
  • S/P Mastectomy, left.
• 2022-11-16 CT - chest
  • Indication: Malignant neoplasm of unspecified site of left female breast
  • Findings - Comparison was made with previous CT dated on 20220713
    • Lungs:
      • There is interlobular septal thickening and ground-glass opacities in both lungs scatteredly, seem stationary.
      • Mediastinum and hila: a well-defined fluid density mass (33mm in longest dimension) at left thymic bed. no enlarged LN.
    • Vessels:
      • Aorta: normal caliber of thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LA and LV.
    • Pleura: minimla Rt and small Lt effusions.
    • Chest wall and visible lower neck: interval increase in size infiltrative bilateral breast tumors with overlying skin thickening as compared with previous CT.
      • two small thyroid cysts or nodules.
    • Visible abdominal-pelvic contents:
      • two small Rt hepatic cysts and an ill-defined hypodense lesion at S4 is still visible. a 5mm Lt renal cyst.
      • several small stones in gallbladder. unremarkable of the spleen, both adrenal glands, pancreas, and Rt kidney.
      • no enlarged lymph node.
    • Visualized bones: compression fracture of T7 and blastic metastasis in pedicle of T8.
  • Impression:
    • both breast cancers with pulmonary lymphangitic carcinomatosis and hepatic and bony metastases, in progression compared with CT on 20220713, a thymic cyst.
• 2022-07-13 CT - chest
  • both breast cancers, statiionary, with pulmonary lymphangitic carcinomatosis and hepatic and bony metastases, stationary, a thymic cyst.
• 2022-04-02 CT - chest
  • Breast cancer at both breast, in regression.
  • Diffuse intersitial change at both lungs. suspected lymphangitis carcinomatosis.
  • Bone meta and liver meta.
• 2022-01-19 Cell Block
  • Smears and cell blockshow lymphocytes, reactive mesothelial cells, and clusters of large, pleomorphic tumor cells.
  • IHC: CK(+), GATA3(+), and Calretinin(-).
  • The results are consistent with metastatic breast carcinoma.
• 2021-12-28 Pleural Effusion
  • 50 cc yellow cloudy pleural effusion
  • The smears show lymphocytes, reactive mesothelial cells and a few hyperchromatic atypical cell clusters, compatible with metastatic carcinoma.
• 2021-11-09 Patho - breast biopsy
  • pathologic diagnosis
    • Breast, right, biopsy - Invasive carcinoma of no special type
      
    • The sections show invasive carcinoma of no special type, composed of breast tissue with nests and cords of polygonal neoplastic cells, embedded in fibrous stroma.
    • IHC:
      • ER (Ab): Negative
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Positive (score= 3+)
      • Ki-67: 25%
• 2021-11-08 Tc-99m MDP whole body bone scan with SPECT
  • The scintigraphic findings suggest multiple bone metastases in the skull, some T- and L-spine, sacrum, sternum, left scapula, bilateral multiple ribs, multiple pelvic bones, S-I joints, and femurs.
  • Increased tracer uptake at bilateral shoulders, the nature is to be determined (bone mets, DJD, or other nature ?)
• 2021-11-08 SONO - Breast
  • Bilateral breast tumors with left axillary lymph node, suspected malignancy.
  • BI-RADS: Category 5 - highly suggestive of malignancy, appropriate action should be taken.
• 2021-11-04 Pleural Effusion
  • diagnosis: Adenocarcinoma
  • smears show tumr cells with large hyperchromatic nuclei, pleomorphism, prominent nucleoli and mitoses.

[surgical operation]

• 2021-11-09
  • Surgery
    • Port-A insertion, R’t after R’t cephalic vein exploration        
    • R’t breast tumor core biopsy under sonography guided       
  • Finding
    • We explore and identify the R’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.        
    • A 5x5x5 cm hard tumor over R’t subareolar region       

[chemoimmunotherapy]

• 2023-02-10 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2023-01-16 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 105mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-12-28 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-12-07 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-11-14 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-10-25 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-09-30 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
• 2022-08-30 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 500mL
• 2022-08-05 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-07-12 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-06-15 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-05-20 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-04-21 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-03-31 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-03-08 - trastuzumab 8mg/kg 400mg NS 250mL 90min + pertuzumab 840mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr (loading)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2022-02-11 - docetaxel 75mg/m2 100mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + metoclopramide 10mg + NS 250mL
• 2022-01-20 - doxorubicin 60mg/m2 80mg NS 100mL 10min + cyclophosphamide 600mg/m2 800mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-12-28 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-12-03 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2021-11-12 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[blood WBC]

• 2023-02-10 WBC 7.41 *10^3/uL
  
• 2023-02-01 WBC 10.99 *10^3/uL
  
• 2023-01-15 WBC 12.72 *10^3/uL
  
• 2023-01-06 WBC 3.91 *10^3/uL
  
• 2022-12-28 WBC 9.28 *10^3/uL
  
• 2022-12-16 WBC 3.59 *10^3/uL
  
• 2022-12-07 WBC 8.85 *10^3/uL
  
• 2022-11-25 WBC 16.46 *10^3/uL
  
• 2022-11-14 WBC 7.13 *10^3/uL
  
• 2022-11-04 WBC 15.00 *10^3/uL
  
• 2022-10-26 WBC 4.23 *10^3/uL
  
• 2022-10-24 WBC 6.53 *10^3/uL
  
• 2022-10-07 WBC 2.24 *10^3/uL
  
• 2022-09-29 WBC 6.27 *10^3/uL
  
• 2022-09-09 WBC 7.98 *10^3/uL
  
• 2022-08-29 WBC 5.24 *10^3/uL
  
• 2022-08-17 WBC 14.06 *10^3/uL
  
• 2022-08-05 WBC 8.61 *10^3/uL
  
• 2022-07-27 WBC 9.02 *10^3/uL
  
• 2022-07-11 WBC 6.59 *10^3/uL
  
• 2022-06-24 WBC 6.87 *10^3/uL
  
• 2022-06-14 WBC 6.48 *10^3/uL
  
• 2022-05-27 WBC 2.86 *10^3/uL
  
• 2022-05-19 WBC 6.17 *10^3/uL
  
• 2022-04-29 WBC 2.90 *10^3/uL
  
• 2022-04-20 WBC 6.51 *10^3/uL
  
• 2022-04-08 WBC 5.58 *10^3/uL
  
• 2022-03-30 WBC 5.88 *10^3/uL
  
• 2022-03-16 WBC 1.72 *10^3/uL
  
• 2022-03-08 WBC 3.99 *10^3/uL
  
• 2022-02-18 WBC 0.84 *10^3/uL
  
• 2022-02-11 WBC 7.70 *10^3/uL
  
• 2022-02-04 WBC 5.58 *10^3/uL
  
• 2022-01-26 WBC 7.65 *10^3/uL
  
• 2022-01-24 WBC 2.41 *10^3/uL
  
• 2022-01-18 WBC 4.81 *10^3/uL
  
• 2022-01-07 WBC 0.60 *10^3/uL
  
• 2021-12-31 WBC 4.52 *10^3/uL
  
• 2021-12-27 WBC 11.22 *10^3/uL
  
• 2021-12-10 WBC 1.82 *10^3/uL
  
• 2021-12-03 WBC 8.73 *10^3/uL
  
• 2021-12-01 WBC 4.32 *10^3/uL
  
• 2021-11-27 WBC 25.99 *10^3/uL
  
• 2021-11-25 WBC 2.41 *10^3/uL
  
• 2021-11-23 WBC 0.75 *10^3/uL
  
• 2021-11-22 WBC 0.69 *10^3/uL
  
• 2021-11-19 WBC 1.92 *10^3/uL
  
• 2021-11-17 WBC 2.64 *10^3/uL
  
• 2021-11-12 WBC 5.80 *10^3/uL
  
• 2021-11-10 WBC 5.34 *10^3/uL
  
• 2021-11-08 WBC 7.80 *10^3/uL
  
• 2021-11-04 WBC 7.79 *10^3/uL

[G-CSF]

• Granocyte (lenograstim) CGRAN01
  • 2022-02-18 ~ 2022-02-20 250ug SC 2022-02-18 IPD
  • 2022-01-07 ~ 2022-01-09 250ug SC 2022-01-07 IPD
  • 2021-11-22 250ug SC 2021-11-04 IPD
• Neulasta (pegfilgrastim) CNEUL01
  • 2022-10-02 6mg SC 2022-09-29 IPD
  • 2022-08-08 6mg SC 2022-08-05 IPD
  • 2022-07-14 6mg SC 2022-07-11 IPD
  • 2022-04-02 6mg SC 2022-03-30 IPD
  • 2022-03-11 6mg SC 2022-03-08 IPD
  • 2022-01-24 6mg SC 2022-01-18 IPD

[assessment]

• 2023-01-17 bone scan showed most of the previous bone lesions are either less evident or have disappeared in comparison with the previous study on 2021-11-08.
• According to the CT scan performed on 2022-11-16, both breast cancers had pulmonary lymphangitic carcinomatosis and hepatic and bony metastases that were in progression, as compared to the earlier CT scan performed on 2022-07-13.

221115

[assessment]

• 2022-11-16 CT scan suggested that the disease was progressing.
• Following the administration of AC-THP (doxorubicin and cyclophosphamide followed by docetaxel, trastuzumab, and pertuzumab) for one year (since November 2021), it seems that the disease has gradually developed resistance to these drugs.
• The subsequent line treatment options for the patients with HER2+ metastatic breast cancer might include trastuzumab emtansine or lapatinib, which are covered by NHI, and trastuzumab deruxtecan, which is not covered by NHI at this time.

220309

[assessment]

• The patient is diagnosed with breast cancer cT4aN3M1 stage IV and bone mets, and she is fitted with AC followed by docetaxelc + trastuzumab + pertuzumab regimen (the latter two drugs started on 2022-03-08).

701464962

230512

[exam findings]

• 2023-04-11 CT - abdomen
  • History and indication:
    • A case of newly diagnosed rectal cancer at 10-14 cm AAV Advanced rectal cancer, cT4aN2bM0 pre-op CCRT
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Stable condition of rectal cancer.
    • Renal cysts (up to 0.8cm).
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • Emphysema at bil. upper lungs.
  • IMP:
    • Stable condition of rectal cancer.
• 2023-04-11 ECG
  • Sinus bradycardia with occasional Premature ventricular complexes
• 2023-04-11 Colonoscopy
  • Rectal cancer s/p CCRT, mild regression
• 2023-03-16 CT - abdomen
  • History and indication:
    • Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Mild regression of rectal cancer.
    • Renal cysts (up to 0.8cm).
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • Emphysema at bil. upper lungs.
  • IMP:
    • Mild regression of rectal cancer.
• 2023-03-01 CXR
  • Atherosclerotic change of aortic arch
• 2023-02-06 KUB
  • Spondylosis of the L-spine is noted.
• 2023-01-30 CXR
  • Atherosclerotic change of aortic arch
• 2023-01-04 ECG
  • Sinus bradycardia with 1st degree A-V block
  • Nonspecific ST abnormality
• 2022-12-22 Patho - colrectal polyp
  • Rectum, 10 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
  • The sections show adenocarcinoma, moderately differentiated, composed of low columnar to couboidal neoplastic cells, arranged in glandular and cribrifrom patterns with desmoplastic stromal reaction. Mucosal ulcer is present.
  • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
• 2022-12-20 Sigmoidoscopy
  • Rectal cancer s/p biopsy
  • Rectal polyp s/p polypectomy
• 2022-12-19 CT - abdomen
  • History and indication: A case of newly diagnosed rectal cancer at 10-14 cm AAV
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with adjacent fat stranding and regional LAP.
    • Renal cysts (up to 0.8cm).
    • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • Emphysema at bil. upper lungs.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T: T4a(T_value) N: N2b(N_value) M: M0(M_value) STAGE: IIIC(Stage_value)

[MedRec]

• 2023-02-16 SOAP Colorectal Surgery
  • A/P
    • radiotherapy on 2023-01-05 ~ 2023-02-13
    • CCRT with FOLFOX IV Q2W x 4~6 months
• 2023-02-21 SOAP Radiation Oncology
  • O: RT (2022-12-30 ~ 2023-02-13): 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions (15 MV photon) of the rectal tumor bed area.
• 2023-02-06 SOAP Hemato-Oncology
  • S: c/o vague abd discomfort, KUB: stool impact, give Lactulose.
• 2023-01-10 SOAP Hemato-Oncology
  • S
    • HBsAg, anti-HCV (12/26 22): negative. anti-HBc: positive… on Baraclude
    • On R/T to rectal tumor by Dr Huang Jingmin.
    • Owing to advanced stage of rectal CA, pre-Op CCRT wt FOLFOX is preferred rather than lower dose 5-FU 24 hr QD x 5 per wk x 6 plus R/T (20230110).
    • #1 pre-Op CCRT wt mFOLFOX6 IV Q2W x 3 plus R/T on 20230103.
    • Adm on 20230130 for #2 pre-Op CCRT wt mFOLFOX6 IV Q2W x 3 plus R/T.
• 2023-01-03 ~ 2023-01-05 POMR Hemato-Oncology
  • Discharge diagnosis
    • Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC).
    • Chronic viral hepatitis B without delta-agent, 2022/12/26 Anti-HBc: postive
    • Porta catheter insertion at right Internal Jugular Vein on 2023/01/4
  • Present illness
    • This a 77 year-old male, who has hypertension for years, a patient of Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC), diagnosis in Dec 2022.
    • He suffered from initial presentation of jaundice & clay-colored stool in May 2016. The palpatedv small elastic nodule, 3 cm in size, painless & non-tender, movable at upper back from June 2015. So, he went to GS OPD for help on 2022/12/19.
    • Follow-up Abdomen CT (12/19 22): Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC).
    • Sigmoidoscopy : Rectal cancer s/p biopsy. Rectal polyp s/p polypectomy on 2022/12/20.
    • The rectum, 10 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated. IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+) on 2022/12/20.
    • He was referred to our hemato-oncologic clinic on 12/26 14 by Dr Xiao Guanghong for CCRT with FOLFOX Q2W IV x 4-6 months.
    • Consult Dr. Huang Jingmin for CCRT enaluation. Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed. Starting on 2022/12/30.
    • HBsAg, Anti-HBc, Anti-HCV: negative on 12/26 22.
    • Port-a insertion on 2023/1/4 by Dr. Chen Yanzhi
    • This time, he is admitted for CCRT with FOLFOX Q2W IV x 4-6 months.
  • Course of Inpatient Treatment
    • After be admitted, he received radiotherapy with deliver 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed, since 2022/12/30 until now.
    • CCRT with #1 FOLFOX (oxalip 6070mg/m2, covorin 400mg/m2, 5-FU 2400mg/m2) IV Q2W x 6 on 1/3-1/5 22, Imperan + Promeran for vomitin, hydration, and Baraclude 0.5mg/tab 1tab QDAC for Anti-HBC(+). The port-a catheter insertion at right Internal Jugular Vein on 2023/01/04.
    • After chemotherapy, he denied having a fever, chillness, vomiting, diarrhea, and the surgery wound condition stably.
    • Under the stable condition, he can be discharged on 2023/01/05, the OPD follow-up and the next admission will be arranged.
• 2022-12-22 SOAP Radiation Oncology
  • A: Adenocarcinoma, moderately differentiated, of the rectum, EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+), stage cT4aN2bM0 (IIIC).
  • P: Radiotherapy is indicated for this patient with the following indicators: stage T4aN2bM0
    • Goal: curative
    • Treatment target and volume: pelvic area
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2022-12-27.
• 2022-12-22 SOAP Colorectal Surgery
  • A: Advanced rectal cancer , cT4aN2bM0
  • P: Suggest pre-op CCRT (favor TNT) then OP
• 2022-12-19 SOAP Colorectal Surgery
  • S
    • A case of newly diagnosed rectal cancer at 10-14 cm AAV
    • PH: HTN
      
  • O
    • pre-op study
    • Arrange sigmoidoscopy for R/O colonic lesion

[radiotherapy]

• 2022-12-30 ~ 2023-02-13 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions (15 MV photon) of the rectal tumor bed area.

[chemotherapy]

• 2023-05-11 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4410mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-26 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4435mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-12 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4415mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-15 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4450mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-01 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-13 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-30 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4450mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-03 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4510mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-05-29

[medication reconciliation]

• According to the PharmaCloud database, the patient had visited WanFang Hospital and a local clinic for upper respiratory symptoms in late March and early May. However, the prescriptions from these healthcare providers have now expired. No medication reconciliation issues were identified during this patient’s current admission.

2023-05-12

• According to the PharmaCloud database, the patient visited WanFang Hospital on 2023-03-27 for his unspecified chronic bronchitis and visited Dr. Wu’s local clinic on 2023-03-29 for an unspecified acute upper respiratory infection. To date, no current respiratory problems have been reported and no medication reconciliation issues have been identified.
• The patient underwent radiotherapy with 4500 cGy/25 fractions (15 MV photon) to the pelvic region and 5040 cGy/28 fractions (15 MV photon) to the rectal tumor bed from 2022-12-30 to 2023-02-13. Concurrently, the patient has been receiving chemotherapy with the FOLFOX regimen since 2023-01-03. The initial treatment plan was to reduce the tumor size for possible surgical resection. However, the CT scans of 2023-04-11 showed stable disease compared to 2023-03-16, which showed a slight regression, suggesting that the treatment may not be as effective as it once was. It would be recommended to obtain new tumor marker lab data to assist in evaluating the efficacy of the current treatment.

701465142

230511

[past history]

• Heart:(-)

• Chest:(-)

• Liver:(-)

• Kidney:(-)

• H/T:(-)

• DM:(-)

• Surgical:

  • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy) Paraaortic lymphadenectomy on 2022/12/29
  • Port implantation on 2023/01/31

• Menstrual history: G2P2, menopause at age of 48

[allergy]

• NKDA     

[family history]

• There is no family history of cancer,hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[lab data]

2023-01-11 Anti-HBc Nonreactive
2023-01-11 Anti-HBc-Value 0.89 S/CO
2023-01-11 Anti-HBs 329.77 mIU/mL
2023-01-11 Anti-HCV Nonreactive
2023-01-11 Anti-HCV Value 0.07 S/CO
2023-01-11 HBsAg Nonreactive
2023-01-11 HBsAg (Value) 0.31 S/CO

[exam findings]

• 2023-04-22 CT - abdomen
  • History and indication: Endometrioid carcinoma of the right ovary s/p Debulking surgery and paraaortic lymphadenectomy on 2022/12/29, pT1cN0M0, stage IC1, FIGO IC1, s/p chemotherapy with Taxol(175mg/m2)/Carboplain(AUC:6) from 2023/02/17
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Tumors (4.7cm, 7.9cm) at pelvic cavity with adjacent structures invasion causing right hydronephrosis and hydroureter. Some small LNs at retroperitoneum.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Recurrent tumors (4.7cm, 7.9cm, progression) at pelvic cavity with adjacent structures invasion causing right hydronephrosis and hydroureter. Some small LNs at retroperitoneum.
• 2023-02-16 MRI - pelvis
  • Clinical history: 54 y/o female patient with Malignant neoplasm of unspecified ovary.
  • With and without contrast enhancement CT of abdomen - whole:
    • S/P hysterectomy and oophorectomy.
    • There is irregular soft tissue tumors, 5x4.9cm (RLQ) and 1.2cm in lower abdomen, suspected recurrence.
    • Cystic lesion in bilateral pelvic side wall regions (right 2.7x1.3cm and left 3.2x1.3cm), suspected lymphocele.
    • Unremarkable change of the liver, spleen, pancreas and both kidneys.
    • No enlarged lymph node in the paraaortic region.
    • Presence of some ascites in the pelvic cavity.
  • Impression:
    • S/P hysterectomy and oophorectomy. Suspected recurrnt tumors in lower abdomen.
    • Suspected lymphocele in the pelvic cavity. (Lymphoceles are collections of lymphatic fluid)
• 2023-02-08 Gynecologic ultrasonography
  • ATH + BSO
  • Asictes (+)
• 2023-02-07, -01-31 CXR
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-02-07 Mammography (magnification)
  • Dense calcifications in left breast, LOQ (around 6’region), suggest close follow up.
  • BI-RADS: Category 3: probably benign finding-short interval follow-up suggested.
• 2023-02-07 Pure Tone Audiometry
  • PTA:
  • Reliability FAIR
  • Average RE 13 dB HL; LE 16 dB HL
  • bil normal to moderate SNHL
• 2023-01-12 Mammography
  • Screening digital mammography of both breasts with MLO and CC views:
  • Findings
    • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
    • There is no obvious mass lesion.
    • No obvious architectural distortion.
      
    • Group amorpohrus microcalcificatios in left breast, LIQ of left breast (around 6’region posterior third portion), suggest spot magnification study.
    • No periareolar skin thickening.
    • No enlarged axillary lymph node.
  • Impression:
    • Dense breast.
    • Group amorpohrus microcalcificatios in left breast, LIQ of left breast (around 6’region posterior third portion), suggest spot magnification study.
    • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)
• 2023-01-11 SONO - breast
  • Benign neoplasm of breast, infavor of benign fibrocystic disease(FCD)
  • Regular OPD follow-up
  • BI-RADS 2 - Benign Finding
• 2022-12-29 Patho - ovary (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Ovary, right, salpingo-oophorectomy (tumor intra-operative rupture) —- carcinoma.
      • IHC stains: CK7 (+), CK20 (-), GATA-3 (+), PAX-8 (-), CDX-2 (-), P40 (-), Napsin-A (-). Please check urinary tract and breast.
    • Ovary, left, salpingo-oophorectomy —- endometrioma
    • Fallopian tube, right, salpingo-oophorectomy —- free
    • Fallopian tube, left, salpingo-oophorectomy—– free
    • Uterus, corpus, total hysterectomy — myoma; atrophic endometrium.
    • Uterus, cervix, total hysterectomy — free
    • Omentume, omentectomy —- endometriosis.
    • Lymph node, bilateral pelvic and left para-aortic, dissection — Free.
  • MACROSCOPIC EXAMINATION:
    • Procedure-Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy) : Uterus: 170 gms, 13 x 8 x 5 cm; myoma: 7 x 5 x 3 cm; omentum: 31 x 15 x 3 cm, endometriosis; right ovary: 21 x 15 x 6 cm. Solid part: 12 x 9 x 5 cm.   
      • Pleurocentesis (pleural fluid)
    • Specimen size:
      • right ovary: 21 x 15 x 6 cm; cystic; solid part: 12 x 9 x 5 cm
      • left ovary: 2 x 1.5 x 1.4 cm;
      • right tube: 5 x 0.5 x 0.5 cm;
      • left tube: 5 x 0.5 x 0.5 cm;
      • uterus: 13 x 8 x 5 cm.
    • Specimen Integrity:
      • Specimen Integrity of Right Ovary- ruptured: intra-operative ruture
      • Specimen Integrity of Left Ovary -Capsule intact
      • Specimen Integrity of Right Fallopian Tube-Serosa intact
      • Specimen Integrity of Left Fallopian Tube- Serosa intact
    • Tumor Site: right ovary
    • Ovarian Surface Involvement - Absent
    • Fallopian Tube Surface Involvement - Absent
    • Tumor Size - 12 x 9 x 5 cm
    • Greatest dimension (centimeters): 12 cm
    • Additional dimensions (centimeters): 9 x 5 cm
    • Sections are taken and labeled as: A: left iliac lymph nodes; B: left obturator lymph nodes; C: right iliac lymph nodes; D: right obturator lymph nodes; E: left para-aortic lymph nodes; F: omentum; G1: cervix; G2: myoma; G3: endometrium; G4: right tube; G5: left adnexa; H1-5: right ovary (H1-3: solid part; H4-5: non-solid part).
  • MICROSCOPIC EXAMINATION:
    • Histologic type: carcinoma; please check urinary tract and breast. IHC stains: CK7 (+), CK20 (-), GATA-3 (+), PAX-8 (-), CDX-2 (-), P40 (-), Napsin-A (-).
    • Histologic grade: grade 3
    • Contralateral ovary involvement: absent
    • Tumor side ovarian surface involvement: absent
    • Contralateral ovary surface involvement: absent
    • Right tube involvement: absent
      
    • Left tube involvement: absent
    • In situ adenocarcinoma in right and/or left fallopian tube: absent
    • Right adnexa soft tissue involvement: absent
    • Left adnexa soft tissue involvement: absent
    • Pelvic soft tissue involvement: absent
    • Uterine serosa involvement: absent
    • Omentum involvement: absent
    • Uterine Cervix involvement: absent
    • Endometrium involvement: absent
    • Myometrium involvement:absent
    • Appendix involvement: absent
    • Largest Extrapelvic Peritoneal Focus -none.
    • Peritoneal/Ascitic Fluid- N2022-04855: Negative
    • Regional Lymph Nodes: free
      • Negative for metastasis: describe locations (0/17) = A: left iliac lymph nodes (0/4); B: left obturator lymph nodes (0/1); C: right iliac lymph nodes (0/3); D: right obturator lymph nodes (0/2); E: left para-aortic lymph nodes (0/7).
    • Other organs or specimens involvement: absent.
• 2022-12-21 CT - abdomen - urinary bladder
  • Hx: P2 NSDX2, menopause at the age of 48
    • patient noticed that she has the tumor over the right side of the ovary, she has regular follow up, covid (+) in May 2022
    • BW decreased from 72kg -> 58kg, difficulty of voiding
    • 20221221 CA125 427U/mL (<35), CA199 231U/mL (<35), CEA normal.
  • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is a huge cystic mass with enhancing mural nodules in the lower abdomen and pelvis, measuring 22.4 x 14 x 28 cm (width x depth x cranial-caudal length).
      • The uterus shows right lateral displacement.
      • Cystic adenocarcinoma of left ovary is highly suspected.
      • Please correlate with clinical oondition.
    • There are several enlarged nods in para-aortic space and bilateral inguinal area. please correlate with clinical condition.
    • Others
      • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        
      • There is no ascites.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • Cystic adenocarcinoma of left ovary is highly suspected. Please correlate with clinical oondition.
      
    • There are several enlarged nods in para-aortic space and bilateral inguinal area. please correlate with clinical condition.
• 2022-12-21 Gynecologic ultrasonography
  • Huge pelvis mass size over: 345x178mm with papillary: (1) 91x36mm (2) 51x39mm
  • Adenomyosis

[consultation]

• 2023-02-17 Dermatology
  • Q
    • The 54 y/o ovary cancer with disease progress. Due to left heel skin itchy with redness, so we need your help for assessment. Thanks!
  • A
    • This patient suffered from erytheamtous papules on bil feet for days
    • Imp: Subacute dermatitis
    • Suggestion
      • Sinpharderm x 1 tube/bid
      • Topsym cream x 3 tubes/bid

[MedRec]

• 2023-03-09 SOAP Hemato-Oncology
  • O
    • Now on C/T with TP
    • AE: Gr 2 Anemia
• 2023-03-01 SOAP Hemato-Oncology
  • O
    • Cancer Treatment Radiotherapy/Targeted Therapy Side Effect Evaluation
      • Decreased white blood cells: G1: 3000 - 4000/mm3
      • Decreased white blood cells [Management]: Observation
• 2023-02-07 ~ 2023-02-20 POMR Hemato-Oncology
  • Discharge diagnosis
    • Malignant neoplasm of unspecified ovary
    • Fever, unspecified
    • Vaginitis, U/C: Gardnerella vaginalis
    • Subacute dermatitis
  • Course of Inpatient Treatment
    • After admission, will do schedule chemotherapy, but fever was noted without chillness, check lab and follow up culture for infection survey.
    • Empirical antibiotic with Cefuroxime 750mg/vial 1500mg IVD Q8H from 2023/02/07, Acetal 500 mg/tab 1# PO PRNQ6H if BT > 38.3’C. and consult GYN for check Gynecologic ultrasonography on 2023/02/08, no special finding.
    • Naproxen 250 mg/tab 0.5# PO BID for suspect tumor fever, close monitor -> DC 2/10, start from 2/16.
    • Due to urine/culture showed Gardnerella vaginalis, given Metrozole 250mg/tab 2# PO BID 7days from 2023/02/10 to 2023/02/17.
    • Before chemotherapy, PTA and 24 Ccr were done. PTA on 2023/02/07 showed bil normal to moderate SNHL. 24hrs CCr, urine output 3700ml, CCr 70.9mL/min.
    • Mammography (Magnification) on 2023/02/07 showed dense calcifications in left breast, LOQ (around 6’region), probably benign finding.
    • Pelivs MRI for survey on 2023/02/16 showed S/P hysterectomy and oophorectomy, R/O recurrent tumors in lower abdomen, R/O lymphocele in the pelvic cavity.
    • Pre-medication as Dorison 20mg PO on 2/16 23:00 and 2/17 05:00, chemotherapy as C1 Paclitaxel 175mg/2 + Carboplatin 150mg/15mL/vial (AUC 6) on 2023/02/17.
    • Consult for erytheamtous papules on bil feet for days, suggest Sinpharderm x 1 tube/bid、Topsym cream x 3 tubes/bid use. Patient tolerated the chemotherapy without nausea and vomiting.
    • With the stable condition, she/he was discharged on 2023/02/20 and OPD followed up later.   
  • Prescription
    • naproxen 250mg 0.5# BID
    • Smecta (dioctahedral smectite 3mg) 1# PRNQ8H (if watery diarrhea > 3 times)
    • Sinpharderm Cream (urea) BID TOPI (for subacute dermatitis)
    • Topsym Cream (fluocinonide) BID EXT (for subacute dermatitis)
    • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
• 2023-02-02 SOAP Hemato-Oncology
  • O
    • Conclusion of the Multidisciplinary Cancer Team Meeting, Meeting Date: 20230105
      • Treatment Plan: Arrange cystoscopy (GATA-3+) and breast ultrasound examination, and then refer to the hematology department for further evaluation.
  • A/P
    • Lab
    • RTC by herself
    • Waiting for the conclusion from Breast and GU
    • Arrange admission with magnification Mammography and then C/T

[surgical operation]

• 2022-12-29
  • Surgery
    • Diagnosis: Cystic adenocarcinoma of right ovary s/p debulking surgery.
  • Operation
    • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)    
    • Paraaortic lymphadenectomy

[chemotherapy]

• 2023-05-02 - topotecan 1.5mg/m2 2.3mg NS 70mL 30min + gemcitabine 1000mg/m2 1400mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
• 2023-04-24 - topotecan 1.5mg/m2 2.3mg NS 70mL 30min + gemcitabine 1000mg/m2 1400mg NS 250mL
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-03-13 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 6 510mg NS 300mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-17 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 6 570mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL

2023-05-11

[assessment]

• The PharmaCloud database reveals that the patient’s recent drugs have all been prescribed at our hospital. Currently, there are no issues detected with medication reconciliation in the active prescription.

• The patient’s anemia, as evidenced by a decrease in hemoglobin level from 10.2 g/dL on 2023-05-02 to 8.1 g/dL on 2023-05-09, is currently being treated with a transfusion of 2 units of packed red blood cells (P-RBC), scheduled for 2023-05-11, as indicated.

• The patient’s lab data reveals a decreasing trend in serum albumin levels, raising the possibility of a protein-losing gastroenteropathy. However, current records do not indicate the presence of edema, ascites or pleural and pericardial effusions. Furthermore, liver and kidney function appear to be within or not far from normal ranges based on the lab data, suggesting that heavy proteinuria or impaired protein synthesis due to liver disease are less likely causes. It is recommended to encourage the patient to pay more attention to nutritional supplementation to prevent malnutrition.

  • 2023-05-09 Albumin 2.8 g/dL
    
  • 2023-05-02 Albumin 3.1 g/dL
    
  • 2023-04-19 Albumin 3.0 g/dL
    
  • 2023-04-12 Albumin 3.1 g/dL
    
  • 2023-03-30 Albumin 3.1 g/dL
    
  • 2023-03-23 Albumin 3.1 g/dL
    
  • 2023-03-09 Albumin 3.2 g/dL

• Intestinal leakage of plasma proteins occurs via one of the following mechanisms:

  • Inflammatory exudation: Mucosal injury results in exudation of protein-rich fluids across the eroded epithelium. The degree of mucosal involvement typically correlates with the severity of protein loss.
  • Increased mucosal permeability: Altered integrity of the mucosa of the stomach, small bowel, and colon due to inflammatory, infiltrative, and genetic causes results in protein leakage into the lumen.
  • Intestinal loss of lymphatic fluid: Lymphatic obstruction, congenital abnormalities of the lymphatic system, or disorders of increased central venous pressure (eg, congestive heart failure or constrictive pericarditis) result in increased lymphatic pressure.

• The CT scan on 2023-04-22 revealed recurrent tumors in the pelvic cavity measuring 4.7cm and 7.9cm, respectively. These tumors have invaded adjacent structures, causing right hydronephrosis and hydroureter, and lymph nodes are also evident in the retroperitoneum. These findings might be related to the observed clinical phenomena mentioned above?

2023-03-14

[assessment]

• On 2023-03-13, the second cycle of paclitaxel/carboplatin began with the addition of antiemetics (palonosetron and aprepitant) and a larger volume of normal saline for each drug compared to the first cycle which began on 2023-02-17. Specifically, the volume for both paclitaxel and carboplatin was increased from 250mL to 300mL.
• Based on the available lab data, the patient’s HGB levels have been often below 10g/dL, and since mid-Feb, they have decreased to below 9g/dL. On 2023-03-13, the patient received a blood transfusion of 2 units of LPRBC. Please continue to monitor changes in blood cell count as always.
• Thre is no medication reconciliation issue found in the patient.

701477623

230511

[exam findings]

• 2023-05-09 CT - abdomen
  • Clinical history: 60 y/o male patient with rectal swelling with suspect infection.
  • With and without contrast enhancement CT of abdomen:
    • Severe swelling/edema at middle and lower rectum.
    • Wall edema at gallbladder.
    • Liver cysts, up to 2.5cm in S7.
    • Bilateral pleural effusion.
    • Diffuse subcutaneous edema.
  • Impression:
    • Severe swelling/edema at middle and lower rectum. R/O colitis, suggest clinical correlation.
    • Wall edema of Gallbladder.
    • Bilateral pleural effusion, diffuse subcutaneous edema.
    • R/O liver cysts.
• 2023-05-09 CXR
  • There are diffuse nodular and linear infiltrations in both lungs. please correlate with clinical condition or CT.
  • Enlargement of cardiac silhouette.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-04-18 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (129 - 39) / 129 = 69.77%
    • M-mode (Teichholz) = 70
  • Conclusion:
    • Mildly dilated LV; normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Mild AR; mild MR; mild TR; mild PR.
    • Mildly dilated aortic root.
• 2023-04-17 Patho - bone marrow biopsy
  • Bone marrow, iliac crest, biopsy — Compatible with acute myeloid leukemia with maturation
  • The sections show hypercellular marrow (90%). The erytrhoid precursors are depressed in CD71 stain. The marrow space is partially replaced by a population of medium to large-sized immature cells with oval nucleus and moderate amount cytoplasm.
  • IHC: increased CD34- /CD117+ blasts, constitue 30% of marrow cells. Most marrow are also positive for MPO (80%) and a few are positive for CD68 (5%). The finding is compatible with acute myeloid leukemia with maturation. Suggest bone marrow smear evaluation and clinic correlation.
• 2023-04-14 ECG
  • Normal sinus rhythm with sinus arrhythmia
  • RSR or QR pattern in V1 suggests right ventricular conduction delay
  • ST & T wave abnormality, consider lateral ischemia
  • Abnormal ECG

[MedRec]

• 2023-04-14 SOAP Hemato-Oncology
  • O
    • 2023/04/14 WBC = 30.60 x10^3/uL;
    • 2023/04/07 WBC = 19.13 x10^3/uL;
    • 2023/04/14 PLT = 77 *10^3/uL;
    • 2023/04/07 PLT = 98 *10^3/uL;
    • 2023/04/07 Blast = 19.0 %;
  • P
    • Suspect Acute leukemia -> refer to ER for admission
• 2023-04-07 SOAP Hemato-Oncology
  • S
    • 177 cm, 70 kg, 60 y man
    • Occupation: Notebook R/D chief
    • PH: healthy platelet donor since 1992 until 2022
    • 2023-01-01: common cold, and anemia found, Hb: 10.0, in China
    • 2023-03-31: WBC 14000, Hb 11.1, Plt 122k, monocytes 20%, blast is found on PB smear
    • 2023-04-03: WBC 15400, Hb 11.2, blast 10.5%, mono 21%
    • 2023-04-06: BM exam at Shin Kong Hospital, acute leukemia was told
  • O
    • No hepatosplenomegaly
  • Imp:
    • Suspected Acute leukemia

[consultation]

• 2023-05-09 Colorectal Surgery
  • Q
    • The 60 y/o man has AML (Acute Myeloid Leukemia) undergoing induction chemotherapy and is in the stage of neutropenia.
    • Because he has been feeling a heavy sensation of anal fullness and downward pressure, we need your help for management.
  • A
    • This is a case of AML with neutropenia. Anal pain and dysuria develo[ed thses days.
    • DRE: no palpable mass, no fistula, no abscess, rectal wall edema and wall swelling.
    • Suapect leukemic infiltration of the rectum, AML induced anorectal pain.
    • Please arrange pelvic MRI for detail information.
• 2023-05-09 Urology
  • Q
    • The 60 y/o man has AML under induction chemotherapy with neutropenia stage.
    • Due to acute urine retention cause unknown, so we need you for management. Thanks!
  • A
    • We were consulted for AUR s/p Foley
      • This 60 yo male has underlying BPH
      • PI: no straining, no weak stream
      • Lab: UTI
    • Impression: AUR due to UTI
    • Suggestion:
      • keep anti
      • keep Foley and alpha-blocker for one week
      • arrange UFM and PVR after Foley removal
• 2023-05-05 Infectious Disease
  • Q
    • The 60 y/o man has AML under induction chemotherapy with neutropenia stage, he had spiky fever with shaking chills on 20230503.
    • We need you agree for give micarfuncgin. Thanks!
  • A
    • The 60-year-old AML male patient, who received recent chemotherapy, has neutropenic fever in recent two days.
    • CBC today revealed severe pancytopenia, with WBC only 90 and no neutrohils.
    • Besides Targocid and cefepime, anti-fungal Mycamine is added since yesterday for coverage of possible fungal infection, especially Candida species.
    • Please continue the present antimibrocial regimen and check blood culture report.

[chemotherapy]

• 2023-04-20 - daunorubicin 45mg/m2 84mg NS 100mL D1-3 + cytarabine 100mg/m2 187mg NS 500mL 24hr D1-7 (daunorubicin/cytarabine 3+7, Q4W)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-7

2023-05-11

• Please be aware that the patient’s renal function has been declining over the past three days. At present, there’s no need for a dose adjustment, but it’s crucial to continue monitoring closely.

  • 2023-05-11 Creatinine 1.11 mg/dL
    
  • 2023-05-09 Creatinine 0.92 mg/dL
    
  • 2023-05-08 Creatinine 0.65 mg/dL
    
  • 2023-05-11 eGFR 71.82
    
  • 2023-05-09 eGFR 89.19
    
  • 2023-05-08 eGFR 133.18

• Lab data has shown signs of recovery in the patient’s WBC count. However, the PLT count continues to hover at relatively low levels, never reaching 100K/uL.

  • 2023-05-11 WBC 2.38 x10^3/uL
    
  • 2023-05-09 WBC 0.24 x10^3/uL
    
  • 2023-05-08 WBC 0.12 x10^3/uL
    
  • 2023-05-06 WBC 0.12 x10^3/uL
    
  • 2023-05-05 WBC 0.09 x10^3/uL
    
  • 2023-05-03 WBC 0.24 x10^3/uL
    
  • 2023-05-02 WBC 0.32 x10^3/uL
    
  • 2023-04-29 WBC 0.53 x10^3/uL
    
  • 2023-04-27 WBC 1.64 x10^3/uL
    
  • 2023-04-26 WBC 2.75 x10^3/uL
    
  • 2023-04-24 WBC 8.09 x10^3/uL
    
  • 2023-04-23 WBC 18.55 x10^3/uL
    
  • 2023-04-22 WBC 25.63 x10^3/uL
    
  • 2023-04-21 WBC 40.55 x10^3/uL <= 4/20 started “daunorubicin/cytarabine 3+7”
  • 2023-04-19 WBC 35.06 x10^3/uL
    
  • 2023-04-16 WBC 37.99 x10^3/uL
    
  • 2023-04-14 WBC 30.60 x10^3/uL
    
  • 2023-04-07 WBC 19.13 x10^3/uL

• Indications for platelet transfusion include actively bleeding patients with thrombocytopenia who should receive immediate platelet transfusion to maintain platelet counts above 50K/uL in most bleeding situations, including disseminated intravascular coagulation (DIC), and above 100K/uL in central nervous system bleeding.

• Unfortunately, there are no perfect tests to predict spontaneous bleeding. Studies in patients with thrombocytopenia suggest that spontaneous bleeding can occur even with platelet counts above 50K/uL. However, bleeding is much more likely when the platelet count falls below 5K/uL. For individuals with platelet counts between 5K and 50K/uL, clinical observations may be useful in deciding whether to transfuse platelets.

2023-04-21

• The patient started his first “3+7 daunorubicin/cytarabine” treatment on 2023-04-20 for his AML. No identified issue found in the active prescription.

701333841

230510

[diagnosis] - 2023-02-06 discharge note

• Myelodysplastic syndrom, RAEB I
• Malignant neoplasm of upper gum
• Myelodysplastic syndrome, unspecified
• Allergic contact dermatitis, unspecified cause
• Splenomegaly, not elsewhere classified
• Thrombocytopenia, unspecified
• Antiphospholipid syndrome
• Other secondary gout, unspecified site
• Acute kidney failure, unspecified
• Heart failure, unspecified
• Hyperuricemia without signs of inflammatory arthritis and tophaceous disease

[lab data]

• 2022-08-13 Ferritin 694.9 ng/mL
  
• 2022-08-13 Folic Acid 9.65 ng/mL
  
• 2022-08-13 Vitamin B12 948 pg/mL
  
• 2022-08-13 Reticulocyte count 0.360 %
  
• 2022-08-13 Fe (Iron-bound) 47 ug/dL
  
• 2022-08-13 TIBC 143 ug/dL
  
• 2022-08-13 UIBC 96 ug/dL
  
• 2022-08-13 DBI/TBI 21.88 %

[exam findings]

• 2023-03-27, 2022-12-26, -11-25 CXR
  • Atherosclerotic change of aortic arch
• 2023-03-14 CT - abdomen
  • Clinical history: 71 y/o male patient with RLQ pain for 2 days, constant pain, precipitated by positional change, no related to meal, no bowel movement change, no fever, no nausea
  • PH: Oral cancer s/p OP
  • WITHOUT contrast enhancement CT of abdomen - whole:
    • Presence of gallbladder stones.
    • Presence of splenomegaly.
      
    • No enlarged lymph node in the paraaortic region.
    • Minimal ascites.
    • Right lower lung nodule, 0.8cm.
    • Tree-in-bud infiltrates in left lower lung.
  • Impression:
    • Gallbladder stones.
    • Splenomegaly.
    • Tree-in-bud infiltrates in left lower lung.
    • Right lower lung nodule, 0.8cm.
• 2023-03-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (128.9 - 68.9) / 128.9 = 46.55%
    • M-mode (Teichholz) = 46.6
    • 2D (M-simpson) = 50.1
  • Conclusion
    • Borderline LV systolic function with mildly global hypokinesia
    • Mitral valve prolapse (anterior leaflet) with mild mitral regurgitation
    • Trivial tricuspid regurgitation, mild pulmonic regurgitation
    • Impaired LV relaxation
    • Dilated LA and aortic root; thick IVS and LVPW
• 2022-11-10, -11-04 CXR
  • Enlargement of cardiac silhouette.
  • Atherosclerotic change of aortic arch
  • Peri-bronchial wall thickening of the right and left lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2022-10-31 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Meylodysplasia syndrome (refractory anemia with excess blast-I).
  • Specimen submitted in B5 fixative consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 2.6 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
  • Section shows piece(s) of bone marrow with 90% cellularity and M:E ratio of approximately 8:1. Three cell lineages are present with left shift of leukocytes. Megakaryocytes are adequate in number with mild nucleat atypia.
  • IHC stains: CD117: 10%; CD34: 5%; MPO: 80-85%, CD61: 5 %; CD71: 10 % (of the nucleated cells).
• 2022-10-04 KUB
  • There is splenomegaly.
  • Spondylosis of the L-spine is noted.
• 2022-09-28 CXR
  • Lung markings: consolidation in the right lower lung field.
• 2022-09-28 ECG
  • Sinus rhythm with Premature atrial complexes
  • Possible Left atrial enlargement
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2022-09-15, -09-08 CXR
  • Enlargement of cardiac silhouette.
  • Atherosclerotic change of aortic arch.
  • Increased lung markings on both lower lung are noted.
• 2022-09-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (135 - 66) / 135 = 51.11%
    • M-mode (Teichholz) = 50
  • Dilated LA and LV; mildly abnormal LV systolic function with global hypokinesia
  • Septal hypertrophy; LV diastolic dysfunction, Gr 1
  • Trivial MR, mild AR, mild TR and trivial PR
  • Preserved RV systolic function
  • Rare isolated premature atrial beat (PAC) at the exam
• 2022-08-29 CXR
  • Increase bilateral lung markings.
  • Mild cardiomegaly.
  • Thoracic spondylosis.
  • Post-op with metallic clips in right neck.
• 2022-08-15 CXR
  • Crowding of vascular markings over both lungs
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • Normal heart size
  • Rt and Lt subpulmonary effusion
  • Marginal spurs of multiple vertebral bodies
  • Compression fracture of L1 vertebral body
• 2022-08-11 MRI - kidney, adrenals
  • Splenomegaly with compression on left kidney.
  • Focal T2 hyperintensity in the spleen, suspected splenic infarct.
  • Left pleural effusion.
• 2022-08-11 SONO - nephrology
  • bilateral chronic change of both kidneys.
• 2022-08-10 CXR
  • Bilateral parahilar infiltrates, suspected lung edema.
    
  • No cardiomegaly.
  • Intimal calcification of thoracic aorta.
  • Thoracic spondylosis.
• 2022-08-09 CT - abdomen
  • Splenomegaly with low attenuations.
  • Compression fracture of L1.
  • Tiny gallbladder stones.
• 2022-08-08 ECG
  • Normal sinus rhythm
  • Prolonged QT
  • Abnormal ECG
• 2022-08-03 Transrectal Ultrasound of Prostate, TRUS-P
  • benign prostatic hyperplasia
• 2022-06-01 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with myelodysplastic syndrom with myelodysplastic/myeloproliferative neoplasm transformation
  • The sections show hypercellular marrow (95%). Marked granulocytic proliferation with left shift in MPO stain. CD61+ megakaryocytes are increased and occasional atypical and small megakaryocytes are present. Decreased in number of CD71+ erythroid precursors. A few CD34+ blasts (2%) and scattered CD117+ immature cells (15%) in paratrabecular and interstitial areas. The finding is compatible with MDS with myelodysplastic/myeloproliferative neoplasm transformation. Suggest bone marrow smear evaluation and clinic correlation.
• 2022-05-31 CT - abdomen
  • Splenomegaly with low attenuations suspected infarcts.
  • Some LNs (up to 1.5cm) at bil. inguinal regions.
  • Compression fracture of L1.
  • Tiny gallbladder stones.
• 2022-05-31 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (149 - 49) / 149 = 67.11%
    • M-mode (Teichholz) = 67
  • Gr I LV diastolic dysfunction and impaired RV relaxation.
  • Dilated LV with normal LV and RV systolic function.
  • Aortic valve sclerosis; mild MR; mild PR.
  • Mildly dilated aortic root with mild calcification.
• 2022-05-30 KUB
  • Increased density of left abdomen.
  • Compression fracture of L1.
• 2022-04-09 X Ray
  • Rt 7th-9th ribs fracture
• 2022-03-07 Patho - bone marrow biospy
  • Bone marrow, iliac, biopsy — hypercellular marrow.
  • IHC stains: CD117: <2 %; CD34: <2 %; MPO: 60-70 %, CD61: 5 %; CD71: 15-20 % (of the nucleated cells).
  • Section shows piece(s) of bone marrow with 100 % cellularity and M:E ratio of approximately 4-5:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number with mild nuclear atypia. IHC stains: CD117: ＜2 %; CD34: ＜2 %; MPO: 60-70 %, CD61: 5 %; CD71: 15-20 % (of the nucleated cells). The findings are compatible with myelodysplastic syndrome.
• 2022-03-04 ECG
  • Normal sinus rhythm
  • Prolonged QT
  • Abnormal ECG
• 2021-12-06 CT - brain
  • Swelling of left parietal scalp.
  • A soft tissue nodule (1.2cm) at right parotid region.
  • Fat tissue at right deep neck.
• 2021-12-06 CXR
  • Nasogastric tube in place, proper position
  • Consolidation in Rt lung, in regression as compared with the previous image
  • Elevation of both hemidiaphragms
  • Right internal jugular venous catheter with tip in the SVC
• 2021-11-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (133 - 54) / 133 = 59.34%
    • M-mode (Teichholz) = 58
  • Adequate LV systolic function with normal resting wall motion
  • Dilated LA, septal hypertrophy; impaired LV systolic function
  • Trivial MR adn trivial TR
  • Preserved RV systolic function
• 2021-09-23 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Hypercellular marrow, favor myelodysplastic syndrome
  • The sections show hypercellular marrow (80%). M/E ratio = 5:1 in MPO and CD71 stains. The erythoid precursors are dispersed and scattered. The myeloid cells show left shift with neutrophilia. The CD61+ megakaryocytes are increased in number and occasional abnormal and small megakaryocytes are present. Slightly increased CD34+ and/or CD117+ blasts, accout for 3% of marrow cells. Myelodysplastic syndrom can be considered. Suggest further bone marrow smear evaluation and clinic correlation.
• 2021-09-23 CT - liver, spleen, biliary duct, pancreas
  • Splenomegaly.

[chemoimmunotherapy]

• 2023-05-10 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
• 2023-03-28 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
• 2023-02-27 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
• 2023-01-30 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
• 2022-12-26 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
• 2022-11-25 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7

2023-05-10

[assessment]

• The patient’s reliance on blood transfusions to maintain HGB and PLT levels is a critical aspect of his clinical history and care. The levels of both HGB and PLT have been consistently below the lower limit of normal since 2021, according to available laboratory data in HIS5.
• Anemia and thrombocytopenia are present prior to the initiation of azacitidine treatment, suggesting that these conditions are unlikely to be due solely to the drug. However, azacitidine may exacerbate these conditions because it can cause myelosuppression.
• The most update PLT level on 2023-05-09 was 21K/uL. In circumstances where the PLT count dips below 25K/uL, a dose reduction of 50% for the upcoming treatment cycle is typically recommended.

2023-03-28

[assessment]

• The patient’s serum creatinine level has remained below 2mg/dl until late March 2023, and there is currently an obvious upward trend in the level.

  • 2023-03-27 Creatinine 2.52 mg/dL
    
  • 2023-03-24 Creatinine 2.21 mg/dL
    
  • 2023-03-20 Creatinine 1.95 mg/dL
    
  • 2023-03-16 Creatinine 1.71 mg/dL

• Deferasirox can cause acute renal failure and death, particularly in patients with comorbidities and those who are in the advanced stages of their hematologic disorders. Deferasirox is contraindicated in patients with eGFR less than 40mL/min/1.73m2.

  • 2023-03-27 eGFR 26.95
    
  • 2023-03-24 eGFR 31.35
    
  • 2023-03-20 eGFR 36.22
    
  • 2023-03-16 eGFR 42.15

• Other iron chelators are available in the market, but this hospital does not procure deferiprone and deferoxamine is currently out of stock.

• To prioritize kidney function over iron overload, an alternative option could be to reduce or hold the dose of deferasirox to prevent the serum creatinine from exceeding 2mg/dL. (eGFR 40 to 60 mL/minute/1.73m2: Reduce initial deferasirox dose by 50%. ref: UpToDate)

2023-03-01

[assessment]

• Transfusional iron overload occurs when transfusions are given for anemia not caused by iron deficiency. Despite the administration of Jadenu (deferasirox) since early December 2022, the patient’s ferritin level has been consistently fluctuating at a high level since that time.

  • 2023-02-24 Ferritin (NM) 2013.24 ng/ml
    
  • 2023-02-21 Ferritin (NM) 1844.19 ng/ml
    
  • 2023-01-05 Ferritin (NM) 1838.62 ng/ml
    
  • 2022-12-16 Ferritin (NM) 2051.18 ng/ml
    
  • 2022-12-01 Ferritin 1554.2 ng/mL
    
  • 2022-08-13 Ferritin 694.9 ng/mL

• Vidaza (azacitidine) to treat MDS: Subsequent cycles 75 mg/m2/day for 7 days every 4 weeks; dose may be increased to 100 mg/m2/day if no benefit is observed after 2 cycles and no toxicity other than nausea and vomiting have occurred. Patients should be treated for a minimum of 4 to 6 cycles; treatment may be continued as long as patient continues to benefit.

• Since the patient has been admitted to receive his 4th cycle of azacitidine during this hospitalization, it would be appropriate to evaluate the effectiveness of the treatment in the next few follow-up visits.

2022-12-23

[assessment]

• Lab data (2022-12-23) showed low HGB (8.4g/dL, grade 3) and PLT (33K/uL, grade 3). Jadenu (deferasirox) 360mg PO DQAC is applied to lower the excess iron storage in this patient following times of LPRBC transfusion.
• Since September 20, 2022, Feburic (febuxostat 80mg) has been successful in lowering the patient’s serum uric acid. Rare excess ULN events have been observed since then. The recommended initial dose of febuxostat is 40 mg once daily, as the patient is senior aged, his hyperuricemia has been well-controlled, and his renal function readings are outside the normal limits, it is recommended to adjust the febuxostat dose to 40mg QD.
• It appears that Allegra (fexofenadine), Feburic (febuxostat), Jadenu (deferasirox), Smecta (dioctahedral smectite), Stogamet (cimetidine), Utapine (quetiapine) have been prescribed twice (one of each drug marked as a self-carried item). Please confirm the need for multiple prescriptions.

2022-11-28

[assessment]

• 2022-11-25 albumin 3.2g/dL. The patient is receiving azacitidine for the first time. In a study, it was suggested that the use of azacitidine is not recommended when albumin levels are lower than 3 g/dL. (ref: Dose recommendations for anticancer drugs in patients with renal or hepatic impairment. Lancet Oncol. 2019;20(4):e200-e207. doi:10.1016/S1470-2045(19)30145-7). A closer monitor might be necessary.

2022-09-30

[assessment]

• Allogeneic hematopoietic cell transplantation (HCT) is the treatment with the highest potential to cure MDS. However, because of advanced age, comorbid conditions, lack of adequately matched donors, and/or patient preferences, only a small subset of patients with MDS are candidates for allogeneic HCT.
• Ferritin 694.9ng/mL (2022-08-13, normal 23.9~336.2). A high level of iron in the blood might lead to hemochromatosis. The clinical manifestations of iron overload can be influenced by the amount of tissue iron and the presence of other conditions that lead to organ dysfunction. Cardiac iron overload can lead to the following complications: dilated cardiomyopathy, diastolic dysfunction, heart failure, conduction disturbances, sinus node dysfunction. (NT-proBNP 14016 pg/mL 2022-09-28 <- 5491 pg/mL 2022-09-16)
• There is no further deterioration in kidney function during Sep 2022 as ceatinine remains around 1.5 mg/dL and eGFR remains around 45-50 mg/dL.

2022-03-04

[drug identification]

requesting drug identification for 2 items.

all the 2 items are identified as following…

• allegra (fexofenadine 60mg) - antiallergic agent, antihistamine, second generation
• orolisin (orotic acid 30mg + glycyrrhizinate extract 50mg + chlorpheniramine maleate 5mg) - antiallergic agent, antihistamine, second generation

these drugs will be sent back to ward by an in-hospital porter.

700072177

230509

[diagnosis] - 2023-05-08 admission note

• Adenocarcinoma of the low rectum just above dentate line, cT4aN2bM0, stage IIIC, status post concurrent chemoradiotherapy with 5-Fu from 2023/02/02 to 2023/03/09, s/p TNT chemotherapy with FOLFOX from 2023/03/24
• Squamous cell carcinoma of left lower lip, cT2N0M0, stage II
• Constipation, unspecified

[MedRec]

• 2023-01-12 SOAP Colorectal Surgery
  • Assessment: Suggest neoadjuvant chemotherapy Favor TNT then restaging, Consider observation if cCR or local excision (TAMIS) for sphincter preserving.
• 2023-01-11 SOAP Radiation Oncology
  • A:
    • Squamous cell carcinoma of the left buccal to lip commissure area, stage T4aN0M0, s/p induction chemotherapy, and s/p CCRT.
    • Adenocarcinoma of the low rectum just above dentate line, stage cT4aN2bM0(IIIC)
  • P:
    • Radiotherapy is indicated for this patient with the following indicators: Adenocarcinoma of the low rectum just above dentate line, stage cT4aN2bM0(IIIC)
      • Goal: curative
      • Treatment target and volume: pelvic including low rectal tumor.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-02-01.
• 2023-01-11 SOAP Hemato-Oncology
  • O
    • 2022/12/19 PATHO - Colon biopsy: Colorectum, low rectum just above dentate line, (3 cm from anal verge), Biopsy. Specimen: B — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • 2023/01/05 CT: ABD: T:T4a(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • P
    • Arrange PET-CT
    • Refer to CRS for surgical evaluation
    • Refer to RTO for CCRT
    • Arrange admisson for CCRT

[radiotherapy]

• 2023-02-02 ~ 2023-03-14 - 4500cGy/25 fractions (15MV photon) of the pelvic, and 5040cGy/28 ractions of the rectal tumor bed area.
• 2018-03-20 ~ 2018-05-08 - 5000cGy/25 ractions (6MV photon) of the bilateral neck, 6000cGy/30 fractions of the left buccal to lip commissure tumor, and 7000cGy/35 fractions of the reduced left buccal to lip commissure tumor bed.

[chemotherapy]

• 2023-05-08 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
• 2023-04-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 400mg/m2 730mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
• 2023-03-24 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 400mg/m2 730mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
• 2023-03-03 - fluorouracil 225mg/m2 420mg NS 100mL D1-4 (CCRT)
  • none
• 2023-02-13 - fluorouracil 225mg/m2 420mg NS 100mL D1-4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-02-09 - fluorouracil 225mg/m2 420mg NS 100mL D1-2 (CCRT)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2
• 2020-04-23 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1900mg leucovorin 100mg/m2 190mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-04-16 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1900mg leucovorin 100mg/m2 190mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-04-02 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 1900mg leucovorin 100mg/m2 190mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-03-27 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg leucovorin 100mg/m2 200mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-03-13 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg leucovorin 100mg/m2 200mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2020-03-06 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg leucovorin 100mg/m2 200mg NS 1000mL 22hr (TPFL Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

[assessment]

• On 2023-01-12, the PET scan showed no significant abnormal focal FDG uptake elsewhere except in the rectum with two regional lymph nodes and an old lesion in the left buccal region. The patient has been treated with TNT for rectal cancer. CCRT with FU was performed in February and March of 2023. The patient is currently being treated with the FOLFOX regimen.
• According to PharmaCloud records, all recent medications were prescribed at our hospital and no medication reconciliation issues were identified.

700536063

230509

[diagnosis] - 2023-03-23 admission note

• Adenocarcinoma of gastric antrum, pT3N1 (1/48) M0, Stage IIB, s/p Op.
• Diabetes mellitus, type 2
• Hypertension
• Viral hepatitis B anti-Hbc: positive

[past history]

• medical
  • Anemia
  • Diabetes mellitus, type 2
  • Hypertension
• operation
  • Gallballder stones status post laparoscopic cholecystectomy on 2022/02/14

[allergy]

• NKDA                                         

[family history]

• Father had history of hypertension, colo-rectal cancer
• No members of the family with diabetes.

[exam findings]

• 2023-02-01 CT - abdomen
  • History: General fatigue for months, poor appetite ++, epigastric discomfort +, Anemia (Hb 8.2), stool: OB 4+
    • 20220622 gastroscopy: One raised and nodularity mucosa lesion with clean base ulcer was noted at LC site of low body to antrum, suspected cancer, s/p biopsy. Patho: adenocarcinoma.
    • 20220629 CT：gastric antrum cancer, cT3N1M0, cSTAGE:III
    • 20220711 S/P subtotal gastrectomy:pT3N1 (1/48) M0, Stage IIB
  • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • S/P subtotal gastrectomy and S/P cholecystectomy.
    • Prior CT identified Adenoma or hyperplasia 1.2 cm in left adrenal gland is noted again, stationary.
    • A renal cyst 1.5 cm in right middle-lower pole is noted.
  • Impression:
    • There is no evidence of tumor recurrence.
• 2022-09-28 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis with scoliosis of the T-spine with convex to right side
• 2022-07-12 Patho - stomach subtotal/total (tumor)
  • pathologic diagnosis
    • Stomach, subtotal gastrectomy — Tubular adenocarcinoma, poorly differentiated
    • Margins, bilateral cutting ends, subtotal gasdtrectomy — Free of tumor invasion
    • Lymph nodes, D2 LN dissection — Metastatic adenocarcinoma (1/48)
    • Omentum, omentectomy — Free of tumor invasion
    • AJCC Pathologic staging — pT3N1 (if cM0), stage IIB
  • microscopic examination
    • Histologic type: Tubular adenocarcinoma (Lauren classification: intestinal type)
    • Histologic grade: Poorly differentiation (G3)
    • Depth of tumor invasion: Tumor invades the subserosa
    • Margins: All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin: 1 mm from radial margin
    • Perineural invasion: Present
    • Lymphovascular space invasion: Absent
    • Regional lymph nodes: Metastatic adenocarcinoma (1/48)
      • 0/3 (omentum), 0/5 (LN 1), 1/8 (LN 3), 0/10 (LN 4), 0/2 (LN 5), 0/5 (LN 6), 0/15 (LN 7, 8, 9, 11p), 0 (LN 12a), 0 (LN14v) (Number of LN involved/Number of LN examined) 3
    • Extracapsular extension: Absent
    • Omentum: free of tumor invasion
    • Additional pathologic findings: Helicobacter-associated non-atrophic chronic gastritis
    • Pathologic Staging: pT3N1, stage IIB, if cM0
    • IHC: HER2 (Negative, score= 1+)
• 2022-07-07 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (118 - 43) / 118 = 63.56%
    • M-mode (Teichholz) = 63
  • Adequate LV systolic function with normal resting wall motion
  • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
  • Mild MR and trivial TR
  • Preserved RV systolic function
• 2022-07-05 ECG
  • Sinus tachycardia
  • Septal infarct, age undetermined
• 2022-06-29 CT
  • History: General fatigue for months, poor appetite ++, epigastric discomfort +, Anemia (Hb 8.2), stool: OB 4+
    • 20220622 gastroscopy: One raised and nodularity mucosa lesion with clean base ulcer was noted at LC site of low body to antrum, suspected cancer, s/p biopsy. Patho: adenocarcinoma.
  • Indication: CT for gastric cancer staging
  • Findings:
    • There is lobulated wall thickening at the gastric low body and antrum, measuring 2.1 cm in wall thickness that is c/w adenocarcinoma (T3).
    • There are two lymph nodes in the gastrohepatic ligament that may be metastatic nodes (N1).
    • Adenoma 1.2 cm in left adrenal gland is suspected.
    • A renal cyst 1.5 cm in right middle-lower pole is noted.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3 (T_value) N:N1 (N_value) M:M0 (M_value) STAGE:III(Stage_value)
• 2022-06-22 Patho - stomach biopsy
  • Stomach, angle to LC site of antrum, biopsy — Adenocarcinoma
  • Microscopically, the sections show a picture of adenocarcinoma, poorly differentiated, characterized by tumor cells arranged in crowded nest or tubular pattern with enlarged and hyperchromatic nuclei infiltrating in ulcerative stroma with mild intestinal metaplasia.
  • Immunohistochemistry of CK(+), P53(+) and Her2/neu (2+, equivocal) for tumor.
• 2022-06-22 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • Gastric mucosa lesion with ulcer, LC site of low body to antrum, s/p biopsy, suspected gastric cancer
    • Duodenal ulcer scar, bulb, AW site
  • Suggestion
    • PPI use
    • Pursue CLO test and biopsy result
• 2022-02-14 Patho - gallbladder (benign lesion)
  • Gallbladder, laparoscopic cholecystectomy — Chronic cholecystitis and cholelithiasis
• 2022-02-11 SONO - abdomen
  • Diagnosis
    • Fatty liver, moderate
    • Suspected fatty infiltration of pancreas
    • Propable GB stones
    • Heterogeneous echogenecity in somach and duodenum area(?). Please correlate with EGD
    • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
  • Suggestion
    • OPD f/u
    • Follow liver function test and AFP
    • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
    • Because of poor echo window,infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months

[consultation]

• 2022-10-17 Cardiology
  • Q
    • The 67 y/o woman has gastric cancer, stage IIB. She was admitted for chemotherapy. She regular take anti-hypertension from CV OPD. We need your help for hypertension assessment. Thanks!
  • A
    • This is a 67 years old lady who has gastric cancer for chemotherapy with FOLFOX (self-paid) IV Q2W x 12 on 20221017.
    • He recieved sevkiar and natrilix at CV OPD for BPcontrol.        
    • BP on 20221017
      • 192/ 94
      • 205/107
      • 211/115
      • 226/105
      • 141/ 82
    • Cardiac echo 2020/07/07
      • Echo EF: 63%
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
      • Mild MR and trivial TR
      • Preserved RV systolic function
    • EKG: 20220705 sinus tachycardia
    • CXR 20220928 no cardiomegaly
    • echocardiogram 20220707
      • Findings:
        • AO(mm) = 31; LA(mm) = 42;
        • IVS(mm) = 12; LVPW(mm) = 9;
        • LVEDD(mm) = 50; LVESD(mm) = 32;
        • LV mass(gm) = 201;
        • TAPSE(mm) = 27;
        • M-mode(Teichholz) = 63
        • TR: Trivial; Max pressure gradient = 27 mmHg
        • E/A ratio = 0.6
        • IVC size 14 mm with respiratory collapse > 50%
      • Conclusion:
        • Adequate LV systolic function with normal resting wall motion
        • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
        • Mild MR and trivial TR
        • Preserved RV systolic function
    • Impression
      • Hypertensive cardiovascular disease.
    • Suggestion
      • Keep sevikar + natrilix as OPD
      • Might add norvasc 1# qd and hydralazine 1# prn-Q8h if SBP > 160mmhg
        
      • If still poor control, add nebivolol 1# qd
      • Watch sleeping condition or pain status
• 2022-07-20 Hemato-Oncology
  • Q
    • This 66-year-old female had history of
      • Anemia
      • Diabetes mellitus, type 2
      • Hypertension
    • She was a case of Adenocarcinoma of gastric antrum, poorly differentiated, cT3N1M0
    • Laparoscopic subtotal gastrectomy, D2 LN dissection with B-II gastrojejunostomy anastomosis was done on 20220711
    • Pathology revealed
      • Stomach, subtotal gastrectomy — Tubular adenocarcinoma, poorly differentiated (G3)
        • Tumor site: Antrum, lesser curvature, 3.2 cm from distal margin
        • Tumor size: 6.1 x 4.8 cm
      • Margins, bilateral cutting ends, subtotal gasdtrectomy — Free of tumor invasion
      • Lymph nodes, D2 LN dissection — Metastatic adenocarcinoma (1/48), LN3
      • Omentum, omentectomy — Free of tumor invasion
      • AJCC Pathologic staging — pT3N1 (if cM0), stage IIB
    • We need your expertise for post-op chemotherapy +/- radiotherapy
  • A
    • Impression:
      • Adenocarcinoma of gastric antrum s/p Radical subtotal gastrectomy with D2 LN dissection on 20220711, pT3N1M0, stage IIB, pathology show tubular adenocarcinoma, poorly differentiated(G3), HER-2 negative
      • Diabetes mellitus, type 2
      • Hypertension
    • Suggestion:
      • Postoperative chemotherapy is recommended following primary D2 lymph node dissection (Capecitabine and oxaliplatin (category 1) or Fluorouracil and oxaliplatin)
      • Arrange port A insertion and arrange our OPD after discharge
      • Please check HbsAg, Anti Hbc, Anti HCV
    • PostOperative Chemotherapy (for patients who have undergone primary D2 lymph node dissection)
      • Capecitabine and oxaliplatin
        • Capecitabine 1000 mg/m2 PO BID on Days 1–14
        • Oxaliplatin 130 mg/m2 IV on Day 1
        • Cycled every 21 days for 8 cycles
      • Fluoropyrimidine and oxaliplatin
        • 1
          • Oxaliplatin 85 mg/m2 IV on Day 1
          • Leucovorin 400 mg/m2 IV on Day 1
          • Fluorouracil 400 mg/m2 IV Push on Day 1
          • Fluorouracil 1200 mg/m2 IV continuous infusion over 24 hours daily on Days 1 and 2
          • Cycled every 14 days
        • 2
          • Oxaliplatin 85 mg/m2 IV on Day 1
          • Leucovorin 200 mg/m2 IV on Day 1
          • Fluorouracil 2600 mg/m2 IV continuous infusion over 24 hours on Day 1
          • Cycled every 14 days

[surgical operation]

• 2022-07-11
  • Surgery
    • Radical subtotal gastrectomy with D2 LN dissection
  • Finding
    • 7 * 5 cm ulcerative mass at lesser curvature of antrum
    • Previous cholecytectomy
    • Omentum adhension
  • Procedure
    • ETGA
    • 12-12-5-3.5 mm trocars
    • Adhesiolysis
    • subtotal gastrectomy with 1,3,4,5,6,7,8,9,11p,12a,14v LN dissection
    • Frozen section : margin free of carcinoma
    • GJ B-II anastomosis with EndoGIA
    • two J-vac inserted
    • wound closed
• 2022-02-14
  • Surgery
    • LC
  • Finding
    • two 1.2cm pigment stones iwth chroinc inflam
  • Procedure
    • ETGA
    • 10-5-3.5 mm trocars
    • cholecystectomy
    • wound closed

[radiotherapy]

• 2022-10-31 ~ 2022-12-02 - completed RT to the stomach and adjacent lymphatic drainage area: 45 Gy/ 25 fx.

[chemotherapy]

• 2023-05-08 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4695mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-12 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-23 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-07 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-20 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-20 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL + fluorouracil 2800mg/m2 4670mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
• 2022-11-28 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-5 (CCRT QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-11-24 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-5 (CCRT QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-11-07 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-5 (CCRT QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-11-02 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-3 (CCRT QW)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-10-18 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4685mg 46hr
• 2022-09-26 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4715mg 46hr
• 2022-09-12 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4715mg 46hr
• 2022-08-29 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
• 2022-08-15 - oxaliplatin 70mg/m2 100mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr

230308

[assessment]

• The patient’s underlying diabetes mellitus is well controlled. However, on admission to the hospital, her systolic blood pressure was found to be over 200 mmHg. Her current blood pressure is 142/65 mmHg.
• Based on the lab data resulted on 2023-03-23, the patient’s results were generally within normal limits. In addition, no medication reconciliation issues were noted for the patient.

221125

[assessment]

• The results of the laboratory test on 2022-11-24 were generally normal.
• A pre-prandial blood sugar level was recorded as 181 mg/dL (2022-11-25 07:20) this morning. It might be necessary to consider additional anti-diabetic agents if the reading persists high (> 180 mg/dL) for two consecutive days.
• Around the ULN, blood pressure fluctuates up and down. Please keep a close eye on the reading as always.

220913

[assessment]

• The underlying conditions of HTN and T2DM were treated with the patient-carried medications Natrilix (indapamide), Sevikar (amlodipine + olmesartan) and Xigdou (dapagliflozin + metformin) without extremely outlier findings during this hospitalization.
• The results of the laboratory test on 2022-09-12 were grossly normal.

220816

[assessment]

• As there is no fluorouracil bolus used in the current chemotherapy regimen, the dose of leucovorin may be reduced to 200mg/m2.

700598723

230509

{not completed}

[MedRec]

• 2023-03-02 SOAP Hemato-Oncology
  • A/P
    • Ovary, left, left salpigo-oophorectomy (20230220) — pT1c2 pN0 (if cM0); pStage: IC; FIGO stage: IC2 with clear cell component
    • Her sister worked in another hospital.
• 2023-02-17 SOAP Obstetrics and Gynecology
  • S
    • a case of ovarian endometiroid adenocarcinoma, s/p LSC LSO + pelvic adhesion lysis + TCR-P on 2023/02/09
  • O
    • Cancer Multidisciplinary Team Meeting Conclusion, meeting date: 20230216
      • Postoperative adjuvant chemotherapy (referred to hematoma department Dr. Wan Xianglin / patient expressed desire to preserve fertility).
      • Consensus on the period: pT1c2N0M0, FIGO IC2. -> Suggest staging/debulking surgery due to pathology revealing clear cell carcinoma.

[chemotherapy]

• 2023-05-08 - paclitaxel 70mg/m2 100mg NS 250mL 1hr + carboplatin AUC 2 565mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-04-07 - paclitaxel 70mg/m2 100mg NS 250mL 1hr + carboplatin AUC 2 565mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-14 - paclitaxel 70mg/m2 100mg NS 250mL 1hr + carboplatin AUC 2 565mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[assessment]

• Prior to the current chemotherapy session, WBC counts were observed to decrease approximately one week after the previous two sessions on 2023-03-14 and 2023-04-07, with levels dropping to 3.07K/uL on 2023-03-21 and 2.68K/uL on 2023-04-14. Given these observations, it is reasonable to anticipate potential leukopenia following this current session, which should be noted.
  • 2023-05-08 WBC 3.50 x10^3/uL
    
  • 2023-04-14 WBC 2.68 x10^3/uL
    
  • 2023-04-06 WBC 3.83 x10^3/uL
    
  • 2023-03-21 WBC 3.07 x10^3/uL
    
  • 2023-03-12 WBC 4.21 x10^3/uL
    
  • 2023-02-27 WBC 3.33 x10^3/uL
    
  • 2023-02-24 WBC 5.97 x10^3/uL
• According to PharmaCloud records, all recent medications were prescribed at our hospital and no medication reconciliation issues were identified.

701457374

230509

[MedRec]

• 2023-04-27 ~ 2023-05-08 POMR Oral and Maxillofacial Surgery
  • Inpatient Treatment Process
    • Nasopharynx MRI showed squamous cell carcinoma of right tongue and floor of mouth with lymph node metastasis cT4bN3bM0 stage IVb.
    • His treatment plans were palliative chemotherapy followed by salvage surgeries.
    • lntraoral wound change dressing qd. Oral intake with clear liquid diet because of patient refused N-G placement.
    • Systemic antibiotic with Cefa 1g Q8H IV for infection control.
    • He finished modified induction chemotherapy with #1a 80% TPF (Taxotere 32mg/M2, Cisplatin 32mg/M2, 5-Fu 800mg/M2 plus Leucovorin 80mg/M2, MTX 24mg/M2) on 2023/05/3-2023/05/06.
    • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Zinga 1 tab PO QD for zinc supplement, B-Red 1 mg IVD QD for hematogenesis, Magnesium Sulfate 10% 20 mL IVD QD for hypomagnesemia.
  • Prescription
    • Actein (acetylcysteine 600mg) 1# BID
    • Acetal (acetaminophen 500mg) 1# PRNQ6H (if pain)
    • Zinga (zinc gluconate 78mg) 1# QD
    • Foliromin (ferrous sodium citrate 50mg) 1# BID
    • loperamide 2mg 2# PRNQ8H (if diarrhea >= 4 times)
    • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC (if vomit)
• 2023-04-25 SOAP Oral and Maxillofacial Surgery
  • S: The patient has been missing for 4 months
    • Body: Apart from oral cancer, there are no other systemic diseases,
    • Mind: The patient is not anxious
    • Spirit: No specific beliefs
    • Social: Family’s financial situation is poor (rent is about 30,000, high stress), very thin
  • A: SCC of right tongue (cT3N2bM0) with local inflammation (now progressed to T4bN3bMx)
• 2022-12-22 ~ 2022-12-26 POMR Oral and Maxillofacial Surgery
  • Inpatient Treatment Process
    • After admission, we had arranged physcial examination which his ANC showed 3630/mm2.
    • Then we had arranged induction chemotherapy with #3b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) were delivered on 2022/12/22 - 2022/12/24.
    • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. No obvious of discomfort were noted excepted mild mucositis of right buccal mucosa were noted.
• 2022-12-15 ~ 2022-12-19 POMR Oral and Maxillofacial Surgery
  • Inpatient Treatment Process
    • After admission, we had arranged physcial examination for him which ANC showed 2901/mm2.
    • Then we had arrange induction chemotherapy with #3a TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) were delivered on 2022/12/15 - 2022/12/17.
    • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Intraoral wound change dressing qd. Mouth care and cool soft diet were educated.
  • Prescription
    • Smecta (dioctahedral smectite 3mg) 1# PRNBID (if watery diarrhea > 3 times)
    • Acetal (acetaminophen 500mg) 1# Q8H (if pain)
    • amoxicillin 250mg 2# Q8H
• 2022-11-28 ~ 2022-12-03 POMR Oral and Maxillofacial Surgery
  • Inpatient Treatment Process
    • After admission, we had arranged physcial examination for him which ANC showed 3351/mm2.
    • Then we had arrange induction chemotherapy with #2b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/28 - 2022/11/30.
    • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Radi-K 2 tab PO TID for prevent hypokalemia. Zinga 1 tab  PO  QD for zinc supplement. Folina 15mg 1 tab PO QD for hematogenesis. B-Red 1 mg IVD  QD for hematogenesis. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
• 2022-11-21 ~ 2022-11-25 POMR Oral and Maxillofacial Surgery
  • Inpatient Treatment Process
    • After admission, we had arranged physcial examination for him which ANC showed 3769/mm2. Empirical antibiotic agents with Cefa 1g Q8H IV was prescribed. Then we had arrange induction chemotherapy with #2a TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/21 - 2022/11/23.
    • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
  • Prescription
    • Strocain (oxethazaine, polymigel 5mg) 1# TIDAC
    • Zinga (zinc gluconate 78mg) 1# QD
    • Folina (folinate 15mg) 1# QD
    • Eurodin (estazolam 2mg) 1# PRNHS
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
• 2022-11-07 ~ 2022-11-12 POMR Oral and Maxillofacial Surgery
  • Inpatient Treatment Process
    • After admission, we had arranged physcial examination for him which ANC showed 7918 /mm2. Empirical antibiotic agents with Cefa 1g Q8H IV was prescribed.
    • Then we had arrange induction chemotherapy with #1b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/07 - 2022/11/09.
    • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer.
    • Additional, hopeless tooth with local inflammation were noted, We had arranged extraction of 14 15 and curettage of the extraction socket under local anesthesia on 2022/11/11. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
  • Prescription
    • Acetal (acetaminophen 500mg) 1# Q6H
    • Eurodin (estazolam 2mg) 1# HS
    • amoxicillin 250mg 2# Q8H
    • Megest (megestrol 40mg/mL) 10mL BID
• 2022-10-24 ~ 2022-11-02 POMR Oral and Maxillofacial Surgery
  • Discharge diagnosis
    • Squamous cell carcinoma of right tongue cT4aN2bM0 stage IV in process chemotherapy
    • Malignant neoplasm of border of tongue
    • INFECTION OF TONGUE AND FLOOR OF MOUTH
    • Encounter for antineoplastic chemotherapy
    • HOPELESS CARIES OF MANY TEETH
  • CC
    • HE WAS ADMITTED BECAUSE HE HAD an ulcerative MALIGNANT mass at HIS right tongue for more than 6 weeks    
  • Illness
    • The local finding showed a BIG ulcerative malignant tumor WITH INDURATION AND LOCAL INFECTION at his right tongue border AND VENTRAL SURFACE with muscle invasion, about 5.0 cm in size. BESIDES, several palpate lymph nodes at the right neck are detected. After we had adequately explained the finding and treatment plans to the patient and his WIFE, he recided to accept our treatment plans for him. His treatment plans were induction chemotherapy follow by surgery and CCRT. Under the impression of squamous cell carcinoma of right tongue cT4aN2bM0 stage IV, he was admitted to ward for tumor work up and prepare induction chemotherapy.
  • Inpatient Treatment Process
    • The induction chemotherapy with TPF (Taxotere 40mg/M2, cisplatin 40mg/M2, 5-FU 1000mg/M2) were delivered on 10/28~10/30/2022. He did’t had nausea and vomiting after chemotherapy. Intraoral wound change dressing qd. Mouth care with Parmason solution q3h.
  • Prescription
    • Acetal (acetaminophen 500mg) 1# Q6H
    • Eurodin (estazolam 2mg) 1# HS
    • loperamide 2mg 1# ASORDER (if diarrhea > 4 times)
    • Promeran (metoclopramide 3.84mg) PRNTIDAC (if N/V)
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
• 2022-10-21 SOAP Oral and Maxillofacial Surgery
  • S
    • He came to our OS OPD for help because is a tongue cancer patient who had been proved in ShuangHe Hospital ENT.
  • O
    • An ulcerative SCC with local inflammation at the right tongue border with muscle invasion, about 4.0 cm in size, is noted. several palpate lymph nodes at the right neck are detected. many hopeless caries are noted. edntulous ridge of mandible was noted. gingivitis and gingival recession of residual teeth are noted. no crown, no bridges and no wisdom teeth are noted.
  • A
    • SCC of right tongue (cT3N2bM0) with local inflammation
  • P
    • Panoramic film showed no bone destruction by tumor. periodontal bone loss is noted.
    • explain the finding and treatment plan to the patient.
    • debridement and cruettage at the right tongue border to remove food debris and necrotic tissue.
    • amoxilline + scanol to control pain and infection.
    • arragne admission for further treatment

[chemotherapy]

• 2023-05-03 - docetaxel 32mg/m2 50mg NS 100mL 1hr + cisplatin 32mg/m2 NS 150mL 3hr + fluorouracil 800mg/m2 1200mg leucovorin 80mg/m2 120mg NS 1000mL 22hr D2 + methotrexate 24mg/m2 35mg NS 100mL 30min D4
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
• 2022-12-22 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-12-15 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-11-28 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-11-21 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-11-07 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-10-28 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

[assessment]

• The patient’s weight dropped dramatically from 57kg on 2023-04-25 to 48kg on 2023-05-03, a loss of 9 kilograms in just 8 days. This significant weight loss could be due to a data entry error or rounding inconsistencies, as the patient had a lapse in follow-up between late December 2022 and late April 2023.
• Even as early as November 2022, there was a need to enhance the patient’s appetite (megestrol was prescribed at discharge on 2022-11-12). As of the most recent chemotherapy session on 2023-05-03, the same regimen was used but the dose was reduced to 80% of the original. It seems unlikely that the recent chemotherapy is the sole culprit for the patient’s severe weight loss.
• If the patient is still able to consume food orally, it would be advisable to reintroduce megestrol to help stimulate his appetite. This may potentially help to counteract the significant weight loss he has been experiencing.

701470089

230509

[lab data]

• 2023-03-03 Anti-HBc Reactive
  
• 2023-03-03 Anti-HBc-Value 6.75 S/CO
  
• 2023-03-03 Anti-HBs 68.82 mIU/mL
  
• 2023-03-03 HBsAg Nonreactive
  
• 2023-03-03 HBsAg (Value) 0.39 S/CO
  
• 2023-03-03 Anti-HCV Nonreactive
  
• 2023-03-03 Anti-HCV Value 0.09 S/CO
  
• 2023-02-16 MTBC PCR NOT DETECTED CFU/ml
  
• 2023-02-16 MTBC PCR Value <11.8 CFU/ml

[exam findings]

• 2023-04-29 MRI - L-spine
  • Indication: Squamous cell carcinoma of upper to lower third esophagus with bilateral lung and bone metastasis, cT3N3M1, stage IVB. This time, lower back pain for 1 week
  • Thoraco-lumbar spine MRI without and with IV Gd-DTPA administration shows:
    • Abnormal thick nerve roots and the filum terminale.
    • After IV contrast administration shows well nodular like enhancement along those nerve roots.
    • A small right SI joint lesion, nature?
    • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression at L4/5/S1.
  • IMP: Highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis. No obvious lumbar spine bone destructing lesion. A small right SI joint lesion, metastasis?
• 2023-04-27 ECG
  • Decreased disc height at L5/S1 is found.
  • Phlebolith at pelvic cavity is also found.
• 2023-03-27 CXR
  • Fibrosis of right and left upper lung are suspected.
• 2023-03-06 Pure Tone Audiometry
  • PTA:
  • Reliability FAIR
  • Average RE 14 dB HL, LE 15 dB HL
  • bil WNL
• 2023-02-13 CXR
  • widening of Lt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
• 2023-02-11 MRI - brain
  • No evidence of intracranial lesion.
• 2023-02-10 Patho - esophageal biopsy
  • Ulcerative lesion, 19-33 cm below the incisors, biopsy — Squamous cell carcinoma
  • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated characterized by solid tumor nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the stroma without keratin formation and ulcer with necrotic debris.
  • Immunohistochemistry of CK(+), P63(+) and P16(-) for tumor
• 2023-02-10 SONO - abdomen
  • Suspected liver hemangioma, three
  • Renal stones, both kidney
  • Renal cyst, right kidney
• 2023-02-10 Miniprobe Endoscopic Ultrasound
  • Highly suspected esophageal cancer, s/p biopsy*6
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
• 2023-02-09 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a faint hot spot in the posterior aspect of right rib cage and increased activity in some middle T-spines, right 9th costovertebral junction, right S-I joint and greater trochanter of right femur in whole body survey.
  • IMPRESSION:
    • Increased activity in some middle T-spines, right 9th costovertebral junction and right S-I joint. Bone metastases should be watched out. Please correlate with other imaging modalities for further evaluation.
    • A faint hot spot in the posterior aspect of right rib cage and mildly increased activity in the greater trochanter of right femur. The nature is to be determined (post-traumatic change? bone metastases?). Please follow up bone scan for further evaluation.
• 2023-02-08 PET scan
  • Glucose-hypermetabolism in the upper to middle esophagus, compatible with the primary esophageal cancer.
    
  • Glucose-hypermetabolism in bilateral SCF lymph nodes and bilateral pulmonary hilar and mediastinal lymph nodes, highly suspected cancer with regional lymph nodes metastases.
    
  • Glucose-hypermetabolism in the left axillary lymph nodes, probably reactive nodes.
    
  • Glucose-hypermetabolism in bilateral lungs and skeleton including T5, T6 spines, right 9th costovertebral junction, and right iliac bone, highly suspected cancer with distant metastases.
    
  • Esophageal cancer with regional lymph nodes, bilateral lungs and multiple bones metastases, cTxN3M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-02-08 Nasopharyngoscopy
  • Findings:
    • smooth NPx, OPx, HPx, mild saliva pooling at Hpx, left vocal palsy at paramedian position, congested
  • Diagnosis/conclusion
    • L vocal palsy, related to esophageal ca
• 2023-02-07 Bronchoscopy
  • Abnormal Tracheal mucosa infiltration due to esophageal cancer invades
• 2023-02-04 CT - chest
  • Indication: esophageal cancer
  • MDCT (80-detector rows, Aquilion Prime SP, was performed with 2.5 mm lung window, 5 mm soft-tissue window slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Diffuse ground glass patches at both lungs is found.
      • Diffuse wall thickening at upper third esophagus is found about 8.5cm*1.2 in length and width.
      • Enlaged lymph nodes (n>8) are found around the main mass.
      • No evidence of bilateral pleural effusion.
      • Multiple round solid nodules (each about 0.6cm) scattered in both lungs, favor lung metastases.
    • Visible abdomen:
      • Bilateral renal stones are found.
      • The spleen, pancreas and adrenals are intact.
      • Low density lesion at liver surface measuring 1.7cm is found. Hemangioma is favored.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
    • Suggest clinical correlation
  • IMP:
    • Long segmental wall thickening at upper third esophagus, with bilateral lung nodules. Esophageal cancer with bilateral lung metastases is considered.
    • Diffuse ground glass pacthes at both lungs. Previous repeated inflammation is considered.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M1(M_value) STAGE:IV__(Stage_value)

[consultation]

• 2023-05-02 Radiation Oncology
  • Q
    • Progression lower back pain for 1 week. Fall developed on 2023/04/24. Lspine MRI on 2023/04/29 showed highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis. No obvious lumbar spine bone destructing lesion. A small right SI joint lesion, metastasis? Now, for evaluate palliative radiotherapy to L spine. Thank you.
  • A
    • This 52-year-old man patient is a case of Squamous cell carcinoma of upper to lower third esophagus with bilateral lung and bone metastasis, cT3N3M1, s/p CCRT.
    • Progression lower back pain for 1 week. Fall developed on 2023/04/24. Lspine MRI on 2023/04/29 showed highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis.
    • Palliative RT is indicated. CT-simulation will be arranged on 2023-05-10. Plan to deliver 30 Gy/ 10 fx to the L-spine and partial S-I joint (at least the Rt side metastatic lesion shown on PET). RT will start around 2023-05-11. Thank you very much.
• 2023-02-11 Hemato-Oncology
  • A
    • This 52 year old man is a case of esophagus squamous cell carcinoma with lung metastasis, cT3N3M1, stage IV (initial presentation was hoarseness for 3 months and dysphagia with body weight loss). He had been admitted to HsinChu Cathay Hospital on 2023/01/30, where Panendoscope on 2023/01/31 showed esophageal tumor with stricture, biopsy show squamous cell carcinoma, moderate to poorly differentiated. We are consulted for further evaluation.
    • Systemic therapy is indicated for metastasis esophagus SCC. Palliative CCRT followed by systemic chemotherapy may consider in this case. Please arrange our OPD after discharge. Thanks for your consultation.
• 2023-02-10 Radiation Oncology
  • A
    • This 52-year-old man, a heavy smoker and alcoholism denied any systemic disease. He has suffered from hoarseness since 3 months ago. Dysphagia even liquid diet for 2 weeks, associated with weight loss 4 kg in a month. Endoscopic biopsy was done, and pathology reported squamous cell carcinoma, moderate to poorly differentiated. Chest CT on 2023-02-04 showed long segmental wall thickening at upper third esophagus, with bilateral lung nodules. Esophageal cancer with bilateral lung metastases is considered. Stage cT3N3M1. Whole body PET and bone scan showed highly suspected spine and lung mets.
    • He can’t swallow the saliva. Palliative CCRT is indicated. CT-simulation will be arranged on 2023/02/16. Plan to deliver 45 Gy/ 25 fx to the esphagus and bil. SCF. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. If the dose distribution is feasible, spine mets can be included in the RT field. RT will start around 2023/02/20 or 21.

[MedRec]

• 2023-03-02 SOAP Hemato-Oncology
  • A
    • C15.9 Malignant neoplasm of esophagus, unspecified
  • P
    • Admission for systemic chetmoehrapy when admission, 24 hours CCr and audiometry
    • Plan: palliative radiohterapy with systemic chemotherapy followed by paliative C/T with PF
• 2023-02-24 SOAP Radiation Oncology
  • P: Plan to deliver 45 Gy/ 25 fx to the esphagus and bil. SCF and T-spine mets. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx.

[radiotherapy]

[chemotherapy]

• 2023-05-09 - cisplatin 75mg/m2 110mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, CCRT)
  • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3
• 2023-03-30 - cisplatin 75mg/m2 125mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF, CCRT)
  • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3
• 2023-03-07 - cisplatin 75mg/m2 125mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF, CCRT)
  • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3

2023-05-09

[tube feeding]

Nexium (esomeprazole) should not be crushed. Instead, it should be dissolved in sufficient drinking water before tube feeding.

2023-04-28

[tube feeding]

• All of the oral medications prescribed can be administered via a feeding tube.

2023-03-27

[tube feeding]

• All of the oral medications in the patient’s active prescription are able to be administered through a feeding tube.

700070514

230508

[diagnosis] - 2023-05-07 admission note

• K-RAS mutation Adenocarcinoma of the sigmoid colon near complete obstruction invasion to bladder with fistula formation, and carcinomatosis and liver metastases, cT4bN2bM1c, stage IVc status post T-loop colostomy on 2022/10/26
• Iron deficiency anemia, unspecified

[present illness]

• This 57-year-old male has past history of major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.

[past history] - 2023-05-07 admission note

• Systemic disease:
  • Major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.
• Surgery:
  • Left femoral fracture s/p THR

[family history]

• Father has diabetes
• No cancer history in his family

[lab data]

• 2022-10-01 HBsAg Nonreactive
  
• 2022-10-01 HBsAg (Value) 0.37 S/CO
  
• 2022-10-01 Anti-HBc Reactive
  
• 2022-10-01 Anti-HBc-Value 5.99 S/CO
  
• 2022-10-01 Anti-HCV Nonreactive
  
• 2022-10-01 Anti-HCV Value 0.15 S/CO

[exam findings]

• 2023-05-02, -04-24, -04-22, -03-19 CXR
  • There are multiple nodular opacity projecting in both lung that are c/w lung metastases after correlate with CT.
• 2023-03-07 CT - abdomen
  • History and indication: Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected and urinary bladder fidtula, cT4bN2bM1c, stage IV
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Mild regression of S-colon cancer and peritoneal invasion but progression of LN/ lung/ liver and left sacral metastases.
    • Left hydronephrosis.
    • S/P left THR.
    • Minimal ascites.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Mild regression of S-colon cancer and peritoneal invasion but progression of LNs/ lung/ liver and left sacral metastases.
    • Left hydronephrosis.
• 2023-02-03 Tc-99m MDP bone scan
  • Increased activity in the sacrum. Please correlate with other imaging modalities for further evaluation and to rule out the possibility of bone metastasis.
  • Mildly increased activity in the lower C-spine, some middle and lower T-spines. Degenerative change may show this picture. However, please keep follow-up to rule out other possibilities.
  • Some hot and faint hot spot in bilateral rib cages and increased activity in the right clavicle and right ischium. The nature is to be determined (bone metastases? post-traumatic change? ). Please correlate with other clinical findings for further evaluation.
• 2023-02-01 Long Bones series
  • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
  • S/P total hip arthroplasty, left hip
• 2022-12-02 CT - abdomen
  • History
    • 20221202 CC: Started to have a fever this morning, vomiting, general weakness, abdominal pain, blood pressure in the right hand 79/52mmhg
    • 20220921 CC: diarrhea for 1/2 yrs. bw loss 14 kg. CEA 33.86; anemia (initial 8.2); favor IDA (iron deficiency anemia)
    • 20220921 sigmoidoscopy: Suspected colon ca, R-S juncton s/p biopsy
    • 20220923 CT: R-S juncton cancer, cT4b(UB)N2bM1c, cSTAGE:IVC
  • Indication: sepsis
  • Findings: Comparison: prior CT dated 2022/09/23.
    • Prior CT identified long segmental sigmoid colon cancer is noted again, stable in size.
      • S/P colostomy at right transverse colon.
      • There is no gas in the urinary bladder.
      • Prior CT identified Multiple Metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space are noted again, mild increasing in size and number that are c/w progressive disease.
      • In addition, There is mild hydroureteronephrosis and delayed contrast excretion of left kidney and the etiology is due to metastatic node in left common iliac chain with passive compression left side ureter.
    • There are newly-developed multiple poor enhancing masses on both hepatic lobes that are c/w liver metastases with progressive disease.
      • The largest one measuring 5.9 cm in S6/7.
    • Prior CT identified smuddgy appearance of the omentum is noted again, stationary. Follow up is indicated.
    • There are multiple newly-developed soft tissue nodules on both lung that are c/w lung metastases.
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & right kidney.
      
    • There is no evidence of ascites.
      
    • The abdominal aorta and IVC are grossly unremarkable.
      
    • There is no evidence of intrinsic or extrinsic bladder mass.
      
  • Impression:
    • Multiple liver and lung metastases c/w progressive disease.
      
    • Multiple Metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space show progressive disease.
• 2022-10-31 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (101 - 35) / 101 = 65.35%
    • M-mode (Teichholz) 65
  • Adequate LV systolic function with normal resting wall motion
  • Septal hypertrophy
  • Mild MR, trivial TR
  • Preserved RV systolic function
• 2022-10-31 CXR
  • Pneumoperitoneum (note: Pneumoperitoneum is the presence of air or gas in the abdominal (peritoneal) cavity. It is usually detected on x-ray, but small amounts of free peritoneal air may be missed and are often detected on computerized tomography (CT).)
  • A nodule at RLL.
• 2022-10-25 Barium Enema with water soluble contrast medium
  • Findings
    • Obstruction at sigmoid colon.
    • A defect at between sigmoid colon and urinary bladder. Prominent air the the urinary bladder.
  • Impression
    • Obstruction at sigmoid colon
    • c/w sigmoid colon-vesical fistula (may be dominate at proximal end)
• 2022-10-05 Whole body PET scan
  • Glucose-hypermetabolic lesions in the lower abdomen, pelvis, and in a left para-arotic lymph node, highly suspected S-colon cancer with carcimatosis.
    
  • A glucose hypermetabolic lesion in the right lobe of the liver, highly suspected colon cancer with liver metastasis.
    
  • Increased uptake of FDG at the left hip joint, probably benign in nature.
    
  • S-colon cancer with carcimatosis and liver metastases, cTxN2bM1c, stage IVC (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2022-10-03 All-RAS + BRAF mutations assay
  • All-RAS mutations assay
    • Detection range
      • KRAS codon 12, 13, 59, 61, 117, 146
      • NRAS codon 12, 13, 59, 61, 117, 146
    • Results
      • Detected (KRAS condon 61 CAA>CTA, p.Q61L)
    • Interpretation
      • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • BRAF mutations assay
    • Detection range
      • BRAF codon 600
    • Results
      • There was no variant detected in the BRAF gene.
    • Interpretation
      • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
• 2022-09-30 ECG
  • Sinus rhythm with short PR
  • Nonspecific ST abnormality
  • Abnormal ECG
• 2022-09-23 CT - abdomen
  • Findings:
    • There is a long segmental lobulated wall thickening with irregular contour at the sigmoid colon, measuring 10 x 5.3 cm in size, causing lumen narrowing and proximal colon dilatation that is c/w adenocarcinoma of the sigmoid colon with near complete obstruction.
      • In addition, there is fistula formation between the sigmoid colon mass and the urinary bladder, causing air-fluid level in the urinary bladder that is c/w tumor invasion (T4b).
      • In addition, There are multiple enlarged nodes in the sigmoid mesocolon and perirectal space, the largest one measuring 4 cm, that are c/w metastatic nodes (N2b).
    • There is a poor enhancing mass measuring 0.9 cm in S6 of the liver. Liver metastasis is highly suspected (M1a). Please correlate with sonography or MRI.
      • The omentum shows smuddgy appearance that may be tumor seeding (M1C).
    • There is no focal lesion in both lung and mediastinum.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b (T_value) N:N2b (N_value) M:M1c (M_value) STAGE:IVC(Stage_value)
• 2022-09-22 Patho - colon biopsy
  • Colon, R-S junction, biopsy — Adenocarcinoma, moderately differentiated
    
  • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2022-09-21 Colonoscopy
  • Diagnosis
    • Highly suspected colon cancer, R-S junction, s/p biopsy
    • Mixed hemorrhoid
    • Incomplete colonoscopy due to tumor stricture
  • Suggestion
    • F/U pathology report
    • Further image for cancer staging may be indicated.
  • Complication
    • No immediate complication
• 2022-08-30 Patho - stomach biopsy
  • Esophagus, EC junction, biopsy — Barrett’s esophagus
  • Microscopically, it shows chronic inflammation with lymphoplasmacytic infiltrate and intestinal metaplasia with goblet cells present.
• 2022-08-29 SONO - abdomen
  • suspected liver parenchymal disease.
• 2022-08-29 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade A
    • Hiatus hernia
    • Suspect Barrett’s esophagus, s/p biopsy, C1M3
    • Superficial gastritis
    • Gastric polyp, high body, GC/PW site
  • Suggestion
    • Pursue biopsy result
• 2022-08-25 ECG
  • Sinus tachycardia
  • Nonspecific ST abnormality
  • Abnormal ECG

[consultation]

• 2022-12-07 Colorectal Surgery
  • A: Diver-T-loop colostomy was done, please control underline disease
• 2022-11-22 Radiation Oncolgoy
  • A
    • The 57 y/o man has adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC. s/p T-colonostomy. Palliative C/T has been started on 2022/11/21.
    • Palliative CCRT is indicated. CT-simulation will be arranged on 11/28. Plan to deliver 45 Gy/ 25 fx to the S-colon tumor and adjacent carcinomatoses. r/o IVC thromboemboli shown on abd. CT (2022/09/23) with PVT? I will consult radiologist Dr. Yu later. Thank you very much.
    • no PVT. just r/o IVC thromboemboli.
• 2022-10-06 Colorectal Surgery
  • Q
    • Under the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC, pending RAS report. He was admitted for further management. Port-A insertion on 2022/10/04 and PET was arrange on 2022/10/05.
    • we had explained the current condition to patient and family,they agreed to do the T-loop colostomy. We need your expertise for further management, thanks
  • A
    • This is a 57-year old man with the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC,
    • protective T-loop colostomy will be considered
    • we will arrange operation for him
• 2022-10-05 Radiation Oncology
  • Q
    • This 57-year-old male has past history of major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.
    • He had suffered from watery diarrhea with body weight loss 17kg in half year. The condition is worse than before within this year. EGD on 2022/08/29 showed Reflux esophagitis LA Classification grade A. Hiatus hernia. Suspect Barrett’s esophagus, s/p biopsy, Superficial gastritis. Gastric polyp, high body, GC/PW site. Biopsy proved Barrett’s esophagus.
    • He came to our GI OPD and colonscopy was performed on 2022/09/21 which showed Highly suspected colon cancer, R-S junction, s/p biopsy. Mixed hemorrhoid. Biopsy proved Adenocarcinoma, moderately differentiated.
    • CT of abdomen was performed on 2022/09/25 revealed There is a long segmental lobulated wall thickening with irregular contour at the sigmoid colon, measuring 10 x 5.3 cm in size, causing lumen narrowing and proximal colon dilatation that is c/w adenocarcinoma of the sigmoid colon with near complete obstruction. In addition, there is fistula formation between the sigmoid colon mass and the urinary bladder, causing air-fluid level in the urinary bladder that is c/w tumor invasion (T4b). In addition, There are multiple enlarged nodes in the sigmoid mesocolon and perirectal space, the largest one measuring 4 cm, that are c/w metastatic nodes (N2b). There is a poor enhancing mass measuring 0.9 cm in S6 of the liver. Liver metastasis is highly suspected (M1a). The omentum shows smuddgy appearance that may be tumor seeding (M1C).
    • Under the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC, pending RAS report. He was admitted for further management. Port-A insertion on 2022-10-04. We need your expertise for radiotherapy evalaution, thanks
  • A
    • He was persuaded to have colostomy first.
    • CCRT will be arranged thereafter.
• 2022-08-26 Psychosomatic Medicine
  • A
    • MSE: thin and cachexia, impaired attention focus and sustain, low mood, poor energy, psychomotor retardation, suicidal ideation, alcohol drinking all day long.
    • PE: mild upper limb tremor, yellowish skin, icteria scerdela
    • IMP:
      • Major depressive disorder, recurrent, severe
      • Suspected alcohol induced mood disorder
      • Alcohol use disorder, in withdrawal status.
    • Suggestion:
      • Correct electrolytes, treat physical condition
      • Saline hydration with B-complex 1 amp QD, with kentamin supply for B12 defiency.
      • Add dosage of our medications: keep zoloft 50mg 1# QN, add utapine to 25mg 2# HS, Eurodin 1# HS, and add anxiedin to 2# Q12H
      • Arrange psy OPD f/u.

[MedRec]

• 2023-03-19 ~ 2023-03-24 POMR Hemato-Oncology
  • Inpatient Treatment Process
    • After admission, C6 Avastin plus C2D1 FOLFIRI was administered on 2023/03/21-23.
    • Dizziness and headache was noted during chemotherapy and adequate hydration was done.
    • With the relatively stable condition, he was discharged on 2023/03/24 and will OPD follow up later.
• 2022-11-29 SOAP Hemato-Oncology
  • A/P: Bevacizumab 5 mg/kg iv q2wks for 36 wks (18 wks each apply) colostomy in late Oct. 2022
• 2022-09-30 SOAP Hemato-Oncology
  • A/P: Discussed the suggestion of a protective T-loop colostomy with the patient and his wife (which could also help reduce the risk of urinary tract infections). The patient indicated that he is currently able to have bowel movements and would like to try chemotherapy and radiation first.

[surgical operation]

• 2022-10-26 T loop colostomy        
  • adenocarcinoma of Sigmoid colon with invasion to bladder and fistula formation    
  • short T-colon with adhesion to liver and middle colic mesentery region 

[radiotherapy]

• 2022-11-29 ~ 2023-01-10 - completed RT to the pelvisthe S-colon tumor, partial bladder, and adjacent carcinomatoses: 45 Gy/ 25 fx.

[chemoimmunotherapy]

• 2023-04-06 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 2150mg NS 500mL 46hr (FOLFIRI, 5FU infusion 50% off)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
• 2023-03-21 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 2150mg NS 500mL 46hr (FOLFIRI, 5FU infusion 50% off due to encephalopathy during last time)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
• 2023-03-01 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
• 2023-02-13 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
• 2023-01-27 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4250mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
• 2023-01-09 - bevacizumab 5mg/kg 245mg NS 100mL 90min + oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-12-26 - bevacizumab 5mg/kg 255mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-12-13 - oxaliplatin 85mg/m2 133mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-11-21 - oxaliplatin 85mg/m2 133mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[assessment]

• From 2022-11-21 to 2023-01-09, the patient was treated with Avastin plus FOLFOX for his K-RAS-mutated sigmoid colon adenocarcinoma. However, a CT scan on 2022-12-02 showed progressive disease with multiple liver and lung metastases, as well as metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space. As a result, the regimen was changed to Avastin plus FOLFIRI on 2023-01-27. Due to dizziness and headache experienced during chemotherapy on 2023-03-01, the fluorouracil dose was reduced by half starting on 2023-03-21.

• After the new regimen was applied, the tumor marker CEA has remained relatively unchanged; however, the readings are approximately twice as high as they were before.

  • 2023-04-21 CEA (nuclear medicine) 1376.700 ng/ml
    
  • 2023-04-03 CEA (nuclear medicine) 1203.450 ng/ml
    
  • 2023-03-17 CEA (nuclear medicine) 1261.1 ng/ml
    
  • 2023-02-24 CEA (nuclear medicine) 1322 ng/ml
    
  • 2023-02-14 CEA (nuclear medicine) 1371.12 ng/ml
    
  • 2023-01-27 CEA (nuclear medicine) 667.3 ng/ml
    
  • 2023-01-09 CEA (nuclear medicine) 627.64 ng/ml
    
  • 2022-12-29 CEA (nuclear medicine) 907.05 ng/ml
    
  • 2022-11-29 CEA (nuclear medicine) 382.654 ng/ml
    
  • 2022-10-07 CEA (nuclear medicine) 52.567 ng/ml

• The Covid-19 fast screen was positive on 2023-04-24, but the patient has since recovered. Vital signs are currently stable. CT and CXR revealed lung mets with multiple nodular opacities in both lungs, which do not significantly impair the patient’s respiratory function yet.

• The underlying conditions are currently being managed with appropriate medications: anemia is treated with Foliromin (ferrous sodium citrate), toe numbness is treated with Kentamin (B1, B6, B12), right upper quadrant abdominal and rib area pain is treated with Tramacet (tramadol, acetaminophen) and Neurontin (gabapentin), respiratory symptoms are treated with Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), oral candidiasis is treated with Mycostatin (nystatin), and intermittent diarrhea is managed with loperamide and Smecta (dioctahedral smectite) as needed (PRN).

230110

[drug interaction]

• The ability of oral iron preparations to reduce the absorption of oral quinolones is well established and has been demonstrated in numerous pharmacokinetic studies. Various oral iron preparations have been reported to reduce quinolone AUCs by the following percentages: ciprofloxacin (33% to 70%), levofloxacin (19%), lomefloxacin (14%), moxifloxacin (61%), norfloxacin (51% to 73%), ofloxacin (25%), and sparfloxacin (28%). The maximum serum concentrations of oral quinolones were reduced by the following percentages: ciprofloxacin (46% to 75%), levofloxacin (45%), lomefloxacin (28%), moxifloxacin (41%), norfloxacin (75% to 82%), ofloxacin (36%), and sparfloxacin (46%). It is recommended to administer oral quinolones at least several hours before (4 h for moxifloxacin and sparfloxacin, 2 h for others) or after (8 h for moxifloxacin, 6 h for ciprofloxacin and delafloxacin, 4 h for lomefloxacin, 3 h for gemifloxacin, 2 h for enoxacin, levofloxacin, norfloxacin, ofloxacin, pefloxacin, or nalidixic acid) oral iron preparations.

• Due to the fact that Cravit (levofloxacin) and Foliromin (ferrous sodium citrate) were prescribed as QDAC and BID, respectively. To maintain Cravit’s effectiveness, Foliromin might be moved to QL and QN.

• Please monitor for diminished effects of the quinolone if dose separation cannot be achieved.

230109

[assessment]

• Oxaliplatin is associated with high incidence of peripheral neuropathy (76%, grades 3/4: 7%; acute: 65%, grades 3/4: 5%; delayed (persistent): 43%, grades 3/4: 3%) Ref: UpToDate
• The acute neurotoxicity that is seen frequently in the 72 to 96 hours after each infusion of oxaliplatin is often linked to cold exposure (drinking cold liquids, inhaling cold air, placing hands in the freezer). Avoidance of cold during this time frame should mitigate this toxicity to some extent, but not all symptoms (eg, perioral numbness, hand cramping) are related to cold. As of now, no evidence of peripheral neuropathy has been recorded.
• The patient vomited several times throughout the week as documented in the record of 2023-01-06. A prescription for metoclopramide has been issued.

221226

• chief complaint
  • watery diarrhea with body weight loss 17kg in half year
• present illness
  • This 57-year-old male has past history of major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.
• past history
  • Systemic disease:
    • Major depressive disorder comorbid with alcohol dependence under medication treatment
  • Surgery:
    • Left femoral fracture s/p THR
• lab data
  • 2022-10-01 HBsAg Nonreactive
    
  • 2022-10-01 HBsAg (Value) 0.37 S/CO
    
  • 2022-10-01 Anti-HBc Reactive
    
  • 2022-10-01 Anti-HBc-Value 5.99 S/CO
    
  • 2022-10-01 Anti-HCV Nonreactive
    
  • 2022-10-01 Anti-HCV Value 0.15 S/CO
• exam finding
  • 2022-12-02 CT - abdomen
    • History
      • 20221202 CC: Started to have a fever this morning, vomiting, general weakness, abdominal pain, blood pressure in the right hand 79/52mmhg
      • 20220921 CC: diarrhea for 1/2 yrs. bw loss 14 kg. CEA 33.86; anemia (initial 8.2); favor IDA (iron deficiency anemia)
      • 20220921 sigmoidoscopy: Suspected colon ca, R-S juncton s/p biopsy
      • 20220923 CT: R-S juncton cancer, cT4b(UB)N2bM1c, cSTAGE:IVC
    • Indication: sepsis
    • Findings: Comparison: prior CT dated 2022/09/23.
      • Prior CT identified long segmental sigmoid colon cancer is noted again, stable in size.
        • S/P colostomy at right transverse colon.
        • There is no gas in the urinary bladder.
        • Prior CT identified Multiple Metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space are noted again, mild increasing in size and number that are c/w progressive disease.
        • In addition, There is mild hydroureteronephrosis and delayed contrast excretion of left kidney and the etiology is due to metastatic node in left common iliac chain with passive compression left side ureter.
      • There are newly-developed multiple poor enhancing masses on both hepatic lobes that are c/w liver metastases with progressive disease.
        • The largest one measuring 5.9 cm in S6/7.
      • Prior CT identified smuddgy appearance of the omentum is noted again, stationary. Follow up is indicated.
      • There are multiple newly-developed soft tissue nodules on both lung that are c/w lung metastases.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & right kidney.
        
      • There is no evidence of ascites.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
    • Impression:
      • Multiple liver and lung metastases c/w progressive disease.
        
      • Multiple Metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space show progressive disease.
  • 2022-10-31 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (101 - 35) / 101 = 65.35%
      • M-mode (Teichholz) 65
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy
    • Mild MR, trivial TR
    • Preserved RV systolic function
  • 2022-10-31 CXR
    • Pneumoperitoneum (note: Pneumoperitoneum is the presence of air or gas in the abdominal (peritoneal) cavity. It is usually detected on x-ray, but small amounts of free peritoneal air may be missed and are often detected on computerized tomography (CT).)
    • A nodule at RLL.
  • 2022-10-25 Barium Enema with water soluble contrast medium
    • Findings
      • Obstruction at sigmoid colon.
      • A defect at between sigmoid colon and urinary bladder. Prominent air the the urinary bladder.
    • Impression
      • Obstruction at sigmoid colon
      • c/w sigmoid colon-vesical fistula (may be dominate at proximal end)
  • 2022-10-05 Whole body PET scan
    • Glucose-hypermetabolic lesions in the lower abdomen, pelvis, and in a left para-arotic lymph node, highly suspected S-colon cancer with carcimatosis.
      
    • A glucose hypermetabolic lesion in the right lobe of the liver, highly suspected colon cancer with liver metastasis.
      
    • Increased uptake of FDG at the left hip joint, probably benign in nature.
      
    • S-colon cancer with carcimatosis and liver metastases, cTxN2bM1c, stage IVC (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-10-03 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • Detected (KRAS condon 61 CAA>CTA, p.Q61L)
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-09-30 ECG
    • Sinus rhythm with short PR
    • Nonspecific ST abnormality
    • Abnormal ECG
  • 2022-09-23 CT - abdomen
    • Findings:
      • There is a long segmental lobulated wall thickening with irregular contour at the sigmoid colon, measuring 10 x 5.3 cm in size, causing lumen narrowing and proximal colon dilatation that is c/w adenocarcinoma of the sigmoid colon with near complete obstruction.
        • In addition, there is fistula formation between the sigmoid colon mass and the urinary bladder, causing air-fluid level in the urinary bladder that is c/w tumor invasion (T4b).
        • In addition, There are multiple enlarged nodes in the sigmoid mesocolon and perirectal space, the largest one measuring 4 cm, that are c/w metastatic nodes (N2b).
      • There is a poor enhancing mass measuring 0.9 cm in S6 of the liver. Liver metastasis is highly suspected (M1a). Please correlate with sonography or MRI.
        • The omentum shows smuddgy appearance that may be tumor seeding (M1C).
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b (T_value) N:N2b (N_value) M:M1c (M_value) STAGE:IVC(Stage_value)
  • 2022-09-22 Patho - colon biopsy
    • Colon, R-S junction, biopsy — Adenocarcinoma, moderately differentiated
      
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2022-09-21 Colonoscopy
    • Diagnosis
      • Highly suspected colon cancer, R-S junction, s/p biopsy
      • Mixed hemorrhoid
      • Incomplete colonoscopy due to tumor stricture
    • Suggestion
      • F/U pathology report
      • Further image for cancer staging may be indicated.
    • Complication
      • No immediate complication
  • 2022-08-30 Patho - stomach biopsy
    • Esophagus, EC junction, biopsy — Barrett’s esophagus
    • Microscopically, it shows chronic inflammation with lymphoplasmacytic infiltrate and intestinal metaplasia with goblet cells present.
  • 2022-08-29 SONO - abdomen
    • suspected liver parenchymal disease.
  • 2022-08-29 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Hiatus hernia
      • Suspect Barrett’s esophagus, s/p biopsy, C1M3
      • Superficial gastritis
      • Gastric polyp, high body, GC/PW site
    • Suggestion
      • Pursue biopsy result
  • 2022-08-25 ECG
    • Sinus tachycardia
    • Nonspecific ST abnormality
    • Abnormal ECG
• consultation
  • 2022-10-06 Colorectal Surgery
    • Q
      • Under the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC, pending RAS report. He was admitted for further management. Port-A insertion on 2022/10/04 and PET was arrange on 2022/10/05.
      • we had explained the current condition to patient and family,they agreed to do the T-loop colostomy. We need your expertise for further management, thanks
    • A
      • This is a 57-year old man with the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC,
      • protective T-loop colostomy will be considered
      • we will arrange operation for him
  • 2022-10-05 Radiation Oncology
    • Q
      • This 57-year-old male has past history of major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.
      • He had suffered from watery diarrhea with body weight loss 17kg in half year. The condition is worse than before within this year. EGD on 2022/08/29 showed Reflux esophagitis LA Classification grade A. Hiatus hernia. Suspect Barrett’s esophagus, s/p biopsy, Superficial gastritis. Gastric polyp, high body, GC/PW site. Biopsy proved Barrett’s esophagus.
      • He came to our GI OPD and colonscopy was performed on 2022/09/21 which showed Highly suspected colon cancer, R-S junction, s/p biopsy. Mixed hemorrhoid. Biopsy proved Adenocarcinoma, moderately differentiated.
      • CT of abdomen was performed on 2022/09/25 revealed There is a long segmental lobulated wall thickening with irregular contour at the sigmoid colon, measuring 10 x 5.3 cm in size, causing lumen narrowing and proximal colon dilatation that is c/w adenocarcinoma of the sigmoid colon with near complete obstruction. In addition, there is fistula formation between the sigmoid colon mass and the urinary bladder, causing air-fluid level in the urinary bladder that is c/w tumor invasion (T4b). In addition, There are multiple enlarged nodes in the sigmoid mesocolon and perirectal space, the largest one measuring 4 cm, that are c/w metastatic nodes (N2b). There is a poor enhancing mass measuring 0.9 cm in S6 of the liver. Liver metastasis is highly suspected (M1a). The omentum shows smuddgy appearance that may be tumor seeding (M1C).
      • Under the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC, pending RAS report. He was admitted for further management. Port-A insertion on 2022-10-04. We need your expertise for radiotherapy evalaution, thanks
    • A
      • He was persuaded to have colostomy first.
      • CCRT will be arranged thereafter.
  • 2022-08-26 Psychosomatic Medicine
    • A
      • MSE: thin and cachexia, impaired attention focus and sustain, low mood, poor energy, psychomotor retardation, suicidal ideation, alcohol drinking all day long.
      • PE: mild upper limb tremor, yellowish skin, icteria scerdela
      • IMP:
        • Major depressive disorder, recurrent, severe
        • Suspected alcohol induced mood disorder
        • Alcohol use disorder, in withdrawal status.
      • Suggestion:
        • Correct electrolytes, treat physical condition
        • Saline hydration with B-complex 1 amp QD, with kentamin supply for B12 defiency.
        • Add dosage of our medications: keep zoloft 50mg 1# QN, add utapine to 25mg 2# HS, Eurodin 1# HS, and add anxiedin to 2# Q12H
        • Arrange psy OPD f/u.
• surgical operation
  • 2022-10-26 T loop colostomy        
    • adenocarcinoma of Sigmoid colon with invasion to bladder and fistula formation    
    • short T-colon with adhesion to liver and middle colic mesentery region 
• chemoimmunotherapy
  • 2022-12-26 - bevacizumab 5mg/kg 255mg 90min + oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 630mg 2hr + fluorouracil 2800mg/m2 4400mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-12-13 - oxaliplatin 85mg/m2 133mg 2hr + leucovorin 400mg/m2 630mg 2hr + fluorouracil 2800mg/m2 4400mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-11-21 - oxaliplatin 85mg/m2 133mg 2hr + leucovorin 400mg/m2 630mg 2hr + fluorouracil 2800mg/m2 4400mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

[assessment]

• The patient is receiving bevacizumab for the first time during this hospital stay. The patient was recently diagnosed with gastro-esophageal reflux disease (2022-11-17), however, no CVD related records have been kept for the past three months. As bevacizumab is associated with concerns regarding gastrointestinal perforation/fistula, heart failure, and hemorrhage. There may be a need for regular monitoring.

221205

[assessment]

• The patient’s body temperature fluctuated between 36.2 and 38.2, with two peaks at around 08:00 and 22:00 on a daily based cycle roughly.
• In this instance, tapimycin (piperacillin + tazobactam) is used, which has been shown to be effective against the 2022-12-02 blood cultured Escherichia coli (MIC <= 4 mcg/mL according to the lab report).
• There was a downward trend in renal function, especially in late November 2022, which should be noted. In the event of CrCl < 40mL/min, the dose of tapimycin should be reduced to two thirds.
  • 2022-12-02 Creatinine 0.91 mg/dL
    
  • 2022-11-28 Creatinine 0.96 mg/dL
    
  • 2022-11-21 Creatinine 0.59 mg/dL
    
  • 2022-11-17 Creatinine 0.58 mg/dL
    
  • 2022-10-31 Creatinine 0.48 mg/dL
    
  • 2022-10-24 Creatinine 0.43 mg/dL
    
  • 2022-10-17 Creatinine 0.41 mg/dL

221121

[assessment]

• Glomerular hyperfiltration (eGFR 150 2011-11-21, recent peak 229 2022-10-17) was noted. Intraglomerular hypertension, resulting from the transmission of systemic pressures or via glomerular-specific processes, may be deleterious over the long term. The use of NSAIDs (celecoxib in current prescription as a patient-carried item) should be limited to the necessary duration and should not be prolonged.

221003

[assessment]

• Hypoalbuminemia (2.8 g/dL 2022-09-30) <= decreased hepatic albumin synthesis <= possible liver mets? (2022-09-23 CT)
• The use of Alglutol (acamprosate 333mg/tab) 2# TID may be considered as a means of helping the patient quit alcohol following his withdrawal symptoms.

700138669

230508

[assessment]

• On 2023-05-08 at 06:05, the patient’s SpO2 dropped to 69%, accompanied by an increased heart rate of 100 bpm. This indicates possible respiratory distress or compromised oxygenation, and an O2 mask is placed appropriately.

• If the patient continues to experience hemoptysis, inhaled tranexamic acid could be considered as a potential treatment option to reduce bleeding. This antifibrinolytic agent has been shown to effectively control bleeding and may provide relief to the patient.

230427

[diagnosis] - 2023-04-26 admision note

• Hemoptysis
• Malignant neoplasm of nasopharynx, unspecified
• Essential (primary) hypertension
• Hypertensive heart disease without heart failure

[past history] - 2023-04-26 admision note

• Nasopharyngenl Carcinoma T4N3M1, stage IVB, proved at 2020/05 at Wan Fang Hospital (No biopsy) s/p radiotherapy to the C- and T- spine bone mets: 21 Gy/ 7 fx. on 2023-01-03 ~ 11, (early termination due to the patient reject) at our hospital
• hypertension for years with Concor 5mg/tab 0.5tab QD, Bokey 100mg/cap 1cap QD, Cozaar 50mg/tab 0.5tab QD, Norvasc 5mg/tab 0.5tab QD control and the clinic follow-up.
• hyperlipidemia for years with Lipitor 40mg/tab 1tab QD control and the clinic follow-up.
• L3 compression fracture without surgery for years.

[allergy]

• NKDA

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-04-25 Nasopharyngoscopy
  • Findings: massive blood-coating mass over right nasopharynx, much sputum over hypopharynx
  • Conclusion: nasopharyngeal carcinoma
• 2023-02-17, -01-13 Nasopharyngoscopy
  • Findings: rt NP tumor
  • Conclusion: NPC
• 2022-12-28 Bone Scan
  • Hot areas at the skull base, some C-, T- and lower L-spine, NPC with bone mets shoulde be consideded, suggesting PET scan for further evaluation.
  • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, and knees.
• 2022-12-19 MRI - nasopharynx
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
    • Right nasopharynx tumor mass, with skull invasion, extending to right Foramen of ovale, up to 4.5 cm.
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • Multiple right necrotic LAPs were noted down to supraclavicular fossa.
    • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
    • Destruction of right transverse process of T1 also was noted indicating bony metastasis.
  • IMP: Right NPC with multiple right neck LAPs and right T1 bony metastasis. T4N3M1 stage IVB (AJCC 9th edition).
  • Nasopharyngeal Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:1(M_value) STAGE:IVB (Stage_value)
• 2022-12-02 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasopahrynx, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
  • IHC stains: CK highlights infiltrative epithelum. EBV (-).
• 2022-11-23 Nasopharyngoscopy
  • rt NP tumor
• 2022-11-23 ENT Hearing Test
  • Tymp:
    • R’t type B; L’t type A.
  • ART:
    • Bil absent.
  • PTA
    • Reliability FAIR
    • Average RE 70 dB HL; LE 56 dB HL.
    • R’t moderaet to profound MHL.
    • L’t mild to severe HL. (BC masking dilemma)
    • Dialogue: R’t 65 dB HL; L’t 45 dB HL.
    • SDT: R’t 60 dB HL; L’t 40 dB HL.
• 2021-10-26 MRI - L-spine
  • Multiple old compression fractures at T11, L2,3, poor healing at upper L3 body. A left T10/11 perineural cyst.
• 2018-08-07 Bone densitometry - hip
  • Hip BMD performed by DXA revealed:
    • Hip, BMD is 0.674 gms/cm2, about 1.2 SD below the peak bone mass (84%) and 1.8 SD above the mean of age-matched people (131%).
  • IMP: osteopenia

[lab data]

• 2022-12-24 EBV DNA quantative PCR <120 copies/mL
  
• 2022-12-01 EB VCA IgA Borderline Ratio
  
• 2022-12-01 EB VCA IgA Value 0.9 Ratio
  
• 2022-12-01 EBV EA/NA IgA Negative EU/mL
  
• 2022-12-01 EBV EA/NA IgA Value 2.97 EU/mL

[consultation]

• 2023-04-25 Ear Nose Throat
  • Q
    • Chief complaint: coughing of blood with clots this morning
      • difficult swallowing, poor intake, nausea and vomiting, easy choking after eating for months
      • denied fever, respiratory symptoms, or urinary discomfort
    • Past Medical History: NPC, T4N3M1 stage IVB (2020/05)
      • currently R/T at bone metastasis areas
      • hypertension, hyperlipidemia
      • L3 compression
    • History of Operation: denied
    • Regular Medications: Aspirin
  • A
    • A case of NPC end stage, under palliative treatment
    • dysphagia recently, and family ask for NG insertion
    • scope: massive blood-coating mass over right nasopharynx, much sputum over hypopharynx
    • status post NG insertion under scope
    • sugget CXR f/u before feeding from NG tube

[MedRec]

• 2023-04-14 SOAP Hemato-Oncology
  • Plan: referred to hospice care
• 2023-01-13 SOAP Radiation Oncolgoy
  • She decided to quit RT.
• 2022-12-30 SOAP Radiation Oncolgoy
  • Plan: CT-simulation will be arranged on 20230102. Plan to deliver 30 Gy/ 10 fx to the C- and T- spine and Rt shoulder bone mets. RT will start around 20230104.
• 2022-12-23 SOAP Radiation Oncolgoy
  • Plan: arrange bone scan for palliative bone mets RT.
    • RTC: around 1 wk.
• 2022-12-23 SOAP Hemato-Oncology
  • O
    • 2022/12/19 MRI Nasopharynx: Right NPC with multiple right neck LAPs and right T1 bony metastasis. T4N3M1 stage IVB (AJCC 9th edition).
  • Assessment:
    • NPC, T4N3M1 stage IVB
  • Plan:
    • apply for major disease
    • refer to the radiation oncologist
    • pain control
• 2022-11-23 SOAP Hemato-Oncology
  • S
    • She was referred on account of NPC proved at 202005 at Wan Fang Hospital. (No biopsy)
    • No treatment was applied from that time. Hospice care from that time.
    • Headache for 3 weeks, bilateral ear cannal ulceration without discharge from one month ago.
    • Hearing loss progressed
  • Assessment
    • NPC, staging
    • Check MRI
  • Plan
    • Check BCS
    • Check CBC&DC, PT, aPTT, bleeding time and stool OB
    • Check CXR
    • refer to the ENT

[assessment]

• Alpraline (alprazolam 0.5mg) 1# HS QD for 28 days and Bokey (aspirin 100mg) 1# QD for 28 days were prescribed at RenJi Hospital on 2023-02-28, with the 2nd refill on 2023-03-27. These medications are not currently shown in the patient’s medicine list. Please consider adding them back if they are still needed for the patient’s ongoing care. (Aspirin should be added to the patient’s medication list only after the hemoptysis has resolved.)

230426

[assessment]

• Hemoptysis was noted in the patient. The solitary pulmonary nodule in the left mid-lung zone seen on chest x-ray 2023-04-25 was not seen on chest x-ray 2023-04-26. However, ground-glass opacities remain in the right lower lobe. The patient is currently being treated with Amsulber (ampicillin and sulbactam), Mycostatin (nystatin), and Hemoclot (tranexamic acid) without issues.
• On 2023-04-26 at 10:31, the patient’s blood pressure was recorded as 177/85. If this elevated level persists, it is recommended that the dosage of Norvasc (amlodipine 5mg) be increased from 0.5 tablet once daily to 1 tablet once daily. If the blood pressure still remains high, then consider increasing Cozaar (losartan 50mg) from 0.5 tablet once daily to 1 tablet once daily as well.

701199326

230508

[exam findings]

• 2023-05-05, -05-01, -04-24, -04-17, -04-10, -04-08, -03-28, -03-15, -03-01, -02-24 CXR
  • Osteolytic defect in left humeral head is suspected.
  • Please correlate with CT to R/O bony metastasis.
  • S/P port-A implantation.
  • Blunting of bilateral right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
  • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    
  • S/P metalic autosuture at right upper lung.
• 2023-04-05 CXR
  • Deformity of left humeral head.
  • S/P Port-A infusion catheter insertion.
  • Ground glass opacities in bil. lungs.
  • Presence of ileus.
  • Normal appearance of trachea and bil. main bronchus.
  • Right pleural effusion.
• 2023-04-05 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Possible Inferior infarct , age undetermined
  • Abnormal ECG
• 2023-03-10 SONO - joint soft tissue
  • Finding:
    • Bulging of the left ACJ.
    • Heterogeneous hypoechoic appearance of the left supraspinatus tendon.
  • Impression And Suggestions:
    • Left AC distention.
    • Left supraspinatus tendinosis. Please correlate with the clinical presentations.
• 2023-03-01 Shoulder LT
  • Osteolytic defect and deformity of left humeral head and neck is noted. Please correlate with CT to R/O bony metastasis.
• 2023-01-04, 2022-12-15, -10-20 CXR
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
  • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    
  • S/P metalic autosuture at right upper lung.
• 2022-12-17 CT - chest
  • Indication: Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Nodular and mass like lesions (n>5) at both lungs up to 4.09 cm in largest dimension at left lower lobe is found. Lung meta is considered. In comparison with CT dated on 2022-04-14, the lesions enlarged.
      • Miliary lesions scattered at both lungs are found. Lung meta is considered.
      • Collapsed right lower lobe with soft tissue like change attaching to right hemidiaphragm is found.
    • Visible abdomen:
      • s/p RFA at S7, S4 and S6 of liver. No evidence of recurrent/residual tumor at both lobes of liver.
      • The GB is well distended without soft tissue lesion
      • Right hydronephrosis and hydroureter is found. Distal obstruciton is considered
  • Imp:
    • Rectal cancer with bilateral lung meta and bone meta. In progression.
    • Liver meta s/p RFA. NO recurrent/residual tumor at both lobes of liver.
    • Right hydronephrosis and hydroureter, suggest double J catheter placement.
• 2022-11-02 SONO - abdomen
  • Poor echo window due to bowel gas
  • Chronic liver parenchymal disease
  • Hepatic tumors, two C/W mets s/p MWA
  • Renal cysts, bil
  • Hydronephrosis, right kidney
• 2022-10-20 CT - abdomen
  • History and indication: rectal ca
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Rectal cancer with liver/ lung metastases s/p operation and RFA.
    • Multiple nodules at bil. lungs.
    • Right hydronephrosis. Bil. renal cysts (up to 1.3cm).
    • A cystic lesion (4.0cm) at LUQ.
    • Collapse of gallbladder.
    • Atherosclerosis of aorta, iliac arteries.
• 2022-09-29 Cell block cytology
  • one panc tumor was noted at neck with downstream P duct dilate, s/p FNB.
    • a case of rectal cancer with liver and lung mets
      
  • 15 cc pink clear fluid — Atypia
  • The smears and cell block show few epithelial clusters with mild enlarged nuclei. Please correlate with S2022-16564 for conclusive diagnosis.
• 2022-09-29 Patho - pancreas biopsy
  • Labeled as “pancreas”, needle biopsy — benign pancreas tissue with fibrosis.
  • IHC stains: CK highlights regular acinar structures. CD56 (-).
• 2022-08-16 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A (minimal)
  • Superficial gastritis, body
  • Duodenal ulcer scar, bulb, AW site
• 2022-07-20 CT - abdomen
  • History: Rectal cancer with liver and lung metastasis, stage IV
    • rectal ca with liver mets at inital s/p op then two liver mets s/p RFA at VGH, then lung mets, refer for r/o liver mets
    • 20220120 CT: Several poor enhancing tumors (up to 5.4cm) in liver c/w metastases.
    • 20220211 S/P MWA for liver tumor
  • Findings:
    • There are four poor enhancing lesions measuring 3.5 cm in S8, 6.7 cm in S4/8, 8.7 cm (the largest dimension) in S7 liver and 2.4 cm in S5 liver that are c/w metastases S/P MVA.
    • Some soft tissue nodules in RUL, RLL, LUL, and LLL of the lung are noted that are c/w lung metastases.
      • In addition, There are several enlarged nodes in paratracheal space that are c/w metastatic nodes.
    • Encapsulated fluid collection in right CP angle pleura space with passive atelectasis and few linear hyperdense shadow are noted. please correlate with clinical history.
    • S/P LAR with autosuture retention over the rectum.
• 2022-07-20 CXR
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
  • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    
  • S/P metalic autosuture at right upper lung.
• 2022-06-14 SONO - abdomen
  • Chronic liver parenchymal disease
  • Hepatic tumors, two C/W mets s/p MWA
  • Renal cysts, bil
• 2022-06-14 Esophagogastroduodenoscopy, EGD
  • Suboptimal study due to much food residual retention at stomach
  • Reflux esophagitis LA Classification grade A (minimal)
  • Superficial gastritis,body, s/p CLO test
  • Duodenal ulcer scar, bulb, AW site
  • Duodenal shallow ulcer, 2nd portion
• 2022-04-14 CT - lung/mediastinum/pleura
  • Bilateral pulmonary metastasis with progression.
  • Consolidation over right lower lobe with right pleural effusion.
  • Heterogeneous low density lesions are found at residual right lobe liver is found. Liver hematoma is favored.
• 2022-02-16 Abdominal Ultrasonography
  • chronic liver parenchymal disease
  • hepatic tumors, three c/w mets s/p MWA
  • ascites, mild
  • subcapsule hematoma
  • GB sludge
• 2022-02-11 CT - liver, spleen, biliary duct, pancreas
  • Hematoma in S4-8 of the liver subcapsule is noted.
  • Hematoma or bloody ascites in subphrenic space, perisplenic space, and bilateral paracolic gutter space.
• 2022-01-20 CT - liver, spleen, biliary duct, pancreas
  • Rectal cancer with liver/lung metastases s/p operation and RFA. Segeral poor enhancing tumors (up to 5.4cm) in liver c/w metastases.
  • Right pleural effusion with adjacent lung collapse. Some nodules at bil. basal lungs c/w metastases.
• 2022-01-13 CT- lung/mediastinum/pleura
  • Colon cancer with liver and lung meta s/p op. and RFA at both lungs. Recurrent/residual tumor at both lungs and liver, suggest further treatment.
• 2021-09-28 Patho - pleura/pericardial biopsy
  • Lung and pleura, right, decortication
    • empyema
      
    • metastatic adenocarcinoma, moderately differentiated, consistent with colonic origin
      
  • IHC: CK7(-), CK20(-), CDX2(focal +), and TTF-1(-). The results are consistent with metastatic colonic adenocarcinoma.
• 2021-09-21 CT - lung/mediastinum/pleura
  • S/P right lung operation. Right pneumothorax with right lung collapse. Right pleural effusion. Some patchy densities at left lung.
• 2021-07-27 CT - lung/mediastinum/pleura
  • bilateral pulmonary metastatic tumors, in progression compared with CT on 20210311.
• 2021-03-29 Patho - lung wedge biopsy
  • Pathologic Diagnosis
    • Lung, left, upper lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
    • Lung, left, lower lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
      
    • Lymph node, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
      
  • Microscopic Description
    • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobe (S2021-4686)
      
    • Histologic Type (select all that apply): Adenocarcinoma; The morphology is consistent with metastatic colonic tumor.
      
    • Histologic Grade: G2: Moderately differentiated
      
    • Spread Through Air Spaces (STAS): Not identified
      
    • Visceral Pleura Invasion: Not identified
      
    • Lymphovascular Invasion (select all that apply): present
      
    • Direct Invasion of Adjacent Structures: No adjacent structures present
      
    • Margins (select all that apply): All margins are uninvolved by carcinoma
      
    • Treatment Effect: No known presurgical therapy
      
    • Regional Lymph Nodes: group 9: 0/1
      
    • Extranodal Extension: Not identified
      
    • Additional Pathologic Findings: No tumor is seen in specimen A.
• 2021-03-11 CT - chest
  • Multiple spiculated nodules, in enlargement. Compatible with lung mets.
• 2021-03-04 CT - abdomen
  • Mild decreased size of liver metastases. Small nodules at bil. lower lungs.
  • Left hydronephrosis and hydroureter. Bil. tiny renal stones.
• 2020-12-30 CT - abdomen
  • Two metastases in S7/8 and S7 show stable disease.
  • Two lung metastases show stable disease.
• 2020-09-23 CT - abdomen
  • Two metastases in S7/8 and S7 show stable disease.
  • A metastasis 5 mm in LUL of the lung is suspected.
  • Left L/3 ureter stone causing hydroureteronephrosis and delayed contrast excretion of left kidney.
• 2020-07-19 CT - chest
  • right pneumothorax
  • suspicious a nodular lesion, about 20mm, in the lower lobe of the right lung.
• 2020-07-02 Patho - lung wedge biopsy
  • Lung, right, middle lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
  • Lung, right, lower lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
• 2020-07-01 Patho - lung wedge biopsy
  • Lung, right, upper lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
  • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes (S2020-8766 and S2020-8767)
  • IHC: MSH2(+), MSH6(+), MLH1(+), and PMS2(+).

[consultation]

• 2023-04-18 Ear Nose Throat
  • Q
    • for tinnitus & obstruction sensation for one day
    • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted due to dyspnea & pneumonia for anti treatment. He complained of tinnitus & obstruction sensation for one day. We need expertise to evaluate his condition thanks!
  • A
    • S
      • Hx of COM and OME?
      • Complained of aural fullness, s/s relieved intermittently via Vasalva maneuver
    • O
      • Ear: bil intact, no sign of OME
      • NPx: smooth via scope
    • Imp: Eustachian tube dynsfuction
    • Plan:
      • May try Sindecon nasal spray 2 puff QD per NA
      • Explained th further tx of ventilation tube insertion and tuboloplasty to patient
• 2023-04-06 Family Medicine
  • Q
    • for share care or hospice care
    • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted due to dyspnea & pneumonia for anti treatment. Owing to disease progression noted and we explained his poor condition to patient and DNR was consented. We need expertise to evaluate his condition thanks!
  • A
    • 59 y/o gentleman Advanced Colon cancer
    • DNR(+)
    • Our share care would follow up.
    • Would put p’t on hospice ward list if family agree.
• 2023-03-23 Infectious Disease
  • Q
    • The 59 y/o male was Dx: (1) COVID-19 (2) Pneumonia (3) Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis . Allergy: Penicillin. We need your expertise for further treatment. Thank you very much
  • A
    • keep present antibiotic Rx, and adjust to culture data later
    • monitor CRP
• 2023-02-27 Rehabilitation
  • Q
    • for left hand pain & limited of activity (unable to raise hands)
    • for nerve block or steroid treatment
    • This 60-year-old man, a patient of colon cancer with liver & lung mets S/P C/T. He was admitted due to pneumonia for anti treatment. He complained of left hand pain & limited of activity (unable to raise hands) for days. We need expertise to evaluate his condition thanks!
  • A
    • The patient complained left shoulder pain and ROM limitation for at least 1 year, rather than left hand pain or weakness.
      • Due to left shoulder pain and ROM limitation, we were consulted for further evaluation and treatment.
      • Present illness: The patient fell in 2021/11 with hitting to left shoulder. The pain and ROM limiation progressed. He had a diagnosis of left rotator cuff tear 0.5cm over left shoulder in other rehab clinic, and recieved prolo-injection with glucose, amniotic membrane (2022/09) or steriod injection, but all in vain during 2022 ~ 2023.
    • Left shoulder ROM(a/p)
      • Flex: 30’/90’
      • ABD: 30’/80’
      • Ext.: 70’/75’
      • Int: 15’/15’
    • Left shoulder sonogram at 2023/2/27 1700:
      • No tear was noted. (but we could not see all tendon part due to severe ROM limiation)
      • SS tendinitis.
    • Assessment
      • Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis
      • r/o left frozen shoulder
    • Plan
      • Please send patient to 5F Sono Room at 20230303 08:30 for treatment
      • Please arrange left shoulder X ray
      • Please arrange rehab OPD follow up after discharge
• 2022-09-29 Ophthalmology
  • Q
    • this consultation is for right eye foreign body sensation management.
    • We have arranged EUS FNB for gastric submucosal lesion on 2022/09/28. After he came back from examination room, he complained right eye foreign body sensation and painful sensation. The symptom persisted after ice packing. He had no blurred vision, visual field defect. There was also no swelling nor subconjuntival hemorrhage noted. Due to above reason, we sincerely need your expertise for right eye foreign body sensation management.
  • A
    • S OD FBS since yesterday
    • O
      • FBS, tearing
      • EUS FNB under aesthesia yesterday
      • rectal cancer with liver and lung metastasis, DU, hypothyroidism and chronic hepatitis B
      • denied oph hx
      • nka
      • BCVA od 0.8x-1.75/-1.0x25 os 0.9x-1.50/-0.50x80
      • IOP 14/13mmHg
      • Pupil 3/3 +/+
      • conj np ou
      • K od peripheral ED 3*2.8mm, no infiltration os clear
      • AC D/cl ou
      • Lens ns+ ou
    • A Corneal ED od
    • P
      • Cravit 1gtt qid + duratear 1qs bid od
      • inform the risk of infection, if worsen vision, come back asap
      • the patient will follow at LMD first
• 2022-09-24 General and Gastroenterological Surgery
  • Q
    • this consultation is for gastric submucosal lesion management.
    • This 59 y/o man is a case of rectal cancer with liver and lung metastasis, DU, hypothyroidism and chronic hepatitis B. He had sudden onset of epigastric pain on 2022/09/22 and went to Tamsui Mackey’s ER for help. PES and abdominal CT showed a huge submucosa tumor around 6.2cm at posterior wall of the body. He was suggested admission but patient refused and visited our ER for his previous medical record at our hospital.
    • Due to above reason, we sincerely need your expertise for gastric submucosal lesion management. Thanks!
  • A
    • A case of rectal ca with liver and lung meta s/p tx
    • sudden on set of upper abd pain and CT scan revealed an submucosal gastric mass that was not noted at last two months CT scan.
    • gastric submucosal tumor with bleeding may considered. I wound like to suggested EUS and aspiration cystology to proved any tumor present, Thanks and let me know if there is any tumor present.
• 2022-02-11 Diagnostic Radiology
  • Q
    • FOR ANGIO.
    • this is a 58 y/o, a case of rectal ca with liver and lung meta. s/p RFA on 2022/02/11.
    • CTA showed HYPODENSE LESION over RUQ, r/o hematoma after RFA.
    • we need your expertise for angio.
  • A
    • According to the clinical condition and imaging findings, angiography is indicated.
• 2021-09-21 Thoracic Surgery
  • Q
    • dyspnea.
    • chest ct in 2021/07: bilateral pulmonary metastatic tumors, in progression compared with CT on 2021/03/11.
  • A
    • The patient had metastastic lung cancer s/p RF, Rt. treatment recently.
    • Dyspnea, hemoptysis and hemopneumothorax was found today
    • Suggestion:
      • Catheter drainage
      • ICU monitoring
• 2021-09-17 Diagnostic Radiology
  • Q
    • Purpose: for lung nodules RFA, right
    • This 58-year-old a case of Rectum cancer metastasis to liver and lung.
    • Rectum cancer with liver and lung metastases, cT3N1M1, stage IVB s/p neoadjuvant short radiotherapy s/p subsegmentectomy, ypT3N2aM1,s/p chemotherapy and RFA
    • There were no discomfort was told, included cough, sputum, chest pain, chest tightness and hemoptesis.
    • We need your help to arrange right lung nodules RFA on 2021-09-16 12:30. Thank you very much.
  • A
    • CT guided RFA for lung tumor is scheduled at 12:30 2021/09/16. Thank you for your consultation.
• 2020-07-20 Thoracic Surgery
  • Q
    • PH: rectal cancer ; lung cancer s/p op this July
    • allergy: penicillin
  • A
    • I will take over this case. Thanks for your consultaiton!!

[surgical operation]

• 2022-02-11 MWA, Microwave ablation

  • Procedure
    • Liver metastatic tumors, three (5.5 cm, 2.5 cm and 1.9 cm) s/p MWA x (total 11 sessions)
  • Course
    • By sono-guided, MWA probe was inserted to the 1st tumor (total 9 sessions; 100 W, 5 mins). MWA probe were inserted to the other two tumors (total 2 sessions; 70 W, 3 mins). The patient tolerated the procedure. IV anesthesia was performed during the procedure.
  • Findings
    • A 5.5 cm tumor was noted at S7 near diaphragm. A 2.5 cm mass at rt post seg near liver surface. A 1.9 cm mass at rt ant seg near liver surface.

• 2021-09-27 VATS, decortication

  • Loculated serosanguenous pleural effusion with fibrotic debris over visceral and parietal pleura
  • Necrotic RLL parenchyma were bleeding during debridement s/p 4D field hemostatic powder treatment

• 2021-03-29 VATS, LUL and LLL wedges resection for metastasectomy + pneumolysis

  • multiple solid nodules over LUL and LLL r/o rectal cancer metastasis
  • LUL nodules x7 and LLL nodules x3 were resected with one of the maximum about 1cm in diameter
  • no noted pleural effusion. Intrapleural cavity adhesion s/p pneumolysis

• 2021-09-16 RFA, Radiofrequency Ablation

• 2021-08-19 RFA, Radiofrequency Ablation

• 2020-07-01 3D VATS RUL, RML and RLL wedge resections + LND. decortication        

  • Multiple lung nodules were noted over right lung field.

• 2018-03-29 laparoscopic lower anterior resection w/ TaTME and S3, S8 subsegmentectomy + S5 cyst unroofing (Taipei Veterans General Hospital)

[radiotherapy]

• 2018-002-01 ~ 2018-02-06 - neoadjuvant short radiotherapy of 25Gy/5fx for adenocarcinoma of lower rectum with liver mets, at Taipei Veterans General Hospital

[chemoimmunotherapy]

• 2023-01-31 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 300mg NS 100mL 1.5hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + irinotecan 175mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-01-04
• 2022-12-15
• 2022-11-21
• 2022-10-31
• 2022-09-05
• 2022-08-16
• 2022-07-19
• 2022-06-30
• 2022-06-06
• 2022-05-03
• 2022-04-19 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2021-07-14 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2021-06-21
• 2021-05-27
• 2021-05-04 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2021-02-17 - bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 330mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5400mg NS 500mL 46hr (FOLFOXIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2021-02-02
• 2021-01-13
• 2021-12-30
• 2020-12-09
• 2020-11-25
• 2020-11-10
• 2020-10-27
• 2020-10-13
• 2020-09-29
• 2020-09-15
• 2020-09-01 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 175mg/m2 330mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2020-08-18 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 160mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2020-08-03 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 140mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

[note]

FOLFOXIRI chemotherapy for metastatic colorectal cancer 2023-04-25 https://www.uptodate.com/contents/image?topicKey=ONC%2F2503&imageKey=ONC%2F70559

• Cycle length: 14 days.

• Regimen

  • Irinotecan
    • 165 mg/m2 IV
    • Dilute with 500 mL D5W to a final concentration of 0.12 to 2.8 mg/mL and administer over 60 minutes.
    • Day 1
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute with 500 mL D5W and administer over two hours after irinotecan. Administer concurrently with leucovorin in separate bags via y-line connection. Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Levoleucovorin
    • 200 mg/m2 IV
    • Dilute with 250 mL D5W and administer over two hours, concurrent with oxaliplatin.
    • Day 1
  • Fluorouracil (FU)
    • 2400 to 3200 mg/m2 IV
    • Dilute in 500 to 1000 mL D5W and administer over 48 hours, after leucovorin. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL). The original protocol used 3200 mg/m2, but many United States oncologists use a lower starting dose (2400 mg/m2) and escalate as tolerated to reach a final dose of 3200 mg/m2.

• Pretreatment considerations:

  • Emesis risk
    • HIGH (>90% frequency of emesis).
  • Prophylaxis for infusion reactions
    • There is no standard premedication regimen.
  • Vesicant/irritant properties
    • Oxaliplatin and fluorouracil are irritants, but oxaliplatin can cause significant tissue damage; avoid extravasation.
  • Infection prophylaxis
    • Routine primary prophylaxis with G-CSF is not warranted (estimated risk of febrile neutropenia 5%). However, given the high rate of grade 3 or 4 neutropenia (approximately 50%), primary prophylaxis may be considered for high-risk patients.
  • Dose adjustment for baseline liver or renal dysfunction
    • A lower starting dose of oxaliplatin and irinotecan may be needed for patients with severe renal insufficiency.[4,5] A lower starting dose of irinotecan and FU may be needed for patients with hepatic impairment.
  • Maneuvers to prevent neurotoxicity
    • Pharmacologic methods to prevent/delay the onset of oxaliplatin-related neuropathy are controversial due to the absence of large clinical trials proving benefit. Counsel patients to avoid exposure to cold during and for approximately 48 hours after each infusion. Prolongation of the oxaliplatin infusion time from two to six hours may mitigate acute neurotoxicity.
  • Cardiac issues
    • QT prolongation and ventricular arrhythmias have been reported after oxaliplatin. ECG monitoring is recommended if therapy is initiated in patients with heart failure, bradyarrhythmias, coadministration of drugs known to prolong the QT interval, and electrolyte abnormalities. Avoid oxaliplatin in patients with congenital long QT syndrome. Correct hypokalemia and hypomagnesemia prior to initiating oxaliplatin.

• Monitoring parameters:

  • CBC with differential and platelet count prior to each treatment.
  • Assess electrolytes (especially potassium and magnesium) and liver and renal function prior to each treatment.
  • Irinotecan is associated with early and late diarrhea, both of which may be severe. Patients must be instructed in the early use of loperamide for late diarrhea. Patients who develop diarrhea should be closely monitored and supportive care measures (eg, fluid and electrolyte replacement, loperamide, antibiotics, etc) should be provided as needed. For patients who develop abdominal cramping and/or diarrhea within 24 hours of receiving irinotecan, administer atropine (0.3 to 0.6 mg IV) and premedicate with atropine for later cycles.
  • Assess changes in neurologic function prior to each treatment.

• Suggested dose modifications for toxicity (The specific dose alteration parameters for the FOLFOXIRI regimen in colorectal cancer patients were not published in the original phase III trial. The following suggestions are based upon dose reductions used in a trial using a comparable regimen (FOLFIRINOX) for advanced pancreatic cancer.)

  • Myelotoxicity
    • Do not retreat unless granulocyte count >= 1500/microL and platelet count is >= 75,000/microL.
    • Neutropenia:
      • If day 1 treatment delayed for granulocytes < 1500/microL or febrile neutropenia or grade 4 neutropenia > 7 days, reduce irinotecan dose to 150 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce oxaliplatin dose to 60 mg/m2 and the dose of infusional FU an additional 25%. If nonrecovery after two weeks, delay or third occurrence of granulocytes < 1500/microL on day 1, or febrile neutropenia or grade 4 neutropenia at any time during cycle, discontinue treatment.
    • Thrombocytopenia:
      • If day 1 treatment delayed for platelet count is < 75,000/microL, reduce oxaliplatin dose to 60 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce irinotecan dose to 150 mg/m2. If nonrecovery after two weeks delay or third occurrence of platelets < 75,000/microL, discontinue treatment. For grade 3 or 4 thrombocytopenia during treatment, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 150 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
  • Diarrhea
    • Do not retreat with FOLFOXIRI until resolution of diarrhea for at least 24 hours without antidiarrheal medication. For diarrhea grade 3 or 4, or diarrhea with fever and/or grade 3 or 4 neutropenia, reduce irinotecan dose to 150 mg/m2 and the continuous FU dose to 75% of original dose. For second occurrence, reduce the oxaliplatin dose to 60 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
    • NOTE: Severe diarrhea, mucositis, and myelosuppression after FU should prompt evaluation for DPD deficiency.
  • Mucositis or palmar-plantar erythrodysesthesia
    • For grade 3 to 4 toxicity, reduce dose of infusional FU by 25%.
  • Neurotoxicity
    • For transient grade 3 paresthesias/dysesthesias or grade 2 symptoms lasting more than seven days, decrease oxaliplatin dose by 25%. Discontinue oxaliplatin for grade 4 or persistent grade 3 paresthesia/dysesthesia.
    • There is no recommended dose for resumption of FU administration following development of hyperammonemic encephalopathy, acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances; the drug should be permanently discontinued.
  • Pulmonary toxicity
    • Oxaliplatin has rarely been associated with pulmonary toxicity. Withhold oxaliplatin for unexplained pulmonary symptoms until interstitial lung disease or pulmonary fibrosis is excluded.
  • Cardiotoxicity
    • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of FU administration following development of cardiac toxicity, and the drug should be discontinued.
  • Other toxicity
    • Any other toxicity >= grade 2, except anemia and alopecia, can justify dose reduction if medically indicated.
    • For other nonhematologic toxicities, if grade 2, hold treatment until ≤grade 1; if grade 3 or 4, hold treatment until ≤grade 2.[5]
  • If there is a change in body weight of at least 10%, doses should be recalculated.

[assessment]

• Blood culture results from 2023-05-04 and 2023-04-27 indicate that Acinetobacter nosocomialis is susceptible to cefepime with a MIC of 2 ug/mL and levofloxacin with a MIC of less than 0.12 ug/mL. Cefepime has been administered since 2023-04-25, while levofloxacin was administered between 2023-04-06 and 2023-04-20. Since the 2023-05-08 CXR shows no significant improvement in the pneumonia, it might be appropriate to consider including meropenem or imipenem-cilastatin as potential next candidate antibiotics for treatment.

[tube feeding]

• Since Harnalidge (tamsulosin 0.4mg PO QDAC) is not suitable for tube feeding, it is recommended to switch to Urief (silodosin 8mg PO QD) as an alternative for the patient’s needs.

230425

[assessment]

• On 2023-04-25, the patient’s CRP was 4.03mg/dL, WBC count was 23.36K/uL, and neutrophils were at 89.1%. Tachycardia and tachypnea were also observed, along with a body temperature exceeding 38 degrees Celsius in the morning. Signs of lung infection remain evident. Cefim (cefepime) at 2000mg Q8H has been administered, and blood culture results are pending. Cravit (levofloxacin) was used for 2 weeks prior to cefepime.
• Ipratran (ipratropium bromide), Sindecon (oxymetazoline), Actein (acetylcysteine) and Medason (methylprednisolone) are used to relieve respiratory symptoms.
• The patient’s underlying conditions are being managed with appropriate medications: hypothyroidism is treated with Eltroxin (levothyroxine), HTN with Amtrel (amlodipine and benazepril), constipation with Through (sennoside), BPH with Harnalidge (tamsulosin), oral thrush with Mycostatin (nystatin) and pain with morphine and fentanyl.
• No medication reconciliation issues have been identified after reviewing the PharmaCloud database. As the lab results indicate generally normal liver and kidney function, there is no need to adjust the drug dosages for liver or kidney-related reasons.
• The patient has experienced a weight loss of more than 5 kg in the past two weeks (48.7 kg on 2023-04-05 and 54.5 kg on 2023-04-19). Adequate nutritional support may be needed to address this problem.

220420

[assessment]

• This patient has MMR-proficient lower rectal cancer with liver and lung metastases (2020-07-01 pathology). The lung mets were confirmed to be in progress (2022-04-14 CT) followed by the MWA (2022-02-11) for the liver mets.
• During this hospital stay, the patient resumed using FOLFOXIRI plus self-paid bevacizumab and pembrolizumab as a palliative treatment, the same regimen was used during 2021-05-04 to 2021-07-14. Before that, FOLFOXIRI plus bevacizumab were also used from August 2020 to February 2021.
• Lab data reported on 2022-04-19 revealed that liver and kidney function, serum electrolytes, and blood cell counts were generally normal.
• The nursing note does not indicate any intolerances so far since this hospitalization. No issue with current medication.

700358146

230505

{not completed}

[MedRec]

• 2023-05-05 POMR progress note
  • Leukocytosis, suspect CML
    • Assessment: improved (WBC 225330 -> 72330 -> 71950 -> 64290 /uL)
    • Plan:
      • Bone marrow biopsy performed on 2023/05/02
      • Plasma exchange + Vitacal 60mL IVD for calcium supplement on 2023/05/02
      • Hydrea 500 mg/cap 2# BID start from 2023/05/02
  • Type 2 diabetes mellitus
    • Assessment: stable
    • Plan:
      • Januvia 100mg/tab 1# QD
      • Glucose one touch QDAC
      • Diet modification
  • Hypertension and hyperlipidemia
    • Assessment: stable
    • Plan:
      • Norvasc 5mg/tab 1# QD
      • Crestor 10mg/tab 0.5# QD
  • Hypokalemia + hypomagnesemia
    • Assessment: improving
    • Plan:
      • 0.298% KCl in 0.9% NaCl Injection 500 mL BID
      • Magnesium Sulfate 10% 20mL BID
• 2023-04-27 SOAP Hemato-Oncology
  • S
    • Referred for leukocytosis noted on 2023-04-27.
    • Occupation touched paint solvent in the past
  • O
    • 2023/04/26
      • Band = 12.0 %;
      • Neutrophil = 51.0 %;
      • Lymphocyte = 2.0 %;
      • Monocyte = 6.0 %;
      • Eosinophil = 0.0 %;
      • Basophil = 1.0 %;
      • Metamyelocyte = 10.0 %;
      • Myelocyte = 3.0 %;
      • Promyelocyte = 15.0 %;
      • WBC = 104.08 x10^3/uL;
      • RBC = 3.61 x10^6/uL;
      • HGB = 11.6 g/dL;
      • HCT = 34.9 %;
      • MCV = 96.7 fL;
      • MCH = 32.1 pg;
      • MCHC = 33.2 g/dL;
      • PLT = 380 x10^3/uL;
      • RDW-CV = 16.1 %;
      • MPV = 11.1 fL;
  • A/P
    • Admission for BM study and leukopheresis
    • Already request patient to ER if any condition

[exam findings]

• 2023-05-02 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Myeloproliferative neoplasm (Differential diagnosis: Chronic myeloid leukemia and, … etc.)
    • NOTE: Correlation of bone mrrow smear, peripheral blood data, molecular genetic study (BCR/ABL), flow cytometery and clinical findings is recommended.
  • Microscopically, it shows nhyper cellularity (> 95%), 10:1 of M:E ratio. Both myeloid and erythroid lineages demonstrate maturation. Megakaryocytes are present in increased in numbers (6~8 per HPF) and demonstate hypholobulated morphologic pattern. Blast-like cells (CD117+, < 5%) are present.
  • Immunohisotchemical stain reveals CD34(-), CD138(focal+, 1~2%), MPO(+), CD71(focal +), CD61(+).

[assessment - not posted]

• Hyperleukocytosis has been mitigated by the administration of Hydrea (hydroxyurea 500mg) 2# BID since 2023-05-02.
  • 2023-05-05 WBC 64.29 x10^3/uL
    
  • 2023-05-04 WBC 71.95 x10^3/uL
    
  • 2023-05-03 WBC 72.33 x10^3/uL
    
  • 2023-05-02 WBC 225.33 x10^3/uL
    
  • 2023-05-02 WBC 107.47 x10^3/uL
    
  • 2023-04-30 WBC 90.67 x10^3/uL
    
  • 2023-04-29 WBC 93.95 x10^3/uL
    
  • 2023-04-26 WBC 104.08 x10^3/uL
• While allopurinol or febuxostat might be considered for prophylaxis of potential tumor lysis syndrome, laboratory data shows a decrease in serum uric acid levels.
  • 2023-05-03 Uric Acid 6.9 mg/dL
    
  • 2023-04-30 Uric Acid 8.1 mg/dL
    
  • 2023-04-29 Uric Acid 8.3 mg/dL

700514733

230505

[exam findings]

• 2023-04-13 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette
• 2023-04-13 All-RAS + BRAF
  • ALL-RAS: Detected(KRAS codon 12 GGT>AGT, p.G12S)
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-03-31 CT - abdomen
  • CC: BW loss (+), anemia
    • 20230320 colonoscopy: An ulcerative tumor with lumen obstruction was noted at level probably at ascending colon
    • PATHO: Adenocarcinoma, moderately differentiated
  • Findings:
    • There is segmental circumferential asymmetrical wall thickening at the ascending colon with irregular contour and adjacent omentum fatty stranding, measuring 8 cm in length that is c/w adenocarcinoma (T4b).
      • In addition, there are seven enlarged nodes in the adjacent mesocolon (N2b).
    • There is mild ascites in the cul-de-sac.
    • There is a small soft tissue nodule in RLL of the lung, measuring 3 mm in size at lung window setting.
      • Follow up chest CT 3 months later is indicated.
    • There are several stones in the distal CBD.
      • In addition, there are multiple gallstones.
    • The spleen shows prominence in size (long axis:11.4 cm).
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2023-03-27 Bronchodilator Test
  • Normal ventilatory function
  • Not significant bronchodilator reversibility
• 2023-03-21 Patho - colon biopsy
  • Colon, ascending, biopsy — Adenocarcinoma, moderately differentiated
    
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2023-03-20 Colonoscopy
  • Colon cancer, ascending colon, s/p biopsy
  • Colon polyp, transvers colon, s/p biopsy
  • Internal hemorrhoid
• 2023-03-20 Esophagogastroduodenoscopy, EGD
  • Superfical gastritis, antrum
  • Duodenal ulcer scar, bulb, LC
• 2023-03-03, -02-27 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Interstitial and alveolar infiltrates involving predominantly the mid-and lower-lung fields, and mild pleura effusions are seen. Acute pulmonary edema is highly suspected.
• 2023-02-24 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (171 - 64) / 171 = 62.57%
    • M-mode (Teichholz) = 62
  • Conclusion
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA and LV, elevated LA filling pressure
    • Mild to moderate TR, moderate MR, PR
    • Pulmonary hypertension
• 2023-02-23 ECG
  • Sinus tachycardia
  • Nonspecific ST and T wave abnormality
• 2023-02-23 SONO - nephrology
  • No significant abnormality from echography for both kidneys.
  • Bilateral plerual effusion.

[MedRec]

• 2023-04-12 ~ 2023-04-15 POMR Hemato-Oncology
  • Discharge diagnosis
    • adenocarcinoma, moderately differentiated of colon cancer T4N2bM0 stage IIIC S/P C1 chemotherapy with Erbitux (self-paid)/FOLFIRI
    • chronic viral hepatitis B without delta-agent HBsAg positive
  • CC
    • for C1 chemotherapy with Erbitux (self-paid)/FOLFIRI
  • Discharge prescription
    • Baraclude (entecavir 0.5mg) 1# QDAC 7D
    • loperamide 2mg 1# PRNQ6H 7D (if watery diarrhea > 3 times)
    • Roumin (prochlorperazine maleate 5mg) 1# TID 7D (note: used to treat severe nausea and vomiting)
• 2023-04-07 SOAP Hemato-Oncology
  • O
    • 2023/04/07 CA-199 (NM) = 192.235 U/ml;
    • 2023/04/07 CEA (NM) = 347.620 ng/ml;
  • A/P
    • arrange admission on April 10 + port-A chemotherapy
• 2023-04-06 SOAP Colorectal Surgery
  • A/P
    • Lung nodule, cause ?? metastasis ??
    • Advanced A-colon cancer with retroperitoneal invasion;
    • Suggest systemic chemotherapy +/- target therapy for tumor shrinkage and may increase resectability
• 2023-03-15 SOAP Hemato-Oncology
  • O
    • 2023/03/08 FKLC = 39.3 mg/L;
    • 2023/03/08 FLLC = 51.0 mg/L;
    • 2023/03/08 FK/FL ratio = 0.77 ratio;
    • 2023/03/04 M-peak = Positive;
    • 2023/03/04 Stool OB (LIA) = Positive;
    • 2023/03/04 Occultblood (LIA) quantitative value = >999 ng/mL;
    • 2023/03/03 B2-Microglobulin = 2906 ng/mL;
    • 2023/03/02 Ferritin = 23.1 ng/mL;
    • 2023/02/27 WBC = 9.48 x10^3/uL;
    • 2023/02/27 HGB = 8.7 g/dL;
    • 2023/02/27 PLT = 412 x10^3/uL;
    • 2023/02/24 OB = Negative;
    • 2023/02/24 Fe (Iron-bound) = 363 ug/dL;
    • 2023/02/24 TIBC = 442 ug/dL;
    • 2023/02/24 UIBC = 79 ug/dL;
  • A/P
    • suggest to check bone marrow
    • patient is scheduled to check colonfibroscopy at 2023/03/20
    • wait the colonfibroscopy result.
• 2023-02-23 ~ 2023-02-27 POMR Cardiology
  • Discharge diagnosis
    • Heart failure, EF 62%, moderate MR, NT pro BNP 1812
    • Anemia, Fe 363, stool OB negative
    • Essential (primary) hypertension
    • Hypoalbuminemia, proteinuria(+/-)
  • CC
    • bilateral lower limbs edema and exertional shortness of breath progressively for the past 2 weeks
  • Discharge prescription
    • spironolactone 25mg 0.5# QD 5D
    • Zanidip (lercanidipine 10mg) 0.5# QD 5D
    • Ulstop (famotidine 20mg) 1# BID 5D
    • Torsix (torsemide 5mg) 1# QD 5D
    • Torsix (torsemide 5mg) 0.5# PRNQD 5D (prepared for BW increase > 0.5kg or edema)
    • Blopress (candesartan 8mg) 1# QD 5D
• 2023-02-23 SOAP Nephrology
  • S
    • Bilateral lower leg edema for one week
    • DOE (+) for one week
    • Orthopnea (-) PND (-)
    • Foamy urine (-)
    • PH: DM (-) HTN (-) Drug allergy: denied
    • Herb use : denied
    • To ER for CHF with severe anemia.
  • O
    • BP:170/54; HR:105;
    • BW not measured
    • Leg edema (+++)
    • CVA knocking pain (-)
    • BS: clear
    • NT-proBNP elevated
    • Bilateral pleural effusion
    • Hb 4.4
    • MCV 56.9
    • Urine examination: not collected
  • A/P:
    • Refer to ER for suspected CHF with severe anemia.

[chemoimmunotherapy]

• 2023-05-04 - cetuximab 500mg/m2 700mg 2hr + irinotecan 160mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3360mg NS 500mL 46hr (cetuximab + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + acetaminophen 500mg PO + NS 250mL
• 2023-04-13 - cetuximab 400mg/m2 500mg 2hr + irinotecan 160mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (cetuximab + FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + acetaminophen 500mg PO + NS 250mL

[assessment]

• Microcytic anemia, possibly caused by iron deficiency, has been present in the patient’s laboratory data for months, with low RBC, HGB, MCV, MCH, MCHC, and high RDW, even before the start of Cetuximab/FOLFIRI chemoimmunotherapy. Iron supplementation is recommended. After the planned blood transfusion, the addition of an oral form such as Foliromin tablets (ferrous sodium citrate 50mg) or Ferrum Hausmann drops (ferric hydroxide polymaltose complex) or an injectable form such as Ferrum (ferric hydroxide sucrose) may be considered.
  • 2023-05-04 HGB 7.7 g/dL
    
  • 2023-04-21 HGB 8.5 g/dL
    
  • 2023-04-12 HGB 7.0 g/dL
    
  • 2023-03-31 HGB 7.1 g/dL
    
  • 2023-02-27 HGB 8.7 g/dL
    
  • 2023-02-24 HGB 7.7 g/dL
    
  • 2023-02-23 HGB 4.4 g/dL
    
  • 2023-05-04 MCV 76.8 fL
    
  • 2023-04-21 MCV 76.8 fL
    
  • 2023-04-12 MCV 74.9 fL
    
  • 2023-03-31 MCV 74.3 fL
    
  • 2023-02-27 MCV 71.1 fL
    
  • 2023-02-24 MCV 66.6 fL
    
  • 2023-02-23 MCV 56.9 fL
    
  • 2023-05-04 MCH 22.3 pg
    
  • 2023-04-21 MCH 22.9 pg
    
  • 2023-04-12 MCH 21.7 pg
    
  • 2023-03-31 MCH 21.0 pg
    
  • 2023-02-27 MCH 20.4 pg
    
  • 2023-02-24 MCH 19.6 pg
    
  • 2023-02-23 MCH 14.9 pg
    
  • 2023-05-04 MCHC 29.1 g/dL
    
  • 2023-04-21 MCHC 29.8 g/dL
    
  • 2023-04-12 MCHC 28.9 g/dL
    
  • 2023-03-31 MCHC 28.3 g/dL
    
  • 2023-02-27 MCHC 28.7 g/dL
    
  • 2023-02-24 MCHC 29.5 g/dL
    
  • 2023-02-23 MCHC 26.2 g/dL
    
  • 2023-05-04 RDW-CV 22.7 %
    
  • 2023-04-21 RDW-CV 23.5 %
    
  • 2023-04-12 RDW-CV 27.0 %
    
  • 2023-02-24 RDW-CV 30.5 %
    
  • 2023-02-23 RDW-CV 21.2 %

700732120

230505

{not completed}

[MedRec]

• 2021-03-30 ~ 2021-05-06 POMR General and Digestive Surgery
  • Discharge diagnosis
    • Adenocarcinoma of renmant anterior gastric with liver S2-3 invasion, pT4bN2(cM0); pStage: IIIB, status post total gastrectomy with splenectomy + en block S2-3 resection and lymph node dissection on 2021/04/22. ECOG:2
    • Malignant neoplasm of stomach, unspecified
    • Distal common bile duct stone status post common bile duct explore with stone resection with scope and common bile duct primary repair on 2021/04/22.
    • Bacteremia due to Acinetobacter ursingii related
    • Hypoalbuminemia
  • CC
    • RUQ abdominal pain with radiation to back for over 1 week

[surgical operation]

• 2021-04-22
  • Surgery
    • total gastrectomy with splenectomy
    • en block S2-3 resection
    • retreoperitoneal LN dissection
    • CBDE with stone retraction with scope and CBE primary repair
  • Finding
    • 7 x 6.5 cm ulcerative mass at renmant anterior stomach with S2-3 invasion
    • multiple LN enlarge at 7,8,9
    • multiple pigment stones at distal CBD with CBD 1.8cm diameter

[medication]

2023-03-15 ~ 2023-03-29 - UFT (tegafur 100mg, uracil 224mg) 2# BID

2022-02-08 ~ 2022-04-25 - TS-1 (tegafur, gimeracil, oteracil) 2# BID

2021-09-09 ~ 2021-10-15 - Xeloda (capecitabine 500mg) 2# BID

B-Red (hydroxocobalamin 1mg)

700905127

230505

[MedRec]

• 2023-04-19 SOAP Hemato-Oncology
  • A/P: On 2023-04-19, already mention that admission for tissue biopsy (bronchoscopy), otherwise self pay osimertinib directly, or IV or oral C/T.
• 2023-02-01 SOAP Hemato-Oncology
  • O
    • AE: Gr 1 Anorexia
    • AE: Gr 2 Anemia
• 2022-12-28 SOAP Hemato-Oncology
  • A/P: Due to more amount of left pleural effusion on 2022-12-28, increase erlotinib from 1# QOD to 1# QD since 2022-12-28.
  • Prescription
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
    • Tarceva (erlotinib 150mg) 1# QD for QODAC use
    • Alpraline (alprazolam 0.5mg) 1# HS if insomnia
• 2022-11-30 SOAP Hemato-Oncology
  • O
    • Cancer Multidisciplinary Team Meeting Conclusion, meeting date 20221108
      • NSCLC, stage IVA
      • TKI.
  • Prescription
    • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
    • Tarceva (erlotinib 150mg) 1# QOD for QODAC use
    • Alpraline (alprazolam 0.5mg) 1# HS if insomnia
• 2022-11-01 ~ 2022-11-15 POMR Hemato-Oncology
  • Discharge diagnosis
    • Malignant neoplasm of upper lobe, left bronchus or lung
    • Pleural effusion in other conditions classified elsewhere
    • Secondary malignant neoplasm of right lung
    • Hyperlipidemia, unspecified
    • Hypothyroidism, unspecified
    • Essential (primary) hypertension
    • Type 2 diabetes mellitus without complications
  • CC: Dyspnea noted during activity

700930564

230505

[diagnosis] - 2023-03-22 SOAP

• pancrease cancer with liver metastasis and perinteal seeding stage IV, with maligancy ascites
• gastric adenocarcinoma in situ

[past history]

• Denied TB, Asthma, DM, HTN or Malignancy diseases.
• No known allergens
• Denied other admission or operation history.    

[allergy]

• NKDA

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-05-02 Ascites Tapping
  • 3000ml yellowish color ascites were drained.
• 2023-04-28 ECG 24hr portable
  • Sinus rhythm
  • Occasional isolated apcs
  • Frequent apc couplets
  • Paroxysmal atrial flutter-fibrillation
  • Occasional isolated vpcs
  • No long pause
• 2023-04-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 10) / 53 = 81.13%
    • M-mode (Teichholz) = 81
  • Conclusion:
    • Normal LV filling pressure; impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis and prominent posterior mitral annulus calcification with mild AR; mild MR.
    • Sinus tachycardia.
    • Ascites and pleural effusions.
• 2023-04-27 ECG
  • Supraventricular tachycardia
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2023-03-27 Ascites Tapping
  • Indication: Ascites
  • Symptoms: Abdominal fullness
  • Course: 18G needle was inserted at RLQ under echo guided insertion.
  • Findings: 3000 ml straw color ascites was drained.
• 2023-03-26 KUB
  • Fecal material store in the colon.
  • Ascites is highly suspected. Please correlate with sonography.
  • Spondylosis with scoliosis of the L-spine with convex to right side
• 2023-03-17 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
• 2023-03-09 Patho - pancreas biopsy
  • PATHOLOGIC DIAGNOSIS
    • Pancreas, FNB — Ductal adenocarcinoma, poorly differentiated
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consists of multiple small pieces of tan gray soft tissue, labeled pancreas, measuring up to 1.0 x 0.1 x 0.1 cm. All for section.
  • MICROSCOPIC EXAMINATION
    • The sections show a picture of adenocarcinoma, composed of nests, cords, and single pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation and mucin secretion can be found. Tumor necrosis is present also.
• 2023-03-08 Endoscopic Ultrasound
  • Diagnosis
    • Pancreatic body tumor, s/p CH-EUS & EUS/FNB
    • Pancreatic cystic tumor, body
    • Lymphadenopathy, periarotic area
  • Suggestion
    • Pursue pathology result
    • regular F/U
• 2023-03-03 MR Cholangiography, MRCP
  • History
    • 20230226 CC: Abdominal Pain
    • 20230226 CT: A poor enhancing lesion (3.2x5.1cm) at pancreatic body and tail with SMA and SMV invasion r/o malignancy. R/O peritoneal carcinomatosis and liver metastases.
    • 20230227 CA199:582 U/mL (< 35), CEA: normal.
  • Findings:
    • There is a mass lesion in the pancreatic body and tail, 7.8 x 3.2 cm in size, showing hypointensity on T1WI, mild hyperintensity on T2WI and DWI. During contrast enhanced study, this lesion shows poor enhancement in arterial phase, portal venous phase, and delayed phase images.
      • Adenocarcinoma of the pancreatic body and tail (T3) is noted.
      • In addition, there is non-visualization of the splenic vein that is c/w tumor invasion.
    • There are five enlarged nodes in the celiac trunk, gastrohepatic ligament, and hepatoduodenal ligament that are c/w metastatic nodes (N2).
    • There are two masses 1.8 cm and 1.2 cm in S7 of the liver, shows mild hyperintensity on both T2WI and DWI, and poor enhancement.
      • Two liver metastases (M1) are noted.
    • There is massive ascites and multiple soft tissue nodules in the omentum that is c/w carcinomatosis (M1).
      • Please correlate with ascites cytology.
    • Bil. renal cysts (up to 6.6cm).
    • Hyperplasia of left adrenal gland.
  • IMP:
    • Adenocarcinoma of the pancreatic body and tail with liver metastases and carcinomatosis is suspected.
      
    • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for pancreatic cancer: T3 N2 M1, stage: IV
• 2023-03-01 Patho - stomach biopsy
  • Duodenum, SDA to second portion, biopsy (A) — chronic inflammation and Brunner’s gland hyperplasia.
  • Stomach, Gastric ulcer, AW of lower antrum, s/p biopsy(B)— Chronic gastritis with intestinal metaplasia, H pylori NOT present
  • Stomach, Gastric erosion, PW of upper antrum, s/p biopsy(C)— ulcer with adenocarcinoma in situ (AIS), demonstrated with IHC stain of cytokeratin.
  • Stomach, Gastric lesion, GC of upper antrum, s/p biopsy(D)— Chronic gastritis, H pylori NOT present
• 2023-02-27 Cell Block - Ascites
  • DIAGNOSIS:
    • SMEARS and CELLBLOCK: positive for malignancy; IHC stains: CK7 (+), CK20 (-), CDX2 (-), CA19-9 (-), CK19 (-).
      
  • GROSS DESCRIPTION:
    • 21 ml turbid
      
  • MICROSCOPIC DESCRIPTION:
    • SMEARS and CELLBLOCK: clusters of papillae with large nuclei and large cytoplasmic vacuole, a picture od adenocarcinoma.
      
    • IHC stains: CK7 (+), CK20 (-), CDX2 (-), CA19-9 (-), CK19 (-). The picture does NOT support gastric or pancreato-biliary origin.
• 2023-02-26 CTA - abdomen
  • A poor enhancing lesion (3.2x5.1cm) at pancreatic body and tail with SMA and SMV invasion r/o malignancy. R/O peritoneal carcinomatosis and liver metastases. Massive ascites. Enlargement of prostate.

[MedRec]

• 2023-03-22 SOAP Hemato-Oncology
  • S
    • This 78 year old man is a case of pancrease cancer with liver and peritoneal metastasis, stage IV, and gastric adenocarcinoma in situ.
    • The patient is currently unaware of the pancreatic cancer situation and only knows about the presence of a gastric tumor.
  • O
    • Lab
      • 2023-02-27 CA199 582.59 U/mL
        
      • 2023-02-27 CEA 1.82 ng/mL
        
    • Will on Abraxane plus gemcitabine
  • A
    • pancrease cancer with liver metastasis and perinteal seeding stage IV, with maligancy ascites
    • gastric adenocarcinoma in situ
  • P
    • admiited for port A insertion, family meeting, symptom control, discuss with palliative chemotherapy
    • refer to ER for ascites tapping and then admission for further management.
• 2023-02-26 ~ 2023-03-09 POMR Gastroenterology and Hepatology
  • Discharge diagnosis
    • Suspicious pancreas cancer of body and tail with liver and peritoneum metastasesis T3N2M1, stage: IV, ECOG:2, status post paracentesis, status post endoscopic ultrasound-guided fine needle biospy on 2023/03/08
    • Gastric adenocarcinoma in situ
    • Gastric ulcer
    • Duodenal erosion
    • Colon polyps, cecum, proximal ascending and transverse colon, status post polypectomy
  • CC: abdominal distention for days
  • Prescription
    • spironolactone 25mg 2# QD
    • Nexium (esomeprazole 40mg) 1# QDAC
    • Through (sennoside 12mg) 1# HS
    • Curam (amoxicillin 875mg + clavulanic acid 125mg) 1# Q12H 3D

[chemotherapy]

• 2023-04-24 - Nab-paclitaxel 80mg/m2 100mg 90min + gemcitabine 800mg/m2 800mg NS 100mL 30min (D1) dose reduced due to adverse reactions
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-04-03 - Nab-paclitaxel 100mg/m2 120mg 90min + gemcitabine 1000mg/m2 1200mg NS 100mL 30min (D1,8,15)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-03-27 - Nab-paclitaxel 100mg/m2 120mg 90min + gemcitabine 1000mg/m2 1200mg NS 100mL 30min (D1,8,15)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

[note]

hyperbilirubinemia - ref: 2023-05-05 UpToDate

• An increase in unconjugated bilirubin in serum results from overproduction, impairment of uptake, or impaired conjugation of bilirubin. Unconjugated hyperbilirubinemia may be caused by:
  • Hemolysis
  • Extravasation of blood into tissue
  • Dyserythropoiesis
  • Stress situations (eg, sepsis) leading to increased production of bilirubin
  • Impaired hepatic bilirubin uptake
  • Impaired bilirubin conjugation
• An increase in conjugated bilirubin is due to decreased excretion into the bile ductules or leakage of the pigment from hepatocytes into serum. Conjugated hyperbilirubinemia may be caused by:
  • Biliary obstruction (eg, gallstones, pancreatic or biliary malignancy, AIDS cholangiopathy, parasites)
  • Viral hepatitis
  • Alcoholic hepatitis
  • Nonalcoholic steatohepatitis
  • Primary biliary cholangitis
  • Drugs and toxins
  • Ischemic hepatopathy
  • Liver infiltration
  • Inherited disorders (eg, Dubin-Johnson syndrome, Rotor syndrome, progressive familial intrahepatic cholestasis)
  • Total parenteral nutrition
  • Postoperative jaundice
  • Intrahepatic cholestasis of pregnancy
  • End-stage liver disease
  • Organ transplantation (eg, bone marrow, liver)

CA199, CEA - ref: 2023-05-05 ChatGPT

• CA199: Elevated levels of CA199 can be associated with certain types of cancer, particularly pancreatic cancer. It may also be elevated in other malignancies such as colorectal, gastric, liver, and bile duct cancers.
• CEA: CEA is a tumor marker, which means that its levels in the blood can become elevated in the presence of certain types of cancer, particularly colorectal cancer. However, CEA is not a specific marker, and its levels can also be elevated in other malignancies, such as lung, breast, stomach, pancreas, and ovarian cancers.

[assessment]

• Nab-paclitaxel and gemcitabine treatment was first initiated on 2023-03-27 and is currently ongoing. The 3rd dose was administered on 2023-04-24 with a 20% reduction in dosage due to dizziness, nausea, and vomiting. The patient also experienced conscious disturbance and abdominal fullness, which led to ascites tapping on 2023-05-02.

• After receiving 3 doses of the regimen, the patient’s tumor marker CA199 remains relatively unchanged, while there is a significant increase in CEA levels.

  • 2023-05-05 CA199 1087.93 U/mL
    
  • 2023-04-11 CA199 1161.06 U/mL
    
  • 2023-03-28 CA199 (Nuclear Medicine) 1151.56 U/ml
    
  • 2023-02-27 CA199 582.59 U/mL
    
  • 2023-05-05 CEA 5.54 ng/mL
    
  • 2023-04-11 CEA 3.78 ng/mL
    
  • 2023-03-28 CEA (Nuclear Medicine) 1.869 ng/ml
    
  • 2023-02-27 CEA 1.82 ng/mL

• The TPR panel indicated no bowel movement on 2023-05-03 and 2023-05-04. It is suggested to assess whether the patient has developed constipation, as bisacodyl is prescribed as needed (PRN) for this issue.

230502

[tube feeding]

• As of 2023-05-01, the patient’s serum potassium level has returned to the normal range of 3.5 mmol/L. However, the current prescription for Const-K will expire on 2023-05-04, and it may be worth considering discontinuing this medication. It should be noted that the potassium content of fruits is relatively low (for example, about 2.2 mEq/inch or 0.9 mEq/cm in bananas), meaning that it would take about two to three bananas to provide 40 mEq. Const-K is an extended-release formulation containing 10 mEq/tab, which is less potassium than is found in one banana. If injectable potassium supplementation is not preferred (Const-K remains the only oral potassium supplement available today), please crush the tablet into particles and administer it with water.

• For patients who have difficulty swallowing Protase (pancrelipase) capsules, the capsule can be opened and the enteric-coated granules can be released into a small amount of liquid food with a pH not exceeding 5.5. Tube feed the drug particles with drinking water or juice to ensure complete ingestion.

• As for Megejohn (megestrol acetate), since our hospital has Megest (megestrol 40mg/mL, 120mL/bot) in stock, it is suggested to switch Megejohn to the Megest oral suspension.

230325

[assessment]

• The patient has been diagnosed with stage IV pancreatic cancer with liver metastasis and peritoneal seeding, as well as in situ gastric adenocarcinoma. Although the patient is currently only aware of the stomach tumor, the pancreatic cancer is more advanced and should be prioritized for treatment.
• It is possible that the modified FOLFIRINOX regimen could be considered for this patient, provided that the patient has an ECOG score of 0 or 1.

701300015

230505

[exam findings]

• 2023-02-14 CT - abdomen
  • History and indication:
    • CEA = 89.37 ng/mL;
    • Adenocarcinoma of sigmoid colon with obstruction, cT3N1M0, stage IIIB post T-loop colosotmy (2021/06/16) status post laparoscopic sigmoidectomy on 2021/08/05, pT3N1bM0(3/14), G2, LVI(+), PNI(+), CRM(+), stage IIIB
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P colon operation with colostomy. Recurrent tumors (up to 3.0cm) at LLQ.
    • Right renal stone (8mm).
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • S/P colon operation with colostomy. Recurrent tumors (up to 3.0cm) at LLQ.
• 2023-01-17 Colonoscopy
  • Findings
    • 10cm to previous operation site, ulcerative lesion but re-stenosis
    • 30cm from distal osteomy, then much old clot in colon and can not be removed.
  • Diagnosis
    • Anastomosis s/p transanal dissection but re-stenosis
  • Suggestion
    • OPD discuss treatment strategy.
• 2022-12-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (56 - 11) / 56 = 80.34%
    • M-mode (Teichholz) = 81
  • Conclusion
    • Asymmetrical septal hypertrophy and apical hypertrophy, suspected non-obstructive type hypertrophic cardiomyopathy; indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA.
    • Normal LV and RV systolic function
    • Aortic valve sclerosis with mild AR.
    • Degenerative changes of mitral valve with mild to moderate MR; mild TR; moderate PR.
    • Prominent aortic root calcification with multiple protruding non-mobile atheromas (7-10 mm of thickness).
• 2022-12-07 ECG
  • Sinus bradycardia
  • Left ventricular hypertrophy
  • Marked ST abnormality, possible anterior subendocardial injury
• 2022-12-05 CT - abdomen
  • s/p colostomy with its orifice at RLQ.
  • s/p LAR with autosuture retention. No evidence of recurrent/residual tumor in the study.
• 2022-08-24, -05-20 CT - abdomen
  • There is no evidence of tumor recurrence.
• 2022-02-11, 2021-11-03 CT - abdomen
  • S/P LAR with autosuture retention over the sigmoid colon.
  • S/P colostomy of right transverse colon.
  • There is no evidence of tumor recurrence.
• 2021-05-05 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Large intestine, sigmoid colon, laparoscopic sigmoidectomy — Adenocarcinoma, moderately differentiated
      
    • Resection margins, proximal and distal: Free
      
    • Lymph node, mesocolic, dissection — Metastatic adenocarcinoma (3/14)
      
    • Pathology stage: pT3N1b(if cM0); AJCC stage IIIB
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: laparoscopic sigmoidectomy
      
    • Specimen site: sigmoid colon
      
    • Specimen size: 12 cm in length
      
    • Tumor size: 4x 3 cm
      
    • Tumor location: 3 cm away from the closest resection margin
      
    • Depth of invasion grossly:pericolorectal tissue
      
    • Mucosa elsewhere: Not remarkable
      
    • Representative section: A1-2:LNs, A3-6:tumor, B＆C:cut-ends
      
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
      
    • Histology Grade: moderately differentiated
      
    • Depth of invasion: pericolorectal tissue
      
    • Angiolymphatic invasion: Present.
      
    • Perineural invasion: Present
      
    • Discontinuous extramural tumor extension: Not identified.
      
    • Circumferential (radial) margin of rectum: Uninvolved
      
    • Lymph node metastasis, mesocolic: Positive (3/14)
      
    • Lymph node metastasis, IMA/SMA: N/A.
      
    • Extranodal involvement: Present.
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT)
        • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
      • Regional Lymph Nodes (pN)
        • pN1b: Two or three regional lymph nodes are positive
          
      • Distant Metastasis (pM)
        • N/A
          
    • Type of polyp in which invasive carcinoma arose: Not identified
      
    • Additional pathologic findings: None identified
      
    • TNM descriptors: N/A
      
    • Tumor regression grading S/P CCRT: N/A.
• 2021-08-03 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 33) / 126 = 73.81%
    • M-mode (Teichholz) = 74
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA, LVH, grade 2 LV diastolic dysfunction
    • Mild AR, and PR, mild to moderate MR
• 2021-06-21 Patho - colon biopsy
  • Colon, 18 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2021-06-13 CT - abdomen
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M0(M_value) STAGE:IIIB(Stage_value)

[MedRec]

• 2023-02-22 SOAP Radiation Oncology
  • A: Adenocarcinoma, moderately differentiated, of the sigmoid colon, stage cT3N1bM0(IIIB), s/p Laparoscopic sigmoidectomy, stage pT3N1b(cM0), AJCC stage IIIB, with local recurrence, status during chemotherapy.
  • P: Radiotherapy is indicated for this patient with the following indicators: local recurrence
    • Goal: curative
    • Treatment target and volume: abdominal LLQ to pelvic area.
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 4500cGy/25 fractions of the abdominal LLQ to pelvic area.
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2023-03-07.
• 2021-08-27 SOAP Hemato-Oncology
  • A: Adenocarcinoma of sigmoid colon with obstruction, cT3N1M0, stage IIIB post T-loop colosotmy (2021/06/16) status post laparoscopic sigmoidectomy on 2021/08/05, pT3N1bM0(3/14), G2, LVI(+), PNI(+), CRM(+), stage IIIB
  • P
    • F/U CEA (2021-09), CXR, CT, colonoscopy (2022-05)
    • suggest adjuvant chemotherapy, arrange chemotherpay
    • close colostomy 3 months later (2021-11)

[radiotherapy]

• 2023-03-15 ~ 2023-04-20) - 4500cGy/25 fractions of the abdominal LLQ to pelvic area.

[chemotherapy]

• 2023-05-04 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4555mg NS 250mL 46hr (FOLFIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

• 2023-04-07 (FOLFIRI)

• 2023-03-22 (FOLFIRI)

• 2023-03-08 (FOLFIRI)

• 2023-02-22 (FOLFIRI)

• 2022-02-23 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-02-09 (FOLFOX)

• 2022-01-26 (FOLFOX)

• 2022-01-12 (FOLFOX)

• 2021-12-29 (FOLFOX)

• 2021-12-15 (FOLFOX)

• 2021-12-01 (FOLFOX)

• 2021-11-17 (FOLFOX)

• 2021-11-03 (FOLFOX)

• 2021-10-20 (FOLFOX)

• 2021-10-01 (FOLFOX)

• 2021-09-09 (FOLFOX)

[assessment]

• No medication reconciliation issues have been identified for this patient.

• The patient appears to be tolerating the current regimen well, and his labs are mostly within normal ranges, with the exception of slightly elevated liver function tests and BUN.

700279535

230504

[allergy]

• NKDA

[family history]

• Aunt: DM
• Uncle: Colon ca
• Father: heart disease, ESRD under hemodialysis

[exam findings]

• 2023-05-03 Endoscopic Ultrasound, EUS
  • Pancreatic body cancer, s/p CH-EUS & EUS/FNB (B)
  • Hepatic tumors, s/p CH-EUS & EUS/FNB (A)
  • Lymphadenopathy
• 2023-05-02, -04-27 CXR
  • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
• 2023-04-17 CT - abdomen
  • Indication:
    • HBV f/u, elevated CEA and CA-199
    • multiple liver tumor, suspicious pancreatic tumor with liver metastasis.
  • Abdominal CT with and without enhancement revealed:
    • Soft tissue mass at pancreatic body/neck junction measuring 2.9cm in largest dimension is found. Pancreatic cancer is considered. The distal pancreatic duct is obstructed with dilatation.
    • Low density lesions scattered at both lobes of liver measuring 2.8cm are found. Liver meta is considered.
  • IMP: Pancreatic cancer with liver meta.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T2(T_value) N:N0(N_value) M:M1(M_value) STAGE:____(Stage_value)
• 2023-04-15 SONO - abdomen
  • Diagnosis
    • Liver tumors, favor metastatic tumors
    • pancreatic tumor
    • mild fatty liver, suspected mild liver parenchyma disease
  • Suggestion
    • 4 phase CT or dynamic MRI study
• 2022-10-08 SONO - abdomen
  • Diagnosis
    • Liver tumor favor hemangioma
    • mild fatty liver, suspected mild liver parenchyma disease
    • fatty infiltration of pancreas
    • suspected pancreatic lesion: hypoechoic
  • Suggestion
    • suggest further image study such as CT scan or MRI or EUS
• 2022-03-26 SONO - abdomen
  • Diagnosis
    • Liver tumor favor hemangioma
    • mild fatty liver, suspected mild liver parenchyma disease
    • some parts of pancreas not shown
  • Suggestion
    • Regular F/U

[consultation]

• 2023-05-04 Dermatology
  • Q
    • Patient was 50 years old men, history of HBV carrier regular follow up.
    • For suspect pancreatic cancer with liver meta. cT2N0M1, This time, admission for EUS biopsy and/or CT-guided biopsy, Chest CT, Port A insertion.
    • He has psoriasis more than ten years, we need your consultation for evaluation.

[MedRec]

• 2023-04-19 SOAP Hemato-Oncology
  • A: Suspect pancreatic cancer with liver meta. cT2N0M1
  • P: Admission for EUS biopsy and/or CT-guided biopsy, Chest CT, Port A insertion

701103011

230504

[diagnosis] - 2023-05-06 discharge note

• Gastric cancer with pancreas, spleen and liver metstases, stage IV s/p oral chemotherapy with UFUR from 2022/08/16 to 2023/05/02 with lung metastasis s/p chemotherapy with CapOx at SYSCC s/p chemotherapy with FOLFOX (Oxalip 65mg/m2, LV 400mg/m2, 5FU 400mg/m2, 5FU 2400mg/m2) from 2023/05/03
• Chronic viral hepatitis B without delta-agent

[MedRec]

• 2023-04-19 SOAP Hemato-Oncology
  • S:
    • Hx of gastric cancer s/p C/T with UFUR
  • O:
    • 2018/01/30 Surgical pathology Level IV
      • Stomach, antrum and body, AW, LC, PW, biopsy — modertaely differentiated adenocarcinoma
  • P:
    • Admssion for checking HBV, HCV, CBC/DC, Biomchemistry and AFP/CA125/CA199/CEA, FOLFOX

[chemotherapy]

• 2023-05-03 - oxaliplatin 65mg/m2 90mg D5W 250mL 6hr + leucovorin 400mg/m2 550mg NS 500mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFOX, Oxa long infusion to prevent allergy)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

[assessment]

• The patient received the FOLFOX regimen on 2023-05-03, with a reduced dose of oxaliplatin (85mg/m2 to 65mg/m2) and an extended infusion time (from 2 hours to 6 hours), as well as the addition of famotidine 20mg as premedication. As of now, no significant adverse reactions have been observed.

701158070

230504

[exam findings]

• 2023-05-02 CT - abdomen
  • Without contrast enhancement CT of abdomen shows:
    • Presence of splenomegaly. Focal fluid density at its dorsal part, r/o infarct.
    • Right renal stone. Mild dilatation of right urotract.
    • Suspect increased density of bony structures.
  • Impression
    • Splenomegaly with suspected splenic infarct
    • Increased density of bony structures

[assessment]

• Hyperleukocytosis (leukostasis) was confirmed by laboratory tests, and the patient has been treated with Hydrea (hydroxyurea 500mg) 2# TID since 2023-05-03, which has helped to control the high WBC count.

  • 2023-05-04 WBC 237.23 x10^3/uL
    
  • 2023-05-03 WBC 295.36 x10^3/uL
    
  • 2023-05-02 WBC 412.38 x10^3/uL
    
  • 2023-04-24 WBC 364.18 x10^3/uL
    
  • 2023-05-04 Blast 1.0 %
    
  • 2023-05-03 Blast 1.0 %
    
  • 2023-05-02 Blast 11.0 %

• Leukostasis can be diagnosed when a biopsy of affected tissue shows white cell clots in the microvasculature (2023-05-02 CT: suspected splenic infarct). Please be aware of possible clinical signs of leukostasis, such as

  • Pulmonary signs and symptoms: dyspnea, hypoxia with or without diffuse interstitial or alveolar infiltrates on imaging studies. Pulse oximetry provides a more accurate assessment of O2 saturation in this setting.
  • Neurologic signs and symptoms: visual changes, headache, dizziness, tinnitus, gait instability, confusion, somnolence, and occasionally coma.

• Feburic (febuxostat) is used as prophylaxis for potential tumor lysis syndrome. Lab data show that elevated serum uric acid levels have returned to normal following administration of the drug.

• Caution should be exercised when using intravenous contrast at a time when renal function may be compromised by leukostasis or tumor lysis syndrome and dehydration. (2023-05-04 BUN 29mg/dL, Cre 1.10mg/dL, eGFR 70.75, normal values in K. The patient is currently hydrated with NS 500mL BID. No apparent renal insufficiency at this time).

701476884

230504

[lab data]

• 2023-05-03 Anti-HBc Reactive
  
• 2023-05-03 Anti-HBc-Value 8.55 S/CO

[exam findings]

• 2023-04-14 Patho - pancreas biopsy
  • Pancreas, EUS FNA/B — Ductal adeocarcinoma, moderately differentiated
  • The sections show a picture of ductal adenocarcinoma, moderately differentiated, composed of nests, cords and single large pleomorphic neoplastic cells in fibrous stroma. Focal tubular formation and mucin secretion can be found.
• 2023-04-14 Endoscopic Ultrasound, EUS
  • Diagnosis
    • Pancreatic head cancer s/p CH-EUS & EUS/FNB
    • MPD and CBD dilatation
    • Reflux esophagitis
  • Suggestion
    • Follow up pathology
• 2023-04-14 SONO - abdomen
  • Diagnosis
    • Pancreatic tumor favor cancer
    • Dilated CBD
    • GB polyp
    • Parenchymal liver disease
  • Suggestion
    • further investigation
• 2023-04-07 CT - abdomen
  • Indication: 2023/03/28 abdominal pain off and on for several months, BW loss (+)
    • PI: appetite: good
    • PHx: HTN (+), HBV carrier
  • Findings:
    • There is a well-defined poor enhancing mass measuring 4.5 x 3.4 cm in the pancreatic neck, causing upstream pancreatic duct dilatation. This mass shows direct attachment and narrowing of the trifurcation of portal vein, superior mesenteric vein, and splenic vein that is c/w portal vein invasion and encasement.
      • Adenocarcinoma of the pancreatic neck (T4) is highly suspected.
      • Please correlate with CA199 and EUS.
      • In addition, there are four lymph nodes in gastrohepatic ligament and hepatoduodenal ligament that are c/w metastatic nodes (N2).
    • There is mild dilatation of IHDs and CHD that is due to upper described pancreatic neck mass with directly invasion the CHD.
    • There is an ill-defined equivocal faint poor enhancing area in S7 of the liver that may be flow artifact.
      • The differential diagnosis includes metastasis.
      • Please correlate with sonography and MRI.
    • There is a renal stone 0.9 cm in left lower pole and another tiny renal stone in left upper pole.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)

[MedRec]

• 2023-04-26 SOAP Hemato-Oncology
  • P
    • Family request admission
• 2023-04-25 SOAP Hemato-Oncology
  • O
    • 2023/04/14 Fine needle aspiration cytology - Pancreatic aspiration (Pancereas) — Malignancy
    • 2023/04/14 HBsAg = Reactive;
    • 2023/04/14 HBsAg (Value) = 4773.38 S/CO;
    • 2023/04/14 2023/04/14 Anti-HCV = Nonreactive;
    • 2023/04/14 2023/04/14 CEA = 11.25 ng/mL;
    • 2023/04/14 2023/04/14 CA199 = 2507.98 U/mL;
    • 2023/04/14 planning: neoadjuvant C/T first
    • 2023/04/14 arrange Port-A
  • A
    • May try OPD C/T with biweekly FOLFIRINOX.

[note]

FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-04 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F79571

• Cycle length: 14 days.
• Regimen
  • Oxaliplatin
    • 85 mg/m2 IV
    • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
    • Day 1
  • Leucovorin
    • 400 mg/m2 IV
    • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
    • Day 1
  • Irinotecan
    • 180 mg/m2 IV
    • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
    • Day 1
  • Fluorouracil (FU)
    • 400 mg/m2 IV bolus
    • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
    • Day 1
  • FU
    • 2400 mg/m2 IV
    • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
    • Day 1

[chemotherapy]

• 2023-05-02 - irinotecan 120mg/m2 200mg D5W 250mL 90min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 500mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + NS 250mL + aprepitant 125mg D1-3

[assessment]

• This is the first time the patient has received FOLFIRINOX chemotherapy for his pancreatic cancer, with a reduced dose of irinotecan (180mg/m2 reduced to 120mg/m2) and oxaliplatin (85mg/m2 reduced to 65mg/m2). Thus far, no significant adverse reactions have been observed.

• 2023-05-03 Anti-HBc Reactive
  2023-05-03 Anti-HBc-Value 8.55 S/CO

701432621

230503

[diagnosis] - 2023-05-02 admission note

• Adenocarcinoma of gastric middle body anterior wall, pT4aN1M0 stage IIIA status post total gastrectomy with lymphadenectomy of station 1 to 12 and 14V, retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA on 2022-09-05.
• Iron deficiency anemia, unspecified

[exam findings]

• 2022-12-26 PET
  • Increased FDG uptake in several celiac lymph nodes, gastric cancer with regional lymph nodes involvement should be considered, suggesting further investigation.
    
  • Increased FDG uptake in the right lobe of the liver, highly suspected gastric cancer with distant metastases.
    
  • Increased FDG uptake in the right nasopharynx, the nature is to be determined (inflammation/infection process or other nature ?), suggesting further investigation.
  • Gastric cancer s/p treatment with suspected regional lymph nodes and liver metastases, cTxN2M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2022-11-28 CT - abdomen
  • Indication: Adenocarcinoma of gastric middle body anterior wall, pT4aN1M0 stage IIIA status post total gastrectomy with lymphadenectomy of station 1 to 12 and 14V, retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA on 2022-09-05.
  • Abdominal CT with and without enhancement revealed:
    • s/p gastrectomy.
    • Hepatic tumors at S7 about 3.2cm and S6 about 2.9cm in largest dimension is found. Liver meta is considered. In comparison with CT dated on 2022-07-19, the tumors are enlarged.
  • Imp:
    • s/p gastrectomy.
    • Liver meta. In progression.
• 2022-09-06 Patho - stomach subtotal/total (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Stomach, total gastrectomy — Tubular adenocarcinoma
    • Margins, bilateral cutting ends and radial, total gastrectomy — Free of tumor invasion
    • Lymph nodes, LN dissection — Metastatic adenocarcinoma (2/40)
    • Omentum, omentectomy — Free of tumor invasion
    • AJCC Pathologic staging — pT4aN1(cM0), stage IIIA
  • MACROSCOPIC EXAMINATION
    • Specimen type: Stomach, lymph nodes, omentum
    • Specimen size: (a) Stomach: 36 cm long greater curvature and 19 cm along lesser curvature, (b) Omentum: 35 x 20 x 5.0 cm
    • Number of lesions: Solitary
    • Tumor site: Middle body, anterior wall, lesser curvature, 6.0 cm from distal margin
    • Tumor size: 9.2 x 7.5 x 3.5 cm
    • Tumor configuration: Fungating tumor with central ulceration
    • Representative sections as follows: A1= proximal margin, A2= distal margin, A3-A9= tumor, A10= lesser curvature LN, B= LN 1, C= LN 2, D= LN 3, E1-E2= LN 4, F= LN 5, G= LN 6, H1-H2= LN 7,8,9,11,12, I= LN 10, J= LN 14v, K1-K3= omentum
  • MICROSCOPIC EXAMINATION
    • Histologic type: Tubular adenocarcinoma (Lauren classification: intestinal type)
    • Histologic grade: Moderately differentiated (G2)
    • Depth of tumor invasion: Tumor invades the serosa
    • Margins: All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin: 3 mm from radial margin
    • Perineural invasion: Present
    • Lymphovascular space invasion: Present
    • Regional lymph nodes: Metastatic adenocarcinoma (2/40)
      • 1/1 (lesser curvature LN), 0/2 (LN 1), 0/3 (LN 2), 1/4 (LN 3), 0/6 (LN 4), 0 (LN 5), 0/8 (LN 6), 0/13 (LN 7, 8, 9, 11, 12), 0/3 (LN 10), 0 (LN14v) (Number of LN involved/Number of LN examined)
    • Extracapsular extension: Present
    • Omentum: Free of tumor invasion
    • Additional pathologic findings: Non-atrophic chronic gastritis
    • Pathologic Staging: pT4aN1(cM0), stage IIIA
    • IHC (S2022-12775): HER2 (Positive, score= 3+)
• 2022-08-30 MRI - liver, spleen
  • History and indication: Gastric cancer, suspect liver metastasis
  • With and without contrast MRI of liver revealed:
    • Gastric cancer with peritoneal seeding and LNs metastases.
    • Two enhancing tumors (2.7cm, 2.9cm) at S5 and S7 of liver without venous wash out pattern. Another small enhancing nodules at both hepatic lobes.
    • Tiny liver and renal cysts.
  • IMP:
    • Gastric cancer with peritoneal seeding and LNs metastases.
    • Suspected liver hemangiomas.
• 2022-08-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (205 - 59) / 205 = 71.22%
    • M-mode (Teichholz) = 71
  • Conclusion:
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis.
    • (suboptimal parasternal echo window barrel chest)
• 2022-08-04 Patho - stomach biopsy
  • Stomach, AW side of mid body, biopsy — Adenocarcinoma, moderately differentiated
  • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
  • The immunohistochemical stains reveal CK(+) and Her-2/neu (Ab): Positive (3+).
• 2022-08-04 Esophagogastroduodenoscopy, EGD
  • Highly suspected gastric malignancy, s/p biopsy
  • Reflux esophagitis LA grade A
  • Superficial gastritis
• 2022-07-19 CT - abdomen
  • History: easy hunger(+),
    • weight loss 72 (before) -> 68.5 (2022/04) -> 63kg (2022/06)
    • 2022/07/07 exertional dyspnea recent months.
    • 2022/07/18 s/p one week iron supplement, no adverse effect
  • Indication: Abnormal weight loss
  • Findings:
    • There is lobulated circumferrential irregular wall thickening at the stomach fundus and body, measuring 2.8 cm in the maximal wall thickness (T3).
      • Lymphoma is highly suspected.
      • The differential diagnosis include signet ring cell carcinoma.
      • Please correlate with gastroscopy.
      • In addition, There are ten enlarged nodes in the adjacent omentum, gastrohepatic ligament and hepatoduodenal ligament that may be metastatic nodes (N3a).
    • There are two ill-defined homogeneous enhancing lesion measuring 2.5 cm in S7 and 2.2 cm in S5 of the liver at arterial phase images but isodensity (no contrast washout) in portal venous phase and delayed phase images.
      • The differential diagnosis include Atypical hemangioma, FNH and metastasis. Please correlate with MRI.
    • There are several small poor enhancing lesions on both hepatic lobes, the largest one 5 mm, that may be cysts?
      • However, they are too small to chracterize.
    • Please correlate with sonography.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3 (T_value) N:N3a (N_value) M:M0 (M_value) STAGE:III(Stage_value)
• 2022-07-12 SONO - abdomen
  • Diagnosis
    • Liver tumors, S5 and S7
    • Possible small para-aortic pymph nodes
  • Suggestion
    • 4 phase CT or dynamic MRI study

[consultation]

• 2022-08-30 Gastroenterology
  • Q
    • This is a 61 year-old male, without underlying disease, admitted because of body weight loss 5 kg in 3months.
    • Panendoscope revealed one massive ulcerative tumor at gastric body. Pathology showed adenocarcinoma.
    • Abdominal CT also revealed 2 Liver tumor, differential diagnosis included atypical hemangioma, FNH and metastasis.
    • We need your expertise for TPN support
  • A
    • A case of gastric cancer who request pre-op nutrition support.
      • General appearance: ill looking
      • GI tract: Dysphagia (-), Abd pain (-), Abd distension (-), Nausea (-), Vomiting (-), Diarrhea (-), Poor appetite (-), Poor digestion (-), BW loss (+, 5kg/3Ms) , stool (+), Bowel sound (-)
        
      • Feeding: as tolerance
      • Allergy: NKA
      • Nutrition assessment:
        • BH 176cm BW 64.5kg
        • IBW 68.2kg 95%IBW BMI 20.8
          
        • BEE 1421kcal TEE 2217kcal
      • Lab data: Alb 3.7 K 4.2 TP 7.0 BS 98
      • According to the patient’s present conditions, parenteral nutrition plus enteral feeding (as tolerance) will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
    • PN Use Suggestion:
      • DC SMOFkabiven peri 1440ml QD (KCL 10ml)
      • SMOFkabiven central 1477ml QD, 61.5ml/hr
      • Lyo-Povigent 4ml/QD (add in TPN) (when out of stock, switch to adding B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
      • Addaven 10ml/QD（add in TPN）
    • Items to monitor during PN (Parenteral Nutrition) use:
      • TPN is used with single route, do not mix with other medications besides TPN drugs.
      • Check BW QW5 and record I/O Q8H
      • Check one touch Q6H x 2days, if stable QD check
      • Please control BS <200 mg/dl with RI sliding scale
      • QW1 check CBC/DC
      • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
      • When TPN is insufficient, substitute with YF5 or D10W
      • On the day of surgery, temporarily hold the lipid emulsion
      • Kabiven requires daily pump set replacement

[MedRec]

• 2022-12-27 SOAP Hemato-Oncology
  • S
    • PET scan (12/26 22):
      • several celiac LNs, gastric CA wt regional LNs involvement should be considered.
      • Lesion at R lobe of the liver, R/I mets. Imp: Gastric CA s/p Tx wt suspected regional LNs & liver mets, cTxN2M1, stage IVB (AJCC 8th ed.).
    • Liver mets poved by PET scan post post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 (12/27 22).
    • Adm 2 wk later on 1/9 23 for #1 2nd line palliative C/T wt FOLFIRI IV Q2W x 6.
• 2022-09-24 SOAP Hemato-Oncology
  • S
    • adjuvant C/T wt mFOLFOX IV Q2W x 12 & post-Op adjuvant CCRT (9/24 22).
    • HBsAg, anti-HCV (7/26 22): negative. will do anti-HBc (9/24 22).
    • will consult Dr in Radiation Oncology for R/T to gastric tumor bed. (9/24 22).
    • will give post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 then post-Op adjuvant CCRT wt 5-FU 24hr QD x 5 per wk x 6 plus R/T then post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 (9/24 22).
    • Adm 1 wk later on 10/3 22 for #1 post-Op adjuvant C/T wt mFOLFOX ( self-paid ) IV Q2W x 6.
  • A
    • Gastric CA, pT4aN1 (2/40) cM0, stage IIIA, s/p total gastrectomy on 9/5 22
• 2022-08-11 SOAP Gastroenterology and Hepatology
  • Assessment
    • Consider gastric cancer with LN metastasis
    • the liver tumor may be not metastasis but may arrange MRI to check if it was hemangioma or FNH.

[surgical operation]

• 2022-09-05
  • Surgery
    • Total gastrectomy with lymphadenectomy of station 1 to 12a and 14v.
    • Retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA.
  • Finding
    • 8x7x4 cm tumor at middle body anterior wall of stomach invaded the serosa.
    • Lymph node enlargement at station 3.
    • Scarring around gastroduodenal junction.
    • No ascites, no peritoneal seeding and no liver surface metastasis.
    • cT4aN2M0 stage III.

[chemoimmunotherapy]

• 2023-05-02 - trastuzumab 440mg NS 100mL 1.5hr + irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4090mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
• 2023-04-07 - trastuzumab 440mg NS 100mL 1.5hr + irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
• 2023-03-17 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
• 2023-02-21 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
• 2023-02-06 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
• 2023-01-12 - irinotecan 170mg/m2 285mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
• 2022-12-23 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-09 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-25 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-10 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-10-24 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-10-05 - oxaliplatin 70mg/m2 100mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr (FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[assessment]

• The patient was diagnosed with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05, followed by FOLFOX treatment starting on 2022-10-05.

• A CT scan on 2022-11-28 showed liver metastases in progression, and a PET scan on 2022-12-26 revealed that the gastric cancer had progressed, with suspected regional lymph nodes and liver metastases, cTxN2M1, stage IVB. After receiving six doses of FOLFOX (with the last dose administered on 2022-12-23), the patient’s regimen was changed to FOLFIRI starting on 2023-01-12.

• The patient was admitted to the hospital for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, making this the 2nd dose). The patient tolerates the regimen well, and no significant adverse reactions have been observed.

• After partial or total gastrectomy, the availability of gastric acid and intrinsic factor, both essential for vitamin B12 absorption, is reduced or eliminated. As a result, individuals who have undergone partial or total gastrectomy would benefit from supplementing their diet with oral vitamin B12 or receiving intramuscular or subcutaneous injections of vitamin B12. B-Red (hydroxocobalamin) is appropriately administered as a daily supplement for this patient.

• The patient’s underlying condition of chronic viral hepatitis B is appropriately treated with Baraclude (entecavir).

• A review of the PharmaCloud database reveals that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

The patient was proved with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05 then FOLFOX was applied since 2022-10-05.

2022-11-28 CT showed liver mets in progression and 2022-12-26 PET showed the gastric cancer progressed with suspected regional lymph nodes and liver mets, cTxN2M1, stage IVB. After administration of 6 times of FOLFOX (last dose on 2022-12-23), then the regimen changed to FOLFIRI since 2023-01-12.

The patient admitted this hospitalization for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, this time the 2nd dose). The patient tolerates the regimen well and no obvious adverse reaction is found.

The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

700758055

230502

[diagnosis]

• Malignant neoplasm of left renal pelvis, small cell neuroendocrine carcinoma, ypT4NxcM0, ypStage IV

[past history]

• hypertension
• type II diabetes mellitus
• dyslipidemia
• insomnia
• OP history: appendectomy 30 years ago, left laparoscopic nephroureterectomy on 2021-08-30.      

[family history]

• Father - CVA.
• Mother - hepatoma.

[exam findings]

• 2023-04-29 CT - abdomen
  • Indication: Small cell neuroendocrine carcinoma of left kidney, ypT4NxcM0, ypStage IV s/p chemotherapy with Topotecan from 2023/01/16
  • With and without contrast enhancement CT of abdomen shows:
  • Imaging Protocol: 5mm slice thickness, axial scan and coronal reconstruction
    • s/p left nephrectomy.
    • Para-aortic mass lesions, in progression.
    • Enlarged lymph nodes along bilateral iliac vessels.
    • Small nodular lesions, up to 0.8cm, in liver.
    • No ascites or extraluminal free air.
    • No bony destructive lesion on these images.
  • Impression
    • s/p left nephrectomy
    • Para-aortic mass lesion, in progression; DDx: recurrent tumor, lymph node metastasis
    • Suspect liver metastasis
• 2023-02-06, -01-23, -01-16 Standing KUB
  • Fecal material store in the colon.
• 2023-01-27 PD-L1 IHC 28-8
  • S2021-11516A9, renal pelvic cancer
  • Tumor cell (TC) staining assessment: >= 1% and <5%
  • Percentage of PD-L1 expressing tumor cells (TC):1%
• 2023-01-27 PD-L1 IHC 22C3
  • Combined Positive Score (CPS) assessment: >=1 and <10
  • Combined Positive Score (CPS) : 2
• 2023-01-05 CT - abdomen
  • History and indication: renal pelvis tumor, s/p OP
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • Non-contrast CT of abdomen-pelvis revealed:
    • S/P left nephrectomy. Soft tissues in paraaortic region and pelvic cavity (progression).
    • Collapse of gallbladder.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • S/P left nephrectomy. Progression of tumor recurrence.
• 2022-11-09 Gynecologic ultrasonography
  • EM: 3.7mm
• 2022-11-02 KUB
  • Disc space narrowing at L4/5.
• 2022-10-07 CT - abdomen
  • History:
    • 20210510 CT: left renal pelvis UC with LN metastases, cT3N1M1
    • 20210830 left nephrectomy: pT4Nx (if cM0), pstage:IV
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
      • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
    • Findings:
      • S/P left nephrectomy.
        • Prior CT idenified metastatic nodes in left para-aortic space are noted again, increasing in size that are c/w metastatic nodes S/P C/T with progressive disease.
          • In addition, Prior CT idenified enlarged nodes in right para-cava space are noted again, stable in size.
          • Follow up is indicated.
            
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
    • IMP:
      • Prior CT idenified metastatic nodes in left para-aortic space are noted again, increasing in size that are c/w metastatic nodes S/P C/T with progressive disease.
• 2022-09-23 Tc-99m MDP whole body bone scan
  • Increased activity in the middle and lower T-spines and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Some faint hot spots in the right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, wrists, hips, knees and feet, compatible with benign joint lesions.
• 2022-07-22 CT - abdomen
  • Findings:
    • S/P left nephrectomy.
      • Prior CT idenified metastatic nodes in left para-aortic space are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response .
        
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
  • IMP:
    • Prior CT idenified metastatic nodes in left para-aortic space are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response .
• 2022-04-07 CT - abdomen
  • Findings
    • S/P left nephrectomy. Soft tissues in paraaortic region.
  • IMP:
    • S/P left nephrectomy. Soft tissues in paraaortic region suspected tumor recurrence.
• 2022-01-05 CT - abdomen
  • Findings:
    • S/P left nephrectomy.
      • There is lobulated soft tissue lesions in left para-aortic space and left common iliac chain that may be metastatic nodes.
        
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
  • IMP:
    • Metastatic nodes in left para-aortic space and left common iliac chain are suspected.
• 2021-09-06 Cystography
  • Cystography via foley catheter administration revealed:
    • The bladder capacity is about 100cc.
    • No evidence of contrast medium leakage.
• 2021-08-31 Patho - kidney partial/total resection
  • Diagnosis
    • A
      • Kidney, left pelvis, laparoscopic nephroureterectomy — Small cell neuroendocrine carcinoma, s/p chemotheraphy, AJCC 8th edition: ypStage IV, ypT4Nx(if cM0)
        
      • Ureter, left, nephrectomy — Negative for malignancy
        
      • Blood vessel, left, nephrectomy — Negative for malignancy
        
      • Capsule, left kidney, nephrectomy — Small cell neuroendocrine carcinoma, by direct invasion
        
    • B: Soft tissue, labeled as “para-aortic lymph node”, excision — Negative for malignancy (0/0)
      
  • Gross Description
    • Procedure: laparoscopic nephroureterectomy
      
    • Laterality: Left
      
    • Specimen size:
      • Kidney: 7.4 x 4.0 x 2.5 cm; 60 gm
        
      • Ureter: 15.9 cm in length and 0.4 cm in maximal diameter
        
      • Adrenal gland: not received
        
    • Tumor size: 1.5 x 1.5 x 1.2 cm
      
    • Tumor site: Renal pelvis, parenchyma, hilar soft tissue, and invasion through the capsule to the perinephric fat
      
    • Tumor appearance: fibrosis
      
    • Tumor focality: Unifocal
      
    • A piece of tissue, labeled as “para-aortic lymph node”, is received.
    • Sections are taken and labeled as: A1: ureteral resection margin; A2: capsule; A3: blood vessel; A4: kidney, non-tumor; A5: ureter; A6-7: hilar soft tissue; A8-13: tumor (A11: with upper ureter); A14-16: tumor with capsule and the perinephric fat; B: para-aortic lymph node.
      
  • Microscopic Description
    • Histological type:: Small cell (neuroendocrine) carcinoma;
      • The immunohistochemical stains reveal CK(+), CD56(+), Synaptophysin(+), Chromogranin A(focal +), CD10(-), PAX8(-), CK5/6(-), and GATA3(-).
      • The Ki-67 is < 5%.
        
    • Histological grade: poorly differentiated
      
    • Pathological staging (pTNM, AJCC 8th edition):
      • TNM Descriptors: (required only if applicable) (select all that apply): y (posttreatment)
        • Primary tumor (pT): pT4: Tumor invades adjacent organs, or through the kidney into the perinephric fat
          
        • Regional lymph nodes (pN): pNx: Regional lymph node cannot be assessed
          
        • Distant metastasis (pM): (required only if confirmed pathologically in this case): if cM0
          
    • Section margins: Uninvolved by invasive carcinoma; 15.9 cm away from the ureteral resection margin; 0.8 cm away from the hilar soft tissue resection margin; 0.5 cm away from the perinephric fat resection margin.
      
    • Lymphovascular invasion: Present
      
    • Pathologic findings in ipsilateral nonneoplastic kidney: lymphocytic infiltration and fibrosis
      
    • Additional pathologic findings: No lymph node is seen in “para-aortic lymph node” specimen.
      
    • Perineural invasion is seen.
• 2021-08-29 CXR
  • Intimal calcification of thoracic aorta.
• 2021-08-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 32) / 79 = 59.49%
    • M-mode (Teichholz) = 59
  • Adequate LV systolic function with normal resting wall motion
  • Dilated LA; septal hypertrophy; LV diastolic dysfunction, Gr 1
  • Mild MR and trivial TR
  • Preserved RV systolic function
• 2021-08-10 CT - abdomen
  • Clinical history: 76 y/o female patient with right renal pelvis UC with lymph node metastasis, cT3N1M1, PD-L1 all negative.
  • WITHOUT contrast enhancement CT: ABD — whole abdomen, pelvis:
    • Regression of left renal tumor and paraaortic soft tissue, could be due to regression of renal pelvis UC with lymph nodes metastasis.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
  • Impression:
    • Left renal UC with lymph nodes metastasis, regression.
• 2021-06-09 PD-L1 (SP142)
  • VENTANA PD-L1 (SP142) Assay for Urothelial Carcinoma
    • PD-L1 Expression: <5% IC
      
    • Scores: Immune cells (IC): <1%; Tumor cells (TC): 0%
• 2021-05-29 KUB
  • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
  • Mild lumbar spondylosis.
• 2021-05-29 Bladder Sonography
  • PVR 10.7mL
• 2021-05-24 Patho - kidney biopsy
  • Kidney, left, CT guided biopsy — Compatible with invasive urothelial carcinoma, high-grade
    
  • The sections show sheets of spindle to oval-shaped pleomorphic neoplastic cells with hyperchromatic nuclei, embedded in fibrous stroma. Severe crush artifact is present.
  • IHC: GATA3(focal +), CK5/6(focal +), PAX8(-), CD10(focal +), and Vimentin(focal +).
  • The finding is compatible with high-grade invasive urothelial carcinoma. Renal cell carcinoma is less likely.
• 2021-05-24 Body fluid cytology - urine
  • Diagnosis: Atypia
  • Macroscopic examination: L’t ureter: 6 cc colorless clear urine by URS
    
  • Microscopic examination: Smears show a few urothelial cells with mild enlarged nuclei. No morphologic evidence of high grade, but low grade urothelial carcinoma can not be excluded completely due to cytologic limitation. Please correlate with the biopsy result for conclusive diagnosis.
• 2021-05-23 ECG
  • Normal sinus rhythm
  • Cannot rule out Inferior infarct, age undetermined
  • T wave abnormality, consider anterior ischemia

[chemotherapy]

• 2023-03-31 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-4
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-4
• 2023-03-06 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-4
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-4
• 2023-02-13 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
• 2023-01-18 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-3 (topotecan 1.5mg/m2 adjusted to 0.75mg/m2 due to impaired renal function)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
• 2023-01-16 - topotecan 1.5mg/m2 2mg NS 50mL 30min D1-5
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-5
• 2022-07-21 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3 + granisetron 1mg D1
• 2022-06-23 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3 + granisetron 1mg D1
• 2022-05-26
• 2022-04-28
• 2022-01-04
• 2021-12-07
• 2021-10-28
• 2021-10-05 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3
• 2021-08-10 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • furosemide 20mg (post chemotherapy)
• 2021-08-03 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • furosemide 20mg (post chemotherapy)
• 2021-07-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • furosemide 20mg (post chemotherapy)
• 2021-07-13 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • furosemide 20mg (post chemotherapy)
• 2021-06-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • furosemide 20mg (post chemotherapy)
• 2021-06-22 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • furosemide 20mg (post chemotherapy)
• 2021-06-08 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • furosemide 20mg (post chemotherapy)
• 2021-06-01 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
  • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • furosemide 20mg (post chemotherapy)

[assessment]

• On 2022-10-07, 2023-01-05, and 2023-04-29, CT scans demonstrated disease progression, with the most recent scan also revealing possible liver metastases. This information highlights the need for close monitoring and potentially re-evaluating the patient’s treatment plan.

• The patient’s renal function improved according to the most recent lab values.

  • 2023-04-28 Creatinine 0.92 mg/dL
    
  • 2023-04-19 Creatinine 1.46 mg/dL
    
  • 2023-04-11 Creatinine 1.44 mg/dL
    
  • 2023-03-28 Creatinine 1.47 mg/dL
    
  • 2023-04-28 eGFR 62.91
    
  • 2023-04-19 eGFR 36.92
    
  • 2023-04-11 eGFR 37.52
    
  • 2023-03-28 eGFR 36.63

• If the initial consideration for reducing the dose of topotecan was due to the patient’s inadequate renal function, this reason becomes less important. However, the patient also experienced leukopenia and thrombocytopenia after the standard dose of 1.5 mg/m2 topotecan in January 2023. The full standard dose may potentially lead to episodes of leukopenia and/or thrombocytopenia. A moderate titration to 0.9 or 1.0 mg/m2 from 0.75mg/m2 could be considered as a feasible option to balance treatment efficacy and side effect profile if the same regimen is intended to be continued.

230307

[assessment]

• This patient has a tendency to develop leukopenia and/or thrombocytopenia after receiving the normal dose of 1.5mg/m2 topotecan. However, after the dose was reduced to 0.75mg/m2, no further high-grade adverse reactions were observed.

  • 2023-03-02 WBC 5.87 x10^3/uL
    

  • 2023-02-23 WBC 12.24 x10^3/uL
    

  • 2023-02-16 WBC 3.07 x10^3/uL
    

  • 2023-02-13 WBC 4.44 x10^3/uL
    

  • 2023-02-09 WBC 22.96 x10^3/uL
    

  • 2023-02-06 WBC 2.70 x10^3/uL
    

  • 2023-02-03 WBC 2.09 x10^3/uL
    

  • 2023-02-01 WBC 2.32 x10^3/uL
    

  • 2023-01-30 WBC 1.66 x10^3/uL
    

  • 2023-01-27 WBC 0.71 x10^3/uL
    

  • 2023-01-26 WBC 0.70 x10^3/uL
    

  • 2023-01-22 WBC 2.41 x10^3/uL
    

  • 2023-01-16 WBC 5.05 x10^3/uL

  • 2023-03-02 PLT 234 x10^3/uL
    

  • 2023-02-23 PLT 109 x10^3/uL
    

  • 2023-02-16 PLT 275 x10^3/uL
    

  • 2023-02-13 PLT 308 x10^3/uL
    

  • 2023-02-09 PLT 270 x10^3/uL
    

  • 2023-02-06 PLT 123 x10^3/uL
    

  • 2023-02-03 PLT 65 x10^3/uL
    

  • 2023-02-01 PLT 47 x10^3/uL
    

  • 2023-01-30 PLT 50 x10^3/uL
    

  • 2023-01-27 PLT 154 x10^3/uL
    

  • 2023-01-26 PLT 38 x10^3/uL
    

  • 2023-01-22 PLT 155 x10^3/uL
    

  • 2023-01-16 PLT 312 x10^3/uL

230214

[assessment]

• S2021-11516A9 (renal pelvic cancer) 2023-01-27 PD-L1 IHC lab results:

  • [28-8]
    • Tumor cell (TC) staining assessment: >= 1% and <5%
    • Percentage of PD-L1 expressing tumor cells (TC): 1%
  • [22C3]
    • Combined Positive Score (CPS) assessment: >=1 and <10
    • Combined Positive Score (CPS): 2

• PD-L1 expression is not high, suggesting that certain PD-L1 targeted drugs are less likely to be effective against the tumor.

• In light of the patient’s diarrhea episodes last month, please keep an eye on her bowel movements. Topotecan is associated with nausea (grade 3/4 8-10%), diarrhea (grade 3/4 6%), and vomiting (grade 3/4 10%). Since the administration days and daily dose of topotecan have been reduced (1.5mg/m2 -> 0.75m2/m2; 5 days -> 3 days), the adverse reaction should be mitigated. As well, Smecta (dioctahedral smectite) 3mg PO PRNTIDAC has been prescribed.

230127

[assessment]

• 2023-01-27 WBC 710 cells/uL, Neutrophil 5%, ANC < 500 cells/uL, grade 4 neutropenia developed, Granocyte (lenograstim) and Cefim (cefepime) have been initialized since 2023-01-26 morning. Since 2023-01-26 19:00, the patient’s body temperature has not exceeded 37.5 degrees Celsius.
• During the period of 2023-01-24 to 26, there were 3, 2, 3 bowel movements, and Nako No.5 (electrolyte supplement) was administered appropriately.
• As far as the active prescription is concerned, there is no problem.

700509855

230428

[diagnosis] - 2023-04-27 admission note

• Malignant neoplasm of stomach, unspecified
• Secondary malignant neoplasm of right ovary
• Secondary malignant neoplasm of retroperitoneum and peritoneum
• Essential (primary) hypertension

[exam findings]

• 2023-04-27 KUB
  • S/P port-A insertion.
  • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    
  • Lumbar spondylosis.
  • T12 and L1 compression fractures.
• 2023-04-27 CXR
  • Emphysematous change of bilateral lungs.
  • No cardiomegaly.
  • Thoracolumbar spondylosis.
  • R/O old fractures at left ribs.
• 2023-04-24 Cytology - ascites
  • 17 cc yellow turbid ascites — Atypia (before IP C/T)
• 2023-04-20 CT - chest
  • Indication: GIST with peritoneal and ovarian metastasis, stage IV s/p HIPEC and operationr/o other metastasis
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Calcified dot at subpleural space of right lower lobe is found measuring 0.24cm in largest dimension.
      • Bilateral apical pleura fibrosis is found.
      • Calcified coronary arteries is found.
      • There is moderate bilateral pleural effusion.
    • Visible abdomen:
      • Moderate ascites formation is found. Dirty appearance of the mesentery is found. Cancerous peritonitis is considered. In comparison with CT dated on 2022-12-13, the lesion is stationary.
      • Bilateral hydronephrosis and hydroureter is found. Stable.
      • Dilatation of the IHDs and CBD is noted.
      • The intestines are dilated.
  • IMp:
    • Moderate bilateral pleural effuison and massive ascites with cancerous peritonitis
    • Bilateral hydronephrosis and hydroureter. Stable
    • Dilatation of the IHDs and CBD
• 2023-04-19 Tc-99m MDP bone scan with SPECT
  • The hot spot in the lateral aspect of a left lower rib (10th rib ?) comes to faint compared with the previous study on 2023-01-04, probably post-traumatic change.
  • However, there are several new lesions of increased tracer uptake in the posterior aspect of the left rib cage and in three lower T- and upper-L-spine, bone metastasis and/or pathological fracture should be considered, suggesting MRI for investigation.
  • Suspected benign lesions in the maxilla, both rib cages, bilateral shoulders, and hips.
• 2023-04-17 ECG
  • Low voltage QRS
• 2023-03-27 L-spine Ap + Lat (including sacrum)
  • Degeneration and spondylosis of L-S spine.
  • Atherosclerosis of the aorta.
• 2023-03-27 Peripheral Vascular Test - vein, lower limbs
  • Conclusion
    • No evidence of venous thrombosis at bilateral lower limbs venous systems.
    • No significant venous refluxes at biateral lower limbs venous systems.
    • Tissue edema at bilateral lower legs.
    • The ratios of MVO and SVC of bilateral legs were within normal limits.
• 2023-03-10 ECG
  • Sinus rhythm with Premature atrial complexes
• 2023-02-16 SONO - abdomen
  • Hepatic cysts
  • Bil hydronephrosis
  • Ascies, mild
  • CBD dilatation
  • Rt renal cyst
• 2023-01-13 Patho - peritoneum biopsy
  • DIAGNOSIS:
    • Peritoneum, biopsy — metastatic adenocarcinoma, consistent with gastric origin
    • Soft tissue, right pelvic tumor, biopsy — metastatic adenocarcinoma, consistent with gastric origin
    • Ovary, right, oophorectomy — Metastatic adenocarcinoma, consistent with gastric origin — Serous cystadenoma
      
    • Fallopian tube, right, salpingectomy — Metastatic adenocarcinoma, consistent with gastric origin
  • MICROSCOPIC DESCRIPTION:
    • Section shows fibroadipose tissue with infiltration of signet-ring cells.
      • The immunohistochemical stain of CK is positive. Metastatic adenocarcinoma from stomach is favored. Please correlate with the clinical presentaion.
    • Sections show ovary with metastatic glandular and signet-ring tumor cells. An ovarian cyst lined by a single layer of benign serous epithelium is also seen. The fallopian tube reveals transmural invasion of glandular and signet-ring tumor cells. Lymphovascular and perineural invasion is seen.
      • The immunohistochemical stains reveal CK7(+), CK20(+), CDX2(+), and PAX8(-). The results are consistent with metastatic adenocarcinoma from stomach.
• 2023-01-04 Tc-99m MDP bone scan with SPECT
  • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the lateral aspect of a left lower rib (10th rib ?), faint hot spots in both rib cages, and increased activity in the maxilla, some T- and L-spine, bilateral shoulders, and S-I joints, in whole body survey. Radiotracer retention in bilateral kidneys was noted.
  • IMPRESSION:
    • A hot spot in a left lower rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, and S-I joints.
    • Radiotracer retention in bilateral kidneys, the nature is to be determined, suggesting further evaluation.
• 2022-12-29 Cell block
  • Clinical Finding: ovary cancer
  • 50cc, turbid, orange — Positive for malignancy
    
  • Smears and cell block show atypical neoplastic cells with abundant clear cytoplasm and pushing nuclei with signet ring-like picture.
• 2022-12-28 CT - chest
  • Indication: moderate right pneumothorax.
  • Findings
    • lungs: dependent partial atelectasis of RLL and band subsegmental atelectasis of RUL. tiny granuloma (3mm) at LLL and two tiny granulomas (3mm) at RLL. two noncalcified solid nodules (up to 6mm) and several faing lobular GGOs at LUL. suspicious cylindrical bronchiectasis at LLL.
    • Mediastinum and hila: no enlarged LN or mass. mild calcified plaques of the LAD and LCX coronary arteries.
    • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers..
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents:
      • massive ascites and soft tissue densities in the omentum, along peritoneum.
      • a ulcerative tumor at posterior wall of the body of stomach.
      • Lt heaptic cyst 7cm, Rt renal cyst 1.6cm, and bilateral hydronephrosis.
      • normal appearance of gall bladder. unremarkable of the spleen, both adrenal glands, and pancreas.
      • no enlarged lymph node.
    • Visualized bones: unremarkable. .
  • Impression:
    • moderate right pneumothorax. tiny granulomas in RLL and LLL and small nodules in LUL (favor benign nodules) of lung.
    • gastric cancer with massive ascites and peritoneal carcinomatosis
• 2022-12-27 Patho - stomach biopsy (Y1)
  • Stomach, upper body, PW, biopsy — Adenocarcinoma, signet ring-like, non-cohesive.
  • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and signet ring-like neoplastic cells.
    • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
    • ADDENDUM: IHC stains: PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2022-12-26 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis, lower esophagus, LA classification, grade A
  • Superfical gastritis, antrum
  • Advanced gastric cancer, type III, upper body, PW, s/p biopsy
• 2022-12-26 Colonoscopy
  • The scope had been inserted up 20 cm above anal verge, probably at level of rectal-sigmoidal juncction. Futher insertion is difficult because acute angle. Thus, the exam was stopped
  • Diagnosis
    • Internal hemorrhoid
    • Incomplete study
• 2022-12-19 ECG
  • Low voltage QRS
  • Nonspecific T wave abnormality
• 2022-12-19 CXR
  • Mild cardiomegaly.
  • Tortuous thoracic aorta with intimal calcification.
  • Thoracic spondylosis.
  • Osteoporosis of the bones.
• 2022-12-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 24) / 93 = 74.19%
    • M-mode (Teichholz) = 75
  • Conclusion:
    • Normal LV filling pressure; impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis with mild AR; mild MR; mild TR.
    • Mild aortic root calcification with multiple protruding atheromas (4-5 mm of thickness).
• 2022-12-13 CT - abdomen
  • Clinical history: 77 y/o female patient with p3 (NSD)
    • prev abd op(-), low abd pain, leukorrhea and dysuria, low abd pain, leukorrhea and dysuria
    • 2022/12/12 sonar: EM 0.85cm RASD mass 7.3x7cm, solid?? uterine myoma or ROV tumor? ovarian malignancy cannot be excluded ROV cyst 5.3 x 5cm ascites > 500 c.c
  • With and without contrast enhancement CT of abdomen–whole:
    • Heteregneous cystic tumor, 7.6cm in right adnexa, r/o right ovarian malignancy.
    • Dilatation of the appendix with enhancement, r/o appendiceal malignancy.
    • Presence of massive ascites and soft tissue densities in the omentum, along peritoneum, r/o peritoneal carcinomatosis.
    • Large cystic tumor, 6.9cm in left lobe liver, r/o liver cyst.
    • Bilateral renal cysts, up to 1.6cm in right kidney.
    • Bilateral hydronephrosis.
    • No enlarged lymph node in the paraaortic region.
  • Impression:
    • Peritoneal carcinomatosis.
    • Dilatation of appendix with focal enhancement, r/o appendiceal malignancy.
    • Right ovarian cystic tumor, r/o right ovarian malignancy.
    • Liver and renal cysts.
    • Bilateral hydronephrosis.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1(M_value) STAGE:IV(Stage_value)
• 2022-12-12 Gynecologic Ultrasonography
  • Uterus Position: AVF
    • Size: 68 x 40 mm
  • Endometrium
    • Thickness: 8.5 mm
  • IMP
    • Ascites
    • R/O Rt mass or bowel ?? 73x33mm
    • R/O Rt cyst: 51x46mm

[consultation]

• 2023-04-18 Hemato-Oncology
  • Q
    • This is a 78 y/o female with diagnosis of gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, stage IV, s/p laparoscopic examination and tumor excisional biopsy + laparoscopic HIPEC + IP port implantation + laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis on 2023/01/12.
    • She received neoadjuvant intraperitoneal and systemic chemotherapy with Oxaliplatin 130mg/m2 IV + Xeloda 1000mg BID PO + Paclitaxel 20mg IP Q4W on 2023/02/14. However, general malaise, oral ulcer, poor appetite, skin rash , bilateral lower limbs edema and diarrhea were noted after first cycle of chemotherapy and was admitted during 2023/03/14 ~ 28.
    • Due to above reason, we would like to consult your expertise on evaluation and recommendation on chemotherapy for the patient, thank you!
  • A
    • This 78 year old woman is a case of gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, stage IV, s/p laparoscopic examination and tumor excisional biopsy + laparoscopic HIPEC + IP port implantation + laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis on 2023/01/12, s/p systemic chemotherapy with Oxaliplatin 130mg/m2 IV + Xeloda 1000mg BID PO + Paclitaxel 20mg IP on 2023/02/14. Due to symptom after first cycle chemotherapy, we are consulted for furhter evaluation.
      • Perform HER2, programmed death ligand 1 (PD-L1), and microsatellite testing (if not done previously).
      • If intolerable to CapOx or FOLFOX, might consider docetaxel (30-35 mg/m2) plus 5-FU 2000-2600 mg/m2 and leucovorin 200 mg/m2 with or without cisplatin (20-30 mg/m2) Q2W.
      • Thanks for your consultation.
• 2023-02-14 Gastroenterology
  • Q
    • for pre-chemotherapy HBV treatment
    • This 78 y/o female a case of gastric cancer with ovarian and peritoneal metastasis. She underwent HIPEC on 20230112. Further neo-adjuvant chemotherapy will arrange. However, we check hepatitis showed HBsAg and anti-HCV (-), but anti-HBc (reactive). We need your expertise for pre-chemotherapy HBV treatment. Thanks for your times.
  • A
    • P
      • Check HBV DNA
      • Arrange abdominal sonography
      • Vemlidy 25mg (GFR > 15 no adjustment; GFR < 15 contraindicated; HD: no adjustment, after HD)
      • GI OPD follow up
• 2022-12-30 Anesthesiology
  • Q
    • For CVC insertion
    • This 77y/o female a case of suspect gastric cancer with ovarian metastasis. She had poor appetite and body weight loss was noted. She need TPN for nutrition supplement. She ever tried right neck for CVC insertion, but failure and iatrogenic pneumothorax was noted. Following CXR showed pneumothorax with pleural effusion of right side, thus pig-tail was inserted on 20221229. We need your expertise for CVC insertion. Thanks for your times. On femoral, thanks.
  • A
    • Finding
      • The sonography reported small, much thrombosis and overlapped with artery at right IJV and SCV.
      • After positioning via Trendelenburg position,head rotated, elevated shoulder, the skin was sterilized and anesthetized with 2% lidocaine 2 ml.
      • We performed 3-lumen 7 fr CVC insertion to LEFT internal jugular vein under Seldinger technique
      • The CVC was fixed at 16cm
      • The pt tolerant the procedure well.
      • There was no sign of hematoma, pneumothorax, infection after the procedure.
    • The recommandation is as followed:
      • Please check chest roentgenography for localization.
      • Change IV set QD if TPN used or Q4D if general fliud.
      • Change OP site at least every week. IF loosening or blood accumulation please change it ASAP.
      • We do not recommand routinely change the CVC unless there are some infectious signs.
    • Thanks for your consultaion.
• 2022-12-27 Thoracic Surgery
  • Q
    • For CVC insertion
    • This 77y/o female a case of suspect gastric cancer with ovarian metastasis. She had poor appetite and body weight loss was noted. She need TPN for nutrition supplement. We need your expertise for CVC insertion. Thanks for your times.
  • A
    • Central venous catheterization has been tried but failed. Please consult ANES for the procedure. Thanks for your consultation.
• 2022-12-26 Urology
  • Q
    • For on D-J catheterization.
    • This 77-year-old female with ovarian cancer was admitted for Debulking surgery at 20221227 . We need your evaluation of her condition for on D-J catheterization. Thanks for your help!
  • A
    • CT showed massive ascites and mild bilateral hydronephroiss
    • We will arrange bilateral DBJ insertion.
• 2022-12-26 General and Digestive Surgery
  • Q
    • For combine surgery
    • This 77-years-old female with ovarian cancer and ascites was admitted Debulking surgery.
    • The abdomen CT scan revealed
      • Peritoneal carcinomatosis.
      • Dilatation of appendix with focal enhancement, r/o appendiceal malignancy.
      • Right ovarian cystic tumor, r/o right ovarian malignancy.
    • Debulking surgery will arrange on 20221227 . We need your evaluation of her condition for combine surgery. Thanks for your help!
  • A
    • BW loss 7kg (49 -> 42) in past one month
    • suggest
      • we will performe combined surgery for her tomorrow
      • we will resected GI tract if necessary
      • PN support after operation
      • consult urologist for double J catheter implantation
      • We did not discuss with the family about HIPEC due to too weak to receive HIPEC
  • Supplementary reply 2022-12-26 17:41:10
    • PES: Advanced gastric cancer, type III, upper body, PW
    • impression: gastric cancer with peritoneal carcinomatosis and krukengerg tumor
    • suggest
      • debulking surgery is not indicated now
      • pending the report of pathology
      • nutrition support
      • may consider neoadjuvant intraperitoneal and systemic chemotherapy (NIPS) with following total gastrectomy, cytoreductive surgery, BSO and HIPEC
    • we wound like to take over this case if the patient and her family agree

[MedRec]

• 2023-04-06 SOAP General and Gastroenterological Surgery
  • S
    • fair appetite
    • tarry stool passage?
    • SOB?
  • O
    • smooth respiration
    • pink conjunctiva
    • bilateral lower limb pitting edema
  • P
    • admit for TS-1 and IP chemotherapy
• 2023-03-07 SOAP General and Gastroenterological Surgery
  • S
    • poor appetite, bilateral lower limbs edema
    • pink conjunctiva
  • O
    • smooth respiration
    • but poor general condition
    • hold xeloda and dexamethasone
• 2023-01-27 SOAP General and Gastroenterological Surgery
  • S
    • Gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, STAGE:IV post status laparoscopic examination and tumor excisional biopsy, laparoscopic tumor excision/debulking with right salpingo-oophorectomy, laparoscopic HIPEC and IP port implantation on 2023/01/12
    • Postprocedural pneumothorax status post thoracentesis on 2022/12/28
    • Malignant ascites
  • P
    • admission on 20230206 for bidirectional chemotherapy

[surgical operation]

• 2023-01-12
  • Surgery
    • Diagnosis: suspected gastric cancer with ovarian metastasis (Krukenberg tumor?); pelvic bowel adhesion
    • laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis
  • Finding
    • previous gastric biopsy – malignancy (adenocarcinoma)
    • suspected gastric cancer with ovarian metastasis (Krukenberg tumor?)
    • right ovary and tube: 9x8cm, two parts–solid part 7x7cm, fragile, suspected metastastic cancer? ; cystic part 5x4cm with clear fluid
    • right tube -np (ROV + tube)
    • right pelvic tumor –2x2cm, solid suspected metastastic cancer?
• 2023-01-12
  • Surgery
    • laparoscopic examination and tumor excisional biopsy
    • laparoscopic HIPEC
    • IP port implantation
  • Finding
    • serous ascites, about 2700ml
    • diffuse peritoneal carcinomatosis, total PCI: 23/39
    • RUQ 2
    • epigastrium 2
    • LUQ 2
    • right flank 1
    • central 1
    • left flank 1
    • RLQ 3
    • pelvis 3
    • LLQ 2
    • small bowel PCI: 2+2+1+1/12
    • HIPEC: oxalipatin 400mg + paclitaxel 120mg in D5S 3000ml, 90min, 42 degree

[chemotherapy]

• 2023-04-21 - docetaxel 30mg/m2 38mg D5W 250mL 1hr + leucovorin 200mg/m2 250mg NS 250mL 2hr + fluorouracil 2000mg/m2 2515mg NS 500mL 24hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 4200mg] IP 1hr (NIPS)

• 2023-02-14 - oxaliplatin 130mg/m2 150mg D5W 250mL 2hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 2800mg] (with 2023-02-16 ~ 2023-03-14 oral capecitabine)

• 2023-01-12 - [oxaliplatin 400mg + paclitaxel 120mg + D5W 2500mL] IP 90min

Xeloda (capecitabine 500mg) KXEL)01

• 2023-02-16 ~ 2023-03-14 2# BID

[assessment]

• Significant weight loss has been observed in the patient, from 43.5kg on 2023-01-06 to 33.3kg on 2023-04-27. Megestrol has been prescribed intermittently between late Dec 2022 and late Feb 2023. If the patient can still tolerate oral intake and there are no contraindications, it may be beneficial to consider adding megestrol back into the patient’s treatment plan to help increase appetite and promote weight gain.

• Additionally, providing nutritional support and guidance, including a consultation with a dietician, may further assist in addressing the patient’s weight loss.

• The patient has had 7 episodes of diarrhea since 2023-04-26, as noted in the admission record. It is recommended that the number of bowel movements be included in the TPR panel along with the I/O data. If the symptom persists, the addition of loperamide may be beneficial in the management of diarrhea.

• Both docetaxel and fluorouracil are associated with diarrhea as a side effect. If diarrhea is suspected to be more related to fluorouracil (2000mg/m2 D1), reducing the dose of fluorouracil (70~80% of the intended dose) at the next treatment may be an option to consider.

701445069

230428

[exam findings]

• 2023-04-26 CXR
  • extensive heterogeneous consolidation in both hypoinflated lungs due to severe pulmonary fibrosis in progression as compared with the previous image
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    
  • enlarged cardiac silhoutte due to dilated prominent pericardial fat/prominent cardiophrenic angle mediastinal fat pad/ supine position
• 2023-04-21 CT - chest
  • Indication: Malignant neoplasm of unspecified part of left bronchus or lung
  • Chest and Abdominal CT with and without enhancement revealed:
    • Chest:
      • S/p port-A placement with its tip at Superior vena cava.
      • There is enlarged lymph nodes in the mediastinum. In comparison with CT dated on 2023-02-17, these lymph nodes increased in size and numbers
      • There is interstitial change at both lungs with honey combing mostly at bilateral peripheral and lower lungs. In comparison with CT dated on 2023-02-17, the extension and severity progressed slightly.
      • Minimal pericardial effusion is found.
    • Visible abdomen:
      • The GB is well distended without soft tissue lesion
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • The urinary bladder is well distended without soft tissue lesion.
      • There is no evidence of destructive bone lesion.
  • Imp:
    • Interstitial change of both lungs. In progression.
    • Enlarged lymph nodes in the mediastinum. In enlargement.
    • Minimal pericardial effusion.
• 2023-03-22, -03-15, -02-15, -01-26, -01-20, -01-16, -01-11, -01-06, -01-03, 2022-12-29, -12-26, -12-22, -12-19, -12-08, … CXR
  • There are linear and nodular opacities projecting at bilateral middle and lower lung that are c/w subpleural boneycombing feature after correlate with CT.
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Spondylosis of the T-spine
• 2023-02-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (47 - 11) / 47 = 76.60%
    • M-mode (Teichholz) = 75
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA, grade 1 LV diastolic dysfunction
    • Mild TR
• 2023-07-17 CT - chest
  • Diagnosis
    • Malignant neoplasm of unspecified part of left bronchus or lung
    • Hypertensive heart disease without heart failure
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Soft tissue mass at left upper lobe with bony erosion measuring 4.57x1.45cm in largest dimension. In comparison with CT dated on 2023-01-17, the lesion is stationary or slightly regressed.
      • Diffuse interstitial change at both lungs with honey combing at bilatearl lower lungs are found. IPF is considered.
      • Ground glass patches at both lungs is found. In regression.
      • Calcified coronary arteries is found.
      • Hypertrophic left ventricle is found.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • The GB is well distended without soft tissue lesion
  • Imp:
    • left upper lobe lung cancer with bony erosion, in regression.
    • Diffuse intertitial change at both lungs with lower lobes predominance. IPF is suspected.
    • Hypertrophic left heart with Calcified coronary arteries is found.
• 2023-01-17 CT - chest
  • Indication: Lung cancer with dyspnea
  • Comparison was made with previous CT dated on 2022/12/16
    • Chest
      • interval significant decrease in size of a large tumor at left upper anterior chest wall and heterogeneous consolidation at LUL as compared with CT on 2022/12/16.
      • there is subpleural and basal predominant pulmonary fibrosis charaterized by reticulation, traction bronchiectasis, traction bronchioectasis, archiectural distortion, and subpleural honeycombing.
      • extensive centrilobular emphysema and subpleural paraseptal emphysema at both upper lobes too.
      • Mediastinum and hila: interval regression of extensive lymphadenopathy the visceral space and both hila,as compared with CT on 2022/12/16
      • mild calcified plaques of the LAD, and LCX, and right coronary arteries.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: mild dilated right main artery.
      • Heart: normal in size of cardiac chambers.
      • Pleura: trace Lt-sided effusion
    • Visible abdominal-pelvic contents:
      • normal appearance of gall bladder.
      • several bilateral renal cysts measuring up to 1.5cm (longest axial diameter)
      • unremarkable of the liver, spleen, both adrenal glands, pancreas, and no enlarged lymph node.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • LUL cancer with chest invasion and mediastinal-hilar LAP, signficant as compared with CT on 2022/12/16.
    • combined emphysema and IPF.
• 2023-01-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (43 - 19) / 43 = 55.81%
    • M-mode (Teichholz) = 55
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Mild MR, trivial TR
    • Preserved RV systolic function
• 2022-12-22 MRI - brain
  • Clinical information: Lung cancer with lymph nodes and bone metastases, cT4N3M1b, stage IVA, R/O brain metastasis
  • Findings:
    • Known a case of lung cancer. No evidence of brain metastasis.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • An outpouch (8.5 mm) projecting anteriorly from ACom artery, indicating an aneurysm. Suggest endovascular treatment.
• 2022-12-16 CT - chest
  • < BGB-A317-A1217-302 (iIRB No: 10-FS-043) C3D15 Visit >
    • IP: Tislelizumab or Pembrolizumab 200 mg (D1) + BGB-A1217 900 mg or Placebo (D1) Q3W
  • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Mass like lesion occupying left anterior chest about 7.9cm in largest dimension is found. Stable.
      • S/p port-A placement with its tip at Superior vena cava.
      • Centrilobular Emphysematous change over both lungs and honey combing at peripheral lungs is found. IPF like change is considered. In comparison with CT dated on 2022-10-07, the lesion progressed rapidly.
      • Tortous aorta with calcification is noted.
      • Enlarged, enhanced lymph nodes are found at both sides of the mediastinum, in enlargement.
      • No evidence of bilateral pleural effusion.
      • Calcified coronary arteries is found.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • Suggest clinical correlation
  • Imp: Left anterior chest wall lung cancer s/p treatment with immune related pulmonary fibrosis. The primary tumor is stationary in size but the mediastinal lymph nodes enlarged. Pseudoprogression? Suggest close observation.
• 2022-12-08 CXR
  • Patchy opacity projecting at left upper lateral lung was noted that is c/w lung cancer after correlate with CT.
  • There are several nodular opacities projecting at both lung. Please correlate with CT to R/O lung to lung metastases?
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2022-11-17, -10-27 CXR
  • Patchy opacity projecting at left upper lateral lung or pleura was suspected. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2022-10-12 CXR
  • Patch densities at bil. lungs.
  • Atherosclerosis of the aorta.
• 2022-10-07 CT - chest
  • < BGB-A317-A1217-302 (iIRB No: 10-FS-043) Screening ICF Process >
    • I myself have already discussed the whole details concerning the investigational product, A1217, an anti TIGIT antibody, in combination with Tislelizumab compared to Pembrolizumab, and the trial, BGB-A317-A1217-302 (iIRB No: 10-FS-043), with subject and family via both on-site and remote on 2022.09.15, and on site disscussion on 2022.09.28.
      
  • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Soft tissue mass attaching left anterior chest about 6.28cm in largest dimension is found. In comparison with CT dated on 2022-08-04, the lesion enlarged.
      • Centrilobular Emphysematous change over both lungs is found.
      • Cystic fibrotic change and cystic Bronchiectatic change at both peripheral lungs is found. Stationary.
      • Patent airway is found.
      • Enlarged lymph nodes are found at both sides of the mediastinum. Stationary.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Left upper lobe lung cancer with mediastinal lymphadenopathy, The primary tumor enlarged.
    • COPD.
• 2022-10-06 MRI - brain
  • ACom aneurysm (8.5 mm).
  • No interval change as compared with MRI on 20220822.
  • Please close follow up and consult neurosurgeon.
  • No evidence of brain metastases.
• 2022-10-04 Tc-99m MDP whole body bone scan
  • Increased activity in the antelateral aspect of left 3rd rib, compatible with malignancy with local bone invasion.
  • Increased activity lower T- to upper L-spines and lower L-spines. Either bone metastases or degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Some faint hot spots in the sternum and bilateral rib cages. Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2022-10-04 Pulmonary Function Test, Spirometer
  • preexam spo2:98%; postexam spo2:94%
  • mild obstructive ventilatory impairment with partial reversibility, FEV1/FVC 65%, FVC 81->92%, FEV1 68->77%
  • normal slow vital capacity, SVC 89%
  • airway trapping, RV/TLC 131%
  • normal diffusing capacity, DLCO/VA 73% (low DLCO 58% favor due to low VA)
  • suggest to use bronchodilator such as spiriva for mild obstructive ventilatory impairment
• 2022-08-31 ROS1 FISH
  • ROS1 fluorescent-in-situ hybridization report
  • Rearrangement of ROS1 gene is NOT detected.
  • Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
• 2022-08-31 ALK IHC
  • Result: Negative
  • The immunostaining of the section slide labeled S2022-13261, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining of tumor cells.
• 2022-08-23 Tc-99m MDP whole body bone scan with SPECT
  • Increased activity in the antelateral aspect of left 3rd rib, compatible with malignancy with local bone invasion. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the lower T- to upper L-spines and lower L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2022-08-22 MRI - brain
  • History and Indication
    • hemoptysis and severe chest pain
    • A case of HTN and 2-V CADs/p POBA for trifurcation lesion in ShinKong hospital got medical treatment
    • Active smoking 1/2+ PPD for 30+ years
    • Complained of migratory localized chest pain in the recent 2~3 days, duration lasted for seconds, but denied effort related angina
    • 20220803 EKG: sinus rhythm, 1st AV block
    • 20220803 Current medications: aspirin 1# QD, inderal 1# BID, atozet 1# QD, gaster 1# BID, erispan 1# BID, stilnox 1# prnHS, uricin 1# QD
    • CXR yesterday at LMD revealed left lung tumor, refer to chest clinic
  • Without- and with-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
    • Mild degree of general enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
    • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
    • No midline shift, nor space-occupying lesion.
    • No remarkable finding of skull base and bony structures.
    • No remarkable finding of nasopharynx visible in these images.
    • An outpouch (8 mm) projecting anterolaterally from ACom artery, indicaitng an aneurysm.
  • IMP: ACom aneurysm (8 mm). Mild general brain atrophy.
• 2022-08-19 EGFR gene mutation
  • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen S22-13261
• 2022-08-19 PD-L1 (22C3)
  • PD-L1 Immunostaining Result
    • Tumor Proportion Score (TPS) assessment: 95%
    • Combined Positive Score (CPS) assessment: 95
• 2022-08-12 Patho - bronchus biopsy
  • Labeled as “left chest wall tumor”, needle biopsy — non-small cell carcinoma.
  • IHC stains:
    • TTF-1 (-), Napsin-A (-), p40 (focal +), calretinin (-), CK7 (+), CK20 (-).
    • GATA-3 (-), CK5/6 (+), p63 (+). The pattern is in favor of squamous cell carcinoma.
  • Section shows fibrotic soft tissue with infiltration of irregular nests of non-small cell carcinoma.
• 2022-08-11 Myocardial perfusion SPECT with persantin
  • Probably mild myocardial ischemia at the inferolateral wall, basal lateral wall and posterior wall.
• 2022-08-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 31) / 79 = 60.76%
    • M-mode (Teichholz) = 60
  • Adequate LV systolic function with normal resting wall motion
  • Dilated LA, concentric LVH; LV diastolic dysfunction, Gr 1
  • Trivial MR, trivial AR and trivial TR
  • Preserved RV systolic function
• 2022-08-04 CT - chest
  • Findings
    • Chest:
      • Severe centrilobular Emphysematous change over both lungs is found.
      • Pleural based fibrotic change at both lungs more on peripheral lung is found.
      • Soft tissue mass encasing left atnerior chest wall with bony invasion is found up to 4.5cm. suggest tissue proof.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • Suggest clinical correlation
  • IMp:
    • Severe COPD.
    • Soft tissue mass encasing left atnerior chest wall with bony invasion is found. suggest tissue proof.
• 2022-08-03 CXR
  • Patchy opacity projecting at left upper lateral lung or pleura was suspected. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2022-08-03 ECG
  • Sinus rhythm with 1st degree A-V block
  • Nonspecific ST abnormality

[MedRec]

• 2023-04-26 SOAP MER
  • S
    • SOB and desaturation during OPD
    • He developed decreased O2 Sat 5 days (90-95% initially), S/S exacerbated recent 2 days (<90%, about 84%)
      • no fever
      • no chest pain
    • A case of lung ca received clinical trial Tx, got PCP, CMV infection Hx
    • CXR showed pneumonitis
  • A/P
    • Respiratory failure, hypoxia, Critical, CRP15, bil PN
    • Hx: left lung CA, HTN, COPD; Patent CAD many years ago, PCP, CMV infection
    • CRP 15.4, WBC 7k, Medason, Tapimycin; OA Hema
    • 20230421 lung CT: Interstitial change of both lungs. In progression.
• 2023-04-26 SOAP Dermatology
  • S: itchy and sweating sensation over trunk for weeks.
  • O
    • Diffuse annular lesions with spreading tendernecy and mild pruritus over trunk and gerion for weeks.
    • Past history: denied major systemic disease
    • Impression: tinea cruris et intertrigo eczema.
  • P
    • education about drug side effec and explain
    • strongly suggested OPD f/u
  • Prescription
    • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI 7D
    • Zalain (sertaconazole nitrate) BID TOPI 7D
• 2023-04-19 SOAP Hemato-Oncology
  • P
    • Due to purpura over arms and legs, the subject uses Hirudoid Gel, which is over the counter medicine, from 2023-04-19.
    • For prevention of contrast-induced nephropathy, hydration is given to the subject from 2023-04-19 to 2023-04-21.
• 2023-04-12 SOAP Infectious Disease
  • A: refill Valcyte dose to 2# qd for 4 more weeks, has received 3-week full dose Valcyte till 2023-02-22.
  • P: FU on 2023-05-10
• 2023-03-29 SOAP Hemato-Oncology
  • P: For creatinine increased, hydration is given to the subject from 2023-03-29 to 2023-03-31.
• 2023-03-29 SOAP Infectious Disease
  • A: refill Valcyte dose to 2# qd for two more weeks, has received 3-week full dose Valcyte till 2023-02-22.
  • P: FU on 2023-04-12
• 2023-03-22 SOAP Hemato-Oncology
  • P: Due to improvement of appetite, the dose of megestrol was adjusted from 160 mg PO QD to 80 mg PO QD since 2023-03-16.
• 2023-03-16 SOAP Hemato-Oncology
  • AE:
    • Fever Gr 1 on 2022-10-20, related to IP.
    • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
    • Mucositis oral Gr 2 from 2023-01-26 to now, not related to IP. (Related to removable denture)
    • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
    • Diarrhea Gr 1 from 2022-12-05 to 2022-12-18, not related to IP.
    • Anorexia Gr 2 from 2022-12-05 to now, not related to IP.
    • Lung infection Gr 2 from 2023-01-21 to 2023-01-26, not related to IP.
    • Cytomegalovirus infection reactivation Gr 1 from 2023-01-16 to 2023-01-30, Gr 2 from 2023-01-31 to 2023-03-14, not related to IP.
    • Alanine aminotransferase increased Gr 1 from 2023-02-22 to 2023-03-14, not related to IP.
    • Aspartate aminotransferase increased Gr 1 from 2023-02-08 to 2023-02-21, not related to IP.
    • Anemia Gr 2 from 2023-01-09 to 2023-01-12, not related to IP.
    • Creatinine increased Gr 1 from 2023-03-01 to 2023-03-07, not related to IP.
    • Blood bilirubin increased Gr 1 from 2023-03-08 to now, not related to IP.
• 2023-03-15 SOAP Infectious Disease
  • A: refill Valcyte dose to 2# qd for two more weeks, has received 3-week full dose Valcyte till 2023-02-22.
  • P: FU on 2023-03-29
• 2023-03-15 SOAP Hemato-Oncology
  • O
    • 2023/03/13 CMV viral load assay = Target not deteceted IU/mL;
    • 2023/02/20 CMV viral load assay = <35 IU/mL;
    • 2023/02/06 CMV viral load assay = 181 IU/mL;
    • 2023/01/27 CMV viral load assay = 62 IU/mL;
    • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
  • P: For prevention of creatinine increased, hydration is given to the subject from 2023-03-15 to 2023-03-16.
• 2023-03-01 SOAP Hemato-Oncology
  • P: For Gr 1 creatinine increased, hydration is given to the subject from 2023-03-01 to 2023-03-03.
• 2023-02-22 SOAP Infectious Disease
  • A: reduce Valcyte dose to 2# qd for two weeks, has received 3-week full dose Valcyte till 2023-02-22
  • P: FU on 2023-03-08
• 2023-02-22 SOAP Hemato-Oncology
  • O
    • 2023/02/20 CMV viral load assay = <35 IU/mL;
    • 2023/02/06 CMV viral load assay = 181 IU/mL;
    • 2023/01/27 CMV viral load assay = 62 IU/mL;
    • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
• 2023-02-15 SOAP Hemato-Oncology
  • P: For prevention of contrast-induced nephropathy, hydration is given to the subject from 2023-02-15 to 2023-02-17.
• 2023-02-08 SOAP Hemato-Oncology
  • O
    • 2023/02/06 CMV viral load assay = 181 IU/mL;
    • 2023/01/27 CMV viral load assay = 62 IU/mL;
    • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
  • P: Highly suspect CMV reactivation complicated with hepatitis -> After discussion with infection expertise, follow up CMV viral load after 2 weeks of using Valcyte and adjust Prednisolone from 4 tab QD to 2 tab QD.
• 2023-02-08 SOAP Infectious Disease
  • S: CMV related hepatitis follow up, easy fatigue, exertional dyspnea, intake still acceptable, loss of weight 1kg.
  • O
    • BT no fever, BW 65.2kg
    • 20230208 AST/ALT 80/335,
    • 20230206 CMV viral load 181
  • A
    • refill Valcyte for the 2nd and 3rd week therapy
    • reduction of steroid use indicated
  • P: FU on 2023-02-22
• 2023-02-01 SOAP Infectious Disease
  • S
    • 2023/02/01 Referred from Onco OPD for CMV related hepatitis
    • no cough, exertional dyspnea and easy fatigue still noted,
    • PJP and interstitial lung discharged from Onco on 2023-01-20, with prednisolone and Baktar use
    • Underlying lung cancer, cT4N3M1b stage IVA SCC, cachexia.
  • O
    • BT no fever
    • 20230131 WBC 23290, AST/ALT 131/252
    • 20230127 CMV viral load assay = 62 IU/mL;
    • 20230117 CT chest: LUL cancer with chest invasion and mediastinal-hilar LAP, signficant as compared with CT on 2022/12/16. combined emphysema and IPF.
    • 20221224 CMV viral load not deteceted;
  • A
    • refill Valcyte for one week first, under CMV-related hepatitis impression.
  • P
    • FU on 20230208
• 2023-01-31 SOAP Hemato-Oncology
  • O
    • 2023/01/27 CMV viral load assay = 62 IU/mL;
    • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
  • P: Highly suspect CMV reactivation complicated with hepatitis -> After discussion with infection expertise, prescribe Valcyte and refer to Infection expertise for futher evaluation and management.
  • Prescription
    • Valcyte (valganciclovir 450mg) 2# BID 1D
• 2023-01-26 SOAP Hemato-Oncology
  • P:
    • Due to impaired renal function which might be related dehydration, IV fluid support will be given.
    • In addition, potassium-binding agent will be used for hyperkalemia.
  • Presciption
    • Kalimate (calcium polystyrene sulfonate 5mg) 1# QD 5D
• 2022-12-15 SOAP Hemato-Oncology
  • P: Because new main ICF (Version 2.0, 12-Oct-2022) and Optional Future Research ICF (Version 1.0, 12-Oct-2022) are proven, I give the new version ICF to the subject and let the subject have adequate time to read it, subsequently ask question and discuss with us. Then the subject sign the version ICF on 2022-12-15. A copy of the signed main ICF and Optional Future Research ICF were provided to the subject.
    • For prevention of contrast-induced nephropathy, hydration is given to the subject from 2022-12-15 to 2022-12-17.
    • The subject discontinued Cyproheptadine from 2022-12-15, and switched to Megestrol Acetate 160 mg PO QD for anorexia from 2022-12-15.
    • Due to relatively lower BP and occasionally dizziness, the subject hold Bisoprolol Fumarate from 2022-12-08.
    • The subject discontinued Lorazepam from 2022-12-08, and switched to Quetiapine from 2022-12-08.
    • Due to Morphine induced dry mouth, the subject discontinued Morphine and switched to Tramacet from 2022-12-08.
    • On 2022-12-16, the CT revealed the possibility of lung infection or pneumonitis. Therefore, oral empirical antibiotics with cephalexin 500 mg Q6H is given since 2022-12-16. If not working, admission for lung infection would be done.
  • Prescription
    • cephalexin 500mg 1# Q6H 7D
• 2022-12-07 SOAP Hemato-Oncology
  • O
    • AE:
      • Fever Gr 1 on 2022-10-20, related to IP.
      • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
      • Mucositis oral Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
      • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
      • Diarrhea Gr 1 from 2022-12-05 to now, not related to IP.
      • Anorexia Gr 2 from 2022-12-05 to now, not related to IP.
  • P
    • Due to sweating a lot, hydration is given to the subject from 2022-12-07 to 2022-12-09.
    • Cyproheptadine 4 mg PO TID for anorexia from 2022-12-07.
    • The subject discontinued Orolisin from 2022-11-30.
• 2022-11-30 SOAP Hemato-Oncology
  • O
    • AE:
      • Fever Gr 1 on 2022-10-20, related to IP.
      • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
      • Mucositis oral Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
      • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
      • Diarrhea Gr 1 from 2022-11-28 to 2022-11-29, not related to IP.
  • P
    • Due to suspect the sweating coming from taking Tramacet (tramadol/acetaminophen), discontinued Tramacet from 2022-11-17.
    • Because the subject mentions the eczema over bilateral upper limbs which is actually existed before being enrolled onto this trial, Levocetirizine, Fluocinonide and Urea are prescribed by dermatologist on 2022-11-30.
    • Due to sweating a lot, hydration is given to him on 2022-11-30.
• 2022-11-30 SOAP Dermatology
  • S: itchy over exposesite of upper limbs
  • O: Widespread multiple reddish to brownish maucles, papules and confluent plaques with excoriations and scales over the upper limbs for months. No fever
    • Past history: denied major systemic disease
    • Impression: eczema, less likely drug-related. r/o pityriasis disorder.
  • P:
    • education about drug side effec and explain
    • strongly suggested OPD f/u
  • Prescription
    • Xyzal (levocetirizine 5mg) 1# QN
    • Topsum Cream (fluocinonide 0.05%) BID EXT
    • Sinpharderm Cream (urea) BID TOPI
• 2022-11-24 SOAP Hemato-Oncology
  • O
    • AE:
      • Fever Gr 1 on 2022-10-20, related to IP.
      • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
      • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
      • Hyperkalemia Gr 2 from 2022-11-24 to now, not related to IP.
  • P
    • Sodium Chloride for hyperkalemia (K: 5.9 mmol/L)
    • Triamcinolone 1 qs TOPI PRNBID for prevention of mucositis.
• 2022-11-09 SOAP Hemato-Oncology
  • O
    • AE:
      • Fever Gr 1 on 2022-10-20, related to IP.
      • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
      • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
      • Hyperkalemia Gr 2 from 2022-11-03 to 2022-11-08, not related to IP.
  • P: Due to sweating after taking Tramacet (tramadol/acetaminophen), hydration is given to him on 2022-11-09.
• 2022-11-03 SOAP Hemato-Oncology
  • O
    • AE:
      • Fever Gr 1 on 2022-10-20, related to IP.
      • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
      • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to now, not related to IP. (Related to removable denture)
      • Hyperkalemia Gr 2 from 2022-11-03 to now, not related to IP.
  • P
    • Triamcinolone for mucositis oral from 2022-11-03.
    • Sodium Chloride for hyperkalemia (K: 5.7 mmol/L)
• 2022-10-27 SOAP Hemato-Oncology
  • S
    • BGB-A317-A1217-302 (iIRB No: 10-FS-043) C1D8 Visit
      • IP: Tislelizumab or Pembrolizumab 200 mg (D1) + BGB-A1217 900 mg or Placebo (D1) Q3W
      • C1D1 on 2022-10-20
  • O
    • PE (Body system: vision, general, HEENT, cardiovascular, chest and respiratory, abdomen, extremities/musculoskeletal, neurological) –> Yes & maculopapular rash and plaques
    • Examinations and Tests
      • Sample collection:
        • Lab tests:
          • Blood collection at 08:57 AM on 2022-10-27
          • PK of Tislelizumab or Pembrolizumab & A1217 or Placebo; ADA of Tislelizumab or Pembrolizumab & A1217 or Placebo (pre-dose): Nil
          • PK of Tislelizumab or Pembrolizumab & A1217 or Placebo (post dose within 30mins): Nil
    • AE: Fever Gr 1 on 2022-10-20, related to IP.
  • P
    • Monitor adverse event
• 2022-10-18 SOAP Hemato-Oncology
  • P
    • Acetylcysteine 600 mg PRBBID PO for productive cough.
    • Piroxicam 1 QS PRNBID TOPI for tumor pain.
• 2022-10-12 SOAP Hemato-Oncology
  • P
    • Refil the medicine
    • The subject has still Aspirin, Bisoprolol, Atozet, Candesartan, Famotidine, Sennoside, Morphine, MgO, Acetylcysteine, Fluocinonide, Orolisin, Exelderm Cream, Urea at home, no priscription on 2022-10-12.
• 2022-10-04 SOAP Hemato-Oncology
  • P
    • Refil the medicine
    • Actein for prevention of contrast-induced nephropathy.
    • Preliminarily discuss the content of trial on 2022-09-15 and 2022-09-26.
• 2022-09-20 SOAP Hemato-Oncology
  • S
    • << BGB-A317-A1217-302 (iIRB No: 10-FS-043) Pre-screening ICF Process >>
      • I myself have already discussed the whole details concerning the investigational product, A1217, an anti TIGIT antibody, in combination with Tislelizumab compared to Pembrolizumab, and the trial, BGB-A317-A1217-302 (iIRB No: 10-FS-043), with subject and family on 2022.09.15, using the virtual discussion via web.
      • Before the Pre-screening informed consent form (V1.1_TC_20May2021) is signed, the Pre-screening ICF was read by patient and family with adequate time.
      • They had enough time to ask questions and I answered their questions thoroughly as well.
      • The subject agreed to provide the tumor slides to central lab for determination of PD-L1 expression, and had signed Pre-screening informed consent form on 2022.09.20.
      • A copy of the signed Pre-screening informed consent form was provided to the subject.
  • O
    • Study Title: BGB-A317-A1217-302
    • A Phase 3, Randomized, Double-Blind Study of BGB A1217, an Anti TIGIT Antibody, in Combination With Tislelizumab Compared to Pembrolizumab in Patients With Previously Untreated, PD L1 Selected, and Locally Advanced, Unresectable, or Metastatic Non Small Cell Lung Cancer
    • Pre-screening No.: SCR-886019-001
      
    • Initial: SJC
    • Date of birth: 1940.11.23
    • Gender: Male
    • ALK IHC: Negative
    • EGFR: Negative
  • A
    • Anticipate to arrange the freshly cut unstained FFPE slides on 2022-09-20.
• 2022-09-15 SOAP Hemato-Oncology
  • O
    • 2022/08/31 Anti-HBc = Reactive;
    • 2022/08/31 Anti-HBc-Value = 7.15 S/CO;
    • 2022/08/31 ROS1 FISH: Negative
    • 2022/08/31 ALK IHC: Negative
    • 2022/08/19 EGFR: Negative
• 2022-08-30 SOAP Hemato-Oncology
  • A
    • ALK, ROS1 and lab
    • T3N0M1a stage M1a SCC
• 2022-08-17 SOAP Cardiology
  • Prescription
    • Bokey (aspirin 100mg) 1# QD 14 days
    • Concor (bisoprolol 5mg) 0.5# QD 14 days
    • Atozet (ezetimibe 10mg + atorvastatin 20mg) 1# QD 14 days
    • Blopress (candesartan 8mg) 1# QD 14 days
    • Ulstop (famotidine 20mg) 1# QD 14 days
• 2022-08-03 SOAP Chest Medicine
  • S
    • hemoptysis
    • A case of HTN and 2-V CADs/p POBA for trifurcation lesion in ShinKong hospital got medical treatment
    • Active smoking 1/2+ PPD for 30+ years
    • Denied past history of DM
    • Complained of migratory localized chest pain in the recent 2~3 days, duration lasted for seconds, but denied effort related angina
    • 20220803 EKG: sinus rhythm, 1st AV block
    • 20220803 Current medications:
      • aspirin 1# QD,
      • inderal 1# BID,
      • atozet 1# QD,
      • gaster 1# BID,
      • erispan 1# BID,
      • stilnox 1# prnHS,
      • uricin 1# QD
    • CXR yesterday at LMD revealed left lung tumor, refer to chest clinic
    • Arrange echocardiography and Tl-201 myocardial perfusion scan for further evaluation

[chemoimmunotherapy]

• 2023-04-07 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
• 2023-03-16 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
• 2023-02-23 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
• 2022-12-01 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
• 2022-11-10 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
• 2022-10-20 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)

[assessment]

221229

[Trimethoprim/Sulfamethoxazole (TMP/SMX) dosing

• Trimethoprim/sulfamethoxazole(TMP/SMX) for patients with moderate to severe Pneumocystis pneumonia infection: IV 15 to 20 mg/kg/day (TMP component) in 3 or 4 divided doses; may switch to oral therapy after clinical improvement.

  • In-hospital Baktar spec: sulfamethoxazole 400mg + trimethoprim 80mg in 5mL/amp. The patient’s body weight is 70kg.
  • 70kg * 15 = 1050mg ~ 13.125 amp ~ 4amp TID or 3amp QID
  • 70kg * 20 = 1400mg ~ 17.5 amp ~ 6amp TID or 4amp QID

• As recent lab results revealed no abnormalities in the liver and kidney functions, it is less likely that dosage adjustments will be needed.

• Patients with moderate or severe infection (PaO2 <70 mm Hg at room air or alveolar-arterial oxygen gradient >= 35 mm Hg) should receive adjunctive glucocorticoids.

700691239

230427

{not completed}

[exam findings] (not completed)

• 2023-04-25 MRI - pelvis
  • Indication: posterior iliac crest tender mass, r/o abscess formation
  • With and without-contrast multiplannar and multisequences MRI of pelvis revealed:
    • Fluid accumulation in right pelvis, involving erector spinae muscle, iliopsoas muscles, and sacroiliac joint. Marginal enhancement after contrast adminstration. Another fluid collection in left L1-2 paravertebral region.
    • An intramudullar lesion in right sacral ala, adjacent to right sacroiliac joint. Enhancement after contrast administration.
    • T2 hyperintense lesions in spine and left acetabulum. Enhancement after contrast administration.
  • Impression
    • c/w tuberculous infection with cold abscess in right pelvis and left paravertebral regions, in progression
    • c/w bone metastasis in spine, right sacral ala, and left acetabulum
• 2023-04-13 CXR
  • Scoliotic alignment of the thoracolumbar spine is noted.
• 2023-04-06 SONO - abdomen
  • Right renal cyst (0.90x1.38cm).
• 2023-03-23 MTBC PCR
  • S2023-04099 — Positive
• 2023-03-07 Patho - bone exostosis
  • Soft tissue, labeled as “bone, right sacral”, CT-guide biopsy — Necrosis
    • NOTE: Correlation of micro-organism culture, image study and clinical findings is recommended.
  • Microscopically, it shows necrotic debris, mixed inflammatory infiltrate of lymphocytes and leukocytes and focal stromal fibrosis.
  • Immunohistochemical stain reveals CK(-) and GATA3(-) for tumor.
  • Acid-fast stain — Positive for mycobacterial bacilli, PAS stain — Negative; Suggest of mycobacterial infection
• 2023-03-06 CXR
  • Old fracture of right clavicle S/P compression plate and screws fixation shows good alignment and good union.
  • There is soft tissue density in paraspinal area in T11-T12 level. Please correlate with CT.
  • Osteolytic lesion in T12 vertebral body is highly suspected.
• 2023-03-01 PET scan
  • Increased FDG uptake in the T10-L1 spines, right aspect of sacrum, and inferior aspect of the left acetabulum, highly suspected tumor (breast or others ?) with multiple bone metastases. .
    
  • Increased FDG uptake in soft tissue in the RLQ and LUQ of abdomen, the nature is to be determined (another primary malignancy or others ?), suggesting biopsy for further investigation.
    
  • Right breast cancer s/p treatment, highly suspected tumor (breast or others ?) with multiple bone metastases, by this F-18 FDG PET scan.
• 2023-02-16 Tc-99m MDP bone scan
  • In comparison with the previous study on 2022/02/16, the lesions in the lower T-spines, manubrium of the sternum, right aspect of sacrum, adjacent right iliac bone and inferior aspect of left acetabulum are new.
  • Multiple bone metastases should be watched out.
• 2023-02-10 CT - abdomen
  • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
  • Findings:
    • There are osteoblastic change from T11 to L1.
      • In addition, There is osteolytic lesion in T12 vertebral body and soft tissue tumor extension from T12 vertebral body into anterior and left lateral aspect of the vertebral body and left psoas muscle.
      • Metastases are highly suspected. Please correlate with tumor marker and PET scan.
    • There is an ill-defined osteoblastic change and osteolytic lesion in right 1st sacrum that also may be bony metastasis.
    • Two low density lesion in the upper pole of both kidney are noted. Please correlate with sonography to R/O cyst?
    • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
  • IMP:
    • Bony metastases are highly suspected.
    • Please correlate with tumor marker and PET scan.
• 2023-02-06 SONO - nephrology
  • Bilateral renal cysts
• 2022-12-26 SONO - abdomen
  • Right renal cyst and stone.

[consultation]

• 2023-04-26 Anesthesiology
  • Q
    • This 53-year-old female patient has past history of
      • Left breast tumor s/p left tumor excision in 2003
      • Right clavicle fracture s/p ORIF
      • Right breast tumor s/p tumor excision after needle localization on 2022/01/28
    • Right breast ductal carcinoma in situ status post right axillary sentinel lymph node biopsy on 2022-03-11. She denied any TOCC histories in recent 3 months.
    • This time she was admitted due to right iliac crest biopsy site severe pain with tenderness for 2 days. The pain was accompanied with fever up to 39.5 degC and chillness.
    • Under the impression of right iliac crest cellulitis, she was admitted for antibiotics treatment.
    • 2023/03/01 bone scan: Increased FDG uptake in the T10-L1 spines, right aspect of sacrum, and inferior aspect of the left acetabulum, highly suspected tumor (breast or others ?) with multiple bone metastases.
    • However, on 2023/03/02 Bone marrow biopsy showed no metastatic carcinoma
    • 2023/03/07 CT-guided biopsy of right sacrum showed positive AFS, and subsequently at 2023/03/23 tissue report showed TB positive
    • Lab data (20230424): CRP 12.68, WBC 15010; blood culture result pending
    • Currently the patient has been taking AKuriT-4 for 5 weeks.
    • MRI pelvis done on 20230425 showed c/w tuberculous infection with cold abscess in right pelvis (invading erector spinae muscle, iliopsoas muscles, and sacroiliac joint.), in progression; c/w bone metastasis in spine, right sacral ala, and left acetabulum
    • ID man suggested needle aspiration by radiologist; and Radiologists warned us about the risk of cutaneous fistula formation and skin TB after drainage procedure.
    • This morning, the patient started to notice right leg numbness radiating from hip downward from the side of thigh all the way down to right sole, but resolved after 2 hours
    • PE showed pain on right hip flexion, and restricted AROM on right hip extension.
    • Therefore, we also consulted neurosurgeon and replied no apparent invasion of spine.
    • GS was also consulted, and due to the lesions were deeply located, therefore, surgical debridement was not feasible
    • ORTHO will arrange debridement for her right sacral abscess on 20230427.
    • This time we would really need your expertise in providing preoperative anesthetic evaluation for this patient.
    • Thanks a lot in advance!
  • A
    • I’ve visited the patient and reviewed her data
    • CC: right iliac crest severe pain with tenderness, fever and chillness
    • DX: c/w tuberculous infection with cold abscess in right pelvis (invading erector spinae muscle, iliopsoas muscles, and sacroiliac joint.), in progression; c/w bone metastasis in spine, right sacral ala, and left acetabulum
    • OP: right sacral abscess debridement on 20230427
    • Anes plan:
      • ASA III
      • We will arrange ETGA for this patient
      • The patient has been informed on the anesthesia- and surgery-associated risks
• 2023-04-25 Neurosurgery
  • Q
    • This time we would really need your expertise in evaluating the feasibility of incisional drainage with biopsy, and the possible cause of right sciatica.
  • A
    • A case of 53 y/o female, Hx have been reviewed; Extrapulmonary TB(+) under Tx.
    • NS is consulted for right LBP and wraist mass with tenderness; Fever(+);
    • O
      • Current status: Cons: clear
      • Walk ok; MP: bil 5-; sensation: symmetric; gait: fair; sphincter: continence
      • A pelvis MRI:
        • Fluid accumulation in right pelvis, involving erector spinae muscle, iliopsoas muscles, and sacroiliac joint. Marginal enhancement after contrast adminstration. Another fluid collection in left L1-2 paravertebral region.
        • An intramudullar lesion in right sacral ala, adjacent to right sacroiliac joint. Enhancement after contrast administration.
        • T2 hyperintense lesions in spine and left acetabulum. Enhancement after contrast administration.
    • A
      • c/w tuberculous infection with cold abscess in right pelvis and left paravertebral regions, in progression
      • c/w bone metastasis in spine, right sacral ala, and left acetabulum; breast cancer
    • P
      • May arrange CT guide or echo guide pigtail drainage and biopsy; pain control; Tx TB as usual;
• 2023-04-22 Infectious Disease
  • A
    • 81-year-old breasst cancer female patient has right sacroiliac crest TB and has received 5 more week anti-TB treatment till now.
    • O
      • Painful growing mass is noted over right posterior lower back, where previous biopsy site.
      • Lab data revealed no drop of ESR and CRP levels.
    • A
      • Either hematoma or abscess formation is the first consideration.
      • No need for change the anti-TB regimen, but MRI or CT study necessary for the mass lesion nature.
    • Suggestion
      • Continue the present AkuriT-4 medication to complete the first 60-day medication.
      • Continue Tramacet and add Celebrex for pain relief.
      • Arrange MRI of T-L-S spine for evaluation of spine and iliac mass lesion.
• 2023-03-10 Infectious Disease
  • A
    • 52-year-old breast cancer with suspect multiple bony metastases female patient, received right sacrum bone biopsy on 2023-03-07.
    • Patholgoy report revealed positive AFB smear and no cancer cell, that bone TB is the first consideration.
    • Review the PET report, there are multiple bone lesions, including sternum, T-spine, right sacrum and left acetabulum.
    • TB bone rarely presents so many sites.
    • TB bone culture was not done, that bone tissue TB-PCR study is necessary.
    • Please contact the TB practioner.
    • TB disease notification is necessary first, that anti-TB therapy can be started, even without PCR report.

[assessment]

• AKuriT-4 (RIF 150mg + INH 75mg + PZA 400mg + EMB 275mg) 3# PO QDAC is administered according to the patient’s bone tuberculosis.

• It is important to note that the patient is currently taking multiple NSAIDs (Laston (ketorolac) ST, Celebrex (celecoxib) QD, naproxen PRNQ8H). Concomitant use of multiple NSAIDs is not recommended due to the increased risk of side effects such as bleeding and kidney damage. Please monitor the patient closely for signs of bleeding or changes in kidney function and consider adjusting her medication regimen if necessary.

701048984

230427

[diagnosis] - 2023-03-29 admission note

• gastric cancer with liver invasion, cT4bN1M0, stage IV s/p gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection
• constipation

[past history] - 2023-03-06 admission note

• The patient had no systemic diseases
• history of operation:
  • gastric cancer with liver metastasis, cTT4bN2M1, stage IVB, s/p liver S3 partial resection, cholecystectomy, choledochoduodenal bypass and gastrojejunal bypass on 2023/01/09
• Regular medications or herb:
  • Tramacet 1tab PO HS
  • Sketa 1tab PO TID
  • Pariet 1tab PO QDAC
  • Mosapride 1tab PO TID         

[allergy]

• NKDA         

[family history]

• His father has hypertension.
• Denied of any families have cancer history.

[exam findings]

• 2023-04-18 Patho - stomach biopsy
  • Stomach, proximal to the anastomosis site, biopsy — Adenocarcinoma, moderately differentiated
  • Section shows fragments of gastric tissue with chronic inflammation, intestinal metaplasia and focal invasive cribriform glands.
  • The immunohistochemical stain of CK is positive.
• 2023-04-18 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Gastric ulcer, LC site, proximal to the anastomosis, s/p biopsy
    • Remnant gastritis
    • Post subtotal gastrectomy with Billroth II anastomosis
  • Suggestion
    • Keep PPI therapy
    • Pursue pathology report
• 2023-04-02, -02-06, -02-04 KUB
  • Presence of ileus.
  • Degeneration and spondylosis of L-S spine.
• 2023-02-04 CXR
  • Atherosclerosis of the aorta.
  • Presence of ileus.
• 2023-01-09 Patho - liver partial resection
  • Gallbladder, cholecystectomy — Chronic cholecystitis and cholelithiasis
  • The sections show a picture of chronic cholecystitis and cholelithiasis, composed of congestion, mild chronic inflammatory cells infiltration, mild mural fibrosis, and scattered Rokitansky-Aschoff sinuses.
• 2023-01-09 Patho - liver partial resection
  • PATHOLOGIC DIAGNOSIS
    • Liver, S3, partial S3 resection — Adenocarcinoma, moderately differentiated, compatible with gastric origin
      
  • MACROSCOPIC EXAMINATION
    • Procedures: Partial S3 resection
      
    • Specimen Size: 4.5 x 3.2 x 2.5 cm
      
    • Tumor Focality: Solitary
      
    • Tumor Site: S3
      
    • Tumor Size: 0.8 x 0.6 x 0.4 cm
      
    • Large vessel involvement: Not identified
      
    • Non-tumorous part: Not cirrhotic
    • Sections are taken and labeled as: A1-A2 = tumor, A3 = non-neoplastic liver
  • MICROSCOPIC EXAMINATION
    • Diagnosis: Adenocarcinoma, compatible with gastric origin
      
    • Histologic grade: Moderately differentiated
      
    • Tumor growth pattern: Pushing
      
    • Tumor pseudocapsule: Absent
      
    • Tumor necrosis: Moderate (40%)
      
    • Parenchymal margin: Uninvolved by carcinoma
      
    • Distance of invasive carcinoma from closest margins: 1.2 cm
      
    • Vascular invasion: Not identified
      
    • Perineural invasion: Not identified
      
    • Non-neoplastic liver parenchyma: Mild lymphocytic portal inflammation, no interphase hepatitis, no lobular inflammation, and regenerative hepatocytes
    • Fatty Change: Present (3%)
• 2023-01-05 CT - abdomen gastric filling with water
  • History and indication: gastric cancer
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A large ulcerative lesion at gastric antrum with regional LAP.
    • Normal appearance of liver, spleen, pancreas, adrenals and kidneys.
    • Gallbladder stone (6mm).
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • No abnormal density at bilateral basal lungs.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
• 2023-01-04 Flow Volume Chart
  • normal screening
• 2023-01-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (94 - 34) / 94 = 63.83%
    • M-mode (Teichholz) = 64
  • Adequate LV systolic function with normal resting wall motion
  • Trivlal MR and trivial TR
  • LV diastolic dysfunction, Gr 1
  • Preserved RV systolic function
• 2022-12-28 Patho - stomach biopsy
  • Stomach, antrum LC, biopsy — Adenocarcinoma.
  • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=1+).
  • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and isolated neoplastic cells.
• 2022-12-27 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Superficial gastritis, s/p CLO test
    • Suspected gastric cancer, antrum, LC site, s/p biopsy
  • Suggestion
    • Pursue pathology report
• 2021-02-23 Auditory Brainstem Response, ABR
  • Absence of ABR wave I was noticed in L’t ear.
  • Prolonged ABR wave I latency in R’t ear.
  • ILD-V 0.08
  • no evidence of retrocochlear lesion
• 2021-02-16 ENT Hearing Test
  • PTA:
    • Reliability FAIR
    • Average R’t 30 dB HL; L’t 44 dB HL
    • R’t normal to profound SNHL.
    • L’t normal to severe SNHL.
  • Tymp: Bil type A.
  • ART:
    • R’t ipsi 4k Hz and contra absent.
    • L’t absent.

[consultation]

• 2023-04-17 Anesthesiology
  • Q
    • for anesthesia assessment
    • Arrange painless of EGD on 4/18 8AM
    • This 80-year-old male, who has a histiry of gastric cancer with liver invasion, cT4bN1M1 s/p gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09 s/p palliative chemotherapy with mFOLFOX IV, and IP chemotherapy Taxotere/Cisplatin. He suffered from initial presentation of RUQ of abd pain in Jan 2023, s/p sent to ER of ShuangHe Hospital and weight loss (+) (5kg in 12 months). Surgical pathology with liver, S3, partial S3 resection (20230109) proved Adenocarcinoma, MD. c/w gastric origin. Gallbladder, cholecystectomy: Chronic cholecystitis and cholelithiasis. Ascites (20230109) showed negative. Stomach, antrum LC, biopsy (20221227) proved adenocarcinoma.IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=1+). He received gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09, and received palliative chemotherapy with mFOLFOX IV, and IP chemotherapy Taxotere/Cisplatin Q2W x 12 , #1 on 20230216, #2 on 20230306, #3 on 20230330 - Acording to the patient describe, he suferred from vomiting dark red once and tarry stool noted on 2023/04/15, so he was brought to ChangGung Hospital for help first, then due to personal reason, so he went to our ER for help. At ER, the vital signs: BT 36.3 degC; HR: 99bpm; RR: 18bpm; SpO2 98% under room air, conscious: E4V5M6. The lab of CBC/DC showed anemia (Hb: 8.8g/dL), so gave blood tranfusion with LPRBC, hydration, Transamine, and PPI with Pantoloctreatment. After treatment, the Hb level go up to 10.1g/dL. Under the impression of Gastrointestinal hemorrhage, so he is admitted for future evaluation.
  • A
    • 80 y/o man has
      • Hx: gastric cancer stage VI
      • gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09
    • Dx: GI Bleeing
    • Op: PES
    • Condition: Cons. clear, previous walking ok but now weakness and tired unable to sit on wheelchair, no dyspnea, chest tightness or leg edema
    • Lab: Hb10
    • ASA3
    • Plan:
      • High risk of aspiration, sepsis, shock
      • Anes. plan and risk was told to him at bedside
      • Resucitation, ETT will be procedured if emergence condition.
      • We will arrange IVGA, GI man will injection local anesthsia at GI tract.
      • Correct underly dx such as anemia, hypovulemia as your expertise.
      • Follow onetouch q6h or even q4h when nil per os if DM or high risk of hypoglycemia

[surgical operation]

• 2023-01-09
  • Surgery
    • Laparoscopy
    • Liver S3 partial resection
    • Cholecystectomy
    • Choledochoduodenal bypass
    • Gastrojejunal bypass
  • Finding
    • A whitish hard tumor was protruding from the anterior wall of gastric antrum near lesser curvature.
    • A whitish tumomr was noted at the posterior wall of S3 segment, r/o direct invasion from the gastric tumor.
    • Hard tumors were noted at the pancreatic head and retroperitoneum.
    • After discussion with his family, tumors could not excised entirely. His son agreed with performing bypass surgery only.
    • No gallbladder stone was found.
    • At least cT4bN1

[chemotherapy]

• 2023-04-27 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 100mL 2hr + fluorouracil 2000mg/m2 2900mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-29 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 100mL 2hr + fluorouracil 2000mg/m2 2800mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-06 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 100mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-16 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 100mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[assessment]

• 2023-04-26 lab results showed low serum Na (133 mmol/L), K (3.4 mmol/L), Mg (1.4 mg/dL), and albumin (3.3 g/dL). These electrolyte imbalances are currently being addressed with appropriate supplementation. With the exception of mild anemia, the patient’s blood cell counts are within normal limits and do not represent a contraindication to the planned chemotherapy.

• The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

230330

[assessment]

• Laboratory data on 2023-03-29 showed normal liver/kidney function, however, cation electrolytes and HGB were slightly decreased, which would not contraindicate the planned chemotherapy.

• Ascites cytology on 2023-03-08, 2023-03-07, 2023-02-20, 2023-02-17 showed no evidence of positive results.

• No medication reconciliation issue identified.

230307

[assessment]

• The patient is undergoing FOLFOX NIPS treatment for the second time during this hospital stay. There are no apparent complaints of adverse reactions following the patient’s last treatment.
• Potassium supplementation is currently administered appropriately to manage low serum K level (2023-03-06 3.0mmol/L) in this patient.

230217

[assessment]

• The patient undergos palliative chemotherapy with a combination of mFOLFOX IV/IP C/T every two weeks for a total of 12 cycles since this hospital stay. After the first 6 cycles the patient will undergo an abdominal CT scan to evaluate the response to treatment.
• Lab data 2023-02-16 showed grossly normal readings, and the patient’s TPR and blood pressure vital signs have remained stable throughout his hospitalization as of now.
• Megestrol is appropriately used as an appetite stimulant in this patient with poor appetite and unintended weight loss.

701173522

230427

{not completed}

[exam findings]

[surgical operation]

• 2019-08-26
  • Diagnosis: Malignant ovary neoplasm with peritoneal carcinomatosis
  • PCS code: 73043B
  • Finding
    • ascite (-)
    • small bowel adhesion (++)
    • tumor (-)
• 2019-07-15
  • Diagnosis: Malignant ovary neoplasm
  • PCS code: 73014B
  • Finding: mutiple tumor seeding over s7, right diaphragm, left paracolic gutter, pelvis, surface of urinary bladder, ascending colon, and sigmoid colon
• 2019-07-15
  • Diagnosis: Ovarian cancer
  • PCS code: 80418B
  • Finding:
    • Supraumbilical midline vertical skin incision.
    • Uterus: 6x3 cm, tense contact with bladder, no obvious tumor noted
    • Adnexa:
      • Lt: 3x2 cm, capsule intact, papillary surface, severe adhesion to uterus, pelvic wall and rectum due to tumor seeding
      • Rt: 4x3 cm, capsule intact, papillary surface, severe adhesion to uterus, pelvic wall and rectum due to tumor seeding
    • CDS: invisible due to tumor mass occupied
    • Ascites: little
    • Bilateral paraaortic and pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
    • Omentum: with multiple hard, variablesized millitary nodules
    • Liver: with rough surface
    • Subdiaphragmatic surface: miliary tumor seeding(+), bean sized
    • After the operation, HIPEC was performed.
    • Residue tumor: multiple millitary tumors, diameter about 0.1 cm, over peritoneal wall, small intestine and colon
    • Estimated blood loss: 850ml (include ascites)
    • Blood transfusion: nil
    • Complication: nil
• 2019-04-11
  • Diagnosis: Maliganat cervix uteri neoplas
  • PCS code: 47080B
  • Finding:
    • peritoneal carcinomatosis, PCI: 17/39, small bowel PCI: 4
    • malignant ascites(+), about 2600ml
    • omentum cake(+)
• 2017-07-15
  • Diagnosis: Malignant ovary neoplasm
  • PCS code: 50010C
  • Finding: bilateral ureter was indwelled with 4Fr. catheter under direct vision

[chemotherapy]

• 2023-04-19 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-04-12 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-03-29 - topotecan 1.75mg/m2 2.5mg NS 100mL 30min + bevacizumab 10mg/kg 600mg NS 100mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
• 2023-03-22 - topotecan 1.75mg/m2 2.5mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
• 2023-03-08 - topotecan 3.75mg/m2 5.0mg NS 100mL 30min + bevacizumab 10mg/kg 600mg NS 100mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
• 2023-01-18 - bevacizumab 7.5mg/kg 450mg NS 250mL 90min + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-12-26 - bevacizumab 7.5mg/kg 450mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-12-05 - bevacizumab 7.5mg/kg 450mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-11-14 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-10-24 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-10-04 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-09-12 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-08-22 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-08-01 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-07-25 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-07-11 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-06-13 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-05-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-05-03 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-04-20 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-03-21 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-03-15 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-02-22 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-01-24 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-01-18 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2021-12-28 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2021-11-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2021-11-09 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2021-10-19 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2021-09-27 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2021-09-06 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2021-08-16 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2021-07-26 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-06-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-06-07 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-05-17 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-04-27 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-03-29 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 60mg/m2 90mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-02-01 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2021-01-04 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2020-12-07 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2020-10-26 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2020-10-05 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2020-09-01 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Medication

• Lynparza (olaparib 150mg) 2# BIDCC PO
  • 2023-04-12 ~ undergoing (OPD)

[assessment]

• The patient experienced severe neutropenia after their last chemotherapy session on 2023-04-19, with the low WBC count observed on 2023-04-24. G-CSF (filgrastim) 300ug QD for 14 days has been prescribed since 2023-04-24 to address this issue. To date, the WBC count has improved slightly, increasing from a low of 260/uL to 420/uL.
  • 2023-04-27 WBC 0.42 x10^3/uL
    
  • 2023-04-26 WBC 0.30 x10^3/uL
    
  • 2023-04-25 WBC 0.26 x10^3/uL
    
  • 2023-04-24 WBC 0.33 x10^3/uL
    
  • 2023-04-19 WBC 12.02 x10^3/uL
    
  • 2023-04-12 WBC 3.56 x10^3/uL
• The patient has received blood transfusions for their anemia, with 2 units of L-PRBC administered on 2023-04-24 at around 20:00, 1 unit at around 23:00, and an additional 2 units on 2023-04-27 at around 13:00.
  • 2023-04-27 HGB 7.6 g/dL
    
  • 2023-04-26 HGB 8.1 g/dL
    
  • 2023-04-25 HGB 8.6 g/dL
    
  • 2023-04-24 HGB 7.6 g/dL
    
  • 2023-04-19 HGB 8.8 g/dL
    
  • 2023-04-12 HGB 10.2 g/dL
• The patient’s platelet count has shown a steep drop and, as of now, there is no obvious sign of recovery. If the risk of bleeding is high, platelet transfusion may be necessary.
  • 2023-04-27 PLT 18 x10^3/uL
    
  • 2023-04-26 PLT 28 x10^3/uL
    
  • 2023-04-25 PLT 47 x10^3/uL
    
  • 2023-04-24 PLT 7 x10^3/uL
    
  • 2023-04-19 PLT 91 x10^3/uL
    
  • 2023-04-12 PLT 184 x10^3/uL

700618096

230426

[past history] - 2023-04-20 admission note

• Hypertension for 10 years with regular medication control.

• DM with triopathy for 10+ years with regular OHA, insulin control.

• Asthma: Asthma since young with regular OPD f/u.

• Operation history: Appendectomy 10 yrs ago.

• Denied history of Hypertension, DM, asthma

• Denied any operation, accident and other medical Hx.        

[allergy]

• Primperan (metoclopramide): other

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.  

[exam findings]

• 2023-04-24 Tc-99m MDP bone scan with SPECT
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in both rib cages, maxilla, mandible, some T- and L-spine, sacrum, bilateral sternoclavicular junctions, shoulders, and S-I joints.
• 2023-04-21 ECG
  • Normal sinus rhythm
  • Low voltage QRS
  • Borderline ECG
• 2023-04-21 Nasopharyngoscopy
  • Findings: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord movement without finding of vocal cord lesion.
  • Diagnosis: suspect functional dysphonia, or medication-related dysphonia.
• 2023-04-20 CXR
  • There are few nodular opacities projecting in right lung that may be metastases. Please correlate with CT.
• 2022-10-21 CT - abdomen (at other hospital)
  • Findings
    • Fatty liver
    • post-operative change of colon
    • no definite lesion in pancreas, spleen, bilateral adrenal glands, kidneys
    • soft tissue lesions within pelvic cavity, peritoneal, metastases are considered
    • no definite lymphadenopathy
    • no ascites
  • Impression:
    • Peritoneal metastases
    • Fatty liver

[consultation]

• 2023-04-21 Ear Nose Throat
  • Q
    • The 37 y/o woman has Rectosigmoid cancer diagnosed 3 years ago s/p left hemicolectomy and then adjuvant chemotehrapy with 12 doses of FOLFOX. Due to elevated tumor markers in 2022-02, PET was done and showed disease in progression over lung and peritoneum. Then she received Avastin plus FOLFIRI * 10 doses. Then the PET was arranged and disclosed bilateral lungs, peritoneum and liver. This time, admitted for chemotherapy with FOLFOXIRI.
    • For hoarse was noted for 3 weeks, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • Scope: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord movement without finding of vocal cord lesion.
    • Impression: suspect functional dysphonia, or medication-related dysphonia.
    • Plan: Please give Broen-C 2# TID and arrange ENT OPD follow-up after discharge.

[lab data]

• 2023-04-12 Anti-HBc Nonreactive
  
• 2023-04-12 Anti-HBc-Value 0.08 S/CO
  
• 2023-04-12 HBsAg Nonreactive
  
• 2023-04-12 HBsAg (Value) 0.49 S/CO
  
• 2023-04-12 Anti-HCV Nonreactive
  
• 2023-04-12 Anti-HCV Value 0.06 S/CO

[MedRec]

• 2023-04-06 SOAP Hemato-Oncology
  • S
    • s/p sigmoidectomy with LND on 2020-03-20
    • s/p Port-A on 2020-04-10
    • s/p adjuvant chemtoehrapy with FOLFOX from 2020-04-20 to 2020-10-28 -> PD over RML of lung and LN of left iliac chain, Stage IVA, rcT0N1bM1a
    • s/p Laparoscopic plevic LND on 2022-03-11
    • s/p A-FOLFIRI
    • s/p Laparoscopic intran-abdominla excision of peritoneal carcinomatosis on 2023-01-09 -> PD over lung, liver, bilateral iliac LNs and peritoneal carcinomosis by 2023-03-16 PET-CT, M1c, Stage IVB
  • P
    • Admission for FOLFOXIRI
• 2023-04-06 SOAP Hemato-Oncology
  • S
    • Rectosigmoid cancer diagnosed 3 years ago s/p left hemicolectomy and then adjuvant chemotehrapy with 12 doses of FOLFOX.
    • Due to elevated tumor markers in 2022-02, PET was done and showed disease in progression over lung and peritoneum.
    • Then she received A-FOLFIRI 10 doses. Then the PET was arranged and disclosed bilateral lungs, peritoneum and liver.
  • P
    • Request medical records and report
• 2017-12-14 SOAP Hemato-Oncology
  • O
    • 2017/12/07 Ferritin：5.2 ng/mL
    • Start iron therapy (20171214)
  • A
    • Iron deficiency anemia, unspecified [D50.9]
    • Thrombocytopenia [D69.6]
  • Prescription
    • Foliromin (sodium ferrous citrate 50mg) 1# QN 14 days
• 2017-12-07 SOAP Hemato-Oncology
  • S
    • Referred from clinic on account of microcytic anemia
    • suspected thalassemia in her sister
    • Unexplained purpura
  • O
    • BH 168 BW 66
    • slight pale skin
  • Diagnosis
    • Anemia, unspecified [D64.9]
    • Thrombocytopenia [D69.6]

[assessment]

• The patient was diagnosed with rectosigmoid cancer and underwent sigmoidectomy followed by treatment with the FOLFOX regimen in 2020. However, the patient experienced progressive disease. Laparoscopic plevic LND was performed in March 2022, and the patient was subsequently treated with the A-FOLFIRI regimen, but again experienced PD. This time, the patient was admitted to receive the planned FOLFOXIRI regimen.

• Flumarin (flomoxef sodium) has been administered since 2023-04-23 to address the elevated sediment WBC and leukocyte esterase in the patient’s urine without issues.

• The patient’s platelet count (PLT) has been decreasing over the past three years, with levels not exceeding 100K/uL in 2023. This should be carefully monitored, as it may suggest the presence of undiagnosed underlying conditions that require further evaluation and management.

  • 2023-04-25 PLT 83 *10^3/uL
    
  • 2023-04-24 PLT 95 *10^3/uL
    
  • 2023-04-11 PLT 100 *10^3/uL
    
  • 2022-12-24 PLT 143 *10^3/uL
    
  • 2020-12-28 PLT 160 *10^3/uL

701137983

230426

[diagnosis] - 2023-04-25 admission note

• pancreatic head carcinoma,cT4N0M0, stage III, Dx in June 2022 , obstructive jaundice s/p PTGBD on 20220613
• Type 2 diabetes mellitus without complications
• Chronic obstructive pulmonary disease, unspecified
• Obstruction of bile duct

[past history] - 2023-04-25 admission note

DM, HTN, CHF, COPD, Hyperlipidemia, Asthma                                                    

[allergy]

• penicillin: rash;

[family history]

no hypertension, diabetes mellitus, cancer history

[exam finding]

• 2023-04-03 KUB
  • Fecal material store in the colon.
  • S/P PTGBD with pigtail catheter implantation
• 2023-03-13 CXR
  • Port-A catheter inserted into RA via left subclavian vein.
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • Nodular opacitiy projecting over Rt lower lung zone due to nipple shadow
  • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad/ supine position
  • S/p PTGB drainage
• 2023-03-13 ECG
  • Sinus tachycardia with Premature supraventricular complexes
  • ST & T wave abnormality, consider inferior ischemia
• 2023-03-13 Endoscopic Retrograde Cholangiopancreatography, ERCP
  • Diagnosis
    • Failed Cholangiography
    • Pancreatic cancer s/p PTGBD
  • Suggestion
    • EUS/CDS or Rendevous ERCP
• 2023-03-09 Cholangiography
  • Cholangiography via PTCD catheter administration revealed:
    • Patency of the catheter.
    • Obstruction of CBD.
• 2023-03-08 SONO - abdomen
  • Post PTGBD with dilated IHD and CBD
  • Dilated main pancreatic duct
  • Pancreatic head tumor
• 2023-03-08 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade D
    • Esophageal ulcers and erosions, lower to middle esophagus
    • Superficial gastritis, s/p CLO test
    • Gastric subepithelial lesion, anterior wall of upper body
  • Suggestion
    • PPI Q12H IV
    • EUS
• 2023-03-06 ECG
  • Sinus tachycardia
  • Premature atrial complexes
  • Premature ventricular complexes
  • Marked ST abnormality, possible inferior subendocardial injury
  • Abnormal ECG
• 2023-02-18, 2022-11-24 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • S/P pigtail catheter implantation at the gallbladder .
• 2023-02-01 CT - abdomen
  • History:
    • 20220610 US: R/O pancreatic head tumor with obstructive jaundice.
    • 20220624 CT：Pancreatic head cancer, cT4N0M0, stage:III
  • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings: Comparison prior CT dated 2022/11/24.
    • Prior CT identified an ill-defined poor enhancing mass measuring 3.5 cm in the pancreatic head, causing marked dilatation of the bile duct and pancreatic duct, is noted again, mild increasing in size to 4 cm.
      • It is c/w adenocarcinoma of the pancreatic head S/P C/T with stable disease.
      • Prior CT identified tumor direct invasion the celiac trunk, superior mesenteric artery, and the trifurcation of superior mesenteric vein, splenic vein, and portal vein is noted again, stationary.
    • Prior CT identified liver metastasis 1.4 cm in S5 of the liver is noted again, mild decreasing in size and poor margination that is c/w liver metastasis S/P C/T with partial response. Follow up is indicated.
    • There are two cyst 1.7 cm and 0.5 cm in S6 liver.
      • Please correlate with sonography.
    • S/P PTGBD with pigtail catheter implantation
  • Impression:
    • Pancreatic head cancer S/P C/T show stable disease.
    • Liver metastasis in S5 S/P C/T show partial response.
• 2023-01-31 SONO - abdomen
  • Post PTGBD
  • Dilated main pancreatic duct
  • Rule out pancreatic head tumor
• 2022-11-24 CT - abdomen
  • History and indication: 71 y/o female, a pt of pancreatic head carcinoma, cT4N0M0, stage III
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Stable condition of pancreatic head cancer.
    • S/P PTGBD. Right liver cyst (2.0cm).
• 2022-09-08 Ocular fundus photography
  • fundus c/d 50% ou
  • moderate NPDR ou
    • ChatGPT: NPDR in the context of ocular fundus photography stands for Non-Proliferative Diabetic Retinopathy. There are two main stages of diabetic retinopathy:
      • Non-Proliferative Diabetic Retinopathy (NPDR): This is the early stage of diabetic retinopathy and is characterized by changes in the retinal blood vessels, including microaneurysms (small outpouchings), retinal hemorrhages (bleeding), and retinal edema (swelling). In some cases, NPDR may progress to a more advanced form called diabetic macular edema (DME), which is characterized by swelling in the central part of the retina (macula) and can lead to vision loss.
      • Proliferative Diabetic Retinopathy (PDR): This is the more advanced stage of the disease and is characterized by the formation of abnormal new blood vessels on the surface of the retina or the optic disc. These new vessels are fragile and prone to bleeding, which can lead to further complications like vitreous hemorrhage, retinal detachment, or severe vision loss.
• 2022-06-30 Patho - pancreas biopsy
  • Pancreatic head, EUS-FNB — Ductal adenocarcinoma, moderately differentiated
  • The sections show a picture of ductal adenocarcinoma, composed of nests and cords of columnar to cuboidal neoplastic cells with abundant clear cytoplasm, embedded in fibrous stroma. Glandular differentiation and mucin secretion are present. Tumor necrosis can be identified also.
• 2022-06-30 Cell Block Cytology
  • pancreas, SMEAR and CELL : adenocarcinoma;
  • SMEAR and CELL: show clusters of adenocarcinoma
• 2022-06-30 Needle Aspiration Cytology - pancreas
  • pancreas, FNA: adenocarcinoma;
  • Smears show clusters of adenocarcinoma
• 2022-06-30 Endoscopic Ultrasonography, EUS
  • suspected pancreatic head cancer, T4N1Mx, s/p EUS/FNB
  • reflux esophagitis, LA-A
• 2022-06-29 CXR
  • Atherosclerosis of the aorta.
• 2022-06-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 20) / 79 = 74.68%
    • M-mode (Teichholz) = 74.7 ~ 61.2
  • Conclusion
    • Normal AV with no AR
    • Normal MV with mild MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • Normal LV wall motion
    • No PR, trivial TR, normal IVC size
• 2022-06-27 Flow-volume loops
  • Mild obstructive ventilatory impairment
• 2022-06-24 CT - liver, spleen, biliary duct, pancreas
  • Imaging Report Form for Pancreatic Carcinoma
  • Impression (Imaging stage): T4N0M0, stage III
• 2022-06-10 ECG
  • Sinus rhythm with 1st degree A-V block
  • Cannot rule out Inferior infarct, age undetermined
  • Abnormal ECG
• 2022-06-10 CXR
  • Presence of ileus.
• 2022-06-10 SONO - abdomen
  • diagnosis
    • suspicious, pancreatic head tumor with obstructive jaundice
    • fatty liver, mild
  • suggestion
    • correlate with other image study and tumor markers
• 2022-03-17 Optical Coherence Tomography
  • fundus c/d 50% ou
  • moderate NPDR ou
• 2022-02-14 CXR
  • elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • mild enlarged cardiac silhoutte
• 2021-03-15 CXR
  • elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • moderate enlarged cardiac silhoutte
  • ……

[consultation]

• 2022-06-24 General and Gastrointestinal Surgery
  • Q
    • For operation evaluation
    • This 71 y/o female has hitory of DM, HTN, CHF, COPD, Hyperlipidemia, Asthma under regular follow up at our CV, Meta, and CM’s OPD and this time she came our GI’s OPD for epigastric dullness pain for several weeks and jaundice, where PE and Lab data were surveyed and abdomen echo was also done and pancreatic head tumor with obstructive jaundice was suspected, so referal to ER for Covid-19 PCR checking and admission to GI’s ward for further management was done. However, the PCR result at ER showed positive result with CT value 17, the patient was admitted to our quarantine ward for Covid-19 infection. She transfer to GI ward on 2022/06/24. Abdominal CT was arranged on 2022/06/24. So we need you evaluation and suggestion of this patient. Thank you very much ~
  • A
    • S:
      • The patient was suspected pancreatic head tumor with obstructive jaundice. Surgical evaluation is consulted.
    • O:
      • vital signs: stable, no fever
        
      • abdomen: a PTGBD over R’t abdomen with bile content, soft, ovoid, decrease bowel sound, no tenderness, no Murphy’s sign
        
      • lab data: see chart
    • A:
      • Pancreatic head Ca, cT2N0M0, stage IB
    • P:
      • Please arrange echocardiogram & test
      • If heart function & PFT is OK, pylorus preserving pancreaticoduodenectomy is suggested next week.
• 2022-06-13 Radiation Oncology
  • Q
    • For pancreat cancer with on PTGBD. (PTGBD: percutaneous transhepatic gallbladder drainage)
  • A
    • According to the clinical condition and imaging findings, PTGBD is indicated.

[MedRec]

• 2022-07-05 SOAP Hemato-Oncology
  • S
    • PH:
      • COVID-19, virus identified
      • Chronic systolic (congestive) heart failure
      • Type 2 diabetes mellitus without complications
      • Chronic obstructive pulmonary disease
    • weight loss (+) (10kg in 2~3 Mo )
    • suffered from initial presentation of genealized jaundice in June 2022
    • referred to our clinic on 7/5 22 for pre-Op neoadjuvant C/T
    • ancreatic head carcinoma, cT4N0M0, stage III, Dx in June 2022
    • obstructive jaundice s/p PTGBD on 6/13 22.
    • explain to pt about the indication & risk / benefit of pre-Op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 6 or more then do abd CT for response / Op evaluation (7/5 22).
    • HBsAg, anti-HBc (6/11 22): negative.
    • will give pre-Op neoadjuvant C/T wt FOLFIRINOX ( self-paid ) IV Q2W x 6 (7/5 22).
    • Adm 1 wk later on 7/15 22 for #1 pre-Op neoadjuvant C/T wt FOLFIRINOX ( self-paid ) IV Q2W x 6.
• 2017-05-22 SOAP Cardiology
  • Diagnosis
    • Chronic systolic (congestive) heart failure [I50.22]
    • Essential (primary) hypertension [I10]
  • Prescription
    • Hexal (carvedilol 25mg) 1# QD 28 days
    • Blopress (candesartan 8mg) 0.5# BID 28 days
    • Aldactin (spironolactone 25mg) 1# QD 28 days
• 2017-05-22 SOAP Chest Medicine
  • Diagnosis
    • Pulmonary TB, unspecified, by culture (+) [A15.0]
    • Acute respiratory failure [J96.00]
    • Pneumonia, unspecified organism [J18.9]
    • Congestive heart failure [I50.22]
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension, benign [I10]
    • Mixed hyperlipidemia [E78.2]
    • hyperuricemia [E79.0]
  • Prescription
    • NovoNorm (repaglinide 1mg) 1# TIDAC 7 days
    • colchicine 0.5mg 1# QD 14 days
    • Vit B6 (pyridoxine 50mg) 1# QD 14 days
    • Euricon (benzbromarone 50mg) 1# QD 14 days
    • Through (sennosides) 12mg 1# HS 14 days
    • Rifinah (RIF 300mg + INH 150mg) 2# QD 14 days
    • pyrazinamide 500mg 2.5# QD 8 days
    • Welizen (famotidine 20mg) 1# BID 14 days
    • Epbutol (ethambutol 400mg) 2# QD 8 days
• 2017-03-25 SOAP Metabolism
  • Diagnosis
    • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Essential hypertension, benign [I10]
    • Mixed hyperlipidemia [E78.2]
  • Prescription
    • Trajenta (linagliptin 5mg) 1# QD 4 days
    • Glucobay (acarbose 100mg) 1# TIDAC 4 days
    • Uformin (metformin 500mg) 1# TIDCC 4 days
    • Kludone (gliclazide 60mg) 1# BID 4 days
    • Uretropic (furosemide 40mg) 1# QD 4 days

[chemoimmunotherapy]

• 2023-04-25 - oxaliplatin 80mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 190mg NS 500mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-04-03 - oxaliplatin 80mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 190mg NS 500mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-03-03 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 205mg NS 500mL 2hr + leucovorin 400mg/m2 545mg NS 250mL 2hr + fluorouracil 2400mg/m2 3285mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2023-02-13 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 205mg NS 500mL 2hr + leucovorin 400mg/m2 545mg NS 250mL 2hr + fluorouracil 2400mg/m2 3285mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2022-12-29 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2022-12-08 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2022-11-11 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2022-10-20 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 215mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3440mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2022-09-12 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3440mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2022-08-26 - oxaliplatin 80mg/m2 115mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3450mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2022-08-10 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
• 2022-07-18 - oxaliplatin 60mg/m2 80mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRINOX)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

[note]

• Pancreatic Adenocarcinoma NCCN Evidence Blocks Version 1.2022 - May 3, 2022, p39,41
  • neoadjuvant therapy
    • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
    • Gemcitabine + albumin-bound paclitaxel +- subsequent chemoradiation
    • Only for known BRCA1/2 or PALB2 mutations
      • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
      • Gemcitabine + cisplatin (>= 2-6 cycles) +- subsequent chemoradiation
  • adjuvant therapy
    • preferred regimens
      • Modified FOLFIRINOX (category 1)
      • Gemcitabine + capecitabine (category 1)
    • other recommended regimens
      • Gemcitabine (category 1)
      • 5-FU + leucovorin (category 1)
      • Continuous infusion 5-FU
      • Capecitabine (category 2B)
      • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation
      • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation followed by subsequent chemotherapy  - Gemcitabine followed by chemoradiation followed by gemcitabine -Bolus 5-FU + leucovorin followed by chemoradiation followed by bolus 5-FU + leucovorin -Continuous infusion 5-FU followed by chemoradiation followed by continuous infusion 5-FU
• Modified FOLFIRINOX chemotherapy for pancreatic cancer (UpToDate 20220719)
  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 150 mg/m2 IV
      • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1
  • Pretreatment considerations:
    • Emesis risk
      • HIGH (greater than 90% frequency of emesis).
    • Prophylaxis for infusion reactions
      • Although infusion reactions have been reported with oxaliplatin, there is no recommended standard premedication for this regimen.
    • Vesicant/irritant properties
      • Oxaliplatin and FU are irritants, but oxaliplatin can cause significant tissue damage; avoid extravasation.
    • Infection prophylaxis
      • Primary prophylaxis with G-CSF is not warranted. However, given the risk of grade 3 or 4 neutropenia (46%), primary prophylaxis with G-CSF is used at many institutions, especially when this regimen is used in the adjuvant setting.
    • Dose adjustment for baseline liver or renal dysfunction
      • A lower starting dose of oxaliplatin and irinotecan may be needed for severe renal insufficiency. A lower starting dose of irinotecan and FU may be needed for patients with hepatic impairment.
      • NOTE: We do not recommend administration of FOLFIRINOX unless serum bilirubin is normal.
    • Maneuvers to prevent neurotoxicity
      • Pharmacologic methods to prevent/delay the onset of oxaliplatin-related neuropathy are controversial due to the absence of large clinical trials proving benefit. Counsel patients to avoid exposure to cold during and for approximately 48 hours after each infusion. Prolongation of the oxaliplatin infusion time from two to six hours may mitigate acute neurotoxicity.
    • Cardiac issues
      • QT prolongation and ventricular arrhythmias have been reported after oxaliplatin. ECG monitoring is recommended if therapy is initiated in patients with heart failure, bradyarrhythmias, coadministration of drugs known to prolong the QT interval, and electrolyte abnormalities. Avoid oxaliplatin in patients with congenital long QT syndrome. Correct hypokalemia and hypomagnesemia prior to initiating oxaliplatin.
      • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, electrocardiographic changes, and cardiomyopathy.
  • Monitoring parameters:
    • CBC with differential and platelet count prior to each treatment.
    • Electrolytes (especially potassium and magnesium) and liver and renal function prior to each treatment.
    • Irinotecan is associated with early and late diarrhea, both of which may be severe. For patients who develop abdominal cramping and/or diarrhea within 24 hours of receiving irinotecan, administer atropine (0.3 to 0.6 mg IV) and premedicate with atropine during later cycles. Patients must be instructed in the early use of loperamide for late diarrhea. Patients who develop diarrhea should be closely monitored and supportive care measures (eg, fluid and electrolyte replacement, loperamide, antibiotics, etc) should be provided as needed.
    • Assess changes in neurologic function prior to each treatment.
  • Suggested dose modifications for toxicity:
    • Myelotoxicity
      • Do not retreat unless neutrophil count is >=1500/microL and platelets are >=75,000/microL. The following dose reduction guidelines for hematologic toxicity are recommended; several of these are based upon recommendations in the original FOLFIRINOX protocol.
      • Neutropenia
        • If day 1 treatment delayed for granulocytes is <1500/microL or febrile neutropenia or grade 4 neutropenia >7 days: Reduce irinotecan dose to 120 mg/m2. For second occurrence: Reduce oxaliplatin dose to 60 mg/m2. If nonrecovery after a two-week delay, or if there is a third occurrence of granulocytes <1500/microL on day 1, discontinue treatment. For grade 4 neutropenia >7 days during treatment or febrile neutropenia, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 120 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
      • Thrombocytopenia
        • If day 1 treatment delayed for platelet count <75,000/microL, reduce oxaliplatin dose to 60 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce irinotecan dose to 120 mg/m2. If nonrecovery after a two-week delay, or if there is a third occurrence of platelets <75,000/microL, discontinue treatment. For grade 3 or 4 thrombocytopenia during treatment, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 120 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
    • Diarrhea
      • Do not retreat with FOLFIRINOX until resolution of diarrhea for at least 24 hours without antidiarrheal medication. For diarrhea grade 3 or 4, or diarrhea with fever and/or grade 3 or 4 neutropenia, reduce irinotecan dose to 120 mg/m2. For second occurrence, reduce the oxaliplatin dose to 60 mg/m2 and the continuous FU dose to 75% of original dose. Discontinue treatment for third occurrence.
      • NOTE: Severe diarrhea, mucositis, and myelosuppression after FU should prompt evaluation for DPD deficiency.
    • Mucositis or hand-foot syndrome
      • For grade 3 to 4 toxicity, reduce dose of infusional FU by 25%.
    • Pulmonary toxicity
      • Oxaliplatin has rarely been associated with pulmonary toxicity. Withhold oxaliplatin for unexplained pulmonary symptoms until interstitial lung disease or pulmonary fibrosis is excluded.
    • Neurologic toxicity
      • For persistent grade 3 paresthesias/dysesthesias or transient grade 2 symptoms lasting >7 days, decrease oxaliplatin dose by 25%. Discontinue oxaliplatin for grade 4 or persistent grade 3 paresthesia/dysesthesia.
      • There is no recommended dose for resumption of FU administration following development of hyperammonemic encephalopathy, acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances; the drug should be permanently discontinued.
    • Cardiotoxicity
      • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of FU administration following development of cardiac toxicity, and the drug should be discontinued.
    • Other toxicity
      • Any other toxicity >=grade 2, except anemia and alopecia, can justify dose reduction if medically indicated.
      • For other nonhematologic toxicities, if grade 2, hold treatment until <=grade 1; if grade 3 or 4, hold treatment until <=grade 2.
    • If there is a change in body weight of at least 10%, doses should be recalculated.

[assessment]

• There is no medication reconciliation issue for the current active formulary, which includes medications prescribed by our cardiologist, pulmonologist, and metabolic specialist.

• The patient’s underlying conditions of hypertension (HTN) and type 2 diabetes mellitus (T2DM) are not well controlled during this hospitalization. Blood pressure readings show systolic values between 170 and 184 mmHg, and HbA1c levels have been consistently above 8% for the past 4 months. Serum glucose was recorded as 231mg/dL on the evening of 2023-04-25 and as 158mg/dL on the morning of 2023-04-26. Addition of antihypertensive and/or hypoglycemic agents may be considered if symptoms persist.

  • 2023-04-08 HbA1c 8.3 %
    
  • 2023-01-14 HbA1c 8.6 %
    
  • 2022-10-20 HbA1c 7.4 %
    
  • 2022-07-25 HbA1c 7.0 %
    
  • 2022-04-30 HbA1c 8.3 %

220719

[assessment]

• UGT1A1 genotyping result is not found in HIS5, please monitor if early and/or late (irinotecan caused) diarrhea occurs
• There has been an upward trend in HbA1c levels over the past 12 months, a follow-up update might be considered.
  • 2022-04-30 HbA1c 8.3 %
    
  • 2022-02-05 HbA1c 8.2 %
    
  • 2021-11-13 HbA1c 7.4 %
    
  • 2021-08-21 HbA1c 7.0 %
    
• Since this hospitalization, the level of blood sugar remains high
  • 2022-07-19 06:06 215 mg/dL
  • 2022-07-18 16:18 191 mg/dL
• As for this patient has been taking metformin (DC for now), vildagliptin (DPP4i), glimepiride (sulfonylurea), and acarbose (alpha-glucosidase inhibitors) for a considerable period of time. Basal insulin might be an optional add-on if HbA1c rises above 8.5% and AC glucose rises above 250 mg/dL for most of the days.
• A c-peptide test is also recommended for her.

700074348

230424

[exam findings] (not completed)

• 2023-04-03 PET scan
  • In comparison with the previous study on 2022-02-22, some glucose hypermetabolism lesions in the retroperitoneum and in the left lower pelvic region come to less evident or disappear; several glucose hypermetabolism lesions in the right supra-renal region, in the right para-aortic space, in bilateral common iliac chains, and in soft tissue in RLQ of abdomen, however, are noted. The nature is to be determined (metastatic disease in progression or even another primary malignancy), suggesting biopsy (the soft tissue in RLQ of abdomen) for further investigation,.
    
  • Glucose hypermetabolism lesions in bilateral pulmonary hilar and mediastinal lymph nodes and in bilateral axillary lymph nodes, probably reactive nodes, suggesting follow-up.
    
  • Increased FDG uptake in the right lobe of the liver and in two right ribs, highly suspected malignancy with distant metastases.
    
  • Glucose hypermetabolism in the left shoulder, compatible with arthritis.
  • Seconary malignancy of lymph nodes of head and neck s/p treatment with suspected tumor progression in the abdomen as well as liver and bone metastases, by this F-18-FDG PET/CT scan.
• 2022-10-31 Tc-99m MDP bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, L3-5 spines, both shoulders, sternoclavicular junctions, elbows, S-I joints, hips, knees, and feet, in whole body survey.
  • IMPRESSION:
    • No strong evidnece of bone metastasis.
    • Suspected benign lesions in the maxilla, mandible, L3-5 spines, both shoulders, sternoclavicular junctions, elbows, S-I joints, hips, knees, and feet.
• 2022-09-17 MRI - L-spine
  • Past Hx: gouty arthritis; steroid(+); oral cancer. Right tonsillar cancer with right neck lymph node metastasis, T1N2cM0, stage IVA s/p concurrent chemoradiotheraphy in 2006. 20220819: LBP and right sciatica for 6 months; ongoing C/T;
  • Findings
    • General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral mild neuroforaminal narrowing at L2-3.
    • Decreased vertebral body height, end-plate degeneration, disc collapse with severe general bulging, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral neuroforaminal narrowing at L3-4, much more severe on left side.
    • End-plate degeneration, disc collapse with general bulging and right lateral focal protrusion, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral neuroforaminal narrowing at L4-5, much more severe on right side.
    • Mild general bulging disc at L5-S1.
    • No intramedullary lesion.
    • Mild scoliosis of L-spine.
    • A 17-mm T2-hyperintense cyst at left kidney.
  • IMP: Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L3-4 and L4-5 (with right HIVD).
• 2022-06-28 CT - abdomen
  • Left renal cyst (1.4cm).
  • A cyst (9mm) at LLL.

[consultation]

• 2023-04-24 Diagnostic Radiation
  • Q
    • This is a 58-year-old male with underlying history of:
      • Metastatic squamous cell carcinoma of the neck with unknown primary site, s/p CCRT (2006).
      • Squamous cell carcinoma of the right mouth floor, s/p operation (right mouth floor cancer wide excision. Right selective neck dissection, level 1~3, 2013-10-07), stage pT1N0(cM0).
      • Squamous cell carcinoma of the left mouth floor, s/p induction chemotherapy and operation (wide excision of left side mouth floor cancer with left side; tongue flap; tooth extraction, 2016-05-04), stage ypStage III, ypT1N1(cM0).
      • Metastatic squamous cell carcinoma of the right low neck to SCF, s/p operation (right neck dissection, level III, IV, V, 2020-09-02), and s/p CCRT, with left pelvic metastasis, s/p CCRT, with progression.
      • Squamous cell carcinoma of the anterior mouth floor, s/p wide excision and partial mandibulectomy.
    • On follow-up PET on 2023/04/03, report showed:
      • several glucose hypermetabolism lesions in the right supra-renal region, in the right para-aortic space, in bilateral common iliac chains, and in soft tissue in RLQ of abdomen
      • Seconary malignancy of lymph nodes of head and neck s/p treatment with suspected tumor progression in the abdomen as well as liver and bone metastases was impressed
    • Therefore, this time we would really need your expertise in performing CT-guided biopsy at RLQ abdomen soft tissue mass for this patient. Thanks a lot in advance!
  • A
    • According to the clinical condition and imaging findings, biopsy is indicated.
• 2021-09-29 Radiation Oncology
  • Q
    • For RT evaluation
    • This is a 56-year-old male patient with a history of
      • right tonsillar cancer, T1N2cM0, stage IVA, status post concurrent chemoradiotheraphy in 2006,
      • right anterior mouth floor squamous cell carcinoma in situ, status post excision and revisional wide excision in 2010,
      • right mouth floor cancer, pT1N0cM0, status post wide excision and right selective neck dissection over level 1~3 in 2013,
      • left mouth floor cancer cT4aN0M0, status post induction chemotherapy and surgical excision in 2016, ypT1N1,
      • right lower neck tumor recurrence s/p right radical neck dissection on 2020-9-16, post-op CCRT completed on 2020-11-06, s/p oral ufur,
      • Left pelvic lesion s/p CT guided biopsy on 2021-03-12 (pathology: Metastatic squamous cell carcinoma, poorly differentiated), PET also revealed a new nodular lesion in RUQ of abdomen s/p CCRT for pelvic lesion (completed on 2021-05-17).
    • This time, he came to our hospital due to left lower gingiva lesion noted for weeks. Therefore, he came to our OPD for help. Abnormal painful leukoplakia-erythroplakia lesion at the left mandible was noted at OPD. Biopsy was done for left lower gingival lesion, and the pathology report was SCC. He received operation of oral tumor wide excision + marginal mandibulectomy +- local flap reconstruction on 2021-09-24, and the pathology was pending.
    • Also, pelvic and abdomen CT f/u on 2021-09-06 revealed A soft tissue lesion (2.4cm) at right perirenal region r/o tumor seeding and Enlarged LNs (up to 2.6cm) at retroperitoneum r/o metastases. Urologist was consulted and suggested CCRT.
    • Therefore, we need your expertised for further RT management for the patient.
  • A
    • Metastatic squamous cell carcinoma of the neck with unknown primary site, s/p CCRT (2006).
    • Squamous cell carcinoma of the right mouth floor, s/p operation (right mouth floor cancer wide excision. Right selective neck dissection, level 1~3, 2013-10-07), stage pT1N0(cM0).
    • Squamous cell carcinoma of the left mouth floor, s/p induction chemotherapy and operation (wide excision of left side mouth floor cancer with left side; tongue flap; tooth extraction, 2016-05-04), stage ypStage III, ypT1N1(cM0).
    • Metastatic squamous cell carcinoma of the right low neck to SCF, s/p operation (right neck dissection, level III, IV, V, 2020-09-02), and s/p CCRT, with left pelvic metastasis, s/p CCRT, with progression.
    • Squamous cell carcinoma of the anterior mouth floor, s/p wide excision and partial mandibulectomy.
  • P: Radiotherapy is indicated for this patient with the following indicators: metastatic lesions over the soft tissue lesion at right perirenal region and enlarged LNs at retroperitoneum.
    • Goal: palliation
    • Treatment target and volume: the soft tissue lesion at right perirenal region and enlarged LNs at retroperitoneum.
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 4500cGy/25 fractions
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter. They understand and would like to receive radiotherapy. The treatment planning of radiotherapy will be started at 11AM, 2021-10-01.
• 2020-09-01 Colorectal Surgery
  • Q
    • This time, PET scan showed left pelvic lesion, and pelvis CT showed a lymph node (0.8cm) at left pelvic cavity. Owing to his clinical condition mentioned above, we sincerely need your expertise regarding further management for this patient. Thank you very much!
  • A
    • S: Consult for left pelvic nodule.
    • O: CT > A LN (0.8cm) at left pelvic cavity.
      • with suspect adhesion to vessel and sacal bone
      • Also nodule lesion over right inguinal region.
    • A: Multiple PET lesion
    • P:
      • please arrange colonoscopy to check colon tumor
      • high risk for surgical remove this nodule. and PET also show multiple lesion.
      • If no colonic lesion is seen, suggest medical treatment first (by neck etilogy)
• 2020-09-01 Urology
  • Q
    • This time, PET scan showed left pelvic lesion, and pelvis CT showed a lymph node (0.8cm) at left pelvic cavity. Owing to his clinical condition mentioned above, we sincerely need your expertise regarding further management for this patient. Thank you very much!
  • A
    • 55M with left pelic LNs
    • S: oral cancer, s/p op,
    • O: PET and CT: showed one 1cm LN near left internal ileac artery
    • A: oral cancer, stage IVa
    • P:
      • oral cancer with LNs mets is highly suspected
      • difficult position for CT-guided biopsy
      • please check PSA, U/A, and urine cytology to r/o prostate cancer and bladder cancer

[chemotherapy]

• 2022-09-27 - doxorubicin 60mg/m2 85mg NS 100mL 10min

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-08-30

• 2022-08-01

• 2022-07-01

• 2022-05-31

• 2022-01-03 - cisplatin 100mg/m2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1550mg NS 500mL 21hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2021-11-12 - NS 500mL (before cisplatin) + cisplatin 30mg/m2 40mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + 1S 250mL

• 2021-11-05

• 2021-10-29

• 2021-05-11

• 2021-05-04

• 2021-04-28

• 2020-11-03

• 2020-10-27

• 2020-10-20

[assessment]

• On 2023-04-03, a PET scan revealed multiple glucose hypermetabolic lesions in the right supra-renal region, right paraaortic space, bilateral common iliac chains, and soft tissue in the right lower quadrant (RLQ) of the abdomen. These lesions could indicate metastatic disease progression or even another primary malignancy. A CT-guided biopsy of the soft tissue mass in the right lower quadrant of the abdomen is scheduled for 2023-04-25 at 11:00 AM to determine the nature of these lesions.

• 2023-04-24 eGFR 46. OxyNorm (oxycodone) - CrCl 30 to <60 mL/minute: Immediate release, Oral: Initial: Administer 50% to 75% of usual dose no more frequently than every 6 hours. Use with caution; titrate gradually based on patient response and adverse effects.

700267861

230424

[exam findings]

• 2023-04-11 Patho - kidney biopsy
  • Kidney, left, CT-guided biopsy — Invasive urothelial carcinoma, high-grade
  • The sections show following features:
    • Histologic type: Urothelial carcinoma, invasive
    • Histologic grade: High-grade
    • Tumor configuration: Nodular
    • Muscularis propria: Absent
    • Lymphovascular invasion: Not identified
  • IHC: CK7(+), CK5/6(+), GATA3(+), CA 9(-), and CD117(-)
• 2023-04-10 CT - abdomen
  • History and indication: Retroperitoneal tumor with aorta and left kidney involvement, r/o left urothelial carcinoma, suspected renal cell carcinoma
  • With and without-contrast CT of abdomen-pelvis revealed:
    • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
    • Some LNs at retroperitoneum.
    • Liver cysts (up to 1.5cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
• 2023-04-01 CXR
  • Blunting of left CP angle
  • Borderline enlarged cardiac sihoutte
• 2023-04-01 EXG
  • Sinus tachycardia
  • ST & T wave abnormality, consider inferior ischemia
  • ST & T wave abnormality, consider anterolateral ischemia
  • Abnormal ECG
• 2023-03-27 SONO - neurology
  • Chronic renal parenchymal disease, mild degree
  • Suspected left renal pelvic mass lesion with hydronephrosis
• 2023-03-23 CT - abdomen
  • Indication: nausea without vomiting and abdominal pain for half a monthalso, mild dyspnea was notedwent to Feng Rong Hospital, ileus and mild pneumonia was told
  • Without contrast enhancement CT of abdomen shows:
    • Infiltrating mass lesion in retroperitoneum, possibly derived from left ureter. Imperceptible margin with adjacent kidney and aorta. Regional enlarged lymph nodes noted.
    • Left hydronephrosis.
    • No ascites or extraluminal free air.
    • No evidence of bowel obstruction.
    • No bony destructive lesion on these images.
  • Impression
    • Retroperitoneal tumor with aorta and left kidney involvement, suspected left urothelial carcinoma; DDx: renal cell carcinoma
    • Suspect regional lymph node metastsis
• 2023-03-23 KUB
  • Degenerative change of the lumbar spine
• 2023-03-23 ECG
  • ST & T wave abnormality, consider anterolateral ischemia

[consultation]

• 2023-03-24 Urology
  • Q
    • nausea without vomiting and abdominal pain for half a month
    • also, mild dyspnea was noted
    • went to Feng Rong Hospital today, ileus and mild pneumonia was told
    • PH: DM, HF
    • OP: hysterectomy 50 yrs ago, left inguinal hernia, s/p op 10 yrs ago
    • NKA
  • A
    • please treat her ileus and pneumonia first, due to advanced age and poor condition, she may not fit for further diagnostic or therapeutic intervention for cancer currrently.

[MedRec]

• 2023-04-21 SOAP Hemato-Oncology
  • Con’s:E4V5M6
  • 2023/04/11 PATHO - kidney biopsy
    • Invasive urothelial carcinoma, high-grade
      • Histologic type: Urothelial carcinoma, invasive
      • Histologic grade: High-grade
      • Tumor configuration: Nodular
      • Muscularis propria: Absent
      • Lymphovascular invasion: Not identified
    • IHC: CK7(+), CK5/6(+), GATA3(+), CA 9(-), and CD117(-)
  • 2023/04/10 CT: ABD
    • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
  • 2023/03/23 CT: ABD
    • Retroperitoneal tumor with aorta and left kidney involvement, r/o left urothelial carcinoma
    • Suspect regional lymph node metastsis
  • Lab
    • 2023/04/10
      • HBsAg = Nonreactive;
      • Anti-HBc = Reactive;
      • Anti-HCV = Nonreactive;
• 2023-04-07 SOAP Hemato-Oncology
  • Past hx : hypertension, hyperlipidemia, T2DM, renal tumor
  • Allergy : NKDA
  • She was treated at Cathay hospital for her CV problem.
  • preliminary impression: R10.9 Unspecified abdominal pain
  • Discussion about tissue proof
  • Inform the patients son and sons wife about the risk and benfit of biopsy
• 2023-03-23 SOAP Emergency
  • preliminary impression: Retroperitoneal tumor with aorta and left kidney involvement, suspected left urothelial carcinoma
  • lab data
    • 2023/03/23 21:22 BUN = 31 mg/dL;
    • 2023/03/23 21:22 Creatinine = 1.51 mg/dL;

230401

[assessment]

• On 2023-03-23, a CT scan revealed a retroperitoneal tumor involving the aorta and left kidney, with a differential diagnosis of left urothelial carcinoma or renal cell carcinoma. Regional lymph node metastasis is also suspected.
• Further work on staging is pending. Family members requested not to inform the patient about the diagnosis until the pathology report is confirmed.
• There are no medication reconciliation issues after checking the PharmaCloud database.

700287641

230424

[diagnosis] - 2023-04-22 discharge note

• Left breast cancer, rpT4bN1M0, stage IIIB,ER (+): +, PR (+): +, HER-2/Neu +:  Negative (1+), Ki-67: 10-20 %. ECOG：1.
• Right breast invasive carcinoma, pT2N3aM0, stage IIIB. ER (+), PR(-), Her2/neu: negative(score=0), Ki-67:30 %. ECOG：1.
• For adjuvant chemotherapy with Taxotere
• Nasopharyngeal carcinoma, cT1N0M0, stage I
• Essential (primary) hypertension

[exam findings]

• 2023-03-11 Anoscopy

  • mild mixed hemorrhoids, perianal dermatitis

• 2023-02-09 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (95 - 20) / 95 = 78.95%
    • M-mode (Teichholz) = 79
  • Conclusion:
    • Gr II LV diastolic dysfunction and impaired RV relaxation; mildly dilated LA.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; mild MR; mild TR; mild PR.

• 2022-12-22 Nasopharyngoscopy

  • Findings
    • bi NP smooth, no tumor found; bi MM clear, larynx and hypopharynx np
    • a few watery discharge at left posterior nasal cavity floor
  • Diagnosis/Conclusion
    • NPC s/p treatment, no evidence of recurrence

• 2022-11-24 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (95.9 - 20.0) / 95.9 = 79.14%
    • M-mode (Teichholz) = 79
  • Conclusion:
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR, mild MR, TR and PR
    • No regional wall motion abnormalities

• 2022-11-17 SONO - abdomen

  • Right renal cyst (0.87x0.98cm).

• 2022-10-26 PET scan

  • Glucose hypermetabolic lesions in the right axillary lymph nodes, compatible with metastatic lymph nodes.
    
  • Glucose hypermetabolism in the right mediastinal lymph nodes, the nature is to be determined (metastatic or reactive nodes ?), suggesting biopsy for further investigation.
    
  • Increased FDG uptake in the left pulmonary hilar region, probably reactive nodes.
    
  • Left breast cancer s/p treatment with tumor recurrence and right axillary lymph nodes metastases, by this F-18 FDG PET/CT scan.

• 2022-10-18 Patho - breast mastectomy with regional lymph nodes

  • PATHOLOGIC DIAGNOSIS
    • Breast tumor, right, modified radical mastectomy —- Invasive carcinoma of no special type
    • Resection margins, ditto — Free of tumor invasion
    • Skin and nipple, ditto — Free of tumor invasion
    • Lymph node, R’t axillary SLN, frozen section — Tumor metastasis (3/3) with extracapsular extension (3/3)
    • Lymph node, R’t axillary non-SLN, MRM — Tumor metastasis (10/10) with extracapsular extension (8/10)
    • AJCC Pathologic Anatomic Stage — pT2N3a, if cM0, stage IIIC; Prognostic Stage — Stage IIIB
  • MACROSCOPIC EXAMINATION
    • Breast: 21 x 13.3 x 3.7 cm
    • Skin: 18 x 5.1 cm, normal appearance
    • Nipple: 1.2 x 1.2 cm, mild retraction
    • Tumor: 3 x 2.2 x 2.1 cm
    • Resection margins: Free, 0.7 cm away from closest base
    • Lymph node: R’t axillary sentinel and non-sentinel lymph node
    • Representatively embedded for sections as: A1-A2: Nipple + skin + tumor, A3-A8: Tumor, X1: tumor + base and X2: four peripheral margins and B1-B2: R’t axillary LNs [Reference F2022-00487, FSA1-FSA2 and A: R’t axillary sentinel LN]
  • MICROSCOPIC EXAMINATION
    • Histologic type: Invasive carcinoma of no special type
    • Size of invasive carcinoma: 3 x 2.2 x 2.1 cm
    • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1]
    • Margins: Free, 0.7 cm from closest base margin
    • Lymph node, R’t axillary SLN: Tumor metastasis (3/3) with extracapsular extension (3/3)
    • Lymph node, R’t axillary non-SLN: Tumor metastasis (10/10) with extracapsular extension (8/10)
    • Treatment Effect: N/A
    • Lymphovascular space invasion: present, multiple
    • Perienural invasion: present
    • Immunohistochemistry: E-cadherin(+)

• 2022-10-18 Frozen Section

  • R’t axillar sentinel lymph nodes, frozen section — Tumor metastasis (3/3)

• 2022-10-17 Flow Volume Loop

  • mild obstructive impairment

• 2022-10-07 Patho - breast biopsy (no need margin)

  • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains: ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: negative(score=0), Ki-67(30 %), E-cadherin (+).
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.

• 2022-10-07 SONO - breast

  • S/P left mastectomy.
  • Right subareolar irregular tumor with regional skin edema/thickening. Suggest biopsy.
  • BI-RADS: Category 4: suspicious abnormality-biopsy should be considered.

• 2022-10-07 Mammography

  • Impression:
    • S/P left mastectomy.
    • Right periareolar skin thickening, suggest further study.
  • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)

• 2022-08-25 SONO - abdomen

  • Right renal cyst (1.08x1.14cm).

• 2022-08-11 Nasopharyngoscopy

  • Findings: bi NP smooth, no tumor found; bi MM clear, larynx and hypopharynx np
  • Diagnosis/Conclusion: NPC s/p treatment, no evidence of recurrence

• 2022-06-30 ENT Hearing Test

  • Tymp RE type C, LE type B
  • PTA:
    • Reliability FAIR
    • Average RE 74 dB HL, LE 81 dB HL
    • RE moderately severe to profound HL
    • LE severe to profound MHL

• 2022-06-08 Neurosonology

  • Moderate to severe atheromatous lesion in R CCA bifurcation; mild (to moderate) atheromatous lesions in R middle CCA and L CCA bifurcation; mild atheromatous lesion in L distal CCA.
  • Elevated flow velocities in bilateral MCAs (PS/ED: R = 234/80, L= 182/55 cm/s), suggesting bilateral MCA stenosis; relatively reduced flow in R cervical VA as compared to L VA.
  • Normal extracranial carotid, L vertebral, and intracranial vertebral, basilar arterial flows.
  • Normal bilateral ophthalmic arterial flows

• 2022-06-02 SONO - abdomen

  • Right renal cyst (0.85x1.12cm).

• ……

• ……

• 2017-05-26 Surgical pathology Level VI

  • PATHOLOGIC DIAGNOSIS
    • Breast, left, modified radical mastectomy —- Invasive carcinoma of no special type, grade 3
    • Resection margins, ditto — Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
    • Skin, ditto — Tumor invasion
    • Nipple, ditto — Tumor invasion
    • Lymph nodes, left axillary, dissection — Positive for tumor metastasis (1/20) with extracapsular extension (1/1)
    • AJCC Pathologic Stage — pT4N1Mx, stage IIIB at least
  • MACROSCOPIC EXAMINATION
    • Breast: 18 x 12 x 3 cm
    • Skin: 15.5 x 7 cm
    • Nipple: 1.8 x 1.8 x 0.7 cm
    • Tumor: difficult to assess grossly. Only mild fibrosis of skin and few foci of fibrous nodules found. Microscopically, multiple foci of tumor measures up to 2.3 x 2 cm is noted.
    • Resection Margins: Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
    • Lymph node: left axillary LNs
    • Representative sections as follows: A1: nipple, A2-A6: tumor; B1-B6: LNs.
  • MICROSCOPIC EXAMINATION (FOR INVASIVE CARCINOMA)
    • Histologic type: Invasive carcinoma of no special type
    • Size of invasive carcinoma: Multiple foci, up to 2.3 x 2 cm
    • Histologic grade (Nottingham histologic score): Grade III (score 8)
      • [(A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 3 and (C) Mitotic count: score 2]
    • Margins: Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
    • Nodal status: Positive for tumor metastasis (1/20) with extracapsular extension (1/1)
    • Treatment Effect: N/A
    • Immunohistochemical study of CK highlights tumor is very close to base margin

• 2017-05-25 PET scan

  • Glucose hypermetabolism in the left breast, compatible with breast malignancy.
  • Mild glucose hypermetabolism in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammatory process is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Mild glucose hypermetabolism in the L3 spine. Degenerative spine disease may show this picture.

• 2017-05-22 Gynecologic ultrasonography

  • Endometrial thickening

• 2017-05-16 Surgical pathology Level IV

  • Breast, left, sono-guide biopsy — Invasive carcinoma of no special type
  • Immunohistochemical stains:
    • CK14: loss of myoepithelial cells
    • E-cadherin: positive for tumor cells
    • ER: 90%, intensity 2+
    • PR: 10%, intensity 3+
    • Her2/neu: negative; DAKO score 1+
    • P53: positive, 100%
    • Ki67: 60-70% activity
  • Microscopically, the sections show a picture of invasive carcinoma of no special type of the breast tissue characterized by pleomorphic tumor cells show linear or nested pattern, infiltrate in the desmoplastic stroma.

• 2017-05-16 SONO - breast

  • CC/Indication:
    • Lt breast mass and CNB performed 2012-11-06, 2012-11-19 (CNB = Core Needle Biopsy)
    • DCIS was told. (Chat GPT: DCIS stands for ductal carcinoma in situ. It is a non-invasive form of breast cancer where abnormal cells are found in the lining of the breast ducts but have not spread beyond the ducts into surrounding breast tissue. Although DCIS is not an invasive cancer, it is considered a pre-cancerous condition and has the potential to develop into invasive breast cancer if left untreated. Treatment options for DCIS typically include surgery, radiation therapy, and hormonal therapy.)
  • Suggestion and Plan
    • Bilateral breast cysts and fibroadenomas.
    • Left breast 9’region irregular hypoechoic tumor with prominent vascularity, suggest biosy.
  • BIRADS4

[consultation]

• 2022-10-17 Rehabilitation
  • Q
    • This 70 year-old women, she has right breast cancer with right simple mastectomy + SLNB on 2022/10/18. We need your help for rehabilitation after surgery, thank you!!
  • A
    • We were consulted for rehabilitation for preventing complications and post-operation lymphedema.
    • Premorbid functional status
      • Walk ID, ADLs ID.
    • Physical examination
      • 2022/10/17 10:42 T/P/R: 36.0 / 61bpm / 18bpm BP:134/64mmHg
      • Consciousness: clear
      • Cognition: intact
      • MP: RUE/RLE: 5/5, LUE/LLE: 5/5
      • Functional status: ID
      • ADLs: ID
      • Bilateral shoulders ROM: nearly full range of ative and passive ROM
    • Past hx: left forzen shoulder (improved)
    • Hand and arm circumference (R/L,cm):
      • Elbow joint above 5cm 25/27
      • Elbow joint below 5cm 22.5/24
    • Left arm lymph edema now:
      • ISL grade I, stage I
      • soft, intact skin, no fibrotic change in left arm
    • previous record:
      • 2021/09/15 rehab OPD
        • Skin test +
        • ISL stage: III: fibrotic changes over the forearm and arm
        • Other complications: Frozen shoulder at end-range
    • Imp
      • Rt breast ca ,cT2N0M0 stage 2A
      • OP: right simple mastectomy + SLNB on 2022/10/18.
      • Past hx:
        • Recurrent lt breast ca s/p MRM on 2017-05-26
        • adjuvant C/T with EC ->T since 2017-06-19
        • Lt upper limb lymphedema
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
      • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[MedRec]

• 2022-11-23 SOAP General and Gastroenterological Surgery
  • The multidisciplinary cancer team meeting concluded on 2022-10-28. The treatment plan for the patient is as follows: TC chemotherapy every three weeks for a total of four cycles, followed by CDK4/6 inhibitor (self-paid), radiotherapy, and five years of hormone therapy.
• 2022-11-08 SOAP Radiation Oncology
  • A:
    • Non keratinizing undifferentiated carcinoma of the nasopharynx, stage cT1N0M0, s/p radiotherapy (2004-05-25 ~ 2004-07-16).
    • Predominant ductal carcinoma in situ, intermediate grade, with focal microinvasive ductal carcinoma of the left breast, stage pStageIA, pT1aN0(0/2)(cMx); ER(weak positive, 30%), PR(weak positive, 30%), Her2/neu: (negative, 1+), s/p partial mastectomy, left axillar sentinel lymph node biopsy, radiotherapy in 2013/03, and status during hormone therapy (Tamoxifen) since 2012/12/10, with left breast recurrence, s/p MRM and ALND (2017-05-26), stage pT4N1(1/20)(cN0), stage IIIB, s/p chemotherapy and radiotherapy, and status during endocrine therapy.
    • Invasive carcinoma of no special type, of the right breast, ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: negative(score=0),AJCC Pathologic Anatomic Stage pT2N3a, cM0, stage IIIC; Prognostic Stage — Stage IIIB, s/p MRM (2022-10-18)
  • P: Radiotherapy is indicated for this patient with the following indicators: stage pT2N3a, cM0
    • Goal: curative
    • Treatment target and volume: right chest wall, axilla, to low SCF
    • Technique: IMRT
    • Preliminary planning dose: 5000cGy/25 fractions of the right chest wall, axilla, to low SCF
      
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her elder sister. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started after completion of chemotherapy. RTC: at the last cycle of chemotherapy.

[surgical operation]

• 2022-10-18
  • Surgery: MRM        
    • ChatGPT: MRM stands for modified radical mastectomy, which is a surgical procedure to remove breast cancer. It involves the removal of the entire breast tissue, including the nipple, areola, and axillary lymph nodes. In addition, the lining over the chest muscles is also removed in this procedure. The goal of MRM is to remove the cancerous tissue and prevent the spread of cancer to nearby lymph nodes and tissues.
  • Finding
    • a 3x2x2 cm slight firm subareolar mass in rt breast
    • SLN 3/3(+)    
    • multiple axillary LNs up to 1.5 cm in size  
• 2017-05-26
  • Diagnosis: left breast cancer
  • PCS code: 63007B: Radical mastectomy - unilateral
  • Finding
    • Three nodules up to 0.5 cmin size over lt breast
    • axillar LNs sl enlarged

[radiotherapy]

• 2004-05-25 ~ 2004-07-16 - Past Hx (according to the Hua-Lien record): After admission, systemic work up was done and NPC cT1N0M0 was diagnosed.
  • Non keratinizing undifferentiated carcinoma of the nasopharynx, stage cT1N0M0, s/p radiotherapy. RT total dose was 7020 cGy.

[chemotherapy]

• 2023-04-21 - docetaxel 75mg/m2 110mg NS 250mL 1hr

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-03-31 - docetaxel 75mg/m2 111mg NS 250mL 1hr

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-03-10 - docetaxel 75mg/m2 108mg NS 250mL 1hr

  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2023-03-02 - docetaxel DC (due to WBC 1.57K/uL)

• 2023-02-09 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 866mg NS 500mL 1hr

  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL

• 2023-01-18 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr

  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL

• 2022-12-21 - liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 988mg NS 500mL 1hr (2023-01-11 WBC 1.67K/uL)

  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL

• 2022-11-29 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 864mg NS 500mL 1hr

  • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL

Femara (letrozole) KFEMA01

• 2017-12-04 ~ undergoing 2.5mg QD

Granocyte (lenograstim) CGRAN01

• 2023-04-26 - 250ug 2 days (2023-04-21 IPD)
• 2023-04-05 - 250ug 2 days (2023-03-31 IPD)
• 2023-03-13 - 250ug 2 days (2023-03-13 OPD)

Foliromin (ferrous sodium citrate) KFOLIR01

• 2023-01-18 IPD on and off

[assessment]

• The patient’s HGB levels show a marked downward trend, even though there is no record of blood transfusion. With recent MCV and MCH levels both above the normal range, this macrocytic anemia is less likely to be caused by iron deficiency. The addition of oral Kentamine (vitamin B1, B6, B12) may be helpful.

• The development of anemia during chemotherapy suggests that the patient’s HGB levels are not fully recovered at the current dosage, interval, and frequency of the treatment regimen. In cases of severe chemotherapy-induced anemia, blood transfusion is recommended. Another potential option could be to reduce docetaxel from 75mg/m2 to 65mg/m2.

• If the patient refuses a blood transfusion, a less optimal alternative may be the use of erythropoiesis-stimulating agents (ESAs). However, it is important to note that ESAs have been associated with shorter overall survival and/or increased risk of tumor progression or recurrence in clinical trials involving patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To minimize these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid red blood cell transfusions. ESAs should only be used for anemia resulting from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the expected outcome is cure. It is also recommended that ESAs be discontinued after completion of chemotherapy.

230403

[assessment]

• On 2022-10-28, the multidisciplinary cancer team held a meeting and decided on the following treatment plan for the patient: TC chemotherapy every three weeks for a total of 4 cycles, followed by a CDK4/6 inhibitor (patient self-paid), radiotherapy, and 5 years of hormone therapy.

• The patient received 4 cycles of AC (liposome doxorubicin plus cyclophosphamide) on 2022-11-29, 2022-12-21, 2023-01-18, and 2023-02-09. On 2023-01-11, leukopenia occurred with a WBC count of 1.67K/uL, leading to a reduction in liposome doxorubicin dosage from 35mg/m2 to 30mg/m2 for the last two cycles. On 2023-03-02, another leukopenia episode was observed with a WBC count of 1.57K/uL, causing the scheduled docetaxel on that day to be postponed.

• The patient’s HGB and PLT levels are showing a obvious decline trend, despite no record of blood transfusion being available. This suggests that under the current dose, interval, and frequency of administration, the patient’s HGB and PLT levels are not able to fully recover.

  • 2023-03-31 HGB 7.7 g/dL
    
  • 2023-03-13 HGB 8.4 g/dL
    
  • 2023-03-10 HGB 8.3 g/dL
    
  • 2023-03-02 HGB 8.6 g/dL
    
  • 2023-02-09 HGB 8.6 g/dL
    
  • 2023-01-18 HGB 8.4 g/dL
    
  • 2023-01-11 HGB 8.3 g/dL
    
  • 2022-12-21 HGB 11.4 g/dL
    
  • 2022-12-07 HGB 11.5 g/dL
    
  • 2022-11-28 HGB 11.9 g/dL
    
  • 2022-10-17 HGB 11.6 g/dL
    
  • 2022-06-08 HGB 12.6 g/dL
    
  • 2022-02-24 HGB 12.6 g/dL
    
  • 2021-04-29 HGB 12.7 g/dL
    
  • 2023-03-31 PLT 130 x10^3/uL
    
  • 2023-03-13 PLT 139 x10^3/uL
    
  • 2023-03-10 PLT 156 x10^3/uL
    
  • 2023-03-02 PLT 123 x10^3/uL
    
  • 2023-02-09 PLT 175 x10^3/uL
    
  • 2023-01-18 PLT 233 x10^3/uL
    
  • 2023-01-11 PLT 154 x10^3/uL
    
  • 2022-12-21 PLT 249 x10^3/uL
    
  • 2022-12-07 PLT 127 x10^3/uL
    
  • 2022-11-28 PLT 228 x10^3/uL
    
  • 2022-10-17 PLT 191 x10^3/uL
    
  • 2022-06-08 PLT 227 x10^3/uL
    
  • 2022-02-24 PLT 262 x10^3/uL
    
  • 2021-04-29 PLT 248 x10^3/uL

• When severe anemia caused by chemotherapy is present, blood transfusion is recommended. However, if the patient refuses to receive transfusion, a suboptimal option could be to use erythropoiesis-stimulating agents (ESAs). It is important to note that ESAs have been associated with a shortened overall survival and/or an increased risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid RBC transfusions. ESAs should only be used for anemia from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure. It is also suggested to discontinue ESAs following the completion of a chemotherapy course.

700835257

230421

[diagnosis] - 2023-03-22 admissiion note

• Malignant neoplasm of unspecified site of right female breast
• Unspecified lump in breast

[past history]

• The patient had no systemic diseases

• History of operation: NIL

• Regular medications or herb: no

• G2P2

• menarche : 16y/o

• menopause: 51y/o

• Hormone therapy: (-)

• Family history of breast cancar: NIL                        

[allergy]

• NKDA         

[family history]

• Her mother has type II diabetes mellitus and liver cirrhosis, father has pancreatic cancer.

[exam findings]

• 2023-03-24 CT - chest
  • Indication: Invasive lobular carcinoma of right breast cT1bN0M0, stage IA status post right partial mastectomy and sentinel lymph node biopsy on 2022/11/17, ECOG:0, ER(+), PR(+), Her2/neu(-), Ki-67: 5-10%
  • Imp: s/p op. over right breast. Suggest follow up.
• 2022-12-19 ECG
  • Right bundle branch block
• 2022-12-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 24) / 93 = 74.19%
    • M-mode (Teichholz) = 66
  • Normal LV filling pressure.
  • Normal LV and RV systolic function.
  • Mild aortic valve sclerosis; trivial MR; trivial TR.
• 2022-11-18 Patho - breast mastectomy with regional lymph nodes
  • Diagnosis
    • Breast, right, partial mastectomy — Invasive lobular carcinoma
    • Resection margin: free
    • Lymph node, right, axilla, sentinel, lymphadenecomy —- Negative for malignancy (0/3)
    • AJCC 8 th edition, Pathology stage: Anatomic stage: pStage IA, pT1cN0(sn)(if cM0) Prognostic stage: IA
  • Gross Description
    • Procedure: partial mastectomy
      
    • Lymph node sampling (if lymph nodes are present in the specimen): Sentinel lymph node(s)
    • Specimen laterality: Right
    • Breast: Size: 5.7 x 5.5 x 2.0 cm
    • Skin: Size: 2.8 x 0.5 cm.
      
    • Nipple: Not Included
    • Tumor: Size: 1.1 x 1.0 x 1.0 cm.
    • Resection Margin: Free, 0.2 cm from the deep margin
      
    • Sections are taken and labeled as: FsA: deep margin; FsB1-2: sentinel lymph nodes (FsB1: a bisected lymph node), for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: skin; X2: breast, non-tumor; X3-5: tumor.
  • Microscopic Description
    • For Invasive Carcinoma
      • Histologic type: Invasive lobular carcinoma; The immunohistochemical stain of E-cadherin is negative.
      • Size of invasive carcinoma (mm): 11 x 10 x 10
      • Histologic grade (Nottingham histologic score): grade II (score 6)
        • Tubule formation: score 3
        • Nuclear pleomorphism: score 2
        • Mitotic count: score 1
      • Extent of tumor (required only if the structures are present and involved)
        • Skin involvement: Absent
          
        • Chest wall invasion deeper than pectoralis muscle: not received
    • For Ductal Carcinoma In Situ: absent
      
    • Margins: Negative, Closest margin (2 mm from deep margin)
    • Nodal status: Negative, sentinel
      • No. examined: 3
      • No. macrometastases (>2 mm): 0
      • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
      • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
    • Treatment Effect: patient not received
    • Lymphovascular invasion: absent.
    • Perineural invasion: present
    • Immunohistochemical Study: S2022-16430
• 2022-11-17 Lymphoscintigraphy
  • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
  • IMPRESSION: Probably a sentinel lymph node at the right axillary region.
• 2022-11-16 ECG
  • Normal sinus rhythm
  • Right bundle branch block
  • Abnormal ECG
• 2022-10-14 Bone Scan
  • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the mandible, middle C-spine, L4, bilateral shoulders, hips, knees and feet in whole body survey.
  • IMPRESSION:
    • Mildly increased activity in the middle C-spine and L4 spine. Degenerative change may show this picture.
    • Increased activity in the mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
    • No prominent bone abnormality was noted elsewhere.
• 2022-10-14 CT - chest
  • Right breast cancer with non-specific lymph nodes are found at bilatral axillary region is found.
• 2022-09-27 Patho - breast biopsy
  • PATHOLOGIC DIAGNOSIS
    • Breast tumor, right 10.5/7 area, core needle biopsy — Invasive lobular carcinoma
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consisted of two strips of breast tissue measuring up to 0.8 x 0.1 x 0.1 cm in size, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for sections in one cassette.
  • MICROSCOPIC EXAMINATION
    • Microscopically, the sections show a picture of invasive lobular carcinoma characterized by dyscohesive tumor cells arranged in linear or cord pattern with desmoplasia. Immunohistochemistry shows CK5/6 and P63: loss of myoepithelial cell, E-cadherin(-), ER(＞90%, intensity 2~3+), PR(＞90%, intensity 1~2+), Her2/neu(-, Dako score 1+) and Ki-67: 5-10% for tumor.
• 2022-09-27 SONO - breast
  • Treatment: core needle biopsy
  • Suggestion and Plan: Right breast tumor, suggest biopsy.
    
  • BI-RADS: Category 4c: suspicious abnormality-biopsy should be considered.
• 2020-10-22 Gynecologic ultrasonography
  • RT adnexae: free I - EM:4.7mm

[consultation]

• 2022-11-16 Rehabilitation
  • A
    • Imp
      • Invasive lobular carcinoma of right breast cT1bN0M0, stage IA status post right partial mastectomy and sentinel lymph node biopsy on 2022/11/17, ECOG:0, ER(+), PR(+), Her2/neu(-), Ki-67: 5-10%
    • OP: right partial mastectomy and SLND on 2022/11/17.
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
        • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[surgical operation]

• 2022-11-17
  • Surgery
    • partial mastectomy and SLNB        
  • Finding
    • right 10/7 tumor, about 1cm in diameter
    • SLNB: negative of malignancy, 0/3

[chemotherapy]

• 2023-04-20 - epirubicin 90mg/m2 145mg NS 100mL 30min + fluorouracil 500mg/m2 820mg NS 100mL 30min + cyclophosphamide 500mg/m2 820mg NS 500mL 1hr (CEF, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-03-22 - epirubicin 90mg/m2 145mg NS 100mL 30min + fluorouracil 500mg/m2 820mg NS 100mL 30min + cyclophosphamide 500mg/m2 820mg NS 500mL 1hr (CEF, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-27 - epirubicin 70mg/m2 100mg NS 100mL 30min + fluorouracil 500mg/m2 800mg NS 100mL 30min + cyclophosphamide 500mg/m2 800mg NS 500mL 1hr (CEF, Q3W) Epicin (decrease dosage from 90mg/m2 to 70mg/m2 due to WBC:3580, seg:37.6, ANC:1346)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-07 - epirubicin 90mg/m2 140mg NS 100mL 30min + fluorouracil 500mg/m2 800mg NS 100mL 30min + cyclophosphamide 500mg/m2 800mg NS 500mL 1hr (CEF, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-11 - epirubicin 80mg/m2 120mg NS 100mL 30min + fluorouracil 500mg/m2 770mg NS 100mL 30min + cyclophosphamide 500mg/m2 770mg NS 500mL 1hr (CEF, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-20 - epirubicin 80mg/m2 120mg NS 100mL 30min + fluorouracil 500mg/m2 770mg NS 100mL 30min + cyclophosphamide 500mg/m2 770mg NS 500mL 1hr (CEF, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[note]

in-hospital “Prescription Collection of Chemotherapy for Breast Cancer” protocol (dated 2022-03-11)

• CE (Epirubicin or Lipodox) F (Lipodox is not strongly recommended in the adjuvant setting)
  • Cyclophosphamide 500 mg/m2 IV Days 1
  • Epirubicin 90 mg/m2 IV Day 1 or Lipodox 30 mg/m2 IV Day 1
  • 5-fluorouracil 500 mg/m2 IV Days 1
  • _ References
    • Citrom, ML, et al.J Clin Oncol 21:1431-, 2003.1439
    • Martin M, et al. J Natl Cancer Inst 2008; 100:805-814.
    • O’brien, et al. Annals of oncology, 15(3). 440-449.
    • Rau KM, et al. BMC Cancer, 2015; 15: 423

[assessment]

• Except for a slightly elevated ALT 52U/L, all other labs were normal on 2023-04-20. No problem with the active prescription.

230323

[assessment]

• After the episode of neutropenia on 2023-02-27, the decision to reduce the dose of epirubicin in the CEF regimen was made. Subsequently, no further episodes of neutropenia were observed, even when the dose was increased to the standard recommended level.

700392038

230419

{not completed}

[diagnosis] - 2023-04-21 discharge note

• Right lower lobe lung cancer, adenocarcinoma, T4N3M1c, stage IVB, with brain and lung to lung metastases s/p Target therapy with Afatinib from 2021/09/08~  
• Secondary malignant neoplasm of brain
• Chronic obstructive pulmonary disease, unspecified
• Type 2 diabetes mellitus without complications
• Diarrhea, unspecified

[exam findings]

• 2023-04-10 CXR
  • Patchy opacity projecting at right lower lung zone was noted that is c/w lung cancer after correlate with CT.
  • There are multiple small nodular opacities on both lung that are c/w lung to lung metastases.
  • Atherosclerotic change of aortic arch
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-03-28 Tc-99m MDP bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in multiple T- and L-spines, sternum, some ribs, sacrum, left S-I joint and possible left sternoclavicular junction.
  • IMPRESSION: In comparison with the previous study on 2022/08/08, more new bone lesions are noted. The scintigraphic findings suggest multiple bone metastases.
• 2023-03-21 CXR
  • Patchy opacity projecting at right lower lung zone was noted that is c/w lung cancer after correlate with CT.
  • There are multiple small nodular opacities on both lung that are c/w lung to lung metastases.
• 2023-02-08 EGFR mutation
  • Cell block No: S2023-01756
  • Result: Two mutations were detected at exon 20 (T790M) and exon 21 (L858R) of EGFR gene in this specimen.
• 2023-02-06 CXR
  • A poorly defined large tumor with reticular opacities over Rt lower lobe
  • Enlargement of Rt hilum due to lymphadenopathy
  • Thoracic aortic calcified atheriosclerotic plaque
• 2023-02-03 Patho - bronchus biopsy
  • Lung, RLL, bronchioscopic biopsy — adenocarcinoma, poorly differentiated
  • Sections show bronchial mucosa with infiltration of large pleomorphic solid tumor cells and acinar galndular cells.
  • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), CD56(-), and p40(-). The results are supportive for the diagnosis.
• 2023-02-01 CT - chest
  • Indication: Lung cancer, adenocarcinoma, T4N3M1c with brain, lung to lung metastasis
  • Comparison was made with previous CT dated on 2022/08/03
    • Lungs: interval significant increase in size of RLL tumor with newly developed extensive interlobular septal thickening and peribronchoscular bundle thickeninng and new RML nodule as compared with CT on 2022/8/3. the tumor involves Rt inferior pulmonary artery and hilum.
    • Mediastinum and hila: enlarged LN in Rt hilum.
    • Vessels:
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura:small Rt effusion with parietal thickening.
    • Chest wall: metastatic LAP at Lt supraclavilar fossa
    • Visible abdominal contents: several small hepatic cysts and a Lt renal cyst 28mm
      • unremarkable of the adrenal glands, spleen, pancreas, adrenal glands
    • Visualized bones: no lytic or blastic lesion.
      • axial brain images: no evidence of brain metastasis based on noncontrast images. diffuse cerebral atrophy.
  • Impression:
    • RLL tumor, T4N3, in progression as compared with previous CT on 2022/08/03
• 2023-01-30 ECG
  • Sinus tachycardia
  • Left anterior fascicular block
  • Abnormal ECG
• 2022-08-08 Tc-99m MDP bone scan
  • A hot area at the L4-5 spines, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in both rib cages, some C- and L-spine, bilateral shoulders, and S-I joints.
• 2022-08-03 CT - chest
  • RLL tumor, inccrease in size of the tumor T4 as compared with previous CT on 2022/03/02. no mediastinal LAP.
• 2022-03-02 CT - chest
  • RLL tumor, slightly decrease in size of the tumor as compared with previous CT on 2021/11/24. no mediastinal LAP.
• 2021-11-24 MRI - brain
  • Findings
    • Markedly regression of the nodules seen on Scan MRI, 2021/08/19.
    • Only two small dark noudles were seen in right cerebellum and left anterior temporal lobe.
    • Poor or equivocal abnormal enhancement after contrast administration of those two nodules seen.
    • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
  • Imp: Markedly regression of the nodules seen on Scan MRI, 2021/08/19.
• 2021-11-24 CT - chest
  • RLL tumor, significant decrease in size of the tumor (21 mm on this exam) as compared with previous CT on 2021/08/10
• 2021-08-31 Patho - bronchus biopsy
  • Lung, RLL, CT-guide biopsy — adenocarcinoma, moderately differentiated
    
  • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.

[lab data]

2021-09-23 EGFR Sample No S21-11584
2021-09-23 EGFR G719X not detected
2021-09-23 EGFR Exon19 del not detected
2021-09-23 EGFR S768I not detected
2021-09-23 EGFR T790M not detected
2021-09-23 EGFR Exon20 ins not detected
2021-09-23 EGFR L858R detected
2021-09-23 EGFR L861Q not detected

[MedRec]

• 2021-09-23 SOAP Chest Medicine
  • S
    • just discharged on 20210917 due to hemoptysis
    • EGFR mutation: L858R (+), exon 19 (-), ALK(-)
  • O
    • Multidisciplinary Cancer Team Meeting Conclusion> Meeting Date: 20210914
    • Dr Huang JunYao: check EGFR mutation status, apply TKIs for this case if indicated
    • Conclusion: palliation C/T, RT, best supportive care, EGFR TKIs if definite mutation
• 2021-09-08 SOAP Chest Medicine
  • S
    • admission on 20210916 for Cyramza 600mg
    • A case of Lung cancer, adenocarcinoma, T4N3M1c with brain, lung to lung metastasis, ECOG 1,
      • T4: RLL mass with RLL, RML
      • N3: bilateral mediastinal LAPs
      • M1c: multiple brain metasatsis
    • EGFR mutation: L858R (), exon 19 (), ALK(),
    • PD-L1:
    • Right hilum tumor, nature?
• 2021-08-30 POMR Chest Medicine
  • Discharge Diagnosis
    • Chronic obstructive pulmonary disease, unspecified
    • Right hilum tumor, nature?
    • Right lower lung mass.
  • CC: Cough intermittent with hemoptysis for months
  • Present Illness
    • He suffered from hemoptysis to Zhongxiao Hospital for help in early August, Chest CT on 2021/08/10 showed RLL carcinoma with lung to lung metastasts and mediastinal LAP is considered first. Multiple small hypodense nodules in liver. Brain MRI on 2021/08/19 showed Multiple brain metastatic tumors should be considered. Whole body bone scan on 2021/08/20 showed likely DJD or certain entity in the L4.
• 2021-08-23 SOAP Chest Medicine
  • S
    • Right hilum tumor, nature?
    • cough intermittent without scanty sputum for months, sorethroat(-), chest tightness for weeks, dyspnea, rhinorrhea(-), nasal congestion(-), post nasal dripping(-), acid regurgitation, DOE(+), exercise limitation(+)
    • Past history: Allergic rhinitis, asthma
    • Family history of asthma
    • Smoking(-)
    • Allergic history(-)
    • Traveling history(-)
  • O
    • BP:120/70, HR:70
    • Throat: hyperemia
    • Tonsil: enlargement
    • Neck LAP(-)
    • Breathing sound: course(+), wheezing(+), crackle(+), decreased(+)
    • HS: RHB
    • Abdomen: soft and flat
    • Pitting edema(-)
• 2021-05-19 SOAP Dermatology
  • S
    • Multiple painful erythematous papule-nodules on face, trunk and 4 limbs
    • Multiple erythematous scars and keloids on face for months, progressive enlarged recently. Itching(+), keloid(+)
  • O
    • Imp: acne on face and trunk for months, multiple pustule (+), inflammation(+), painful(+)
    • NSAID for pain release
  • Plan
    • education about drug side effec and explain
    • strongly suggested OPD f/u
  • Diagnosis
    • L70.2 Acne varioliformis
    • L73.0 Acne keloid
  • Prescription
    • doxycycline 100mg/cap 1# BID PO 7 days
    • fusidic acid 1 tube BID EXT 7 days
    • Shincort (triamcinolone acetonide) 50mg ST IS (intrasynovial)

[medication]

• 2023-03-07 ~ undergoing - Giotrif (afatinib 30mg) tab 1# QDAC
• 2021-09-08 ~ 2022-10-05 - Giotrif (afatinib 30mg) tab 1# QDAC

700181400

230418

[diagnosis] - 2023-04-13 admission note

• Rectosigmoid colon cancer with lymph node metastases s/p da Vinci robotic assisted radical low anterior resection on 2023/03/17, pT4aN2aM0, pStage IIIC
• Insomnia, unspecified

[present illness] - 2023-04-13 admission note

• This 45 year old woman suffered from diarrhea and loose stool passage since 2022/12. She also developed nausea notede, epigastric dull pain, fullness belching, acid regurgitation. Also bloody stool passage was noted on 2023/02/20 evening. Stool was collected and shoed occult blood 3+.
• Colonoscopy was performed on 2023/03/02 and found one tumor occupied almost intralumenal circumference of colon at 15 cm from anal verge, pathology reported adenocarcinoma. Pelvis MRI on 2023/03/14 showed: 1. Rectosigmoid colon cancer about 3.5cm in length with regional lymphadenopathy about 3 in number. 2. A prominent soft tissue mass at left inguinal canal. 3. Small uterine myoma. 4. A nabothian cyst about 0.7cm. T3N1bMX. Due to above reasons, she was admitted for colon cancer staging. She received da Vinci robotic assisted LAR on 2023/03/17 and pathology showed adenocarcinoma, moderately to poorly-differentiated with lymph node metastatic (6/22), pStage IIIC, pT4aN2aMX, immunohistochemistry (IHC) Testing for Mismatch Repair (MMR) Proteins, no loss of nuclear expression of MMR proteins: low probability of microsatellite instability-high (MSI-H). Now, she was admitted to ward for Port-A catheter insertion and chemotherapy with FOLFOX(C1D1).
  • ChatGPT:
    • The term “no loss of MMR protein” refers to the absence of any detectable decrease or loss in the expression or function of proteins involved in the DNA mismatch repair (MMR) system. The MMR system is a crucial mechanism in cells that helps maintain genomic stability by correcting errors that may occur during DNA replication.
    • The primary MMR proteins include:
      • MLH1 (MutL homolog 1)
      • MSH2 (MutS homolog 2)
      • MSH6 (MutS homolog 6)
      • PMS2 (postmeiotic segregation increased 2)
    • Loss or dysfunction of any of these MMR proteins can lead to a condition called microsatellite instability (MSI), which is characterized by a higher rate of mutations in the DNA. MSI is associated with certain types of cancer, such as colorectal cancer and endometrial cancer, particularly in the context of Lynch syndrome (also known as hereditary nonpolyposis colorectal cancer or HNPCC).
    • When there is “no loss of MMR protein,” it means that the MMR system is functioning properly in the cells, and the risk of developing cancers due to microsatellite instability is reduced. However, it is important to note that the presence of functional MMR proteins does not guarantee the complete absence of cancer risk, as there may be other factors or mechanisms contributing to cancer development.

[past history]

• DM(-), HTN(-)
• Uterine myoma uteri status post myomectomy on 2018/08/09
• GERD, LA grade A history of Hp infection before noted at LMD.
• da Vinci robotic assisted radical low anterior resection on 2023/03/17

[allergy]

• NKDA

[family history]

1.There is no family history of cancer, hypertension, mental diseases or asthma. 2.No members of the family with diabetes.

[lab data]

2023-04-17 Anti-HCV Nonreactive
2023-04-17 Anti-HCV Value 0.10 S/CO
2023-04-17 Anti-HBc Reactive
2023-04-17 Anti-HBc-Value 4.11 S/CO
2023-04-17 Anti-HBs 774.10 mIU/mL
2023-04-17 HBsAg Nonreactive
2023-04-17 HBsAg (Value) 0.40 S/CO

[chemotherapy]

[assessment]

• Lab data for hepatitis B virus is provided. It is recommended to initiate treatment with either Baraclude (entecavir) or Vemlidy (tenofovir alafenamide) before starting chemotherapy to minimize the risk of reactivation.
  • 2023-04-17 Anti-HBc Reactive
    
  • 2023-04-17 Anti-HBc-Value 4.11 S/CO
    
  • 2023-04-17 Anti-HBs 774.10 mIU/mL
    
  • 2023-04-17 HBsAg Nonreactive
    
  • 2023-04-17 HBsAg (Value) 0.40 S/CO

700534651

230418

[exam findings]

• 2023-04-06 SONO - chest
  • Special Procedure:
    • echo-assisted
    • Pleural tapping 16 #-needle Left side 550 ml bloody
  • Echo diagnosis:
    • pleural effusion
      • Chest echography was performed first. The suitable intercostal space was selected and located.
      • Catheter was inserted with negative pressure smoothly.
      • Left side pleural effusion was drawn smoothly.
      • Watch out BP after tapping.
  • Suggestion:
    • Send pleural effusion for examination about cytology (cell block),
    • biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
• 2023-04-03 CT - chest
  • Findings
    • moderate Lt pleural effusion.
    • Lungs: a subsegmental consolidation at LLL-laterobasal segment.
      • mosaic attenuation changes in Rt lung, LUL, and aerated Lt lower lobe. there is subpleural reticulation and ground-glass opacity at both lower lobes too.
    • Mediastinum and hila: a 15mm calcification in posterior Rt hilum.
      • extensive mild calcified plaques of the LAD, and LCX, and right coronary arteries.
    • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: dilated trunk (3.3cm in caliber) and right main artery.
    • Heart: normal in size of cardiac chambers. mild calcified aortic valves.
    • Chest wall and visible lower neck: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • moderate transudative pleural effusion. LLL subsegmental consolidation, infection or suspected tumor.
    • obstructive chronic airway diease in lungs and suspect mild fibrosis in lower lobes of lungs.
    • extensive 3V-CAD.
• 2023-03-29 CXR
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
  • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
  • small Lt pleural effusion
  • volume reduce over Lt lower lung zone
  • a short linear high density over Rt infrahilar shadow, foreign body?
  • S/P posterolateral bony fusion at L-spine
• 2020-06-29 Right knee standing
  • Osteoarthritis change of right knee with joint space narrowing and marginal spur formation. Loose bodies in the right knee joint.
• 2020-06-29 KUB and Lumbar spine lateral:
  • Bilateral clear psoas shadows. Unremarkable bowel gas pattern. Grade 1 degenerative spondylolisthesis at L4-5 level. Degenerative change of the spine with marginal spur formation. Osteopenia of visible bones. L5-S1 disc space narrowing.

[SOAP]

• 2023-04-06 Chest Medicine
  • past history: alzheimzer disease under licodin, HTN
  • chest tapping for exam.
• 2023-04-06 Hemato-Oncology
  • S
    • This 77 year old woman with dementia, HTN and insomnia came to our OPD due to hemptosis for 10+ days, shortness of breath on excertion, body weight loss (4-5kg in 10 months)
    • Smoking history for 20+ years, quit for 20+ years
    • Lives in Nanshijiao, has five children (lives with the eldest daughter, one passed away from throat cancer, one lives in Tainan, one was given to another family to raise, and the youngest daughter lives in Nangang).
  • O
    • 2023/04/03 CT: Lung/Mediastinum/Pleura
      • moderate transudative pleural effusion. LLL subsegmental consolidation, infection or r/o tumor.
      • obstructive chronic airway diease in lungs and suspect mild fibrosis in lower lobes of lungs.
      • extensive 3V-CAD.
  • A
    • Arrange admisson for CT-guided biopsy
    • Suspected lung cancer
    • Suggestion: admitted for further evaluation
  • P
    • Chest contrast CT
    • CT gudide biopsy
    • check tumor marker
• 2023-04-03 Chest Medicine
  • chest sono on 2023/04/06 PM0230
  • hold Licodin (ticlopidine) since 2023/04/04
  • refer to oncologist for suspected Left lower lung pleural based tumor
• 2023-03-29 Chest Medicine
  • S: hemoptysis (blood in phlegm) for 10 days, mld short of breath
    • consciousness: clear
    • breath sound: clear
      
    • abdomen: soft, no tenderness
      
    • extremities: freely movable; no pitting edema
    • smoking:quit for 20 years
    • past history: alzheimzer disease, HTN
  • O: CXR: bilateral increased infiltrate
  • P:
    • suggest ER for admission, but the patient and family hesitate (unable to be hospitalized these days)
    • suggest if hemoptysis progressed -> ER admission
    • check lab
    • arrange chest CT on 2023/04/03
    • sputum TB x3
  • Diagnosis
    • R04.2 Hemoptysis
    • J15.9 Unspecified bacterial pneumonia
  • Medication
    • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) cap 1# TID 5 days
    • Cravit (levofloxacin 500mg) tab 1.5# QDAC 5 days
    • Transamin (tranexamic acid 250mg) cap 1# BID 5 days
• 2023-02-22 Oral and Maxillofacial Surgery
  • S
    • current medication
      • antihypertensive drug
      • peripheral vasodilators for dementia
  • O
    • Panoramic findings:
      • Missing: nil
      • Impaction: nil
      • Crown and Bridge: 11,15,16,25,26,34-35X,43-44-45XX
      • Caries: nil
      • Periodontal condition: chronic periodontitis
    • vascular spot on the lower alveolar mucosa and tongue was noticed, might be drug-related
• 2023-02-16 Family Medicine
  • CC
    • HTN loss f/u
    • headache
    • mild petechiae over lips and gum -> ginko related?
  • Past history HTN, dementia
  • Allergy history (-)
  • previous medication: Ginkgo, Stilnox, Xyzal

[assessment]

• The patient should have been diagnosed with dyslipidemia and hypertension with heart failure, as he has regularly refilled prescriptions for rosuvastatin, valsartan, and spironolactone within the past 3 months, according to PharmaCloud. Additionally, a CT scan on 2023-04-03 revealed extensive 3-vessel coronary artery disease (3V-CAD), indicating significant atherosclerotic plaque in the LAD, LCX, and RCA.

• If there are no contraindications, it is recommended to reintroduce these medications and consult a cardiologist to assess whether the patient requires aggressive medical management or revascularization procedures, such as coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI angioplasty with stent placement).

700555767

230418

[chief complaint] - 2023-04-17 admission note

• Vertigo since 2023/01/07, progress for 2 weeks

[present illness] - 2023-04-17 admission note

The 57 y/o woman has history of hypertension. She had fall down in bus on 2022/11 and then fatigue, vertigo and right hip pain since 2023/01/07, so she bedridden for 3 months. Right breast tumor noted also 3 months. This time, she has dizziness and severe vertigo, so she was brought to our ED for help on 2023/04/17. Her right lower limbs MP down to 3 for 3 months. She denied fever, chills, vomit, SOB or hematuria. At ED, the brain CT showed 1. Mild cortical brain atrophy. 2. Left parietal skull osteolytic destruction, metastasis or less likely arachnoid granulation? 3. Chronic left mastoiditis. UTI noted from urinalysis. Under the impression of right breast tumor, vertigo, suspect spinal stenosis, so she was admitted on 2023/04/17.

[past history]

• hypertension under CV OPD follow up
• constipation

[allergy]

• NKDA

[family history]

• No cancer, CVA, CAD or DM in her family

[exam findings]

• 2023-04-17 CT - brain
  • CC
    • bedridden for 3 months after falling down
    • dizziness, vertigo, nausea, no tinnitus
    • right hip pain
  • phx: HTN, dyslipidemia, HBV carrier
    • NKDA
    • pregnancy: denied
  • Cranial CT scans without IV contrast medium enhancement was performed smoothly and show:
    • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • The interhemispheric fissure is centered on the midline.
    • The basal ganglia, internal capsule, corpus callosum, and thalamus appear normal.
    • Sella and pituitary are normal, parasellar structures are unremarkable.
    • There are no abnormalities in the cerebellopontine angle areas on both sides.
    • Left parietal skull osteolytic destruction, nature?
  • Imp:
    • Mild cortical brain atrophy.
    • Left parietal skull osteolytic destruction, metastasis or less likely arachnoid granulation?
    • Chronic left mastoiditis.
• 2023-04-17 Hip joints Rt
  • Permeative osteolysis over Rt acetabulum and superior pubic ramus and body, metastatic lesion d/d diffuse osteoporosis
• 2023-04-17 CXR
  • marginal spurs of multiple vertebral bodies of T-spine due to spondylosis.

[SOAP]

• 2023-04-17 Emergency
  • Diagnosis
    • N63 - Unspecified lump in breast
    • M89.59 - Osteolysis, multiple sites
    • R42 - Dizziness and giddiness
    • Z74.01 - Bed confinement status
• 2021-08-03 Cardiology
  • Objective
    • 2021/08 123/75; 70;
  • Medication
    • Olmetec (olmesartan medoxomil 20mg) 1# QD
    • Concor (bisoprolol 5mg) 0.5# QD
    • Norvasc (amlodipine 5mg) 1# QD
• 2019-11-21 Cardiology
  • Objective
    • 2019/11 128/80; 65
  • Medication
    • Concor (bisoprolol 5mg) 0.5# QD <- 1# QD
• 2019-08-02 Cardiology
  • Assessment
    • Essential hypertention, unspecified [I10]
    • Obesity, unspecified [E66.9]
    • Hepatitis B carrier [Z22.51]
    • Gout, unspecified [M10.9]
  • Medication
    • Olmetec (olmesartan medoxomil 20mg) 1# QD
    • Concor (bisoprolol 5mg) 1# QD
    • Natrilix SR (indapamide 1.5mg) 1# QD

[assessment]

• An unspecified breast lump and multiple-site osteolysis are under investigation.
• The patient’s underlying hypertension and obesity are well controlled with Olmetec (olmesartan), Norvasc (amlodipine) and Concor (bisoprolol) prescribed by our cardiologist without any medication reconciliation issues.
• To date, there is no evidence of hyperuricemia (although this diagnosis remains in the cardiology OPD records). On 2023-04-17, the patient’s serum uric acid level was 5.4 mg/dL.
• The most recent data for total cholesterol, triglycerides, LDL, and HbA1c were obtained on 2022-09-20 and may need to be updated.

700891439

230418

[diagnosis] - 2023-04-12 admission note

• Malignant neoplasm of rectum
• Malignant neoplasm of bladder, unspecified
• Iron deficiency anemia, unspecified
• Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
• Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection)

[past history]

• Squamous cell cacinoma of the Lt buccal region, stage T4aN0M0 (IVA), s/p wide excision, segmental osteotomy, and supraomohyoid neck dissection, radiotherapy, and chemotherapy in 2008
• Small bowel ileus post enterolysis with bowel decompression in 2018
• Ileus s/p Explosive laparotomy in 2018
• Adenocarcinoma of rectum, pT2N2a(cM0), stage IIIB, s/p EXP LAP with AR and enterolysis, and s/p CCRT
• Invasive urothelial carcinoma s/p transurethral resection of bladder tumor on 2021/05/28
• Adhesion ileus s/p operation on 2018/04/20

[family history]

• elder brother: lung cancer
• father: liver disease
• No members of the family with colon cancer.

[lab data]

• 2021-07-14 All-RAS not detected
  
• 2021-07-14 BRAF not detected
  
• 2021-07-07 PD-L1(22C3) CPS>=1 and <10
  
• 2021-07-07 PD-L1(28-8) TC>=1% and <5%

[exam findings]

• 2023-04-14 Patho - gingival/oral mucosa biopsy
  • Mass, right buccal mucosa, biopsy — Squamous cell carcinoma
  • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated characterized by tumor nests with enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the stroma with keratin material.
  • Immunohistochemical stains show CK(+); P63(+) and P16(-) for tumor.
• 2023-04-13 Nasopharyngoscopy
  • Finding: granular tumor over right buccal, retromolar, gingivobuccal
  • Conclusion: right buccal ca
• 2023-03-28 CT - neck
  • Indication: right facial tumor bleeding noted on 1AM. he had similar episode 2 weeks ago. The mass was noted for 2-3 months, which is growing with bleeding and pus formation.
  • Past history: double ca (colon ca and bladder ca) folfox 6 R/T, Bladder cT2N0M0 stage II UC with squamous change
  • Protocols: Axial scans with 2 mm slice thickness with multiplanar image reformation using Aquilion Prime CT.
  • Neck CT without/with contrast enhancement shows:
    • large enhancing mass at right buccal region (maximal diameter about 8cm), with direct invasion to right mandibular bone and right masticator space muscles, including masseter and temporalis muscles and probably also pterygoid muscles. Advanced right buccal cancer is compatible. T4b disease is considered.
    • multiple enlarged lymphadenopathy at right level Ib, II, Va. Possible extranodal invasion cannot be well evaluated in CT. N2b disease is favored.
    • bilateral symmetric pharyngeal mucosa.
    • chronic right maxillary sinusitis with complete sinus opacity and sinus bone thickening.
  • Impression: Advanced right buccal cancer, image staging favor AJCC T4bN2b, stage IVB.
• 2022-12-24 CT - abdomen
  • s/p LAR. No evidence of recurrent/residual tumor in the study.
• 2022-07-30 CT - abdomen
  • S/P colon and bladder operation. No evidence of tumor recurrence.
• 2022-02-15 CT - abdomen
  • Post-op at the colon. Suggest follow up.
  • Liver cysts.
  • Left lower lung nodule 0.4cm, stationary, suggest follow up.
• 2021-06-24 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Rectum, EXP LAP with low anterior resection — Adenocarcinoma, moderately differentiated
      
    • Resection margins, EXP LAP low anterior resection — Free
      
    • Lymph nodes, mesocolorectal, dissection — Metastatic adenocarcinoma (6/22)
      
    • Pathology stage: pT3N2a(cM0); Stage IIIB
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: EXP LAP low anterior resection
      
    • Specimen site: Rectum + sigmoid colon
      
    • Specimen size: 20.5 cm in length
      
    • Tumor size: 5.8 x 4.5 cm
      
    • Tumor location: 4.0 cm away from the distal resection margin
      
    • Depth of invasion grossly: Perirectal soft tissue
      
    • Mucosa elsewhere: Unremarkable
      
    • Representative parts are taken for section and labeled: A1-A5=tumor, A6-A10= regional LNs, B= proximal end, C= distal end.
      
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
      
    • Histology Grade: Moderately differentiated
      
    • Depth of invasion: Perirectal soft tissue
      
    • Angiolymphatic invasion: Not identified
      
    • Perineural invasion: Not identified
      
    • Tumor cell budding: Intermediate
      
    • Circumferential (radial) margin of rectum: Uninvolved, 5 mm from the margin
      
    • Lymph node metastasis, mesocolorectal: Metastatic adenocarcinoma (6/22) (No. Positive / No. Total)
      
    • Extranodal involvement: Present
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT): pT3 (Tumor invades pericolorectal tissues)
        
      • Regional Lymph Nodes (pN): pN2a (4 to 6 regional lymph nodes are positive)
        
      • Distant Metastasis (pM): cM0
        
    • Type of polyp in which invasive carcinoma arose: Not identified
      
    • Additional pathologic findings: None identified
      
    • Tumor regression grading S/P CCRT: N/A
      
    • IHC (S2021-7997): EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2021-06-23 PD-L1 (SP142)
  • VENTANA PD-L1 (SP142) Assay for Urothelial Carcinoma (S2021-08015)
    • PD-L1 Expression: <5% IC
    • Scores – Immune cells (IC): 2%; Tumor cells (TC): 0%
• 2021-06-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 47.8) / 126 = 62.06%
    • M-mode (Teichholz) = 62.1
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mitral valve prolapse (posterior leaflet) with trivial regurgitation
    • Trivial tricuspid regurgitation
    • Thick IVS and dilated aortic root
• 2021-05-28 Patho - urinary bladder TUR
  • PATHOLOGIC DIAGNOSIS
    • Urianry bladder, “tumor”, near neck at 11-1 o’clock, TURBT — Invasive urothelial carcinoma with marked squamous differentiation, high-grade
      
    • Urinary bladder, “base”, TURBT — Involved by carcinoma
      
  • MICROSCOPIC EXAMINATION
    • Histologic type: Urothelial carcinoma, invasive, with marked squamous differentiation
      
    • Histologic grade: High-grade
      
    • Tumor configuration: Papillary and nodular
      
    • Muscularis propria: Present
      
    • Lymphovascular invasion: Not identified
      
    • Microscopic tumor extension: Tumor invades muscularis propria
      
    • Specimen labeled “base”: Involved by carcinoma
• 2021-05-27 Patho - colon biopsy
  • Intestine, large, rectum, near R-S junction, biopsy — adenocarcinoma
    
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    
  • IHC stain — EGFR(+), PMS2(+), MSH2(+), MSH6(+), MLH1(+)
• 2021-05-27 Colonoscopy
  • Suspected colon cancer, rectum near R-S junction, 15cm from anal verge, s/p biopsy
  • Mixed hemorrhoid
• 2021-05-24 CT - abdomen
  • History and indication: fever, L’t abd pain, cause?
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with regional LAP.
    • A tumor (3.3cm) in urinary bladder r/o malignancy.
    • A soft tissue nodule (2.5x5.8cm) in presacral region r/o GIST.
    • Small liver cysts (3-6mm).
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T2(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIB(Stage_value)

[surgical operation]

• 2021-06-23
  • Surgery
    • EXP LAP with AR and enterolysis     
  • Finding
    • Rectal tumora invasion to bladder, Adenocarcinoma of rectum, stage T2N2aM0, stage IIIB
    • Anastomosis by CDH 33#
    • Previous surgery, severe adhesion  
• 2021-05-28
  • Surgery
    • Transurethral resection of bladder tumor
  • Finding
    • urethral trauma during urethral dilation
    • Bilateral U/O normal with clear efflux
    • A large round shape tumor with hypervascularity tumor beneath normal mucosa was noted at anterior wall or urinary bladder. The location is very near 11 o’clock bladder neck. Based on clinical finding, it is hard to tell whelther it came from urinary bladder or prostate
    • Risk evaluation:
      • Tumor size: >3cm
      • Multifocality: solitary
    • a wrinkle at left posterior wall, compatible with location of sigmoid colon with wall thickening

[chemotherapy]

• 2022-01-24 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4250mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-01-10 - (FOLFOX Q2W)
• 2021-12-27 - (FOLFOX Q2W)
• 2021-12-13 - (FOLFOX Q2W)
• 2021-11-29 - (FOLFOX Q2W)
• 2021-11-15 - (FOLFOX Q2W)
• 2021-10-25 - (FOLFOX Q2W)
• 2021-10-11 - (FOLFOX Q2W)
• 2021-09-27 - (FOLFOX Q2W)
• 2021-09-13 - (FOLFOX Q2W)
• 2021-08-30 - (FOLFOX Q2W)
• 2021-08-02 - (FOLFOX Q2W)

700154637

230417

[past history] - 2023-04-13 admission note

• s/p appendectomy at the age of 18
• Brenner tumor and benign mucinous cystadenoma s/p left salpingo-oophorectomy on 2008-05-20 at our hospital
• The recurrence of brenner tumor and benign mucinous cystadenoma s/p ATH and right oophorectomy on 2012-02 at CGMH
• Brenner tumor and benign mucinous cystadenoma with pelvic seeding and partial intestinal obstruction, due to tumor involvement and adhesion s/p excision of pelvic tumor and enterolysis and segmental resection of ileum with anastomosis on 2014-01-20
• Brenner tumor s/p chemotherapy x3 three years ago (from peripheral line)
• Colon cancer s/p OP
• GB stone
• Hemmorhoids

OB/GYN history:

• Menarche: 18 Y/O
• Menopause: 52 y/O
• G5P4AA1
• No perimenopausal hormone therapy
• No smoking
• No family members had breast CA, endometrial CA, ovary CA and colon CA

[allergy]

• Ulexin (cephalexin 500 mg/cap) local rash

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-04-14 Tc-99m MDP bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, middle and lower T-spines, L5-sacrum junction, bilateral shoulders, right sternoclavicular junction and bilateral elbows in whole body survey.
  • IMPRESSION:
    • Mildly increased activity in the middle and lower T-spines and L5-sacrum junction. Degenerative change is more likely.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Increased activity in bilateral shoulders, right sternoclavicular junction and bilateral elbows, compatible with benign joint lesions.
    • No prominent bone abnormality was noted elsewhere.
• 2023-04-12 CXR
  • Patch density at RUL.
• 2023-04-12 CT - abdomen
  • CC: abdominal pain, Lower abdominal dull pain for 3 months, progressed in 2 days. No diarrhea, no N/V, No fever, No dysuria
  • Past history:
    • Right ovarian cancer s/p TAH + BSO
    • Metastatic carcinoma in left pelvic cavity with sigmoid colon and left distal ureteral involvement, T4N0Mx s/p sigmoid colon resection
    • GB stones
  • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There are multiple poor enhancing masses on both hepatic lobes, the largest one 3 cm in S2/3, that are c/w metastases.
    • Multiple gallstones are noted.
    • S/P hysterectomy
    • S/P LAR with autosuture retention over the sigmoid colon.
    • There are two small soft tissue nodules 5 mm in RML of the lung.
      • Please correlate with chest CT to R/O metastases or inflammatory process.
    • Others
      • There is no focal abnormality in the biliary system, pancreas, spleen & both kidneys.
        
      • There is no evidence of ascites or lymphadenopathy.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • Multiple metastases on both hepatic lobes.
      
    • Two small soft tissue nodules 5 mm in RML of the lung, nature?
      • Please correlate with chest CT.
• 2023-04-12 KUB
  • Degeneration of bony structures.
  • Stool retention in bowl.
• 2023-03-21 KUB
  • Rim calcification in RUQ.
  • Mild lumbar spondylosis.
• 2023-03-21 Renal ultrasound
  • Grossly normal, bilateral kidneys
• 2020-06-19 Pap Smear
  • Atrophy with inflammation
• 2020-03-10 KUB
  • Degenerative change of the lumbar spine
• 2020-03-10 CT - abdomen
  • Indication: acute onset diffused abdominal pain, with radiation to the back, nausea.
  • PMH: ovarian and uterus cancer s/p OP
  • Protocols: Axial scans with 5 mm slice thickness with multiplanar image reformation using 64-slice MDCT.
  • Abdomen & Pelvis CT without/with contrast enhancement shows:
    • postoperative change with suture material in the pelvic cavity.
    • clustered dilated small bowel loops (mainly ileum) in the pelvic cavity, with abrupt tapering of lumen at transition zone. Adhesion ileus is first considered.
    • colon is not dilated.
    • no ascites; no intraperitoneal free air.
    • tiny simple hepatic cysts in left hepatic lobe.
    • no definite focal lesion in the spleen, pancreas, bilateral kidneys and adrenal glands.
    • multiple gallbladder stones.
  • Impression:
    • Postoperative change in the pelvic cavity. Focal small bowel ileus in the pelvis, favor adhesion ileus.
    • Multiple gallbladder stones.
    • Tiny simple hepatic cysts, left lobe.
• 2018-11-30 CT - abdomen
  • Chief Complaints: abd pain, upper abodmen, Nausea (+), vomiting (-), Diarrhea (-) Radiation to back (-) constipatin (-)
    • Past History: Nil
    • Surgical history: Hysterectomy and oophorectomy
    • Drug allergy: Ulex
    • Stomach ache sudden onset since 4 pm
  • Indication: R/O intestinal obstruction.
  • Without and with contrast Abdomen CT showed
    • unremarkable change in the solid organs, such as liver, pancreas, spleen, and both kidneys
    • post-OP change in the rectosigmoid colon.
  • Impression: post-OP change in the rectosigmoid colon.
• 2018-11-30 CXR
  • Scoliotic alignment of the thoracolumbar spine is noted.
  • Osteopenia of the bony structure is noted.
• 2018-11-30 KUB
  • Osteopenia of the bony structure is noted.
• 2018-03-06 Surgical pathology Level V
  • Clinical diagnosis: Malignant ovary neoplasm
  • Pathological diagnosis
    • Labeled as “pelvic mass”, excision — Adenocarcinoma.
      • IHC stains: CK7 (+), CK20 (focal +), pattern the same as previos pattern (S2014-1036).
      • Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-).
    • Labeled as “sigmoid colon”, resction — Free
    • Lymph node, epricolonic, sigmoid colon resection — Metastatic carcinoma (1/1) with extra-nodal extension.
  • MICROSCOPIC DESCRIPTION:
    • Sections of the pelvic tumor mass show adenocarcinoma with neoplastic glands lined by goblet cells and elongated nuclei.
      • IHC stains: CK7 (+), CK20 (focal +), the pattern the same as previos pattern (S2014-1036).
      • Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-).
        
    • Section of the sigmoid colon show bland colonic mucosa, submucosa, muscular layer and serosa. One lymph node at the resection margin shows tumor metastasis with extra-nodal extension.
• 2018-01-30 Sigmoid fiberscopy
  • external compression and scopy can not pass through since 10 cm from AV
• 2018-01-30 Upper GI panendoscopy
  • Hiatal hernia with reflux esophagitis, Gr A 　- Superficial gastritis, antrum and body
• 2018-01-29 CXR
  • Scoliotic alignment of the thoracolumbar spine is noted.
  • Osteopenia of the bony structure is noted.
• 2018-01-29 CT - abdomen
  • A multiloculated cystic lesion (4.9x8.8cm) at left pelvic cavity.
  • Gall stones (0.3-1.4cm). A hypodense nodule (0.3cm) at left hepatic lobe.
  • S/P colon operation.
  • Focal wall edema of small bowel at pelvic cavity.
• 2016-03-15 SONO - OBS
  • L’t adnexal mass: 62x51mm (RI:0.17, RI:0.78)
• 2016-03-15 CT
  • S/P hysterectomy.
  • R/O recurrence malignancy in left pelvic cavity with sigmoid colon and left distal ureteral involvement.
  • GB stones with GB fundus wall thickening.
• 2015-04-22 CT
  • In favor of S-colon cancer (T4N0Mx) (The gold standard of evaluation of lymph node metastases and detailed tumor status is microscopic examination).
  • cStage: T4N0Mx.

[consultation]

• 2023-04-17 Family Medicine
  • Q
    • This 79 year old woman patient is a case of right ovairan cancer s/p TAH + BSO with pelvic cavity, sigmoid, ureteral involvement s/p OP with liver metastases. Laparotomy on 2008/05/21. OP with TAH+BSO in 2012/02 at CGMH. Debulking with pelvic lymph node enlargement, suspect recurrent ovarian tumor and pelvic tumor, r/o recurrent ovarian cancer with invasion to sigmoid colon on 2018/03/05 and pathology showed Adenocarcinoma. IHC stains: CK7 (+), CK20 (focal +), pattern the same as previos pattern (S2014-1036). Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-). Lymph node, epricolonic, sigmoid colon resection pathology showed metastatic carcinoma (1/1) with extra-nodal extension. Patient and family refuse further chemotherapy.
    • For pain control and hospice care, we need your further evaluation and management.

[surgical operation]

• 2018-03-05 Debulking
• 2012-02 (at CGMH) TAH + BSO
• 2008-05-21 Laparotomy

[assessment]

• This patient and her family refuse further chemotherapy, so family medicine is consulted for combined hospice care and pain management.
• Palliative and supportive care is provided. There is no problem with the active prescription.

700824633

230417

[exam findings]

• 2023-02-22 CT - abdomen
  • History:
    • 20230117 CT: Ileocecal mass lesion causing small bowel obstruction. Please correlate with colonoscopy.
    • 20230118 S/P ileostomy for decompression.
    • 20230216 S/P right hemicolectomy: A locally advanced tumor was found at cecum with adhesion to RLQ abdomen wall and invasion of great omentum, with obstruction s/p loop-ileostomy.
  • Indication: R/O IAI (Intra-Abdominal Infection)
  • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformatted isotropic images were obtained in non-contrast scan.
  • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status cannot be determined without IV contrast.
  • Findings:
    • There is pneumoperitoneum that may be post-operative change.
      • The differential diagnosis includes hollow organ perforation.
    • There are free gas bubbles in the gastrohepatic ligament and ligamentum teres. Please correlate with gastroscopy.
    • S/P right hepatectomy
    • S/P cholecystectomy.
    • S/P Jackson-Pratt drainage tube insertion from right flank area and the tip located over subhepatic space.
    • Others
      • There is no hyper-or hypodense lesion in the liver, biliary system, pancreas, spleen & both kidneys.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
  • IMP:
    • There is pneumoperitoneum that may be post-operative change. The differential diagnosis includes hollow organ perforation.
    • There are free gas bubbles in the gastrohepatic ligament and ligamentum teres. Please correlate with gastroscopy.
• 2023-02-17 Patho - colon segmental resection for tumor
  • Diagnosis:
    • Intestine, large, cecum, right hemicoloectomy — Mucinous adenocarcinoma, poorly differentiated
    • Margin, proximal and distal: Free
    • Omentum, right hemicoloectomy — Adenocarcinoma, seeding
    • Lymph node, regional, dissection — Meatastatic adenocarcinoma (2/17)
    • Ileostomy, closure — Confirmed
    • AJCC 8th edition pathology stage: pT4aN1bM1a; AJCC stage IVA
  • Gross Description:
    • Procedure: Right hemicolectomy
    • Tumor Site: Cecum
    • Tumor Size: 6.2x 4.2 cm
      
    • Macroscopic Tumor Perforation: Not identified
    • Macroscopic Intactness of Mesorectum (if applicable): Complete
    • Sections are taken and labeled as:1:bil cut-ends, A2:stomy, A3-5:tumor, A6-8:LNs, X1-3:tumor, X4:omentum, X5:LNs
  • Microscopic Description:
    • Histologic Type: Mucinous adenocarcinoma
    • Histologic Grade: G3 - Poorly differentiated
    • Tumor Extension
      • Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
        
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Involved
        
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Not identified
    • Tumor Budding
      • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2)
        • Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
    • Tumor Deposits: Present
      • Specify number of deposits: Mesocolon
    • Regional Lymph Nodes
      • Number of Lymph Nodes Involved/Examined: Positive (2/17)
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply)
      • m (multiple primary tumors) r (recurrent) y (posttreatment)
        • Primary Tumor (pT)
          • pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
        • Regional Lymph Nodes (pN)
          • pN1b: Two or three regional lymph nodes are positive
        • Distant Metastasis (pM)
          • pM1a: Metastasis to one site or organ is identified without peritoneal metastasis
    • Additional Pathologic Findings (select all that apply): None identified
    • Ancillary Studies: Pending
      
    • Comment(s): None
    • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
• 2023-02-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (98 - 27) / 98 = 72.45%
    • M-mode (Teichholz) = 73
  • Conclusion:
    • Indeterminated LV filling pressure; mild RV hypertrophy with impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; trivial MR; trivial TR; mild PR.
• 2023-02-15 Flow Volume Chart
  • normal ventilation
• 2023-02-14 CXR
  • A calcification at LUQ.
• 2023-01-17 CT - abdomen
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:M1(M_value) STAGE:____(Stage_value)
• 2021-03-24 Treadmill Exercise Electrocardiogram
  • The patient exercised according to the BRUCE for 06:16 min:s, achieving a work level of max METS: 7.3. The resting heart rate of 67 bpm rose to a maximal heart rate of 115 bpm. This value represents 77 % of the maximal, age-predicted heart rate. The resting blood pressure of 139/57 mmHg, rose to a maximum blood pressure of 216/70 mmHg. The exercise test was stopped due to Dizziness, Leg discomfort.
  • Conclusion: Inadequate exercise load
• 2018-11-14 Myocardial perfusion SPECT with persanti
  • The Tl-201 stress myocardial perfusion scan was performed after sequentially injecting 38.1 mg of dipyridamole and 2.3 mCi of the radiotracer to the patient. The images after stress revealed mildly decreased radiotracer perfusion to the apical lateral wall of the left ventricle. The images at rest revealed further decline radiotracer perfusion to aforementioned hypoperfused area of the left ventricle. No dilatation of the left ventricle was noted.
  • IMPRESSION:
    • Probably normal variant or mild myocardial ischemia in the apical lateral wall of the left ventricle.
    • No post-stress dilatation of the left ventricle.
• 2023-02-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (78.2 - 25.6) / 78.2 = 67.26%
  • Report
    • AO(mm) = 32.8
    • LA(mm) = 36
    • IVS(mm) = 13.1
    • LVPW(mm) = 10.9
    • LVEDD(mm) = 41.9
    • LVESD(mm) = 26.4
    • LVEDV(ml) = 78.2
    • LVESV(ml) = 25.6
    • LV mass(gm) = 177.5
    • RVEDD(mm)(mid-cavity) =
      
    • TAPSE(mm) = 22.6
    • LVEF =
      
    • M-mode(Teichholz) = 67.3
    • 2D(M-Simpson) =
      
  • Diagnosis
    • Heart size: Normal
    • Thickening: IVS
    • Pericardial effusion: None
    • LV systolic function: Normal
    • RV systolic function: Normal
    • LV wall motion: Normal
    • Valve lesions:
      • MV prolapse: None
      • MS: None
      • MR: None
      • AS: None, Max.AV velocity = 1.3 m/s
      • AR: None
      • TR: Trivial, Max.pressure gradient = 22.8 mmHg
      • TS: None
      • PR: None
      • PS: None
    • Mitral E/A = 53.5 / 68.1 cm/s (E/A ratio= 0.79 )
    • Mitral E’/A’ = 6.9 / 12 cm/s (septal MA); E/E’ = 7.8
    • Intracardiac thrombus: None
    • Congenital lesion: None
  • Conclusion
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Trivial tricuspid regurgitation
    • Mildly thicked IVS

[consultation]

• 2023-01-17 Colorectal Surgery
  • Q
    • For small bowel illeus due to suspected cecum tumor obstruction
    • The 75 year old woman suffered from no stool and no gas release for 1 week and her abdomen became distended and gradually painful. She visited our ER today and KUB showed small bowel illeus, and CT was done that it was suspected a cecum tumor obstructed the bowel. As a result, we need your expertise to evaluate if she needed emergent operation, thanks!
  • A
    • O
      • CT:
        • Dilatation of small bowel and collapse of colon, r/o obstruction.
        • Wall thickening at ileocecal junction with perifocal fat stranding.
        • Several lymph nodes, at least 8, in right mesocolon.
        • Unremarkable chagne of the liver, spleen, pancreas, and kidneys.
        • No ascites or extraluminal free air.
        • No bony destructive lesion on these images.
      • No fever
      • Vital signs: stable
      • Abdomen: soft, no peritoneal signs or muscle guarding, mild tenderness and distended
    • A: R/O tumor of cecum with obstruction
    • P:
      • Diverting ileostomy for decompression first followed by staged right hemicolectomy 2-3 weeks later is recommeneded
      • The operation will be performed tomorrow on call
      • Please keep current treatment (NPO, NG, nutrition support, antibiotics, Albumin use, check tumor makers)
      • We’ll take over this patient tomorrow morning

[surgical operation]

• 2023-02-16
  • Surgery
    • Exp. Lap with right hemicolectomy and closre of loop-ileostomy
  • Finding
    • A locally advanced tumor was found at cecum with adhesion to RLQ abdomen wall and invasion of great omentum, with obstruction s/p loop-ileostomy
    • Right hemicolectomy was carried out smoothly and anastomosis using endo-GIA for both ends and side-to-side hand-sewn sutures with 4/0 PDS+ silk.
    • Blood loss was about 30ml. A drain in right subhepatic region
• 2023-01-18
  • Surgery: Loop-ileostomy    
  • Finding: Dilation of small bowel with wall edema and some ascites. Loop-ileostomy was created at RLQ abdomen. The whole procedure was smooth. 
• 2017-11-20
  • Diagnosis: varicose vein
  • PCS code: 69014B
  • Finding: left varicose vein with posterior thigh varicose lake

[chemotherapy]

• 2023-04-13 - oxaliplatin 85mg/m2 131mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4323mg NS 1000mL 46hr (FOLFOX Q2W)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-03-27 - oxaliplatin 85mg/m2 131mg D5W 250mL 2hr + leucovorin 400mg/m2 617mg NS 250mL 2hr + fluorouracil 2800mg/m2 4320mg NS 1000mL 46hr (FOLFOX Q2W)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[assessment]

• The modified FOLFOX6 regimen was administered on 2023-03-27 and 2023-04-13, and severe diarrhea with 10 bowel movements each day occurred on 2023-03-28 and 2023-04-14.
• Treatment should be withheld for grade 2 or worse diarrhea and restarted at a 20% lower dose of all agents after complete resolution. A dose reduction of oxaliplatin is recommended (to 75 mg/m2 for patients in the adjuvant setting and 65 mg/m2 for patients with advanced disease). Since the bolus FU is skipped in the regimen used, consideration may be given to reducing the infusional FU from 2800mg/m2 to 2400mg/m2 after recovery from grade 3 or 4 diarrhea in the previous cycle.
• Severe diarrhea, mucositis, and myelosuppression following FU should lead to evaluation for DPD deficiency.
• Loperamide is recommended as initial therapy for chemotherapy-related diarrhea (CRD). For mild to moderate (grade 1 or 2) uncomplicated CRD, an initial dose of 4 mg should be administered, followed by 2 mg every 4 hours or 2 mg after each loose stool (maximum daily dose of 16 mg). For severe (grade 3 or 4) diarrhea, or mild to moderate diarrhea complicated by moderate to severe abdominal cramping, grade 2 or worse nausea/vomiting, decreased performance status, fever, sepsis, neutropenia, frank bleeding, or dehydration, or mild to moderate uncomplicated diarrhea that persists after 24 hours of loperamide, high-dose loperamide (4 mg initially followed by 2 mg every 2 hours; maximum daily dose 16 mg) should be used. Loperamide was prescribed on 2023-03-30 when the patient was discharged after her first dose of FOLFOX.

700841910

230417

{not completed}

[exam findings]

• 2023-04-16 Nasopharyngoscopy
  • Findings
    • smooth NPx, OPx, supraglottic swelling, vocal cord edema, R vocal palsy, L vocal paresis, saliva pooling over hypopharynx aspirated to trachea, whitish lesion over left AE fold
  • Diagnosis/Conclusion
    • hypopharynx ca
• 2023-03-02 Nasopharyngoscopy
  • Findings: 3/2 fiber = RT since 3/1 + CT (3/2 3 courses left), dyspnea, R false cord bulging
• 2023-02-13 MRI - larynx
  • Indication
    • Hypo ca, R+ neck mets (R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT = suspect liver mets), s/p incomplete CCRT (2022-09-21 ~ 10-20).
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows (comparison: 2022/08/19 MRI)
    • No evident abnormal enlarged lymph node in the visible neck. Regressed LNs seen on prior MR study.
    • Markely Regressed hypopharygeal tumor.
    • After IV contrast administration shows well or heterogenous enhancement in right hypopharynx and around the esophagus inlet (around NG tube, edema?).
    • Presence of soft tissue swelling over bil. neck, post R/T change likely.
    • No evident bony destructive lesion.
  • IMP: Markedly regressed neck LAPs. Markely regressed right hypopharyngeal tumor, likely with minimal residual tumor mass or edematous change, suggest follow up.
• 2023-02-02 Nasopharyngoscopy
  • Hypo ca undergoing CCRT
  • NG+
• 2023-01-30 CT - abdomen
  • Abdominal CT with and without enhancement revealed:
    • Bilateral renal cysts measuring 4.3cm is found at right side.
    • Enlarged prostate measuring 6.3cm with calcification is found.
    • The GB is well distended without soft tissue lesion
    • S/P NG tube placement.
    • The spleen, pancreas and adrenals are intact.
    • Very small nodule at hepatic hilum measuring 0.8cm in largest dimension. In comparison with CT dated on 2022-10-12, the lesion regressed.
    • There is no evidence of paraarotic LAPs.
    • There is no ascites accumulation at abdominal cavity.
    • No definite inguinal or pelvic sidewall LAP
    • Visible chest
      • Normal heart size.
      • Calcified coronary arteries is found.
      • The lung fields are clear.
  • Imp:
    • Hepatic hilar nodule. In regression.
    • Enlarged prostate. 6.3cm
• 2023-01-05 Nasopharyngoscopy
  • Hypo ca undergoing CCRT
  • NG+
  • saliva stasis
• 2022-11-03 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
• 2022-10-27 ECG
  • Sinus tachycardia
  • T wave abnormality, consider anterior ischemia
• 2022-10-12 CT - abdomen
  • Indication:
    • Poor intake after R/T, dysphagia, odynophagia
    • 68 y/o male, a pt of Hypo ca, R+ neck mets (R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT＝ suspect liver mets) Dx in Aug 2022
  • Findings
    • Regression of S1 liver lesion (or hepatic hilar lesion), from 1.9cm to 1.0cm.
    • Right kidney cyst, 5.2cm.
    • No ascites or extraluminal free air.
    • No evidence of bowel obstruction.
    • No enlarged lymph nodes in para-aortic and pelvic regions.
    • Enlargement of prostate gland.
    • No bony destructive lesion on these images.
  • Impression
    • Regression of S1 liver lesion (or hepatic hilar lesion)
    • Prostate enlargement
• 2022-09-15 Nasopharyngoscopy
  • 202208 Hypo ca, R+ neck mets(R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT = suspect liver mets) = wish CCRT@XD
  • 20220915 fiber = new R vocal palsy + supraglottic smooth bulging progress + no glottis visible (no dyspnea) + mucopus
• 2022-09-06 Patho - odontogenic/dental cyst
  • Labeled as “granulation tissue in the extraction socket of tooth 34”, removal — Granulation tissue
  • Section shows benign squamous mucosa lined granulation tissue composed of proliferative small blood vessels, fibrosis, and moderate diffuse acute and chronic inflammation.
• 2022-08-29 CT - abdomen
  • Liver low density lesion at S1, liver meta is favored.
  • Enlarged prostate. Please correlate with PSA.
• 2022-08-25 Esophagogastroduodenoscopy, EGD
  • Right hypopharynx mass
  • Gastric ulcers, antrum
  • Reflux esophagitis LA Classification grade A
  • Hiatal hernia
  • Superficial gastritis, s/p CLO test
• 2022-08-25 SONO - abdomen
  • Prob. Parenchymal liver disease
  • Bil renal cysts
• 2022-08-23 Patho - larynx biopsy
  • Labeled as “right hypopharyngeal tumor”, additional biopsy (S2022-13982) for formalin fixation — squamous cell carcinoma (SCC). IHC stains: p16 (-), Ki-67: 10-15%.
  • Labeled as “right hypopharyngeal tumor”, initial biopsy with frozen section examination (F2022-391) — squamous cell carcinoma in situ (CIS), at least.
• 2022-08-23 Frozen section
  • Preliminary diagnosis: right hypopharynx, squamous cell carcinoma in situ (CIS), at least.
• 2022-08-22 Whole body PET scan
  • Glucose-hypermetabolic lesions in the right hypopharynx, highly suspected the primary hypopharyngeal cancer, suggesting biopsy for investigation.
  • Glucose hypermetabolic lesions in lymph nodes in bilateral cervical regions and in the right supraclavicular fossa, highly suspected cancer with regional lymph nodes metastases.
    
  • A glucose hypermetabolic lesion in the right lobe of the liver, highly suspected cancer with distant metastasis. However, another primary cancer (HCC) should be excluded.
    
  • Suspected benign lesions in the lesser curventure of the stomach, and physiological uptake of FDG in the colon.
  • Right hypopharyngeal cancer with bilateral cervical and right SCF lymph nodes and liver metastases, cTxN2cM1, stage IVC (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2022-08-19 MRI - larynx
  • Imaging Report Form for Hypopharynx Carcinoma
  • Impression (Imaging stage) : T:4a(T_value) N:2b(N_value) M:0(M_value) STAGE:IVA(Stage_value)
• 2022-08-18 CT - neck
  • IMP: Right hypopharynx CA with neck LAPs. T4aN2BMx. stage IVA
  • Imaging Report Form for Hypopharynx Carcinoma
  • Impression (Imaging stage) : T:T4A(T_value) N:N2B(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
• 2022-08-18 Nasopharyngoscopy
  • Findings
    • 3x3 cm palpable non-tender mass over right neck Level I-II region
    • Scope: bilateral intact ear drums, smooth nasopharynx, oropharynx
      • mass lesion over right AE fold, with moderate airway patency
    • Diagnosis and conclusion
      • right hypopharynx mass, cause to be determined
• 2021-04-09 KUB
  • The psoas shadow is clear.
  • There is no evidence of destructive bone lesion.
  • Calcified dot(s) is found at left paravertebral region, ureter stone(s) is most likely.
    
  • Increased intestinal gas is found.

[consultation]

• 2023-04-16 Ear Nose Throat
  • Q
    • Chief Complaints: just done C/T 1 month ago.
    • progressive dyspnea, productive cough today.
    • Past History: hypophagreal ca cT4aN2bM1 sp CCRT. liver metastasis
    • Surgical history: Denied
    • Drug allergy: Denied
  • A
    • Stridor for 20 days.
    • Scope: smooth NPx, OPx, supraglottic swelling, vocal cord edema, R vocal palsy, L vocal paresis, saliva pooling over hypopharynx aspirated to trachea, whitish lesion over left AE fold (compared to 202303)
    • Imp: Supraglottic sweillng, suspect C/T related or acute infection
  • Plan:
    • Failed NG insertion due to supraglottic swelling, may consult GI man for insertion
    • Monitor airway, informed the risk of tracheostomy, prescribed Bosmin (adrenalin) + steroid inhalation, IV steroid (if no contraindication)
• 2022-10-27 Metabolism and Endocrinology
  • Q
    • The 64 y/o man has DM, HCVD and R hypopharyngeal CA wt bil cervical & R SCF LNs & liver mets, cTxN2cM1, stage IVC. He just did chemotherapy on 2022/10/18. Due to weakness and hyperglycemia noted, suspect DKA, so the RI pump use from ED. We need your help for management. Thanks!
  • A
    • We were consulted for blood sugar control.
    • O:
      • BH: 162 cm, BW: unknown
      • Diet: NPO except water and drugs
      • Medication in OPD: unknown
      • Medication during hospitalization: RI pump 30 ml/hr
      • Na: 123, K: 5.4, Ca: 2.75
      • ALT: 32
      • BUN/Cr: 71/1.95 (eGFR: 36.54)
      • F/S: 275
      • Blood glucose: 673 mg/dL
      • HbA1c: unavailable
      • Blood osm: 317, effective osm: 283
      • Urine ACR: unavailable
      • OPH OPD: nil
    • A: Type 2 DM, poor control
    • Suggestions:
      • Avoid all OADs. Keep NPO except water and drugs
      • RI pump 50U in 500ml N/S run as protocol
      • H/S 500ml Q12H, 0.298% KCl QD + STAT (STAT after serum K reading)
      • Check F/S Q2H. Check Na, K, vein gas Q8H until off RI pump
      • Switch to basal bolus therapy later. (contact us to adjust)
      • Check HbA1c, urine ACR
      • Consult OPH for DM retinopathy if his condition is stable.
      • Consider to consult nutritionist for DM diet education (self-paid approximate TWD 600)
      • Basic educations for Diet control, Hypoglycemic precautions, DM complications and Self-Monitoring of Blood Glucose were given at bedside
      • Contact us if needed. I’d like to follow up this patient. Meta-OPD F/U.
• 2022-08-18 Ear Nose Throat
  • Q
    • Right neck pain for 1 month
    • Never seek medical help, only took pain-killers and then tarry stool noted. called at our GI OPD this morning. EGD was arranged for R/O UGI bleeding.
    • Right ear tingling pain, horseness also noted
    • Odynophagia (+)
    • No fever noted
    • Occupation: Taxi driver
    • Medication: Bokey for
    • Past hx: DU, DM
    • OP hx: renal stone s/p op
  • A
    • S
      • sore throat with FB sensation for a month
      • fair saturation under room air
      • odynophagia(+), dysphagia(-), dyspnea(-),stridor (-), mouth drooling(-), voice change (+), otalgia (+, right), fever(-), alcohol(+), smoking(+), betelnut(-)
    • O
      • 3x3 cm palpable non-tender mass over right neck Level I-II region
      • Scope:
        • bilateral intact ear drums, smooth nasopharynx, oropharynx
        • mass lesion over right AE fold, with moderate airway patency
    • A
      • Impression: Right hypopharynx or larynx tumor with neck mass, r/o metastasis
    • P
      • inhalation therapy with steroid + bosmin if no contraindication
      • keep monitor breathing pattern and saturation, intubation or cricothyrodectomy may be considered then if s/s worsen
      • we will f/u the patient

[chemotherapy]

• 2023-03-15 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-03-08 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-03-01 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-10-18 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-10-11 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-10-04 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-09-26 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

UFT (tegafur 100mg + Uracil 224mg) KUFT01

• 2023-02-02 ~ undergoing - 2# BID
• 2022-08-29 ~ 2022-10-03 - 2# BID

[assessment]

• For the patient’s shortness of breath (SOB), in addition to the currently prescribed Ipratran (ipratropium bromide), the addition of Butanyl (terbutaline) could be considered if there are no contraindications. Inhaled glucocorticoids such as beclomethasone, budesonide, ciclesonide, fluticasone, mometasone and triamcinolone may also be considered.

701010079

230417

[exam findings]

• 2023-03-24 MRI - pelvis
  • CC: Stool passage from urine, hematuria, turbid urine
    • 20210111 CT: Rectal cancer,T4bN2aM0,STAGE:IIIC. Rectal-vesical fistula.
    • 20220413 CT: Soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
    • 20230218 CT: soft tissue mass at left lateral pelvis with left hydroureteronephrosis.
    • 20230223 TURBT of Bladder tumor: Adenocarcinoma c/w colorectal origin.
  • Past History: Liver abscess S/P right hepatectomy, old TB
  • Findings:
    • There is an ill-defined soft tissue mass-like lesion in between the rectum and the urinary bladder, measuring 4.4 x 2.8 cm in size.
      • Rectal cancer with urinary bladder invasion is highly suspected. Please correlate with contrast enhanced CT or MRI.
      • In addition, rectal-vesical fistula is noted.
    • There is no evidence of left hydroureteronephrosis.
    • There is no focal abnormality in the prostate.
      • Non-visualization of the seminal vesicle is noted.
    • There is no evidence of ascites or lymphadenopathy.
    • The visible abdominal aorta and IVC are grossly unremarkable.
      
  • IMP:
    • There is an ill-defined soft tissue mass-like lesion in between the rectum and the urinary bladder, measuring 4.4 x 2.8 cm in size.
      • Rectal cancer with urinary bladder invasion is highly suspected. Please correlate with contrast enhanced CT or MRI.
      • In addition, rectal-vesical fistula is noted.
    • No evidence of left hydroureteronephrosis.
• 2023-02-27 PD-L1 (SP142)
  • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • Tumor type: colorectal adenocarcinoma with bladder invasion
    • Tumor location: urinary bladder
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark ULTRA
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: [V]Pass, [ ]Fail
    • Adequate tumor cells present (>=50 viable tumor cells): [V] Yes, [ ] No
  • Result:
    • Tumor cell (TC) staining assessment:
      • TC category: TC < 1%
      • Percentage of PD-L1 expressing tumor cells (%TC): <1%
    • Tumor-infiltrating immune cell (IC) staining assessment:
      • IC category: IC >=1% and <5%
      • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 2%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2023-02-27 PD-L1 IHC
  • Tumor cell (TC) staining assessment:
    • TC: <1%
• 2023-02-27 PD-L1 (22C3)
  • Combined Positive Score (CPS) assessment: CPS >= 10
  • Combined Positive Score (CPS): 15
• 2023-02-23 Patho - urinary bladder TUR
  • Bladder tumor, TURBT — Adenocarcinoma, compatible with colorectal origin
  • Microscopic examination
    • Histologic type: Adenocarcinoma, compatible with colorectal cancer with bladder invasion
      
    • Histologic grade: moderately differentiated
      
    • Tumor configuration: tubular, cribriform or papillary tumor with focal necrosis and muscle invasion. Besides, normal colonic mucosa is also included in the submitted specimen
      
    • Immunohistochemistry: CK7(+, scatter), CK20(+), GATA-3(-), CDX2(+) and P63(-) for tumor
    • Clinical correlation is advised.
• 2023-02-22 CXR
  • Fibrocalcified infiltrates in right upper lung.
  • Right lower lung nodule, 0.9cm, stationary.
• 2023-02-18 CT - abdomen
  • Indication: new bladder cancer, colon cancer history
  • Abdominal CT without IV contrast ehnancement shows:
    • The urinary bladder is collapsed with thick wall and suspeced soft tissue infiltration to perirectal region measuring 5.65*3.03cm in largest dimension. In comparison with CT dated on 2022-04-13, the lesion enlarged. Suggest further treatment.
    • Left hydronephrosis and hydroureter obliterated by the tumor mass is found.
    • The spleen, liver, pancreas and adrenals are intact.
    • There is no evidence of paraarotic LAPs.
    • There is no ascites accumulation at abdominal cavity.
    • Visible chest
      • Calcified coronary arteries is found.
      • Normal heart size.
      • One calcified dot at right lower lobe is found measuring 0.45cm in largest dimension. Old insult is considered.
      • No pleural effusion is found.
  • IMP: Soft tissue mass at bladder base with left hydronephrosis and hydroureter. Uroepithelial cancer is favored.
  • Imaging Report Form for Urinary Bladder Carcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2022-12-09 Patho - urinary bladder TUR
  • Urinary bladder, TURBT — high-grade invasive urothelial carcinoma. Muscularis propria not present.
  • Microscopically, section showsinvasive urothelial carcinoma characterized by papillary architecture of the neoplasm lined by high-grade atypical urothelial cells. The tumor cells have irregular nuclear contours with hyperchromasia and pleomorphism, variably prominent nucleoli and mitotic activity. The tumor has invaded subepithelial connective layer. Muscularis propria is not present.
• 2022-12-07 SONO - nephrology
  • left severe hydronephrosis
• 2022-04-13 CT - abdomen
  • History: 20210111 CT:rectal cancer with rectal-vesical fistula, cT4bN2aM0, cStage: IIIC
  • Past History: Liver abscess S/P right hepatectomy, old TB
  • Findings:
    • S/P right hepatectomy and S/P cholecystectomy.
    • S/P right transverse colostomy
    • There is soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
    • Prior CT identified a metastasis measuring 7.5 mm in RLL of the lung is noted again, stationary.
    • Fibro-calcified shadows of right upper lung are noted, which is c/w old TB.
  • Impression:
    • There is soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
    • Prior CT identified a metastasis measuring 7.5 mm in RLL of the lung is noted again, stationary.
• 2021-09-11 CT - abdomen
  • NO evidence of tumor invasion into urinary bladder is found.
  • The urinary bladder is collaped with thick wall. Although no tumor invasion is found in the current study. Cystoscopy is suggested if hematuria persisted.
  • Right lower lobe nodule, in regression.
• 2021-01-26 CT - chest
  • Indication: rectal intramucosal adenocarcinoma, Chest x-ray showed right lung nodule
  • MDCT (256-detectors, GE Revolution, was performed with 0.625 mm collimation & 1.25 mm slice thickness) of the chest without contrast enhancement, coronal and sagittal reformatted images and axial MIP images obtained shows:
    • Lungs:
      • reticular and nodular opacities with architextural distortion in RUl. reticular opacities in anterior RLL.
      • two solid nodules in RLL (up to 9 mm in largest axial dimension) and snother smaller solid nodule in RML.
    • Mediastinum and hila: no enlarged LN or mass.
      • old calcified LNs in the mediastinum and hila, sequela of previous TB infection
    • Vessels: mild coronary arterial calcification
    • Aorta: normal caliber, minimal atherosclerotic change of aortic arch.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: Rt apical pleural thickening.
    • Chest wall: unremarkable.
    • Visible abdominal contents: s/p Rt hepatic posterior segmentectomy.
    • Visualized bones: no lytic or blastic lesion.
  • Impression:
    • three solid nodules in Rt lung, firstly considered metastases.
    • post inflammatory fibrotic change in RUL and anterior RLL.
• 2021-01-25 CXR
  • Interstitial pattern at RUL.
  • A nodule at right middle lung zone.
  • Blunted right costophrenic angle.
• 2021-01-19 Patho - colorectal polyp
  • Rectal tumor, biopsy — Intramucosal adenocarcinoma at least
    
  • Microscopically, the sections show a picture of intramucosal adenocarcinoma at least characterized by tumor arranged in cribriform or villous pattern with subtle stromal reaction.
    
  • Immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
• 2021-01-19 Barium Enema (double contrast)
  • LGI series with water soluble contrast medium revealed:
    • Total occlusion of rectum, about 9cm from anal verge. No further passage of contrast medium even on a 10mins delayed image.
    • Plain pelvis CT was performed for comparison and prooved above description.
  • IMP:
    • c/w rectal mass with total occlusion
    • Suggest oral contrast study if a colo-vesical fistula is suspected clinically.
• 2021-01-19 Colonoscopy
  • Suspected rectal cancer obstruction s/p biopsy
• 2021-01-11 CT - abdomen
  • History and indication: rectal-vesical fistula
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with adjacent fat stranding and regional LAP. Presence of rectal-vesical fistula.
    • S/P right hepatic lobe operation.
    • Some small LNs at retroperitoneum.
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • S/P cholecystectomy.
    • Patency of portal vein.
    • No ascites.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral basal lungs.
    • Degeneration and spondylosis of L-S spine.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIc(Stage_value)

[chemotherapy]

• 2023-04-14 - leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + NS 250mL
• 2021-05-05 - irinotecan 120mg/m2 180mg D5W 250mL 90min
  • betamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO + NS 500mL
• 2021-03-29 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
• 2021-03-24 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
• 2021-03-08 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
• 2021-03-04 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2

[assessment]

• The patient’s serum creatinine has been above 2 mg/dL since 2022Q4 and has not dropped below that level since. The eGFR has been consistently around 30 since 2023.

• On 2023-04-13 the following lab results were obtained: HGB 5.1g/dL, Iron bound Fe 22ug/dL, UIBC 145ug/dL, TIBC 146ug/dL, AST 14U/L, and ALT 13U/L. On 2023-04-14, Ferritin was 545ng/mL and Transferrin was 124ng/mL. There is no evidence of iron deficiency or liver dysfunction. Anemia of chronic disease and/or anemia of inflammation might be possible, as well as nutritionally deficiency. The body weight of 36.5 kg recorded on the TPR panel on 2023-04-13 appears to be too low, which may be an erroneous entry.

701091164

230417

[diagnosis] - 2022-11-25 admission note

• Rectal cancer s/p neoadjuvant concurrent chemoradiotherapy at TP-VGH in 2012, with response of CR, so no OP. Due to near total obstruction on 2018/06, receiving T-colostomy on 2018/06/11 followed by neoadjuvant radiotherapy for 17 doses, then neoadjuvant FOLFOX or CapOx for 3 cycles, subsequently receiving APR on 2018/10/11, and then FOLFOX or CapOx for 9 cycles (to 2019-05) at TSGH in 2018 with lung metastases.
• Malignant neoplasm of colon, unspecified
• Chronic viral hepatitis B without delta-agent
• Chronic kidney disease, stage 5
• Hyperuricemia
• hypertension
• Constipation
• Anemia due to antineoplastic chemotherapy

[past history]

• Hypertension for years with drug control,
• CKD stage 5,
• colorectal cancer s/p operation on 2018 and 2019,
• Right ureteral stricture with hydronephrosis s/p D-J since 2020.
  • 3-6 months to replace the DBJ regularly
  • Last changed right DBJ in June (at TSGH)

[allergy]

• penicillin

[family history]

• Mother had hypertension and diabetes.
• There is no family history of cancer, mental diseases or asthma.

[exam findings]

• 2023-03-21 CT - abdomen
  • WITHOUT contrast enhancement CT of abdomen - whole:
    • S/P colostomy, presence of ventral herniation.
    • Soft tissue tumor in presacral region with urinary bladder wall involvement.
    • Hyperdensity in the urinary bladder.
    • S/P double J catheter drainage, right side.
    • S/P PCN catheter drainage, left side.
    • Presence of gallbladder stones.
    • R/O liver cysts, up to 4.7cm in left lobe.
    • Bilateral lung tumors, stationary.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
  • Impression:
    • S/P colostomy, presence of ventral herniation.
    • Soft tissue tumor in presacral region with urinary bladder wall involvement.
    • Hyperdensity in the urinary bladder, hematoma? or tumor.
    • S/P double J catheter drainage, right side. S/P PCN catheter drainage, left side.
    • GB stone.
    • R/O liver cysts.
    • Bilateral lung tumors, stationary. Suspected lung metastasis.
• 2023-02-14 KUB
  • S/P double J catheter insertion in place, right side.
  • S/P PCN catheter drainage, left side.
  • Lumbar spondylosis.
  • Non-specific bowel gas pattern.
  • Calcifications in the pelvic cavity, could be due to phleboliths.
• 2023-02-13 ECG
  • Normal sinus rhythm
  • Septal infarct, age undetermined
  • Abnormal ECG
• 2023-02-01 Nasopharyngoscopy
  • smooth nasopharynx,oropharynx, hypopharynx
  • pale and boggy inf. turbinate, with clear mucus, erosion wound over inferior turbinate and nasal septum
  • intact ear drum with cerumen, s/p removal
• 2022-10-31, -10-06, -09-22 SONO - kidney
  • Bilateral hydronephrosis
• 2022-10-24, -10-19 CXR
  • Atherosclerotic change of aortic arch
  • Few nodular opacity projecting in both lower lung are noted that are c/w metastases after correlate with CT.
• 2022-10-19 CXR
  • Septal infarct, age undetermined
• 2022-09-20 All-RAS + BRAF mutations assay
  • All-RAS mutations assay
    • Detection range
      • KRAS codon 12, 13, 59, 61, 117, 146
      • NRAS codon 12, 13, 59, 61, 117, 146
    • Results
      • There was no variant detected in the KRAS/NRAS gene.
    • Interpretation
      • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • BRAF mutations assay
    • Detection range
      • BRAF codon 600
    • Results
      • There was no variant detected in the BRAF gene.
    • Interpretation
      • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
• 2022-09-15 PET scan
  • Glucose hypermetabolism in the posterior lower pelvic region, compatible with a metastatic lesion.
  • A glucose hypermetabolic lesion in the lower lobe of left lung, compatible with lung metastasis.
  • Two mild glucose hypermetabolic lesions in the right lung. Metastatic lesions can not be ruled out. Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in the lower portion of the esophagus. The nature is to be determined (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
• 2022-09-14 Tc-99m MDP bone scan
  • Faint hot spots in both rib cages, and increased activity in bilateral pubic bones, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
  • Suspected benign lesions in the mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, and hips.
• 2022-09-14 Bladder Sonography
  • PVR (post-void residual volume) 16.79 ml
• 2022-09-13 PD-L1 (22C3)
  • Combined Positive Score (CPS) category: CPS >= 1 and < 10
  • Combined Positive Score (CPS): 2
• 2022-09-13 PD-L1 (SP142)
  • Result:
    • Tumor Cell Staining Assessment:
      • PD-L1 Expression: Absent (TC = 0%)
    • Tumor Infiltrating Immune Cell Staining Assessment:
      • PD-L1 Expression: 10% Immune cells (IC= 10%)
  • Note:
    • Percent of PD-L1 expression in tumor cells (TC):
      • The percentage of viable tumor cells with membrane positivity at any intensity
    • Percent of PD-L1 expression in immune cells (IC):
      • The percentage of tumor-infiltrating immune cells with discernible staining of any intensity
• 2022-09-13 PD-L1 (IHC)
  • Result:
    • Tumor cell (TC) staining assessment: 0%
    • Combined Positive Score (CPS) assessment: 0.1
• 2022-09-12 CT - abdomen
  • S/P colostomy with incisional hernia and small bowel ileus.
  • Increased soft tissue in pelvic cavity. S/P right side double J catheter insertion. S/P left PCN. Some hematoma in left perirenal region.
  • Lung metastases.
• 2022-09-09 Body fluid cytology - urine
  • DIAGNOSIS: atypia;
    
  • GROSS DESCRIPTION: 15 ml turbid clear
    
  • MICROSCOPIC DESCRIPTION: numerous neutrophils and many atypical urothelial cells present. Further work up, including biopsy or tumor excision, may be considered.
• 2022-09-08 Patho - urinary bladder TUR
  • PATHOLOGIC DIAGNOSIS
    • Urianry bladder, posterior wall, left, TURBT — Adenocarcinoma, enteric type, in favor of colorectal origin
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consists of seven small pieces of gray-brown soft tissue, labeled “bladder tumor, left posterior wall”, measuring up to 0.4 x 0.3 x 0.1 cm. All for sections.
  • MICROSCOPIC EXAMINATION
    • Histologic type: Adenocarcinoma, enteric type, composed of columnar to cuboidal tumor cells, arranged in tubular, papillary and cribriform patterns. Tumor necrosis and neutrophil infiltration are present
    • Histologic grade: Moderately differentiated
    • Tumor configuration: Papillary
    • Muscularis propria: Present
    • Lymphovascular invasion: Not identified
    • Microscopic tumor extension: Tumor invades subepithelial connective tissue
    • IHC: CK7(-), CK20(+), GATA3(-), CDX2(+), and B-catenin (extensive membranous and cytoplasmic expression, only few tumor cells show nuclear staining)
    • Comment: According to histology and immunophenotypes, metastatic colonic adenocarcinoma is most likely
• 2022-09-08 Patho - urinary bladder TUR
  • PATHOLOGIC DIAGNOSIS
    • Prostatic urethra, TURBT — Adenocarcinoma, enteric type, favors metastatic colonic carcinoma
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consists of multiple small pieces of gray-brown soft tissue, labeled “prostatic urethra”, measuring 2.0 x 1.5 x 0.4 cm in aggregate. All for sections.
  • MICROSCOPIC EXAMINATION
    • Histologic type: Adenocarcinoma, enteric type, composed of columnar to cuboidal tumor cells, arragned in tubular, papillary and cribriform patterns. Tumor necrosis and neutrophil infiltration are present
    • Histologic grade: Moderately differentiated
    • Tumor configuration: Papillary
    • Muscularis propria: Present
    • Lymphovascular invasion: Not identified
    • Microscopic tumor extension: Tumor invades muscularis propria
    • IHC: CK7(-), CK20(+), GATA3(-), CDX2(+), and B-catenin(extensive membranous and cytoplasmic expression, only few tumor cells show nuclear staining)
    • Comment: According to histology and immunophenotypes, metastatic colonic adenocarcinoma most likely
• 2022-09-01 SONO - nephrology
  • Bilateral hydronephrosis with hydroureter, mild to moderate degree. (right kidney is more prominent)
  • Right chronic parenchymal renal disease.
  • Double J catheter in situ, right kidney.
  • Urinary retention, suspected neurogenic bladder.
  • Gall bladder stones.
• 2022-09-01 Bronchial Dilator Test
  • normal, FEV1/FVC = 81%, FVC = 93%, FEV1 = 95%
  • without significant reversibility
• 2022-08-26 CT - lung/mediastinum/pleura
  • Findings
    • Chest:
      • Ground glass nodule at posterior segment of right upper lobe up to 0.47cm in largest dimension is found.
      • One spiculated nodule at subpleural space of right middle lobe up to 0.88cm in largest dimension is found. Another lobulated nodule at left lower lobe up to 1.9cm is found. Lung meta is favored.
      • No evidence of bilateral pleural effusion.
      • Calcified coronary arteries is found.
    • Visible abdomen:
      • There is stone at dependent portion of GB. GB stone(s) are noted.
      • Bulging renal tumor at left side up to 2.83cm in largest dimension. Nature?
      • The spleen, liver, pancreas and adrenals are intact.
  • Imp:
    • Right upper lobe ground glass nodule, suggest follow up.
    • Right middle lobe and left lower lobe nodules, lung meta is favored.
    • Left renal tumor.
• 2022-08-25 CXR
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • Subtle nodular opacity over Lt retrocardiac lower lobe

[consultation]

• 2022-09-13 Colorectal Surgery
  • Q
    • For Ventral hernia with intestines herniation and ileus
    • Colon cancer s/p operation on 2018 and 2019 at Tri-Service General Hospital (APR and hemicolectomy?)
    • Abdomen CT (20220912) showed parastomal hernia and lung metastases.
    • The patient is a case of bilateral hydronephrosis, was admitted for surgery of URS.
    • At admission, he accepted antibiotics with flumarin therapy due to urine culture (2022-09-01) showed Klebsiella pneumoniae. Preoperative evaluation and examination were done. Anemia (HGB: 7.9) was found and BT LPRBC 2U. The same day, PPI was given due to vomiting multiple times also found and the vomit showed coffee. Consultation Nephrology for renal function impairment (BUN 124 mg/dL, Cr 8.52->10.36mg/dL).
    • Post TURBT, Left PCN and right URS on 2022-09-08. After surgery, abdomrn fullness also found and KUB showed focal small bowel ileus. Due to no drainage from the left PCN, antegrade pyelography (2022-09-09) was done and which showed dislodgement of the pigtail over left side; Ventral hernia with intestines herniation is found. Ileus is also noted. Therefore, left PCN re-insertion was done on 20220909.
    • He complained small amount of vomiting per day. Abdomen distention still was noticed. Abdomen CT showed parastomal hernia and lung metastases.
    • We need your help for further evaluation and management. Thanks for you.
  • A
    • O:
      • Abdomen: soft, parastomal hernia(+), no tenderness, no distended or rigidity
      • Colostomy: pass flatus or stool(+)
      • TURBT — Adenocarcinoma, enteric type, in favor of colorectal origin
      • 20220912 CT
        • S/P colostomy with incisional hernia and small bowel ileus.
        • Increased soft tissue in pelvic cavity. S/P right side double J catheter insertion. S/P left PCN. Some hematoma in left perirenal region.
        • Lung metastases.
    • A:
      • Para-stomal hernia, without bowel incarceration or strangulation
      • Favor local recurrence of rectal adenocarcinoma in low pelvic region
    • P:
      • Please check CEA, and arrange PET scan for more cancer evaluation
      • We would like to follow this patient and make decision for further management
• 2022-09-08 Nephrology
  • A
    • S
      • This 66 years old male patient had underlying history of hypertension, CKD stage 5 and colon cancer s/p op and right hydronephrosis s/p DJ since 2020.
      • Consult for renal function impairment
    • O
      • Lab data:
        • Na: 132, K:4.2, albumin: 4.5
        • WBC: 9.49, Hb: 7.9, Plt: 320
        • BUN: 124, cre: 8.52 -> 10.36
      • Renal echo (20220901): bilateral hydronephrosis with hydroureter (DJ in right kidney), distended urinary bladder with urine retention
      • U/O: 652ml under foley
    • Assessment
      • Acute kidney injury on CKD stage 5, suspect post renal with bilateral hydroneophrosis and hydroureter
    • Suggestion
      • Keep Foley patent, record U/O and BW qd.
      • DC exforge, if BP is high, you may add norvasc
      • Give Recormon 500U sc qW for renal anemia
      • Follow up BUN, cre, Na, K, Ca, P, CO2 or VBG
    • Consider HD if refractory hyperkalemia, metabolic acidosis or pulmonary edema is noted.

[chemotherapy]

• 2023-04-17 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
• 2023-03-22 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
• 2023-03-03 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
• 2023-01-16 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
• 2022-12-28 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
• 2022-11-30 - irinotecan 50mg/m2 80mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
• 2022-11-08 - irinotecan 50mg/m2 80mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
• 2022-10-21 - leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI without Iri)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-09-09 - mitomycin-c 30mg/m2 30mg 1hr BI (bladder irrigation)

[assessment]

• The patient’s renal function appears to be declining recently, which should be noted.
  • 2023-04-17 Creatinine 2.59 mg/dL
    
  • 2023-04-06 Creatinine 2.50 mg/dL
    
  • 2023-03-16 Creatinine 2.07 mg/dL
    
  • 2023-04-17 eGFR 26.50
    
  • 2023-04-06 eGFR 27.60
    
  • 2023-03-16 eGFR 34.32
    
  • 2023-04-17 BUN 49 mg/dL
    
  • 2023-04-06 BUN 38 mg/dL
    
  • 2023-03-16 BUN 35 mg/dL
• The patient has undergone 7 blood transfusions since September 2022, and elevated ferritin levels of 596 and 545 ng/mL were observed in the last quarter of 2022. Kentamin (B1, B6, B12) has been administered, and the patient’s MCV, MCH, and MCHC levels are normal as of 2023-04-17, making iron deficiency less likely. It is advised to reassess the patient’s iron storage before determining if iron supplements are necessary. Currently, Foliromin (ferrous sodium citrate) is prescribed.

230322

[assessment]

• This patient has CKD stage IIIb-IV (eGFR 15-44) and has not undergone dialysis. The patient has received 5 blood transfusions since September of last year and 1 in March of this year. Updated lab results from 2023-03-16 show normal MCV, MCH, and MCHC, but a decreased HGB level of 9.7g/dL, suggesting that iron-deficiency anemia is less likely. The patient’s lab history indicates high ferritin levels of 596 and 545 ng/mL in the last quarter of 2022. The current prescription includes Foliromin (ferrous sodium citrate). It is recommended to assess the patient’s iron storage to determine if iron supplementation is necessary.
• In accordance with the current National Health Insurance medication reimbursement regulations, EPO - hu-erythropoietin such as Eprex and Recormon) and darbepoetin alfa (such as Aranesp) can be used for chemotherapy-related anemia in cancer patients with solid tumors who have symptomatic anemia and Hb<8 gm/dL. And the regulation requires that EPO treatment should not be used for cancer patients who are expected to have reasonable and sufficient survival time, including curative and expected adjuvant chemotherapy.

230117

[assessment]

• His blood lab data indicated that his ferritin level increased by over 30% in less than 20 days after taking iron supplements from time to time.

  • 2022-12-13 Ferritin 596.5 ng/mL
    
  • 2022-11-22 Ferritin 454.2 ng/mL

• High ferritin levels suggest an excess of iron or an acute inflammatory reaction in which ferritin is mobilized without excess iron. Ferritin can be used as an indicator of iron overload disorders, such as hemochromatosis or hemosiderosis. Ferritin can increase the liver proinflammatory mediators IL-1b, iNOS, RANTES, IkappaB alpha, and ICAM1. As ferritin is also an acute-phase reactant, it is often elevated in various diseases. A normal C-reactive protein (CRP) can be used to exclude elevated ferritin caused by acute phase reactions. However, our HIS5 does not contain simultaneous data on ferritin levels and CRP levels.

• As the body content of iron (iron burden) increases beyond that needed for normal production of red blood cells, muscle cells, and iron-containing enzymes, the plasma iron-binding protein transferrin becomes saturated, eventually exceeding its capacity and resulting in binding of iron to other proteins and molecules, including albumin, citrate, acetate, and others. This iron is referred to as non-transferrin-bound iron (NTBI); it begins to appear once the transferrin saturation exceeds 35 percent and rises significantly with transferrin saturation above 70 percent. NTBI is taken up by cells that have active uptake mechanisms. This includes parenchymal cells of the liver, heart, and endocrine organs. In these affected organs, excess iron can chemically interact with hydrogen peroxide. These reactive oxygen species in turn can cause tissue damage, inflammation, and fibrosis. The liver, heart, joints, and endocrine organs appear to be especially susceptible.

• By the time clinical findings have developed (hepatic fibrosis, heart failure, cardiac conduction defect), it is likely that significant iron deposition and tissue injury has occurred. Please ensure that the patient’s iron level is checked as needed and monitor any signs of iron overload if iron supplements are continued.

221229

[assessment]

• The lab data indicated that MCV, MCH, MCHC, UIBC were normal; Ferritin was exceeded; Fe (iron bound) and TIBC was low.

  • 2022-12-28 MCV 89.7 fL
    
  • 2022-12-28 MCH 29.2 pg
    
  • 2022-12-28 MCHC 32.5 g/dL
    
  • 2022-12-13 Ferritin 596.5 ng/mL
    
  • 2022-12-13 Fe (Iron-bound) 32 ug/dL
    
  • 2022-12-13 TIBC 189 ug/dL
    
  • 2022-12-13 UIBC 157 ug/dL
    
  • 2022-11-22 Ferritin 454.2 ng/mL
    
  • 2022-11-22 Fe (Iron-bound) 42 ug/dL
    
  • 2022-11-22 TIBC 197 ug/dL
    
  • 2022-11-22 UIBC 155 ug/dL

• Normal MCV, MCH, MCHC may suggest the anemia is less likely to be caused by iron insufficiency. High ferritin may suggest iron overload. Low TIBC can suggest that there is not enough transferrin available to bind to iron, i.e., the patient has high iron level, so most of the transferrin is bound to it, which leaves very little free in his blood. Frequent blood transfusions may cause iron overload.

• It is recommended to hold the Foliromin (ferrous sodium citrate) until the cause of the anemia is confirmed to be iron deficiency.

221128

[assessment]

• 2022-11-22 lab results showed a low serum iron concentration (42 mcg/dL, normal range 60 to 150 mcg/dL), as well as a low transferrin level (TIBC 197 mcg/dL, normal range 300 to 360 mcg/dL), which resulted in a transferrin saturation level of 21% at the lower end of the normal range (20%~45%). In the meantime, ferritin levels increased (545 ng/mL, normal ranges, 30 to 200 mcg/L for women and 30 to 300 mcg/L for men, prior to the planned transfusion).
• Inflammatory conditions in which cytokine production might lead to altered iron trafficking and decreased production of RBCs. The underlying condition could be a chronic kidney disease or a malignancy.
• Upon discovery of a serum ferritin level exceeding 1000 mcg/L, a daily dose of 14mg/kg of Jadenu (deferasirox, available at this hospital) with regular serum creatinine monitoring might also be an optional add-on.

221109

[assessment]

• Insufficient renal function, 2022-11-02 serum Cre was 2.42mg/dL, BUN was 34mg/dL, and eGFR was 28.66. The active prescription has been well-adjusted to reflect the patient’s renal function.
• The patient is being administered irinotecan (at a lower dose of 50mg/m2) for the first time. Irinotecan can cause early and late forms of diarrhea. Early diarrhea may be accompanied by cholinergic symptoms which has been dealed with prescribed subcutaneous premedication atropine. In the event of late diarrhea, loperamide should be administered as soon as possible. Please monitor the patient for signs of diarrhea.

221020

[assessment]

• This is a patient with rectal cancer who underwent an abdominoperineal resection and a T-colostomy and treated with FOLFOX/CapeOx at Tri-Service General Hospital in 2018.
• 2022-09-20 All-RAS and BRAF assay showed no detected variant in the KRAS/NRAS/BRAF gene. Treatment with anti-EGFR antibodies might be beneficial. The use of encorafenib would not be preferred.
• The level of PD-L1 expression was low (outsourced lab results in late Sep 2022). This might limit the use of immunotherapy methods that involve PD-L1.
• FOLFOX/CapeOx has previously been used, so FOLFIRI (+ bevacizumab or + cetuximab or panitumumab) might be considered as a possible treatment option.
• Neither fluorouracil nor leucovorin nor irinotecan dosage adjustments are provided in the manufacturer’s labeling for the FOLFIRI regimen in patients with impaired kidney function (2022-10-20 Cre 2.54 mg/dL, eGFR 27.10).

701447197

230417

[diagnosis] - 2023-04-06 admission note

• Infectious gastroenteritis and colitis, unspecified
• Diffuse large B-cell lymphoma, lymph nodes of multiple sites
• Cardiomegaly
• Diffuse large B-cell lymphoma, extranodal and solid organ sites
• Diffuse large B-cell lymphoma, spleen
• Hypertensive heart disease without heart failure
• Chronic viral hepatitis B without delta-agent

[past history] - 2023-04-06 admission note

• Hypertension for 15 years with drug control
• Hyperlipidemia for 15 years
• Gout for 15 years        
• COVID-19 positive on 2022/10    
• Stomach diffuse large B cell lymphoma with multiple metastasis (bilateral lungs, spleen, both kidneys) , Lugano stage IV, IPI score2 s/p chemotheraphy
• Multiple myeloma, IgG kappa type, ISS stage II            

[allergy]

• Mobic 7.5mg/tab (meloxicam): skin rash

[family history]

• No known congenital or systemic disease.
• Family history is unremarkable.
• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.  

[exam findings]

• 2023-04-06 CXR
  • Ground glass opacity in RLL.
  • Cardiomegaly.
• 2023-03-28 PET
  • The FDG PET findings are compatible with lymphoma in bilateral pulmonary hilar and mediastinal lymph nodes, bilateral lungs, spleen and bone marrow (stage IV). However, in comparison with the previous study on 2022/08/17, the previous glucose hypermetabolic lesions are either less evident or disappeared, suggesting partial response to the therapy.
  • Increased FDG accumulation in bilateral renal pelvis. Physiological FDG accumulation is more likely.
• 2023-03-27 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • There are few nodular opacities projecting in both lung. Please correlate with CT.
  • Enlargement of cardiac silhouette.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-03-17 CT - chest
  • Indication:
    • Triple cancer, synchronous (lymphoma, myeloma, bladder ca)
    • Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugan 0 stage IV, IPI 2.2: Multiple myeloma, IgG kappa type, ISS stage II
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Diffuse nodular lesiona are found at bilateral lung fields (n>10). In comparison with CT dated on 2022-12-05, the numbers are decreased.
      • Small lymph nodes are found at right paratracheal and AP window.
      • Patent airway is found.
      • Mild bilateral pleural effusion is found.
      • S/p port-A placement with its tip at Superior vena cava.
    • Visible abdomen:
      • Bilateral renal cysts are found.
      • Low density lesion at spleen is found. Stable.
      • The spleen, liver, pancreas and adrenals are intact.
  • IMp:
    • Bilateral lung nodules, decresaed in numbers
    • Mediastinal small lymph nodes
• 2023-02-19, -02-03, -01-19, -01-06 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • There are few nodular opacities projecting in both lung that may be lymphoma. Please correlate with CT.
  • Enlargement of cardiac silhouette.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-01-06 ECG
  • Atrial fibrillation
  • Inferior infarct, age undetermined
  • Abnormal ECG
• 2022-12-28 Patho - urinary bladder TUR
  • Urinary bladder, left lateral wall, TUR-BT — Urothelial carcinoma (high grade), focally invading muscularis prorpia.
  • Section of the larger piece and the smaller piece show urothelial carcinoma composed of papillary structures lined by urothelial cells with enlarged, hyperchromatic nuclei, high N/C ratio and mitoses. The larger piece shows focal invasion of muscularis propria. The smaller piece shows no muscularis propria.
  • IHC stains: GATA-3 (+), SMA highlight muscularis propria in the larger tissue. The smaller tissue shows no muscularis propria.
• 2022-12-27 ECG
  • Atrial flutter with variable A-V block
  • Possible Inferior infarct , age undetermined
• 2022-12-27 CXR
  • Fibrotic infiltrates in right upper lung.
  • Consolidation in right lower lung.
  • Blunting of costophrenic angle, left side, could be due to pleural effusion.
  • Cardiomegaly.
  • Intimal calcification of thoracic aorta.
• 2022-12-05 CT - abdomen
  • Stomach diffuse large B cell lymphoma with multiple metastasis (bilateral lungs, spleen, both kidneys), Lugano stage IV, IPI 2
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Abdominal CT with and without enhancement revealed:
    • Bilateral renal cysts are found.
    • The liver, pancreas and adrenals are intact.
    • Irregular shaped low density change at spleen up to 3.06x2.6cm is found.
    • There is no evidence of paraarotic LAPs.
    • There is no ascites accumulation at abdominal cavity.
    • One filling defect at lateral wall of the bladder base up to 1.2cm in largest dimension. Bladder uroepithelial cancer is considered. In comparison with CT dated on 2022-08-31,
    • The GB is well distended without soft tissue lesion
    • Small lymph nodes are found at paraaortic region. In regression.
    • Visible chest
      • Cardiomegaly is noted.
      • Nodular leisons at both lungs is found. In regression.
      • Increased pulmonary vasculature is found.
      • NOn-specific lymph nodes are found in the mediastinum.
  • Imp:
    • Mediastinal lymphadenopathy and splenic and lung involvement. The lung involvement regressed.
    • Bladder tumor, suspected uroepithelial cancer.
  • Imaging Report Form for Urinary Bladder Carcinoma
    • Impression (Imaging stage) : T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2022-12-27, -11-25, -11-18 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • There are multiple nodular opacity projecting in both lung that may be lymphoma. Please correlate with CT.
  • Enlargement of cardiac silhouette.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • Otherwise, there is no significant abnormality of the chest. (Note that ground-glass lesion, small nodule or retrocardiac lesion might be missed on plain chest radiography.)
• 2022-10-26 CXR
  • Cardiomegaly.
  • Multiple nodules at bil. lungs.
• 2022-10-26 Panendoscopy
  • Diagnosis
    • Gastric ulcers, multiple, antrum, low and mid body
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
  • Suggestion
    • please search for other possible bleeder.
• 2022-10-21, -10-11, -09-14 CXR
  • There are multiple nodular opacity projecting in both lung that may be lymphoma. Please correlate with CT.
  • Enlargement of cardiac silhouette.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
• 2022-09-28 Panendoscopy
  • Diagnosis
    • Gastric ulcers, Forrest classification type IIa, GC site of middle body, s/p hemostasis with APC
    • Gastric ulcers, multiple, GC/PW site of antrum, AW site of low body and middle body
    • Reflux esophagitis LA Classification grade A
    • Esophageal hematoma, EG junction, suspect NG tube friction related
    • Superficial gastritis
  • Suggestion
    • High dose PPI use
    • Consider second-look endoscopy if ACITVE BLEEDING sign or PERESISTED Tarry stool.
• 2022-08-31 CT - abdomen
  • Findings
    • There are bilateral inguinal hernia with small bowel and omentum fat herniation on right side and omenum fat on left side.
      • In addition, fatty stranding and fluid collection in right inguinal hernia sac is suspected that may be incaceration? please correlate with clinical condition.
    • There are multiple soft tissue lesions on both lung that may be lymphoma?
    • There is a low density mass measuring 4.5 cm in the spleen that may be lymphoma involvement.
    • There are multiple enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space that may be lymphoma.
    • There is a soft tissue mass measuring 2 cm in left lateral wall of the urinary bladder. Please correlate with cystoscopy to R/O lymphoma or urothelial cell carcinoma?
    • There are several renal cysts on both kidney and the largest one measuring 4.3 cm in size at right upper pole.
  • Imp
    • Incaceration of right inguinal hernia is highly suspected.
• 2022-08-28 CXR
  • There are multiple nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
  • Enlargement of cardiac silhouette.
• 2022-08-25 SONO - nephrology
  • There are two mass lesions 2.34cm and 1.51cm in the lateral and inferior wall of urinary bladder, suspected bladder tumors.
  • Bilateral renal cysts.
  • Parenchymal renal disease.
• 2022-08-18 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with plasma cell myeloma and free from lymphoma involvement
  • Microscopic Examination
    • Hypercellularity of bone marrow for his age
    • Marked Increased plasma cells, more than 90%, highlights by CD138 and CD117 IHC stains and favor kappa light chain restriction
    • M/E ratio about 1/3 with marked hypoplasia of both series highlights by CD71 and MPO IHC
    • Adequate megakaryocytes with focal mononucleation and hyposegmentation, highlights by CD61 IHC
    • no increase of blast, highlights by CD34 IHC
    • No B-cell lymphoma involvement, CD20 IHC shows scant and scatter positive
    • According to all above histopathologic findings, it is compatible with plasma cell myeloma and free from lymphoma involvement. Clinical and laboratory correlation is advised.
• 2022-08-17 Whole body PET scan
  • Glucose hypermetabolic lesions in bilateral pulmonary hilar and mediastinal lymph nodes, lymph nodes in the upper to mid-abdomen, a lymph node in the lateral aspect of the left upper thigh region, bilateral lungs, stomach, spleen, and both kidneys (Deauville score 5 in all above-mentioned lesions), highly suspected lymphoma with diffuse involvement of more extralymphatic organs with associated lymph node involvement.
    
  • Glucose hypermetabolism in the L2 spine (Deauville score 4) and in the right lobe of the thyroid gland (Deauville score 5), the nature is to be determined, suggesting further investigation.
  • Lymphoma, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2022-08-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 39) / 126 = 69.05%
    • M-mode (Teichholz) = 69
  • Mild septal hypertrophy with Gr II LV diastolic dysfunction and impaired RV relaxation; severely dilated LA.
  • Mildly dilated LV with normal LV and RV systolic function.
  • Dilated aortic root and aortic valve sclerosis with moderate AR; mild MR; mild to moderate PR.
  • Dilated proximal ascending aorta (46mm) with mild calcification.
• 2022-08-15 CXR
  • Nodular lesions in both lung fields

[consultation]

• 2022-09-27 Gastroenterology
  • Q
    • vomiting blood and bloody stool today
    • genrenal weakness was noted
    • no dizziness, no dyspnea, no abdominal pain
    • PH: Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys) , Lugona stage IV, IPI 2, anemia, Gastric ulcer, HTN
    • NKA
  • A
    • S
      • 71M
      • Phx: Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2, anemia, Gastric ulcer, HTN
      • CC: Vomiting blood and bloody stool today
      • NPO: 20220927 12:00
    • O
      • BP: 103/62, HR:81, Conscious clear, under N/C, SpO2: 100
      • Hb: 7(9/26)-> 6.3(9/27)
      • PLT: 136(9/27)
      • INR:1.27
    • A
      • Hematemesis, suspect upper GI bleeding
    • P
      • EGD is indicated for this patient, but NPO duration is not adequate, give high dose PPI first. We will arrange EGD tomorrow
      • well inform-consent to the patient and the family, including the indication, the risks (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, etc.), and the alternatives (conservative treatment, etc.)
      • if the patient and the family all understand the EGD intervention, would take the risk, and sign the permit for EGD, we would arrange EGD
      • Arrange adequate blood transfusion and fluid resuscitation for fear of hypovolemic shock
• 2022-09-21 Urology
  • Q
    • The 71 y/o man has Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2 and multiple myeloma.
    • Due to bladder tumor noted and sometimes has hernia bulge, so we need your help for assessment. Thanks!
  • A
    • This patient has diffuse large B cell lymphoma and multiple myeloma.
    • This time he was admitted for 2nd R-COP chemotherapy.
    • CT: 2cm bladder tumor at left lateral; hernia: 20220831 incarceration, GS was consulted and manual reduction was performed
    • impression: 1. bladder tumor 2. right inguinal hernia suspected incarceration
    • Plan:
      • arrange scrotal echo for suspected incarceration
      • arrange TURBT and hernia repair, time to be determined
• 2022-09-21 Rheumatology
  • Q
    • The 71 y/o man has Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
    • Due to gouty arthritis over left knee, so we need your help for assessment. Thanks!
  • A
    • S
      • History review & physical examination were performed. Patient was admitted due to Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
      • I was consulted for Acute L’t knee arthritis. Meanwhile, allergic skin rash was also noted (mobic or uricon-induced?).
    • O
      • RIA condition:
        • Previous GA Hx(+)
        • UA:4.5 -> 7.6 -> 4.7
        • ANA/RF/anti-CCP(-)
        • ALT/Cre:25/0.87
      • erythematous swelling, L’t knee (less effusion than week ago).
    • Suggestion:
      • Treatment as current your expert’s management.
      • Please take L’t knee x-ray, add colchicine 1#BID (if diarrhea, taper to 1#QD), acetaminophen 1#BID & decan 4mg IVD BID x 2-3 days.
      • When recovered from acute stage, please keep colchicine 1#QD & feburic 1#QD.
      • Inform me again if need.

[SOAP]

• 2022-10-11 Hemato-Oncology
  • Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 20220905
    • IgG type MM stage 2
    • Diffuse large B cell lymphoma with lung involved stage 4
    • use R-COP first
• 2022-10-04 Hemato-Oncology
  • Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 20230213
    • Hold off on chemotherapy mR-CHOP for now,
    • First complete bladder cancer CCRT.
  • Multidisciplinary Cancer Team Meeting Conclusion> Meeting Date, 20220912
    • Synchronous DLBCL and myeloma treatment approach cannot wait due to stage 4 diffuse large B cell lymphoma, so R-COP has been used. Treatment strategy will be determined after review.
• 2022-09-09 Hemato-Oncology
  • Multi-disciplinary team meeting conclusion for cancer patients, Meeting date: 20220829
    • Diffuse large B cell lymphoma stage 4
    • Multiple myeloma IgG kappa ISS stage 2
    • Bladder tumor nature
  • Assessment
    • Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
    • Multiple myeloma, IgG kappa type, ISS stage II
    • Gastrointestinal hemorrhage, unspecified
    • Anemia
    • Postive of anti-HBc
    • Port-a implement on 2022/08/18
    • Dilated aortic root and aortic valve sclerosis with moderate AR; mild MR; mild to moderate PR.
    • Agranulocytosis secondary to cancer chemotherapy
    • Neutropenic fever
    • Acinetobacter pittii bacteremia
    • Gouty arthritis attack over left knee
    • Groin Hernia
    • Bladder tumor natrure?

[surgical operation]

• 2022-12-28
  • Surgery
    • Laparoscopic hernia repair, bilateral
    • Laser TUR-BT
  • Finding
    • TEP OP Finding:
      • Main defect:
        • Right
        • type: primary; M, L
        • Size: II
        • Grading: 2
        • incarceration, adhesion
        • Sac contents: omentum
      • Contralateral occult defect:
        • type: M
        • Size: II
      • Trocar number: 3
      • TEP approach
      • Mesh type: heavy weight
      • Mesh size: Left 13x15 cm; Right 12x15 cm
      • Mesh fixation: absorbatack
  • TUR-BT finding:
    • A cauliflower-like tumor at left lateral wall
    • A diverticulum at right posterior wall
    • Bilateral UO with clear efflux
  • Risk evaluation:
    • Tumor size: <=3cm (V), >3cm()
    • Multifocality: Multifocal(), solitary(V)
    • Recurrence within 1 year: Yes(), No(V)

[chemoimmunotherapy]

• 2023-03-30 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr D2 (R-GemOx)

  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2

• 2023-02-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2

• 2023-01-27 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2

• 2023-01-13 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

• 2023-01-06 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

• 2022-12-29 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

• 2022-12-05 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2

• 2022-11-14 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2

• 2022-10-13 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2

• 2022-09-22 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2

• 2022-08-19 - rituximab 375mg/m2 630mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)

  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2

[assessment]

• Tramadol has been associated with vomiting (5% to 10%). ref: UpToDate.

• Opioid administration can induce nausea or vomiting; the pathophysiology includes peripheral inhibitory effects of opioids on gastrointestinal transit or stimulation of the pyloric sphincter, delaying gastric emptying or causing gastroparesis. However, the primary mechanism of opioid-induced nausea and vomiting is central, with direct stimulation of the chemoreceptor trigger zone in the area postrema in the floor of the fourth ventricle. The clinical efficacy of 5-HT3 antagonists in opioid-induced emesis supports the hypothesis that stimulation of the area postrema may also be relevant to morphine-induced emesis in humans. The addition of a prokinetic (e.g., metoclopramide), prochlorperazine, or a 5-HT3 antagonist (-setron) to the opiate regimen is beneficial. ref: Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017;15(9):1338-1349. doi:10.1016/j.cgh.2017.05.014

• Roumin (prochlorperazine maleate) has been prescribed properly. There is no medication reconciliation issue with the active prescription.

230407

[assessment]

• On both 2023-01-06 and 2022-12-27, the patient’s ECG showed atrial fibrillation (AF), which is a significant contributor to morbidity and mortality in adults. Additionally, a transthoracic echocardiogram from 2022-08-16 indicated severe dilation of the left atrium. While ischemic stroke resulting from embolization of left atrial thrombi is the most common manifestation of embolization, embolization to other sites in the systemic circulation (as well as the pulmonary circulation from right atrial thrombi) can also occur, albeit less frequently recognized.
• The patient’s available PLT count data in 2023 ranged from 70K to 245K /uL, touching the upper limit of grade 2 thrombocytopenia (CTCAE v5.0, grade 2: 50K~75K/uL) a few times. Due to the unstable PLT count, LMWH may be preferred over direct oral anticoagulants (DOACs). ref: EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer. Hemasphere. 2022;6(8):e750. Published 2022 Jul 13. doi:10.1097/HS9.0000000000000750

221027

[assessment]

• Severe, including fatal, mucocutaneous reactions can occur in patients receiving rituximab products. Unless there is no concern for gastrointestinal bleeding, it is recommended to hold R-CHOP therapy for a period of time.

701473049

230417

[diagnosis] - 2023-04-14 admission note

• T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB s/p chemotherapy with FOLFIRI from 2023/03/29~
• Anemia due to antineoplastic chemotherapy
• Chronic obstructive pulmonary disease, unspecified
• Essential (primary) hypertension
• Constipation, unspecified
• Hypokalemia

[past history]

• Hypertension for 10 years without control

[allergy]

• NKDA     

[family history]

• Mother with HTN
• There is no family history of cancer, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-03-27 CXR
  • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
  • Borderline cardiomegaly
• 2023-03-25 CT - abdomen
  • History and indication: T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of A-colon with adjacent fat stranding and regional LAP.
    • Multiple lung tumors.
    • Multple bony metastases.
    • R/O left renal angiomyolipoma (1.0cm).
    • Normal appearance of liver, spleen, pancreas, adrenals.
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
• 2023-03-24 Patho - colorectal polyp
  • Colon tumor, T-colon, biopsy — Compatible with adenocarcinoma, see description
  • Microscopically, the sections show a picture of almost benign colonic mucosa with scant tumor cells arranged in glandular pattern and desmoplasia. According to clinical information and histopathologic fiinding, it is compatible with adenocarcinoma.
• 2023-03-23 Colonoscopy
  • Suspected T-colon cancer with partial obstruction s/p biopsy
• 2023-03-08 Patho - lung transbronchial biopsy
  • Lung, ? side, CT-guide biopsy — in favor of metastatic adenocarcinoma from colorectal origin
  • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma with marked tumor necrosis.
  • The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-). The results are in favor of metastatic adenocarcinoma from colorectal origin. Please correlate with the clinical presentation and image study.
• 2023-03-07 Whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the skull, multiple T- and L-spines, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, bilaterla S-I joints and left humerus.
  • IMPRESSION: The scintigraphic findings suggest multiple bone metastases.
• 2023-03-07 CT - chest
  • Indication: lung ca
  • MDCT (128-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Lungs: a large tumor lesion (60 mm in longest dimension, polylobular borders) over lingula.
      • numerous randomly distributed pulmonary nodules/masses of varying sizes in both lungs due to metastases.
      • centrilobular nodular and branching opacities at LUL.
    • Mediastinum and hila: enlarged LNs in the visceral space and left anterior prevascular space and Lt hilum
    • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: dilated LA and concentric LVH. mild calcified mitral annulus
    • Pleura: small Rt-sided effusion with thickening.
    • Chest wall and visible lower neck: infiltrative soft-tissue mass at Rt middle posterior chest wall with destruction pof 8th rib and adjacent vertebra.
    • Visible abdominal contents: mild dilatation of CHD and CBD as well as Lt IHDs.
      • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
      • bilateral commonl iliac arteries.
  • Impression:
    • lingula ca T4N3M1a
• 2023-03-06 ECG
  • Normal sinus rhythm
  • Voltage criteria for left ventricular hypertrophy
  • Abnormal ECG
• 2023-03-05 CXR
  • Presence of multiple lung nodules/masses.

[consultation]

• 2023-03-29 Radiation Oncology
  • Q
    • This 71-year-old man patient is a case of T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB. Lower back pain developed with whole body bone scan on 2023/03/07 showede skull, multiple T- and L-spines, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, bilaterla S-I joints and left humerus multiple bone metastases. Now, for evaluate palliative radiotherapy to bone metastasis of pain control. Thank you.
  • A
    • Palliative RT is indicated. CT-simulation will be arranged on 20230406, or earlier if there is an earlier vacancy.
    • Plan to deliver 30 Gy/ 10 fx to the L-spine and pelvic bone mets. Thank you very much.

[SOAP]

• 2023-04-02 Emergency
  • S: the patient started to diarrhea for 1 week (5 to 6 times per day) just after discharged on 20230401.
  • prescription: Smecta (dioctahedral smectite) 3mg/pk PRNQ8H for 3 days
• 2023-03-23 Hemato-Oncology
  • O: Will on FOLFIRI with or without targeted therapy
  • P: Admission for Pelvis MRI, T spine MRI and L-S MRI and Consult RTO, Consult CS or Port-A. Then FOLFOX

[radiotherapy]

[chemotherapy]

• 2023-04-14 - irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + atropine 0.5mg IVD + aprepitant 125mg PO D1-3
• 2023-03-29 - irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3

2023-04-17

[assessment]

• The patient experienced diarrhea (5 to 6 times per day) immediately after discharge on 2023-04-01. Both Smecta (dioctahedral smectite) and Through (sennoside) are currently prescribed. It is suggested to confirm the patient’s bowel movement status and determine if both medications are necessary.
• Irinotecan was increased from 120 mg to 150 mg/m2 in this second dose of the FOLFIRI regimen.
• Hypokalemia (2.9 mmol/L) was noted on 2023-04-14 and is currently being treated with oral potassium chloride supplementation.
• Anemia was noted prior to the patient’s first dose of FOLFIRI on 2023-03-29. A packed red blood cell (P-RBC) transfusion of 2 units was performed on 2023-04-14.
  • 2023-04-14 HGB 8.0 g/dL
    
  • 2023-04-02 HGB 8.9 g/dL
    
  • 2023-03-23 HGB 9.6 g/dL
• There is no medication reconciliation issue with the active prescription.

2023-03-29

[assessment]

• The patient is a senior with T-colon cancer, partial obstruction, lung and bone metastases, T4N3M1b, stage IVB. He admitted for his first cycle of FOLFIRI with a 2/3 dose of irinotecan (this time 120mg/m2, standard 180mg/m2).
• Lab results on 2023-03-23 revealed a WBC count of 17K/uL, but no CRP or procalcitonin data were available. Please rule out any infectious symptoms.
• The patient has a history of uncontrolled hypertension for 10 years, which requires further follow-up.

701473874

230414

[diagnosis] - 2023-04-07 admission note

• Pancreatic head cancer with gastric and common bile duct involvement with gastric outlet obstruction and liver metastasis , cT4N1M1 stage IV; status post Roux-en-Y hepatico-Jejunosotmy and gastro-Jejunosotmy bypass and cholecsytectomy on 2023/03/27. ECOG:1
• Encounter for adjustment and management of vascular access device with port-A insertion on 2023/04/06
• Pancreatic head tumor with gastric and common bile duct involvement with gastric outlet obstruction and obstructive jaundice status post Percutaneous Transhepatic Cholangial Drainage on 2023/03/11
• Hypokalemia
• Rheumatoid arthritis history

[exam findings]

• 2023-04-12 KUB
  • known s/p Roux-en-Y hepatico-Jejunosotmy and gastro-jejunostomy bypass and cholecsytectomy.
  • increased air in nondistended loops of small bowel over lower abdomen and pelvic
• 2023-03-27 Patho - gallbladder (benign lesion)
  • Gallbladder, laparoscopic cholecystectomy — Chronic cholecystitis
• 2023-03-16 Patho - pancreas biopsy
  • Labeled as “stomach pyloric wall thickening”, fine needle biopsy (B) — adenocarcinoma.
  • IHC stains: CK 19 (+), CA19-9 (+), CDX-2 (+), CK7 (+), CK20 (-). in favor of pancreato-biliary origin.
• 2023-03-15 Endoscopic Ultrasonography, EUS
  • susp. Pancreatic IPMN main duct type s/p EUS/FNB (A)
  • Prob. gastric pyloric invasion s/p FNB (B)
  • pancreatic cystic neoplasm, tail susp. MCN type
  • Ascites, minimal
  • lymphadenopathy
• 2023-03-10 ECG
  • Normal sinus rhythm
  • T wave abnormality, consider inferior ischemia
  • T wave abnormality, consider anterolateral ischemia
  • Prolonged QT
  • Abnormal ECG
• 2023-03-10 CT - abdomen
  • CC:
    • Mild epigastralgia for 4 days, took medication for ulcer but jaundice noted 2 weeks, Tea color urine, clay color stool, Skin itching
    • No significant poor appetite. mild weight loss.
    • on diet, Alcohol (-) smoking (+). family hepatitis B or C history but she receive hepatitis B vaccination before.
    • PH. RA
  • Occupation: Mount Temple Services
  • Indication: biliary obstruction related jaundice was suspected.
  • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is marked dilatation of IHDs and CHD, but small size of the gallbladder.
      • Cholangiocarcinoma at the CHD-CBD junction is highly suspected.
      • The differential diagnosis includes metastatic nodes in hepatoduodenal ligament and pancreatic head cancer.
    • There is symmetrical wall thickening at the gastric antrum, causing marked distension of the proximal stomach that is c/w gastric outlet obstruction.
      • The differential diagnosis includes adenocarcinoma and old ulcer with deformity. Please correlate with gastroscopy.
      • In addition, there is a cystic lesion in the dorsal aspect of the stomach fundus that may be duplication cyst.
    • Several cystic lesions in the pancreatic body and tail are suspected.
      • The differential diagnosis includes pancreatic duct dilatation.
      • Please correlate with MRCP.
    • Others
      • There is no focal abnormality in the spleen & both kidneys.
        
      • There is no evidence of ascites or lymphadenopathy.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • Cholangiocarcinoma at the CHD-CBD junction is highly suspected.
      • The differential diagnosis includes metastatic nodes in hepatoduodenal ligament and pancreatic head cancer.
      • Please correlate with tumor marker, MRCP and ERCP.
    • Stomach cancer at the antrum is highly suspected.
      • Please correlate with gastroscopy.
• 2023-03-11 Percutaneous Transhepatic Cholangial Drainage, PTCD (drainage)
  • Dilatation of the biliary tree (by CT images).
  • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
• 2023-03-10 Esophagogastroduodenoscopy, EGD
  • c/w tumor compression or invasion, posterior wall of antrum
  • Gastric outlet obstruction
  • duodenal ulcer, bulb
  • Possible ulcer at posterior wall of bulb or antrum
• 2023-03-07 SONO - abdomen
  • Diagnosis
    • Suspect distal CBD tumor with biliary tract obstruction
    • Suspect pancresatic body tumor
    • Intra-abdominal cystic lesion, LUQ area
    • Gastric outlet obstruction
  • Suggestion
    • CT and EGD study.

[SOAP]

• 2023-04-12 Hemato-Oncology
  • Refer to ER for treating BTI (Biliary Tract Infection) and then admission -> consider Abraxane (paclitaxel) plus gemcitabine (see [note] section) after infection under control

[surgical operation]

• 2023-03-27
  • Surgery
    • Roux-en-Y hepatico-Jejunosotmy
    • GJbypass
    • cholecsytectomy
  • Finding
    • pancreatic head cancer invasion to pyloric and hepatico-duodunostomt
    • LLS liver mets with gastric anerior wall invasion

[note]

Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) for advanced pancreatic and biliary cancer 2023-04-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F89668

• Cycle length: 4 weeks.
• Regimen
  • Nabpaclitaxel
    • 125 mg/m2 IV
    • Administer undiluted over 30 minutes.
    • Days 1, 8, and 15
  • Gemcitabine
    • 1000 mg/m2 IV
    • Dilute in 250 mL NS (concentration no greater than 40 mg/mL) and administer over 30 to 60 minutes, after nabpaclitaxel.
    • Days 1, 8, and 15

Treatment protocols for pancreatic cancer REGIMENS 2023-04-14 https://www.uptodate.com/contents/treatment-protocols-for-pancreatic-cancer

• Adjuvant setting
  • Adjuvant gemcitabine
  • Adjuvant gemcitabine plus capecitabine
  • Modified FOLFIRINOX
• Locally advanced/metastatic disease
  • Gemcitabine monotherapy
  • Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) (see above for components)
  • Gemcitabine plus capecitabine
  • Gemcitabine plus cisplatin
  • FOLFIRINOX (fluorouracil plus leucovorin, irinotecan, and oxaliplatin)
  • Modified FOLFIRINOX
  • Modified FOLFOX6 (fluorouracil plus leucovorin and oxaliplatin)
  • Liposomal irinotecan and 5-FU for metastatic pancreatic cancer
  • Pembrolizumab monotherapy for microsatellite-unstable (mismatch repair-deficient) advanced cancer

[assessment]

• Brosym (cefoperazone + sulbactam) 4g IVD Q12H has been prescribed fot the patient’s BTI.

• It is considered to use nab-paclitaxel plus gemcitabine to treat the patient after her BTI is controlled. Please ensure that the ANC is >1500/uL and the platelet count is >100K/uL prior to administering the regimen. Sepsis has occurred in patients with or without neutropenia (risk factors are biliary obstruction or presence of a biliary stent). During the treatment, it is recommended to initiate broad-spectrum antibiotics in the presence of fever, even if not neutropenic. Interrupt nabpaclitaxel and gemcitabine until sepsis resolves and, if neutropenic, until neutrophils are at least 1500/uL, then resume at lower doses.

• No medication reconciliation issues were noted for the patient.

700553084

230413

{not completed}

[past history]

• Myelofibrosis grade 1-2 disease in March 2020 with Bokey treatment.
• Hypertension with Norvasc since 2023/03/24 due to headache with neck soreness.

[allergy]

• NKDA

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-04-13, -04-10, -04-06, -04-03, -04-01 CXR
  • hazy areas of increased opacity and reticular opacities with poor defination of vessels over Rt and Lt lungs
• 2023-04-06 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — compatible with essential thrombocythemia with grade 3 myelofibrosis.
  • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are increased in number.
  • IHC stains: CD117: <2%; CD34: <2 %; MPO:50 %, CD61: 25 %; CD71: 25% (of the nucleated cells).
  • Reticulin stain: marked increased amounts of reticulin.
  • Masson-Trichrome stain: marked increased in the amounts of collage fibers.
• 2023-03-30 Bronchoscopy
  • Trachea: mid- and lower-1/3 segments was patent and the mucosa was swelling.
  • Main carina: sharp and movable on deep breathing.
  • Right bronchial trees: swelling and easy touch bleeding with dynamic collapse of lower bronchial orifices
  • Left bronchial trees:mucosa swelling and touch bleeding was found.
• 2023-03-29 CXR
  • Enlargement of cardiac silhouette.
  • Linear infiltration over both lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-03-28 ECG
  • Sinus tachycardia
  • Possible Left atrial enlargement
• 2022-03-31 SONO
  • Findings
    • Increased echogenicity of the liver.
    • Normal appearance of gallbladder without stone.
    • Patency of PV, HVs, IVC and aorta in hepatic portion.
    • Normal appearance of pancreatic head. The other portions of pancreas masked by gastric/ bowel gas.
      
    • Splenomegaly.
    • No evidence of pleural effusion.
    • Normal appearance of kidneys.
  • IMP:
    • Mild fatty liver.
    • Splenomegaly
• 2020-03-05 Patho - bone marrow biopsy
  • Bone marrow, iliac, history of myeloproliferative neoplasm, JAK2 (+), biopsy — see microscopic description.
    
  • IHC stains: CD117: <1%, CD34: <1%, MPO: 20-30%, CD61: 30-40%, CD71: 30-40%.
  • Reticulin stain: mild to moderately increased reticulin fibers;
  • Mason-Trichrome stain: mild increase in collagen fibers.
• 2019-02-12 SONO - spleen
  • Sonography of spleen revealed splenomegaly without nodule.
• 2017-08-10 SONO - abdomen
  • marked splenomegaly

[SOAP]

• 2023-02-24 Hemato-Oncology
  • Bokey (aspirin 100mg) QD
• 2022-09-23 Hemato-Oncology
  • Suggest bone marrow study
  • OPD follow up x 2 months
• 2022-03-23 Hemato-Oncology
  • Neoplasm of uncertain behavior of polycythemia vera [D45]
  • Hepatitis, unspecified [K75.2]
  • IWG-MRT score 1 (intermediate-1)
  • IPSS: 1. anti-JAK2 inhibitor is not reimbursed by NHI (will be paid on 2 or higher) (202003324).
  • A: MPN wtih myelofibrosis
  • recheck abdominal sonogram
• 2021-10-05 Hemato-Oncology
  • A
    • Neoplasm of uncertain behavior of polycythemia vera [D45]
    • Hepatitis, unspecified [K75.2]
• 2017-01-19 Hemato-Oncology
  • O
    • Marked splenomegaly.
    • JAK2 mutation: present.
    • A: Myeloproliferative neoplasms, MPN
  • A
    • Neoplasm of uncertain behavior of polycythemia vera [D45]
    • Essential hypertention, unspecified [I10]
    • Hepatitis, unspecified [K75.2]
    • Gouty arthropathy [M10.00]

[assessment]

• Triazole antifungal agents include voriconazole, posaconazole, itraconazole, and fluconazole. Fluconazole has no activity against Aspergillus spp, and itraconazole has become a second-line agent for aspergillosis. Voriconazole should be included in the antifungal regimen in most patients with invasive aspergillosis

701244841

230413

[diagnosis] - 2023-03-24 admission note

• Malignant neoplasm of duodenum
• Acute duodenal ulcer without hemorrhage or perforation
• Calculus of gallbladder with chronic cholecystitis without obstruction
• Noninfective gastroenteritis and colitis, unspecified
• Benign neoplasm of duodenum

[past history]

Dx history: - Gout - IDA - Alzheimer’s disease - CAD - CVA

Surgery history: - C-spine compression fracture s/p over 10 years ago    

[allergy]

• NKDA     

[family history]

Father: Liver cancer

[lab data]

• 2023-03-15 Anti-HBc Reactive
  
• 2023-03-15 Anti-HBc-Value 7.62 S/CO
  
• 2023-03-15 Anti-HBs 0.30 mIU/mL
  
• 2023-03-15 Anti-HCV Nonreactive
  
• 2023-03-15 Anti-HCV Value 0.26 S/CO
  
• 2023-03-15 HBsAg Reactive
  
• 2023-03-15 HBsAg (Value) 125.62 S/CO
  
• 2022-12-13 RPR/VDRL Reactive-1:2
  • ChatGPT: RPR (Rapid Plasma Reagin) and VDRL (Venereal Disease Research Laboratory) are blood tests used to screen for syphilis, a sexually transmitted infection caused by the bacterium Treponema pallidum. In this context, “reactive 1:2” means that the test has detected the presence of antibodies against syphilis in the blood at a dilution of 1:2, indicating a low level of infection. However, further confirmatory testing is necessary to determine if the individual has an active syphilis infection or if the antibodies detected are from a past infection that has been successfully treated.
• 2022-10-20 RPR/VDRL(CSF) Non-Reactive
  
• 2022-10-06 TPHA Reactive,1:640
  • ChatGPT: A TPHA (Treponema Pallidum Hemagglutination) result of 1:640 is a high titer and indicates a strong reaction to Treponema pallidum, the bacterium that causes syphilis. This can indicate an active syphilis infection, a previous infection that has been treated, or a false positive result. Further testing and evaluation by a healthcare provider is necessary to determine the significance of the result and whether treatment is needed.
• 2022-09-15 RPR/VDRL Reactive-1:4
  • ChatGPT: A reactive RPR/VDRL result of 1:4 indicates a higher level of antibodies against syphilis in the blood compared to a result of 1:2. A higher titer result generally indicates a more active infection, but it can also indicate a past infection that has been successfully treated. Further testing and clinical evaluation are needed to determine the stage and treatment of syphilis.

[exam findings]

• 2023-03-22 Clinical Dementia Rating
  • CDR score: 2
• 2023-03-22 Mini-Mental State Examination
  • MMSE score: 16
• 2023-03-14 EEG
  • This EEG study recorded background continuous diffuse theta rhythm (6-7 Hz) and plenty beta activity with occasional frontal slow waves.
  • No epileptiform discharge.
  • This EEG study suggested mild cortical dysfunction.
  • Please correlate with clinical features.
• 2023-02-17 Patho - small intestine resection for tumor
  • Diagnosis
    • Small intestine, duodenum, second portion, pancreatico-duodenectomy — Adenocarcinoma, moderately differentiated, s/p subtotal gastrectomy with B-II anastomosis
    • Pancreas, head, pancreatico-duodenectomy — Adenocarcinoma, by direct invasion
    • Common bile duct, pancreatico-duodenectomy — Negative for malignancy
    • Lymph node, peri-pancreatic and mesentery, dissection — Adenocarcinoma, metastatic (2/17)
    • Gallbladder, cholecystectomy — Negative for malignancy
    • Lymph node, retroperitoneal, dissection — Negative for malignancy (0/3)
    • AJCC 8th edition: pStage IIIA, pT4N1(if cM0)
      
  • Gross Description:
    • Specimen Type: pancreatico-duodenectomy and cholecystectomy; s/p subtotal gastrectomy with B-II anastomosis
      
    • Specimen and size:
      • Head of pancreas: 4.5 x 4.0 x 2.7 cm, the pancreatic duct is dilated
        
      • Duodenum: 17.0 cm in lenghth
      • Stomach: not received
      • Common bile duct: 6.0 cm in length and 0.8 cm in diameter
      • Gallbladder: 9.2 x 3.8 x 2.0 cm
    • Tumor Site: Duodenum
    • Tumor Size: 5.5 x 5.0 x 4.4 cm with invasion to pancreatic head
      
    • Sections are taken and labeled as: A1: CBD resection margin; A2-3: pancreatic and soft tissue resection margin; A4: distal duodenal resection margin; A5: blind end margin; A6: peritoneal resection margin; A7: superior soft tissue resection margin; A8: inferior soft tissue resection margin; A9: ampulla Vater, CBD and tumor; A10: panreatic dyct; A11-15: tumor; A16-17: lymph node, peripancreatic and mesentery; B: gallbladder; C: lymph node, retroperitoneal.
  • Microscopic Description:
    • Histologic Type: adenocarcinoma
    • Histologic Grade (applies to ductal carcinoma only): G2: Moderately differentiated
    • Tumor Extension: invasion to pancreatic head and retroperitoneal soft tissue
      
    • Margins
      • All margins are uninvolved by invasive carcinoma,
      • Distance of invasive carcinoma from closest margin: 12 mm.
      • Specify: retroperitoneal soft tissue resection margin
      • Blid end resection margin: 1.5 cm
      • distal duodenum resection margin: 12.2 cm
      • CBD resection margin: 3.0 cm
      • Pancreatic resection margin: 1.5 cm
    • Lymphovascular Invasion: Present
    • Perineural Invasion: Present
    • Regional Lymph Nodes: peri-pancreatic and mesentery: 2/17; retroperitoneal: 0/3
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable): not applicable
        • Primary Tumor (pT): pT4: invasion of pancreas
        • Regional Lymph Nodes (pN): pN1: Metastasis in one to two regional lymph nodes
        • Distant Metastasis (pM): if cM0
    • Additional Pathologic Findings: The pancreatic parenchyma reveals atrophy. The pancreatic duct is dilated with low grade pancreatic intraepithelial neoplasia.
• 2023-02-11 MRI - upper abdomen
  • History and indication: Duodenal cancer before surgery
  • With and without contrast MRI of upper abdomen revealed:
    • Motion artifact.
    • Progression of duodenal cancer with adjacent structures invasion causing p-duct dilatation.
    • S/P gastric operation.
    • Distention of gallbladder.
  • IMP:
    • Motion artifact.
    • Progression of duodenal cancer with adjacent structures invasion causing p-duct dilatation.
    • Distention of gallbladder.
• 2023-02-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 21.7) / 81.3 = 73.31%
    • M-mode (Teichholz) = 73.3
  • Conclusion:
    • Normal chamber size
    • Adequate LV and RV systolic function
    • AV sclerosis with mild AR, mild MR, TR and PR
    • No regional wall motion abnormalities
• 2023-02-07 Flow Volume Loop
  • poor performance
  • the family expressed that the patient is physically weak and therefore unable to blow air.
• 2023-02-06 ECG
  • Atrial fibrillation with slow ventricular response
  • Low voltage QRS
  • Left anterior fascicular block
• 2023-12-30 Patho - doudenum biopsy
  • Labeled as “duodenum, second portion”, biopsy — adenocarcinoma.
  • Section shows piece of duodenal tissue with dysplastic and neoplastic glands.
  • IHC stains: CK 19 (+), CK7 (+), CK20 (focal +), CD56 (-), Ki-67: 90%.
• 2022-12-27 CT - abdomen
  • History and indication: Abdominal pain
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Pectus excavatum.
    • S/P gastric operation ?
    • Wall thickening of duodenum, 2nd portion, r/o malignancy.
    • Distention of gallbladder. Dilatation of p-duct.
  • IMP:
    • Wall thickening of duodenum, 2nd portion, suspected malignancy.
    • Distention of gallbladder.
    • Dilatation of p-duct.

[consultation]

• 2023-02-08 Anesthesiology
  • Q
    • This is 72-year-old man with past history of C-spine s/p OP, CAD, Syphilis infection s/p Penicillin IVD x3 on 2022/10-11 (Treatment finished, 2022/12 RPR: reactive [1:2]), Alzheimer’s disease and Gout. The patient was diagnosed duedenal cancer at the end of 2022, and he admitted for operation.
    • The patient was only 50 kg with poor nutrition in recent several months, so we needed TPN to supply the nutrition for him before surgery. He was also TPN supportive care after surgery.
    • The patient had Syphilis infection, and the patient worried about the CVC insertion. We would like to consult your expertise for CVC insertion.
  • A
    • We were consulted for CVC insertion due to peripherally incompatible infusions .
    • The 3-way CVC was inserted into right IJV, fixed at 15 cm, under sonography guidance smoothly.
    • Please arrange portable CXR for CVC position examination.
    • CXR revealed proper position of the CVC.
• 2022-10-19 Metabolism and Endocrinology
  • Q
    • This 71 y/o man has a history of CAD and C-spine s/p. He visited neurology OPD recently for cognitive decline. Laboratory survey showed syphilis infection and hypothyroidism.
    • We need your expertise for hypothyroidism evaluation and management. Thank you very much.
  • A
    • S
      • This 71-year-old male, with past history of CAD and C-spine s/p, was admitted due to cognitive decline, susp. neurosyphilis or hypothyroidism related. We were consulted for abnormal TFT.
    • O:
      • BW: 49
      • HR: 50-68
      • Possible related medication: nil
      • ALT: 15
      • Cr: 0.95
      • Na/K: unavailable
      • TSH/FT4 (nuclear medicine): 18.697/0.748
      • T3: unavailable
      • ATPO: 3.2, ATG: < 0.9
      • ACTH/Cortisol (random, 3-4pm): ?/8.17
      • Thyroid sono: nil
      • ECG: nil
    • A: Primary hypothyroidism
    • Suggestions:
      • Add on thyroxine 50 mcg, 0.5 tablet, QDAC (please take at least 30 minutes before the first meal of the day), and monitor blood pressure, heart rate, electrolytes, and any cardiovascular complications.
      • Recheck TSH/FT4 (routine biochemistry) in 2 weeks (can be done as outpatient if discharged).
      • Arrange for thyroid sonography (radiology) and ECG for bradycardia.
      • Contact us if necessary. Follow-up with the Endocrine Outpatient Department.

[surigcal operation]

• 2023-02-16
  • Surgery
    • pancreatico-duodenectomy with retroperitoneal LN dissection
  • Finding
    • 7.5 x 6 x 4 cm fungating mass was noted at duoenal 2nd portal with pancreastic head invasion
    • no peritoneal seeding was noted
    • previous subtotal gastrectomy with B-II anastomosis

[chemotherapy]

• 2023-04-12 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (FOLFOX, Oxa 65mg/m2)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-03-24 - leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (FOLFOX, Hold Oxalip due to old age and performance status)
  • dexamethasone 4mg + NS 250mL

[assessment]

• The patient has received a reduced dose of 65mg/m2 of oxaliplatin for the first time during this hospitalization, and no adverse reactions have been observed to date.

• For the patient’s chronic viral hepatitis B and post-pancreatico-duodenectomy status, Protase (pancrelipase 280mg) TIDCC and Baraclude (entecavir 0.5mg) QDAC have been prescribed.

• There is no medication reconciliation issue found.

230327

[assessment]

• The patient has been exposed to the hepatitis B virus (HBV) at some point in his life, Baraclude (entecavir) is properly prescribed.
  • 2023-03-15 Anti-HBc Reactive
• A decrease in RPR/VDRL titer from 1:4 to 1:2 may indicate a treatment response to syphilis (Penicillin IVD x3 on 2022/10-11).
  • 2022-12-13 RPR/VDRL Reactive-1:2
    
  • 2022-09-15 RPR/VDRL Reactive-1:4
    
• High levels of thyroid-stimulating hormone (TSH) and normal levels of free thyroxine (T4) may indicate subclinical hypothyroidism. Subclinical hypothyroidism may not cause any symptoms, but it can increase the risk of developing overt hypothyroidism in the future. It can also increase the risk of heart disease. It is recommended to monitor the levels of TSH and T4 further evaluation and management if necessary.
  • 2022-09-19 TSH (nuclear medicine) 18.697 uIU/ml
    
  • 2022-09-19 Free T4 (nuclear medicine) 0.748 ng/dl
    
• On 2023-02-16, the patient underwent a pancreatico-duodenectomy with retroperitoneal lymph node dissection, and started receiving 5-fluorouracil (5FU) infusion on 2023-03-24. It is important to monitor the patient closely for any signs of gastrointestinal adverse reactions, as 5FU infusion may cause such symptoms. Additionally, given the patient’s history of CAD, it is also important to keep a close eye for any potential cardiovascular adverse reactions.

700537283

230412

[exam findings]

• 2023-04-10 CXR
  • Few nodular opacities projecting in the left middle lung are suspected. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • S/P clips projecting at right lower medial lung.
• 2023-02-16 CT (at SYKCC)
  • bil. breast masses
  • skin nodularities
  • bil. supraclavicular, Lt axillary and upper mediastinal lymphadenopathy.
  • liver and lung metasis

[SOAP]

• 2023-03-30 Hemato-Oncology
  • S
    • History of breast ca before but it recurred in Sep 2021 but she did not seek formal medical attentison. She received biopsy at SYKCC where ER positive, PR (+)， Her-2 (3) when multiple tumor over Rt chest wall. Double target therapy was done on 2023-03-07.
    • Swelling over port-A site (infected) (20230330)
    • She came for subsequent treatment.
  • O
    • Reason for not informing patient of her condition: Currently not suitable to inform.

[chemoimmunotherapy]

• 2023-04-11 - docetaxel 35mg/m2 47mg NS 100mL 1hr (docetaxel + herceptin + perjeta)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

700626863

230412

[exam findings]

• 2023-03-20 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — hypercellularity.
  • Section shows piece(s) of bone marrow with 50-60% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with left of leukocytes. Megakaryocytes are adequate in number.
  • IHC stains: CD117: 30-40%; CD34: 30-40 %; MPO: 50-55 %, CD61: 5 %; CD71: 30-35 % (of the nucleated cells). Acute myelogenous leukemia may be considered.

[POMR]

• 2023-04-10 Hemato-Oncology
  • Problem: Acute myeloblastic leukemia, FLT3 and NPM1 Undetectable, 46,XX,t(16;21)(p11.2;q22)[20] karyotype
    • Assessment: Induction chemotherapy with D3A7 was administered on 2023/03/31 - 04/06
    • Plan
      • Insertion on 2023/03/30
      • Induction chemotherapy with D3A7 was administered on 2023/03/31 - 04/06
      • Prophylasix antibiotics with Cravit po from 2023/03/31(D11) and antifungas with Fluconazole 2 tab QD from 2023/03/31(D11)
      • Adequate hydration with N/S 1500ml QD
      • Followed up laboratory test regularly  

[SOAP]

• 2023-03-18 Medical Emergency
  • Menorrhagia for 2 weeks.
  • 2023/03/18 17:24 Blast = 9.8 %;
  • 2023/03/17 17:29 Blast = 5.9 %;
  • preliminary impression: D61.818 Other pancytopenia
    • Pancytopenia, Hb 7.2 to 6.1 to 6.8, blast 5.9% to 9.8%, OA ONC
• 2023-03-17 Hemato-Oncology
  • 33 y female, PH: IDA (iron deficiency anemia)
  • Abnormal hemogram was informed at Taipei Mackey Hospital
  • recheck here: WBC 2540, Hb 6.1, Plt 116k, balst 5.9%
  • Imp: R/O leukemia

[chemotherapy]

• 2023-03-31 - daunorubicin 45mg/m2 70mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 156mg NS 500mL 24hr D1-7 (3+7 daunorubicin/cytarabine Q4W)
  • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1-2 + NS 250mL D1-2

Induction therapy for acute myeloid leukemia in medically-fit adults. 2023-04-10 https://www.uptodate.com/contents/induction-therapy-for-acute-myeloid-leukemia-in-medically-fit-adults

• 7+3 therapy (cytarabine plus anthracycline)
  • The preferred approach for remission induction is a 7-day continuous infusion of cytarabine and anthracycline treatment on days 1 to 3, which is commonly referred to as “7+3 therapy.”
  • For medically fit patients, we suggest treatment as follows:
    • Cytarabine 100 to 200 mg/m2 daily as a continuous infusion for 7 days
    • Daunorubicin 60 to 90 mg/m2 on days 1 to 3 or idarubicin 12 mg/m2 on days 1 to 3
  • Treatment with 7+3 therapy generally achieves a complete remission (CR) rate of 60 to 80 percent for patients <60 to 65 years old. Long-term outcomes are influenced by cytogenetic/molecular features (the following table) and post-remission management.
    • 2017 European LeukemiaNet risk stratification of acute myeloid leukemia by genetics
      • Risk category: Favorable
        • Genetic abnormality
          • t(8;21)(q22;q22.1); RUNX1-RUNX1T1
          • inv(16)(p13.1;q22) or t(16;16)(p13.1;q22); CBFB-MYH11
          • Mutated NPM1 without FLT3-ITD or with FLT3-ITDlow
          • Biallelic mutated CEBPA
      • Risk category: Intermediate
        • Genetic abnormality
          • Mutated NPM1 and FLT3-ITDhigh
          • Wild type NPM1 without FLT3-ITD or with FLT3-ITDlow (without adverse-risk genetic lesions)
          • t(9;11)(p21.3;q23.3); MLLT3-KMT2A
          • Cytogenetic abnormalities not classified as favorable or adverse
      • Risk category: Adverse
        • Genetic abnormality
          • t(6;9)(p23;q34.1); DEK-NUP214
          • t(v;11q23.3); KMT2A rearranged
          • t(9;22)(q34.1;q11.2); BCR-ABL1
          • inv(3)(q21.3q26.2) or t(3;3)(q21.3;q26.2); GATA2,MECOM(EVI1) –5 or del(5q); –7; –17/abn(17p)
          • Complex karyotype, monosomal karyotype
          • Wild type NPM1 and FLT3-ITDhigh
          • Mutated RUNX1
          • Mutated ASXL1
          • Mutated TP53
  • Patients require aggressive intravenous hydration; monitoring for cardiac, renal, and liver dysfunction; blood product support; and surveillance for infections. Treatment with 7+3 therapy generally causes three to five weeks of profound cytopenias and associated risks of life-threatening infections and bleeding. Many patients will experience nausea and vomiting, mucositis/stomatitis, alopecia, and diarrhea. Cytarabine may cause a flu-like syndrome (including fever and/or rash) and daunorubicin can be associated with infusion reactions and cardiac arrhythmias.
  • Bone marrow examination should be performed 14 to 21 days after initiation of therapy to assess the initial response to therapy and determine whether a second induction course is needed.
  • Approximately four to five weeks after the start of therapy, when sufficient time has passed for recovery of normal blood counts, another bone marrow examination is performed to determine whether the patient has achieved remission.
  • Broadly, findings from randomized trials that examined the dose, schedule, and choice of agents have found that outcomes are similar between daunorubicin and idarubicin; higher dose daunorubicin (ie, 60 or 90 mg/m2/d) is more efficacious but not more toxic than lower dose (ie, 45 mg/m2/d) daunorubicin; and, compared with infusional cytarabine, high dose cytarabine (HiDAC) is associated with increased toxicity without an improvement in efficacy.

[follow up]

• Bicytopenia progresses, Cravit (levofloxacin) and FLU-D (fluconazole) are used to manage potential infections.

  • 2023-04-12 WBC 0.21 x10^3/uL
    
  • 2023-04-09 WBC 0.42 x10^3/uL
    
  • 2023-04-12 Neutrophil 5.8 %
    
  • 2023-04-09 Neutrophil 16.5 %
    
  • 2023-04-12 PLT 37 *10^3/uL
    
  • 2023-04-09 PLT 47 *10^3/uL

• No fever in the past 7 days.

• Blast decreased after 7+3 anthracycline plus cytarabine since 2023-03-31.

  • 2023-04-05 Blast 1.0 %
    
  • 2023-04-03 Blast 1.3 %
    
  • 2023-04-02 Blast 7.0 %
    
  • 2023-04-01 Blast 22.9 %
    
  • 2023-03-31 Blast 23.0 %
    
  • 2023-03-28 Blast 12.0 %
    
  • 2023-03-24 Blast 7.0 %
    
  • 2023-03-22 Blast 29.0 %
    
  • 2023-03-21 Blast 17.6 %
    
  • 2023-03-20 Blast 4.0 %
    
  • 2023-03-18 Blast 9.8 %
    
  • 2023-03-17 Blast 5.9 %

230410

[assessment]

• The patient diagnosed with AML was admitted and received the first dose of “3+7 daunorubicin/cytarabine” regimen on 2023-03-31. Lab data showed the development of severe neutropenia following administration of the regimen.

  • 2023-04-09 WBC 0.42 x10^3/uL
    
  • 2023-04-07 WBC 0.92 x10^3/uL
    
  • 2023-04-05 WBC 1.43 x10^3/uL
    
  • 2023-04-03 WBC 1.78 x10^3/uL
    
  • 2023-04-02 WBC 2.64 x10^3/uL
    
  • 2023-04-01 WBC 3.31 x10^3/uL
    
  • 2023-03-31 WBC 3.63 x10^3/uL
    
  • 2023-03-28 WBC 4.49 x10^3/uL
    
  • 2023-04-09 Neutrophil 16.5 %
    
  • 2023-04-07 Neutrophil 55.0 %
    
  • 2023-04-05 Neutrophil 64.0 %
    
  • 2023-04-03 Neutrophil 39.9 %
    
  • 2023-04-02 Neutrophil 75.3 %
    
  • 2023-04-01 Neutrophil 60.0 %
    
  • 2023-03-31 Neutrophil 33.0 %
    
  • 2023-03-28 Neutrophil 50.0 %

• Treatment with the regimen can cause 3 to 5 weeks of profound cytopenias and associated risks of life-threatening infections and bleeding. And cytarabine may cause a flu-like syndrome (including fever and/or rash) and daunorubicin can be associated with infusion reactions and cardiac arrhythmias.

• It is recommended that a bone marrow examination be performed 14 to 21 days after initiation of therapy to assess the initial response to the therapy and to determine if a second induction course is needed.

• Initial response to therapy - A bone marrow examination on day 14 of treatment provides an assessment of the clearance of blast cells and a preview of the response to induction therapy. Findings from the day 14 examination may be classified as follows:

  • Hypoplastic: Bone marrow cellularity <5 to 20 percent and <5 percent blasts
  • Indeterminate: Bone marrow cellularity <5 to 20 percent with >=5 percent blasts
  • Persistent leukemia: Some clearing of leukemia or no response, but cellularity >=20 percent

• Institutions vary in their responses to findings of the day 14 bone marrow examination.

  • For some centers, all medically-fit patients receive a second cycle of the same induction therapy, but those with persistent disease may receive more intensive/alternate treatment (eg, high dose cytarabine [HiDAC] plus mitoxantrone; mitoxantrone, etoposide, and cytarabine [MEC], other regimen.)
  • Other centers use the following approach, guided on the day 14 marrow results:
    • Hypoplastic: Observation for two to four weeks until recovery of blood counts. If pancytopenia persists, then repeat bone marrow biopsy.
    • Indeterminate: Repeat the bone marrow examination one to two weeks later, with subsequent management guided by whether the repeat study demonstrates hypoplasia versus persistent leukemia.
    • Persistent leukemia: Repeat treatment with the regimen, or treat with a more intensive or alternate induction therapy (eg, HiDAC-based therapy, hypomethylating agent plus venetoclax, other regimen).

• Cravit (levofloxacin) and Flu-D (fluconazole) both have been prescribed to prevent or alleviate the patient from infections. There is no problem that is identified with the active recipe.

700040129

230411

{not completed}

[exam findings]

• 2023-04-11 MRI - brain
  • Indication: Right upper lobe lung cancer with mediastinal lymphadenopathy, lung, liver and bone metastasis, cT3N2M1c, stage IVB
  • Findings
    • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • The interhemispheric fissure is centered on the midline.
    • Sella and pituitary are normal. The parasellar structures are unremarkable.
    • There are no abnormalities in the cerebellopontine angle areas on both sides.
    • There are no abnormalities in the calvarium.
      
    • C2 and right C3 metastases/bone destructions.
      
    • Abnormal enhancement after contrast administration of C2-3 bodies were noted.
  • Imp:
    • No brain or skull metastases.
    • C2 and right C3 metastases.
• 2023-04-11 Bronchoscopy
  • Endo-bronchial tumor with partial obstruction at RB3, s/p Cryobiopsy
• 2023-04-07 CT - chest
  • Indication: multiple bone metastasis - from chest to pelvis please,
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Lobulated mass at right upper lobe measuring 3.8cm in largest dimension is found.
      • Lymphadenopathy at right hilar and paratracheal region is found.
      • Mild bilateral pleural effusion is found.
      • One nodular lesion at right lower lobe measuring 0.85cm is found. suspected lung meta.
    • Visible abdomen:
      • Low density lesions are found at both lobes of liver are found. Liver meta is considered.
      • Diffuse wall thickening of the ascending colon is found. suspeted colitis.
      • The urinary bladder is well distended without soft tissue lesion.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
  • Imp:
    • Right upper lobe lung cancer with mediastinal lymphadenopathy, lung meta and liver meta, bone meta. T3N2M1c.
• 2023-04-03 CXR
  • Lung markings: a nodular lesion, about 32mm, in the right upper lung field
• 2023-04-03 ECG
  • Sinus rhythm with occasional Premature ventricular complexes
• 2023-04-03 MRI - c-spine
  • IMP
    • mild retrolisthesis at C4-5 and C5-6
    • r/o multiple bone metastasis with pathological fracture at C2 vertebral body. PLease correlate with contrast-enhanced study.
• 2023-03-31 C-spine AP & Lat
  • Loss of normal lordotic alignment
  • Disc space narrowing and posterior spur at C4-5-6
• 2023-03-14 C-spine flex & ext view
  • mild angulation at the middle C-spine
  • mild anterior and posterior spur formation at the middle and lower C-spine
  • moderate decreased disc spaces in the C4/5 and C5/6 discs

[consultation]

• 2023-04-03 Neurology
  • Q
    • posterior neck pain for a week, no arms numb nor weak.
    • c spine on 20230331:
      • Loss of normal lordotic alignment
      • Disc space narrowing and posterior spur at C4-5-6
  • A
    • S: complained of severe neck pain while axial loading (relieved by lying down)
    • O
      • E4V5M6
      • pupil: 3+/3+
      • MP full
      • no limbs paresthesia
      • MRI: suspected multiple bone metastasis with pathological fracture at C2 vertebral body
    • P
      • since there’s no MP weakness, limbs numbness, no operation is indicated now
      • suggest oncologist consultation and tumor survey

700711453

230411

{not completed}

[exam findings]

• 2023-03-30 Patho - pancreas biopsy
  • Pancreas, EUS FNB — Ductal adenocarcinoma, poorly differentiated
  • The sections show a picture of ductal adenocarcinoma, composed of nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasm arranged in solid and cribriform patterns, embedded in fibrous stroma. Subtle mucin secretion is present.
• 2023-03-30 Patho - liver biopsy needle/wedge
  • Liver, EUS FNB — Adenocarcinoma, consistent with metastatic pancreatic ductal adenocarcinoma.
  • The sections show a picture of adenocarcinoma, composed of liver tissue with nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasma in fibrous stroma. Focal ductal differentiation and mucin secretion are present. The finding is consistent with metastatic pancreatic ductal adenocarcinoma.
• 2023-03-28 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Adenocarcinoma, pancreatobiliary-type, compatible with metastatic pancreatic ductal adenocarcinoma.
  • The sections show a picture of adenocarcinoma, pancreatobiliary-type, moderately differentiated, composed of nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasma in fibrous stroma. Focal ductal differentiation and mucin secretion are present.
  • IHC shows: CK7(+), CA19-9(+), CK20(-), and Hepatocyte(-). The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
• 2023-03-17 CT - abdomen
  • CC: Severe epigastric hunger pain and loss 6 kgs (42 to 36 Kgs) for 2 months.
    • 2023/03/14 Ca 19-9 > 150
  • Past history: Hearing impairment. Uterine myoma.
  • Findings:
    • There is an ill-defined poor enhancing mass measuring 2.6 cm in the pancreatic body-tail junction, causing the upstream pancreatic duct dilatation that is c/w adenocarcinoma.
      • In addition, there is soft tissue lesions in the celiac trunk area with encasement that is c/w tumor invasion (T4).
    • There is an ill-defined poor enhancing mass measuring 3.3 cm in right lobe liver that is c/w metastasis (M1).
      • In addition, there is another poor enhancing lesion 0.8 cm in S4 of the liver. Metastasis is also highly suspected.
    • There are three calcified masses in the pelvis, the largest one 3.3 cm, that are c/w uterine fibroids.
    • The gallbladder shows small size. please correlate with clinical condition.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T4 (T_value) N:N0 (N_value) M:M1 (M_value) STAGE:IV
• 2022-11-09 ENT SONO - head and neck soft tissue
  • Clinical Impression/Intent：right thyroid tumor
  • Sonographic Impression：right thyroid isoechoic tumor, margin clear, with microcalcification
• 2021-02-03 ENT SONO - head and neck soft tissue
  • Clinical Impression/Intent：thyroid nodule?
  • Sonographic Impression：bilateral thyroid nodule
• 2021-01-27 ENT Hearing Test
  • Tymp bil type A
  • ART
    • RE absent
    • LE 1000-4000 Hz reduced thretholds
  • PTA:
    • Reliability FAIR
    • Average RE >120 dB HL, LE 53 dB HL
    • RE profound SNHL
    • LE mild to profound SNHL
• 2018-03-19 Pure Tone Audiometry
  • Reliabilty Fair
  • R’t : >120 dB HL, profound HL
  • L’t : 49 dB HL, mild to severe SNHL

[chemotherapy]

• 2023-04-10 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

[note]

gemcitabine 2023-04-11 https://www.uptodate.com/contents/gemcitabine-drug-information

• Pancreatic cancer, locally advanced or metastatic:
  • IV: Initial:
    • 1,000 mg/m2 over 30 minutes once weekly for 7 weeks followed by 1 week rest; then administer on days 1, 8, and 15 every 28 days or
  • Off-label dosing/combinations: IV:
    • 1,000 mg/m2 days 1, 8, and 15 every 28 days (in combination with paclitaxel [protein bound]) or
    • 1,000 mg/m2 over 30 minutes days 1, 8, and 15 every 28 days (in combination with capecitabine) or
    • 1,000 mg/m2 over 30 minutes weekly for up to 7 weeks followed by 1 week rest; then weekly for 3 weeks out of every 4 weeks (in combination with erlotinib) or
    • 1,000 mg/m2 over 30 minutes days 1 and 15 every 28 days (in combination with cisplatin) or
    • 1,000 mg/m2 infused at 10 mg/m2/minute every 14 days (in combination with oxaliplatin).

700882997

230411

{not completed}

[exam findings]

• 2023-04-03 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Mild plasmacytosis and see description
  • The sections show normocellular marrow (30%). The erythoid precursors are decreased, dispersed, and scattered in CD71 stain. The myeloid cells show good maturation. The CD61+ megakaryocytes are normal in number and morphology. Increased CD138+ mature plasma cells, account for 15% of marrow cells without lambda or kappa light chains restriction. No CD34+ blasts can be found. Suggest further bone marrow smear evaluation and clinic correlation.
• 2023-03-13 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2023-03-10 Patho - colon biopsy
  • Colorectum, ascending colon, s/p biopsy near total removal (A) — Hyperplastic polyp
  • Colorectum, transverse colon, s/p biopsy removal (B) — Hyperplastic polyp
  • Colorectum, descending colon, s/p biopsy removal (C) — Hyperplastic polyp
  • Colorectum, rectum, s/p biopsy removal (D) — Hyperplastic polyp
  • Colorectum, rectum, 5 cm above anal verge, biopsy (E) — Hyperplastic polyp
• 2023-03-08 Patho - doudenum biopsy
  • Duodenum, bulb to second portion, biopsy — mild to moderate lymphocytic infiltration.
  • Section shows piece(s) of bland duodenal tissue with mild to moderate lymphocytic infiltration.
  • IHC stains: CD3 and CD20: no predominant sub-population, in favor of chronic inflammation.
• 2023-03-08 SONO - abdomen
  • Parenchymal liver disease
  • Cholecystopathy
  • Gallbladder polyp
  • Minimal ascites
  • Sus lymphadenopathy, beside panc body
• 2023-03-06 CTA - chest
  • Indication: Fever, unspecified Dizziness and giddiness, Dyspnea, unspecified Anemia, unspecified
  • MDCT (80-detector rows,Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images and coronal slab MIP PA images shows:
    • Lungs: centrilobular emphysema in both upper lobes (moderate Lt, mild RT), and mild subpleural paraseptal emphysema in LUL. dependent linear band subsegmental atelectasis at lower lobes.
    • Mediastinum and hila:
    • Vessels: mild calcified plaques of the LAD coronary artery.
    • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber and well opacification of ascending
    • Heart: normal in size of cardiac chambers.
    • Pleura: mild bilateral effusions.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal contents: hyperplasia of Lt adrenal gland
      • normal appearance of gall bladder. unremarkable of the liver, spleen, Rt adrenal gland, pancreas, and both kidneys. bile ducts: No dilatation.
      • no enlarged lymph node. no ascites.
      • Atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • emphysema in both upper lobes, most severe on Lt smoking related disease. small pleural effusion, transudate.
• 2023-03-06 CXR
  • Thoracic aortic arch calcified atheriosclerotic plaque
• 2022-09-21 Pure Tone Audiometry
  • PTA Reliability FAIR
  • Average RE 30 dB HL; LE 35 dB HL.
  • R’t normal to moderately severe SNHL. (BC masking dilemma at 4k Hz)
  • L’t normal to moderately severe SNHL with ABG at 4k Hz.
• 2022-03-09 ENT Hearing Test
  • Tymp:
    • R’t type Ad; L’t type A.
  • ART:
    • R’t absent.
    • L’t absent except ipsi 500 Hz.
  • PTA
    • Reliability FAIR
    • Average RE 21 dB HL; LE 26 dB HL.
    • R’t normal to moderate SNHL.
    • L’t normal to moderately severe SNHL.

[consultation]

• 2023-03-13 Hemato-Oncology
  • Q
    • For anemia and thrombocytopenia
    • This 72-year-old male has past history of Hypertension and Af under medication control at West Garden Hospital. According to his statment, intermittent shortness of breath for 2 weeks ago, accompanied with productive cough, dizziness and bilateral hands tremor for 1 weeks. The symptom got worsen, thus he was brought to our ER for help. At ER, vital signs showed TPR: 35.6’C/121bpm/20; BP:125/60 mmHg. Con’s:E4V5M6. Laboratory data revealed normacytic anemia of Hb 7.8g/dL, elevated CRP (8.78 mg/dL), NTpro BNP (1018 pg/mL) and D-dimer (980.96 ng/mL). Chest CTA showed emphysema in both upper lobes. He denied abdomen pain, tarry stool or bloody stool. Urinalysis showed no pyuria. Denied TOCC history. Under the impression of pneumonia and suspect GI bleeding, he was admitted to our ward for further evaluation and treatment.
      
    • After admitted, he recevied IV fluid supplement, empirical antibiotic with unasym for infection control.
    • Stool transfirrin/FOB showed positive. EUS and colonscopy were performed for anemia survey, which showed duodenal ulcers and rectal polypoid lesions with ucer.
    • Anemia was correct with Hb > 9.0.
    • Follow laboratory data revealed thrombocytopenia (PLT 65000/uL -> 70000/uL -> 52000/uL -> 35000/uL). Abdomen echo showed no splenomegaly.
    • We need your expertise to evaluate for anemia and thrombocytopenia further evaluation, sincerely thanks.
  • A
    • This 72 year old man is a case of pneumonia. We are consulted for bicytopenia (normocytic anemia and thrombocytoepnia).
    • Pending endoscopy biopsy result. Please check RBC morphology, haptoglobin (done), total/direct bilirubin (done), ANA, RF, C3, C4, anti Ds DNA, AntiRo/La, IgG,IgA,IgM, total protein/albumin, serum EP, serum IFE, serum light chain, lupus anticoagulant, anti-cardiolipid IgM/IgG, anti B2 glycoprotein Ab, Ferritin (done), Fe/TIBC (done), B12 (done), folic acid(done) and tumor marker. Watch for any bleeding sign which may cause platelet consumption. If still unexplained cytopenia, bone marrow aspiration and biopsy is indicated.
    • Typical recommended platelet count thresholds used for some common procedures are listed below. Platelet transfusion may be considered when the patient platelet count is below the threshold for the corresponding procedure.
      • Neurosurgery or ocular surgery - <100,000/microL
      • Most other major surgery - <50,000/microL
      • Endoscopic procedures - <50,000/microL for therapeutic procedures; 20,000/microL for low risk diagnostic procedures
      • Bronchoscopy with bronchoalveolar lavage (BAL) - <20,000 to 30,000/microL
      • Central line placement - <20,000/microL
      • Lumbar puncture - <10,000 to 20,000/microL in patients with hematologic malignancies and <40,000 to 50,000 in patients without hematologic malignancies; lower thresholds may be used in patients with immune thrombocytopenia (ITP)
      • Neuraxial analgesia/anesthesia - <80,000/microL
      • Bone marrow aspiration/biopsy - <20,000/microL

[lab data]

2023-04-11 Ferritin 1154.7 ng/mL
2023-04-11 Transferrin 143.6 mg/dL
2023-04-11 Fe (Iron-bound) 123 ug/dL
2023-04-11 TIBC 206 ug/dL
2023-04-11 UIBC 83 ug/dL
2023-04-10 BUN 29 mg/dL
2023-04-10 Bilirubin direct 0.22 mg/dL
2023-03-21 Direct Coomb Test Positive
2023-03-21 Indirect Coomb Test Positive
2023-03-21 FKLC 156.0 mg/L
2023-03-21 FLLC 193.0 mg/L
2023-03-17 Anti-beta2-glycoprotein-I Ab 9.2 U/mL
2023-03-17 Gamma 44.3 %
2023-03-15 IgG (blood) 2208 mg/dL
2023-03-09 stool FOB Positive
2023-03-09 Transferrin, stool Postive

701452959

230411

[diagnosis] - 2023-04-10 admission note

• Malignant neoplasm of rectosigmoid junction
• Adenocarcinoma of the rectum and sigmoid colon,T4N2bM1a, stage III
• Type 2 diabetes mellitus without complications
• Essential (primary) hypertension
• Hyperlipidemia, unspecified

[past history]

• diabetes mellitus for years under OHA & insulin control at SanChong LMD and hepatitis B.
• Port-A was inserted on 2023-03-14.     

[allergy]

• NKDA     

[family history]

• Mother: breast cancer
• Sister: lymphoma

[exam findings]

• 2023-04-10 KUB
  • A renal stone in left lower pole is suspected.
  • Fecal material store in the colon.
  • Vas deferens calcification is noted.
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon at right lateral aspect L4-5.
• 2023-03-10 Whole body PET scan
  • Glucose hypermetabolism involving the rectosigmoid colon, compatible with primary rectosigmoid colon malignancy.
  • Mild glucose hypermetabolism in six regional lymph nodes. The nature is to be determined (metastatic lymph nodes of low FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
  • No prominent abnormal focal FDG uptake was noted in the liver and no prominent FDG uptake was noted in the left external iliac lymph node.
  • Increased FDG accumulation in some focal areas in the colon. The nature is to be determined (physiological FDG accumulation? other nature?). Please also correlate with other clinical findings for further evaluation.
• 2023-03-01 CT - abdomen
  • CC:
    • bowel habit change and anal discomfort + tenesmus recent times.
    • Constipation with excessive straining (unstable)
  • 20230224 colonoscopy: One circumferential tumor was noted at proximal rectum, 8-9cm above anal verge, s/p biopsy x6. The scope cannot pass through the lesion.
  • Past history: (DM + HTN)
  • Indication: suspect rectum lesion
  • Findings:
    • There is long segmental circumferential asymmetrical wall thickening with irregular contour at the rectum and sigmoid colon, measuring 12 cm in length that is c/w adenocarcinoma (T4a).
      • The fat plane between the sigmoid colon lesion and the urinary bladder shows equivocal obliteration. Please correlate with MRI to R/O urinary bladder invasion or attachment.
      • In addition, there are ten enlarged nodes in the pericolic area that are c/w metastatic nodes (N2b). IIIC
    • There is an ill-defined poor enhancing lesion 1 cm in S6/7 of the liver that may be cyst, pseudo-lesion, or metastasis?
      • Please correlate with MRI.
    • There is one enlarged node in left external iliac chain, measuring 6 mm in short axis (normal cut of value: 7mm) and fat density that may be reactive node.
      • The differential diagnosis includes non-regional metastatic node (M1a).
      • Please correlate with PET scan.
  • Impression:
    • Adenocarcinoma of the rectum and sigmoid colon.
      • Please correlate with MRI.
    • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T4a or T4b, N2b, M1a?
      • Please correlate with Pelvis MRI and PET scan.
• 2023-02-24 Patho - colon biopsy
  • PATHOLOGIC DIAGNOSIS
    • Proximal rectal tumor, 8-9 cm above anal verge, biopsy — Adenocarcinoma
    • Distal rectal polyp, biopsy removal — Tubular adenoma, low grade dysplasia
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consisted of (A) three small pieces of tumor tissue measuring up to 0.3 x 0.2 x 0.1 cm in size and (B) four tiny pieces of polyp tissue measuring up to 0.2 x 0.2 x 0.1 cm in size respectively, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for sections in cassette A: rectal tumor and B: sessile polyp.
  • MICROSCOPIC EXAMINATION
    • Microscopically, the sections show pictures as follows:
      • Proximal rectal tumor: adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with desmoplasia.
        • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor
      • Distal rectal polyp: tubular adenoma with low grade dysplasia
• 2023-02-24 Colonoscopy
  • high suspected rectal cancer, s/p biopsy (A)
  • rectal polyp, s/p biopsy removal (B)
  • mixed hemorrhoid
• 2022-10-11 Bladder Sonography
  • PVR: 71mL
• 2022-09-28 Humerus RT
  • suspected fracture at the right proximal humeral bone.
• 2022-09-27 Transrectal Ultrasound of Prostate, TRUS-P
  • CC:
    • small stream +
    • nocturia 5/N
  • PH:
    • DM(+), HTN(-), CAD(-), COPD(-), Asthma(-), CVA(-)
  • Surgical history: denied
  • Substance use: denied
  • Prostate：
    • Size of prostate: 4.76(T)cm x 2.59(L)cm x 5.12(AP)cm = 33.0cc
    • Size of adenoma: 3.14(T)cm x 2.25(L)cm x 2.97(AP)cm = 11.0cc
  • Seminal vesicles：
    • L
      • Size：L’t1.68 x 0.802 cm
      • Vas deferens：Normal
      • Cyst：No
      • Abscess：No
      • Tumor：No
    • R
    • Size：R’t1.55 x 1.34 cm
    • Vas deferens：Normal
    • Cyst：No
    • Abscess：No
    • Tumor：No
  • Diagnosis
    • Benign prostatic hyperplasia

[SOAP]

• 2023-03-07 Radiation Oncology
  • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 frcations of the rectal to sigmoid colon tumor bed area.
• 2023-03-07 Hemato-Oncology
  • Arrange admission for C/T (FU or FOLFOX).
  • If the PET indicates as a mets, C/T regimen for CCRT and post-CCRT would be FOLFOX, and TNT is not necessary.
  • If the PET discloses the lesion of liver is not a mets, TNT (CCRT with FU -> FOLFOX x 6-8 cycles -> OP -> follow up) is indicated. The C/T regimen for CCRT would be FU.
  • note ChatGPT:
    • In the context of oncology, TNT stands for “Total Neoadjuvant Therapy.” This refers to a treatment approach where chemotherapy, radiation therapy, or both are given before surgery for the treatment of certain types of cancer. The goal of TNT is to shrink the tumor and potentially increase the chances of a successful surgical outcome.

[chemotherapy]

• 2023-04-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (FOLFOX without 5FU bolus)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-22 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (FOLFOX without 5FU bolus)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

• The patient has been admitted for the 2nd dose of FOLFOX regimen, and there were no remarkable adverse reactions observed after the 1st dose.
• On 2023-04-10, the lab results showed grossly normal blood counts, kidney and liver function, and selected electrolytes, indicating that scheduled chemotherapy is not contraindicated.

• he tumor marker CEA was found to be elevated and increasing before the first chemotherapy, and further follow-up tests can be ordered as necessary.
  023-03-08 CEA: 217.89 ng/mL

  2023-02-25 CEA: 193.69 ng/mL
• The patient’s blood pressure readings are acceptable, but the serum glucose level remains high and unstable, ranging from 229mg/dL to 150mg/dL, and should be monitored closely. If the high serum glucose level persists, metformin may be considered, given the patient’s non-insufficient kidney function.
• No issues with medication reconciliation have been identified.

230323

[assessment]

• The treatment strategy planned on 2023-03-21 is based on the results of PET: if it indicates the presence of metastases, the recommended chemotherapy regimen for concurrent chemoradiotherapy (CCRT) and post-CCRT would be FOLFOX, and total neoadjuvant therapy (TNT) would not be necessary. However, if PET shows that the lesion in the liver is not a metastasis, then the recommended treatment would be TNT, which consists of CCRT with FU, followed by FOLFOX for 6-8 cycles, then surgery and postoperative follow-up. The chemotherapy regimen for CCRT in this case would be FU.

• On 2023-03-10, the results of the PET scan were available and the patient began receiving the FOLFOX regimen for the first time while in this hospital stay.

• According to the patient’s blood glucose records, there is an upward trend and significant variability in his blood glucose levels despite taking Forxiga (dapagliflozin). To address this, it is recommended to investigate if there has been a significant change in the patient’s dietary intake, especially in regards to carbohydrate consumption, as this could have a substantial impact on blood glucose levels.

  • Blood sugar level 148 -> 105 -> 170 -> 173 -> 127 -> 243 mg/dL

701464758

230411

[exam findings]

• 2023-04-07 Ascites tapping
  • 3000 ml light red color ascites was drained.
• 2023-04-03 Ascites tapping
  • After echo localization, paracentesis was performed at RLQ and 3000ml straw-colored scites was drained out with 18Fr cathether.
• 2023-03-29 ECG
  • Sinus rhythm with Premature atrial complexes
  • Poor wave progression
• 2023-03-29 KUB
  • Abdominal ascites
  • increased air in nondistended loops of small bowel over abdomen and pelvic ,could be mechanical ileus.
  • marginal spurs of multiple vertebral bodies
• 2023-03-29 CXR
  • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
  • Elevation of both hemidiaphragms may be due to abdominal ascites and supine position
  • Linear band subsegmental atelectasis at lung bases
  • Multiple nodules in both lungs due to metastases.
• 2023-03-20 Ascites tapping
  • 18G needle was inserted at RLQ under echo guided insertion. Around 75ml ascites was collected for analysis and total 3000 ml for drainage, orange color and symptom relief.
• 2023-03-17 PET
  • Glucose hypermetabolism in a focal area about ascending colon and some adjacent lymph nodes. Primary colon malignancy with some adjacent lymph node metastases may show this picture.
  • Multiple glucose hypermetabolic lesions in bilateral lungs and in the liver, compatible with multiple lung and liver metastases.
  • Increased FDG accumulation in both kidneys. Physiological FDG accumulation is more likely.
• 2023-03-15 All-RAS + BRAF
  • ALL-RAS: Detected (KRAS codon 12 GGT>GAT, p.G12D)
  • BRAF: There was no variant detect in the BRAF gene.
• 2023-03-12 KUB
  • Presence of ileus.
  • Degeneration and spondylosis of L-S spine.
• 2023-03-10 Patho - colon biopsy
  • Colorectum, ascending, biopsy — Adenocarcinoma.
  • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands.
• 2023-03-09 Colonoscopy
  • A-colon cancer with partial obstruction
• 2023-03-09 Asictes tapping
  • 18G needle was inserted at RLQ under echo guided insertion. Around 75ml ascites was collected for analysis and total 2000 ml for drainage and symptom relief.
• 2023-03-07 CXR
  • Solitary pulmonary nodule at RLL.
• 2023-03-07 CT - abdomen
  • Findings
    • Wall thickening of A-colon with adjacent fat stranding and regional LAP. Multiple liver and lung tumors. Massive ascites.
    • S/P cholecystectomy.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
• 2022-12-19 SONO - abdomen
  • Large liver tumor in right lobe, HCC? Suggest dynamic CT or MRI study.
  • Liver cysts.

[consultation]

• 2023-03-14 Hemato-Oncology
  • A
    • This 67 year old man is a case of ascending colon adenocarcinoma with liver and lung metastasis. We are consulted for further evaluation.
    • Please check tumor gene status for RAS and BRAF mutations (All-RAS/BRAF test), Pending tumor mismatch repair (MMR) or microsatellite instability (MSI) status (pathology IHC stains). Arrange PET for complete staging (NHI covered).
    • For metastasis colon cancer, palliative systemic chemoterapy +/- target therapy is indicated. Re-evaluate for conversion to resectable every 2-3 mo if conversion to resectability is a reasonable goal. Furthermore, consult CRS for surgery, if there is present of obstrusion, bleeding or perforation.
    • Arrange our OPD after discharge. Thanks for your consultation.
• 2023-03-14 Colorectal Surgery
  • A
    • O
      • 2023037: CT: Wall thickening of A-colon with adjacent fat stranding and regional LAP r/o malignancy. Multiple liver and lung tumors r/o metastases. Massive ascites.
      • 20230309: Colonoscopy: One mass was noted in the ascending colon with nearly lumen obstruction biopsy — Adenocarcinoma.
      • Abdomen: distended, no tenderness or muscle guarding
    • A: Adenocarcinoma of A-colon with multiple metastases of liver and lungs, stage IVb
    • P:
      • Due to diffuse liver and lungs metastases, palliative chemotherapy with target therapy is the main treatment option
      • Surgical intervention with bypass surgery or ileostomy may be considered if obstruction symptoms developing
      • Please inform us if any problems

[medication]

• 2023-03-21 ~ 2023-04-18 ongoing - Xeloda (capecitabine 500mg) KXELO01 2# BID

[note]

Capecitabine 2023-04-11 https://www.uptodate.com/contents/capecitabine-drug-information

• Dosing: Adult - Colorectal cancer, unresectable or metastatic:
  • Single-agent therapy:
    • Oral: 1,250 mg/m2 twice daily on days 1 to 14 of a 21-day treatment cycle; continue until disease progression or unacceptable toxicity.
      • Note: Capecitabine toxicities, particularly hand-foot syndrome, may be higher in North American populations; therapy initiation at doses of 1,000 mg/m2 twice daily (on days 1 to 14 every 21 days) may be considered.
  • XELOX/CAPOX regimen:
    • Oral: 1,000 mg/m2 twice daily on days 1 to 14 of a 21-day treatment cycle (in combination with oxaliplatin); continue until disease progression or unacceptable toxicity. Some studies administered for a duration of 8 or 16 cycles. A retrospective evaluation of a modified schedule (eg, days 1 to 7 and days 15 to 21 of a 28-day cycle) found improved tolerability and no difference in efficacy outcomes.
  • CAPOX/panitumumab:
    • Oral: 1,000 mg/m2 twice daily on days 1 to 14 every 3 weeks (in combination with oxaliplatin and panitumumab) for at least 6 cycles or until disease progression or unacceptable toxicity.

[assessment]

• The supplemental report for the IHC staining of EGFR, PMS2, MSH6, MSH2, and MLH1 for the colon biopsy pathology performed on 2023-03-10 is still pending and not yet available.

• The patient’s last recorded height on 2023-03-30 is 172 cm, and his last recorded weight on 2023-04-10 is 75.7 kg. Based on these measurements, his body surface area (BSA) is calculated to be 1.9 m2. The patient has been receiving capecitabine at a daily dose of 2000 mg since late March 2023, which is a dose of 1052 mg/m2 based on his BSA. This is approximately 84% of the recommended daily dose of 1250 mg/m2.

• It appears that the patient has had anemia even before the administration of capecitabine, and the cause may be gastrointestinal bleeding (in case of A-colon lesions?) as evidenced by positive occult blood in the stool. Blood transfusion performed on 2023-03-07, 2023-03-29, and 2023-04-07 and PPI is currently prescribed.

  • 2023-04-08 Stool OB 4+
    
  • 2023-04-01 Stool OB 3+
    
  • 2023-03-09 Stool OB 3+
    
  • 2023-04-10 HGB 9.1 g/dL
    
  • 2023-04-07 HGB 6.8 g/dL
    
  • 2023-03-29 HGB 8.3 g/dL
    
  • 2023-03-20 HGB 8.4 g/dL
    
  • 2023-03-17 HGB 8.8 g/dL
    
  • 2023-03-13 HGB 8.8 g/dL
    
  • 2023-03-09 HGB 8.4 g/dL
    
  • 2023-03-07 HGB 7.1 g/dL
    
  • 2023-03-07 HGB 5.7 g/dL
    
  • 2022-12-16 HGB 8.9 g/dL

• There is currently no record of hand-and-foot syndrome (HFS) or any related symptoms such as palmar-plantar erythrodysesthesia or chemotherapy-induced acral erythema.

701465149

230411

[diagnosis] - 2023-04-02 admission note

• Mesothelioma of pleura
• Chronic viral hepatitis B without delta-agent
• Essential (primary) hypertension

[past history] - 2023-04-02 admission note

• Medical PH: 1) HTN 2) BPH
• Inguinal hernia on 2023/01/13
• TEP and Port-A catheter insertion on 2023/01/30
• Hypertension for 20-30 years
  • Carvedilol HEXAC 6.25mg 1# po BID
  • Noravsc 1# po QD
  • Doxaben XL 4mg 1# po QNAC    

[allergy]

• NKDA         

[family history]

• His parents was DM.
• No cancer, CAD, CVA history in his family

[exam findings]

• 2023-04-10, -04-06 CXR
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • Pleura thickening in right lateral aspect is noted.
  • Partial atelectasis of RLL and RML is suspected.
  • Please correlate with CT.
  • Borderline cardiomegaly
• 2023-04-03 SONO - chest
  • Right
    • Right side pleural effusion? -> dry tapping
    • suspect mesothelioma or post R/T related
    • suggest CXR follow up
  • Left
    • Left side negative
• 2023-04-02 CXR
  • Right pleural effusion.
  • Ground glass opacities in bil. lungs.
• 2023-04-02 ECG
  • Atrial flutter with variable A-V block
• 2023-02-24 CXR
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • Pleura thickening in right lateral aspect is noted.
  • Partial atelectasis of RLL and RML is suspected.
  • Please correlate with CT.
• 2023-02-23 ECG
  • Nonspecific T wave abnormality
• 2023-02-07 Bone Scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two hot spots in the anterior aspect of right 1st and 2nd ribs and increased activity in the maxilla, middle and lower T-spines, lower L-spines, bilateral shoulders, hips and knees in whole body survey.
  • IMPRESSION:
    • Increased activity in the middle and lower T-spines and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Two hot spots in the anterior aspect of right 1st and 2nd ribs. Bone metastases can not be ruled out. Please also correlate with other imaging modalities for further evaluation.
    • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
• 2023-02-02 CXR
  • Rt pleural effusion with loculation still visible s/p chest tube placement,
  • partial atelectasis of RLL and RML
• 2023-02-01 PET scan
  • Glucose-hypermetabolism in the right pleura, compatible with malignant mesothelioma of pleural status.
    
  • Glucose-hypermetabolism in the right upper ribs, malignancy with rib involvement should be considered, suggesting bone scan for investigation.
    
  • Increased FDG uptake in the right inguinal region, compatible with right inguinal hernia.
    
  • Increased FDG accumulation in the colon, probably physiological uptake of FDG.
    
  • Malignant mesothelioma of pleural status with suspected right upper ribs involvement by this F-18 FDG PET scan.
• 2023-01-31 CT - abdomen
  • History and indication: mesothelioma of pleural
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Right mesothelioma with pleural effusion. S/P right chest tube insertion with pneumothorax, subcutaneous emphysema.
    • Minimal pneumoperitoneum.
    • A lipoma (2.8cm) in left thigh.
    • Right inguinal hernia.
    • Some poor enhancing nodules (up to 1.0cm) in liver.
    • Bil. renal cysts (up to 1.0cm).
  • IMP:
    • Right mesothelioma with pleural effusion. S/P right chest tube insertion with pneumothorax, subcutaneous emphysema.
    • Minimal pneumoperitoneum.
• 2023-01-31 ENT Hearing Test
  • PTA
    • Reliability FAIR
    • Average RE 34 dB HL; LE 31 dB HL.
    • RE normal to severe SNHL.
    • LE normal to severe SNHL
• 2023-01-18 Patho - pleural/pericardial biopsy
  • PATHOLOGIC DIAGNOSIS
    • Pleura, right, VATS decortication - Malignant mesothelioma, high-grade
    • Tumor subtype — Biphasic type
    • Pathology stage:pT1Nx(if cM0); AJCC stage IA
  • MACROSCOPIC EXAMINATION
    • Operation procedure: VATS decortication
    • Specimen site: right pleura
    • Specimen size: multiple pieces, up to 2.5x 2x 1.5 cm
    • Tumor size: fragmented, at least 2 cm in greatest dimension
    • Tumor description: ill-defined, brownish and solid
    • All for sections are taken and labeled as: F2023-38FSA1-2＆A:frozen control of tumor, A1-2:tumor
  • MICROSCOPIC EXAMINATION
    • Histology Type: Malignant mesothelioma
    • Histology Grade:
      • Nuclear grade 3 [Nuclear atypia score: 3 (severe);Mitotic count score: 3 (hight, ＞ 5 mitoses/ 10 HPF); Sum: total score 6].
      • Necrosis: present
      • Overall tumor grade: High-grade
    • Resection Margins: Cannot be assessed
    • Lymphovascular Invasion: Absent
      
    • Perineural Invasion: Absent
      
    • Tumor Necrosis: Present / Absent
      
    • Lymph Node : Not included
    • IHC stain — Ki-67 index: 90%, CK20(-), calretinin(focal+), CK(+), chromomgranin (-), WT-(Afocal+), D2-40(focal+), P40(-), TTF-1(-), Napsin A(-), CK7(+), vimentin (+), SOX-10(-), CK5/6(-), HBME-1(focal+), SYNAPTOPHYSIN(-), GATA-3(+),S100(-).
• 2023-01-17 Frozen Section
  • FROZEN SECTION INITIAL DIAGNOSIS:
    • Tissue, right pleural, frozen section — Malignant tumor
• 2023-01-16 SONO - chest
  • Echo diagnosis:
    • right side moderate amount of septated pleural effusion, pig-tail drainage via right 7th ICS posterior mid-axillary
    • line was performed and bloody fluid was drained out. The bloody fluid was sent for study.
• 2023-01-12 CT - chest
  • The CT scan of the chest was performed without IV contrast medium enhancement and revealed that:
    • Patchy consolidation over RLL. Suggest check enhanced CT scan for furthter evaluation.
    • Moderate amount of right pleural effusion with some high-density materials. Suggest correlate with enhanced study.
    • Bilateral perirenal fatty strandings.
• 2023-01-12 ECG
  • Possible Left atrial enlargement
  • Nonspecific T wave abnormality
• 2023-01-12 CXR
  • Right pleural effusion.
  • Borderline cardiomegaly.
  • Thoracic spondylosis.
• 2022-12-22 Bladder Sonography
  • PVR 4.81 mL

[consultation]

• 2023-01-28 Hemato-Oncology
  • Q
    • This is a 75 y/o male with underlying disease of HTN.
    • He underwent VATS decortication due to right pleural effusion on 2023-01-17, and the pathological report revealed malignant mesothelioma.
    • We would like to consult your expertise on evaluation and treatment arrangement of the patient, thank you!
  • A
    • This 75 year old man is a case of right malignant mesothelioma (initial presentation: cough and right pleura effusion). He has underline of HTN, BPH and rigth inguinal hernia.
    • For malignant mesothelioma, we are consulted.
      • We will discuss with pahtologist regarding the subtype, e.g., epitheloid, sarcomatoid or biphasic
      • May consider CCRT with weekly CDDP followed by systemic therapy is indicated (cisplatin + pemetrexed +/- bevacizumab) or immunotherapy with dual or single
      • Please check abdominal + pelvic CT extending to chest (+/- contrast), 24hr urine CCR, auditory test
      • Please check HbsAg, Anti Hbc, Anti-HBs, Anti HCV.
      • Arrange Port A insertion
      • We will discuss with patient and family
      • We wound like to follow up this case. May take over or arrange our OPD appointment after discharge.
• 2023-01-27 Radiation Oncology
  • A
    • A:
      • Malignant mesothelioma, high-grade, of the right pleura, s/p VATS decortication.
    • P:
      • Postoperative radiotherapy is indicated for this patient with the following indicators: Malignant mesothelioma, high-grade, of the right pleura.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter-in-law. They understand and agree to receive radiotherapy. Please consider PET for current tumor status and staging work-up. The treatment planning of radiotherapy will be started after completion of PET.

[SOAP}

• 2023-03-30 Radiation Oncology
  • P: Go on the radiotherapy. Plan to complete radiotherapy on 2023-04-03. RTC: 2023-04-18.
• 2023-03-16 Hemato-Oncology
  • Already strong request increasing the salt intake again and again
• 2023-02-16 Thoracic Surgery
  • CT: R’t massive pleural effusion, cause? liver cysts., report?

[surgical operation]

• 2023-01-30
  • Surgery: TEP
    • ChatGPT: TEP stands for Totally Extraperitoneal Repair, which is a minimally invasive surgical technique used to repair inguinal hernias. In this procedure, a small incision is made in the abdominal wall and a laparoscope is inserted, which allows the surgeon to view the hernia and repair it from the outside of the peritoneal cavity. The hernia is repaired with a mesh, which is placed over the defect to prevent the hernia from recurring. TEP is considered less invasive than traditional open hernia repair surgery and has a lower risk of complications.
  • Finding
    • Right indirect hernia type III
    • cord lipoma (+)
    • sac descend to scrotum
    • contralateral defect: none
    • post wall repair yes
    • mesh size 14x15 cm
    • absorbable tacks
    • peritoneal defect (+) cloosed with 3-0 Vicryl sutures
• 2023-01-17
  • Surgery: VATS decortication
    • ChatGPT: VATS decortication refers to a surgical procedure performed to remove the fibrous layer of tissue (pleural peel) that covers the lung. The procedure is performed using a minimally invasive technique called Video-Assisted Thoracic Surgery (VATS), which involves making small incisions in the chest wall and using a video camera and specialized surgical instruments to access and remove the pleural peel. VATS decortication is commonly used to treat conditions such as empyema, a collection of pus in the pleural space, and hemothorax, a buildup of blood in the pleural cavity.
  • Finding
    • Bloody effusion was noted over right pleural cavity, about 800mL
    • Frozen section:carcinoma, unknown origin.
    • One 28 Fr. straight chest tube was inserted via right 8th ICS, another curved one was inserted via right 7th ICS.

[radiotherapy]

• 2023-02-22 ~ 2023-04-03 - at 3060cGy/17 fractions of the right pleura to right upper ribs, and 4680cGy/26 fractions of the right pleura tumor bed.

[chemotherapy]

• 2023-04-10 - pemetrexed 500mg/m2 800mg NS 100mL 10min + cisplatin 60mg/m2 100mg NS 500mL 2hr (Alimta + cisplatin, Q3W. cisplatin to normal 75mg/m2 next time)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2023-03-16 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-03-09 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-03-02 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-02-24 - cisplatin 40mg/m2 70mg NS 500mL 24hr + magnesium sulfate 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) (CCRT with weekly CDDP)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

[assessment]

• The patient’s HGB levels have shown a decreasing trend since the start of CCRT in late Feb 2023, which could be a result of the cisplatin and radiotherapy.
  • 2023-04-10 HGB 7.4 g/dL
    
  • 2023-04-06 HGB 8.9 g/dL
    
  • 2023-04-02 HGB 8.2 g/dL
    
  • 2023-03-30 HGB 8.2 g/dL
    
  • 2023-03-23 HGB 8.9 g/dL
    
  • 2023-03-16 HGB 10.1 g/dL
    
  • 2023-03-09 HGB 10.8 g/dL
    
  • 2023-02-24 HGB 11.0 g/dL
    
  • 2023-02-07 HGB 9.8 g/dL
    
  • 2023-01-30 HGB 11.0 g/dL
    
  • 2023-01-23 HGB 11.1 g/dL
    
  • 2023-01-20 HGB 11.1 g/dL
    
  • 2023-01-19 HGB 11.0 g/dL
    
  • 2023-01-17 HGB 13.3 g/dL
    
  • 2023-01-12 HGB 13.1 g/dL
• The combination of pemetrexed and cisplatin, incorporating prophylactic folic acid and vitamin B12, increased OS compared with single-agent cisplatin in patients with malignant pleural mesothelioma whose disease was either unresectable or who were not otherwise candidates for potentially curative surgery. ref: Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol. 2003;21(14):2636-2644. doi:10.1200/JCO.2003.11.136
  • 2023-04-10 MCV 100.9 fL
    
  • 2023-04-06 MCV 98.1 fL
    
  • 2023-04-02 MCV 94.8 fL

230403

[assessment]

• The patient’s sputum Gram’s stain results on 2023-04-02 showed G(+)Cocci 2+, GNB 2+, GPB 3+ (Neutrophil/LPF < 10, Epithelial cell/LPF 15~20). Antibiotics with Betamycin 4.5gm Q6H have been prescribed since the same day to treat the patient’s respiratory symptoms.
• After checking the PharmaCloud database, no medication reconciliation issue is found.

700450583

230410

[ciclosporin TDM]

On 2023-04-08, the patient’s ciclosporin trough concentration was found to be 169ng/mL, which falls within the acceptable range of 100 to 400ng/mL. However, if the target trough concentration is between 200 and 300 ng/mL, then it is recommended to increase the daily dose from the current 200mg to 250mg and continue with regular follow-up testing.

230407

[chief complaint] - 2023-03-31 admission note

• poor appetite and severe mucositis for one week
• body weight loss 10kg in one week

[present illness] - 2023-03-31 admission note

• Conditioning regimen of MUD-Allogenous PBSCT on 2023/02/09-12 (FuCy Mito), on 2023/02/16-21 (BuCy-ATG), Dilantin 400mg QD on 2023/02/13-20, MTX 15mg/m2 on 2023/02/24(D1), 10mg/m2 on 2023/02/26(D3), 2023/03/01(D6), 2023/03/06(D11) and Leucovorin 15mg Q6H for rescue, starting 12hrs after each MTX dose. We adjust the Fludarabine dose by ABW25 (IBW + 0.25 x (TBW-IBW)), adjust Cyclophosphamide dose by ABW25. MUD-Allogenous PBSCT on 2023/02/23 (D0, 432ml, CD34: 5.69x10^6/kg, 15:00-15:10).
• This time, body weight loss 10kg in one week, poor appetite and severe mucositis were noted for one week. At ER, Laboratory test revealed leukocytosis, impaired renal function, hyperuricemia, hyperkalemia and elevated CRP level.
• Under the impression of AKI and severe mucositis suspect fungus infection, he was admitted for further management.

[past history] - 2023-03-31 admission note

• Denied history of Hypertension, DM, asthma
• Denied any operation, accident and other medical Hx.

[allergy]

• NKDA                     

[family history]

• Father: Type II DM

[exam findings]

• 2023-02-08 Peropheral Vascular Test - AV fistula
  • Result:Adequate size of RIJV
• 2023-01-12 SONO - abdomen
  • Diagnosis
    • Negative finding
  • Suggestion
    • OPD f/u
    • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
    • The visible part of pancreas was normal, but others and tail was masked by gas
• 2023-01-11 Myocardial perfusion SPECT with persantin
  • The Tl-201 stress myocardial perfusion scan was performed after sequentially injecting 0.56 mg/kg of dipyridamole and 3.0 mCi of the radiotracer to the patient. The post-stress and resting images revealed very mildly fixed lesion at the apical anterolateral wall of LV. No dilatation of LV was noted on both post-stress and resting images.
    
  • IMPRESSION:
    • Probably normal variant (priority) or very mildly myocardial ischemia at the apical anterolateral wall of LV.
    • No dilatation of LV is noted on both post-stress and resting images.
• 2023-01-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 45) / 100 = 55.00%
    • 2D (M-simpson) = 55
  • Gr I LV diastolic dysfunction and impaired RV relaxation.
  • Mild hypokinesia of inferoseptum and LV inferior wall; preserved LV systolic function.
  • Normal RV systolic function.
  • Mild aortic valve sclerosis; trivial MR.
• 2023-01-05 Standard spirometry
  • normal standard spirometry
  • normal DLCO (DLCo, diffusion capacity of carbon monoxide)
  • negative BDT (BronchoDilator Test)
• 2022-12-13 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Acute myeloid leukemia
  • The sections show acute myeloid leukemia, composed of hypercellular marrow (70%). The M/E ratio = 6:1 in MPO and CD71 immunostains. The megakatyocytes are increase in number. Scattered and sheets of medium to large-sized, CD34+ and/or CD117+ blasts in interstitium, constitue 40% of marrow cells. Suggest bone marrow smear evaluation and clinic correlation.
• 2022-11-14 CT - brain
  • Indication: AML, pancytopenia
  • Protocols: axial scans with 4 mm slice thickness from skull base to vortex with sagittal image reformation
  • Cranial CT scans without IV contrast medium enhancement was performed smoothly and show:
    • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • The interhemispheric fissure is centered on the midline.
    • The basal ganglia, internal capsule, corpus callosum, and thalamus appear normal.
    • Sella and pituitary are normal, parasellar structures are unremarkable.
    • There are no abnormalities in the cerebellopontine angle areas on both sides.
    • There are no abnormalities in the calvarium.
  • Imp:
    • Mild sulci widening and ventricle dilatation.
• 2022-11-14 CT - abdomen
  • Indication: AML, pancytopenia
  • Abdominal and Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Status post endotracheal tube placement.
      • Infiltrative change at axillary region is found.
      • Right and left pleural effusion is found.
      • Increased pulmonary vasculature is found.
      • Generalized Infiltrative process at subcutaneous tissue of the abdominal and chest wall is found.
    • Visible abdomen:
      • Minimal ascites at abdominal cavity and pelvis is found.
      • The liver, pancreas, both kidneys and adrenals are intact.
      • Borderline splenomegaly is found.
      • There is no evidence of paraarotic LAPs.
      • The GB is well distended without soft tissue lesion
      • There is no evidence of destructive bone lesion.
      • S/P NG tube placement.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
      • Suggest clinical correlation
  • Imp:
    • Generalized Infiltrative process at subcutaneous tissue of the abdominal and chest wall
    • Bialteral pleural effusion and ascites.
    • No evidence of intra-abdominal abscess in the study.
• 2022-11-11 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (141 - 93.4) / 141 = 33.78%
    • M-mode (Teichholz) = 33.8
    • 2D (M-simpson) = 32.1
  • Severely abnormal LV systolic function with global hypokinesia, under vasopressor use
  • Moderate to severe TR (tricuspid regurgitation); trivial MR (mitral regurgitation)
  • Dilated LA, LV, RA and IVC (inferior vena cava); thick IVS (interventricular septum)
  • Mild pulmonary hypertension
• 2022-10-21 Patho - bone marrow biospy
  • Bone marrow, biopsy — Acute myeloid leukemia
  • The sections show acute myeloid leukemia, composed of hypercellular marrow (50%). The M/E ratio = 6:1. The megakatyocytes are increase in number. Scattered medium to large-sized immature cells in interstitium, constitue 25% of marrow cells in CD34 and CD117 immunostains. Suggest bone marrow smear evaluation and clinic correlation.
• 2022-09-19 Patho - bone marrow biospy
  • Bone marrow, biopsy — Acute myeloid leukemia
  • The sections show hypercellular marrow (95%). The marrow space is nearly total replaced by a population of medium to large-sized immature cells with round to oval nucleus and moderate amount cytoplasm.
  • IHC: CD34(+ in 90% marrow cells), CD117(<3%), MPO (10%) and CD68 (20%).
• 2022-08-18 Patho - bone marrow biospy
  • Bone marrow, iliac, biopsy — acute leukemia (Differential diagnosis includes acute myelomonocytic leukemia,…. etc.)
  • Microscopically, it shows hyperceuularity of marrow(>90%), with maked proliferation of CD34+ blasts (>60%) with myelomonocytic differentiation highlighted by CD68 (diffuse +).
  • Immunohistochemical stain reveals CD117 (+,10%), TdT(>50%), MPO(+), CD20 (< 3%), CD138(1-2%), CD71(1%).

[consultation]

• 2023-03-31 Nephrology
  • Q
    • This time, poor appetite and severe mucositis were noted for one week. At ER, Laboratory test revealed leukocytosis, impaired renal function, hyperuricemia, hyperkalemia and elevated CRP level.
    • Under the impression of AKI and severe mucositis suspect fungus infection,he was admitted for further management
  • A
    • We went through his medical records and evaluated his condition. He had been taking Cyclosporin for the prevention of GVHD reaction after undergoing bone marrow transplant.
    • However, over the past one week, he developed acute kidney injury, accompanied with hyperkalemia and hyperuricemia.
    • Serum creatine level was seen to be improving after administering adequate hydration.
    • We suspect that nephrotoxic effects of Cyclosporin was the likely cause of AKI, and hyperuricemia was merely the aftermath of AKI.
    • Our advices are as follow:
      • Administer adequate fluid hydration and record daily I/O
      • Adjust dosage of Cyclosporin and Tenofovir according to deteriorated renal function
      • Follow up on serum concentration of Cyclosporin and resume its usual dose after renal function improves
      • Consider adding Febuxostat for the management of hyperuricemia
    • Please be assured that we will continue to follow up on this patient.
    • Feel free to contact us should you require further assistance. Thank you.
• 2023-03-31 Infectious Disease
  • Q
    • The 30 years old male is a case of Refractory Acute myeloblastic leukemia, FLT3 and NPM1 negative status post MUD-Allogenous PBSCT on 2023/02/23
    • This time, poor appetite and severe mucositis were noted for one week. At ER, Laboratory test revealed leukocytosis, impaired renal function, hyperuricemia, hyperkalemia and elevated CRP level.
    • Under the impression of AKI and severe mucositis suspect fungus infection, he was admitted for further management. We need your expertise for antibiotics used, thanks
  • A
    • The 30 years old male is a case of Refractory Acute myeloblastic leukemia, FLT3 and NPM1 negative status post MUD-Allogenous PBSCT on 2023/02/23.
      • Mucositis: severe, Cough: severe
      • 2023/03/21 S/C: CR-AB
      • Cr: 2.45, uric acid: 17.8
    • Antibiotcs with tygacil for the CR-AB treatment.
    • Antifungal agents with mycamine for the mucositis with suspicious fungal infection.
• 2023-03-21 Urology
  • Q
    • occasionally dysuria was noted during hospitalization
    • After admission, AlloPBSCT was performed on 2023/02/23 (D0, 432ml, CD34: 5.69x10^6/kg, 15:00-15:10). ATG 2.5mg/kg on 2023/02/20-22, CSA 1.5mg/kg Q12H was administered since 2023/02/22.
    • However,occasionally dysuria was noted during hospitalization. Urine routine showed hematuria, proteinuria and bacteria. Empiric antibiotics with Mepem was administered. We need your expertise for further management, thanks
  • A
    • I perform bedside ultrasound for him on 2023/03/21 13:00
    • The residual urine was not much
    • There was no obvious renal stone, no hydronephrosis.
    • Conservative treatment and reduce too much medication may be helpful
• 2023-02-07 Infectious Disease
  • Q
    • will receive allo-PBSCT on 2023-02-23, we need your expertise for antibiotics evaluation,thanks
    • This time, followed up laboratory test revealed leukocytosis (WBC:94090, blast:61%) and will prepare alloPBSCT. He was admitted for further management
      
  • A
    • Consultation for Mycamine anti-fungal prophylaxis before PBSCT.
    • 30-year-old refractory AML male patient is admitted for chemotherapy followed by allo-PBSCT in the near future.
    • Mycamine can be indicated from the initiation of induction chemotherapy to recovery of neutrophil count (absolute neutrophil count > 500/uL for three consecutive days).
    • Dose of Mycamine should be reduced to 50mg iv qd.
• 2023-01-05 Oral and Maxillofacial Surgery
  • Q
    • The 30 years old male denied any systemic disease before. The initial presentations were back pain and dizziness with syncope in a morning. Therefore, he was brought to Cardinal Tien Hospital, Brain CT revealed no ICH then he was refered to our ER for advanced evaluation. At ER, there were no fever, no chest pain, no abdominal pain nor dysuria. The laboratory test revealed leukocytosis (WBC: 345330, blast: 82%), anemia (MCV: 85.7, Hb: 7.8), thrombocytopenia (PLT: 64K), hyperkalemia. Chest film disclosed no pneumonia patch. EKG showed normal sinus rythm. Bone marrow aspiration, biopsy and flow cytometry was performed on 20220818 proved acute leukemia. PICC insertion on 20220818.
    • Induction chemotherapy with C1 D3A7 was administered on 2022/08/22-28. Followed bone marrow biopsy showed hypercellular marrow (95%). The marrow space is nearly total replaced by a population of medium to large-sized immature cells with round to oval nucleus and moderate amount cytoplasm. - IHC: CD34 (+ in 90% marrow cells), CD117 (<3%), MPO (10%) and CD68 (20%). Family meeting held on 2022-09-21 and explained the poor condition to patient and his mother. Reinduction chemotherapy with C1 FLAG-IDA (selfpaid of Fludarabine) was administered on 2022/09/21-25, GCSF 450mcg on 09/26-10/11 after fully explaination to patient and family. Followed bone marrow aspiration and biopsy was performed on 2022/10/21 revealed acute myeloid leukemia, composed of hypercellular marrow (50%). The M/E ratio = 6:1.The megakatyocytes are increase in number. Scattered medium to large-sized immature cells in interstitium,constitue 25% of marrow cells in CD34 and CD117 immunostains
    • COVID-19 virus infection on 2022/10/08.
    • C2 FLAG (selfpaid of Fludarabine) was administered on 2022/10/31-11/04, GCSF 450mcg from 11/5-, half dose of Cytosar on 2022/10/31 due to impaired liver function.
    • He will receive the alloPBSCT on 2023/2/7, we need your expertise for oral examination before the alloPBSCT, thanks
  • A        
    • we have examined the patient and taken the dental panoramic film
    • a retained root of tooth 26 was present, which is suggested to be extracted prior to bone marrow transplant
    • we have planned to remove the tooth 26 tomorrow
• 2023-01-05 General and Gastrointestinal Surgery
  • Q
    • This time, he was admitted for scheduled chemotherapy
    • Owing to port-A infection, we need your expertise for port-A removal, thanks
  • A
    • S: a 30 y/o male patient is a case of acute myeloid leukemia s/p two courses chemotherpay. Due to Port-A infection, removal of it is consulted.
    • O: vital signs: stable, no fever
      • PE: Port-A over L’t subclavian region
      • lab data: see chart
    • A: Port-A infection
    • P: I will arrange Port-A removal, L’t on 20230105
• 2022-12-30 Infectious Diseases
  • Q
    • Neutropenic fever was noted on 2022/12/26 and empiric antibiotics with Tapimycin on 2022/12/26-27 then shifted to Doripenam from 2022/12/28 (D3), Targocid from 2022/12/26 (D5), antifungas with Mycamine from 2022/12/26 (D5), blood culture from port-A yielded Escherichia coli and urine culture yielded CRAB.
    • We need your expertise for antibiotics treatment, thanks
  • A
    • Consultation for neutropenic fever, MDR-E.coli bacteremia, and CRAB UTI.
    • Patient is receiving Finibax, Targocid and Mycamine now.
    • Finibax can cover the E.coli, but CRAB only suscpetible to Colimycin.
    • Addition of Colimycin is indicated for bacteremic combination therapy and UTI treatment, but there is AKI risk around 15 percent.
    • Suggestion:
      • Continue the present antibiotic regimen
      • Add Colimycin 4.5 vials iv stat, then 2.5 vials iv q12h for one week
      • Repeat blood culture today.
      • Repeat urinalysis and urine culture 5 days later.
• 2022-11-18 Dermatology
  • Q
    • For progressive mass and ecchymosis at left axillary regions
    • Due to shock and neutropenic fever, respiratory failure, he was transfer to MICU, heart echo was arranged, poor heart function, LVEF: 33.8%, Severely abnormal LV systolic function with global hypokinesia, under vasopressor use; Moderate to severe TR, trivial MR; Dilated LA, LV, RA and IVC, thick IVS. Under adeqaute weaning profile and SBT was smoothly, he did extubation on 2022/11/15 afternoon. Blood transfusion for anemia and thrombocytopenia. Progressive mass and ecchymosis at left axillary regions, we need your expert to evaluate his condition and give us advise. Thank A lot!
  • A
    • This patient suffered from mass on bil axillary area for days.
    • Imp: Hidradenitis supperativa
    • Suggestion:
      • Doxycycline 100mg/cap 1 / Bid
      • Fucidin (fusidic acid) * 2 tubes/bid
• 2022-11-12 Ophthalmology
  • Q
    • For bilateral eyelid bleeding
  • A
    • For redness ou, no bv, no pain
    • phx: AML with pancytopneia (PLT 20000)
    • O: [Bedside visit]
      • Conscious: clear, E4VTM6
      • VAcNC: OD 20/25 OS 20/30
      • IOP: soft by digits
      • Pupil: 3mm, light reflex + ou
      • Conj: SCH ou
      • K: clear ou
      • ac: deep/clear ou
      • lens: clear ou
      • c/d 0.4 pinkish ou, media clear ou
    • A: Subconjunctival hemorrahge ou, coagulopathy related
    • P:
      • Alminto (antazoline, tetrahydrozoline, chlorhexidine) 1gtt BID ou
      • control underlying disease
      • Informed the risk of massive hemorrhage due to thrombocytopenia
      • If symptom woren/bv, please contact us
• 2022-11-11 Cardiology
  • Q
    • For heart failure
    • Due to shock and neutropenic fever, respiratory failure, he was transfer to MICU, heart echo was arranged, poor heart function, LVEF: 33.8%, Severely abnormal LV systolic function with global hypokinesia, under vasopressor use; Moderate to severe TR, trivial MR; Dilated LA, LV, RA and IVC, thick IVS.
  • A
    • S
      • 30 year-old male had Refractory Acute myeloblastic leukemia.
        • hypotension+
        • tachycardia+
    • O
      • Lab
        • 2022/11/11 Cre 2.59 ALT 88 HB 7.7 PLT 17000 WBC 20 albumin 3.8
      • CXR 2022/11/11 cardiomegaly comparing to 2022/10/31
      • Echocardiogram 20221111
        • Findings
          • AO(mm) = 34 LA(mm) = 49
          • IVS(mm) = 14.3
          • LVPW(mm) = 10.9
          • LVEDD(mm) = 53.9
          • LVESD(mm) = 45.2
          • TAPSE(mm) = 15.6
          • mode (Teichholz) = 33.8
          • 2D (M-Simpson) = 32.1
          • TR: moderate to severe ; Max pressure gradient = 23 mmHg
          • IVC size 23.3 mm with inspiratory collapse <50%
        • Conclusion:
          • Severely abnormal LV systolic function with global hypokinesia, under vasopressor use
          • Moderate to severe TR; trivial MR
          • Dilated LA, LV, RA and IVC; thick IVS
          • Mild pulmonary hypertension
    • Impression
      • Heart failure with reduced EF, r/i cardiomyopathy
      • Febrile neutropenia
      • Acute leukemia
    • Suggestion
      • May give inotropic agent with dopamine
      • If tachycardia is concerned, may give digoxin or ivarbradine for impairing LVEF
• 2022-09-09 Colorectal Surgery
  • Q
    • The 30 y/o man has AML s/p chemotherapy with neutropenic fever stage, due to he complaint of anal pain, so we need your help for assessment.
  • A
    • S: this is a 30-year old man with anal pain for 2-3 days
    • DRE (Digital Rectal Examination): one tiny thrombus hemorrhoids about 0.5cm at 3o’clock region
    • A/P:
      • warm water sitz bath
      • pain control
      • add alcos-anal onitment bid use

[chemotherapy] (not completed)

• 2023-02-24 - methotrexate 15mg/m2 33mg NS 100mL 30min D1 + methotrexate 10mg/m2 22mg NS 100mL 30min D3(02/26), D6(03/01), D11(03/06)
  • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1, 3, 6, 11
• 2023-02-17 - busulfan 3.2mg/kg 250mg NS 400mL 3hr D1-4 + cyclophosphamide 60mg/kg 4900mg NS 500mL 4hr D5-6 (BuCy2, use ABW25)
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + granisetron 2mg D1-6 + NS 250mL D1-6 + aprepitant D5-6
• 2023-02-16 - busulfan 3.2mg/kg 250mg NS 400mL 3hr D1-4 + cyclophosphamide 60mg/kg 4662mg NS 500mL 4hr D5-6 (BuCy2, use ABW25)

  •                      diphenhydramine 30mg D1-6 + granisetron 2mg D1-6 + NS 250mL D1-6 + aprepitant D5-6

• 2023-02-09 - [fludarabine 30mg/m2 50mg NS 250mL 1hr + mitoxantrone 6mg/m2 13mg NS 500mL 3hr + cytarabine 2000mg/m2 4418mg NS 500mL 6hr] D1-4 (conditioning regimen)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-4
• 2023-02-01 - cytarabine 100mg NS 500mL D1-6 (Ara-C)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-6
• 2022-12-16
• 2022-12-15
• 2022-12-14
• 2022-11-04
• 2022-11-03
• 2022-11-02
• 2022-11-01
• 2022-10-31 - fludarabine 30mg/m2 68mg D1-5 + cytarabine 1500mg/m2 1700mg 4hr D1, D5, 3400mg 4hr D2-4 + idarubicin 6mg/m2 14mg 30min D3-4 (cytarabine half dose due to impaired liver function D1, D5)
  • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + palonosetron 250ug D1-5
• 2022-09-21 - fludarabine 30mg/m2 68mg D1-5 + cytarabine 1500mg/m2 3400mg 4hr D1-5 + idarubicin 6mg/m2 14mg 30min D3-4 (FLAG-IDA)
  • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + palonosetron 250ug D1-5
• 2022-08-22 - daunorubicin 45mg/m2 100mg 30min D1-3 + cytarabine 100mg/m2 220mg 24hr D1-7 (3+7, Daunoribicin/Cytarabine, Q4W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

[problem list / assessment / plans] - 2023-03-07

• Problem 1# Refractory Acute myeloblastic leukemia,FLT3 and NPM1 negative,status post induction chemotherapy with D3A7 on 2022/08/22 ~ 28, reinduction chemotherapy with C1 FLAG-IDA (selfpaid of Fludarabine) on 2022/09/21 ~ 25, C2 on 10/31 ~ 11/4, C3 on 12/14 ~ 18
• Assessment: MUD-Allogenous PBSCT on 2023-02-23 (D0) 432ml CD34 5.69x10^6/kg, at 15:00-15:10)
• Plan:
  • Add Atropine 1amp SC on 2023/03/02 due to much saliva
  • On NG and pain control with Xylocaine and Sucraflate 2pk,Durogesic 12ug/hr 1patch for mucositis   
  • Prophylaxis antibiotivcs with Cravit 1.5tab from 2/8-21, antifungas with Mycamine 50mg QD IVD from 2/8-(D24),then shifted to Tienam and Targocid from 2/22(D10), blood culture from Hickman yielded Staphylococcus capitis,sputum culture yielded KP
  • PPI with Pantoloc 1vial Q12h and Strocain 1tab TIDAC for epigastric pain
  • Conditioning regimen of MUD-Allogenous PBSCT on 2023/2/9-12 (FuCy Mito), on 2023/2/16-21 (BuCy-ATG), Dilantin 400mg QD on 2/13-20, MTX 15mg/m2 on 2/24(D1), 10mg/m2 on 2/26(D3),3/1(D6),3/6(D11) and Leucovorin 15mg Q6H for rescue, starting 12hrs after each MTX dose.
  • We adjust the Fludarabine dose by ABW25 (IBW + 0.25 x (TBW-IBW)), adjust Cyclophosphamide dose by ABW25
  • ATG 2.5mg/kg on 2023/02/20-22, CSA 1.5mg/kg Q12H was administered since 2023/02/22
  • keep the target Ciclosporin level 200-300
  • GCSF 450mcg from 2/24-
  • Blood transfusion with LPRBC(ZhaoGuang) and LRP(ZhaoGuang)for correct thrombocytopenia and anemia (In this context, “ZhaoGuang” refers to a leukocyte reduction process in which blood products such as LPRBC and LRP are exposed to ultraviolet light to inactivate leukocytes. This is done to reduce the risk of transfusion-related reactions and complications.)
  • check CSA level on QW14
  • Chemotherapy with Ara-C 100mg 24hrs as continuous infusion from 2023/2/1-2/6
  • Adequate hydration
  • Hydrea 2tab BID for leukocytosis on 1/27-2/1
  • regularly followed up laboratory test and monitor tumor lysis syndrome

[assessment]

• The patient showed signs of renal recovery. AKI developed in late March 2023 is resolved.
  • 2023-04-07 Creatinine 0.71 mg/dL
    
  • 2023-04-03 Creatinine 0.95 mg/dL
    
  • 2023-03-31 Creatinine 2.45 mg/dL
    
  • 2023-03-30 Creatinine 3.10 mg/dL

230403

[assessment]

• The patient’s kidney function results have returned to normal within the last 7 days.
  • 2023-04-03 Creatinine 0.95 mg/dL
    
  • 2023-03-31 Creatinine 2.45 mg/dL
    
  • 2023-03-30 Creatinine 3.10 mg/dL
    
  • 2023-03-28 Creatinine 3.74 mg/dL
    
  • 2023-04-03 eGFR 98.94
    
  • 2023-03-31 eGFR 33.16
    
  • 2023-03-30 eGFR 25.27
    
  • 2023-03-28 eGFR 20.35

230320

[cyclosporine IV to PO conversion]

• There are different recommendations for converting CsA administration from intravenous to oral in HSCT patients, ranging from a 1:1 to a 1:3 conversion rate. For patients receiving voriconazole, it is suggested to use a 1:1 conversion rate. However, for patients receiving fluconazole without azole co-medication, a 1:1.3 substitution is recommended to prevent CsA concentrations from becoming subtherapeutic. ref: Converting cyclosporine A from intravenous to oral administration in hematopoietic stem cell transplant recipients and the role of azole antifungals. Eur J Clin Pharmacol. 2018;74(6):767-773. doi:10.1007/s00228-018-2434-4

• Based on the intended IV dose of 190mg BID, the daily oral dose would range from 418 to 494mg. To start with, a feasible option would be to use Sandimmun Neoral, which is available as 4 100mg capsules, and 2 25mg capsules can be added to achieve the desired dose. The total dose can be divided into two administrations. However, it is important to monitor the patient’s cyclosporine blood levels at repeated intervals and make subsequent dose adjustments to avoid toxicity from high levels and possible rejection from low absorption of cyclosporine.

230310

[ciclosporin TDM]

• Based on the system records, the blood was drawn for ciclosporin at 2023-03-09 08:35, while the medication was administered at 08:24 on the same day. If the intended purpose was to measure the trough concentration, the ideal time for blood draw should be within half an hour before medication administration. Please verify the accuracy of the system records or redraw an blood sample.

230307

[therapeutic drug monitoring for cyclosporine]

• The dosage of cyclosporine has remained at 170mg Q12H since 2023-03-02. A blood sample was taken correctly on 2023-03-06 morning, just half an hour before the next scheduled administration. The trough level result was 266.6ng/mL, which falls within the target range of 100 to 400ng/mL without an issue.
• Based on the trough level result falling within the target range, no dosage adjustment is necessary.

[assessment]

• Today (2023-03-07) marks the 12th day since the Matched Unrelated Donor Allogeneic Peripheral Blood Stem Cell Transplantation. From the lab data, there is a noticeable upward trend in WBC count in the past two days, which is a positive sign.
  • 2023-03-06 D 11 WBC 0.70 x10^3/uL
    
  • 2023-03-05 D 10 WBC 0.28 x10^3/uL
    
  • 2023-03-03 D 8 WBC 0.01 x10^3/uL
    
  • 2023-03-02 D 7 WBC 0.01 x10^3/uL
    
  • 2023-03-01 D 6 WBC 0.01 x10^3/uL
    
  • 2023-02-27 D 4 WBC 0.02 x10^3/uL
    
  • 2023-02-27 D 4 WBC 0.02 x10^3/uL
    
  • 2023-02-26 D 3 WBC 0.04 x10^3/uL
    
  • 2023-02-24 D 1 WBC 0.07 x10^3/uL
    
  • 2023-02-23 D 0 WBC 0.01 x10^3/uL
    
  • 2023-02-22 D -1 WBC 0.01 x10^3/uL
    
  • 2023-02-20 D -3 WBC 0.09 x10^3/uL
    
  • 2023-02-19 D -4 WBC 0.09 x10^3/uL
    
  • 2023-02-17 D -6 WBC 0.23 x10^3/uL
    
  • 2023-02-15 D -8 WBC 0.86 x10^3/uL
    
  • 2023-02-13 D-10 WBC 1.36 x10^3/uL
    
  • 2023-02-12 D-11 WBC 1.70 x10^3/uL
    
  • 2023-02-10 D-13 WBC 4.40 x10^3/uL
    
  • 2023-02-08 D-15 WBC 9.26 x10^3/uL

230303

[therapeutic drug monitoring for cyclosporine]

• The dose of cyclosporine was increased from the original 140mg to 145mg on a later time on 2023-03-01, and further increased to 170mg on 2023-03-02, while the dosing frequency remained Q12H.

• The TDM for cyclosporine was performed on 2023-03-02 at 08:26:39, and the administration time was recorded as 2023-03-02 11:46. The scheduled administration times for Q12H should be 09:00 and 21:00, and the later actual administration time may be due to delayed medication or delayed registration in the system, so it is recommended to confirm the system usage with nursing staff. However, the 08:26 blood draw is consistent with the trough concentration at Q12H.

• Since the dose increase has not reached steady state, it is recommended to perform another blood draw in the middle of next week.

230301

[cyclosporine TDM]

• The cyclosporine TDM result was 79.3 ng/mL, with the blood sample drawn on February 27, 2023 at 09:09:34 and the medication given at 08:46 on the same day.
• Since the blood sample was drawn shortly after the medication was given, the measured concentration is unlikely to be a trough concentration.
• If a trough concentration is desired, a new blood sample should be drawn and tested.

230224

[therapeutic drug monitoring]

Sandimmun injection (ciclosporin)

• The recommended therapeutic trough concentration range for cyclosporine typically falls within 100-400 ng/mL. The current administration is 140mg IVD Q12H.

• Based on the TDM result on 2023-02-23 indicating a level of 43.3 ng/mL, it is suggested to administer a dosage of 180 mg per shot every 12 hours.

• It is also recommended to perform another blood test to examine the trough concentration in the latter half of next week.

230209

[assessment]

• 2023-02-08 Cre 0.72mg/dL, eGFR 136, BUN 19mg/dL, Bil T 0.7mg/dL, Bil D 0.1mg/dL, ALT 455 U/L, AST 123 U/L. The kidneys do not appear to be degraded.
  • Patient body height 180cm, body weight 97kg => BSA 2.2m2
• Selected chemotherapy drugs in the FuCyMito conditioning regimen
  • fludarabine 30mg/m2 => 66mg, compatible with D5W, NS, L-Ringer’s
    • 250mL NS, 1h is recommended.
    • There are no dosage adjustments provided in the manufacturer’s labeling; however, dosage adjustment for hepatic impairment is not likely necessary (Krens 2019).
  • cytarabine 2000mg/m2 => 4400mg, compatible with D5W, D5NS, Sterile water for injection
    • 500mL NS, 6hr is recommended. (according to Trad Chinese package insert, max conc is 100mg/mL)
    • Dose may need to be adjusted in patients with liver failure since cytarabine is partially detoxified in the liver. There are no dosage adjustments provided in the manufacturer’s labeling.
  • mitoxantrone 6mg/m2 => 13.2mg, compatible with D5W, D5LR, D5NS, NS, L-Ringer, Ringer
    • 500mL NS, 3hr is recommended.
    • There are no dosage adjustments provided in the manufacturer’s labeling; however, clearance is reduced in hepatic dysfunction.

230130

[assessment]

• The echocardiography performed on 2023-01-06 showed an improved LVEF (55% versus 33%) compared to 2022-11-11.

• Readings of bilirubin (direct/total) are within normal limits. AST/ALT levels indicate that impaired liver function is improving. There is no need to adjust the dose of medications in the active prescription for liver function. In addition, there is no laboratory evidence of impaired kidney function.

  • 2023-01-30 S-GOT/AST 60 U/L
    
  • 2023-01-28 S-GOT/AST 67 U/L
    
  • 2023-01-27 S-GOT/AST 78 U/L
    
  • 2023-01-30 S-GPT/ALT 129 U/L
    
  • 2023-01-28 S-GPT/ALT 154 U/L
    
  • 2023-01-27 S-GPT/ALT 193 U/L

• In spite of the fact that Hydrea (hydroxyurea) has been administered since 2023-01-27 afternoon, there has not been an obvious decrease in WBC counts since the second day of administration. The blast percentage remains around 60% with only minor fluctuations.

  • 2023-01-30 WBC 76.58 x10^3/uL
    
  • 2023-01-29 WBC 73.19 x10^3/uL
    
  • 2023-01-28 WBC 77.15 x10^3/uL
    
  • 2023-01-27 WBC 94.09 x10^3/uL
    
  • 2023-01-30 Blast 61.9 %
    
  • 2023-01-29 Blast 58.7 %
    
  • 2023-01-28 Blast 59.6 %
    
  • 2023-01-27 Blast 61.0 %

• The PLT count has been trending downward, which should be closely monitored.

  • 2023-01-30 PLT 87 x10^3/uL
    
  • 2023-01-29 PLT 85 x10^3/uL
    
  • 2023-01-28 PLT 111 x10^3/uL
    
  • 2023-01-27 PLT 148 x10^3/uL

• The active prescription does not pose a problem.

230127

[drug identification]

• We have been requested by the patient’s primary nurse to identify one drug. The drug is identified as Vemlidy (tenofovir alafenamide 25 mg) and is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults and pediatric patients 12 years of age and older with compensated liver disease. The in-hospital porter will return the identified drug to the ward.

• Not used:

  • The drug to be identified has not been received until the end of the working day.
  • As of the end of working hours, the drug to be identified has not been received.

700698086

230410

[exam findings]

• 2023-04-10 SONO - abdomen
  • Parenchymal liver disease
  • Fatty liver, mild
  • Mild CBD dilatation
  • Chronic kidney disease
  • Urinary retention
  • Minimal ascites
• 2023-04-06 MRI - brain
  • MR of the brain and MRA of the intracranial vessels and neck carotid systems were performed on a 1.5 T superconducting magnet on supine position utilizing head coil with 6 mm slice thickness and 24 cm field of view without intravenous injection of Gadolinium.
  • Findings:
    • One small cavernous malformation (5.3mm) over right posterior corona radiata.
    • Mild periventricular small vessel disease. NO acute ischemic infarct.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • Mild paranasal sinusitis.
• 2023-03-28 CXR
  • Solitary pulmonary nodule at right lower lung zone.
  • Normal appearance of trachea and bil. main bronchus.
  • Cardiomegaly.
• 2023-03-28 ECG
  • Sinus tachycardia
  • Voltage criteria for left ventricular hypertrophy
• 2023-03-07 CT - brain (at TMUH)
  • Computed tomography of the BRAIN was performed without i.v. contrast administration.
  • Findings:
    • No evidence of acute intracranial hemorrhage (ICH) or space occupying lesion is noted in this study.
    • Widening of the cortical sulci of bilateral cerebral hemispheres, mild dilatation the ventricles, the findings are indicating diffuse brain atrophy, due to aged brain change.
    • Normal mastoid air cells, no evidence of mastoiditis.
    • The paranasal sinuses are clear.
    • Clinical correlation and follow up is needed.
  • IMPRESSION:
    • No evidence of acute ICH or space occupying lesion is noted.
    • Diffuse brain atrophy, due to aged brain change.
• 2022-11-07 CT - chest (at TMUH)
  • Findings: Chest CT without IV contrast study that show: Lung window-setting is also obtained.
    • Still focal consolidative lesion and internal amorphous calcifications in LLL, relatively prominent, as compared with prior CT on 2022-08-19, consistent with post-treatment change.
    • New small nodules in RLL, favored metastatic nodules.
    • Mild left pleural effusion.
    • Mild fibrotic foci in bilateral lungs.
    • Arteriosclerotic changes with mural calcifications of aorta and coronary arteries, suspect CAD.
    • Degenerative spondylosis with marginal spur over thoracolumbar spine.
    • Otherwise, there is no evidence of masses in the anterior, middle and posterior compartment.
    • The hilar region on each side is unremarkable, and the main bronchi appear normal.
    • There is no lymphadenopathy and there are no perihilar masses.
    • The heart has a normal configuration; the cardiac chambers are normal size.
    • No evidence of abnormalities of liver, GB, pancreas, spleen, bilateral kidneys and adrenal glands.
  • IMPRESSION:
    • Post-treatment change of LLL, with focal consolidations and internal amorphous calcifications, relatively prominent, as compared with prior CT on 2022-08-19. Recommend follow-up.
    • But new presence of RLL metastatic nodules.
    • Mild left pleural effusion.
    • Mild fibrotic foci in bilateral lungs.
    • Arteriosclerotic changes with mural calcifications of aorta and coronary arteries, suspect CAD.

[consultation]

• 2023-04-06 Neurology
  • Q
    • Impression
      • Acute delirium, suspected psychotic symptoms due to other medical condition, especially brain metastesis and renal failure
    • Suggestion
      • Treat malignancy and renal failure first. Non-contrast brain MRI could not clearly show malignancy. Please arrange contrast-enhanced brain CT instead, but beware of deterioration of renal failure and risk of developing end-stage renal failure.
      • Please consult neurosurgeon for brain metastasis treatment.
      • Check TSH, free T4, cortisol, ACTH, VDRL, vitamin B12, and folic acid. Treat them accordingly if abnormal findings.
      • I agreed with the psychiatrist’s suggestion of anti-psychotic medication (quetiapine). Please contact psychiatrist for further anti-psychotic drugs adjustment.
• 2023-04-03 Nephrology
  • Q
    • For poor renal function, we need your further evaluation and management.
  • A
    • We visited the patient at the bedside and evaluated his condition. His consciousness was well, speech was coherent and showed no signs of distress. His limbs were not edematous.
    • He complained of poor appetite and minimal fluid intake over the past few days. Blood tests showed progressively deteriorating renal functions but he still urinates approximately 1L everyday.
      • 2023-04-03 BUN 65 mg/dL
        
      • 2023-04-03 Creatinine 5.29 mg/dL
        
    • Our advices are as follow:
      • consider ketosteril 2 PC PO TID
      • Keep daily I/O balance
      • CKD diet (Low K, low P)
      • Arrange renal sonography
      • OPD follow up prn
    • Please feel free to contact us should you require further assistance.
• 2023-04-03 Psychosomatic Medicine
  • Q
    • The patient is restless and keeps saying he wants to find Chen Shui-bian, claiming that Chen Shui-bian is his friend. He is making phone calls everywhere and asking for money from anyone he meets, and he keeps saying that he is going to die. He throws all his belongings on the bed and ties the IV stand to the bed curtain.
  • A
    • This 80-year-old married man previously worked in the construction industry. According to his daughter, he was able to arrange his life and had good memory and daily function, such as supervising construction work in Luodong and taking walks in the park, until one week ago when he developed agitated and disruptive behaviors, such as attacking family members and lying down on the road. He also experienced auditory hallucinations, reality distortion, and hallucinatory behaviors, such as believing that Chen Shui-bian would come to talk to him for 15 minutes every day and telling him to do things. Poor sleep and disturbing behaviors persisted after admission, such as frequently borrowing money from the nursing station and seeking out Chen Shui-bian. The other hospital had diagnosed him with brain metastases. Brain MRI showed white matter intensities.
    • During the mental status examination, he displayed incoherent and irrelevant speech, disorientation (unable to tell the date or how many days he had been hospitalized, and thought he was at VGHTPE), talkativeness, auditory hallucinations, reality distortion, and hallucinatory behaviors.
    • IMP:
      • Acute delirium
      • Suspected Psychotic disturbance due to other medical condition (brain metastesis)
    • Suggestion:
      • Treat physical disease if possible.
      • DC mirtazapine, DC anxiedin. DC PRN haldol. Add utapine 25mg 1# HS, 1# HSPRN. Bini-U 5mg IM PRNQ6H if severe disturbing. Monitor ECG and QTC.
      • Tapper codeine and morphine use if possible.

[SOAP]

• 2023-03-28 Medical Emergency
  • Hx of
    • Rectal cancer adenocarcinoma T3N0M0, stage IIA post anterior resection on 2015/1/23 and received radiotherapy about 45 Gy/25 fractions from 2015/02/23 to 2015/03/27 and lung metasteses, T3N0M1, stage IV in 2020, ECOG:2
    • Suspect obstructive pneumonitis
    • Left side pleural effusion
    • Hypertension
    • Chronic kidney disease, stage 4
  • Preliminary impression
    • C20 Malignant neoplasm of rectum
    • Agitation, Hx rectal Ca s/p op, R/T, lung metas (not treated), K 7 (hemolysis), F/U K 5, hsT 45 to 40, Hb 9, Cr 4.7, Hx HCVD, CKD

[multiteam]

• 2023-03-31 Social Service
  • Referral Date: 2023-03-29
  • Reason for Referral: Patient and family members have emotional distress during hospitalization
  • Status: Not opening a case
  • Reason for Not Opening a Case: On 2023-03-30, separate interviews were conducted with the patient and the patient’s daughter:
    • Family Situation:
      • The patient is an 80-year-old married man with three daughters and one son. He is suffering from rectal cancer and has received treatment at TMUH in the past. He used to live alone in Yilan, but has been living with his son’s family in Taipei in recent years.
      • The patient’s wife is bedridden; the patient’s children are all married. The patient’s son and daughter-in-law currently live with the patient and the patient’s daughter in Zhonghe District. The patient’s daughter is currently unemployed and takes care of the patient full-time.
    • Assessment and Treatment:
      • The patient was admitted to the hospital due to a suicide attempt, which had been reported upon his arrival at the emergency department.
      • A social worker visited the patient’s ward today and found that the patient’s mood was stable, and he even smiled during the conversation. The patient said that he was feeling emotionally stable at the moment, but had trouble sleeping the night before. He was only able to fall asleep after being given sleeping pills. The patient also said that he did not remember what had happened before his hospitalization and was unsure who he was living with now.
      • The social worker talked with the patient’s daughter, who said that the patient’s recent abnormal behavior was likely caused by his illness, and the patient has forgotten what had happened during that time. The patient’s mood is stable when there are family members accompanying him. The patient’s daughter said that the patient has not yet received treatment from any relevant departments regarding his condition. However, she plans to take the patient to see a neurologist and other relevant departments in the future. The patient’s daughter is also currently taking care of the patient full-time and will continue to monitor his emotional changes.
      • This referral provides the above assessment and treatment information. It is confirmed that the patient’s suicide attempt had been reported upon his arrival at the emergency department. During his hospitalization, the patient’s mood has been stable, and he has cooperated with relevant medical treatments. The patient’s children are supportive and able to monitor his emotional changes in a timely manner. There are currently no emerging issues.

701240721

230410

[diagnosis] - 2023-04-07 discharge note

• Left lip and left buccal cancer, cT4aN2cM0, stage IVA

[exam findings]

• 2023-03-20 Nasopharyngoscopy
  • Findings
    • left nasal cavity clear, nasopharynx smooth, mucus at right nasopharynx, oropharynx and hypopharynx np
  • Diagnosis/Conclusion
    • left buccal and upper and lower lip cancer
• 2022-09-12 ECG
  • Atrial fibrillation
• 2022-05-05 MRI - larynx
  • Imaging Report Form for Oral Cavity Carcinoma
    • Impression (Imaging stage) : T:4a(T_value) N:2c(N_value) M:0(M_value) STAGE:IVA(Stage_value)
• 2022-05-05 Patho - duodenum biopsy
  • Duodenum, bulb, biopsy — capillary hemangioma
• 2022-05-04 PET
  • Glucose hypermetabolism in the left buccal region, compatible with the primary left buccal cancer.
    
  • Glucose hypermetabolism in the left cervical lymph nodes and bilateral submandibular lymph nodes, highly suspected cancer with regional lymph nodes metastases.
    
  • Glucose hypermetabolism in the right N-P region, the nature is to be determined (another primary NPC, metastatic lesion, inflammation/infection process or others ?), suggesting biopsy for further investigation.
    
  • Glucose hypermetabolism in bilateral palatine tonsils, probably inflammation/infection process.
  • Left buccal cancer, cT4aN2cM0, stage IVA (AJCC, 8th ed.); suspected another right N-P tumor, nature ? by this F-18 FDG PET scan.
• 2022-05-03 ECG
  • Atrial fibrillation with rapid ventricular response
  • Abnormal ECG
• 2022-04-19 Patho - gingival/oral mucosa biopsy
  • Labeled as “lower lip area”, biopsy — squamous cell carcinoma.
  • Labeled as “left buccal area”, biopsy — squamous cell carcinoma.
  • Section shows squamous cell carcinoma.
  • IHC stain: p16 (-).

[SOAP]

• 2022-09-26 General Surgery
  • bulla aspiration
• 2022-05-12 Ear Nose Throat
  • left lip and left buccal SCC, cT4aN2cM0
  • patient hope bony structure preservation
  • explanation about induction chemotherapy + op (wide excision + left MRND + right SND + tracheotomy + free flap reconstruction) + post-op CCRT
  • consult GS for port-A insertion

[chemotherapy]

• 2023-04-06 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-03-22 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-11-30 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-11-11 - docetaxel 40mg/m2 50mg NS 200mL 1hr + cisplatin 40mg/m2 50mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-11-04 - docetaxel 40mg/m2 70mg NS 200mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-10-20 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 2hr + fluorouracil 2000mg/m2 4000mg NS 500mL 46hr (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-10-14 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 2hr + fluorouracil 2000mg/m2 4000mg NS 500mL 46hr (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

[note]

TPF regimen (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11)

Neoadjuvant Chemotherapy regimen

• TPF
  • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
  • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
  • 5-FU 750~1000 mg/m2 IVD (24 hs) D1-2, D8-9
  • Q3W for 1~3 cycles
  • H&N commission suggestion
  • References: Modified from Posner MRI et al. N.Engl.J.Med.357 (2007):1705-1715.
• Induction Chemotherapy modified with TPF
  • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
  • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
  • 5-FU + Leucovorin 1000mg/m2 + 100mg/m2 IVD (24 hs) D2, 9
  • Q3 week x 3cycles (Q1W, Q2W, Q3W: rest)
  • H&N commission suggestion
  • References: Modified from Jerome Fayette et al. Oncotarget 2016；7(24):37297-37304

[assessment]

• There was a gap in follow-up from early 2022-12 to mid 2023-03. The recommended dose of docetaxel and cisplatin in the TPF regimen for head and neck cancer, as listed in the in-hospital collection of chemotherapy regimens as of 2022-02-11, was 40mg/m2 for both drugs. However, the actual administered doses of the two drugs ranged from 50mg to 80mg. For fluorouracil, except for the first 2 doses at 4000mg, all other administrations since 2022-11 were at 3000mg.
• If the patient’s dyspnea occurred on 2023-04-06 or 2023-04-07, the TPF dose administered on 2023-04-06 (the 7th dose) was docetaxel 60mg, cisplatin 60mg, and fluorouracil 3000mg all at a reduced amount, which might be less likely to cause dose-dependent adverse reactions. Is it possible that the patient experienced an infusion reaction? If this possibility cannot be ruled out, it may be worth trying a slower infusion rate or adding famotidine 20mg IVD as part of premedication in the next administration.

700183019

230406

[exam findings]

• 2023-02-08 Whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, some C- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees, in whole body survey.
  • IMPRESSION:
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, some C- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees.
• 2023-02-08 MRI - nasopharynx
  • Imaging Report Form for Oropharynx Carcinoma
    • Impression (Imaging stage): T:2(T_value) N:2cP16-, N2 P16+(N_value) M:0(M_value) STAGE:IVA P16-; II P16+(Stage_value)
• 2023-02-07 SONO - abdomen
  • Liver cyst, S7
  • Gallbladder polyp or stone
• 2023-01-27 Patho - nasopharyngeal/oropharyngeal biopsy
  • Tonsillar, left, biopsy — Squamous cell carcinoma, non-keratinizing and poorly differentiated (p16+)
  • Immunohistocyhemical stain reveals p16: positive (> 90%), CK: positive, and P40: positive
• 2023-01-20 Nasopharyngoscopy
  • Findings
    • refer from neuro OPD
    • Suggest ENT evaluation.
  • Diagnosis/Conclusion
    • Nasopharyngoscope:
      • left deviated septum, bil. boggy turbinate
      • although NP was smooth, but MRI showed mild mucosal thickening at right lateral nasopharyngeal recess.
    • Oral:
      • left tonsillar hypertrophy - tumor lesion should rule out
      • biopsy done
• 2023-01-12 MRA - brain
  • Indication: still complained about vertigo and unsteadiness
  • IMP:
    • Cerebral small vessel disease.
    • Mild mucosal thickening at right lateral nasopharyngeal recess. Suggest ENT evaluation.
• 2022-11-16 Mini-Mental Status Examination
  • MMSE 23
• 2022-11-16 Clinical Dementia Rating
  • CDR 0.5
• 2022-11-10 Brainstem auditory evoked potentials, BAEP
  • Findings: Normal waveforms, amplitudes, peak latencies, interpeak intervals following click stimulaion to each ear.
  • Conclusion: This is a normal BAEP study.
• 2022-11-10 Neurosonology
  • Minimal atherosclerosis in bilateral CCA bifurcations.
  • Normal PSV in bilateral ICA and CCA. Normal ICA/CCA PS ratio bilaterally
  • Adequate total VA flow (135) may suggest no evidence of VBI
• 2021-07-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (83.5 - 18.3) / 83.5 = 78.08%
    • M-mode (Teichholz) = 78.1
  • Conclusion:
    • Normal AV with no AR
    • Normal MV with trivial MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • No PR, no TR, normal IVC size

[chemotherapy]

• 2023-03-22 - carboplatin AUC 2 120mg D5W 500mL with NS 1000mL (CCRT, carboplatin determ by AUC 2)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-15 - cisplatin 40mg/m2 70mg NS 500mL with with NS 1000mL (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-07 - cisplatin 40mg/m2 70mg NS 500mL with with NS 1000mL (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

• Most patients achieve cooling of the oral mucosa through intraoral administration of ice chips during chemotherapy administration. This is a cost effective and proven beneficial treatment.

• Both topical and systemic analgesic approaches have been used to manage pain associated with mucositis.

  • Topical lidocaine solutions provide pain relief but require frequent administration. In one trial, topical viscous lidocaine (2 percent) was more effective than diphenhydramine and saline, a kaolin and pectin suspension, or placebo. ref: Treatment of radiation- and chemotherapy-induced stomatitis. Otolaryngol Head Neck Surg. 1990;102(4):326-330. doi:10.1177/019459989010200404
  • Topical lidocaine is frequently combined with cleansing and/or coating agents, a mixture that is often referred to as “miracle mouthwash.” There is no fixed formulation, and these mixtures are compounded differently by individual pharmacies, most of which have no set formula. ref: Survey of topical oral solutions for the treatment of chemo-induced oral mucositis. J Oncol Pharm Pract. 2005;11(4):139-143. doi:10.1191/1078155205jp166oa

• Currently, lidocaine 2% PO PRNQD and tramadol IVD PRNQ6H have been prescribed.

• The diet should be limited to foods that do not require significant chewing; acidic, salty, or dry foods should be avoided.

• If poor feeding compromises the patient’s nutritional status, placement of a nasogastric feeding tube may be considered.

700360398

230406

[diagnosis] - 2023-04-03 discharge note

• Immune thrombocytopenic purpura
• Essential (primary) hypertension

[lab data]

• 2023-02-23 HBsAg Nonreactive
  

• 2023-02-23 HBsAg (Value) 0.35 S/CO
  

• 2023-02-23 Anti-HCV Nonreactive
  

• 2023-02-23 Anti-HCV Value 0.07 S/CO
  

• 2023-02-23 Anti-HBs 11.15 mIU/mL
  

• 2023-02-23 Anti-HBc Reactive
  

• 2023-02-23 Anti-HBc-Value 6.43 S/CO
  

• 2023-02-23 Anti-HBc IgM Nonreactive
  

• 2023-02-23 Anti-HBc IgM Value 0.10 S/CO

• 2023-02-10 ANA Negative
  

• 2023-02-10 LA1 39.3 sec
  

• 2023-02-10 LA2 30.7 sec
  

• 2023-02-10 LA1/LA2 ratio 1.2

• 2023-02-08 Anti-Cardiolopin IgG 0.7 GPL-U/mL
  

• 2023-02-08 Anti-cardiolipin-IgM <0.8 MPL U/mL
  

• 2023-02-08 Anti-β2-glycoprotein-I Ab 0.9 U/mL
  

• 2023-02-08 Anti-ENA Sm 1.2 EliA U/ml
  

• 2023-02-08 Anti-ENA RNP 1.1 EliA U/ml

[SOAP]

• 2023-03-10 Hemato-Oncology
  • Plan:
    • continue steroid therapy
    • arrange admission for mabthera therapy
• 2023-02-15 Hemato-Oncology
  • Assessment:
    • ITP, suggest steroid therapy 1 mg/kg
  • Plan:
    • continue steroid x 1 week
    • suggest bone marrow study if persisted thrombocytopenia
• 2023-02-08 Hemato-Oncology
  • S/O
    • He was referred on account of thrombocytopenia, referred from Cardinal Tien Hospital. Dr. Ou
      • 2021-10-24 PLT 135K/cumm
      • 2023-01-11 PLT <10K
      • 2023-01-16 PLT <10K
      • 2023-01-25 PLT <10K
      • 2023-02-08 PLT <10K
    • Past history: Nothing in particular.
    • Family history: No systemic disease in the family members.
    • Personal history: Smoking (no), alcohol consumption (no), betel nut chowing (no)
    • Allergy: NKA.
    • Travel history: No traveling history within one month.
    • Occupation: None
  • Assessment
    • ITP, suggest steroid therapy 1 mg/kg
  • Plan
    • Check BCS
    • Check CBC&DC, PT, aPTT, bleeding time and stool OB
    • Check CXR

[immunotherapy]

• 2023-04-03 - rituximab 375mg/m2 700mg NS 500mL 8hr
  • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL
• 2023-03-17 - rituximab 375mg/m2 700mg NS 500mL 8hr
  • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL
• 2023-02-23 - rituximab 375mg/m2 700mg NS 500mL 8hr
  • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL

[assessment]

• The patient’s PharmaCloud is currently inaccessible. However, based on in-hospital records, the patient received prednisolone at a dose of 80mg daily from 2023-02-08 to 2023-02-22, and dexamethasone at a dose of 8mg daily from 2023-03-10 to 2023-04-07. The patient also received rituximab on 2023-02-23, 2023-03-17, and 2023-04-03.

• The peak in PLT count on 2023-03-01 occurred approximately 1 week after the first dose of rituximab and was not during steroid administration. There has been no similar increase since the second dose of rituximab. It is possible that this peak was due to the delayed effect of rituximab, which can take some time for platelet production to increase after treatment. However, without further information, it is difficult to determine the exact cause. Close monitoring of the patient’s platelet levels and response to treatment is recommended.

  • 2023-04-03 PLT 7 x10^3/uL
    
  • 2023-03-24 PLT 6 x10^3/uL
    
  • 2023-03-17 PLT 27 x10^3/uL
    
  • 2023-03-10 PLT 4 x10^3/uL
    
  • 2023-03-01 PLT 113 x10^3/uL
    
  • 2023-02-27 PLT 13 x10^3/uL
    
  • 2023-02-24 PLT 21 x10^3/uL
    
  • 2023-02-23 PLT 1 x10^3/uL
    
  • 2023-02-22 PLT 1 x10^3/uL
    
  • 2023-02-15 PLT 1 x10^3/uL
    
  • 2023-02-08 PLT 2 x10^3/uL

• Lab data from 2023-02-08 and 2023-02-10 showed normal values for ANA, LA1, LA2, LA1/LA2 ratio, anti-cardiolipin IgG, anti-cardiolipin IgM, anti-beta2-glycoprotein-I Ab, anti-ENA Sm, anti-ENA RNP, and PT, INR, APTT.

• In the event that rituximab is no longer effective, splenectomy or TPO-RAs may be considered options.

700028729

230403

{EGFR wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stageIVB - not completed}

[diagnosis] - 2023-04-02 admission note

• Malignant neoplasm of upper lobe, right bronchus or lung
• Secondary malignant neoplasm of liver and intrahepatic bile duct
• Chest pain, unspecified
• Acute kidney failure, unspecified

[past history]

• Denied history of Hypertension, DM, asthma
• Denied any operation, accident and other medical Hx.                            

[allergy]

• NKDA         

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes. 

[exam findings]

• 2023-04-02, -03-09, -02-10, -02-06 CXR
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • S/P port-A implantation.
  • Patchy opacity projecting in the right upper lung shows stationary.
    
  • Peri-bronchial wall thickening of bilateral lower lung zone is noted, which may be due to old inflammatory process. Please correlate with clinical history and symptom.
• 2023-03-24 MRI - branchial plexus
  • Indication: right arm pain from shoulder to arm, twitching like. better on lying down and hot packing. motion exacerbated.
  • Phx: lung ca.
  • MRI of brachial plexus without/with Gadolinium-based contrast enhancement shows:
    • multiple heterogeneously enhancing tumors at right supraclavicular region, right intercostal spaces, and right upper mediastinum, involving right ribs, right hemithorax apex, and involving right brachial plexus.
    • multiple high signal lesions in visible spine and ribs, compatible with bone metastases.
    • massive left pleural effusion.
  • Impression:
    • Multiple tumors at right supraclavicular region, right intercostal spaces, and right upper mediastinum, involving right ribs, right hemithorax apex, and involving right brachial plexus.
    • Multiple ribs and spine metastases.
• 2023-01-19 SONO - nephrology
  • Left small kidney with chronic parenchymal changes.
  • Hyperechoic pyramids, both kidney, suspected nephrocalcinosis secondary to hypercalcemia, suspected gout or anagelsic nephropathy.
  • Bilateral plerual effusions.
• 2023-01-17 Abdomen - standing (diaphragm)
  • Right side Pneumothorax with air-fluid level at right CP angle.
  • Peri-bronchial wall thickening of the left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • There are several small stones in bilateral kidney?
  • Please correlate with sonography.
  • Few small calcification projecting at left lower pelvis are noted that may be ureter stones or old granulomas?
• 2023-01-16 SONO - chest
  • Special Procedure:
    • Pleural tapping 16 #-needle Right side 950ml yellowish, clear
    • Pleural tapping 16 #-needle Left side 1080ml yellowish, clear
  • Echo diagnosis:
    • Bilateral massive pleural effusion, post left diagnostic and bilateral therapeutic thoracentesis.
• 2023-01-14, -01-05 CXR
  • Patchy opacity projecting in the right upper lung
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • Emphysematous change of both lung field
• 2022-12-29 CT - chest

EGFR wild type Adenocarcinoma of RUL with liver metastases,T4N0M1c,stageIVB

Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)

Chest CT without IV contrast ehnancement shows: Chest: S/p port-A placement with its tip at Superior vena cava. Massive bilateral pleural effuison and loculated effusion at right hemithorax is found. Patent airway is found. There is no evidence of mediastinal LAP

Visible abdomen: Atrophy of both kidneys are found. The GB is well distended without soft tissue lesion The spleen, pancreas and adrenals are intact. Low density lesion at S4 and S2 of liver is found. Liver meta is considered. In comparison with CT dated on 2022-09-28, regression of the tumor is found. There is no evidence of paraarotic LAPs. There is no ascites accumulation at abdominal cavity. Suggest clinical correlation

Imp: Loculated effusion at both hemithorax. Liver tumor, in regression.

• 2022-12-27 SONO - chest
  • Bilateral thorax: large amount pleural effusion s/p drainage of left side, 850 cc, yellowish pleural effusion.
• 2022-12-06 KUB
  • There are several small stones in bilateral kidney? Please correlate with sonography.
  • Few small calcification projecting at left lower pelvis are noted that may be ureter stones or old granulomas?
• 2022-09-28 CT - abdomen

History:眩暈,想吐,表偶爾會流鼻水,有血絲 Nausea without vomit for 2-3 days, mild dizziness SOB sometimes, very mild Abd distension since last chemo(6 days ago) 20220705 CT：RUL lung ca & liver mets;T3N2M1c, cSTAGE:IVB

MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.

This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.

Findings: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. There are bilateral extensive destructive centrilobular emphysema with upper lobes predominant. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT. 3. Prior CT identified few cysts in S1 and S2 are noted again, stationary. 4. There are several renal stones, bilateral. Both kidney show small size and thin parenchyma that are c/w chronic renal disease. 5. There is no hyper-or hypodense lesion in the gallbladder, biliary system, pancreas, and spleen. There is no ascites or lymphadenopathy. There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable. There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.

IMP: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT.

• 2022-09-28 KUB
  • increased air in nondistended loops of small bowel over LUQ and LLQ, could be paralytic ileus.
• 2022-09-28 CXR
  • areas of hyperlucency and decreased lung vascular markings dirty marking due to emphysematous change of both lungs upper lung predominance
  • ill-define consolidation in peripheral of RUL due to tumor
• 2022-08-09 ALK Immunostaining Result
  • The immunostaining of the section slide labeled S2022-11085, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining of tumor cells.
• 2022-07-20 CT - brain
  • no evidence of brain tumors.
• 2022-07-26 ROS1 fluorescent-in-situ hybridization (FISH) report
  • Result
    • Number of invasive tumor cells counted: 50
    • Number of observers: 1
    • Number of cells (%) classified as negative: 48 (96%)
    • Number of cells (%) classified as positive: 2 ( 4%)
  • Interpretation
    • Rearrangement of ROS1 gene is NOT detected. Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
• 2022-07-15 PD-L1 (SP142)
  • Pathologic Report for VENTANA PD-L1 (SP142) Assay for Non-Small Cell Lung Cancer
    • Tumor type: Adenocarcinoma, metastatic
    • Tumor location: Liver
    • Testing assay: SP142 Assay (Ventana)
    • Control slide result: [V]Pass, [ ]Fail
    • Adequate tumor cells present (>=100 viable tumor cells): [V] Yes, [ ] No
  • Result:
    • Tumor Cell Staining Assessment:
      • PD-L1 Expression: Absence of any discernible PD-L1 membrane staining in tumor cells (TC < 50%)
    • Tumor Infiltrating Immune Cell Staining Assessment:
      • PD-L1 Expression: < 3% Immune cells (IC < 10%)
  • Note:
    • Percent of PD-L1 expression in tumor cells (TC): The percentage of viable tumor cells with membrane positivity at any intensity
    • Percent of PD-L1 expression in immune cells (IC): The percentage of tumor-infiltrating immune cells with discernible staining of any intensity
• 2022-07-15 EGFR mutation
  • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen.
    • EGFR Status: no mutation detected
    • EGFR Mutation Status: no mutation detected
  • Description
    • The EGFR mutation testing was based on real-time PCR technique for detection of exons 18 (G719X), 19 (Deletions), 20 (T790M, S7681I, Insertions), 21 (L858R, L861Q) mutations of EGFR gene. The limit of detection (LoD) of this test was 10% mutant gene of whole EGFR gene.
• 2022-07-13 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 25 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, sternum, some T-spine, bilateral shoulders, S-I joints, and knees, in whole body survey.
  • IMPRESSION:
    • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, sternum, some T-spine, bilateral shoulders, S-I joints, and knees.
• 2022-07-12 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Adenocarcinoma, metastatic, consistent with lung primary
  • The sections show a picture of adenocarcinoma, composed of liver tissue with nests and cords of polygonal neoplastic cells in fibrous stroma. Focal glandular differentiation and tumor necrosis are present.
  • IHC shows: CK7(+), CK20(-), TTF1(+), Arginase-1(-), and Hepatocyte(-). The finding is consistent with metastatic adenocarcinoma, lung primary.
• 2022-07-09 CTA - chest
  • PH: emphysema
  • With and Without contrast Chest CT and CTA showed
    • emphysematous change in the bilateral lung fields; a heterogeneous enhancing lesion, about 52mm, in the upper lobe of the right chest. suspected chest wall or pleural tumor or lung tumor. Irregular margins was noted.
    • multiple heterogeneous ill-defined tumors in the bilateral lobes of the liver, esp. left side
      
    • small bilateral renal stones.
  • IMP:
    • suspected right pleural or lung tumor
    • mulitple hepatic tumors
• 2022-07-05 CT - chest
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1c(M_value) STAGE:____(Stage_value)
• 2022-07-02 CXR
  • upper lung hyperlucency and decreased upper lung vascular markings due to emphysema
  • Rt apicolateral pleural effusion or thickening

[SOAP]

• 2022-09-22 Hemato-Oncology
  • EGFR, ROS1, ALK all wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stageIVB
  • No fit for cisplatin doublet due to imparied renal function
    • ChatGPT: “Cisplatin doublet” is a type of chemotherapy regimen used to treat various types of cancer, such as lung cancer, bladder cancer, and ovarian cancer. It consists of a combination of two chemotherapy drugs, with cisplatin being one of them, and the other drug depending on the specific cancer being treated. The doublet regimen is used to increase the effectiveness of chemotherapy by combining two drugs with different mechanisms of action, which can enhance tumor cell kill and reduce the likelihood of drug resistance.
• 2022-08-23 Hemato-Oncology
  • Fail alimta but starting with weekly taxane
• 2022-07-29 Hemato-Oncology
  • BH 169, BW 52
  • EGFR wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stage IVB

[chemotherapy] (not completed)

• 2023-01-05 - docetaxel 35mg/m2 54mg D5W 150mL 1hr (WBC 1.3K/uL 2023-01-12, WBC 2.15K/uL 2023-01-14)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

• 2022-12-15 - ditto (WBC 1.87K/uL 2022-12-22, WBC 1.42K/uL 2022-12-26)

• 2022-12-01 - ditto (WBC 2.54K/uL 2022-12-13)

• 2022-11-15 - ditto (WBC 2.67K/uL 2022-11-29)

• 2022-11-03 - ditto

• 2022-10-25 - ditto

• 2022-10-18 - ditto

• 2022-10-06 - ditto

• 2022-09-22 - ditto

• 2022-09-15 - ditto

• 2022-09-01 - ditto

• 2022-08-25 - ditto

• 2022-08-10 - ditto

• 2022-07-19 - pemetrexed 500mg/m2 818mg NS 100mL 10min + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[medication]

• G-CSF (filgrastim 150ug) CGCSF01
  • 2022-12-26 - 2022-12-26 IPD
  • 2022-12-13 - 2022-12-13 OPD
  • 2022-11-29 - 2022-11-29 OPD
  • 2022-08-23 - 2022-08-23 OPD
  • 2022-08-07 - 2022-08-07 IPD
• Granocyte (lenograstim 250ug) CGRAN01
  • 2023-01-12, 13, 14 - 2023-01-12 OPD

[assessment]

• The patient is currently undergoing supportive and palliative treatment to alleviate his symptoms.
• Cisplatin was not administered due to his insufficient renal function.
• He experienced several episodes of leukopenia during chemotherapy, for which G-CSF was used to mitigate the side effects.
• The last dose of docetaxel was administered on 2023-01-05.

700871378

230403

[diagnosis] - 2023-04-02 admission note

• Diffuse large B-cell lymphoma, unspecified site
• Essential (primary) hypertension
• Chronic viral hepatitis B without delta-agent

[past history]

• hypertentsion under medication control for 20+ years

[allergy]

• NKDA                             

[family history]

• Younger sister has lymphoma

[lab data]

2023-04-03 HBsAg Nonreactive
2023-04-03 HBsAg (Value) 0.52 S/CO
2023-04-03 Anti-HBc Nonreactive
2023-04-03 Anti-HBc-Value 0.91 S/CO
2023-04-03 Anti-HCV Nonreactive
2023-04-03 Anti-HCV Value 0.05 S/CO
2023-04-03 Anti HTLV I/II Nonreactive
2023-04-03 Anti HTLV I/II Value 0.05 S/CO
2023-04-03 HIV Ab-EIA Nonreactive
2023-04-03 Anti-HIV Value 0.06 S/CO
2023-04-03 CMV_IgG Reactive
2023-04-03 CMV_IgG Value 213.4 AU/mL
2023-04-03 CMV IgM Nonreactive
2023-04-03 CMV IgM Value 0.23 Index

[exam findings]

• 2023-02-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (82.6 - 11.9) / 82.6 = 85.59%
    • M-mode (Teichholz) = 80.1
    • 2D(M-simpson) = 75.3
  • Conclusion:
    • Thickened AV with mild AR
    • Normal MV with no MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • No PR, no TR, mildly dilated LA
• 2023-02-17 Myocardial perfusion SPECT with persantin
  • The Tl-201 stress myocardial perfusion SPECT performed after intravenous injection 33.6 mg of dipyridamole revealed mildly decreased perfusion of radioactivity to the apex and inferolateral wall. The Tl-201 redistribution myocardial perfusion SPECT revealed reperfusion of radioactivity to the defects and mildly decreased perfusion of radioactivity to the posterior wall.
  • IMPRESSION:
    • Probably mild myocardial ischemia at the apex and inferolateral wall.
    • Mild reverse redistribution of radioactivity to the posterior wall, either normal variant or myocardial ischemia may show this picture.
• 2023-02-16 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2023-02-16 CT - chest
  • Triple hit, non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Minimal fibrotic change at left lingula lobe is found. Probably due to previous RT
      • The left breast tumor cannot be visualized in the study.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • No evidence of bilateral pleural effusion.
      • S/p port-A placement with its tip at Superior vena cava.
    • Visible abdomen:
      • Bilateral renal cysts are found
      • The spleen, liver, pancreas and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • IMp:
    • Left breast cancer s/p RT and C/T without evidence of recurrent/residual tumor in the lung fields.
    • Suggest closely follow up.
• 2022-11-02 CT - chest
  • Impression:
    • resolution of Lt breast tumor compared with CT on 2022-07-28.
    • extensive V-CAD, suggest further test for evaluation any hemodynamically significant stenosis of coronary arteries.
• 2022-09-24 KUB
  • S/P left femoral operation.
  • Atherosclerosis of the aorta.
• 2022-08-02 Patho - bone marrow biopsy
  • Bone marror, biopsy— Negative for malignancy
  • Immunohistochemical stain revesls CD 20 (sparse +, < 5%), CD138 (sparse +, < 2%), CD71(+), MPO(+).
• 2022-08-01 Whole body PET scan
  • Glucose hypermetabolism lesions in the left breast (Deauville score 5), compatible with lymphoma in the left breast.
    
  • Glucose hypermetabolism lesions in the left N-P region (Deauville score 5) and in bilateral axillary regions (Deauville score 3-4), the nature is to be determined (lymphoma or chronic inflammation/infection process ?), suggesting further investigation.
  • Glucose hypermetabolism lesions in bilateral pulmonary hilar regions, right mediastinal space, bilateral palatine tonsils, and left hip joint, probably benign in nature.
  • Lymphoma in the left breast, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2022-07-28 CT - lung
  • Left breast cancer with left hilar lymphadenopathy
• 2022-07-14 Patho - breast biopsy
  • Breast, left, core biopsy — Diffuse large B-cell lymphoma, in favor of non-GCB type
  • Section shows cores of breast tissue with invasion of large, pleomorphic tumor cells.
  • The immunohistochemical stains reveal CK(-), CD20(+), CD3(-), CD10(< 10% +), BCL6(> 90%+), BCL2(> 80% +), MUM1(> 80% +), cMYC(30% +), Cyclin D1(-). The Ki-67 is >90% positive. The results are in favor of non-GCB type of diffuse large B-cell lymphoma.
• 2022-07-12 SONO - breast
  • Diagnosis:
    • Highly suspicious of malignancy, with sonographic negative axillary LNs
      • clacification
      • lipomas
  • Plan:
    • Core-needle biopsy
  • Suggestion:
    • Regular OPD follow-upsonography guided core biopsy of L’t breast tumor (1,1)
    • BI-RADS 4A - low suspicion for malignancy Biopsy Should Be Considered
• 2022-07-04 Mammography
  • A 2.8cm lobular hyperdense mass with obscured margin at left subareolar breast.
  • BI-RADS category 0, Need additional imaging evaluation.
  • Suggest ultrasound correlation for left breast tumor.

[consultation]

• 2023-04-03 Vascular Surgery
  • Q
    • A case of Triple hit ,non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1
      • will receive PBSC harvest this time, we need your expertise for double lumen insertion on 2023/04/14, thanks
  • A
    • I have had the pleasure of involving with the patient’s care. In brief, this patient is a 69 year old female seen in consultation for opinion regarding treatment options for double lumen insertion on 2023-04-14.
    • The pt’s hx/Dx was noted for
      • Diffuse large B-cell lymphoma, unspecified site
      • Essential (primary) hypertension
      • Chronic viral hepatitis B without delta-agent
    • Lab/CXR reviewed.
    • SUGGESTION & PLAN:
      • double lumen insertion will be arranged on R’t side on 2022/04/14 under LA, 8 AM.
• 2023-02-09 Dermatology
  • Q
    • This 69 y/o woman has hypertentsion under medication control for 20+ years. She suffered from a 2.8cm lobular hyperdense mass with obscured margin at left subareolar breast mammography on 2022/07/05.
    • Owing to the symptom exacerbation, the patient called at our OPD for help. Breast sono showed highly suspicious of malignancy, with sonographic negative axillary LNs1 on 2022/07/16.
    • Biopsy on 2022/07/21 showed Diffuse large B-cell lymphoma, in favor of non-GCB type. CK(-), CD20(+), CD3(-), CD10(< 10% +), BCL6(> 90%+), BCL2(> 80% +), MUM1(> 80% +), cMYC(30% +), Cyclin D1(-). The Ki-67 is >90% positive. CT of chest was performed on 7/29 revealed Left breast cancer with left hilar lymphadenopathy.Port-A insertion on 2022/07/29. PET on 2022/08/01 showed glucose hypermetabolism lesions in the left breast, left N-P region, bilateral axillary regions, bilateral pulmonary hilar regions, right mediastinal space, bilateral palatine tonsils, and left hip joint, probably benign in nature. Bone marrow biopsy on 2022/08/02 showed negative of maglignancy. Under the diagnosis of Triple hit, non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1.
    • She received C1 R-DAEPOCH (Vincristine not available) on 2022/08/03 ~ -08/08. C2 R-DAEPOCH was administered on 2022/08/29 ~ -09/03, C3 R-DAEPOCH on 2022/10/14 ~ 10/19.
    • Urgency and frequency was noted in August, 2022. Klebsiella pneumoniae urinary tract infection was noted.
    • Followed up CT on 2022/11/02 revealed resolution of Lt breast tumor compared with CT on 2022/07/28. extensive V-CAD,suggest further test for evaluation any hemodynamically significant stenosis of coronary arteries.
    • C4 R-DAEPOCH on 2022/11/14 ~ 2022/11/19.
    • She received the radiotherapy at 3240cGy/18 fractions of the left breast from 2022/12/6 ~ 12/31
    • However, Radiation dermatitis was noted after the radiotherapy. We need your expertise for further management,thanks
  • A
    • The patient had sufferred from itchy erythematous papules and plaques over left breat region.
      
    • Under the impression of post-radiation dermatitis
    • The following sugeetion:
      • keep oral allegra 1# bid use.
        
      • Rinderon-V cream 2 tube topical bid use over erytheamtous lesions first, if stable shift to Mycomb cream 1 tube bid use -> (Anti-inflammatory and redness-reducing)
        • body cream mix-up with sinphradem cream 1 tube (1:1) topical QN use.

[radiotherapy]

• 2022-12-06 ~ 2022-12-31 - 3240cGy/18 fractions of the left breast

[chemoimmunotherapy] (not completed)

• 2023-04-03 - rituximab 375mg/m2 598mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 1hr D2-5 + etoposide 40mg/m2 63mg NS 250mL D2-5 + cisplatin 25mg/m2 40mg NS 500mL 18hr D2-5 + cytarabine 2000mg/m2 3000mg NS 500mL 2hr D6 (R-ESHAP)
  • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + NS 250mL D1-6 + acetaminophen 500mg PO D1 + palonosetron 250ug D2-6
• 2023-02-10 - rituximab 375mg/m2 580mg NS 500mL 8hr D1 + [etoposide 50mg/m2 77mg + vincristine 0.4mg/m2 0.6mg + doxorubicin 10mg/m2 15mg + NS 250mL] 24hr D2-5 + cyclophosphamide 750mg/m2 1100mg NS 500mL 1hr D6 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-DAEPOCH)
  • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + NS 250mL D1-5 + acetaminophen 500mg PO D1 + granisetron 2mg D2-6
• 2023-01-12 - ditto R-DAEPOCH
• 2022-11-14 - ditto R-DAEPOCH
• 2022-10-14 - ditto R-DAEPOCH
• 2022-08-29 - ditto R-DAEPOCH
• 2022-08-03 - rituximab 375mg/m2 580mg 8hr D1 + etoposide 50mg/m2 77mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + cyclophosphamide 750mg/m2 1100mg 1hr D6 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 (R-DAEPOCH without vincristine)

[note]

Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients (ref: https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients)

• R-ESHAP (Rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) ref: R-ESHAP as salvage therapy for patients with relapsed or refractory diffuse large B-cell lymphoma: the influence of prior exposure to rituximab on outcome. A GEL/TAMO study. Haematologica 2008; 93:1829.
  • Administration – R-ESHAP includes rituximab (375 mg/m2 on day 1), etoposide (40 mg/m2/day as a one-hour infusion on days 1 to 4), methylprednisolone (250 to 500 mg/day as a 15-minute infusion on days 1 to 5), cisplatin (25 mg/m2/day as a continuous infusion from day 1 to 4), and cytarabine (2 g/m2 as a two-hour infusion on day 5), every three or four weeks.
  • Adverse effects – Hematologic toxicity is universal, with significant rates of neutropenic fever (30 percent) if growth factors are not used. Other adverse effects (eg, nausea, vomiting, diarrhea, nephrotoxicity, electrolyte disturbances) are generally mild.
  • Outcomes – A retrospective study of 163 patients reported that ESHAP for relapsed DLBCL was associated with 75 to 86 percent ORR and 41 to 50 percent CR, while for primary refractory DLBCL, ORR was 33 percent and CR was 8 percent.

[assessment]

• This time, the patient was admitted for PBSC collection.

220818

[assessment]

• It is the first time the patient receive her first chemotherapy in this hospitalization.
• 2022-08-17 CRP 7.2 mg/dL, 2022-08-18 01:14 body temperature 38.4 degree, Sintrix (ceftriaxone) and Mycostatin (nystatin) have been prescribed.

701134216

230403

[diagnosis] - 2023-04-01 admisstion note

• Sepsis, unspecified organism
• Fever, unspecified
• Malignant neoplasm of rectosigmoid junction
• Unspecified jaundice

[present illness] - 2023-04-01 admisstion note

• The 57 y/o man has R-S colon with liver and bone mets s/p OP with colostomy on 2021 and closure it at Cardinal Tien Hospital in early 2023, chemotherapy also at that hospital, postive of anti-HBc.

[exam findings]

• 2023-04-01 CT - abdomen
  • history: Rectal ca with liver mets and bone mets s/p OP with colostomy
  • With and without contrast enhancement CT of abdomen shows:
    • Recosigmoid colon CA, s/p operation.
    • Multiple lung metastasis.
    • Multiple liver metastasis.
    • Peritoneal nodules, r/o peritoneal carcinomatosis.
    • Enlarged lymph nodes in para-aortic region.
    • Mild compression fractures of L2,3,4.
  • Impression
    • Recosigmoid colon CA, s/p operation
    • Liver, lung, and lymph node metastasis
    • Peritoneal carcinomatosis
• 2023-03-31 CXR
  • Multiple nodules at bil. lungs.
• 2018-07-31 Fingers Rt
  • comminuted fracture of distal phalanx, 4th finger post pin fixation
• 2018-06-19 Fingers Rt
  • fracture of distal phalanx, 4th finger post pin fixation, stable
• 2018-06-15 Fingers Rt
  • Crush injury with distal phalange destruction is found.
  • Regional soft tissue swelling is identified.

[SOAP]

• 2023-03-23 Hemato-Oncology
  • Admission for bilirubinemia then C/T
• 2023-03-16 Hemato-Oncology
  • Last dose of Avastin plus FOLFOXIRI on 2023-03-09.
  • Apply cetuximab

[assessment]

• The patient’s fever appears to have improved (with a temperature not exceeding 37.5 degrees Celsius) since the administration of Flumarin (flomoxef) on 2023-04-01. However, blood and urine cultures are not yet available.

• The patient has a high bilirubin level and is icteric 2+. The elevation of serum alkaline phosphatase, which is out of proportion to the serum aminotransferases, indicates possible biliary obstruction or intrahepatic cholestasis. An increased serum alkaline phosphatase is also observed in granulomatous liver diseases, such as tuberculosis or sarcoidosis.

  • 2023-03-31 Alkaline phosphatase 996 U/L
    
  • 2023-03-31 S-GPT/ALT 50 U/L
    
  • 2023-03-31 Bilirubin direct 4.26 mg/dL
    
  • 2023-03-31 Bilirubin total 7.42 mg/dL
    
  • 2023-03-23 Bilirubin total 6.09 mg/dL
    
  • 2023-03-14 Bilirubin total 8.87 mg/dL

• Based on the CT performed on 2023-04-01, there is evidence of liver, lung, lymph node metastasis, and peritoneal carcinomatosis. Further evaluation is recommended, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP) to investigate the presence of intra- or extrahepatic bile duct dilation.

• The patient was prescribed Vemlidy (tenofovir alafenamide) appropriately following a positive anti-HBc test result on 2023-03-14.

• According to PharmaCloud records, medications were prescribed for pulmonary symptoms at Cardinal Tien Hospital in January 2023. If these symptoms are no longer present, then there are no medication reconciliation issues.

700324624

230331

[diagnosis] - 2023-03-30 admission note

• Malignant neoplasm of unspecified site of left female breast
• Pleural effusion, not elsewhere classified
• Acute pulmonary edema
• Dyspnea, unspecified

[exam findings]

• 2023-03-29 ECG
  • Atrial fibrillation
  • Low voltage QRS
  • Incomplete right bundle branch block
  • Possible Right ventricular hypertrophy
  • Possible Anterolateral infarct, age undetermined
  • Abnormal ECG
• 2023-03-29 CTA - chest
  • Indication: Bilateral lower leg edema with shortness of breathing
  • With and Without contrast Chest CT and CTA showed
    • dilated main PA.
    • unremarkable change in the main bronchial trees and the visible trachea
    • consolidation in the lower lobes of the bilateral lung; two nodular lesions, about 17mm, in the upper lobe of the right lung; another small nodular lesion, about 14mm, in the upper lobe of the left lung.
    • moderate bilateral pleural effusion
    • unremarkable change in the chest wall
  • IMP:
    • nodular lesions in the upper lobes of the bilateral lung
    • moderate bilateral pleural effusion.
    • consolidation in the lower lobes of the bilateral lung.
    • no evidence of DAA or PE.
• 2023-03-29 CXR
  • Unremarkable change in the visible trachea
  • Normal cardiac and vascular shadows
  • Lung markings: consolidation in the right lung field and left lower lung field
    
  • blurred bilateral hemidiaphrams
  • blunting bilateral costophrenic angles
  • Unremarkable change in bilateral clavicles

[assessment]

• The patient’s renal function is showing signs of recovery.
  • 2023-03-31 Creatinine 0.91 mg/dL
    
  • 2023-03-29 Creatinine 1.33 mg/dL
    
  • 2023-03-31 eGFR 63.55
    
  • 2023-03-29 eGFR 41.01
• On 2023-03-31, Ocillina (oxacillin sodium), Rolikan (sodium bicarbonate), and 0.9% saline were prescribed, which may relieve hyponatremia.
  • 2023-03-31 Na (Sodium) 131 mmol/L
    
  • 2023-03-29 Na (Sodium) 123 mmol/L
• Hypokalemia was observed on the morning of 2023-03-31, which may be due to the administration of furosemide, which was started on 2023-03-30 after normal serum potassium was detected on 2023-03-29. There were 3 bowel movements without diarrhea recorded on 2023-03-30.
  • 2023-03-31 K(Potassium) 3.3 mmol/L
    
  • 2023-03-29 K(Potassium) 4.0 mmol/L
• Please consider prescribing a potassium supplement if necessary and continue to closely monitor the patient’s serum electrolytes. An alternative option is to consider using the combination of furosemide and spironolactone with adequate sodium supplementation and blood pressure monitoring to prevent hypotension.

700892422

230331

[diagnosis] - 2023-03-10 discharge note

• Squamous cell carcinoma of left upper lip cT4aN0M0 cstage IVA in process chemotherapy
• Infection of the upper lip
• Encounter for antineoplastic chemotherapy
• Hypertension
• Verrucous carcinom of right buccal mucosa and tongue post of 2017.

[exam findings]

• 2023-02-01 Whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two faint hot areas at the T7 and L2-3 spines, respectively, faint hot spots in both rib cages, and increased activity in the maxilla, C-spine, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
  • IMPRESSION:
    • Two faint hot areas at the T7 and L2-3 spines, respectively, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in both rib cages, maxilla, C-spine, bilateral shoulders, S-I joints, hips, and knees.
• 2023-01-31 MRI - nasopharynx
  • Indication: Malignant neoplasm of upper lip, inner aspect
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
    • A upper lip tumor mass, up to 4.4 cm, with bone destruction.
    • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • No evident abnormal enlarged lymph node in the visible neck.
    • Multiple oral cavity cancers s/p operation.
  • IMP: Upper lip CA, T4N0M0 Stage IVA.
  • Imaging Report Form for Oral Cavity Carcinoma
    • Impression (Imaging stage) : T:T4A(T_value) N:0(N_value) M:M0(M_value) STAGE:IVA(Stage_value)
• 2023-01-31 SONO - abdomen
  • GB stone, multiple
  • Adenomyomatosis of GB
• 2023-01-30 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Inferior infarct , age undetermined
  • ST & T wave abnormality, consider lateral ischemia
  • Abnormal ECG
• 2023-01-05 Patho - gingival/oral mucosa biopsy
  • Chronic red lesion, left upper lip, incisional biopsy — Cysts with focal opening and irregular epithelial hyperplasia, compatible with squamous cell carcinoma, well-diifferentiated
  • Microscopically, the sections show a picture of some subepithelial cysts with focal surface opening (fistula-like) lined by well-differentiated squamous cells and focal irregular epithelial hyperplasia with dyskeratosis as well as focal epithelial hyperplasia within inflamed and fibrous stroma. According to histopathologic finding and patient’s past history, it is compatible with well-diifferentiated squamous cell carcinoma.
• 2019-06-19 MRI - nasopharynx
  • SOAP
    • S: He is a patient with double oral cancer at lip and cheek seperately and received operations.
    • O: oral ulcer with malignant potential on the inner surface of left upper lip is noted but improved after injection treatment.
    • A:
      • Dysplasia of right buccal mucosa (2018-01)
      • Verrucous carcinoma of right tongue (2017-05-10)
      • SCC of left buccal mucosa and retromolar area post OP (2015-04)
      • Verrucous carcinoma of right tongue border (2017-05)
      • Verrucous carcinoma of inner surface of left upper lip post OP (2015-04)
    • P
      • check BUN and creatinine before MRI examination
      • arrange MRI examination with contrast to evaluate undermining tumor status
  • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness=3 mm, gap=1 mm), sagittal T1WI (thickness=4 mm, gap=1 mm), axial T1WI and T2WI with FS (thickness=5 mm, gap=1 mm), and post-contrast coronal T1WI with FS (thickness= 3 mm, gap=1 mm), axial T1-WI (thickness=5 mm, gap=1mm) and sagittal T1WI (thickness= 4 mm, gap=1 mm) and show:
    • Post-operation change at left upper lip, left buccal region, and right tongue border, without abnormal soft tissue intensity, nor abnormal enhancement.
    • An oval-shaped nodular lesion, about 16 mm x 10 mm, at left supraclavicular region, r/o an enlarged lymph node, mildly enlarged as compared with MRI on 20180815. Suggest further evaluation and close follow-up.
    • No remarkable finding at nasopharynx, oropharynx, hypopharynx and larynx.
    • No remarkable finding at parotid, submandibular and sublingual glands.
    • No remarkable finding at skull base and visible intracranial structures.
    • Mucosal thickening in bilateral ethmoid and maxillary sinuses, indicating chronic paranasal sinusitis.
  • IMP: C/W multiple oral cavity cancers s/p operation, without evidence of recurrence based on this study. A suspicious enlarged lymph node at left supraclavicular fossa. Suggest further evaluation (such as PET) and close follow-up.
• 2018-08-15 MRI - nasopharynx
  • CC: He is a patient with double oral cancer at lip and cheek seperately. He has mild pain at his left upper lip for few days. He also has rough surface lesions on his both cheeks for weeks and mouth-opening limitation for years. He had received cancer surgery on 2015-04. He wears unfitted denture.
  • Indication:
    • S: He is a patient with double oral cancer at lip and cheek seperately. He had received cancer surgery on 2015-04 and 2017-05. He wears unfitted denture.
    • O: ulceration on the left upper lip is noted. that is probablly due to unfit denture. abnormal scar tissue with fungus patches on the bil. buccal mucosa is noted.
      
    • A:
      • Dysplasia of right buccal mucosa (2018-01)
      • Verrucous carcinoma of right tongue (2017-05-10)
      • Dysplasia of right buccal mucosa,and the right lower lip (2017-05-10)
      • SCC of left buccal mucosa and retromolar area post OP (2015-04)
      • Verrucous carcinoma of right tongue border (2017-05)
      • Verrucous carcinoma of inner surface of left upper lip post OP (2015-04)
    • P:
      • Chech BUN and creatinine before MRI examination
      • Arrange MRI with contrast to evaluate the undermining tumor status
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration showed:
    • No abnormal mass lesion in the nasopharynx, oropharynx, hypopharynx or larynx.
    • No neck LAP.
    • Normal appearance of parotid, submandibular and thyroid glands.
    • Mild mucosal thickening of bilateral maxillary sinuses.
    • Mucosal thickening of rightinferior nasal turbinate.
  • Impression:
    • No obvious buccal or oropharynx mass or nodule.
• 2017-11-20 MRI - nasopharynx
  • No obvious buccal or oropharynx mass or nodule.
• 2017-05-10 Surgical pathology Level IV
  • Clinical diagnosis: Chronic periodontits
  • Patho DIAGNOSIS:
    • Labeled as “tumor of right buccal mucosa”, wide excision — Verrucous hyperplasia with submucosa fibrosis.
    • Labeled as “tumor of right tongue”, wide excision — Verrucous carcinoma, margin free of malignancy.
    • Tongue, right, wide excision — Verrucous carcinoma
    • Lymph node—- N/A.
    • Pathology stage: pT1Nx (cM0); pStage: I.
  • MACROSCOPIC EXAMINATION CHECKLIST
    • Surgical Procedure(s): wide excision
    • Specimen Type:
      • Main location: right tongue
      • Other part(s) included: right buccal mucosa
      • Lymph node dissection: no
    • Specimen Integrity: intact
    • Specimen Size: Greatest dimensions: right tongue: 1.2 x 0.9 x 0.35 cm.
      • Additional dimensions: right buccal mucosa: 1 x 0.8 x 0.4 cm.
    • Tumor Site: right tongue, Laterality : right
    • Tumor Focality : single focus
    • Tumor Size: Greatest dimension: 0.25 cm
      • Tumor thickness (for pT1 and pT2 tumors only): 1.5 mm
    • Mucosal Surface : Intact
    • Gross Tumor Extension : submucosa
  • MICROSCOPIC DESCRIPTION:
    • Section of the “tumor of right buccal mucosa” shows verrucous hyperplsia.
      
    • Section of the “tumor of right tongue” shows one piece of hyperkeratotic squamous mucosa with verrucous carcinoma 2.5 mm in width and 1.5 mm in depth. The tumor is 3. 2, 4, 3, and 2 mm away from the left, right, anterior, posterior and deep margins.
      
  • MICROSCOPIC EXAMINATION CHECKLIST:
    • Histologic Type: Verrucous carcinom
    • Histologic Grade: G1: Well differentiated
    • Microscopic Tumor Extension: submucosa
    • Margins: Margins free, Distance from closest margin: 3. 2, 4, 3, and 2 mm away from the left, right, anterior, posterior and deep margins.
    • Lymph-Vascular Invasion: not identified
    • Perineural Invasion: not identified
    • Neck Lymph Nodes: N/A.

[consultation]

• 2023-02-01 Thoracic Surgery
  • Q
    • For port-A insertion
    • This is a 57 y/o male patient denied of HTN, CAD and DM major disease.
    • His oral tumor of left upper lip biposy reported cysts with focal opening and irregular epithelial hyperplasia, compatible with squamous cell carcinoma, well-diifferentiated (sample number: S2023-00290) on 2023-01-05.
    • His nasopharnyx MRI showed upper lip T4AN0M0 stage IVA.
    • His treatment plans were induction chemotherapy follow by surgery and CCRT.
    • He was admitted to ward for tumor work up and prepare induction chemotherapy.
    • We need your help for port-A insertion, Thanks!           
  • A
    • I will arrange insertion of port-A this week. Thanks for your consultation!

[SDM] - 2023-02-02

• This afternoon, we had a meeting with Mr. Ding and his son to discuss the current status of his illness and future treatment options.
• Dr. Xia:
  • Mr. Ding, your oral cancer examination has been completed. Currently, the diagnosis is stage III left upper lip oral cancer, which can be diagnosed by direct visual inspection or palpation. However, the magnetic resonance imaging (MRI) report shows that the cancer has invaded the adjacent maxilla bone, so it is stage IV left upper lip oral cancer. The purpose of this family meeting is to discuss your treatment options and the potential side effects of each treatment method. In general, your treatment for left upper lip oral cancer will include surgical resection of the tumor and removal of lymph nodes. Depending on the pathology report, radiotherapy may also be necessary after the surgery. Since your cancer is located in the left upper lip, we will take into consideration the future appearance, clarity of speech, and the side effects of lip dysfunction. Therefore, there are two treatment options that we can discuss, and we will arrange appropriate treatment according to your decision.
    • Treatment option 1: Directly remove the left upper lip oral cancer tumor by surgery. The advantage of this method is that it removes the cancer faster, and it makes the existence of left upper lip oral cancer invisible to the eyes and mind. However, the disadvantage of this method is that the tumor area removed is larger, which will affect your appearance in the future. Losing the upper lip will also affect the clarity of your speech, and you will lose the function of closing your lips, causing food and water to spill out while eating and drinking.
    • Treatment option 2: Use chemotherapy first to kill the left upper lip oral cancer cells. The advantage of this method is that if the chemotherapy is effective, it can shrink the tumor and reduce the surgical area in the future, thus reducing the impact on your appearance. It also reduces the impact on speech clarity and the chance of food and water spilling out while eating and drinking. The disadvantage of this method is that you will first face the side effects of chemotherapy, such as nausea, vomiting, diarrhea, decreased white blood cells causing infections, and even life-threatening conditions, anemia, hair loss, and weakness, etc. Have you and your family understood this?
• Mr. Ding:
  • Yes, I have heard and understood. How effective is chemotherapy?
• Dr. Xia:
  • Each person’s oral cancer cells have different characteristics, so the response to chemotherapy will also be different. Basically, about 80% of oral cancer patients respond well to chemotherapy, which can reduce the size of the oral cancer. However, we can only know if it works after injection, and cannot predict it in advance.
• Mr. Ding:
  • I understand. How long will the chemotherapy last? How do I know if it is effective?
• Dr. Xia:
  • This chemotherapy will last for about two months. We will treat you in cycles every three weeks, with three cycles in total, so the chemotherapy will last for a total of nine weeks. Simply put, chemotherapy is administered in the first and second weeks, and you will rest at home in the third week. Chemotherapy will resume in the fourth week, and so on. The entire chemotherapy process will last nine weeks. Two weeks after the end of chemotherapy (around the 11th week), you will undergo surgical treatment. I have a chemotherapy manual for you and your family to refer to. As for whether it is effective, it can only be known after injection, and the patient can feel and see whether the tumor has shrunk. So currently, I cannot know whether the chemotherapy will be effective for you.
• Mr. Ding: What if chemotherapy is not effective?
• Dr. Xia: I will schedule surgery to remove

[surgical operation]

• 2017-05-10
  • Diagnosis: Severe dysplasia of right buccal mucosa with maliganant tendency
  • PCS code: 92014C Complicated extraction
  • Finding
    • Abnormal macule (patch) of erythroplakia 1cm x1.5cm at right buccal mucosa WAS NOTED.
    • Abnormal mass on the right tongue 0.5cm x0.5cm WAS NOTED.
    • Severe trismus is noted
    • Enlongation and caries of 17 16 25 34 32 33 34 48 47

[chemotherapy]

• 2023-03-31 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 800mg/m2 1500mg NS 500mL 22hr + leucovorin 80mg/m2 150mg (in 5-FU drip)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-03-22 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-03-06 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-02-27 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-02-13 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-02-03 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg NS 500mL 22hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

Induction chemotherapy should be used when chemotherapy occurs before radiation therapy. The term neoadjuvant chemotherapy should be used to refer to chemotherapy before surgery. ref: https://www.healthline.com/health/cancer/induction-chemotherapy

[assessment]

• The patient has received (planned total 9-dose) TPF neoadjuvant regimen on 6 occasions, specifically on 2023-02-03, 2023-02-13, 2023-02-27, 2023-03-06, 2023-03-22, and 2023-03-31 (the 6th time during this hospitalization). There was only one episode of WBC less than 3K/uL, which occurred on 2023-02-10, approximately 1 week after the first dose. Otherwise, no other episodes of low WBC count were observed.

  • 2023-03-29 WBC 3.84 x10^3/uL
    
  • 2023-03-20 WBC 3.46 x10^3/uL
    
  • 2023-03-10 WBC 4.19 x10^3/uL
    
  • 2023-03-06 WBC 4.86 x10^3/uL
    
  • 2023-02-27 WBC 4.16 x10^3/uL
    
  • 2023-02-17 WBC 3.63 x10^3/uL
    
  • 2023-02-13 WBC 6.36 x10^3/uL
    
  • 2023-02-10 WBC 2.80 x10^3/uL
    
  • 2023-01-31 WBC 5.32 x10^3/uL

• The TPF regimen was appropriately dose reduced from the second dose, with docetaxel at 32mg/m2 instead of 40mg/m2, cisplatin at 32mg/m2 instead of 40mg/m2, and fluorouracil at 900-800mg/m2 instead of 1000mg/m2. G-CSF was also used in a timely manner.

• According to the latest information, there are no moderate or severe complaints for the patient about adverse reactions.

• By the way, there is a decreasing trend in HGB, which indicates that the HGB does not seem to be fully recovered at the current administration interval/frequency. Please continue monitoring and check for need for blood transfusion for the next 3 scheduled doses.

  • 2023-03-29 HGB 9.9 g/dL
    
  • 2023-03-20 HGB 10.7 g/dL
    
  • 2023-03-10 HGB 11.4 g/dL
    
  • 2023-03-06 HGB 10.9 g/dL
    
  • 2023-02-27 HGB 12.6 g/dL
    
  • 2023-02-17 HGB 12.2 g/dL
    
  • 2023-02-13 HGB 13.8 g/dL
    
  • 2023-02-10 HGB 15.5 g/dL
    
  • 2023-01-31 HGB 14.0 g/dL

701469037

230331

[diagnosis] - 2023-03-09 admission note

• Hypopharyngeal squamous cell carcinoma with tonge involvement, bilateral cervical lymph nodes, liver and multiple bones metastases, cT4aN2cM1, stage IVC s/p chemotherapy with with PF (CDDP 75mg/m2 D1 + 5-Fu 1000mg/m2 D1-4) from 2023/02/07~
• Chronic viral hepatitis B without delta-agent
• Constipation, unspecified
• Hypercalcemia
• Hypomagnesemia
• Hyponatremia

[lab data]

• 2023-01-30 HBsAg Reactive
  
• 2023-01-30 HBsAg (Value) 686.57 S/CO
  
• 2023-01-30 Anti-HCV Nonreactive
  
• 2023-01-30 Anti-HCV Value 0.13 S/CO
  
• 2023-01-30 HIV Ab-EIA Nonreactive
  
• 2023-01-30 Anti-HIV Value 0.06 S/CO
  
• 2023-01-30 Anti-HBc Reactive
  
• 2023-01-30 Anti-HBc-Value 8.95 S/CO
  
• 2023-01-30 Anti-HBs 6.17 mIU/mL

[exam findings]

• 2023-03-30 CT - abdomen
  • The CT scan of the whole abdomen was performed without/with IV contrast medium enhancement and revealed that:
    • Known a case of right hypopharyngeal cancer. Still presence of this tumor at right pyriform sinus. One enlarged node (4.4cm) over right level IV of neck.
    • Multiple liver metastases.
    • Minimal ascites.
    • Focal atrophy of left kidney with stone (2mm).
    • Small amount of bilateral pleural effusion.
    • Multiple osteoblastic lesions of T-L spine, may be metastatic lesions.
    • S/P N-G tube insertion.
• 2023-03-09 CXR
  • Mild Increased infiltration over both lower lungs. May be active infection.
• 2023-02-06 Patho - colorectal polyp
  • Colorectum, descending colon (60 cm from anal verge), Polypectomy — Tubular adenoma with low grade dysplasia
  • Colorectum, rectum Size (10 cm from anal verge), Biopsy removal — Tubular adenoma with low grade dysplasia
• 2023-02-02 CT - abdomen
  • History and indication: left tongue cancer, cT4aN2CM0, echo with multiple liver lesionfor liver tumors, suspected HCC, suspected metastasis
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Multiple liver metastases.
    • Minimal ascites.
    • Focal atrophy of left kidney with stone (2mm).
    • S/P NG tube indwelling.
  • IMP:
    • Multiple liver metastases.
• 2023-02-01 Whole body PET scan
  • Glucose-hypermetabolism in the right hypopharynx, compatible with the primary hypopharyngeal cancer.
    
  • Glucose-hypermetabolism in the middle to basal aspect of tongue and bilateral cervical lymph nodes, highly suspected advanced cancer with regional lymph nodes involvement.
    
  • Glucose-hypermetabolism in both lobes of the liver and multiple bones, highly suspected cancer with distant metastases.
    
  • Hypopharyngeal cancer with tonge involvement, bilateral cervical lymph nodes, liver and multiple bones metastases, cT4aN2cM1, stage IVC (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2023-02-01 Patho - esophageal biopsy
  • Labeled as “esophagus, 35 cm below incisor”, biopsy — squamous mucosa with high grade dysplasia.
  • Section shows squamous mucosa with high grade dysplasia.
  • The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical, and if available, image findings. Further work up might be considered.
• 2023-01-31 Patho - larynx biopsy
  • Labeled as “right hypopharyngeal tumor”, biopsy — squamous cell carcinoma.
  • IHC stains: p16(+, 95%), CK5/6 (+), p40 (+), Ki-67 (90%).
• 2023-01-31 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A
  • Suspected esophageal mucosal lesion, L/3, s/p biopsy
  • Esophageal inlet patch, U/3
  • Superficial gastritis
  • C/W hypopharyngeal cancer
• 2023-01-31 SONO - abdomen
  • multiple hepatic tumors, both lobe
• 2023-01-30 ECG
  • Sinus tachycardia with short PR
  • Right atrial enlargement
  • Nonspecific ST abnormality
  • Abnormal QRS-T angle, consider primary T wave abnormality
  • Abnormal ECG
• 2023-01-30 Laryngoscopy
  • right hypopharyngeal tumor
• 2023-01-26 Nasopharyngoscopy
  • Findings:
    • smooth NPx; right hypopharyngeal mass involved right AE fold, pyriform sinus and laryngx with airway narrowing
  • Diagnosis/Conclusion
    • right hypopharyngeal tumor, favor malignancy
    • left tongue cancer
• 2023-01-24 CT - neck
  • Neck CT with and without IV contrast enhancement shows:
    • Soft tissue mass occupying hypopharynx more on right side measuring 4.9cm with partially obliteration of the supraglottic airway is found. Some lymphadenopathy at bilateral neck mostly at right neck is found.
    • Abnormal necrotic lesion at tongue about 4.65cm in largest dimension is found.
    • Mild wall thickeing at upper third esophagus is found.
    • Intact bony alignment over cervical spine
  • Imp:
    • Probably tongue cancer with bilateral neck lymphadenopathy and hypopharyngeal exntesion.
  • Imaging Report Form for Oral Cavity Carcinoma
    • T4aN2c
• 2023-01-24 Nasopharyngoscopy
  • Findings:
    • ulcerative and fragile tissue over posterior tongue (easy bleeding during examination, status post bosmin compression)
    • 3 cm whitish leision over right retromolar trigone region, no bulging over bilateral peritonsilar region or uvular deviation
    • smooth nasopharynx, oropharynx, no pharyngeal wall bulging
    • tumor mass over right hypopharynx
  • Diagnosis/Conclusion
    • mass lesion over posterior tongue, right retromolar trigone region, right hypopharynx
• 2023-01-19 Pathology (at TuCheng Hospital)
  • SNOMED: 53000-A-M80703
  • DX: Tongue, “posterior”, incisional biopsy — squamous cell carcinoma
  • GROSS D: The specimen submitted consists of a piece of tissue measuring 0.7 x 0.5 x 0.3 cm. Submitted in toto. LYC
  • MICRO D: Sections show squamous mucosa with invasive nests of tumor cells displaying squamous differentiation.

[consultation]

• 2023-02-26 Hemato-Oncology
  • Q
    • Consultation for take over and chemotherapy.
    • This 48 year-old man is diagnosed of (1) left tongue squamous cell carcinoma T4aN3bM1, stage IVc and (2) right hypopharyngeal squamous cell carcinoma T3-4aN3bM1, stage IVc.
    • After discussing with him and his family, he decided to undergo chemotherapy. Colonoscopy is arranged on 2023/02/06 10:30 due to hyperdensity lesion over upper rectum in abdominal CT.
    • We need your expertise to take over this patient and start chemotherapy as your plan. Thank you very much!
  • A
    • According to tumor board discussion, please arrange colonoscopy due to hyperdensity lesion over upper rectum in abdominal CT r/o colonrectal cancer.
    • In addition, please arrange 24 urine CCR and auditory test. Please book 11A and transfer to our service. Thanks for your consultation.
• 2023-01-24 Ear Nose Throat
  • A
    • S
      • Sorethroat for a month
      • Right neck progressive swelling for a week
      • A(+)/B(-)/C(+, 1 PPD for 20 years)
      • voice change (+, for a month), trismus (-), oral bleedeing (-), dyspnea (- **), otalgia (-), fever (-), dysphagia (+, mild)
      • Posterior tongue SCC diagnosed at 土城 hospital on 2023/01/16
    • O
      • Oral cavity and oropharynx: ulcerative and fragile tissue over posterior tongue (easy bleeding during examination, status post bosmin compression)
        • 3 cm whitish leision over right retromolar trigone region, no bulging over bilateral peritonsilar region or uvular deviation
      • Neck : 6 cm non-movable painful firm mass over right neck level III-V region
      • Scope: smooth nasopharynx, oropharynx, no pharyngeal wall bulging
        • tumor mass over right hypopharynx
      • CT: heterogenous mass lesion over posterior tongue, right hypopharynx
        • mild deviated but still visible air way, 3 cm heterogenous mass lesion over right neck
    • A
      • Posterior tongue squamous cell carcinoma
      • Mass lesion over right hypopharynx, r/o metastasis, r/o second primary tumor
      • Right neck heterogenous mass, r/o metastasis
    • P
      • prohylatic antibittics with augmentin, keep oral hygeine with parmason, and adequate pain control (acetaminophen, ultracet, or self-paid comfflam) if no contraindication
      • ENT OPD f/u on 2023/01/26 AM
      • Well education. if disease progression (bleeding, short of breath…), back to ER soon

[SOAP]

• 2023-03-23 Hemato-Oncology
  • Tx Plan: Neoadjuvant TPF followed by CCRT
  • Cancer Multidisciplinary Team Meeting Conclusion
    • Meeting Date: 2023-02-03
    • Treatment Plan:
      • Systemic therapy + Local radiation therapy.
      • Team consensus: Tongue + Hypopharynx: cT4aN3bM1, IVC.

[chemotherapy]

• 2023-03-09 - cisplatin 75mg/m2 110mg NS 500mL 24hr + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg 24hr D1-4
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-07 - cisplatin 75mg/m2 110mg NS 500mL 24hr + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg 24hr D1-4
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

• 2023-03-30 CRP 18.82mg/dL, WBC 12.95K/uL, urine bacteria 1+, urine protein 1+. Blood culture results are not yet available.

• There have been no medication reconciliation issues found in the patient. (PharmaCloud not accessible)

230310

[assessment]

• The patient is undergoing the PF regimen treatment for the second time during this hospital stay and did not experience discomfort symptoms within two weeks after the previous chemotherapy.
• Lab results (2023-03-09) indicate the presence of hypercalcemia (2.78mmol/L), hypomagnesemia (1.6mg/dL), and hyponatremia (130mmol/L).
  • Cisplatin treatment is known to cause hyponatremia, hypomagnesemia, and hypocalcemia, as noted in “Electrolyte Disorders Induced by Antineoplastic Drugs” (Front Oncol. 2020;10:779. Published 2020 May 19. doi:10.3389/fonc.2020.00779).
  • Hypercalcemia, which is typically caused by increased osteoclastic bone resorption and affects up to 10 to 30% of cancer patients (ref: Electrolyte disorders with platinum-based chemotherapy: mechanisms, manifestations and management. Cancer Chemother Pharmacol. 2017;80(5):895-907. doi:10.1007/s00280-017-3392-8), has been confirmed to be present due to bone metastases. If this causal relationship is confirmed, the primary treatment approach would be to administer intravenous bisphosphonates. However, it’s worth noting that this treatment may potentially lower magnesium levels as well.

700029976

230330

[present illness] - 2023-03-29 admission note

This is 77-year-old man who has past medical history of Raynaud phenomenon, Diabetes Type II, right lung adenocarcioma RLL status post VATS wedge resection, prostatic cancer status post TURP under regular oral endoxan and prednisolone. This time, he complained of dyspnea for days, OPD CXR showed right pleural effusion. Loss 5 kg due to poor appetite in one month according to himself. He was admitted to our ward for further evalation and treatment.

[past history]

• Raynaud phenomenon
• Waldenstrom’s macroglobulinemia
• Diabetes Type II
• right lung adenocarcioma RLL status post VATS wedge resection
• prostatic cancer status post TURP

[allergy]

• NKDA         

[family history]

• Dad and mum have diabetes mellulitus.
• Denied any cancer history.

[SOAP]

• 2023-03-15 Hemato-Oncology
  • BT with PRBC 2 U today
• 2023-02-09 Urology
  • Malignant neoplasm of prostate
  • PSA every six months
• 2023-02-01 Hemato-Oncology
  • BT with PRBC 2 U today
• 2023-01-11 Hemato-Oncology
  • Waldenstrom macroglobulinemia. (IgM myeloma less likely)
  • hold endoxan and continue steroid therapy
  • continue surgar control.
  • suggest keep warm and OPD follow up.
  • suggest mabthera therapy if continue elevation of IgM

[medication]

• 2022-04-06 ~ undergoing - Endoxan (cyclophosphamide)

[assessment]

• The patient has been under follow-up in our Hemato-Oncology OPD due to extremely high IgM levels and was diagnosed with Waldenstrom macroglobulinemia. Cyclophosphamide treatment was initiated in April 2022.
• The patient’s IgM levels decreased from approximately 7000 mg/dL in Q2/Q3 2021 to approximately 3000 mg/dL in Q2 2022 and have been around 2500 mg/dL since then. However, LDH levels have remained consistently high, with a record high of 1004 U/L in Q1 2023. The patient’s serum glucose levels have fluctuated between 100-200 mg/dL during the same period.
• The current prescription is appropriate and further evaluation is ongoing.

700199716

230330

[diagnosis] - 2023-03-06 admission note

• Malignant neoplasm of endometrium
• Endometroid carcinoma with marked squamous differentiation, pT1aN1mi; stage III C1; FIGO stage IIIC1
• Polycystic ovarian syndrome
• Iron deficiency anemia, unspecified

[past history]

• Heart:(-)

• Liver:(-)

• Kidney:(-)

• H/T:(-)

• DM:(-) Other

• DVT 2 years ago

• medication: Rivaroxaban regularly and had taken Leuplin

• Surgical: denied

• Menstrual history: G0P0, Last menstrual period: 2022-09-25

• sex –

• Menarche at the age of 12 years old

• Menstrual cycle:irregular with duration of 7 days

• Amount: moderate with blood clots

• Pap smear: denied                

[allergy]

• NKDA                       

[family history]

• There is no family history of cancer,hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-03-07 CT - abdomen
  • Clinical history: 49 y/o female patient with endometroid carcinoma with marked squamous differentiation, pT1aN1mi; stage III C1; FIGO stage IIIC1.
  • With and without contrast enhancement CT of abdomen–whole:
    • S/P hysterectomy. Mild fatty infiltrates in the pelvic cavity, could be due to post-op change, suggest follow up.
    • Presence of gallbladder stones.
    • Suspected right renal cyst, 0.58cm.
  • Impression:
    • S/P hysterectomy. Mild fatty infiltrates in the pelvic cavity, could be due to post-op change, suggest follow up.
    • GB stones.
    • Suspected right renal cyst.
  • 2022-11-16 Peripheral Vascular Test: Vein , lower limbs
    • Chronic DVT, mild intramural thrombus involved left popliteal vein with revascularization
    • Right LSV mild reflux, involved right sphenofemal junction(SFJ); with some small varicose veins(LSV) at right lower legs
    • Rigth CFV trivial reflux
    • Left LSV mild reflux, involved left sphenofemal junction(SFJ); with some small varicose veins(LSV) at right lower legs
    • Left CFV trivail reflux
    • Both SSV without reflux
  • 2022-10-31 CT - chest
    • no abnormality of both lungs and mediastinum.
  • 2022-10-26 Patho - ovary (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Uterus, endometrium, LAVH — Endometroid carcinoma with marked squamous differentiation
      • Lymph nodes, pelvic, bilateral, BPLND — Metastatic carcinoma
      • AJCC 8 th edition, Pathology stage: pT1aN1mi; stage IIIC1; FIGO stage IIIC1
    • MACROSCOPIC EXAMINATION
      • Procedure: LAVH + BSO + BPLND
      • Specimen Size: 10.7 x 9.5 x 3.8 cm (uterus), 3 x 2 x 2 cm (Rt ovary), 4.5 x 0.8 cm (Rt tube), 3 x 2 x 2 cm (Lt ovary), 4.5 x 0.8 cm (Lt tube)
      • Specimen Integrity: Intact
      • Tumor Site: Endometrium
      • Tumor Size: Diffusely thickened, up to 2.0 cm in thickness
      • Lymph Nodes: Four groups including left iliac, left obturator, right iliac, right obturator
      • Representative parts are taken for section and labeled as: A= left iliac LNs, B= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E1-E2= left ovary and fallopian tube, F1-F2= left ovary and fallopian tube. F2022-00502FSA1-FSA2= tumor, A1=cervix, A2= cervix + tumor, A3= parametrium, A4-A6= uterine corpus.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Endometroid carcinoma with marked squamous differentiation
      • Histologic Grade: FIGO grade 1
      • Myometrium Invasin: Present
        • Depth of Invasion: 11 mm
        • Thickness of Myometrium: 25 mm
      • Adenomyosis: Present
      • Uterine Serosal Involvement: Not identified
      • Cervical Stromal Involvement: Not identified
      • Other Tissue/Organ Involvement: Not applicable
      • Peritoneal/Ascitic Fluid: Not submitted
      • Margins: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 1.8 cm
      • Lymphvascular Invasion: Present
      • Regional Lymph Nodes: Metastatic carcinoma
        • number of lymph node examined: 7 (left iliac), 4 (left obturator), 4 (right iliac), 8 (right obturator)
        • number with metastases >2 mm: 0
        • number with metastases >0.2 mm and <=2 mm: 2 (left iliac), 1 (left obturator)
        • number with isolated tumor cells (<=0.2mm): 3 (left iliac), 2 (left obturator)
      • Pathologic Stage
        • Primary Tumor: pT1a (tumor limited to endometrium or less than half of myometrium)
        • Regional Lymph Nodes: pNmi (regional lymph node metastasis > 0.2 mm but <= 2 mm)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IIIC1
      • Additional Pathologic Findings
        • Cervix: Chronic cervicitis
        • Myometrium: Adenomyosis
        • Ovaries, bilateral: No remarkable change
        • Fallopian tubes, blateral: No remarkable change
  • 2022-10-26 Frozen Section
    • Uterus, frozen section — Malignant (endometroid carcinoma)
  • 2022-10-03 MRI - pelvis
    • Findings
      • Diffuse thickening endometrium, endometrial hyperplasia?
      • There are cysts in bilateral adnexa, could be due to ovarian cysts.
      • There are cysts in the uterine cervical region, suggesting Nabothin cysts.
      • There are lymph nodes in bilateral obturator regions, suggest follow up.
      • Non-enhancing nodules in right kidney(up to 1cm), r/o right renal cysts.
    • Impression
      • Diffuse thickening endometrium, endometrial hyperplasia or tumor? Suggest clinical correlation.
      • Nabothin cysts.
      • Bilateral obturator lymph nodes, suggest follow up.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T1a(T_value) N:N1(N_value) M:M0(M_value) STAGE:IIIc(Stage_value)
        
  • 2022-09-15 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, D&C — atypical endometrial hyperplasia with squamous differentiation
    • Microscopically, sections show atypical endometrial hyperplasia composed of complex atypical hyperplasia of endometrial glands with increased glandular complexity and glandular crowding with squamous metaplasia and nuclear atypia.
    • Immunohstochemical stain reveals p16(+), p53(patchy+, wild -type), vimentin(+), CEA (focal +).
  • 2022-09-15 Patho - endometrium curretage/biopsy
    • Uterus, endocervix, ECC — Squamous cell metaplasia with atypia
    • Microscopically, it shows hyperplasia of squamous cells with focal nuclear atypia.
    • Immunohistochemical stain reveals p16(+), p53(patchy+, wild-type), vimentin(+).
  • 2022-05-27, 2021-11-12, 2021-04-23, 2020-08-14 Gynecologic ultrasonography
    • LT adnexae: free
    • adenomyosis
  • 2020-11-16 Peripheral Vascular Test: Vein, lower limbs
    • Acute venous thrombosis from left ostial SFV to distal SFV with minimal recanalization at ostial and proximal SFV; acute venous thrombosis at left popliteal vein with minimal recanalization. Left ATV wasn’t seen. Patent left PTV and LSV.
    • No evidence of venous thrombosis at right lower limb venous systems.
    • Mild venous reflux at right saphenofemoral junction with no varicose change of right LSV.
    • The ratios of MVO and SVC were within normal limtis.

[surgical operation]

• 2022-10-26
  • Surgery
    • Diagnosis
      • D&C show atypical endometrial hyperplasia with squamous differentiation
      • LAVH then sent uterus for frozen section. => Frozen: Malignant (endometroid carcinoma)
    • Operation:
      • Laparoscopic gynecologic oncology staging surgery        
  • Finding
    • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
    • Bilateral adnexa: grossly normal
    • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
    • CDS: free
    • Estimated blood loss: 100 ml
    • Blood transfusion: nil
    • Complication: nil
• 2022-09-15
  • Surgery
    • D&C, theraputic and for diagnostic (D&C: Dilatation and Curettage)
  • Finding
    • Uterus: Anteversion, 8 cm.
    • some endometrial tissue were curetted out.
    • Estimated blood loss: 5 mL, Blood transfusion: nil, complication: nil.    

[radiotherapy]

• 2022-11-30 ~ undergoing - at 2160cGy/12 fractions of the pelvic area.

[chemotherapy]

• 2023-03-06 - paclitaxel 175mg/m2 330mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-02-09 - paclitaxel 175mg/m2 330mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-01-12 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-12-19 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + granisetron 2mg + NS 250mL
• 2022-11-29 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + NS 250mL

[assessment]

• On 2023-03-29, the patient’s lab results indicated generally normal blood cell counts, selected electrolytes, and liver/kidney functions. There is no evidence that contraindicates the scheduled chemotherapy.
• The patient was diagnosed with acute embolism and thrombosis of the femoral and iliac veins on 2020-11-16 and has been taking Xarelto (rivaroxaban) for this condition.
• After reviewing the PharmaCloud database, no medication reconciliation issues were identified.

230307

[assessment]

• After a leukopenia event (WBC 1.65K/uL on 2022-12-31), all subsequent data showed WBC counts above 5K/uL.
• Since receiving paclitaxel + carboplatin regimen in late November 2022, there have been no observations of anemia and/or thrombocytopenia.
• The patient is currently taking rivaroxaban as a self-carried medication due to a history of DVT. No medication reconciliation issues were found during this hospital stay.

221220

[assessment]

• Based on the lab results (2022-12-19), the scheduled chemotherapy did not appear to be contraindicated.

700805458

230330

[diagnosis] - 2023-03-03 admission note

• Malignant neoplasm of nasopharynx, unspecified
• Chronic mucoid otitis media, right ear
• Gastro-esophageal reflux disease with esophagitis
• Gastritis, unspecified, without bleeding
• Postmenopausal atrophic vaginitis
• Unspecified cirrhosis of liver

[past history]

• Thyroid papillary cancer status post thyroidectomy in 2008
  • Eltroxin 50mg 3# po QW2,4,6
  • Eltroxin 50mg 2# po QW1,3,5,7
• Hepatitis B virus infection under medical treatment
  • Vemlidy 1# po QDAC
• Polyarthralgia under medical treatment  
  • Plaquenil 1# po QOD

[allergy]

• Omnipaque (iohexol): skin rash

[family history]

• There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

• 2023-03-03 Gynecologic ultrasonography
  • bilateral adnexae: free
  • IMP: adenomyosis
• 2023-02-23 Patho - cervix/endometrial polyp
  • Uterus, endometrium, TCR-P— Endometrial polyp with decidual reaction
• 2023-02-17 Hysteroscopy
  • OBS/GYN history: G 2 P 2 A ____ LMP ____
  • HSC indication/Pre-exam impression: suspect EM lesion
  • Procedure: Under lithotomy position, HSC exam was performed smoothly
  • Hysteroscopy No. : HYF-XP
  • Finding:
    • Endometrial cavity:
    • Endocervix: WNL
    • Fundus: obliterated with polyp
    • Right tubal ostium: obliterated with polyp
    • Left tubal ostium: obliterated with polyp
  • Post-exam impression: endometrial polyp
    • EBL:minimal , Complication: Nil , BT: Nil
• 2023-02-13 Whole body PET scan
  • No previous study for comparison.
  • The lesion in the right petrous bone shown on the previous MRI of nasopharynx reveals very mildly increased FDG uptake, compatible with NPC s/p R/T.
    
  • Glucose-hypermetabolism in the esophagus, probably chronic inflammation process.
    
  • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    
  • NPC s/p treatment, no evidence of residual, recurrent or metastatic tumor, by this F-18 FDG PET scan.
• 2023-02-11 SONO - abdomen
  • Cirrhosis of liver
  • GB stones/polyp, multiple
  • Hepatic cysts
  • Splenomegaly
• 2023-02-10 Nasopharyngoscopy
  • Findings
    • bulging tumor over rt NP, subside
  • Diagnosis/conclusion
    • NPC, cT4N0M0 s/p CCRT
• 2023-02-10 Gynecologic ultrasonography
  • LT adnexae:free
  • IMP
    • Adenomyosis
    • Uterine myoma
    • EM: 11.5mm, suspect endometrial thickening
• 2023-02-02 MRI - nasopharynx
  • The current study was compared to the prior one obtained on 2022/09/08.
  • Abnormal soft tissue intensity and enhancement involving right cavernous sinus, foramen lacerum, foramen ovale, carotid canal, petrous bone, longus colli muscle and medial pterygoid muscle.
  • Regression of most of the lesion involving right nasopharynx and paraspinal space, but mild progression of the lesion involving right petrous bone around carotid canal.
  • Favor residual tumor with progression.
• 2023-02-02 SONO - abdomen

  • Right liver cysts (3.57x4.19cm, 1.26x1.32cm).

  • Gallbladder stones (3-5mm).

  • 2023-01-06 SONO - thyroid gland.

    • no evidence of mass lesion.

  • 2023-01-06, 2022-12-02, -10-28 Nasopharyngoscopy

    • Findings: bulging tumor over rt NP, subside
    • Summary: NPC, cT4N0M0 s/p CCRT

  • 2022-11-24 Gynecologic ultrasonography

    • Uterine myoma
    • Endometrial thickening, EM: 11.4mm

  • 2022-11-16 CT - abdomen

    • Findings:
      • There are two hepatic cysts 4.5 cm in S8/4 and 1.1 cm in S6.
      • There are multiple gallstones.
      • The liver shows mild irregular contour that may be early cirrhosis or normal variation.
      • There is suspicious endometrium or myometrium lesion in the uterus. Please correlate with GYN. sonography.
    • IMP:
      • Two hepatic cysts 4.5 cm in S8/4 and 1.1 cm in S6.
      • Multiple gallstones.
      • Early cirrhosis of the liver is suspected.
        
      • There is suspicious endometrium or myometrium lesion in the uterus. Please correlate with GYN. sonography.

  • 2022-09-08 MRI - nasopharynx

    • Indication: NPC s/p TPF
    • Findings:
      • Abnormal soft tissue intensity and enhancement involving right cavernous sinus, foramen lacerum, foramen ovale, carotid canal, petrous bone, longus colli muscle and medial pterygoid muscle. Regression of most of the lesion involving right nasopharynx and paraspinal spce, but mild progression of the lesion involving right petrous bone around carotid canal.
      • Mottled T2-hyperintensity in right mastoid air cells, indicating mastoiditis.
    • IMP:
      • NPC s/p treatment, partial regression of most of the tumor, but with mild progression of the lesion in petrous bone, as compared with MRI on 20220426.

  • 2022-09-01, -06-02 SONO - abdomen

    • Cirrhosis of liver
    • GB stones/polyp, multiple
    • Hepatic cysts
    • Splenomegaly

  • 2022-06-14 ECG

    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG

  • 2022-06-14 CXR

    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.

  • 2022-06-14 PTA

    • Reliability FAIR
    • Average RE 78 dB HL; LE 29 dB HL.
    • R’t moderately severe to profound mixed type HL.
    • L’t normal to moderate HL. (BC masking dilemma)

  • 2022-04-28 Tc-99m MDP whole body bone scan

    • The Tc-99m MDP bone scan at 4 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the skull base, L3-4 spines, bilateral shoulders, knees and both feet in whole body survey.
    • IMPRESSION:
      • Increased activity in the skull base. Malignancy with local bony involvement may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Mildly increased activity in the L3-4 spines. Degenerative spine disease is more likely.
      • Increased activity in bilateral shoulders, knees and both feet, compatible with benign joint lesions.

  • 2022-04-28 Gynecologic ultrasonography

    • Bilateral adnexae: free
    • Uterine myoma

  • 2022-04-27 Panendoscopy

    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, body, s/p CLO test
    • Gastric erosion, antrum, LC site

  • 2022-04-27 SONO - abdomen

    • Cirrhosis of liver with splenomegaly
    • Hepatic cysts
    • GB stones/polyp
    • Suboptimal study

  • 2022-04-26 MRI - nasopharynx

    • Indication: Nasopharyngeal carcinoma for cancer work up
      • Allergy to contrast
    • Findings
      • A large lobuated right NPx tumor mass, up to 4.3 cm, invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base.
        
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • No evident abnormal enlarged lymph node in the visible neck.
      • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
    • IMP: Right NPC, invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base.
      
    • Impression (Imaging stage): T:T4(T_value) N:0(N_value) M:M0(M_value) STAGE:IVA (Stage_value)

  • 2022-04-26 PTA

    • Reliability FAIR
    • Average RE 63 dB HL; LE 28 dB HL
    • RE mild to profound MHL
    • LE normal to mild SNHL

  • 2022-04-25 ECG

    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality

  • 2022-04-18 PTA

    • Reliability FAIR
    • Average RE 53 dB HL; LE 34 dB HL.
    • R’t mild to severe MHL.
    • L’t mild to moderately severe SNHL.

  • 2022-04-11 Patho - nasopharyngeal/oropharyngeal biopsy

    • Nasopharynx, biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated type
    • The sections show a picture of non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of nests of large neoplastic cells with oval vesicular nuclei, prominent nucleoli and syncytial growth pattern. Keratin formation is absent.

  • 2022-04-11 Otologic endoscopy

    • rt NP tumor
    • rt MEE

  • 2022-04-11 Nasopharyngoscopy

    • rt NP tumor

  • 2022-03-12 SONO - abdomen

    • Cirrhosis of liver
    • GB stones/polyp
    • Hepatic cysts
    • Splenomegaly

  • 2020-12-16 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 25) / 89 = 71.91%
      • M-mode (Teichholz) = 72
    • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis and aortic root calcification; trivial TR.
    • Prominent epicardial fat.
• consultation
  • 2022-06-21 Ophthalmology
    • Q
      • This 63-year-old woman patient is a case of Nasopharyngeal carcinoma, cT4N0M0, stage IVA. She was admitted for chemotherapy with TPF(C1D1) on 2022/06/16.
      • This time, for right eye redness with itch. Now, for evlauate right eye redness with itch therapy. Thank you.
    • A
      • S: Bilateral eye redness and itchy for 5days
      • O:
        • denied bv
        • discharge++, purulent
        • itchy++
        • BCVA od 0.4(0.5x+3.25/-4.00x90) os 0.5(0.7x+1.50/-2.00x70)
        • IOP 15/18mmHg
        • Pupil 3/3 +/+
        • MGD+
        • conj injected with purulent discharge, no pseudomembrane od>os
        • K clear ou
        • AC D/cl ou
        • Lens ns+ ou
        • Fd c/d 0.3, disc pinkish ou
      • A
        • Conjunctivitis od>os, favor EKC (epidemic keratoconjunctivitis)
      • P
        • Alminto 1gtt qid ou + tetracyclin 1qs hs
        • inform the red flags, if worsen vision, come back asap
        • opd f/u
  • 2022-04-29 Radiation Oncology
    • A
      • Diagnosis: Nasopharyngeal carcinoma, NK SqCC, undifferentiated type, cT4N0M0, with invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base and Rt ORX, ECOG =1.
      • Suggest: Radiotherapy.
        • Goal: Curative.
        • RT Plan may be designed as the following one:
          • Target & Volume: NPX tumor and neck lymphatics.
          • Technique: VMAT.
          • Dose & Fractionation: 7140cGy/34 fx, with concurrent chemotherapy.
      • Plan:
        • Either CCRT followed by adjuvant C/T or induction C/T followed by CCRT is suggested for tumor control. Possible toxicity of radiotherapy (radiation mucositis, pharyngitis, dermatitis) is told. Diet education and psychological support are given.
  • 2022-04-28 Obstetrics and Gynecology
    • Q
      • This 63 y/o woman has historiesr of hypothyroidism, hepatitis B under regular medication control. The patient was admitted for NPC work up. The patient complaint perineal itching and urgency to urinate off and on for one month. She has treated at local clinic under Genxate 1# po tid, anbicyn 1# po tid , Amoxicillin 1# po tid.
    • A
      • This 63 y/o woman, G4P2A2(cesarean section), menopaused at her age of 50.
      • The patient complaint perineal + vaginal itching in recent 3 months, urgency to urinate off and on in recent 1 month. She had been to local clinic for help where Genxate 1# po tid, anbicyn 1# po tid, Amoxicillin 1# po tid were given.
      • Lab data: grossly normal, no leukocytosis or anemia.
        • PV: severe vaginal dryness, little whitish vaginal discharge, cervical lifting pain(-)
        • TVUS: Uterus: AVFL, 77x41mm; Endometrium: 4.3mm; 2 myomas( 26x24mm, 26x25mm)
          • Bilateral adnexa: free, no pelvic mass
          • CDS: no ascites
      • IMP: Suspected postmenopausal atrophic vaginitis
      • Suggestion:
        • May keep current LMD medications
        • Add Vaginal estrogen cream (Premarin 14gm/tube) QD HS and oral metronidazole 1# QID x 3 days.
        • GYN OPD f/u if needed
  • 2022-04-26 Oral and Maxillofacial Surgery
    • Q
      • This 52 y/o woman has history of hepatitis B and hypothyroidism for years under regular medication control. She is acase of nasopharyngeal carcinoma. She was admitted for cancer work up.
      • Due to follow up radiotherapy was indicated, we request your consultation for dental evaluation.
    • A
      • This is a 63 y/o female admitted for cancer evaluation(nasopharyngeal carcinoma). This time we were consulted for dental evaluation.
      • S: Oral examination.
        • Hx: epatitis B and hypothyroidism for years under regular medication control
      • O:
        • Residual root of tooth 24, 25, 44
        • Caries of tooth 14, 15, 23 under ill-fitting prosthesis. Percussion pain and periapical radiolucency of tooth 14, 23 were noted.
        • Full mouth chronic periodontitis and poor oral hygiene was noted.
      • A:
        • Residual root of tooth 24, 25, 44
        • Caries of tooth 14, 15, 23
        • Full mouth chronic periodontitis
      • P:
        • Take panoramic film. Explain the findings and treatment plan to the patient and her family.
        • Suggest extraction of residual root of tooth 24, 25, 44 , patient and family want to consider.
        • Suggest removal of ill-fitting prosthesis and re-evaluation of tooth 14, 15, 23 , patient and family want to consider.
        • Suggest OPD follow up.

[SOAP]

• 2023-03-29 Hemato-Oncology
  • Admission on 2023-03-28 for 4th PF and blood trasfusion due to syncope
• 2023-02-21 Hemato-Oncology
  • EBV viral load Q3M, next in 2023-05
• 2022-12-13 Hemato-Oncology
  • EBV viral load Q3M, next in 2023-02
• 2022-09-20 Hemato-Oncology
  • Due to the tumor invading toward brain stem based on the MRI on 2022-09-08, should consider PF4 after CCRT.
• 2022-08-09 Hemato-Oncology
  • Already give medication education, e.g., hold Mgo and Primperan when diarrhea, hold smecta if no more diarrhea
• 2022-08-02 Hemato-Oncology
  • Patient sustaine Gr 1 mucositis over lip, urinary tract and GYN area, Gr 1 anorexia -> does not like to take C/T on 2022-08-02
• 2022-07-26 Hemato-Oncology
  • If first dose of cycle -> G-CSF for 2 doses
  • If 2nd dose of cycle -> G-CSF for 3 doses
• 2022-07-19 Hemato-Oncology
  • RTC 1 week and next C/T on 2022-07-26 for OPD 2-2 course with G-CSF suport
• 2022-05-10 Hemato-Oncology
  • Treatment plan: induction chemotherapy with TPF x 3 (if spliting dose, that would be 6 doses) followed by CCRT with weekly CDDP

[radiotherapy]

• 2022-09-26 ~ 2022-11-11 - 7140cGy/34 fractions (6 MV photon) to NPX tumor & neck lymphatics

[chemoimmunotherapy]

• 2023-03-30 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
  • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
• 2023-03-03 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
  • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
• 2023-01-13 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
  • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
• 2022-12-14 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
  • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
• 2022-11-08 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
• 2022-11-01 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
• 2022-10-25 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
• 2022-10-18 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
• 2022-10-11 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
• 2022-10-04 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
• 2022-09-27 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
  • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
• 2022-08-16 - docetaxel 35mg/m2 50mg NS 160mL 1hr + cisplatin 35mg/m2 50mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 170mL 48hr (neoadjuvant TPF Q3W)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
• 2022-08-09 - docetaxel 35mg/m2 55mg NS 180mL 1hr + cisplatin 35mg/m2 55mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
• 2022-07-26 - docetaxel 35mg/m2 55mg NS 180mL 1hr + cisplatin 35mg/m2 55mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
• 2022-07-19 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
• 2022-07-12 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
• 2022-07-05 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
  • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
• 2022-06-15 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 500mL 48hr (neoadjuvant TPF Q3W)
  • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3

[assessment]

• Due to her syncope, the patient was admitted for scheduled chemotherapy and received a blood transfusion.
• The patient is receiving PF4 regimen since Dec 2022 after CCRT due to tumor invasion towards brainstem based on MRI on 2022-09-08.
• EBV DNA quantitative amplification results have never exceeded 120 copies/mL since Sep 2022. However, 2023-02-02 MRI showed regression of most of the lesion involving right nasopharynx and paraspinal space, but mild progression of the lesion involving right petrous bone around carotid canal, favoring residual tumor with progression.

230306

[assessment]

The patient was prescribed ergometrine maleate for an unspecified leiomyoma of uterus by our gynecologist on 2023-03-03. However, this drug is not currently shown in the active medication list. It has no known interaction with the patient’s current medications. Therefore, adding it as a self-carried item to the active medication list is recommended for proper medication reconciliation.

In addition, it is noted that fluorouracil, metoclopramide, and hydroxychloroquine are potential QT-prolonging agents. Administration of these drugs in an overlapping manner may enhance the QTc-prolonging effect, which should be monitored.

230116

[assessment]

• As part of the renal protective effect, the patient is hydrated with magnesium supplementation (administratered 1 hr following cisplatin), which can also mitigate the hypomagnesemia (since 2nd half of 2022). ref: https://journalotohns.biomedcentral.com/articles/10.1186/s40463-018-0261-3 and https://link.springer.com/article/10.1007/s00520-016-3426-5

221214

[assessment]

• Since October 2022, serum potassium readings have returned to normal levels:
  • 2022-12-13 3.6 mmol/L
  • 2022-11-29 3.7 mmol/L
  • 2022-11-15 4.2 mmol/L
  • 2022-11-08 3.8 mmol/L
  • 2022-10-25 3.7 mmol/L
  • 2022-10-18 3.6 mmol/L
  • 2022-10-11 3.8 mmol/L
  • 2022-10-04 3.6 mmol/L
  • 2022-09-20 3.4 mmol/L
  • 2022-08-23 3.2 mmol/L
  • 2022-08-16 3.1 mmol/L
  • 2022-08-09 3.1 mmol/L
  • 2022-08-02 3.7 mmol/L
  • 2022-07-26 3.5 mmol/L
  • 2022-07-19 4.0 mmol/L
  • 2022-07-12 3.6 mmol/L
  • 2022-07-05 3.7 mmol/L
  • 2022-06-29 4.2 mmol/L
  • 2022-06-23 3.1 mmol/L
  • 2022-06-08 4.0 mmol/L
  • 2022-05-10 4.0 mmol/L
  • 2022-04-25 3.5 mmol/L
• It may be appropriate to reduce the dosage of the potassium supplement Radi-K (TID -> BID/QD) as well as encourage the patient to consume more potassium-rich foods. Foods with high levels of potassium include: dried figs, molasses, seaweed, dried fruits (dates, prunes), nuts, avocados, bran cereals, wheat germ, lima beans. (Renal function is normal in the patient.)

700998905

230329

[exam findings]

• 2023-03-24 CXR
  • Enlargement of cardiac silhouette.
• 2023-03-09 CT - abdomen
  • History and indication: Low rectal cancer involving anal canal
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of low rectum with adjacent fat stranding, anal canal/ sphincter invasion and regional LAP.
    • Gallbladder stones (3-5mm).
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N1b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2023-03-07 Patho - colorectal polyp
  • Colorectum, low rectum, biopsy — Adenocarcinoma.
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2023-03-07 ECG
  • Normal sinus rhythm
  • Moderate voltage criteria for LVH, may be normal variant
  • Nonspecific T wave abnormality
• 2023-03-07 Colonoscopy
  • Low rectal cancer involving anal canal s/p biopsy
• 2023-03-02 Anoscopy
  • mixed hemorrhoid
  • low rectal mass with bleeding suspected malignancy
• 2017-09-08 Multiple Sleep Test
  • Summary - The diagnostic nocturnal polysomngraphy demonstrated:
    • Respiratory events were both obstructive and hypopnic (obstructive: 43.6%, central: 0%, Mixed: 0% and hypopnea: 56.4%) with an AHI of 57.1. This is consistent with severe sleep apnea. Snoring was present for 20 % of the diagnostic portion of the study.
    • The baseline oxygen saturation was normal. The oxygen desaturation index was 51.8/hr. severely increased. Desaturation events were continuous and clustered. The lowest SaO2 desaturation associated with a respiratory event was 67%.
    • Sleep structure and quality was (abnormal, fragmented due to respiratory events arousals).
      
    • The cardiac rate and rhythm showed (normal sinus rhythm) (frequent, PAC’s, PVC’s).
      
  • Conclusion:
    • This is a case of severe SAS. She had abnormal sleep architecture and nocturnal oxygen desaturation. She is a snorer, too.
      • ChatGPT: SAS in this context refers to Sleep Apnea Syndrome, a condition characterized by repeated episodes of partial or complete obstruction of the upper airway during sleep, resulting in disruptions to breathing and oxygen supply to the body.

[SOAP]

• 2023-03-14 Radiation Oncolgoy
  • Imp: Low rectal cancer involving anal canal with bleeding, cT4bN1bM0, Stage: IIIC.
  • Plan: Pre-operative CCRT for 5040cGy/28 fx then OP
    • CT simulation on 2023/03/16, 14:30.
• 2023-03-14 Hemato-Oncology
  • Port-A insertion
  • Arrange admission for FOLFOX on 2023-03-23
• 2023-03-13 Colorectal Surgery
  • Suggest CCRT then OP (Laparoscopic APR ? due to sphincter invasion)

[radiotherapy]

[chemotherapy]

• 2023-03-27 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

• The patient was diagnosed with low rectal cancer involving the anal canal with bleeding, cT4bN1bM0, stage: IIIC.

• For patients with locally advanced rectal cancer who are at high risk for a margin-positive resection or node-positive disease with a low-lying rectal tumor, total neoadjuvant therapy (TNT) is suggested instead of long-course CRT or short-course RT alone. TNT combines oxaliplatin-based chemotherapy with long-course CRT or short-course RT, leading to increased chemotherapy compliance, improved local control, and the ability to consider nonoperative treatment if the patient declines surgery.

• The patient has been admitted to receive her first dose of FOLFOX. Lab results on 2023-03-23 showed normal liver and kidney function, blood cell counts, serum electrolytes, and no contraindications to chemotherapy.

• The patient’s chronic viral hepatitis B without the delta agent is currently being managed with Baraclude (entecavir).

• The current active prescription has no identified issues.

701064531

230329

[exam findings]

• 2023-02-10 Whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the maxilla, lower L-spines, bilateral shoulders, sternoclavicular junctions and hips in whole body survey.
  • IMPRESSION:
    • Mildly increased activity in the lower L-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2022-12-20 CT - abdomen
  • History and indication: ovary CA
  • IMP:
    • S/P operation.
    • A hypodense nodule (4.5mm) at S5-6 junction of liver.
• 2022-12-12 SONO - kidney urology
  • Grossly normal, bilateral kidneys
• 2022-12-09 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Borderline ECG
• 2022-12-09 Gynecologic ultrasonography
  • ATH + BSO
  • Lt fluid
• 2022-11-24, -11-21 KUB
  • S/P drainage tube in the pelvic cavity.
  • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
  • Non-specific bowel gas pattern.
• 2022-11-16 Patho - uterus with or without SO non-neoplastic/prolapse
  • Diagnosis:
    • Ovary, right, oophorectomy —- Clear cell carcinoma; AJCC 8th edition: pStage IC, pT1c1N0(if cM0); FIGO Stage: IC1
    • Ovary, left, oophorectomy —- Negative for malignancy
    • Fallopian tube, bilateral, salpingectomy —- Negative for malignancy
    • Uterus, corpus, total hysterectomy —- Negative for malignancy
    • Uterus, endometrium, total hysterectomy —- Negative for malignancy
    • Uterus, cervix, total hysterectomy —- Negative for malignancy
    • Omentum, omentectomy —- Negative for malignancy
    • Lymph node, left iliac, dissection —- Negative for malignancy (0/1)
    • Lymph node, left obturator, dissection —- Negative for malignancy (0/3)
    • Lymph node, right iliac, dissection —- Negative for malignancy (0/3)
    • Lymph node, right obturator, dissection —- Negative for malignancy (0/9)
    • Lymph node, left para-aortic, dissection —- Negative for malignancy (0/8)
    • Lymph node, right para-aortic, dissection —- Negative for malignancy (0/5)
  • Gross description:
    • Procedure (select all that apply): Total hysterectomy, bilateral salpingo-oophorectomy, Omentectomy
    • Specimen Integrity
      • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.]
      • Specimen Integrity of Right Ovary (if applicable): intra-op rupture
      • Specimen Integrity of Left Ovary (if applicable): Capsule intact
      • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
      • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
    • Tumor Site: Right ovary
    • Ovarian Surface Involvement (required only if applicable): Absent
    • Fallopian Tube Surface Involvement (required only if applicable): Absent
    • Tumor Size: Greatest dimension (centimeters): 7.0 cm
      • Additional dimensions (centimeters): 6.5 x 5.0 cm
    • Specimen size:
      • left ovary: 2.5 x 1.3 x 0.4 cm;
      • right tube: 5.0 cm in length and 0.3 cm in diameter;
      • left tube: 5.2 cm in length and 0.3 cm in diameter;
      • uterus: 7.0 x 5.1 x 4.0 cm, 88 gm; Cervix: 4.2 x 4.2 x 2.6 cm; Endometrial cavity: 3.2 x 2.0 x 0.2; A leiomyoma: 0.5 x 0.5 x 0.4 cm and adenomyosis are seen
    • Sections are taken and labeled as:
      • F2022-00542: Representative sections are taken and labeled as: FsA1-2, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: fallopian tube; X2-6: ovary.
      • S2022-20256: A: lymph node, left iliac; B: lymph node, left obturator; C: lymph node, right iliac; D1-2: lymph node, right obturator; E: lymph node, left para-aortic; F: lymph node, right para-aortic; G1: cervix; G2: endometrium; G3: left ovary and fallopian tube; G4: leiomyoma; G5: right posterior wall; G6: right adnexa soft tissue; H: omentum.
        
  • Microscopic Description:
    • Histologic Type: Clear cell carcinoma; The immunohistochemical stains reveal PAX8(+), Napsin A(+), WT-1(-), p53(wild type), and PR(-).
      
    • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
      • (Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.): not applicable
    • Implants (required for advanced stage serous/seromucinous borderline tumors only): not applicable
      
    • Other Tissue/ Organ Involvement (select all that apply): Not identified
    • Largest Extrapelvic Peritoneal Focus (required only if applicable): not aplicable
    • Peritoneal/Ascitic Fluid: N2022-04209: Negative for malignancy (normal/benign)
      
    • Regional Lymph Nodes: Negative for metastasis: please see diagnosis
    • Additional Pathologic Findings: A leiomyoma and adenomyosis are seen in uterus.
• 2022-11-16 Frozen section
  • Preliminary diagnosis: Ovary, right, oophorectomy — adenocarcinoma
• 2022-11-15 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • Gastric erosion, angularis
  • Suggestion
    • Pursue CLO test result
• 2022-11-14 ECG
  • ICRBBB pattern
    • ChatGPT
      • ICRBBB stands for “Incomplete Right Bundle Branch Block” and refers to a specific pattern seen on an electrocardiogram (ECG). In a normal heart, electrical impulses travel through both the left and right bundle branches, allowing for coordinated contractions of the ventricles. In ICRBBB, the right bundle branch is delayed or blocked, causing a characteristic pattern on the ECG.
      • The ECG in ICRBBB typically shows a widened QRS complex (greater than 120 milliseconds) with a slurred or notched R wave in leads V1 and V2. There may also be ST segment and T wave changes in leads V1 to V3. ICRBBB is considered “incomplete” because the duration of the QRS complex is not as long as it would be in a complete right bundle branch block.
      • ICRBBB is often considered a benign finding and may be present in otherwise healthy individuals. However, it can also be associated with various underlying cardiac conditions, such as pulmonary embolism, right ventricular hypertrophy, and certain congenital heart defects. Further evaluation by a healthcare provider may be warranted in certain cases.
• 2022-11-14 CTA - pelvis
  • Clinical history: 52 y/o female patient with s/p Chocolate cyst
    • L’t pelvic pain, constipation, Delking on 2022-11-16.
  • With and without contrast enhancement CT of abdomen–whole:
    • There is mulcystic tumor, 8.8x6.1cm in right adnexa, with solid and cystic component and septum, suspected right ovarian malignancy.
    • Liver cyst, 0.5cm in S7.
    • Fibrotic infiltrate in RUL.
    • Unremarkable change of the liver, spleen, pancreas and both kidneys.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
  • If proven ovarian malignancy
  • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ia_(Stage_value)
• 2022-11-08 Gynecologic ultrasonography
  • LT adnexae:free
  • endometrial (+fluid)
  • IMP: Suspected Rt Ovarian mass: (92mm x65mm), papillary:(40mm x31mm), RI: 0.35

[consultation]

• 2022-12-13 Urology
  • Q
    • This 52 years old female, Right ovarian clear cell carcinoma, pStage IC, pT1c1N0cM0; FIGO Stage IC2 status post Debulking surgery on 2022/11/16 and s/p port-A insertion on 2022/11/25. According to the patient, she had intermittent chills and left flank soreness since 2 days ago. After admitted her vital signs were stable and no fever. The PE found no abdominal tenderness, wound clean and no CP angle knocking tenderness. The lab datas revealed no leukocytosis or pyuria, but elevated CRP upto 12.68 -> 20.5 mg/dL. We need your expertised for renal echo. Thanks a lot!
  • A
    • the patient complained of flank or low back pain trigger by walk
    • USK showed no hydronephroiss
    • Therefore, low back pain (ligament, fascia, intervertebral disc) may be another possible cause of pain

[surgical operation]

• 2022-11-16
  • Diagnosis:
    • Right ovarian tumor, suspected malignancy
    • Frozen section: adenocarcinoma
  • Surgery:
    • Debulking surgery (ATH + BSO + BPLND)   - Finding
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder, marked adhesion to the rectum
    • Adnexa:
      • LOV: capsule intact , smooth surface.
      • ROV: intra-op rupture(+)
      • Fallopian tube: bilateral grossly normal
    • CDS: adhesion (+)
    • Ascites: scanty
    • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
    • Omentum: infracolic omentectomy was done.
  • Other
    • Estimated blood loss: 1000 ml
    • Blood transfusion: 2U
    • Complication: nil

[chemotherapy]

• 2023-03-28 - paclitaxel 175mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W, paclitaxel 20% off due to PLT 88K/uL)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-03-03 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-02-09 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2023-01-12 - paclitaxel 160mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
• 2022-12-20 - paclitaxel 160mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL

[assessment]

• The patient experienced nadir levels in her WBC and/or PLT count approximately one week after receiving chemotherapy, as indicated by asterisks in the table below (WBC < 3K/uL, PLT < 100K/uL).

  • 2023-03-28 WBC 3.01 x10^3/uL
    
  • 2023-03-10 WBC 1.89 x10^3/uL * previous chemo on 03/03 - 7 days
  • 2023-03-02 WBC 5.52 x10^3/uL
    
  • 2023-02-17 WBC 1.42 x10^3/uL * previous chemo on 02/09 - 7 days
  • 2023-02-08 WBC 4.19 x10^3/uL
    
  • 2023-01-20 WBC 2.06 x10^3/uL * previous chemo on 01/12 - 8 days
  • 2023-01-12 WBC 5.31 x10^3/uL
    
  • 2022-12-27 WBC 3.09 x10^3/uL
    
  • 2022-12-19 WBC 8.25 x10^3/uL
    
  • 2022-12-12 WBC 5.71 x10^3/uL
    
  • 2022-12-09 WBC 10.45 x10^3/uL
    
  • 2023-03-28 PLT 88 x10^3/uL * previous chemo on 03/03 - 25 days (not fully recovered yet)
  • 2023-03-10 PLT 24 x10^3/uL * previous chemo on 03/03 - 7 days
  • 2023-03-02 PLT 100 x10^3/uL
    
  • 2023-02-17 PLT 131 x10^3/uL
    
  • 2023-02-08 PLT 117 x10^3/uL
    
  • 2023-01-20 PLT 64 x10^3/uL * previous chemo on 01/12 - 8 days
  • 2023-01-12 PLT 75 x10^3/uL * previous chemo on 12/20 - 8 days
  • 2022-12-27 PLT 129 x10^3/uL
    
  • 2022-12-19 PLT 209 x10^3/uL
    
  • 2022-12-12 PLT 126 x10^3/uL
    
  • 2022-12-09 PLT 138 x10^3/uL

• The patient was admitted for her scheduled chemotherapy with a 20% dose reduction of paclitaxel due to her not fully recovered low PLT level.

• No medication reconciliation issues were found after reviewing PharmaCloud and comparing it to the active prescription.

701241752

230329

[exam findings]

• 2023-03-28 Whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the lower T- and upper L-spines, L4, bilateral shoulders, sternoclavicular junctions, hips and knees in whole body survey.
  • IMPRESSION:
    • Mildly increased activity in the lower T- and upper L-spines and L4 spine. Degenerative change may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2023-03-27 KUB
  • Hepatomegaly is suspected.
• 2023-03-23 CT - abdomen
  • Findings
    • A tumor (5.3cm) in left breast with left chest wall invasion.
    • Multiple liver tumors. A LN (1.5cm) at left subphrenic region.
    • Small amount ascites.
    • Perineural cysts at sacrum.
  • IMP
    • Left breast cancer with left chest wall invasion, LN and liver metastases.
• 2023-03-23 KUB
  • Focal small bowel ileus in left abdomen.
  • There are calcifications in the pelvic cavity, could be due to phleboliths.
• 2020-07-01 Gynecologic ultrasonography
  • Suspected Lt Ovarian Cyst
• 2020-06-17 Gynecologic ultrasonography
  • Endometrial thickening
  • Suspected bilateral ovarian cyst

[assessment]

• 2023-03-29 FOBT 4+. A result of 4+ means that a significant amount of blood was detected in the sample, indicating a possible gastrointestinal bleeding. Takepron (lansoprazole) has been prescirbed (ST). Further evaluation and testing may be needed to determine the cause of the bleeding.

701356216

230329

[past history] - 2023-03-25 admission note

• myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment.
• hyperlipidemia
• hepatitis B carrier with Baraclude since 2022/05.
• gastric ulcer for 10+ years ago.

[allergy]

• NKDA

[family history]

• Father: HCC
• Mother: Type II diabetes mellitus

[exam findings]

• 2023-03-28 CXR
  • Bilateral pleura effusion.
  • S/P pigtail catheter implantation at right CP angle.
• 2023-03-27 L-spine AP + Lat. (including sacrum)
  • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
• 2023-03-27 CXR
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-03-27 Hand Lt
  • S/P total amputation of 3rd distal phalanx and middle phalanx, and partial amputation of 3rd proximal phalanx of Left hand.
  • S/P near total amputation of 2nd distal phalanx of Left hand.
  • Angulation deformity of 2nd PIP joint.
• 2023-03-27 C-spine AP + Lat
  • Small Nuchal ligament calcification over the posterior neck
• 2023-03-27 Spirometry
  • Mild reduction of total lung capacity
  • Moderate restrictive ventilatory impairment, Not significant bronchodilator reversibility
  • Moderate reduction of diffusion capacity
• 2023-03-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (102 - 26) / 102 = 74.51%
    • 2D (M-simpson) = 75
  • Conclusion
    • Marked asymmetric septal hypertrophy with Gr II LV diastolic dysfunction; no significant intracardiac pressure; suspected non-obstructive type hypertrophic cardiomyopathy or amyloidosis heart; moderately dilated LA.
    • Preserved LV and RV systolic function.
    • Aortic valve sclerosis with trivial AR; mild MR; mild TR.
    • Multiple oscillation lesions at posterior mitral leaflet with sized 10-12 mm and at tricuspid septal leaflet with sized 8-19 mm, nature? suspected non-bacterial thrombotic endocarditis (NTBE) if no evidence of active infection.
    • Some R’t plerual effusion.
• 2022-04-18 SONO - abdomen
  • Calcified spot, 0.45cm in right lobe liver.
  • Suspected minimal ascites in subphrenic region, right.
• 2022-04-18 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 26) / 120 = 78.33%
    • 2D (M-simpson) = 78
  • Conclusion
    • Septal and RV hypertrophy with Gr I LV diastolic dysfunction.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; trivial MR.
• 2022-03-30 Spirometry
  • Normal baseline without significant reversibility
  • FEV1FVC=91.41%, FVC= 87%, FEV1= 98%
  • normal total lung capacity TLC=101%
  • suspect mild air trapping, RV/TLC=42.07%
  • normal diffusion capacity
• 2022-03-16 Patho - bone marrow biopsy
  • Bone marrow, iliac creast, biopsy — Plasma cell myeloma
  • Microscopically, it shows hypercellularity with hemopoietic components accounting for about 70% of the marrow space, and M/E ration of 2: 1. of the bone marrow space. Plasma cells are increased (> 10%) and highlighted by CD138. Occasional megakaryocytes are seen.
  • Immunohistochemical stain reveals CD34(-), CD117(-), MPO(+), CD71(+), CD20(focal +, < 5%), Kappa light chain(-), Lambda ligh chain (+ for monoclonality).
  • ADDENDUM: Special stain — congo red (+), compatible with amyloidosis
• 2022-03-07 Surgical pathology Level IV
  • PATHOLOGICAL DIAGNOSIS:
    • Kidney, needle biopsy for light microscopic examination — Compatible with amyloidosis (lambda light chain type) — Mild arteriosclerosis
    • COMMENT: We are limited in our assessment because the specimen submitted for light microscopy contains renal medullary tissue only. No glomerulus is available. The semithin sections prepared for electron microscopic examination show glomeruli with mesangial expansion. By immunofluorescence, the lambda staining is stronger than kappa in the glomerular mesangium and capillary walls. The electron microscopy demonstrates the presence of randomly oriented fibrils 8-12 nm in diameter within the mesangium and along the glomerular basement membranes. Although the Congo red staining is not contributory, the above features are mostly compatible with renal involvement by amyloidosis. Clinical correlation is recommended. For EM findings, please see report S111-80825.
• 2022-03-07 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Prolonged QT
• 2022-02-23 SONO -nephrology
  • chronic parenchymal renal disease
  • right renal cyst

[consultation]

• 2023-03-29 Neurology
  • Q
    • for bilateral last of three fingers numbness, and fall down repeatedly.
    • This is a 54-year-old male, underlying hyperlipidemia, myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment. The history of hepatitis B carrier with Baraclude. He visited OPD due to proteinuria found by health examination in 2021 October.
    • This time, he is admitted for Auto HSC collection, then he suffered from bilateral last of three fingers numbness, and fall down repeatedly, and the heart echo showed suspected non-bacterial thrombotic endocarditis. So we need your help, thanks a lot!!
  • A
    • hands weakness esp. at bilateral ulnar sides after the fall
    • NE: aware, fluent speech, bil. hearing impairment, no visual field defect, no facial weakness or tongue deviation, bil. Benedict hands and diffuse hypo-reflexia
    • Impression:
      • ulnar neuropathies, suspect entrapment neuropathy
      • amyloidosis
    • Suggest:
      • C-spine MRI, nerve conduction study and BAEP might be arranged
      • I would like to follow up this patient. Thank you for your consultation.
• 2023-03-27 Cardiology
  • Q
    • for heart function evaluation, hs-Troponin I: 185.1 pg/mL, CKMB: 6.5ng/mL
    • This is a 54-year-old male, underlying hyperlipidemia, myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment. The history of hepatitis B carrier with Baraclude. He visited OPD due to proteinuria found by health examination in 2021 October.
    • This time, he is admitted for Auto HSC collection, then he suffered from pitting edema 4+ at limbs,and the blood pressure lower (SBP: 70-90mmHg), CXR: bilateral pleural effusion, the lab of cardio enyzam poor (hs-Troponin I: 185.1 pg/mL, CKMB: 6.5ng/mL), 12-Lead EKG: Normal sinus rhythm, Left axis deviation, Low voltage QRS, Cannot rule out Anteroseptal infarct, age. The heart echo will be arranged. So we need your help, thanks a lot!!
  • A
    • S
      • 55 year-old male had the history of Myeloma with Amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy and lab test. start chemotherapy with Velcade TD from 20220506
    • O
      • LAB NTproBNP 8184 hsTnI167.9 CKMB 6.1 Cre 0.83 ALT 32 albumin 2.2 Hb 13.5 WBC 25960 PLT 219k band 6.8%
      • echocardiogram 20230327
        • Marked asymmetric septal hypertrophy with Gr II LV diastolic dysfunction; no significant intracardiac pressure; suspected non-obstructive type hypertrophic cardiomyopathy or amyloidosis heart; moderately dilated LA.
        • Preserved LV and RV systolic function.
        • Aortic valve sclerosis with trivial AR; mild MR; mild TR.
        • Multiple oscillation lesions at posterior mitral leaflet with sized 10-12 mm and at tricuspid septal leaflet with sized 8-19 mm, nature? suspected non-bacterial thrombotic endocarditis (NTBE) if no evidence of active infection.
        • Some R’t plerual effusion.
      • CXR 20230327 right pleural effusion 20230307 clear lung field
      • ECG 20230327 sinus rhythm, low voltage, left axis deviation
    • Impression
      • Hypertrophic cardiomyopathy, suspected amyloidosis related
      • Oscillating lesions on mitral and tricuspid valves, nature?; with mild MR and TR
      • Severe hypoalbuminemia
    • Suggestion
      • Collecting blood cultures x3 to exclude bacterial endocarditis
      • Correct hypoalbuminemia
      • Right pleural effusion study
      • By echocardiogram, IVC 13mm suggested low intra-vascular volume
      • Check adrenal and thyroid function; may give midodrine for BP support

[SOAP]

• 2023-02-24 Hemato-Oncology
  • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722, C5W1 20220923, C5W2 20220930, C6W1 20221014, C6W2 20221021, C7W1 20221104, C7W2 20221111, C8W1 20221202, C8W2 20221209, C9W1 20221223, C9W2 20221230. C10W1 20230113, C10 W2 20230120, C11W1 20230203, C11W220230210 )
  • admission at March 25, prepare for GCSF injection at March 26-30, Auto HSC collection at March 30-31.
• 2022-09-23 Hemato-Oncology
  • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722, C5W1 20220923)
  • Dara not approved by NHI
  • continue VTD therapy C5
• 2022-09-09 Hemato-Oncology
  • check light chain and beta2-microglogulinemia
  • check bone marrow (plasma cell myeoloma)
  • apply for Major disease to NHI (approved)
  • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722)
  • apply for Velcade and daraturamab
• 2022-04-20 Hemato-Oncology
  • check light chain and beta2-microglogulinemia
  • check bone marrow (plasma cell myeoloma)
  • apply for Major disease to NHI (approved)
  • apply for velcade
  • start steroid therapy and vemlidy
• 2022-03-30 Hemato-Oncology
  • P
    • check light chain and beta2-microglogulinemia
    • check bone marrow (plasma cell myeoloma)
    • apply for Major disease to NHI
• 2022-03-16 Hemato-Oncology
  • P
    • check light chain and beta2-microglogulinemia
    • check bone marrow
• 2022-03-16 Nephrology
  • P: refer to Hema OPD due to amyloidosis (lambda light chain type)

[chemotherapy]

• 2023-02-10 - bortezomib 1.3mg/m2 2.47mg SC 5min D1,5
• 2023-02-03 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
• 2023-01-20 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
• 2023-01-13 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
• 2022-12-30 - bortezomib 1.3mg/m2 2.46mg SC 5min D1,5
• 2022-12-23 - bortezomib 1.3mg/m2 2.46mg SC 5min D1,5
• 2022-12-09 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-12-02 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-11-11 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-11-04 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-10-21 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-10-14 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-09-30 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-09-23 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-07-22 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-07-15 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-07-01 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-06-24 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-06-10 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-05-27 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-05-13 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
• 2022-05-04 - bortezomib 1.3mg/m2 2.39mg SC 5min D1,5

[medication]

• 2022-05-04 ~ 2023-03-17 - Thado (thalidomide 50mg) 1# HS

[assessment]

• The patient was admitted for planned HSC harvest, but bilateral numbness in the last three fingers and elevated cardiac enzymes were observed, so further studies are being conducted.
• There is no issue with the active recipe being used.

700753896

230328

[diagnosis] - 2023-03-27 admission note

• Squamous cell carcinoma of upper third of esophagus, cT3N1M0, stage II status post feeding jejunostomy and left port-A implantation on 2023/02/20 and concurrent chemoradiotherapy with PF(CDDP 75mg/m2, 5FU 1000mg/m2 x4 days) from 2023/02/27~
• Gastro-esophageal reflux disease without esophagitis
• Hypertensive heart disease without heart failure
• Constipation, unspecified
• Cachexia
• Insomnia, unspecified
• Hypomagnesemia

[exam findings]

• 2023-03-03 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Scoliosis of the T-spine with convex to right side.
• 2023-02-22 Pure Tone Audiometry
  • Reliabilty Fair
  • PTA
    • R’t : 10 dB HL, WNL
    • L’t : 13 dB HL, normal to mild SNHL.
• 2023-02-20 CXR
  • widening of Rt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
• 2023-02-18 MRI - brain
  • no evidence of brain tumors.
• 2023-02-17 SONO - abdomen
  • suspected liver calcification, left
  • suspected GB stones
• 2023-02-16 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, lower L-spines, right S-I joint, bilateral shoulders, hips and left knee in whole body survey.
  • IMPRESSION:
    • Increased activity in the lower L-spines and right S-I joint. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, hips and left knee, compatible with benign joint lesions.
    • No prominent bone abnormality was noted elsewhere.
• 2023-02-15 Bronchoscopy
  • no endotreacheal or endobronchial lesions
• 2023-02-14 Whole body PET scan
  • The [F-18] Fluorodeoxyglucose (FDG) PET scan from head to upper thigh regions was performed at 40 minutes after i.v. injection 284 MBq of FDG. Fasting for at least 6 hours was required prior to this examination. Images were reconstructed iteratively with CT scan attenuation correction.
  • There was increased FDG uptake in a focal area in the proximal portion of the esophagus (SUVmax early: 17.72, delay: 22.73) and in bilateral shoulders (SUVmax early: 3.37, delay: 1.72). In addition, there was increased FDG accumulation in both kidneys and bilateral ureters.
  • IMPRESSION:
    • A glucose hypermetabolic lesion in the proximal portion of the esophagus, compatible with primary esophageal malignancy.
    • Mild glucose hypermetabolism in bilateral shoulders. Arthritis may show this picture.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2023-02-13 CXR
  • Widening of Rt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • Minimal dextroscoliosis of the T-spine
• 2023-02-03 CT - chest
  • Indication: esophageal inlet mucosal lesion, pending patho. suspected esophageal cancer, for staging
  • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Submucosa soft tissue mass at upper third esophagus measuring 2.49cm is found.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP, but small lymph nodes (n＝2) are found at paraesophageal region.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • The GB is well distended without soft tissue lesion
      • Suggest clinical correlation
  • Imp: Esophageal submucosa tumor, 2.49cm.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T1(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-02-03 Patho - esophageal biopsy
  • Esophageal tumor, 16 cm below the incisors, biopsy — Squamous cell carcinoma
  • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated of the esophageal tumor tissue characterized by some solid tumor nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the fibrotic stroma.
  • Immunohistochemical stains of CK5/6(+), P16(-) and P63 (+) for tumor.
• 2023-02-02 Esophagogastroduodenoscopy, EGD
  • Suspected esophageal malignancy, L/3, s/p biopsy*4
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
• 2022-07-22 Nasopharyngoscopy
  • suspected acute thyroiditis
• 2021-11-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (86.3 - 17.7) / 86.3 = 79.49%
    • M-mode (Teichholz) = 79.5
  • Normal AV/MV with trivial MR
  • Normal LV chamber size and wall thickness
  • Preserved LV and RV systolic function
  • No PR, trivial TR, normal IVC size

[consultation]

• 2023-02-20 Hemato-Oncology
  • A
    • We are consulted for CCRT.
    • Please check 24 urine CCR, auditory test, HbsAg, AntiHbc, Anti HCV. Arrnage our OPD after discharge.
• 2023-02-17 Radiation Oncology
  • A
    • CCRT is indicated.
    • CT-simulation will be arranged on 2/22.
    • Plan to deliver 45 Gy/ 25 fx to the upper 2/3 esophagus and bil. SCF. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. RT will start around 2/27.
• 2023-02-14 Gastroenterology
  • Q
    • This 76-year-old woman denied any systemic disease. She has suffered from dysphagia for solid material with odynophagia for 2 months, associated with weight loss 7 kg in 6 months. She has visited our GI OPD, where PES revealed suspected esophageal malignancy S/P biopsy was done. Chest CT showed esophageal submucosa tumor, 2.49cm. suspected GIST. For this newly diagnosed esophageal cancer, she was admitted for cancer work-up.
    • Thus we need consult you for arrange EUS and abdominal ultrasound. Thank you very much.
    • schedule
      • 112/02/14 10:30 PET scan
      • 112/02/15 bronchoscope
      • 112/02/16 11:00 bone scan
      • 112/02/18 08:40 brain MRI
      • hope to arrange the examination before 112/02/17.
  • A
    • For EUS:
      • Miniprobe EUS is technically challenging and NOT recommended due to the position of the lesion.
      • Please consider other diagnostic/staging modality
    • For abd echo:
      • Already arrange abdominal echo on 0217.

[surgical operation]

• 2023-02-20
  • Surgery
    • Feeding jejunostomy + port-A
  • Finding
    • 18 Fr. silicon Foley catheter as jejunostomy tube
    • 8.0 Fro. Polysite, left cephalic vein, cut-down method.
• 2022-11-15
  • Surgery: Hemorrhoidectomy        
  • Finding: Prolasped hemorrhoids at 3,7,11 o’clock
• 2021-09-23
  • Surgery: lt PF MIS lateral release
    • The patient underwent a lateral release of the lateral patellofemoral ligament using minimally invasive surgery techniques.
  • Finding: PF OA PFPS
    • The patient has patellofemoral osteoarthritis (PF OA) and patellofemoral pain syndrome (PFPS), which are conditions that affect the knee joint. The lateral release surgery was likely performed to address these conditions, as it can be used to alleviate pain and improve the alignment of the patella.
• 2019-09-23
  • Diagnosis: left knee osteoarthritis
  • PCS code: 64164B
• 2018-09-03
  • Diagnosis: rt OA knee
  • PCS code: 64164B

[chemotherapy]

• 2023-03-27 - cisplatin 75mg/m2 80mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] post cisplatin + fluorouracil 1000mg/m2 1000mg NS 500mL 24hr D1-4 (PF CCRT Q4W)
  • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3
• 2023-02-27 - cisplatin 75mg/m2 80mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] post cisplatin + fluorouracil 1000mg/m2 1000mg NS 500mL 24hr D1-4 (PF CCRT Q4W)
  • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3

[assessment]

• On 2023-03-22, the patient had a BUN/serum creatinine ratio of 31. The normal ratio is 10 to 15:1 but can be greater than 20:1 in prerenal disease due to the increased passive reabsorption of urea that follows the enhanced proximal reabsorption of sodium and water. This selective rise in BUN is known as prerenal azotemia. The serum creatinine concentration will increase in this setting only if the degree of hypovolemia is severe enough to lower the GFR. Therefore, it is recommended to rule out hypovolemia or upper gastrointestinal bleeding as possible causes for the elevated BUN/serum creatinine ratio.
  • 2023-03-22 BUN 29 mg/dL
    
  • 2023-02-27 BUN 13 mg/dL
    
  • 2023-02-13 BUN 11 mg/dL
    
  • 2022-11-14 BUN 9 mg/dL
    
  • 2023-03-22 Creatinine 0.94 mg/dL
    
  • 2023-02-27 Creatinine 0.60 mg/dL
    
  • 2023-02-13 Creatinine 0.71 mg/dL
    
  • 2022-11-14 Creatinine 0.59 mg/dL

230301

[exam findings]

• 2023-02-22 Pure Tone Audiometry
  • Reliabilty Fair
  • PTA
    • R’t : 10 dB HL, WNL
    • L’t : 13 dB HL, normal to mild SNHL.
• 2023-02-20 CXR
  • widening of Rt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
• 2023-02-18 MRI - brain
  • no evidence of brain tumors.
• 2023-02-17 SONO - abdomen
  • suspected liver calcification, left
  • suspected GB stones
• 2023-02-16 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, lower L-spines, right S-I joint, bilateral shoulders, hips and left knee in whole body survey.
  • IMPRESSION:
    • Increased activity in the lower L-spines and right S-I joint. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, hips and left knee, compatible with benign joint lesions.
    • No prominent bone abnormality was noted elsewhere.
• 2023-02-15 Bronchoscopy
  • no endotreacheal or endobronchial lesions
• 2023-02-14 Whole body PET scan
  • The [F-18] Fluorodeoxyglucose (FDG) PET scan from head to upper thigh regions was performed at 40 minutes after i.v. injection 284 MBq of FDG. Fasting for at least 6 hours was required prior to this examination. Images were reconstructed iteratively with CT scan attenuation correction.
  • There was increased FDG uptake in a focal area in the proximal portion of the esophagus (SUVmax early: 17.72, delay: 22.73) and in bilateral shoulders (SUVmax early: 3.37, delay: 1.72). In addition, there was increased FDG accumulation in both kidneys and bilateral ureters.
  • IMPRESSION:
    • A glucose hypermetabolic lesion in the proximal portion of the esophagus, compatible with primary esophageal malignancy.
    • Mild glucose hypermetabolism in bilateral shoulders. Arthritis may show this picture.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2023-02-13 CXR
  • Widening of Rt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • Minimal dextroscoliosis of the T-spine
• 2023-02-03 CT - chest
  • Indication: esophageal inlet mucosal lesion, pending patho. suspected esophageal cancer, for staging
  • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Submucosa soft tissue mass at upper third esophagus measuring 2.49cm is found.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP, but small lymph nodes (n＝2) are found at paraesophageal region.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • The GB is well distended without soft tissue lesion
      • Suggest clinical correlation
  • Imp: Esophageal submucosa tumor, 2.49cm.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T1(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-02-03 Patho - esophageal biopsy
  • Esophageal tumor, 16 cm below the incisors, biopsy — Squamous cell carcinoma
  • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated of the esophageal tumor tissue characterized by some solid tumor nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the fibrotic stroma.
  • Immunohistochemical stains of CK5/6(+), P16(-) and P63 (+) for tumor.
• 2023-02-02 Esophagogastroduodenoscopy, EGD
  • Suspected esophageal malignancy, L/3, s/p biopsy*4
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis
• 2022-07-22 Nasopharyngoscopy
  • suspected acute thyroiditis
• 2021-11-08 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (86.3 - 17.7) / 86.3 = 79.49%
    • M-mode (Teichholz) = 79.5
  • Normal AV/MV with trivial MR
  • Normal LV chamber size and wall thickness
  • Preserved LV and RV systolic function
  • No PR, trivial TR, normal IVC size

[consultation]

• 2023-02-20 Hemato-Oncology
  • A
    • We are consulted for CCRT.
    • Please check 24 urine CCR, auditory test, HbsAg, AntiHbc, Anti HCV. Arrnage our OPD after discharge.
• 2023-02-17 Radiation Oncology
  • A
    • CCRT is indicated.
    • CT-simulation will be arranged on 2/22.
    • Plan to deliver 45 Gy/ 25 fx to the upper 2/3 esophagus and bil. SCF. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. RT will start around 2/27.
• 2023-02-14 Gastroenterology
  • Q
    • This 76-year-old woman denied any systemic disease. She has suffered from dysphagia for solid material with odynophagia for 2 months, associated with weight loss 7 kg in 6 months. She has visited our GI OPD, where PES revealed suspected esophageal malignancy S/P biopsy was done. Chest CT showed esophageal submucosa tumor, 2.49cm. suspected GIST. For this newly diagnosed esophageal cancer, she was admitted for cancer work-up.
    • Thus we need consult you for arrange EUS and abdominal ultrasound. Thank you very much.
    • schedule
      • 112/02/14 10:30 PET scan
      • 112/02/15 bronchoscope
      • 112/02/16 11:00 bone scan
      • 112/02/18 08:40 brain MRI
      • hope to arrange the examination before 112/02/17.
  • A
    • For EUS:
      • Miniprobe EUS is technically challenging and NOT recommended due to the position of the lesion.
      • Please consider other diagnostic/staging modality
    • For abd echo:
      • Already arrange abdominal echo on 0217.

[surgical operation]

• 2023-02-20
  • Surgery
    • Feeding jejunostomy + port-A
  • Finding
    • 18 Fr. silicon Foley catheter as jejunostomy tube
    • 8.0 Fro. Polysite, left cephalic vein, cut-down method.
• 2022-11-15
  • Surgery: Hemorrhoidectomy        
  • Finding: Prolasped hemorrhoids at 3,7,11 o’clock
• 2021-09-23
  • Surgery: lt PF MIS lateral release
    • The patient underwent a lateral release of the lateral patellofemoral ligament using minimally invasive surgery techniques.
  • Finding: PF OA PFPS
    • The patient has patellofemoral osteoarthritis (PF OA) and patellofemoral pain syndrome (PFPS), which are conditions that affect the knee joint. The lateral release surgery was likely performed to address these conditions, as it can be used to alleviate pain and improve the alignment of the patella.
• 2019-09-23
  • Diagnosis: left knee osteoarthritis
  • PCS code: 64164B
• 2018-09-03
  • Diagnosis: rt OA knee
  • PCS code: 64164B

[chemotherapy]

• 2023-02-27 - cisplatin 75mg/m2 80mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1000mg NS 500mL 24hr D1-4 (PF CCRT Q4W)
  • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] post cisplatin

[assessment]

• The patient underwent surgery for feeding jejunostomy and port-A placement on 2023-02-20 and she began receiving cisplatin and fluorouracil starting from 2023-02-27.

• Patients who have undergone feeding jejunostomy surgery often require additional nutritional support and close monitoring of their hydration status. All the oral drugs in the current prescription are compatible with tube feeding.

700947307

230328

[diagnosis] - 2023-03-27 admission note

• Advanced cecal cancer partial obstruction with perforation to retroperitoneum and dense adhesion/invasion to small bowel status post 3 dimensions single incision laparoscopic right hemicolectomy with laparoscopic adhesion lysis and resection of small bowel on 2021/12/01
• Metastatic uterine adenocarcinoma status psot Laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy on 2021/12/01
• Hepatitis B carrier

[past history]

• The patient is B hepatitis carrier
• history of operation:
  • Status post Caesarean section about 40 years ago
  • Status post Tympanoplasty on 2011/04/19
  • Right renal stone status post extracorporeal shock wave lithotripsy on 2009/04/15
• Denied recent traveling history
• Blood transfusion history: NIL
• Occupational function (premorbid): OK。
• Regular medications or herb：no                                                                     

[allergy]

• NKDA                                                             

[family history]

• Father had liver cancer
• Mom had diabetes mellitus type 2 and hypertension

[exam findings]

• 2023-03-27 KUB
  • S/P metalic autosuture and few clips projecting at right lower abdomen.
  • Fecal material store in the colon.
• 2023-02-09 All-RAS + BRAF mutations assay
  • ALL-RAS:
    • Detected (KRAS codon 12 GGT>GTT, p.G12V)
  • BRAF
    • There was no variant detect in the BRAF gene.
• 2023-02-08 CT - abdomen
  • History: cecal CA wt terminal ileum invasion (T4b), lung, liver, uterus mets (M1b), pT4bN2aM1b; stage IVB,
  • Indication: multiple lung metastases
  • Findings:
    • There is a newly-developed lobulated enhancing soft tissue mass 1.3 cm in right middle pelvis with direct invasion right L/3 ureter causing moderate hydroureteronephrosis but no delayed contrast excretion of right kidney.
      • Metastasis in right middle pelvis induce obstructive uropathy is highly suspected.
      • In addition, There is a newly-developed lobulated enhancing soft tissue mass 3.2 cm in right uterine fossa that is also c/w tumor recurrence.
    • There are at least seven newly-developed soft tissue nodules in right lower omentum that are c/w tumor seeding.
    • There are several newly-developed metastatic nodes in para-aortic space and para-cava space .
    • Prior CT identified Multiple metastase in bil. lungs are noted again, increasing in size and number that is c/w progressive disease.
    • S/P right hemicolectomy and S/P hysterectomy
    • Right renal stone (5mm).
    • Tiny gallbladder stones.
  • Impression:
    • Two metastases or local recurrent tumor in right middle pelvis and right uterine fossa.
    • Seven tumor seeding in right lower omentum.
    • Metastatic nodes in para-aortic space and para-cava space
    • Multiple lung metastases show progressive disease.
• 2022-10-04 CT - chest
  • Indication
    • Secondary malignant neoplasm of right lung
    • Malignant neoplasm of cecum
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Several nodular lesions are found at both lungs with some of them shows cavitation. Recurrent/residual metatsatic lung nodules are considered.
        • In comparison with CT dated on 2022-07-25, the numbers of the lesions increased.
      • S/p port-A placement with its tip at Superior vena cava.
      • Patent airway is found.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Tiny low density lesion at S6/7 of liver is found. Suspected liver meta.
      • The spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
  • Imp:
    • Bilaeral lung meta. In progression.
    • Suspected liver meta.
• 2022-07-26 Patho - lung transbronchial biopsy
  • Lung, RLL, CT-guide biopsy — adenocarcinoma, moderately differetiated, consistent with metastatic colorectal orgin
  • Sections show cribriform glandular cells infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal CDX2(+) and TTF-1(-).
  • The results are consistent with metastatic colorectal adenocarcinoma.
• 2022-07-25 CXR
  • a ndular lesion with extensive ground glass opacity over Rt upper lobe s/p cryoablation
  • recticular opacities over both lower lung zones
• 2022-07-25 Right Lower Lobe Lung Mets Cryotherapy
  • Indication: right lower lobe lung meta
  • Position: Prone
  • Cryotherapy was done with cryoneedles placed into right lower lobe lung tumor region. One session of cryotherap with 3-7-10 minutes of cryotherapy was done. Iceball was visualized with total coverage of the tumor.
• 2022-07-05 CT - abdomen
  • History and indication: cecal cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Cecal cancer s/p operation.
    • Multiple nodules in bil. lungs.
    • Right renal stone (4mm).
    • Tiny gallbladder stones.
  • IMP:
    • Cecal cancer s/p operation.
    • Multiple nodules in bil. lungs c/w metastases.
• 2022-06-26 Colonoscopy
  • Diagnosis
    • C/W post right hemicolectomy, no evidence of cancer recurrence.
    • Internal hemorrhoid
  • Suggestion
    • OPD F/U
  • Complication
    • No immediate complication
• 2022-05-17 CT - abdomen
  • Cecal cancer s/p operation.
  • Multiple nodules in bil. lungs suspected metastases.
• 2021-12-28 CT - chest
  • Indication: colon cancer with liver & lung mets
  • Comparison made with previous CT dated on 2021/11/29 abdominal CT.
    • lungs:
      • multiple numerous nodules of variable sizes in both lungs (up to 8.2 mm at RLL), consistent wth metastatic lesions
    • Mediastinum: no enlarged LN or mass.
    • Hila: unremarkable.
    • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Pleura: no effusion or nodule.
    • Chest wall: unremarkable.
    • Visible abdominal-pelvic contents:
      • a metastitc hepatic tumor 23 mm in S7.
      • several small bilateral renal cysts.
      • unremarkable of the spleen, adrenal glands, pancreas, and gall baldder.
      • no enlarged lymph node or ascites.
      • s/p Rt hemicolectomy with retained surgical clips.
    • Visualized bones: unremarkable.
  • Impression:
    • colon ca s/p with multiple lung metastatic tumors and solitary hepatic metastatic tumor.
• 2021-12-02 Patho - uterus with or without SO non-neoplastic/prolapse
  • DIAGNOSIS:
    • Uterus, myometrium, laparoscopic hysterectomy — Metastatic adenocarcinoma, compatible with colorectal origin — Intramural leiomyoma
      
    • Uterus, endometrium, laparoscopic hysterectomy — Postmenopausal state.
      
    • Uterus, cervix, laparoscopic hysterectomy — Negative for malignancy
      
    • Adnexae, bilateral, salpingo-oophorectomy — Negative for malignancy
      
  • Microscopically, the myometrium shows metastatic adenocarcinoma composed of invasive neoplastic glands
• 2021-12-02 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Large intestine, ascending colon, laparoscopic right hemicolectomy — Adenocarcinoma, moderately differentiated
      
    • Resection margins, proximal and distal — Free
      
    • Terminal ileum — Involved by adenocarcinoma
      
    • Lymph node, mesocolic, dissection — Positive for adenocarcinoma (4/12)
      
    • Labeled posterior abdominal wall — Involved by adenocarcinoma
      
    • Pathology stage: pT4bN2aM1a; AJCC stage IVA
      
  • MICROSCOPIC EXAMINATION
    • Histology: Adenocarcinoma
• 2021-11-29 CT - abdomen
  • Impression:
    • Cecal tumor, with extension to appendix and terminal ileum, and lymphadenopathy at right lower quadrant. Malignancy is highly suspected.
    • A 5.4cm uterine tumor, suspect malignancy. Suggest GYN ultrasound correlation.
    • RLL pulmonary nodule.
    • Mild ascites.
    • Bilateral renal cysts. Right renal stone.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:4b(T_value) N:2a(N_value) M:1a(M_value) STAGE:IV(Stage_value)
• 2021-11-29 Gynecologic Ultrasonography
  • RT adnexae: free
  • IMP : Uterine mass: (1) 45x38mm, (2) 21x18mm

[surigcal operation]

• 2021-12-01
  • Surgery
    • Laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy
  • Finding
    • Uterus: enlarged, 11x6x3cm, corpus – right posterior uterine mass 6x5cm with iiregular border, primary uterine tumor or colon cancer metastasis?
    • border adhesion to right pelvic wall, tumor adhesion?
    • another small myomas 2~3# 2cm for each
    • EM – np
    • cervix eroded
    • bil adnexa: normal-looking
    • CDS: some pelvic adhesion (due to previous cesarean section and tumor asdhesion>?) were noted between ant peritoneum and bladder; between post uterus, right pelvic wall and bowels s/p laparoscopic lysis
• 2021-12-01
  • Surgery
    • 3D SILS right hemicolectomy + laparoscopic adhesion lysis + resection of small bowel      
  • Finding
    • Lower abdomen adhesion due to previous C/S Advanced cecal cancer partial obstruction with perforation to retroperitoneum and dense adhesion/invasion to small bowel

[chemoimmunotherapy]

• 2023-03-27 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOXIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

• 2023-03-01 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOXIRI)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

• 2023-02-07 (Avastin + FOLFOX)

• 2023-01-09 (Avastin + FOLFOX)

• 2022-12-12 (Avastin + FOLFOX)

• 2022-11-18 (Avastin + FOLFOX)

• 2022-10-26 (Avastin + FOLFOX)

• 2022-07-04 (Avastin + FOLFIRI)

• 2022-06-08 (Avastin + FOLFIRI)

• 2022-05-16 (Avastin + FOLFIRI)

• 2022-04-20 (Avastin + FOLFIRI)

• 2022-03-29 (Avastin + FOLFIRI)

• 2022-03-04 (Avastin + FOLFIRI)

• 2022-02-11 (Avastin + FOLFIRI)

• 2022-01-12 (Avastin + FOLFIRI)

• 2021-12-27 (Avastin + FOLFIRI)

[assessment]

• On 2021-12-01, the patient underwent surgery for cecal cancer with terminal ileum invasion and metastases to the lung, liver, and uterus, resulting in a diagnosis of pT4bN2aM1b, stage IVB. The surgery involved a 3D SILS right hemicolectomy with laparoscopic adhesion lysis and resection of the small bowel, as well as a laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy. The patient then received Avastin + FOLFIRI from 2021-12-27 to 2022-07-04, and Avastin + FOLFOX from 2022-10-26 to 2023-02-07.
• On 2023-02-08, a CT scan showed two metastases or a local recurrent tumor in the right middle pelvis and right uterine fossa, seven tumor seedings in the right lower omentum, and metastatic nodes in the para-aortic space and para-cava space, as well as multiple lung metastases showing progressive disease. Consequently, the patient’s regimen was changed to FOLFOXIRI from 2023-03-01 and the treatment is ongoing.
• On 2023-02-09, a KRAS mutation was identified in the patient’s tumor (codon 12 GGT>GTT, p.G12V), which suggests that certain targeted therapies, including anti-EGFR therapies such as cetuximab or panitumumab, are unlikely to be effective. Patients with KRAS mutations are typically not eligible for these treatments.
• The patient has received the 2nd cycle of FOLFOXIRI during this hospital stay, and it is too early to determine its effectiveness. There have been no severe adverse reactions related to the treatment so far.
• Based on the patient’s prescription records in the PharmaCloud database for the last 3 months, there are no issues with medication reconciliation.

701027894

230328

[diagnosis] - 2023-03-28 discharge note

• Malignant neoplasm of endometrium
• Endometrial cancer, grade 2 endometroid carcinoma with bilateral obturator LAP metastasis s/p LAVH + BSO + BPLND + PA LN dissection, partial omentectomy on 2022/09/26, pT1bN1acM0, stage IIIC1; FIGO stage IIIC1, ECOG =1 s/p concurrent chemoradiotherapy
• Essential (primary) hypertension
• Constipation, unspecified
• Hypomagnesemia
• Anemia due to antineoplastic chemotherapy

[exam findings]

• 2023-03-03 Mammography
  • Old mammographic study: 2021-04-15 (BIRADS 1)
  • Digital mammography of both breasts with MLO and CC views:
    • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
    • There is no obvious mass lesion.
  • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
  • BI-RADS: Category 1: negative.-annual screening.
• 2022-11-23 ECG
  • Sinus tachycardia
  • Left axis deviation
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2022-10-27 CT - abdomen
  • History and indication: Endometrial cancer
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy. Swelling of anterior abdominal wall. A LN (1.5cm) at left paraaortic region. Small LNs at bil. inguinal regions.
    • Grade 4 fatty liver.
    • Left renal cyst (5mm).
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • S/P hysterectomy.
    • Swelling of anterior abdominal wall. A LN at left paraaortic region.
• 2022-10-27 ENT Hearing Test
  • PTA
  • Reliability FAIR
  • Average RE 19 dB HL; LE 23 dB HL.
  • Bil WNL.
• 2022-10-01 CT - chest
  • Indication: GYN cancer, suspected metastasis
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • S/p port-A placement with its tip at Superior vena cava.
      • Linear atelectatic change at right lower lobe is found.
      • Subpleural nodule at left upper lobe up to 0.4cm in largest dimension is found. (Se8 Im44).
      • Non-specific lymph nodes are found at right hilar and left paratracheal region.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Marked fatty liver is found.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Compatible with endometrial cancer s/p C/T, No definte lung meta but non-specific lymph nodes in the mediastinum. Suggest follow up.
• 2022-09-26 Patho - uterus with or without SO
  • pathologic diagnosis
    • Uterus, endometrium, staging surgery — Endometroid carcinoma
    • Fallopian tube, right, BSO — Endometriosis with atypical hyperplasia
    • Lymph nodes, pelvic and para-aortic, bilateral, BPLND+PALND— Metastatic carcinoma (8/35)
    • AJCC 8 th edition, Pathology stage: pT1bN1a; stage IIIC1; FIGO stage IIIC1
  • macroscopic examination
    • Procedure: LAVH + BSO + partial omentectomy + BPLND + para-aortic LN dissection
    • Specimen Size: 15 x 11 x 7.0 cm and 430 gm (uterus), 2.5 x 1.4 cm (Rt ovary), 5.2 x 1.0 cm (Rt tube), 2.2 x 1.5 cm (Lt ovary), 5.0 x 1.2 cm (Lt tube), and 25 x 12 x 5.0 cm (omentum)
    • Specimen Integrity: Intact
    • Tumor Site: Endometrium, diffuse
    • Tumor Size: 7.5 x 5.6 x 2.8 cm
    • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic LNs
    • Representative parts are taken for section and labeled as: A= left iliac LNs, B1-B4= left obturator LNs, C= right iliac LNs, D1-D2= right obturator LNs, E= left para-aoric LNs, F1-F2= right para-aortic LNs, G1-G4= cerivx, G5-G8= endometrial tumor, G9-G10= right ovary and fallopian tube, G11-G12= left ovary and fallopian tube, H1-H2= omentum
  • microscopic examination
    • Histologic Type: Endometroid carcinoma
    • Histologic Grade: FIGO grade 2
    • Adenomyosis: Present
    • Uterine Serosal Involvement: Not identified
    • Cervical Stromal Involvement: Not identified
    • Other Tissue/Organ Involvement: Not applicable
    • Peritoneal/Ascitic Fluid: Negative
    • Margins: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin: 1.5 cm
    • Lymphvascular Invasion: Present
    • Regional Lymph Nodes: Metastatic carcinoma (8/35)
      • number of lymph node examined: 3 (left iliac), 11 (left obturator), 4 (right iliac), 10 (right obturator), 2 (left para-aortic), and 5 (right para-aortic)
      • number with metastases >2 mm: 4 (left obturator), 4 (right obturator)
      • number with metastases <=2 mm or less: 0
      • number with isolated tumor cells (<=0.2mm): 0
    • Pathologic Stage
      • Primary Tumor: pT1b (tumor invading one-half or more of the myometrium)
      • Regional Lymph Nodes: pN1a (regional lymph node metastasis(> 2mm) to pelvic lymph nodes)
      • Distant Metastasis: Not applicable
    • FIGO Stage: Stage IIIC1
    • AdditionalPathologic Findings
      • Cervix: Chronic cervicitis with Nabothian cyst and squamous metaplasia
      • Myometrium: Adenomyosis
      • Ovary, right: Unremarkable
      • Ovary, left: Endometriosis
      • Fallopian tube, right: Endometriosis with atypical hyperplasia
      • Fallopian tube, left: Endometriosis
      • Omentum: No remarkable change
• 2022-09-21 MRI - pelvis
  • Clinical history: 47 y/o female patient with 2022/09/14 PATHO-endometrium curretage/biopsy, DIAGNOSIS: Uterus, endometrium, TCR — Endometrioid carcinoma.
  • With and without contrast enhancement MRI: Pelvis (Sag T2, axial T1, T2 and T1FS, coronal T2, post contrast enhancement axial and coronal T1FS, upper abdomen survey)
    • There are diffuse soft tissue tumors in the uterine cavity, suspected endometrial malignancy.
    • Tubular cystic lesion in right adnexa, suggesting hydrosalpinx.
    • Cysts in the uterine cervix, suggesting Nabothin cysts.
    • Unremarkable change of the liver, spleen, pancreas.
    • There are multiple enlarged lymph nodes in bilateral obturator region, internal and common iliac regions. Could be due to metastatic lymph nodes.
    • Non-enhancing nodule in left kidney, 0.45cm, suspected left renal cyst.
    • No ascites.
  • Imaging Report Form for Endometrial Carcinoma
    • Impression (Imaging stage) : T:T1b(T_value) N:N1a(N_value) M:M0(M_value) STAGE: IIIC1____(Stage_value)
• 2022-09-14 Patho - endometrium curretage/biopsy
  • Uterus, endometrium, TCR — Endometrioid carcinoma
    
  • Specimen submitted in formalin consists of multiple pieces of red, irregular tissue measuring up to 3.2 x 1.4 x 0.5 cm. All for section in 5 cassettes A1-5.
  • Sections show pieces of blood clots and endometrial tissue with solid and cribriform glands. Moderate to severe nuclear atypia and frequent mitoses are seen.
• 2022-09-09 Gynecologic ultrasonography
  • LT adnexae: free
  • Endometrial thickening (RI:0.15)
  • Rt Ovarian cyst suspected hydrosalpinx

[consultation]

• 2022-11-28 Radiation Oncology
  • Q
    • This 47-year-old woman patient is a case of Endometrial cancer, grade 2 endometroid carcinoma with bilateral obturator LAP metastasis s/p LAVH + BSO + BPLND + PA LN dissection, partial omentectomy on 2022/09/26, pT1bN1acM0, stage IIIC1; FIGO stage IIIC1, ECOG =1 s/p concurrent chemoradiotherapy.
    • This time, for severe nausea with vomiting after concurrent chemoradiotherapy. Now, for follow up. Thank you.
  • A
    • This 47 Y/O female has received adjuvant CCRT since 2022/10/24. She suffers from grade 2 nausea and vomiting during CCRT, although self-paid Emend has been prescribed.
    • RT dose: 4680cGy/26 fractions to vaginal stump, pelvic & PA lymphatics, 2022/10/24 to 11/28.
    • Concurrent weekly cisplatin: 10/29, 11/04, 11/11, 11/18, 11/25.
    • RT side effects, 11/28: Radiation dermatitis, grade 0; nausea, grade 2; enteritis, grade 1; proctitis, grade 1; cystitis, grade 0.

[surgical operation]

• 2022-09-26
  • Surgery
    • Diagnosis
      • Pelvic MRI on 09/21 showed Diffuse soft tissue in the uterus with multiple enlarged pelvic lymph nodes, suspected endometrial malignancy, cstage T1bN1aM0, IIIC1.
      • Endometrial cancer
    • Operation
      • Laparoscopic gynecologic oncology staging surgery  
      • change to exploratory laparoscopy + laparotomy (ope) gynecologic oncology staging surgery (BPLND and bilateral para-aortic lymphadenectomy)    
  • Finding
    • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
    • Bilateral adnexa: severe adhesion, s/p adhesiolysis
    • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
    • CDS: ascites (+)
  • Others
    • Estimated blood loss: 300ml
    • Blood transfusion: nil
    • Complication: nil  
• 2022-09-26
  • Surgery
    • Operation
      • Adhesionolysis
  • Finding
    • s/p lower midline incision with periumbilical hernia
    • severe adhesion of omentum and small bowel in lower peritoneal cavity
• 2022-09-14
  • Surgery
    • TCR, for endometrial thickening.
    • with D&C      
  • Finding
    • Endometrial thickening, occupying the whole uterine cavity, suspected endometrial hyperplasia.
    • Bilateral ostium: difficult to see.
    • Usage of dextrose water: 1000ml/900 ml.
    • Estimated bloodloss: 10 ml;
    • Blood Transfusion: nil; Complication: nil.  

[radiotherapy]

• 2022-10-24 ~ 2022-11-28 - 4680cGy/26 fractions to vaginal stump, pelvic & PA lymphatics

[chemotherapy]

• 2023-03-27 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
  • dexamethasone 4mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-03 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
  • dexamethasone 4mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-03 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-13 - paclitaxel 140mg/m2 240mg NS 500mL 3hr + carboplatin AUC 5 450mg 2hr (adjuvant Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-24 - cisplatin 40mg/m2 70mg 2hr (CCRT)
  • dexamethasone 8mg + palonosetron 250ug + magnesium sulfate 10% 20mL 1hr + aprepitant 125mg D1-3
• 2022-11-17 - cisplatin 40mg/m2 70mg 2hr (CCRT)
  • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
• 2022-11-10 - cisplatin 40mg/m2 70mg 2hr (CCRT)
  • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
• 2022-11-03 - cisplatin 40mg/m2 70mg 2hr (CCRT)
  • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
• 2022-10-28 - cisplatin 40mg/m2 70mg 2hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg D1-3

[assessment]

• The patient’s hypomagnesemia, which has been ongoing since November 2022, continues to persist (2023-03-23 serum Mg 1.7mg/dL). It is recommended to include magnesium supplements in the patient’s discharge plan.

230116

[assessment]

• The hypomagnesemia observed since Nov 2022 might be related to the cisplatin administered as part of the CCRT in early October and November 2022. Creatinine levels rose from roughly 0.6 mg/dL in late September 2022 to 1.0 mg/dL in late November 2022. Hypomagnesemia due to urinary magnesium wasting can occur in over one-half of cases of cisplatin-induced nephrotoxicity. Magnesium supplements have been prescribed for the patient both orally (MgO) and intravenously (MgSO4).
• Since the end of December 2022, no further hypocalcemia has been observed.
• At this hospitalization, there have been no symptoms of nausea or vomiting observed (as a result of concurrent chemotherapy and radiotherapy, the patient experienced severe nausea and vomiting in late November 2022).

701320413

230328

[ciclosporin TDM]

• Based on the available system records, the blood for ciclosporin was drawn at 00:48 on 2023-03-27, approximately 4 hours after medication administration at 20:32 on 2023-03-26. If the purpose of the blood draw was to measure the trough concentration, the ideal time to draw blood is within 30 minutes before next scheduled medication administration. Therefore, it is recommended to verify the accuracy of the system records or to redraw a blood sample at the appropriate time for accurate measurement.

• The recorded concentration result for ciclosporin is 331.4ng/mL, but its accuracy as a trough level may be questionable due to the possibility of an inappropriate blood draw time.

221213

[assessment]

• The peak concentration of cyclosporine-A was 326 ng/mL on 2022-12-12, which is within the normal therapeutic range.
• 2022-12-13 WBC 670/uL, PLT 2000/uL.

221128

[cyclosporine trough concentration]

As a follow-up of the change in dose of cyclosporine from 100mg Q12H to 120mg Q12H since 2022-11-25, it is recommended that the trough concentration of cyclosporine be renewed by drawing blood within 30 minutes of the first dose on 2022-11-29.

221125

[cyclosporine trough concentration]

• Following the administration of 100 mg Q12H since 2022-11-21, a blood sample was taken for cyclosporine trough concentration, and the level was 63.9 ng/mL. In general, the effective range is considered to be between 100 and 400 ng/mL. In the event that the clinical effect not shown, increasing the daily dose to 300mg (divided in 3 seperate administration) can be considered and then recheck the trough concentration 3 days after the dose alteration. The goal is to limit the concentration with a minimum dose while retaining the necessary clinical effect.

• According to UpToDate database, cyclosporine for patients with altered kidney function, CrCl <60 mL/minute: No dosage adjustment necessary (0.1% excreted in the urine unchanged) (Nemecek 2019; expert opinion). For nontransplant indications (eg, autoimmune disease), the manufacturer’s labeling states use is contraindicated in patients with abnormal renal function (not defined); however, when potential benefits outweigh the risks, may consider cautious use with frequent monitoring of kidney function, or consider use of an alternative agent due to increased risk of worsening kidney function, especially for patients with more severe impairment (expert opinion).

221122

{Chronic myelomonocytic leukemia, CMMoL}

• diagnosis
  • 2022-10-19 adminsion note
    • Anemia, unspecified
    • Chronic myelomonocytic leukemia not having achieved remission
    • Unspecified viral hepatitis B without hepatic coma
    • Type 2 diabetes mellitus without complications
    • Chronic myeloproliferative disease
• exam finding
  • 2022-11-19 Skull, Pelvis, Femur
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
  • 2022-11-18 Abdomen
    • Eqivocal osteoblastic change of the L-spine are suspected. please correlate with clinical condition or CT.
    • Splenomegaly is highly suspected.
  • 2022-10-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (84 - 19) / 84 = 77.38%
      • M-mode (Teichholz) = 77
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA
    • Mild MR, TR
  • 2022-10-20 Bronchodilator Test
    • normal ventilation, non-significant bronchodilator response
  • 2022-10-19 Abdomen, standing (diaphragm)
    • Eqivocal osteoblastic change of the L-spine are suspected.
    • Splenomegaly is highly suspected.
  • 2022-09-07 Cardiac Catheter
    • In conclusion
      • Coronary artery disease, tripple vessel disease, with stage PCI to right coronary artery, long diffuse stenosis with 86 % stenosis lesion in RCA-P with 83% stenosis in RCA-M.
      • S/P PTCA to RCA-P, with drug eluting stent (Abbott Xience Sierra drug-eluting stent. 4.0 X 38 mm), self expense, successful, from 86% stenosis reduced to 0% residual stenosis.
      • S/P PTCA to RCA-M, with drug eluting stent (Abbott Xience Sierra drug-eluting stent. 3.5 X 33 mm), successful, from 83% stenosis reduced to 11% residual stenosis.
    • Recommendation
      • Keep DAPT (dual antiplatelet therapy).
  • 2022-08-12 Cardiac Catheter
    • In conclusion :
      • Coronary artery disease, triple vessel diseases, with a A 74% stenosis lesion in LAD-P to LAD-M, A 72% stenosis lesion in LCx and A 85% stenosis lesion in RCA-M.
      • S/P PTCA to LAD-P to LAD-M, Drug eluting stent (Abbott Xience. 3.0 X 48 mm), successful, from 74% stenosis lesion reduced to 4% residual stenosis.
      • S/P PTCA to LCX, Drug eluting stent, (: Abbott Xience. 3.5 X 15 mm), successful, from 72% stenosis lesion reduced to 10% residual stenosis lesion.
    • Recommendation
      • Continue DAPT (dual antiplatelet therapy).
      • Stage PCI for RCA-M later.
  • 2022-07-25 Cardiac Catheter
    • Syntax Score = 22
    • In conclusion: CAD TVD
    • Recommendation: Due the comorbidity of pancytopenia, stem cell transplantation need revascularization earlier, will discuss with the patient and family for further management about CABG or PCI.
    • Left Ventriculogram: Normal LV size and LV wall motion, no MR, LVEF = 66%
    • Left Main: Patent
    • Left Anterior Descending: 80% stenosis ovre proximal LAD and 70% stenosis over mid LAD
    • Left Circumflex: 80% stenosis over proximal LCX and 70% stenosis over mid LCX
    • Right Coronary: diffuse atherosclerosis with 70% stenosis and 90% tandem lesions at mid RCA
  • 2022-07-19 CT - coronary artery calcium score, without contrast
    • Indication: a case of CKD and suspected CAD with chest pain, Hb 6.4
    • Findings
      • Extensive calcification of coronary arteries. LAD:419 LCX:302 RCA:187 total calcium score＝908 (Agatston)
      • Unremarkable of the pericardium.
      • Normal size of cardiac chambers.
      • Mild calcified atherosclerosis of the thoracic aorta
    • Impression:
      • extensive atherosclerotic plaque plaque indicating very high cardiovascular disease risk
  • 2022-07-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 29) / 104 = 72.12%
      • M-mode (Teichholz) = 71.8
    • Dilated LA
    • Adequate LV,RV systolic function with normal wall motion
    • Mild LV hypertrophy, Impaired LV relaxation
  • 2022-06-17 Myocardial perfusion SPECT with persantin
    • Probably mild to moderate myocardial ischemia at the inferoseptal wall and mild myocardial ischemia at the apex and anteroseptal wall.
    • Mild reverse redistribution of radioactivity to the inferoapical wall, either normal variant or myocardial ischemia may show this picture.
  • 2022-04-26 Patho - bone marrow biopsy
    • Bone marrow, iliac creast, biopsy — myeloproliferative neoplasm, favor chronic myelomonocytic leukemia
      
    • Microscopically, it shows hypercellularity of bone marrow (90%) with a proliferation of myeloid and monocytic lineage cells highlighted by CD68 and MPO, decreased erythrocytoid cells and megakaryocytes.
    • Immunohistochemical stain reveals CD68(diffuse+), MPO(diffuse+), TdT(-), CD138(<=1%), CD71(focal+), CD34(-) and CD117.
      
  • 2022-10-20 Patho - bone marrow biopsy
    • Bone marrow, iliac creast, biopsy — myeloproliferative neoplasm
      • NOTE: The differential diagnosis includes chronic myelomonocytic leukemia and ….. etc.
    • Microscopically, the bone marrow shows hypercellularity (90%) with a proliferation of myeloid and monocytic lineage cells highlighted by CD68 and MPO, decreased erythrocytoid cells and a few megakaryocytes.
      
    • Immunohistochemical stain reveals CD68(diffuse+), MPO(diffuse+), TdT(-), CD138(<5%), CD71(<5%), CD20(-), CD34(-) and CD117(<5%).
• 2021-07-26 Abdominal Ultrasonography
  • Diagnosis
    • Mild splenomegaly
    • Fatty liver, mild
    • Fatty pancreas
    • Hydropelvis, bilateral
    • Atrophy of right kidney
  • Suggestion
    • Please correlate with clinical information, other imaging and follow sonography in 3-6 mon.
    • Please check LFTs, tumor markers, and metabolic profiles.
• chemoimmunotherapy
  • 2022-07-08 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2022-06-10 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2022-04-25 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2022-03-21 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2022-02-21 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2022-01-24 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2021-12-27 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2021-11-30 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7

221020

{Chronic myelomonocytic leukemia, CMMoL}

• diagnosis
  • 2022-10-19 adminsion note
    • Anemia, unspecified
    • Chronic myelomonocytic leukemia not having achieved remission
    • Unspecified viral hepatitis B without hepatic coma
    • Type 2 diabetes mellitus without complications
    • Chronic myeloproliferative disease
• exam finding
  • 2022-10-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (84 - 19) / 84 = 77.38%
      • M-mode (Teichholz) = 77
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA
    • Mild MR, TR
  • 2022-10-20 Bronchodilator Test
    • normal ventilation, non-significant bronchodilator response
  • 2022-10-19 Abdomen, standing (diaphragm)
    • Eqivocal osteoblastic change of the L-spine are suspected.
    • Splenomegaly is highly suspected.
  • 2022-09-07 Cardiac Catheter
    • In conclusion
      • Coronary artery disease, tripple vessel disease, with stage PCI to right coronary artery, long diffuse stenosis with 86 % stenosis lesion in RCA-P with 83% stenosis in RCA-M.
      • S/P PTCA to RCA-P, with drug eluting stent (Abbott Xience Sierra drug-eluting stent. 4.0 X 38 mm), self expense, successful, from 86% stenosis reduced to 0% residual stenosis.
      • S/P PTCA to RCA-M, with drug eluting stent (Abbott Xience Sierra drug-eluting stent. 3.5 X 33 mm), successful, from 83% stenosis reduced to 11% residual stenosis.
    • Recommendation
      • Keep DAPT (dual antiplatelet therapy).
  • 2022-08-12 Cardiac Catheter
    • In conclusion :
      • Coronary artery disease, triple vessel diseases, with a A 74% stenosis lesion in LAD-P to LAD-M, A 72% stenosis lesion in LCx and A 85% stenosis lesion in RCA-M.
      • S/P PTCA to LAD-P to LAD-M, Drug eluting stent (Abbott Xience. 3.0 X 48 mm), successful, from 74% stenosis lesion reduced to 4% residual stenosis.
      • S/P PTCA to LCX, Drug eluting stent, (: Abbott Xience. 3.5 X 15 mm), successful, from 72% stenosis lesion reduced to 10% residual stenosis lesion.
    • Recommendation
      • Continue DAPT (dual antiplatelet therapy).
      • Stage PCI for RCA-M later.
  • 2022-07-25 Cardiac Catheter
    • Syntax Score = 22
    • In conclusion: CAD TVD
    • Recommendation: Due the comorbidity of pancytopenia, stem cell transplantation need revascularization earlier, will discuss with the patient and family for further management about CABG or PCI.
    • Left Ventriculogram: Normal LV size and LV wall motion, no MR, LVEF = 66%
    • Left Main: Patent
    • Left Anterior Descending: 80% stenosis ovre proximal LAD and 70% stenosis over mid LAD
    • Left Circumflex: 80% stenosis over proximal LCX and 70% stenosis over mid LCX
    • Right Coronary: diffuse atherosclerosis with 70% stenosis and 90% tandem lesions at mid RCA
  • 2022-07-19 CT - coronary artery calcium score, without contrast
    • Indication: a case of CKD and suspected CAD with chest pain, Hb 6.4
    • Findings
      • Extensive calcification of coronary arteries. LAD:419 LCX:302 RCA:187 total calcium score＝908 (Agatston)
      • Unremarkable of the pericardium.
      • Normal size of cardiac chambers.
      • Mild calcified atherosclerosis of the thoracic aorta
    • Impression:
      • extensive atherosclerotic plaque plaque indicating very high cardiovascular disease risk
  • 2022-07-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 29) / 104 = 72.12%
      • M-mode (Teichholz) = 71.8
    • Dilated LA
    • Adequate LV,RV systolic function with normal wall motion
    • Mild LV hypertrophy, Impaired LV relaxation
  • 2022-06-17 Myocardial perfusion SPECT with persantin
    • Probably mild to moderate myocardial ischemia at the inferoseptal wall and mild myocardial ischemia at the apex and anteroseptal wall.
    • Mild reverse redistribution of radioactivity to the inferoapical wall, either normal variant or myocardial ischemia may show this picture.
  • 2022-04-26 Patho - bone marrow biopsy
    • Bone marrow, iliac creast, biopsy — myeloproliferative neoplasm, favor chronic myelomonocytic leukemia
      
    • Microscopically, it shows hypercellularity of bone marrow (90%) with a proliferation of myeloid and monocytic lineage cells highlighted by CD68 and MPO, decreased erythrocytoid cells and megakaryocytes.
    • Immunohistochemical stain reveals CD68(diffuse+), MPO(diffuse+), TdT(-), CD138(<=1%), CD71(focal+), CD34(-) and CD117.
      
  • 2022-10-20 Patho - bone marrow biopsy
    • Bone marrow, iliac creast, biopsy — myeloproliferative neoplasm
      • NOTE: The differential diagnosis includes chronic myelomonocytic leukemia and ….. etc.
    • Microscopically, the bone marrow shows hypercellularity (90%) with a proliferation of myeloid and monocytic lineage cells highlighted by CD68 and MPO, decreased erythrocytoid cells and a few megakaryocytes.
      
    • Immunohistochemical stain reveals CD68(diffuse+), MPO(diffuse+), TdT(-), CD138(<5%), CD71(<5%), CD20(-), CD34(-) and CD117(<5%).
• 2021-07-26 Abdominal Ultrasonography
  • Diagnosis
    • Mild splenomegaly
    • Fatty liver, mild
    • Fatty pancreas
    • Hydropelvis, bilateral
    • Atrophy of right kidney
  • Suggestion
    • Please correlate with clinical information, other imaging and follow sonography in 3-6 mon.
    • Please check LFTs, tumor markers, and metabolic profiles.
• chemoimmunotherapy
  • 2022-07-08 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2022-06-10 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2022-04-25 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2022-03-21 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2022-02-21 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2022-01-24 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2021-12-27 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
  • 2021-11-30 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7

[assessment]

• 2022-10-20 eGFR 35. The dosage of prescribed drugs is within the recommended range for patients with altered kidney function.

221014

[assessment]

• 2022-10-20 eGFR 35. The dosage of prescribed drugs is within the recommended range for patients with altered kidney function.

701471705

230328

[Diagnosis] - 2023-03-27 admission note

• High grade serouns carcinoma of bilateral ovaries, pT2bNxMx, at least 2B, s/p Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection) the 2023/03/09, ypTxN0(if cM0)
• Chronic viral hepatitis B without delta-agent

[present illness] - 2023-03-27 admission note

• This 47-year-old woman patient is a case of Ovarian malignancy s/p LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy (at HuaLien TzhChi Hospital). She had palpable progressively enlarging masses over right inguinal area for 4 months. Three months ago, she went to HuaLien TzhChi Hospital GYN OPD due to her progressively enlarging masses over right inguinal area and LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy were done.
• This time, she came to our GYN OPD on 2023/02/16 seeking second opinion for surgical intervention. Received 3 rd times chemotherapy with Taxol/Carboplatin in Hualien (due to high grade serous carcinoma) on 2023/01/30. Transvaginal sonography on 2023/02/17 revealed multiple myomas 22x18, 23x20, 17x16mm and EM 5.00mm. PES on 2023/03/08 showed chronic superficial gastritis. Colonoscopy on 2023/03/08 showed no immediate complication. Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection) on 2023/03/09 and pathology showed AJCC 8th edition pathology stage: ypTxN0(if cM0), high grade serouns carcinoma of bilateral ovaries: pT2b NxMx, at least 2B. Tumor markers on 2023/03/24 showed normal (CA-125:17.8 U/mL, CEA:0.94 ng/mL, CA199- 6.52U/mL). Now, she was admitted to ward for adjuvant chemotherapy with TP (Taxol 175mg/m2, Carboplatin AUC:5)(C4) on 2023/03/28.

[past history] - 2023-03-27 admission note

• Hypertension without medication control
• DM:(-) Other
• medical:denied
• Not taking any hormone medications
• Surgical: Ovarian malignancy s/p LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy (at HuaLien TzhChi Hospital)
• Menstrual history: G0P0, Last menstrual period: 2022/11
• Menarche at the age of 13 years old
• Menstrual cycle: Duration/Interval: 4-5days/14-28days
• Amount: moderate without blood clots
• Last pap smear examination at 2022/9            

[allergy]

• NKDA

[family history]

• Father has colon cancer and hypertension.
• No members of the family with diabetes.

[exam findings]

• 2023-03-09 Patho - uterus with or without SO non-neoplastic/prolapse
  • Ovarian/ Fallopian tube/ Peritoneum Cancer Checklist
  • Diagnosis:
    • Uterus, endometrium, debulking surgery — No residual malignant tumor
    • Uterus, myometrium, debulking surgery — Intramural myoma; adenomatoid tumor; adenomyosis
    • Uterus, cervix, debulking surgery — No residual malignant tumor
    • Omentum, infracolic omentectomy — No residual malignant tumor
    • Lymph node, left iliac, dissection — Negative for malignancy ( 0 / 9)
    • Lymph node, left obturator, dissection — Negative for malignancy ( 0 / 5)
    • Lymph node, right iliac, dissection — Negative for malignancy ( 0 / 5)
    • Lymph node, right obturator, dissection — Negative for malignancy ( 0 / 5)
  • AJCC 8th edition pathology stage: ypTxN0(if cM0)
• 2023-03-08 Colonoscopy
  • Diagnosis
    • Mixed hemorrhoid, gr 3-4
    • incomplete study due to poor preparation.
  • Suggestion
    • Small lesions may be missed due to inadequate colon preparation.
  • Complication
    • No immediate complication
• 2023-03-07 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Nonspecific T wave abnormality
• 2023-02-16 Gynecologic ultrasonography
  • Bilateral adnexae: free
  • Uterine myoma

[surgical operation]

• 2023-03-09
  • Diagnosis
    • High grade serous carcinoma of bilateral ovaries, pT2bNxMx (2022/12/15), at least IIB, status post glove-port LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15.
  • Surgery:
    • Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection).
  • Finding
    • uterus with multiple small myomas, its total size measuring 7x5cm
    • right side atrophic partial ovary was attached to the posterior wall of the uterus
    • there was dense adhesion from last surgery found between the intestine and left side pelvic wall, adhesionlysis was performed
    • left side pelvic lymph nodes enlarged (+)
    • right side pelvic lymph nodes (-)
    • cytology was performed
    • there was no residual tumor found while entering the pelvic cavity
    • omentectomy was done

[chemotherapy]

• 2023-03-27 paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

• The patient was diagnosed with high grade serous carcinoma of bilateral ovaries, with a pathological stage of pT2bNxMx, at least IIB. She underwent LSO, right ovarian cystectomy, and right salpingectomy on 2022/12/15 and received three cycles of taxol chemotherapy at HuaLien TzhChi Hospital, with the last dose on 2023-01-30. On 2023-03-09, she underwent debulking surgery for ovarian cancer, which included a hysterectomy, right oophorectomy, infracolic omentectomy, and bilateral pelvic lymph node dissection.
• She was admitted this time for the fourth adjuvant chemotherapy cycle using paclitaxel and carboplatin, with the previous three cycles being administered at HuaLien TzhChi Hospital.
• Paclitaxel can cause severe hypersensitivity reactions, so the premedication regimen includes dexamethasone, an H1 receptor antagonist (diphenhydramine), and an H2 receptor antagonist (famotidine).
• Carboplatin is also associated with infusion reactions, which typically occur after six cycles, and no specific premedication regimen is recommended.
• Lab data on 2023-03-27 showed normal liver and kidney function with CBC grossly in normal range. No dose adjustment is needed for the scheduled chemotherapy.
• According to the PharmaCloud database, the patient has only taken drugs prescribed at our hospital in the last three months, and there is no medication reconciliation issue.

700335007

230327

[diagnosis] - 2023-03-13 admission note

• Intrahepatic bile duct carcinoma
• Type 2 diabetes mellitus without complications
• Cardiac arrhythmia, unspecified

[past history]

• Medical PH: recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. NTUH, anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
• Hospitalization: several times due to UTI
• urethral stone s/p at NTUH
• DM (+): under pioglitazone 15mg/metformin 850mg BID, glimepride 2mg QD
• HTN (-)
• Peptic ulcer

    

[allergy]

• NKDA     

[family history]

• Mother: DM

[exam findings]

• 2023-03-24, -03-13 KUB
  • S/P clips projecting at the liver
  • Spondylosis of the L-spine is noted.
• 2023-03-16 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (67 - 28) / 67 = 58.21%
    • M-mode (Teichholz) = 57
  • Conclusion:
    • Adequate LV systolic function with normal resting wall motion
    • Mild to moderate MR, mild AR, moderate TR and trivial PR
      • ChatGPT: In a cardiac echocardiogram, the abbreviations MR, AR, TR, and PR refer to different types of heart valve regurgitation:
        • MR: Mitral regurgitation, which is the backflow of blood from the left ventricle to the left atrium through the mitral valve during systole.
        • AR: Aortic regurgitation, which is the backflow of blood from the aorta to the left ventricle during diastole.
        • TR: Tricuspid regurgitation, which is the backflow of blood from the right ventricle to the right atrium through the tricuspid valve during systole.
        • PR: Pulmonary regurgitation, which is the backflow of blood from the pulmonary artery to the right ventricle during diastole.
    • Preserved RV systolic function
    • Atrial fibrillation with HR 90~128 at the exam
• 2023-03-14 SONO - abdomen
  • Parenchymal liver disease
  • Post left lobectomy of liver
  • Postcholecystectcomy
• 2023-03-13 CXR
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
• 2023-03-13 ECG
  • Atrial fibrillation with rapid ventricular response
• 2023-02-16 CT - abdomen
  • History and indication: intraheapatic cholangiocarcinoma
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P left liver operation without interval change.
    • Hydrops of left scrotum.
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • S/P cholecystectomy.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • A calcified spot (4.7mm) at RLL.
  • IMP:
    • S/P left liver operation without interval change.
• 2022-10-24 CT - abdomen
  • Indication
    • First operation for intraheapatic cholangiocarcinoma, cT2N0M0 post Lt lobectomy on 2020/04/15, pT2pNx, well differentiated.
    • NTUH - Anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 NIDDM under OHA for 4 yrs (20220624)
    • History of arrhythmia
  • Abdominal CT with and without enhancement revealed:
    • s/p left hepatic lobectomy.
    • Low density change at caudate lobe about 2.79cm in largest dimension. post op change or others? Suggest closely follow up.
    • Minimal ascites at abdominal cavity is found.
    • Enlarged prostate up to 4.8cm in largest dimension is found.
    • The spleen, pancreas, both kidneys and adrenals are intact.
    • There is no evidence of paraarotic LAPs.
    • Non-specific bowel gas at abdominal cavity is found.
    • Visible chest
      • Cardiomegaly is noted.
      • The lung fields are clear.
      • No pleural effusion is found.
    • Suggest clinical correlation
  • Imp: s/p left hepatic lobectomy with low density lesion at caudate lobe about 2.79cm, post op change or recurrent tumor should be D.D. Suggest closely follow up.
• 2022-06-30 CXR
  • S/P Port-A infusion catheter insertion.
  • Blunted right costophrenic angle.
  • S/P operation with retention of surgical clips.
• 2022-06-24 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?

MRI (111-2-5, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. focal area 39.5mm in the surgical margins is noted; the lesion was not identified on MR 2020/9/8; new recurrent tumor is considered. (arrow key images) 3. hepatic veins and portal veins are patent 4. there are no focal lesions in the spleen pancreas both adrenal and kidneys; a tiny cyst in the left kidney; 5. there is no evidence of paraaortic LAPs in abdomen; there is no evidence of paraaortic LAPs in pelvic cavity and bilateral inguingal areas. 6. there is no ascites 7. enlarged prostate is noted with posterior urinary bladder indentation; 8. hydrocele of the left scrotum. PET (111-3-2, NTUH): Some intense hot areas along medial border of the liver (figures 1-1 to 1-4, SUVmax=11.85). * Some moderate hot spots at abdominal paraaortic nodes and left iliac nodes (figures 1-5 to 1-9, SUVmax=5.79). * A faint hot spot at right iliac crest (figure 1-10, SUVmax=1.34), probably benign. * Some mild hot areas at L1-L2 vertebral junction, right hip joint, and right ischial enthesis, probably arthritis and enthesitis. * Intense curvilinear-shaped hot areas at bowel loops, suspicious Metformin-related activity. Pathology (P2202854, 2022-3-26, NTUH): Liver segment 5 8 anatomical hepatectomy cholangiocarcinoma Gallbladder cholecystectomy chronic cholecystitis Lymph node peri-gallbladder lymphadenectomy minimal histological change (1/1). Histologic Grade Grade 2: Moderately differentiated (50% to 95% of tumor composed of glands). Margins (check all that apply) Hepatic Parenchymal Margin Uninvolved by invasive carcinoma. Lymph-Vascular Invasion: not identified. Perineural Invasion Not identified. Pathologic Staging (pTNM according to AJCC v.8): Primary Tumor (pT) pT1b: Solitary tumor ＞5cm without vascular invasion Regional Lymph Nodes (pN) pN0: No regional lymph node metastasis. MRI (111-5-4, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. operative change of the anterior right lobe of liver; no evidence of local residual tumor is noted; a small biloma. 3. a recurrent tumor 34.5mm is noted at the S1 of the liver; cholangiocarcinoma is considered. 4. hepatic veins and portal veins are patent 5. there are no focal lesions in the spleen pancreas both adrenal and kidneys 6. there is no evidence of paraaortic LAPs in abdomen 7. there is no ascites

[consultation]

• 2023-03-24 Gastroenterology
  • Q
    • This is a 74-year-old male with underlying DM (under pioglitazone 15mg/metformin 850mg BID, glimepirde 2mg QD) and recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. (NTUH), anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
    • The patient was just discharged last week under the diagnosis of general weakness with mild eleavted liver enzyme suspected poor intake related.
    • The patient sufferred from poor appetite with progressive body weight loss from 54kg -> 50kg in recent one month. Easy satiety with nausea and vomit sensation, he can only tolerate liquid diet intake (the solid food can be swallowed, but the patient vomits immediately after eating.) Mild elevated liver enzyme also noted. KUB during last admission: no ileus, will be followed today. Stool passage only under laxative use recently. Depressive mood also noted and had went to PSY OPD for further managment on 2023/03/22, mertazapine 0.5# HS was precribed. Stool OB obtained in last admission: negative.
    • For poor appeitte with general weakness, we need your expertise for further evaluation and management, thank you!
  • A
    • This time, he was admitted for poor appetite and general weakness. And, we are consulted for problem above.
    • S + O
      • At bedside, stable vital signs noted
      • Recieving blood transfusion
      • Clear conscious,
      • According to his daughter, patient ate well without vomitus yesterday, after stool passage
      • But, vomtius noted today
      • Local tenderness at upper quadrat of abdomen, no rebounding pain
      • normoactive bowel sound
      • Percussion: no tympanic
      • Lab
        • 2023-03-24 Na (Sodium) 133 mmol/L
          
        • 2023-03-24 K(Potassium) 3.9 mmol/L
          
        • 2023-03-24 Ca (Calcium) 2.03 mmol/L
          
        • 2023-03-24 Albumin 2.7 g/dL
          
        • 2023-03-24 Neutrophil 98.0 %
          
        • 2023-03-24 S-GPT/ALT 101 U/L
          
        • 2023-03-24 S-GOT/AST 116 U/L
          
        • 2023-03-24 Alkaline phosphatase 844 U/L
          
        • 2023-03-24 Creatinine 0.64 mg/dL
          
        • 2023-03-24 WBC 14.70 x10^3/uL
          
        • 2023-03-24 HGB 7.9 g/dL
          
        • 2023-03-24 PLT 396 x10^3/uL
          
        • 2023-03-17 HbA1c 8.4 %
          
    • A: poor appetite, vomitus, suspect gastroparesis, suspected obstruction
    • P:
      • Might be on NG feeding with feeding bag or feeding pump for nutrition support, if still vomitus
      • IVF supplement
      • Give medication with gascon and prokinetic agent such as metoclopramide (IV or PO), mosapride or domperidone
      • Regular follow up KUB (standing KUB) to see if symptoms improved
      • Give medication such as sennoside, dulcolax, lactulose, EVAC to keep stool passage
      • Correct electrolytes imbalance
      • Check thyroid and adrenal function.
      • Correct hypoalbuminemia to improve bowel edema.
      • Arrange upper GI series or EGD to rule out mechanical lesion
      • Arrange abdominal CT (with contrast if no contraindication), if still unknow etiology
      • Consider to use megestrol, if cachexia was suspicious and rule out other cause of poor appetite
• 2023-03-14 Cardiology
  • Q
    • This is a 74-year-old male with underlying DM (under pioglitazone 15mg/metformin 850mg BID, glimepirde 2mg QD) and recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. (NTUH), anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
    • Under the impression of unintentional body weight loss with elevated liver enzyme, suspected cancer progression, he was admitted for further survey.
    • Tachycardia with follow up ECG showed Af on admission. According to the patient, he knew he had Af and had ever follow up in CV in the past but lost of follow up for years, anticoagulation was suggested but refused due to personal reasons.
    • We add apixaben 5mg BID for stroke prevention (CHA2DS2 VASC score 2 points)
    • We need your expertise for further evaluation and follow up, thank you!
  • A
    • The patient was examined and hx was reviewed.
    • CHA2DS2 score = 2’ ; HAS-BLED 1’-2’;
    • Suggestion
      • Anticoagulant is indicated for the patient; the risk (eg.: major bleeding rate around 0.1-0.3 %) and indication have been well explained to the patient and his family.
      • Educate about the timing of medication withdrawl.
      • Arrange 2D echo for LV function work-ip.
      • Nebivolol 0.5# qd for rate control.
    • Thanks for your consultation.

[radiotherapy]

• 2022-07-18 ~ 2022-08-22 - 4500cGy/25 fractions of the recurrent tumor and peripheral area.

[chemotherapy]

• 2023-02-21 - gemcitabine 1000mg/m2 1544mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-02-14 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-02-07 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-01-31 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-01-17 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2023-01-03 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-12-20 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-12-06 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-11-22 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-11-08 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-10-25 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-10-11 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-09-27 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-09-06 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-08-16 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-08-02 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-07-19 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
• 2022-07-05 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

[assessment]

• The patient was prescribed regular insulin 10 units Q12H at 08:05 on 2023-03-27, while his serum glucose levels have been fluctuating significantly, ranging from less than 100mg/dL to over 200mg/dL (81mg/dL at 06:06 on 2023-03-25 and 109mg/dL at 06:22 on 2023-03-27). It is recommended to closely monitor the patient for signs of hypoglycemia after administering the insulin and adjust the dosage as needed.
• The patient’s stool occult blood test (OB) is positive (4+, 2023-03-26). Hemoclot (tranexamic acid) 500mg IVD Q12H has been prescribed. The anticoagulant indicated for the patient’s atrial fibrillation is currently withheld due to the patient’s current bleeding.
• The patient’s constipation has been alleviated with the use of Through (sennoside), lactulose, and EVAC Enema, resulting in 1, 0, 0, and 3 bowel movements on March 23rd to March 26th, respectively.
• There are no issues with the current prescription.

230314

[assessment]

• Elevated liver-related enzymes and hemoglobin breakdown readings above the normal range strongly suggest the possibility of hepatic problems.
  • 2023-03-13 S-GOT/AST 89 U/L
    
  • 2023-03-13 S-GPT/ALT 113 U/L
    
  • 2023-03-13 Bilirubin total 1.59 mg/dL
    
  • 2023-03-13 Bilirubin direct 0.66 mg/dL
    
  • 2023-03-13 Alkaline phosphatase 688 U/L
    
  • 2023-03-13 r-GT 876 U/L
• Despite the administration of insulin and oral antiglycemic agents, the patient has experienced blood sugar levels ranging between 320 to 600 mg/dL during this hospitalization. This marked hyperglycemia can lead to an increase in serum glucose, which in turn raises the serum tonicity. This process draws water out of cells and expands the extracellular water space, resulting in a subsequent lowering of the serum sodium concentration. It is recommended to appropriately increase the insulin dose in order to better manage the patient’s hyperglycemia (and the possibly induced hyponatremia).
  • 2023-03-14 Free-T4 1.18 ng/dL
    
  • 2023-03-14 TSH 0.890 uIU/mL
    
  • 2023-03-13 Urine osmolarity 675 mOsm/Kg
    
  • 2023-03-13 Na (Urine) 46 mmol/L
    
  • 2023-03-13 K (Urine) 19.9 mmol/L
    
  • 2023-03-13 Na (Sodium) 127 mmol/L
    
  • 2023-03-13 Albumin 2.7 g/dL

700537683

230327

[exam findings]

• 2023-03-23 Ascites tapping
  • 3000mL
• 2023-03-22, -03-21 CXR
  • S/P port-A implantation.
  • Enlargement of cardiac silhouette.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion.
  • Few gallstones.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
• 2023-03-21 CT - abdomen
  • History and indication: Pancreatic cancer
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A poor enhancing lesion (6.8cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
    • Bil. pleural erffusions with adjacent lung collapse.
    • Some LNs at retroperitoneum.
    • Multiple liver tumors.
    • Some soft tissues in peritoneal cavity with ascites.
    • Normal appearance of kidneys.
    • Gallbladder stones (up to 1.2cm).
    • Patency of portal vein.
    • Intact bony structures.
    • No obvious extraluminal free air.
    • Minimal pericardial effusion.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • S/P Port-A infusion catheter insertion.
    • Cystic lesions (up to 3.1cm) at thyroid glands.
  • IMP:
    • Pancreatic tail with adjacent structures invasion, peritoneal carcinomatosis and liver metastases (progression). Ascites and pleural effusion.
• 2023-03-20, -03-16 Standing KUB
  • Gallbladder stones.
  • Fecal material store in the colon.
  • Ascites is highly suspected. Please correlate with sonography.
  • Degenerative change of the spine with marginal spur formation.
• 2023-03-14, -02-22 ECG
  • Sinus tachycardia
• 2022-12-22 CT - chest
  • Indication: pancrease cancer, cT3N1M1, stage IV, for lung metastasis evaluation
  • MDCT (256-detector rows, GE Revolution, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Lungs: multiple small randomly distributed pulmonary nodules of varying sizes up to 11mm at RML consistent metastases.
    • Mediastinum and hila: no enlarged LN or mass.
      • small pericardial effusion.
      • mild calcified plaques of the LAD coronary arter.
    • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
    • Heart: normal in size of cardiac chambers.
    • Pleura: trace effusion.
    • Chest wall and visible lower neck: enlarged thyroid gland with nodular calcifications and cystic lesions up to 42mm.
    • Visible abdominal contents: a large (6cm) at pancreatic tail canceer with adjacent organs invasion, multiple metastatic tumors, regional LNs metastasis, suspect a small tumor in pancreatic head. two gallstones (1.3mm).
  • Impression:
    • advanced pancreatic cancer (stage IV) with lung metastasis.
    • thyroid goiter.
• 2022-12-21 whole body bone scan with SPECT
  • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed a hot area in the right aspect of mandible, faint hot spots in both rib cages, and increased activity in the skull, maxilla, a upper T-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
  • IMPRESSION:
    • A hot area in the right aspect of mandible and increased activity in a upper T-spine, the nature is to be determined (early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in both rib cages, skull, maxilla, sacrum, bilateral shoulders, S-I joints, hips, and knees.
• 2022-12-20 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Adenocarcinoma, pancreatobiliary type, compatible with metastatic pancreatic ductal adenocarcinoma
  • The sections show a picture of pancreatobiliary-type adenocarcinoma, moderately differentiated, composed of nests, and cords of low columnar neoplastic cells with intracytoplasmic and intraluminal mucin, arranged in tubular and cribriform patterns, and embdded in fibrous stroma.
  • IHC shows: CK7(+), CA19-9(+), amd CK20 (focal +).
  • The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
  • Suggest clinic coirrelation.
• 2022-12-17 CT - abdomen
  • History and indication:
    • liver tumors: suspected metastatic tumors. suspected pancreatic tumor(tail)
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A poor enhancing lesion (5.9cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
    • Some LNs at retroperitoneum.
    • Multiple liver tumors.
    • Some soft tissues in peritoneal cavity.
    • Normal appearance of kidneys.
    • Gallbladder stones (up to 1.2cm).
    • Patency of portal vein.
    • Intact bony structures.
    • Small amount ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • Some nodules at bilateral basal lungs.
  • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T3(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)
• 2022-12-14 SONO - abdomen
  • Diagnosis
    • Hepatic tumors suspected mets
    • Gall stones, two
    • Pancreatic tumor suspected cancer, tail
  • Suggestion
    • abdomen CT
• 2022-12-14 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade A(minimal)
    • Superficial and atrophic gastritis, antrum, s/p CLO test
    • Gastric polypoid lesion, high body, GC site, suspicious external compression
  • Suggestion
    • Pursue CLO test result
    • Consider arrange CT scan for suspicious external compression
• 2019-06-03 ENT Hearing Test
  • Tymp: R’t type As; L’t type A
  • ART:
    • R’t ipsi 4k Hz and contra 500 Hz absent
    • L’t ipsi 4k Hz reduced and contra 500 & 4k Hz absent
  • PTA:
    • Reliability fair
    • Average R’t 45 dB HL; L’t 54 dB HL
    • R’t mild to moderately severe SNHL
    • L’t moderate to moderately severe SNHL

[consultation]

• 2022-12-20 Hemato-Oncology
  • Q
    • This 70 years old female has the history of DM under medication control for years
    • she came to GI OPD for abdomen pain for days and body weight loss 5+ in one month. At OPD abdomen CT was perfromed and reported A poor enhancing lesion (5.9cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
      • Some LNs at retroperitoneum.
      • Multiple liver tumors.
      • Some soft tissues in peritoneal cavity.
    • Pancreatic Carcinoma T3N1M1 STAGE:IV
    • Bone scan was arranged, we need your further further advise. Thanks
  • A
    • This 70 year old woman is a case of suspect pancreae tail cancer with liver and lung metastasis. She receive CT guide bioipsy for liver tumor on 2022/12/20 morning and pending the result. For pancrease cancer, cT3N1M1, stage IV, we are consulted.
    • Suggestions:
      • Well explain to patient and daughter.
      • May arrange contrast enhance chest CT for lung metastasis during this admission, or arrange in my clinics.
      • Please check AntiHbc, HbsAg, AntiHCV
      • Pending the pathology. We will discuss with patient about further treatment according to pathology result.
      • Please arrange our OPD after being discharged.

[chemotherapy]

• 2023-03-07 - nab-paclitaxel 100mg/m2 170mg 90min D1,8,15 + gemcitabine 1000mg/m2 1700mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-02-14 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-02-07 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-01-31 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-01-17 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-01-10 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
• 2023-01-03 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

700490718

230324

[exam findings]

• 2023-03-23 CXR
  • Consolidation or mass lesions in left lower lung zone
• 2023-03-21 Nasopharyngoscopy
  • right OME(+) –> suggest right grommet
• 2023-03-14 MRI - nasopharynx
  • The current study was compared to the prior one obtained on 2022/10/25.
  • The previously seen mucosal enhancing lesion on the nasopharyngeal posterior wall is less distinct. Favor tumor in regression.
  • Severe paranasal sinusitis.
  • Severe bilateral mastoiditis.
• 2023-03-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (113 - 27) / 113 = 76.11%
    • M-mode (Teichholz) = 76
  • Adequate LV, RV systolic function with normal wall motion
  • Impaired LV relaxation
  • Mild PR, AR
• 2023-03-07 Nasopharyngoscopy
  • Findings: curst over NPx, NE of left NP tumor noted, sticky sputum over posterior pharyngeal wall
  • Conclusion: NPC
• 2023-03-06 ECG
  • Normal sinus rhythm
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2023-03-02 CXR
  • Atherosclerotic change of aortic arch
  • Spondylosis of the T-spine
  • Peri-bronchial wall thickening of the left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2023-02-23 CXR
  • Atherosclerosis of the aorta.
  • Ground glass opacity in LLL.
• 2023-02-23 ECG
  • Sinus rhythm with Premature atrial complexes
  • Nonspecific ST and T wave abnormality
• 2023-02-04 Nasopharyngoscopy
  • Findings: stage cT1N1M0, under CCRT
  • Conclusion: NPscope: left NP tumor regression, NE of tumor noted, crust(+)
• 2023-01-07 Nasopharyngoscopy
  • Findings: NPC
  • Conclusion: left NP tumor regression, but still residual tumor
• 2022-11-20 CXR
  • No cardiomegaly
  • No active lung lesion
  • Normal bony contour
• 2022-11-10 ENT Hearing Test
  • Reliabilty Fair
  • PTA
    • R’t : 33 dB HL
    • L’t : 35 dB HL
    • Bil normal to moderate SNHL.
• 2022-11-09 CXR
  • Multiple nodules at bil. lungs.
  • Normal appearance of trachea and bil. main bronchus.
  • Normal size of heart.
  • Intact bony structure(s).
• 2022-11-02 CXR
  • Blunted left costophrenic angle.
  • Normal appearance of trachea and bil. main bronchus.
  • Atherosclerosis of the aorta.
  • Multiple nodules at RUL.
• 2022-10-25 CXR
  • No cardiomegaly
  • Increased infiltration over right lung and LLL. May be active infection.
  • Degenerative joint disease of T-spine with marginal osteophytes.
• 2022-10-26 Tc-99m MDP whole body bone scan
  • IMPRESSION:
    • Increased activity in the skull base and maxilla, either local hyperemia or local bony involvement may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Suspected benign lesions in some T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and left knee.
  • SUGGESTION:
    • Please arrange F-18 FDG PET/CT scan for further staging (Insurance reimbursement indication for head and neck cancer staging).
• 2022-10-25 MRI - nasopharynx
  • Nasopharyngeal Carcinoma
  • Impression ( Imaging stage ): T:T1(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2022-10-18 Patho - nasopharyngeal/oropharyngeal biopsy
  • Nasopharynx, left, NP biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated type
  • The specimen submitted consists of a small piece of gray-tan soft tissue, labeled left nasopharynx, measuring 0.5 x 0.3 x 0.2 cm. All for section.
  • The sections show a picture of non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of nests of large neoplastic cells with oval to spindle-shaped vesicular nuclei and syncytial growth pattern. Keratin formation is absent.
• 2022-10-18 Nasopharyngoscopy
  • Findings
    • blood tinged NR for one month
    • patient has strong gap reflex, hard to assess NP and larynx by mirror
    • no ABC
  • Diagnosis
    • left NP tumor, suggest NP biopsy
• 2022-07-27 SONO - abdomen
  • Diagnosis
    • Probable small hemangioma, S6/7
    • Liver cyst, S8
    • Right renal cyst
    • fatty infiltration of pancreas
  • Suggestion
    • OPD follow-up
• 2022-04-25 Panendoscopy
  • Diagnosis
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis, s/p CLO test
    • Gastric erosions
    • Cardiac insufficiency
  • Suggestion
    • May give PPI trial
    • Pursue CLO test
• 2022-01-26 SONO - abdomen
  • Diagnosis
    • Probable small hemangioma, S6/7
    • Liver cyst, S8
    • Right renal cyst
    • Splenomegaly, mild
  • Suggestion
    • OPD follow-up

[consultation]

• 2023-03-07 Ear Nose Throat
  • Q
    • This 67-year-old man patient is a case of Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, cT1N1M0, stage II s/p concurrent chemoradiotherapy from 2022/12/05 ~ 2022/12/29 and chemotherapy with PF4 (CDDP 80mg/m2, 5FU 1000mg/m2 x4 days) from 2022/11/11. Patient refuse chemotherapy. This time, for F/U. Thank you.
  • A
    • S
      • Hx of Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, cT1N1M0, stage II
      • Suffered from bilateral hearing impairment (tympanocentesis was done before but in vain), dysphagia, sticky sputum, PND, tachycardia after chemo with PF4
    • O
      • Ear drum: bil OME
      • Scope: curst over NPx, NE of left NP tumor noted, sticky sputum over posterior pharyngeal wall
    • Imp:
      • NPC, regression
      • OME, bil, suspect side effects of RT
    • Plan:
      • Treat his symptoms with your expertise
      • ENT OPD f/u for NPC and hearing problem

[cancer multidisciplinary team meeting conclusion] - meeting date: 20221111

• Treatment Plan: Concurrent chemoradiotherapy (CCRT) + adjuvant chemotherapy.
• Consensus of the team: cT1N1M0, Stage II.

[chemoimmunotherapy]

• 2023-02-08 - cisplatin 80mg/m2 130mg NS 500mL 24hr (5-FU side insertion) + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-28 - cisplatin 40mg/m2 65mg NS 500mL 24hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2022-12-21 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2022-12-15 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2022-12-05 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL
• 2022-11-11 - cisplatin 80mg/m2 135mg NS 500mL 24hr (5-FU side insertion) + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (PF)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

• Although the patient’s serum sodium levels have never reached the lower limit of normal based on available laboratory data in HIS5 since 2022-10-25, it is worth noting that the patient has been receiving CCRT (CDDP) and PF regimen since 2022-11-11. Cisplatin, a component of the chemotherapy regimen, is known to induce nephrotoxicity, which can manifest as acute kidney injury (AKI) or electrolyte disturbances such as hypomagnesemia and salt-wasting hyponatremia. The patient’s creatinine levels have been observed to be above the normal range more frequently after receiving chemotherapeutic agents. The patient has also experienced hypomagnesemia, which has shown a similar trend despite receiving sodium and magnesium supplements.
  • ref:
    • Cisplatin nephrotoxicity: a review of the literature. J Nephrol. 2018;31(1):15-25. doi:10.1007/s40620-017-0392-z
    • Risk Factors for Severe Hyponatremia Related to Cisplatin: A Retrospective Case-Control Study. Biol Pharm Bull. 2019;42(11):1891-1897. doi:10.1248/bpb.b19-00477
    • Hyponatremia timing, incidence, and associated risk factors in patients treated with cisplatin for lung cancer: a retrospective study. J Popul Ther Clin Pharmacol. 2022;29(4):e1-e10. Published 2022 Oct 7. doi:10.47750/jptcp.2022.907
• Sodium level correction rate recommendation (ref: Diagnosis and treatment of hyponatremia: compilation of the guidelines. J Am Soc Nephrol 2017; 28(5):1340-1349.)
  • Minimum, 4 to 8 mmol/L/day; MAX 10 to 12 mmol/L/day
  • For patients with high-risk of osmotic demyelination syndrome: Minimum, 4 to 6 mmol/L/day; MAX 8 mmol/L/day

230209

{mucositis}

As of now, Comfflam Anti-inflammatory Spray (benzydamine 1.5 mg/mL) is available in this hospital and can be used as a rinse three to four times daily (depending on the severity of the mucositis).

701337783

230324

{not completed}

[diagnosis] - 2023-03-22 admission note

• Adenocarcinoma of middle rectum with lung metastasis, cT4bN0M1a, stage IVA, status post T-colostomy on 2022/11/24 s/p concurrent chemoradiotherapy (radiotherapy to the pelvis and rectal tumor) with FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5-FU 2800mg/m2) from 2022/12/06 ongoing
• Chronic viral hepatitis B without delta-agent
• Type 2 diabetes mellitus without complications
• Essential (primary) hypertension

[past history]

Irregular drug use

• Type 2 diabetes mellitus
  • Onglyza 5mg 1# po QD
  • Loditon(Metformin) 850mg 1# po BID
• Hypertension
  • Carvedilol 6.25mg 1# po QD
  • Nidil 5mg 1# po BID
  • Funazine 10mg 1# po QD
  • Bestan 300mg 1# po QD
  • Rixia 0.5mg 1# po QD
  • Fylin 400mg 1# po QD
  • Lorazepam 1mg 1# po BID
• Hyperlipidemia
  • Rosuvastatin 5mg 1# po QD
• Hyperuricemia
  • Febuton 40mg 1# po QD                    

[allergy]

• NKDA

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-02-20 CT - abdomen
  • Indication: Adenocarcinoma of middle rectum with lung metastasis, cT4aN0M1b, stage IVB
  • Abdominal and Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Lobulated soft tissue nodule at left upper lobe measuring 2.6cm in largest dimension is found. (Se401 Im15).
      • Enlarged lymph nodes are found at bilateral paratracheal region.
    • Visible abdomen:
      • There is stone at dependent portion of GB. GB stone(s) are noted.
      • s/p colostomy with its orifice at RLQ.
      • Low density lesion at tip of S6 of liver measuring 0.41cm in largest dimension. Simple cyst is favored. Suggest follow up.
      • Eccentric wall thickening at rectum measuring 2.96cm in largest dimension is found. Rectal cancer is favored.
  • Imp:
    • Rectal cancer with suspected left upper lobe lung meta? Mediastinal lymph nodes
• 2023-02-17 Sigmoidoscopy
  • ircumfererntial rectal cancer s/p CCRT with partial regression (middle rectum, about 7cm AAV). The scope can not be passed through it.
• 2022-11-23 All-RAS + BRAF mutation
  • Cell Block: S2022-20665
  • RESULTS
    • There was no variant detect in the KRAS/NRAS gene.
    • There was no variant detect in the BRAF gene.
• 2022-11-23 Whole body PET scan
  • Glucose hypermetabolic lesions at the rectal region, compatible with the primary rectal cancer.
    
  • Glucose hypermetabolic lesions in the left upper lung, probably a chronic inflammation process, suggesting follow-up.
    
  • Glucose hypermetabolic lesions in bilateral mediastinal lymph nodes, probably reactive nodes.
  • Glucose hypermetabolic lesions in the right clavicle bone, P/3, gastric region, and left shoulder joint, probably benign in nature.
  • Rectal cancer, no evidence of distant metastasis, by this F-18-FDG PET/CT scan.
• 2022-11-22 Patho - colon biopsy
  • Rectum, biopsy — Adenocarcinoma, moderately differentiated
  • The sections show adenocarcinoma, composed of cords and single columnarto cuboidal neoplastic cells, arranged in focal glandular pattern with desmoplastic stromal reaction. Mucosal ulcer is present.
  • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
• 2022-11-22 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (113- 34) / 113 = 69.91%
    • M-mode (Teichholz) = 69
  • Conclusion:
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA, grade 1 LV diastolic dysfunction
    • Mild MR, TR and PR
• 2022-11-21 Flow Volume Loop
  • mild obstructive ventilatory impairment
• 2021-11-02 Ga-67 Whole body inflammatory scan with SPECT
  • The whole-body gallium inflammation scan with SPECT was performed 24th and 48th hours after injecting 6 mCi of the radiotracer to the patient. The images showed increased radiotracer uptake in a lower C-spine, maxilla, bilateral sternoclavicular junctions, shoulders, elbows, wrists, hands, knees, and feet. In addition, there was inhomogenously increased tracer uptake in the urethra.
    
  • IMPRESSION:
    • Increased radiotracer uptake in a lower C-spine, bilateral sternoclavicular junctions, shoulders, elbows, wrists, hands, knees, and feet, probably polyarthritis.
      
    • Increased radiotracer uptake in the maxilla, probably dental problems.
      
    • Increased radiotracer in the urethra, probably UTI, suggesting further investigation.
• 2021-10-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (117.9- 46.4) / 117.9 = 60.64%
    • M-mode (Teichholz) = 60.6
  • Conclusion:
    • Adequate LV Systolic function with no regional wall motion abnormality at resting state
    • Mild mitral, tricuspid and pulmonic regurgitation
    • Dilated LA and aortic root
• 2021-10-25 CT - brain
  • IMP: Brain atrophy.
• 2021-09-28 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (63.1- 20) / 63.1 = 68.30%
    • M-mode (Teichholz) = 68.3
    • 2D (M-simpson) =70.8
  • Conclusion:
    • Adequate LV systolic function with no regional wall motion abnormality (under dopamine infusion)
    • Moderate mitral regurgitation, mild tricuspid regurgitation
    • Dilated LA and aortic root, thick IVS and LVPW

[consultation, not completed]

• 2022-11-28 Hemato-Oncology
  • Q
    • This was a 63 y/o male with history of TB. And he was diagnosed with adnocarcinoma of middle rectum, cT4aN0M1b (suspected left lung metastasis) status post T-colostomy on 2022-11-24. Port-A will be arranged today.
    • RT: CT-simulation will be arranged on 2022/11/30. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor to 50.4 Gy/ 28 fx. RT will start around 2022/12/05 or 06.
    • We need your expertise for neoadjuvant CCRT.
  • A
    • Patient examined and Chart reviewed. A case of rectal cancer with suspicious lung and liver mets is noted. I am consulted for the CCRT.
    • My suggestions are:
      • Well discussion with patient and family. (Done)
      • Anti-HBV medication will be prescribed if C/T will be given.
      • For covering the possibility of lung and liver mets, the regimen would be FOLFOX
      • Please arrange the admission to my service if he is discharged.
• 2022-11-25 Radiation Oncology
  • Q
    • This was a 63 y/o male with history of TB. And he was diagnosed with adnocarcinoma of middle rectum, cT4aN0M1b (suspected left lung metastasis) status post T-colostomy on 2022-11-24. We need your expertise for neoadjuvant CCRT.
  • A
    • Neoadjuvant CCRT is indicated.
    • CT-simulation will be arranged on 2022/11/30. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor to 50.4 Gy/ 28 fx. RT will start around 2022/12/05 or 06. Thank you very much.

[radiotheray]

• 2022-12-06 ~ 2023-01-13 - completed RT to the pelvis: 45 Gy/ 25 fx. The rectal tumor: 50.4 Gy/ 28 fx.

[chemotherapy]

• 2023-03-22 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-09 - ditto
• 2023-02-16 - ditto
• 2023-01-30 - ditto
• 2023-01-03 - ditto
• 2022-12-06 - ditto

[assessment]

• The patient is tolerating the FOLFOX regimen without any major issues. In addition, based on the TPR panel results, the patient’s blood pressure and blood glucose levels are well-controlled despite having comorbidities of hypertension and diabetes mellitus. Furthermore, there are no identified issues with the active prescription.

700018223

230323

[diagnosis] - 2023-03-22 admission note

• Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02 and Target therapy with Avastin (self pay) from 2022/11/15
• Gastro-esophageal reflux disease with esophagitis
• Essential (primary) hypertension
• Constipation, unspecified
• Unspecified hemorrhoids

[past history] - 20221213 admission note

• HTN for 15+ years under medical control
• History of operation: Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0M1.   

[family history]

• father: colon cancer was diagnosed at the age of 92, died at the age of 99
• mother: HTN, aplastic anemia
• younger brother: HTN
• elder sister: CVA

[exam findings]

• 2023-01-31 CT - abdomen
  • S/P left hemicolectomy with focal peritoneal infiltrates, post-op change or recurrence? suggest clinical correlation and follow up study.
  • Focal poor enhancement at right renal parenchyma.
  • Bilateral renal cysts, up to 1.3cm in right kidney.
• 2022-10-12 Patho - soft tissue tumor, extensive resection
  • Pathologic diagnosis
    • Soft tissue, inguinal area, right, excision — Compatible with angiofibroma of soft tissue
      
  • Microscopic examination
    • Histologic type: Compatible with angiofibroma of soft tissue, composed of uniform spindle cells in a variable myxoid and collagenous stroma with a nectwork of innumerous small thin-walled, branching blood vessels. Prominent collagenous bundles can be identified focally. Neither necrosis nor marked cellular atypia can be found
      
    • Mitotic rate: <1/10 high power fields
      
    • Necrosis: Absent
      
    • Margins: Free and 0.3 cm from closest margin
      
    • Lymphvascular invasion: No identified
      
  • IHC
    • IHC: MUC4(-), SMA(-), Beta-catenin(-), MDM2(-), STAT6(-)
    • Previous IHC (S2022-15033): CD34(-), CD117(-), DOG-1(-), Desmin(-), S100(-), MUC4(-), EMA(-).
• 2022-09-16 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Colon, splenic flexure, left hemicolectomy — Mucinous adenocarcinoma, moderately differentiated
      
    • Resection margins, left hemicolectomy — Radical margin is involved by carcinoma
      
    • Lymph nodes, mesocolic, left hemicolectomy — Negative for malignancy (0/19)
      
    • Pathology stage: pT4aN0(cM1a); Stage IVA
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: Left hemicolectomy
      
    • Specimen site: Left colon
      
    • Specimen size: 20.5 cm in length
      
    • Tumor size: 12.0 x 4.5 cm
      
    • Tumor location: 3.0 cm and 5.5 cm away from the two resection margins, respectively .
    • Depth of invasion grossly: Pericolic soft tissue
    • Mucosa elsewhere: Unremarkable
    • Representative parts are taken for section and labeled: A1-A2 = bilateral resection margins, A3 = omentum, A4-A6 = pericolic LNs, A7-A12 = tumor.
  • MICROSCOPIC EXAMINATION
    • Histology: Mucinous adenocarcinoma
      
    • Histology Grade: Moderately differentiated
      
    • Depth of invasion: To serosa
    • Angiolymphatic invasion: Not identified
      
    • Perineural invasion: Not identified
      
    • Tumor cell budding: Intermediate
      
    • Margins:
      • Bilateral resection margins: Free
      • Circumferential (radial) margin: Involved by carcinoma
    • Lymph node metastasis, mesocolic: Negative (0/19) (No. Positive / No. Total)
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT): pT4a (Tumor invades serosa)
      • Regional Lymph Nodes (pN): pN0 (no regional lymph node metastasis)
      • Distant Metastasis (pM): cM1a
    • Type of polyp in which invasive carcinoma arose: Not identified
    • Additional pathologic findings: Abscess formation around tumor
    • Tumor regression grading S/P CCRT: N/A
    • IHC: EGFR(+), MLH1(-), PMS2(-), MSH2(+), MSH6(+)
      • Labeled as “right inguinal”, core needle biopsy — spindle cell tumor-like lesion.
      • IHC stains: CD34 (-), CD117 (-), Dog-1 (-): dis-favor gastro-intestinal stromal tumor; desmin (-): dis-favor myomatous origin; S-100 (-): dis-favor nerve origin; Ki-67: <1%. MUC4 (-), EMA (-). No meatstatic adenocarcinoma is present in this specimen.
      • REFERENCE: S2022-15295: colon, splenic flexure: compatible with adenocarcinoma.
• 2022-09-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 34) / 93 = 63.44%
    • M-mode (Teichholz) = 64
  • Normal LV filling pressure.
  • Normal LV and RV systolic function.
  • Trivial MR.
  • Prominent epicardial fat.
• 2022-09-12 Patho - colon biopsy
  • Colon, splenic flexure, biopsy — Compatible with adenocarcinoma, well differentiated
• 2022-09-06 CT - abdomen
  • Findings
    • Soft tissue tumor, 11x7.6cm in left upper abdomen with central necrosis, suspected spelnic fluxure malignancy. With left abdominal wall involvement.
    • Large soft tissue tumor, 9.3cm in right inguinal region, suspected metastasis.
    • Right renal cyst, 1.4cm.
    • Unremarkable change of the liver, spleen, pancreas and left kidney.
    • No enlarged lymph node in the paraaortic region.
    • Presence of ascites.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression ( Imaging stage ): T:T4a(T_value) N:N1b(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • Impression:
    • Left upper abdomen tumor, r/o splenic flexure colon malignancy. Right inguinal tumor, r/o metastasis. If proven colon malignancy, cstage T4aN1M1. Suggest tissue study.
    • Right renal cyst.

[consultation]

• 2023-01-14 Dermatology
  • Q
    • This 71-year-old woman patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02 and Target therapy with Avastin (self pay) from 2022/11/15.
    • This time, of tinea unguium et keratosis suspected possible chemotherapy alert hand-foot syndrome. Now, for F/U and evaluate therapy. Thank you.
  • A
    • This patient suffered from dyskeratotic nails for months.
    • Imp: Tinea unguium
    • Suggestion:
      • Zalain cream * 2 tubes/bid (sertaconazole)
• 2022-12-13 Plastic and Reconstructive Surgery
  • Q
    • This 71-year-old man patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02~ and Target therapy with Avastin(self pay) from 2022/11/15. He was admitted for chemotherapy. He underwent excision of the big tumor over right inguinal region on 2022/10/12. Now, for F/U. Thank you.
  • A
    • I will talk to the patient and explain about the temporary post-operative paresthesia. Thanks.
• 2022-11-29 Dermatology
  • Q
    • This 71-year-old man patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02~ and Target therapy with Avastin(self pay) from 2022/11/15~. He was admitted for chemotherapy. This time, for bilateral toenails desquamation, suspected athlete’s foot. Thank you.
  • A
    • The patient had sufferred from thickening nail with desqumation change on the toenail with nearby keratosis.
      
    • Under the impression of tinea unguium et keratosis suspected possible chemotherapy alert hand-foot syndrome.
    • The following sugestion:
      • step 1: Exelderm lotion 2 bot QN use. Apply the lotion to the nail crevices (sulconazole)
      • step 2: Sinphraderm cream 1 tube topical QN use over keratotic scales. (urea)

[surgical operation]

• 2022-10-12
  • Surgery
    • Dx: soft tissue tumor over right inguinal region
    • OP: excision
  • Finding
    • 12cm X 9cm X 9cm, multi-lobulated, smooth surfaced mass located between the sartorius, iliopsoas muscles, inguinal cannal, and the femoral artery
    • a 10F JP was placed over anterior side of upper right thigh for post operative drainage
• 2022-09-15
  • Surgery
    • Gisgnostic laparoscopy + left hemicolectomy
  • Finding
    • very large tumor with sorrounding adhesion over LUQ.
    • anastomosis by endoGIA*3 + V-lock.
    • Drain into pelvis

[chemoimmunotherapy]

• 2023-03-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-15 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-31 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 400mg/m2 630mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-15 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-02 - irinotecan 120mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

[assessment 2023-01-14, not posted]

• For tinea unguium, if topical Exelderm (sulconazole, applied since late Nov 2022) and Zalain (sertaconazole, applied since mid Jan 2023) failed to cure it, then oral Fungitech (terbinafine 250mg/tab) 1# QD might be considered as a next line treatment.

[assessment]

• The patient had developed tinea unguium in Jan 2023, but there is no longer any evidence of the condition in the updated medical records.

• The patient is currently admitted for his 10th cycle of Avastin + FOLFIRI chemoimmunotherapy, and it is planned that he will receive a total of 12 cycles. His liver and kidney function, as well as his electrolyte levels, are normal, although there is a slight anemia based on the 2023-03-21 lab results.

• There were no medication reconciliation issues found in the patient.

• CT results from 2023-01-31 indicate the presence of focal peritoneal infiltrates, which could suggest post-operative changes or disease recurrence. Further diagnostic tests or imaging studies may be necessary to make a definitive diagnosis and determine whether new treatment should be planned.

700313252

230322

{not completed}

[exam findings]

• 2023-03-20, -03-06 CXR
  • S/P tracheostomy
  • S/P nasogastric tube insertion
  • Borderline cardiomegaly
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
• 2023-03-15 Nasopharyngoscopy
  • hypopharynx lymphoma under R/T
• 2023-02-17 Whole body PET scan
  • Glucose hypermetabolism in the hypopharynx with downward extension to the proximal portion of the esophagus, compatible wtih lymphoma.
  • Glucose hypermetabolism in a focal area in the dome of the liver and in the left adrenal gland. Lymphoma should be considered.
  • Mild and diffuse glucose hypermetabolism in the bone marrow of the skeleton. Lymphoma involving the bone marrow should be watched out. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the posterior aspect of bilateral lower lung fields and around the tracheostomy. Inflammatory process is more likely.
• 2023-02-11 CT - chest
  • Indication: hypopharyngeal lymphoma, suspect recurrent rectal cancer lung metastasis
  • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Spiculated nodular lesiosn at right upper lobe and left upper lobe. Nature?
      • Soft tissue mass encircling upper esophagus is found measuring 3.8cm in largest dimension.
      • Calcified coronary arteries is found.
      • Mild bilateral pleural effusion is found.
      • Increased pulmonary vasculature is found.
    • Visible abdomen:
      • One low density lesion at dome measuring 3.9cm in largest dimension. Liver meta is considered.
      • The spleen, pancreas, both kidneys and adrenals are intact.
  • IMP:
    • Nodular lesions at both lungs (n>5). Suggest PET
    • Cervical esophageal tumor. 3.8cm
    • Liver meta.
    • Calcified coronary arteries is found.
• 2023-02-08 Patho - larynx biopsy
  • PATHOLOGIC DIAGNOSIS
    • Pyriform sinus, right, LMS with laser — Diffuse large B-cell lymphoma, NOS
    • Arytenoid, right, LMS with laser — Diffuse large B-cell lymphoma
    • AE fold, right, LMS with laser — Diffuse large B-cell lymphoma
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consists of (1) four small pieces of brownish soft tissue received for frozen section, labeled right pyriform sinus, measuring up to 0.6 x 0.4 x 0.2 cm. All for paraffin section as: F2023-00056FS. (2) multiple small pieces of tan-gray soft tissue, labeled right arytenoid, measuring up to 0.5 x 0.4 x 0.1 cm. All for section as: S2023-02055A. (3) six small pieces of tan-gray soft tissue, labeled right AE fold, measuring up to 0.8 x 0.2 x 0.1 cm. All for section as: S2023-02055B.
  • MICROSCOPIC EXAMINATION
    • The sections of all three specimens show a picture of malignant lymphoma with following features:
    • Specimen: Right pyriform sinus, right arytenoid, and right AE fold
    • Procedure: LMS with laser
    • Tumor site: Right pyriform sinus, right arytenoid, and right AE fold
    • Histologic type: Diffuse large B-cell lymphoma, NOS
    • Immunophenotyping: CD3(-), CD20(+), BCL2(+), CD10(+), BCL6(+), MUM1(+), c-MYC(-) and CD56(-)
• 2023-02-06 CT - abdomen
  • History and indication: Hypopharyngeal cancer, cT4aN0M0. 20230203 Cr:1.69 liver mass noticed, r/o HCC, r/o metastaisis. DM under metformin
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A poor enhancing tumor (3.5cm) at liver dome.
    • A nodule (6mm) at RML.
    • Left adrenal tumors (1.4cm, 1.6cm).
    • S/P rectal operation.
    • Renal cysts (up to 4.7cm).
    • Normal appearance of spleen, pancreas.
    • Normal appearance of gallbladder.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • Suspected liver and lung metastases.
• 2023-02-03 Tc-99m MDP whole body bone scan
  • Increased activity in some C-, T- and L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, sternoclavicular junction and right foot, compatible with benign joint lesions.
• 2023-02-03 SONO - abdomen
  • Diagnosis
    • Hepatic tumor, right lobe, nature?
    • Collapse GB
    • Renal cysts, both kidney
    • Poor echo window and poor cooperation.
  • Suggestion
    • 4 phase CT or dynamic MRI study
    • tumor markers
• 2023-02-01 ENT Hearing Test
  • Tymp:
    • RE type C; LE type Ad.
  • ART:
    • Bil absent.
  • PTA
    • Reliability FAIR
    • Average RE 80 dB HL; LE >80 dB HL.
    • RE moderately severe to profound MHL.
    • LE moderately severe to profound SNHL.
• 2023-01-31 CT - neck
  • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T:4a(T_value) N:0(N_value) M:IVA(M_value) STAGE:____(Stage_value)
• 2023-01-31 Patho - stomach biopsy
  • Stomach, GC of body, biopsy — erosive gastritis with Helicobacter infection
• 2023-01-31 Patho - gingival/oral mucosa biopsy
  • Labeled as “right hypopharyx”, biopsy — round blue cell infiltration with marked crush artifact.
  • IHC stains: CK (-), dis-favor carcinoma. CD3 and CD20 stains show a predominant B lymphoid sub-population.
  • The possibility of lymphmoa cannot be excluded. Plaes correlate with clinical and image findings. Further work up, including repeat biopsy, might be considered.
• 2023-01-31 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A
  • Superficial gastritis, antrum
  • Suspected gastric erosion, GC of body s/p biopsy
• 2023-01-30, -01-27 Nasopharyngoscopy
  • rt pyriform sinus tumor, bil movable cords
  • suspected rt HP cancer
• 2019-11-19 SONO - nephrology
  • Chronic renal parenchymal disease, mild degree
  • Bilateral renal cysts
• 2019-11-11 L spine AP + Lat (indluding sacrum)
  • Osteoporosis and spondylosis of L-spine.
  • Disc collapse at L5-S1.
  • Surgical clips at RUQ.
  • Calcification along abdominal aorta.

[consultation]

• 2023-03-09 Rehabilitation
  • A
    • P
      • Rehabilitation programs: Bedside PT rehabilitation programs
      • Goal: recondition, improve endurance and muscle strength
• 2023-02-20 Radiation Oncology
  • A
    • Palliative RT to HPX tumor for 3600cGy/20 fx is suggested for symptom control. CT simulation on 2023/02/20 15:30, and RT will be started on Feb 22 or 23 if feasible.
• 2023-02-09 Colorectal Surgery
  • Q
    • This 90 year-old man has history of
      • hypertension
      • diabetic mellitus
      • Rectal cancer, stage III, s/p operation twice due to recurrence and oral chemotherapy many years ago
    • This time, he was admitted to our ward for Hypopharyngeal cancer (biopsy: pending) survey. Abdominal echogram and CT revealed liver tumor, favor metastasis, origin unknown. We need your expertise on further examination.
    • The patient has had recurrent rectal cancer for several years but has not been followed up on. CT scans were unable to rule out the presence of a rectal tumor. The patient also has a pharyngeal tumor, and if a colonoscopy is needed, it is not suitable for painless general anesthesia.
• 2023-02-06 Hemato-Oncology
  • Q
    • This is a 90-year-old man with history of
      • Hypertension
      • Type 2 diabetic mellitus
    • This time, he was admitted to our ward for hypopharyngeal cancer (cT4aN0M0) workup. Concurrent chemoradiotherapy may be arranged after staging. We need your expertise for possible chemotherapy arrangement. Thanks a lot!
  • A
    • This 90 year old man with HTN and DM history is a case of suspect Hypopharyngeal cancer, cT4aN0M0, status post biopsy via LMS on 2023/1/30 (pathology: pending). We are consulted for CCRT.
    • Concurrent cisplatin or cetuximab with radiotherapy may consider in this case. (Due to old age, may prefer bioRT)
      • note: BioRT stands for Biological Radiation Therapy, which is a type of radiation therapy that uses biological agents, such as monoclonal antibodies or immunomodulators, to enhance the effects of radiation treatment. The aim of BioRT is to improve the response of tumor cells to radiation by modifying the tumor microenvironment or by enhancing the immune system’s ability to attack cancer cells.
    • Pending pathology report. Please check HbsAg, Anti Hbc, Anti HCV. 24 hr urine CCR. Arrange port A insertion.
    • Please arrange our OPD after discharge.
• 2023-02-01 Radiation Oncology
  • A
    • Plan: I will discuss with the patient and his second son on Feb 2, 2pm. RT to HPX and cervical esophagus tumor for 7140cGy/34 fx is suggested for locoregional control if he and his son agree. CT simulation will be arranged after teeth extraction (or teeth extraction is declined).
• 2023-02-01 Oral and Maxillofacial Surgery
  • Q
    • This is a 90-year-old man with history of
      • Hypertension
      • Type 2 diabetic mellitus
    • This time, he was admitted to our ward for right hypopharyngeal cancer workup. Concurrent chemoradiotherapy may be arranged after staging. We need yout expertise for dental evaluation bfore radiotherapy. Thanks a lot!
  • A
    • After an oral surgical examination, it is recommended that at least 9 teeth be extracted.
      • If the patient is to continue staying in the hospital, arrangements will be made to begin extracting the teeth during the hospital stay.
      • If the patient is to be discharged, arrangements will be made for outpatient tooth extraction.
      • A family member should be present to accompany the patient during tooth extraction to be aware of the risks involved.
    • If the patient will be discharged first, a NP should prescribe antibiotics to be taken by the patient, and please inform us of the follow-up progress.

[multiteam]

• 2023-03-12 Social Service
  • Family situation:
    • The patient is a 90-year-old married individual with three sons. The patient, his spouse, and his eldest son live together, and during the hospitalization period, a foreign caregiver was hired to care for the patient in the hospital.
    • The eldest son is unmarried; the second son is married with a son (in college) and a daughter (in junior high school); the third son is married with a son (in junior high school).
  • Assessment and Treatment:
    • The social worker visited the patient in the hospital and had a written conversation with him about his emotional state and sleep condition. The patient wrote that he was suffering due to poor sleep and recent obstructive bowel movements. The social worker promised to communicate with the team and the patient accepted. The patient had no other concerns. The social worker also had a written conversation with the patient about his family situation, to which the patient responded in writing. During the assessment, the patient did not show any suicidal ideation and his low mood was primarily due to illness and poor sleep, but he was cooperating with medical treatment.
    • During the assessment, it was found that the patient’s mood was mainly affected by illness, but he was still able to cooperate with medical treatment. The social worker conveyed to the NP about the patient’s poor sleep and bowel movements, and asked the team to pay attention to this issue.
    • On the same day, the team invited the eldest son to the hospital to listen to the explanation of the patient’s illness and reminded him to prepare for the patient’s discharge. After the explanation, the eldest son accepted the arrangements.

[surgical operation]

• 2023-02-07
  • Surgery
    • Laryngomicrosurgery with laser for hypopharyngeal tumor excision       
  • Finding
    • bulging tumor over bilateral pyriform sinus

[radiotherapy]

[chemotherapy]

[assessment]

• The patient is currently self-carrying Betaloc Zok (metoprolol 100mg) for his hypertension. However, the hospital does not have any metoprolol-containing drugs available in stock.
• Instead, Urosin (atenolol 100mg/tab) is available, which selectively blocks beta 1 receptors and has little to no effect on beta 2 receptors except at high doses.
• Atenolol 75mg is approximately equivalent to metoprolol 150mg (ref: https://www.whocc.no/atc_ddd_index/?code=C07AB). Therefore, if the intended dose of Betaloc is 1 tablet per day, we recommend taking half a tablet of Urosin per day (0.5# QD).

230313

[assessment]

• PharmaCloud database reports that Natrilix (indapamide) has been prescribed at VGHTPE on 2022-12-29 as a 84-day refillable prescription, along with other medications such as Norvasc (amlodipine), Betaloc (metoprolol), and Olmetec (olmesartan) to manage the patient’s hypertension. And this patient developed hyponatremia since 2023-02.

  • 2023-03-13 Na (Sodium) 128 mmol/L
    
  • 2023-03-06 Na (Sodium) 128 mmol/L
    
  • 2023-03-01 Na (Sodium) 128 mmol/L
    
  • 2023-02-27 Na (Sodium) 130 mmol/L
    
  • 2023-02-20 Na (Sodium) 132 mmol/L
    
  • 2023-02-16 Na (Sodium) 130 mmol/L
    
  • 2023-01-30 Na (Sodium) 136 mmol/L

• Indapamide is a type of diuretic known as a low-ceiling diuretic, which functions by inhibiting the sodium-chloride co-transporter in the kidneys. This leads to an increase in the excretion of both sodium and water from the body.

• Treatment of diuretic-induced hyponatremia consists of discontinuing the diuretic and administering either isotonic saline or, if the hyponatremia is severe or symptomatic, hypertonic saline. There is a potential risk of overly rapid correction of the hyponatremia with either regimen. Once the diuretic has been cleared and the patient becomes euvolemic, antidiuretic hormone (ADH) release will be appropriately suppressed, resulting in the excretion of a dilute urine, which can lead to rapid excretion of the excess water. Thus, patients with moderate to severe hyponatremia must be monitored carefully during treatment to minimize the risk of osmotic demyelination.

• It is recommended to monitor serum Na levels at a frequency no less than every 12 hours, ensuring that any changes in serum Na levels do not exceed 4-6mEq/L within a 24-hour period to avoid the development of osmotic demyelination syndrome (ODS). Additionally, it is advised to monitor urine output and neurological symptoms. Other recommended tests include checking serum osmolality, TSH, free T4, ACTH (at 8 am), cortisol (at 8 am), urine osmolality, Na, and Cre.

700887556

230322

[exam findings]

• 2023-03-20 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed hot/faint hot spots in both rib cages, and increased activity in the maxilla, sternum, some T- and L-spine, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
  • IMPRESSION:
    • No previous study for comparison.
    • Some hot/faint hot spots in both rib cages, and increased activity in the sternum and some T- and L-spine, cancer with bone metastases may be considered, suggesting further evaluation and follow-up with bone scna in 3 months.
    • Suspected benign lesions in the maxilla, bilateral shoulders, S-I joints, hips, and knees.
• 2023-03-18 CXR
  • Increased infiltration over RLL. May be active infection.
• 2023-03-16 CXR
  • Enlargement of cardiac silhouette.
  • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-03-15 Patho - stomach biopsy
  • Nodularity of mucosa, LC side of upper body, biopsy — Compatible with fundic gland polyp
  • Microscopically, the sections show a picture of benign gastric mucosa with parietal and chief cells, compatible with fundic gland polyp.
• 2023-03-15 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Adenocarcinoma, poorly differentiated
  • The sections show a picture of poorly differentiated adenocarcinoma, composed of solid nests and cords of polygonal neoplastic cells in fibrous stroma. Vascular invasion and subtle glandular differentiation are present.
  • IHC shows following features: CK7(+), CK20(-), p40(-), TTF1(-), and CDX2(-). Metastatic carcinoma from either lung or colon is less likely. Suggest clinic correlation.
• 2023-03-10 CT - chest
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest abd Abdominal CT with and without enhancement revealed:
    • Chest:
      • Tiny nodule at right middle lobe measuring 0.3cm is found. Suggest follow up.
      • Senile fibrotic change is noted at lung fields.
      • Patent airway is found.
      • Non-specific lymph nodes are found in the mediastinum.
      • Bilateral mild pleural effusion is found.
      • Calcified coronary arteries is found.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Visible abdomen:
      • Left renal atrophy is found.
      • The spleen, liver, pancreas and adrenals are intact.
      • Diffuse liver meta up to 6.8cm at S4 is found.
      • There is no evidence of destructive bone lesion.
      • The GB is well distended without soft tissue lesion
      • Degenerative change of the bony structure with marginal osteophyte formation is identified.
  • Imp:
    • Diffuse liver meta.
      • The primary tumor cannot be estimated in the study.
      • Please correlate with tumor marker and suggest panendoscopy.
    • Bone meta at thoracic spine.
• 2023-03-08 MRI - T-spine
  • Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT.
  • With and Without-contrast multiplanar spine MRI (including sagittal and axial T1WI, sagittal and axial T2WI and coronal STIR images) revealed
    • normal bone alignment of the spine
    • unremarkable change in the perivertebral regions
    • unremarkable change in the visible cord.
    • unremarkable change in the disc spaces
    • multiple heterogeneous enhancing lesions in the S1, L5, L4, L3, L2, T11, T10, T5 and T3 vertebral bodies with pathological compression fracture at L4 vertebral body
      
  • IMP:
    • multiple bone metastasis witohut evidence of significant mass effect on the T-cord and with pathological fracture at L4 vertebral body.
• 2023-03-07 ECG
  • Normal sinus rhythm
  • Right bundle branch block
  • Left anterior fascicular block
  • Bifascicular block
• 2023-03-07 L-spine flex. + ext. (including sacrum)
  • Marked degenerative change of the spine with marginal spur formation. Disc space narrowing at multiple levels. Geographic bone lesions at L2, L3, L4 levels. Suggest further evaluation.
• 2023-03-06 MRI - L-spine
  • Indication: Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT. The pain became worse in recent days that he needed bed rest. unable to walk.
  • Imaging protocol: 3-4mm slice thickness; sagittal T1, T2 & STIR, axial T1 & T2, and coronal STIR images
  • MRI of lumbar spine without Gadolinium-based contrast enhancement shows:
    • straightening alignment of lumbar spine.
    • marked degenerative change of the spine with marginal spur formation and dehydrated discs at multiple levels.
    • multiple geographic bone lesions of abnormal signal change at anterior T11, L2, L3, L4, L5 vertebral bodies, bilateral L4 pedicles and posterior elements, sacrum (S1) and right iliac bone, suspect bone metastases. Suggest further evluation.
    • L4 compression fracture with curvilinear fracture line, favor pathological compression fracture.
    • severe right L4-5, L5-S1 neuroforaminal narrowing.
    • severe L2-3, L3-4, L4-5 central canal stenosis.
    • no evidence of abnormal signal lesion in visible spinal cord.
    • multiple left renal cysts; left hydronephrosis.
  • Impression:
    • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone. Suggest further evaluation.
    • L4 compression fracture, favor pathological fracture.
    • Degenerative spinal and disc disease.
    • Severe right L4-5, L5-S1 neuroforaminal narrowing.
    • Severe L2-3, L3-4, L4-5 central canal stenosis.
• 2023-03-05 CT - pelvis - bone
  • History and indication: back pain
  • IMP:
    • Atrophy of left kidney. Bil. renal cysts (up to 2.1cm).
    • Compression fracture of L4.
• 2023-03-04 L-spine AP + Lat (including sacrum)
  • AP and lateral films of the lumbar spine shows:
    • Compression fracture of T12.
    • Degeneration and spondylosis of L-S spine.

[consultation]

• 2023-03-13 Ear Nose Throat
  • Q
    • This 68-year-old man patient suffered back psin in 2023/01. Progression back pain in 2023/02.
    • Pelvic CT on 2023/03/04 showed atrophy of left kidney, bilateral renal cysts (up to 2.1cm) and compression fracture of L4.
    • L-spine MRI on 2023/03/06 showed
      • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone. Suggest further evaluation.
      • L4 compression fracture, favor pathological fracture.
      • Degenerative spinal and disc disease.
      • Severe right L4-5, L5-S1 neuroforaminal narrowing.
      • Severe L2-3, L3-4, L4-5 central canal stenosis.
    • T-spine MRI on 2023/03/08 showed multiple bone metastasis witohut evidence of significant mass effect on the T-cord and with pathological fracture at L4 vertebral body.
    • Tumor mark with SCC on 2023/03/09 showed increased (SCC:2.0ng/mL).
    • Chest CT on 2023/03/10 showed diffuse liver meta. The primary tumor cannot be estimated in the study and bone meta at thoracic spine.
    • Now, for evaluate R/O head and neck cancer with liver and bone metastases for SCC increased. Thank you.
  • A
    • Local finding:
      • Oral cavity: fibrosis over bilateral buccal mucosa.
      • Oropharynx: fibrotic change over bilateral tonsillar fossa.
      • Neck: no palpable neck mass.
    • Portable nasopharyngoscopy: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord.
    • Impression: No definitive finding of ENT lesion indicating malignancy in this visit.
• 2023-03-09 Dermatology
  • Q
    • This time, for bilateral lower limbs skin edema with dull dandruff and pain in 2017.
    • Now, for evaluate bilateral lower limbs, R/O jock itch therapy. Thank you.
  • A
    • The patient had sufferred from dry swelling legs with fissiform scales and stasis change.
    • Under the impression of stasis dermatitis with ichthyosis change.
    • The following sugeetion:
      • wound protection:
        • Biomycin onit 1 tube topical bid use for wound care first.
        • Sinphraderm cream 1 tube topical QN use over dry scales for mositurization.
          
      • notice further circulation state, avoid peripheral swelling edema state.
• 2023-03-07 Neurosurgery
  • Q
    • Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT.
    • The pain became worse in recent days that he needed bed rest
    • unable to walk
    • Past Hx of HTN, DM, lower limbs lymphedema
    • stilck used for Lt knee degeneration
      
    • 2022/12/17 Cre 1.18 mg/dL
  • A
    • 68 y/o male.
    • Low back and right hip pain for more than 1 month. The pain became worse in recent days so that he needed bed rest and was unable to walk.
    • L-spine MRI:
      • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone.
      • L4 compression fracture, favor pathological fracture.
      • Degenerative spinal and disc disease.
      • Severe right L4-5, L5-S1 neuroforaminal narrowing.
      • Severe L2-3, L3-4, L4-5 central canal stenosis.
    • Advice:
      • Enhanced L-spine MRI (and T- and C-spine).

[assessment]

• On 2023-03-19, the urinalysis results showed bacteriuria, UTI, occult blood, and leukocyte esterase positivity. Additionally, there was a significant increase in serum creatinine and a decrease in eGFR.
  • 2023-03-18 Creatinine 3.32 mg/dL
    
  • 2023-03-16 Creatinine 1.61 mg/dL
    
  • 2023-03-13 Creatinine 1.20 mg/dL
    
  • 2023-03-09 Creatinine 1.14 mg/dL
    
  • 2023-03-18 eGFR 19.78
    
  • 2023-03-16 eGFR 45.59
    
  • 2023-03-13 eGFR 63.99
    
  • 2023-03-09 eGFR 67.90
• Please ensure that the patient is receiving enough fluids to maintain adequate hydration, and that his fluid input and output are being closely monitored? Additionally, it is important to closely monitor for any signs of infection and track the patient’s renal function.

230320

[assessment]

• Bone mets were found, but the primary original malignancy has not yet been identified. Investigation is ongoing.

• The patient’s son said on the phone that the patient had no contact with any family members after the divorce with his mother, so no family members would care, and said he would discuss with other family members whether to come to the hospital to understand his condition.

• 2023-03-18 Cre 3.32mg/dL, eGFR 19.78, no height or weight data currently available, CrCl cannot be calculated. If eGFR is considered CrCl and the planned levofloxacin dose is 750 mg QD, in case of CrCl < 20 mL/min: 750 mg initial dose, then 500 mg QOD is recommended.

701118846

230322

{colon cancer - mucinous adenocarcinoma}

[lab data]

2020-09-30 NRAS/KRAS detected
2020-09-30 KRAS 12/13 Not detected
2020-09-30 BRAF Not detected

2020-08-28 HBsAg (NM) Negative
2020-08-28 HBsAg Value (NM) 0.365
2020-08-28 Anti-HBs (NM) Negative
2020-08-28 Anti-HBs value (NM) <2.00
2020-08-28 Anti-HBc (NM) Negative
2020-08-28 Anti-HBc Value (NM) 2.15
2020-08-28 Anti-HCV (NM) Negative
2020-08-28 Anti-HCV Value (NM) 0.0382
2020-08-28 HBsAg (NM) Negative
2020-08-28 HBsAg Value (NM) 0.365
2020-08-28 Anti-HBs (NM) Negative
2020-08-28 Anti-HBs value (NM) <2.00
2020-08-28 Anti-HBc (NM) Negative
2020-08-28 Anti-HBc Value (NM) 2.15
2020-08-28 Anti-HCV (NM) Negative
2020-08-28 Anti-HCV Value (NM) 0.0382

[exam findings]

• 2023-03-07 ECG
  • Sinus rhythm with Premature supraventricular complexes
  • Nonspecific T wave abnormality
• 2022-12-22 CT - abdomen
  • History and indication: Malignant neoplasm of appendix s/p OP and C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Right thyroid nodules (up to 2.6cm).
    • S/P colon operation. Some soft tissues in peritoneal cavity suspected tumor seeding. Ventral hernia with bowel loop herniation.
    • Retroversion of uterus.
    • Liver cysts (up to 2.2cm).
    • Left renal stone (5mm).
    • Normal appearance of spleen, pancreas, adrenals.
    • Gallbladder stone (7mm).
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral lungs.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Some soft tissues in peritoneal cavity suspected tumor seeding.
• 2022-11-24 Clinical Dementia Rating, CDR
  • CDR score = 0.5
  • note: The CDR score ranges from 0 (no cognitive impairment) to 3 (severe dementia). A score of 0.5 indicates very mild dementia, 1 indicates mild dementia, 2 indicates moderate dementia, and 3 indicates severe dementia.
• 2022-11-24 Mini-Mental Status Examination, MMSE
  • MMSE score = 27
  • note: The total score ranges from 0 to 30. A higher score indicates better cognitive function.
• 2022-10-06 Needle Aspiration Cytology - thyroid
  • Negative - Benign follicular nodule
• 2022-09-26 CT - abdomen
  • Indication: Appendiceal cancer s/p OP and C/T, Elalrged thyroid, Elevated CEA
  • Abdominal CT with and without enhancement revealed:
    • Visible chest
      • Cardiomegaly is noted.
      • Lobulated right thyroid lesions are found. Suggest regular sonogrpahy/aspiration if indicated.
      • The lung fields are clear.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
    • Abdomen
      • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thikening.
      • s/p RLQ op.
      • No evidence of recurrent/residual tumor in the study.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
  • Imp: s/p RLQ op.
    • No evidence of recurrent/residual tumor at RLQ.
    • Right thyroid lesions. Suggest regular follow up.
• 2022-09-07 SONO - thyroid
  • Autoimmune thyroid disease, multiple nodules
• 2022-06-29 CT - abdomen
  • History and Indication:
    • 20200823 CT: RLQ tumor with abdominal wall involvement, r/o appendix tumor or appendicitis with tumor formation.
    • 20200827 S/P right hemicolectomy: mucinous adenocarcinoma of the appendix with abscess, pT4N0Mx, stage: IIB. S/P C/T for FU
  • MD CT (Aquilion Prime SP) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images with axial and coronal reformated isotropic images were obtained in non-contrast scan and portal venous phase scan after IV contrast injection.
  • FINDINGS:
    • S/P right hemicolectomy.
      • Ventral hernia in the midline lower pelvis with small bowel herniation.
    • There are several hepatic cysts in both lobes and the largest one is measured about 2.2 cm in size at segment 8.
    • A calcified gallstone 6 mm is noted.
    • Prior CT identified1 a soft tissue nodule 6 mm in the middle mesentery is noted again, mild increasing in size to 8 mm.
    • There is no focal lesion in both lung and mediastinum.
      • Right lobe thyroid shows enlarged in size and few poor enhancing lesions (up to 2.3 cm). Left lobe and isthmus thyroid show few poor enhancing and few enhancing nodules. Nodular goiter is highly suspected. Please correlate with sonography.
        
    • Others
      • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion in the omentum.
  • IMP:
    • S/P right hemicolectomy.
    • There is no evidence of tumor recurrence.
• 2022-04-07 CT - abdomen
  • History and indication: Malignant neoplasm of appendix s/p OP and C/T
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Right thyroid nodules (up to 2.6cm).
    • S/P colon operation. Ventral hernia with bowel loop herniation.
    • Retroversion of uterus.
    • Liver cysts (up to 2.2cm).
    • Left renal stone (5mm).
    • Normal appearance of spleen, pancreas, adrenals.
    • Gallbladder stone (7mm).
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral lungs.
    • S/P Port-A infusion catheter insertion.
  • IMP: No evidence of tumor recurrence.
• 2022-01-21 Needle Aspiration Cytology - thyroid
  • Negative - Smears show colloid and benign follicular cells.
• 2021-12-30 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA grade A
    • Superficial gastritis, antrum, s/p CLO test
    • Gastric erosions, low body and antrum
    • Gastric shallow ulcers, antrum
  • Suggestion
    • Pursue CLO test result
• 2021-12-24 Whole body PET scan
  • A mild glucose hypermetabolic lesion in the lower portion of the esophagus near EG junction. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the right pulmonary hilar region and in the soft tissues around bilateral shoulders and hip. Inflammatory process is more likely.
  • Inhomogenously increased FDG uptake in the right lobe of the thyroid gland. The nature is to be determined (multinodular goiter? other nature?). Please correlate with other clinical findings for further evaluation.
  • Some focal areas of increased FDG accumulation in the colon. Physiological FDG accumulation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2021-11-30 CT - abdomen
  • Indication: Colon cancer, CEA gradually elevated
  • Abdominal and chest CT with and without enhancement revealed:
    • Chest:
      • S/p port-A placement with its tip at Superior vena cava.
      • Tortous aorta with calcification is noted.
      • Cardiomegaly is noted.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • s/p RAR. no evidence of recurrent/residual tumor in the study.
      • Left renal stone is found.
      • Ventral herniation from the mid-abdominal wall is found. No strangulation is found.
      • The spleen, liver, pancreas and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is stone at dependent portion of GB. GB stone(s) are noted.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • s/p RAR. no evidence of recurrent/residual tumor in the study.
    • Left renal stone is found.
• 2021-09-13 MRI - liver, spleen
  • History and indication: Hx of appendeceal cancer s/p right hemicolectomy and C/T 2021-08-11 Abd CT mention a suspected cyst or mets in S6 of liver
  • With and without contrast MRI of liver revealed:
    • S/P colon operation.
    • Bil. liver cysts (up to 2.4cm).
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • Gallbladder stones (2-3mm).
    • Patency of portal vein.
    • No ascites, nor enlarged lymph node.
    • No abnormal intensity in bilateral basal lungs.
  • IMP:
    • S/P colon operation.
    • Bil. liver cysts (up to 2.4cm).
    • Gallbladder stones (2-3mm).
• 2021-08-11 CT - abdomen
  • History and Indication:
    • 20200823 CT: RLQ tumor with abdominal wall involvement, suspected appendix tumor or appendicitis with tumor formation.
    • 20200827 S/P right hemicolectomy: mucinous adenocarcinoma of the appendix with abscess, pT4N0Mx, stage: IIB. S/P C/T for FU
  • FINDINGS:
    • There is a poor enhancing lesion 1.1 cm in S6 liver (Srs:3 Img:64) that may be cyst or metastasis. Please correlate with sonography.
    • There are several hepatic cysts in both lobes and the largest one is measured about 2.2 cm in size at segment 8.
    • A calcified gallstone 6 mm is noted.
  • IMP:
    • There is a poor enhancing lesion 1.1 cm in S6 liver (Srs:3 Img:64) that may be cyst or metastasis. Please correlate with sonography.
• 2021-05-03 CT - abdomen
  • Clinical history: 72 y/o female patient with R/O PERITONITIS
  • Impression:
    • S/P right hemicolectomy.
    • Gallbladder stone
    • Stationary of peritoneal nodules, up to 0.7cm.
    • R/O liver cysts.
    • Bilateral perirenal fatty infiltrates.
• 2021-05-03 CT - brain
  • Clinical history: 72 y/o female patient with R/O SDH.
  • Impression:
    • Brain atrophy.
    • R/O chronic sinusitis.
• 2021-05-03 ECG
  • Normal sinus rhythm
  • T wave abnormality, consider anterolateral ischemia
• 2021-04-20 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 33) / 100 = 67.00%
    • M-mode (Teichholz) = 67
  • Preserved LV and RV systolic function with normal wall motion
  • Grade 1 LV diastolic dysfunction
  • Mild AR, TR
• 2021-04-19 ECG
  • Normal sinus rhythm
  • T wave abnormality, consider lateral ischemia
• 2021-04-19 Flow Volume Loop
  • suspected mild restrictive ventilatory defect
• 2021-03-27 CT - abdomen
  • Indication: 72 y/o female patient with Appendiceal mucinous adenocarcinoma with liver metastasis s/p receving right hemicolectomy on 2020-08-26, pT4aN0M1a, Stage IVA s/p chemotherapy.
  • With and without contrast enhancement CT of abdomen–whole:
    • s/p right hemicolectomy.
    • Peritoneal nodules and stranding, mild in regression.
    • Gallbladder stone.
    • Several liver cysts. 2.4cm of the largest one in right lobe.
  • Impression
    • s/p right hemicolectomy
    • Peritoneal carcinomatosis, mild in regression
• 2021-03-04 Gynecologic Ultrasonography
  • EM: 4.8mm
• 2020-12-29 CT - abdomen
  • Post-op at colon with mesentery nodules and lymph nodes, suspected carcinomatosis.
  • Presecne of gallbladder stone.
  • Liver cysts, up to 2.4cm in right lobe.
• 2022-12-29, -11-10 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
• 2020-09-22 MRI - liver, spleen
  • Liver and renal cysts (up to 2.3cm).
  • Prominent accessory p-duct.
• 2020-08-31 Tc-99m MDP whole body bone scan
  • Mildly and non-focally increased radiotracer uptake in C-spine and lower L-spine, degenerative spine diseases may show such a picture.
  • Some areas of mildly increased radiotracer uptake in maxilla and mandible, dental lesions may show such a picture.
  • Probably degenerative joint lesions in shoulders, sternoclavicular junctions, sacroiliac joints, and hips.
  • No definite evidence of osteoblastic skeletal metastasis by this bone scan.
• 2020-08-27 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Appendix, R’t hemicoloectomy — Mucinous adenocarcinoma with abscess
      
    • Resection margins, bilateral cutting end, ditto — Free of tumor invasion
      
    • Lymph node, mesocolic, dissection — Negative for tumor metastasis (0/20)
      
    • Ascending colon, R’t hemicoloectomy — Free of tumor invasion
      
    • AJCC pathologic stage — pT4aN0 (if cM0), stage IIB
      
  • MACROSCOPIC EXAMINATION
    • Operation procedure: right hemicolectomy
      
    • Specimen site: ascending colon, terminal ileum and appendix
      
    • Specimen size: (a) A-colon: 22.5 x 5.5 cm; (b) Terminal ileum: 4.5 x 3.0 cm; (c) Appendix: 8.5 x 6.0 x 5.5 cm
      
    • Tumor size: 8.5 x 6.0 x 5.5 cm
      
    • Tumor location: appendix
      
    • Tumor appearance: mucinous tumor
      
    • Depth of invasion grossly: Visceral peritoneum
      
    • Representative sections as follows: A1: proximal A-colon margin, A2-A4: peri-tumor soft tissue, A5-A12 and A16-A20: tumor, A13: distal colon margin, A14-A15 and A21-A22: lymph node
      
  • MICROSCOPIC EXAMINATION
    • Histology: mucinous adenocarcinoma
    • Histology Grade: G1-2: well to moderately differentiated
      
    • Depth of invasion: Visceral peritoneum
      
    • Angiolymphatic invasion: absent
      
    • Perineural invasion: present
      
    • Discontinuous extramural tumor extension: absent
      
    • Circumferential (radial) margin: Involved
      
    • Lymph node metastasis, mesocolic: negative (0/20)
      
    • Lymph node metastasis, IMA / SMA: N/A
      
    • Extranodal involvement: N/A
      
    • Pathological TNM Stage: pT4aN0, stage IIB
      
    • Type of polyp in which invasive carcinoma arose: N/A
      
    • Additional pathologic findings: abscess formation
      
    • TNM descriptors: N/A
      
    • Tumor regression grading S/P CCRT: N/A
      
  • IMMUNOHISTOCHEMISTRY
    • CDX-2(+), MLH1(+), PMS2(+), MSH2(+) and MSH6(+) for tumor cells
• 2020-08-25 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (77.7 - 15.5) / 77.7 = 80.05%
    • M-mode (Teichholz) = 80.1
  • Septal hypertrophy. Dilated AsAO (40mm)
  • Normal RV & LV systolic function. No regional wall motion abnormalities.
  • Impaired LV relaxation.
  • Moderate tricuspid regurgitation.
  • Mild pulmonic regurgitation.
• 2020-08-24 Bronchodilator Test
  • Normal spirometry, without significant response to bronchodilator
• 2020-08-24 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis and duodenitis
    • Gastric and duodenal erosions
  • Suggestion
    • PPI therapy
    • No evident malignanct in UGI tract
• 2020-08-23 CT - abdomen
  • There is soft tissue tumor, 3.56cm in right lower abdomen with abdominal wall involvement, suspected appendix tumor or appendicitis with tumor formation.
  • There is skin tumor, 1.37cm in right lower abdominal wall.
  • Presence of gallbladder stone.
  • Hypodense lesions, up to 2.3cm in S8 of right liver, suspected liver cysts.
  • Ill-defined hypodensities in S6 liver, suggest further study.
• 2020-08-18 Gynecologic Ultrasonography
  • Bilateral adnexae: free
  • Subcutaneous mass: 59x39mm (no blood flow)

[consultation]

• 2021-03-04 Obstetrics and Gynecology
  • Q
    • This 72-year-old woman patient is a case of Appendiceal mucinous adenocarcinoma with liver metastasis s/p receving right hemicolectomy on 2020-08-26, pT4aN0M1a, Stage IVA s/p chemotherapy with FOLFIRI, refractory with mesentery carcinomatosis, rT0N0M1c, stage IVB s/p chemotherapy with FOLFIRU/Avastin. She was admitted for chemotherapy with Avastin(C5)/FOLFIRI(C6D1).
    • This time, for perineum mild bleeding. Now, for evlauate perineum bleeding dispose and therapy. Thank you.
  • A
    • PV: atrophic cervix, no obvious lesion
      • discharge: scanty
      • Sono: endometrium 4.8 mm.
    • IMP: vaginal spotting, but improved now
    • suggestion:
      • no obvious GYN problem now. Bleeding tendency or coagulopathy may be consider.
• 2021-01-26 Ear Nose Throat
  • Q
    • This 72-year-old woman patinet is a case of Appendiceal mucinous adenocarcinoma with liver metastasis s/p receving right hemicolectomy on 2020-08-26, pT4aN0M1a, Stage IVA s/p chemotherapy with FOLFIRI, refractory with mesentery carcinomatosis, rT0N0M1c, stage IVB s/p chemotherapy with FOLFIRU/Avastin. She was admitted for chemotherapy.
    • Hoarseness developed in 2020/12. Now, for evaluate hoarseness examination and therapy. Thank you.
  • A
    • After evaluated via scope, we found bilateral vocal cord atrophy and bilateral vocal nodules.
    • We suggested our OPD f/U and the disease needed to receive operation (already explained to family)

[surgical operation]

• 2021-04-21
  • Operation
    • Laparoscopy adhesionolysis
    • Pelvic drainage
  • Finding
    • S/P right hemicoletomy with a midline incisional scar
    • Adhesion of greater omentum to abdominal wall
    • No gross peritoneal seedings and minimal ascites. Normal appearance of liver surface and stomach
    • Drain; 10Fr Blake drain *1, in the pelvic cavity.
    • Wound: treated with New Epi Plus, 5cc
• 2020-08-26
  • Operation
    • Laparoscopic right hemicolectomy
  • Finding
    • A tumor mass over appendix with severe adhesion to omentum and right lower abdoinal wall; with localized abscess
    • Several small liver cysts in right lobe
    • Drain: 15Fr Blake x 1 in the pelvic cavity
    • Wound: treated with New Epi Plus (5cc)

[chemoimmunotherapy]

• 2023-03-21 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-03-07 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-20 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-30 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-26 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2021-03-30 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (_______ + FOLFIRI)
• 2021-03-16 - irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (_______ + FOLFIRI)
• 2021-03-02 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFIRI)
• 2021-02-17
• 2021-01-26
• 2021-01-12
• 2020-12-30
• 2020-12-15
• 2020-11-27
• 2020-11-10
• 2020-10-27
• 2020-10-13
• 2020-09-23

[assessment]

• Between 2020-09 and 2021-03, the patient received bevacizumab + FOLFIRI, and her CEA levels remained within the normal range. After completing the FOLFIRI treatment, the CEA levels began to rise slowly, but no imaging evidence was found until a CT scan on 2022-12-22, which revealed soft tissues in the peritoneal cavity suspected to be tumor seeding. A new regimen of bevacizumab + FOLFOX was initiated on 2022-12-26, and a subsequent decrease in CEA levels was observed, suggesting the effectiveness of the new treatment.
  • 2023-03-07 CEA 340.09 ng/mL
    
  • 2023-01-11 CEA 397.81 ng/mL
    
  • 2022-12-22 CEA 629.24 ng/mL
    
  • 2022-11-24 CEA 543.06 ng/mL
    
  • 2022-10-28 CEA 396.78 ng/mL
    
  • 2022-09-26 CEA 231.52 ng/mL
    
  • 2022-09-01 CEA 212.17 ng/mL
    
  • 2022-08-04 CEA 142.37 ng/mL
    
  • 2022-07-07 CEA 109.08 ng/mL
    
  • 2022-06-09 CEA 86.83 ng/mL
    
  • 2022-05-12 CEA 67.22 ng/mL
    
  • 2022-04-07 CEA 42.21 ng/mL
    
  • 2022-03-17 CEA 33.96 ng/mL
    
  • 2022-02-18 CEA 24.00 ng/mL
    
  • 2022-01-20 CEA 16.97 ng/mL
    
  • 2021-12-24 CEA 16.37 ng/mL
    
  • 2021-11-25 CEA 12.85 ng/mL
    
  • 2021-10-28 CEA 8.01 ng/mL
    
  • 2021-09-30 CEA 6.43 ng/mL
    
  • 2021-09-03 CEA 5.21 ng/mL
    
  • 2021-08-06 CEA 4.60 ng/mL
    
  • 2021-07-08 CEA 4.52 ng/mL
    
  • 2021-06-10 CEA 3.75 ng/mL
    
  • 2021-03-17 CEA 4.00 ng/mL
    
  • 2021-01-26 CEA 3.47 ng/mL
    
  • 2020-12-29 CEA 2.89 ng/mL
    
  • 2020-11-25 CEA 2.98 ng/mL
    
  • 2020-10-27 CEA 2.87 ng/mL
    
  • 2020-09-30 CEA 3.44 ng/mL
• No medication reconciliation issue was identified in the patient.

701474112

230322

[exam findings]

• 2023-03-17 Pathologic Report for PD-L1 (SP142) Assay (Ventana)
  • Sample Number: S2023-4736
    • Tumor type: adenocarcinoma
    • Tumor location: lung
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark XT
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: Pass,
    • Adequate tumor cells present (>=50 viable tumor cells): Yes
  • Result:
    • Tumor cell (TC) staining assessment: TC category: TC < 1%
    • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
  • Note:
    • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
    • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2023-03-15 CXR
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-03-15 Patho - lung transbronchial biopsy
  • Lung, LLL, CT-guide biopsy — adenocarcinoma, moderately differentiated
  • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
  • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
• 2023-03-14 Bone Scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two hot spots in the middle T-spines and increased activity in the skull, lower T-spines, some L-spines, left S-I joint and inferior aspect of left acetabulum in whole body survey.
  • IMPRESSION:
    • Two hot spots in the middle T-spines and increased activity in the skull. Multiple bone metastases may show this picture.
    • Increased activity in the left S-I joint and inferior aspect of left acetabulum. Bone metastases can not be ruled out.
    • Increased activity in lower T-spines and some L-spines. Degenerative change may show this picture. However, please follow up bone scan to rule out the possibility of bone metastasis.
• 2023-03-13 Bronchoscopy
  • normal
  • no obvious tumor was found
• 2023-03-09 CT - chest
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Spiculated mass at left lower lobe measuring 2.7cm is found. Lung cancer is considered. The lession attached to descending aorta and pulmonary artery.
      • Interfissural nodules (n > 10) are found at left upper and lower lobes up to 1.07cm in largest dimension.
      • Mild left pleural effusion is found.
      • Enlarged lymph nodes are found at left hilar and left paratracheal region.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • The GB is well distended without soft tissue lesion
  • Imp: left lower lobe lung cancer with lung to ipsilateral lung meta, pleural meta.
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
• 2023-03-09 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
  • Finding: The repetitive stimulation study shows borderline decremental response in Trapezius.
  • Conclusion: The findings are possibly suggestive of myasthenia gravis. Please correlate clinically
• 2023-03-06 MRA - brain
  • Indication: CT showed brain and skull lesion
  • Imaging protocol: 4-5mm slice thickness; sagittal T2, axial T2 & T2 FLAIR, DWI(b＝1000)/ADC, coronal T1, axial T1+C, coronal T1+C images, and TOF MRA images
  • Head MRI without/with Gadolinium-based contrast enhancement shows:
    • multiple heterogeneous enhancing brain tumors scattered in bilateral cerebra and cerebella, on the cortex and in subcortical white matter, some associated with vasogenic edema. Larger ones are 1.8cm at left medial temporal lobe, and 2.0cm at right parietal-occipital lobe junction. Brain metastases are favored.
    • multiple enhancing bone tumors involving skull base and calvarial vault, larger ones are 3.9cm at right high parietal skull, and 2.0cm at clivus. Multiple bone metastases are favored.
    • symmetric size of bilateral ventricles.
    • no brain herniation.
    • TOF MRA shows patent and unremarkable intracranial arteries.
  • Impression:
    • Multiple brain and cerebellar metastases.
    • Multiple bone metastases, skull base and calvarial vault.
• 2023-03-06 CXR
  • Blunting of left CP angle
• 2023-03-06 CT - brain
  • Indication: SBP200-220mmHg or DBP110-130mmHg
    • noted today with blurred vision ; no recent head injury
    • no vomiting; no fever ; chest discomfort also noted
  • Imaging Protocol: 4mm slice thickness, axial scan and sagittal reconstruction
  • Without-contrast CT of brain shows:
    • White matter edema in right parietal lobe. Suspicious lesion in left medial temporal lobe.
    • Multiple mass lesions in skull, as well as in clivus.
    • Normal size of the ventricles.
    • No midline shift.
  • Impression
    • White matter edema in right parietal lobe and suspiciously in left medial temporal lobe, suspected brain metastasis
    • Multiple skull lesions; DDx: metastasis, multiple myeloma

[consultation]

• 2023-03-17 Radiation Oncology
  • A
    • A: Adenocarcinoma of the lung, LLL, stage cT4N2M1, with multiple bone and brain metastases.
    • P: Radiotherapy is indicated for this patient with the following indicators: brain metastases
      • Goal: palliation
      • Treatment target and volume: the metastatic brain tumors and involved skull bone
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 3000cGy/15 fractions of the metastatic brain tumors and involved skull bone
      • The treatment planning of radiotherapy will be started at 0930, 2023-3-20.
• 2023-03-08 Neurology
  • Q
    • She presented with sudden blurred vision and diplopia from 2023/03/06 morning after waking up. Dizziness and occasionally headache was also noted. Occasionally headache and progression memory deterioration for years.
  • A
    • Under the impression of multiple brain and cerebellar metastases with unknow primary, the patient was recommanded admission for further examination and treatment. I was consulted for further evaluation.
    • O
      • NE E4V5M6
      • CNs: suspect left gaze diplopia, no EOM abnormality
      • MP full
      • sensation: intact
      • FNF: no dysmetria
      • gait: steady
      • Brain CT revealed: 1. White matter edema in right parietal lobe and suspiciously in left medial temporal lobe, r/o brain metastasis 2. Multiple skull lesions; DDx: metastasis, multiple myeloma
      • Brain MRI/MRA: 1. Multiple brain and cerebellar metastases. 2. Multiple bone metastases, skull base and calvarial vault.
        
    • impression:
      • suspect diplopia, r/o leptomeningeal carcinomatosis, r/o cranial neuropathy
    • suggestion:
      • treat cancer as your expertise and agree with steroid treatment
      • consider CSF study to rule out cranial neuritis or leptomeningeal carcinomatosis
      • check serum ACHR ab and RST to rule out myasthenia gravis/LES
      • contact me if any questions and thank you for consultation.
• 2023-03-08 Dermatology
  • Q
    • She presented skin itchy at least 10 years, SLE (skin manifestations) was diagnosis in RenAi Hospital, follow up and medication for 3 years. She had lesions of skin on her head, right calf and buttocks. Due to brain metastasis was found, skin malignancy was suspicious. We need your further evaluation and management. Maybe need to biopsy?
    • She receive cryotherapy for skin lesions at LMD (2023/03/03).
  • A
    • The patient had sufferred from several itchy keraotsis over face, forarm and buttock s/p cryotherapy with poor healing state.
      
    • Under the impression of irriated seborrheic keratosis with partial destruction.
      
    • The following sugeetion:
      • Tetracycline onit. 1 tube topical bid use over wound and crust and Betason-N onit 2 tube topical bid use over regional erythematous itchy lesion
      • If some remain itchy keraotsis develop, avoid self-scretch and consider add Rinderon-V cream 1 tube topical bid use.
• 2023-03-07 Neurosurgery
  • Q
    • MRA: Multiple brain and cerebellar metastases
    • Dizziness and blurred vision
  • A
    • 67 y/o female. Comorbid with SLE.
    • Brain MRI:
      • Multiple brain and cerebellar metastases.
      • Multiple bone metastases, skull base and calvarial vault.
    • Rx:
      • Consult with oncologist for systemic work-up and therapy.

2023-03-08

[assessment]

• This 67-year-old female with comorbid SLE presented with dizziness and blurred vision. Brain MRI showed multiple brain and cerebellar metastases, as well as multiple bone metastases in the skull base and calvarial vault. The patient is currently receiving care from our oncologist for systemic evaluation and treatment.
• The medications previously prescribed by Taipei City Hospital for the patient’s systemic connective tissue involvement have been properly added to the active medication list without a reconciliation issue.

700045553

230321

{Metastatic colon adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA, post segmental hepatectomy on 2019-06-05}

[diagnosis] - 2023-03-20 admission note

• Sigmoid cancer with Metastasis in S7 liver S/P C/T shows progressive disease. Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease. stage IV
• Viral hepatitis B Anti-HBc positive
• Type 2 diabetes mellitus without complications

[past history] - 2022-11-25 admission note

• Type 2 DM
• Descending colon adenocarcinoma pT4aN1bM0 stage IIIB s/p T-loop colostomy, left hemicolectomy, closure of colostomy and FOLFOX chemotherapy in 2018.
• Metastatic colonic adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA post segmental hepatectomy on 2019/06/05. RFA for S6/7 metastases at VGHTPE on 20191226
• Pig-tail drainage for liver abscess since 2019/06/08.
• Enterocutaneous fistula since 2019/08/03

[family history]

• His mother had cervical cancer.

[lab data]

• 2021-07-30 Anti-HCV Nonreactive
  
• 2021-07-30 Anti-HCV Value 0.05 S/CO
  
• 2021-07-30 HBsAg Nonreactive
  
• 2021-07-30 HBsAg (Value) 0.41 S/CO
  
• 2021-07-30 Anti-HBc Reactive
  
• 2021-07-30 Anti-HBc-Value 6.63 S/CO
  
• 2021-07-30 Anti-HBs 22.86 mIU/mL

[exam findings]

• 2023-01-27 MRI - T-spine
  • Indication: Mid-back pain and soreness, associated numbness.
  • Findings
    • T1-hypointensity, heterogeneous T2-hypointensity and inhomogeneous enhancement involving both anterior and posterior components of C6, C7, T3, T4 and T5 vertebral body, indicating metastases. Much more severe at T3-5 levels with bony destruction and compression on spinal cord.
    • An enhacning soft tissue mass, about 39 mm at the largest dimension, with irregular maring in right lung field, abutting right main bronchus and right side of T5 vertebrla body, indicating metastasis.
    • No intramedullary lesion.
  • IMP: Bony metastases (C6-7 and T3-5 vertebral bodies) and right lung metastasis.
• 2023-01-16 CT - Sella
  • Findings
    • An extra-axial tumor (36 mm) at anterior cranial fossa base, can be separated from pituitary fossa by diaphragm sella. Suspected meningioma.
    • After IV contrast administration shows well and homogenous enhancement of the mass or tumor.
  • IMP: Favor a middle frontal base meningioma.
• 2023-01-16 T-spine AP + Lat.
  • Destructions/metastases, at least, at T3-4-5.
• 2022-12-13 Patho - liver biopsy needle/wedge
  • Liver, CT-guided biopsy — Adenocarcinoma, metastatic, colonic origin
  • The sections show a picture of adenocarcinoma, moderately differentiated, composed of nests, cords, and single large pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation is present. Extensive tumor necrosis is evident.
  • IHC shows: CK7(-), CK20(+) and CDX2(+). The finding is consistent with metastatic colonic adenocarcinoma.
• 2022-11-28 CT - abdomen
  • Findings
    • Lobulated hepatic tumor at S7/8 of liver up to 5.5cm in largest dimension is found. In comparison with CT dated on 2022-08-10, the lesion enlarged.
    • Diffuse confluent lymphadenopathy at para-aortic and mesenterric region is found. In progression.
    • Mild bilateral pleural effuison is found.
  • Imp:
    • Hepatic meta. In progression.
    • Extensive lymphadenopathy in the abodminal cavity, in enlargement.
• 2022-09-15 Tc-99m MDP whole body bone scan
  • Prominently increased activity in some upper T-spines. Bone metastases should be considered first.
  • Mildly increased activity in bilateral S-I joints. Degenerative change may show this picture.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, compatible with benign joint lesions.
• 2022-08-27 CXR
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2022-08-10 CT - abdomen
  • Indication
    • History: D-colon cancer with liver & LNs mets
      • 20180406 CT: Distal D-colon cancer — acute total obstruction
      • 20190520 CT: metastasis in S4/8
      • 20190608 CT: metastasis in S4/8 S/P resection with abscess S/P catheter drainage
      • 20201014 CT: metastasis in S7 S/P C/T with partial response.
      • 20211109 CT: metastasis in S7 1.6 cm.
  • Findings
    • Prior CT identified an ill-defined rim enhancing lesion 4.4 cm in S7 of the liver is noted again, increasing in size to 5.3 cm in the current CT that is c/w liver metastasis S/P C/T with progressive disease.
    • Prior CT identified multiple confluent metastatic lymphadenopathy at para-aortic space and para-cava space are noted again, stable in size that are c/w metastatic nodes S/P C/T with stable disease.
    • S/P surgical resection of S4/8 junction and partial resection of S5/6 of the liver. S/P cholecystectomy. Mild Fatty liver is noted.
    • S/P left hemicolectomy.
    • The spleen shows prominence in size (AP dimension: 11.3 cm).
  • Impression:
    • Metastasis in S7 liver S/P C/T shows progressive disease.
    • Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease.
• 2022-08-04 CXR
  • Cardiomegaly is noted.
  • Right pleural effusion is found.
• 2022-07-21 CXR
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
• 2022-05-26 CT - abdomen, pelvis
  • Progression of liver/ LNs metastases.
• 2022-03-12 CXR
  • Ground glass opacity in bilateral lower lungs.
• 2022-01-15 MRI - nasopharynx
  • Metastastic LAPs at left neck. An extra-axial tumor (37 mm) at anterior cranial fossa and pituitary fossa.
  • Suspected meningioma.
  • D/D: craniopharyngioma, pituitary adenoma, metastasis.
• 2022-01-14 CT - whole abdomen, pelvis
  • Metastasis in S7 liver S/P C/T shows progressive disease.
  • Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show partial response.
• 2021-11-10 MRI - nasopharynx
  • multiple enlarged and necrotic lymph nodes in the left lower neck and left supraclavicular fossa.
• 2021-11-09 CT - whole abdomen, pelvis
  • Hepatic meta at S7, in progression.
  • Extensive paraaortic lymphadenopathy, enlarged.
  • Tiny left upper lobe nodule. Stable.
• 2021-09-16 CT - whole abdomen, pelvis
  • Progression of liver/LNs metastases.
• 2021-07-19 Patho - peritoneum biopsy
  • newly developed retroperitoneal LNs, R/I recurrence.
  • malignant neoplasm of descending colon
  • Retroperitoneal lymph node, CT-guide biopsy - Adenocarcinoma, metastatic
  • IHC: CK(+), CK20(-), CDX2(+) and CD31 highlights endothelial cell, compatible with metastatic colonic adenocarcinoma.
• 2020-10-14 CT - whole abdomen, pelvis
  • A metastasis 2.9 x 2 cm in S7 of the liver S/P C/T with partial response. Follow up is indicated.
• 2020-08-25 CT - whole abdomen, pelvis
  • Post-op at the liver with loculated fluid in right subphrenic region, stationary.
  • Stationary of S7 liver tumor.
• 2020-06-15 MRI - brain
  • A pituitary macroadenoma. No evidence of brain metastasis.
• 2020-06-13 CT - whole abdomen, pelvis
  • Post-op at the liver with loculated fluid in right subphrenic region with progression. Post-op biloma or associated with recurrenct, suggest tissue study.
  • Stationary of S7 liver tumor.
  • Small bilateral renal stones.
• 2020-04-01 CT

  • A metastasis 3.9 x 2 cm in S7 of the liver S/P C/T with stable disease.

  • 2019-11-21 Whole body PET scan

    • Three glucose hypermetabolic lesions in the segment 8 of liver, in the segment 7 of liver and in the right upper abdomen just in the inferomedial aspect of the right lobe of liver respectively. Metastatic lesions should be considered.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions and in the soft tissues around bilateral hips. Inflammatory process is more likely.
    • Glucose hypermetabolism in the midline anterior abdominal wall. The nature is to be determined (post-operative change? other nature?).
    • A glucose hypermetabolic lesion the pituitary fossa. The nature is to be determined (some kind of pituitary tumor? other nature?).

  • 2019-11-11 CT - abdomen

    • S/P liver operation. A low attenuation lesion (1.8cm) in S7 of liver without interval change.

  • 2019-08-14 Tc-99m MDP whole body bone scan

    • A faint hot spot in the anterolateral aspect of the right 8th rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scna in 3 months for further evaluation.
    • Suspected benign lesions in the left zygomatic bone, inferior angle of the right scapula, bilateral shoulders, and S-I joints.

  • 2019-08-03 MRI - liver, spleen

    • s/p pigtail placement at previous op. region. Some fluid accumulation at previous op. region with tiny air bubble is found. The adjacent liver parenchyma is hyperemic, suspected regional residual abscess formation.

  • 2019-06-06 Surgical pathology Level V

    • pathologic diagnosis
      • Liver, S4-5-8, segmental hepatectomy — Metastatic colonic adenocarcinoma
        
      • Liver, S7, segmental hepatectomy — Metastatic colonic adenocarcinoma
        
      • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
        
      • Lymph nodes, group 12, lymphadenectomy — Negative (0/3)
    • microscopic examination
      • Diagnosis: Metastatic colonic adenoarcinoma x2
      • Histologic grade: Moderately differentiated
        
      • Tumor growth pattern: Pushing
        
      • Tumor pseudocapsule: Present
        
      • Tumor necrosis: Marked (60%)
        
      • Parenchymal margin: Uninvolved by carcinoma
        
      • Distance of invasive carcinoma from closest margins: 0.1 cm (S4-5-8) and 0.1 cm (S7), respectively
        
      • Vascular invasion: Present
        
      • Perineural invasion: Not identified
        
      • Tumor regression grade: Grade 4/5 (residual cancer cells predominate over fibrosis)
      • Lymph nodes, group 12: Negative (0/3) (LN involved/LN examined)
        
      • Non-neoplastic liver parenchyma: Perivenular congestion, and mild portal lymphocytic infiltration
        
      • Fatty Change: Moderate (50%)

  • 2019-06-08 CT - abdomen

    • S/P operation. Bil. pleural effusion with adjacent lung collapse.
    • Some air and fluid collection in upper peritoneal cavity and right subphrenic region.
    • Inhomogeneous enhancement of right hepatic lobe.

  • 2019-05-20 CT - abdomen

    • Metastasis 4 cm in size at S4 of the liver is noted and it shows indentation or invasion of the gallbladder wall.

  • 2018-11-16 CT

    • S/P left hemicolectomy. Suggest follow up.

  • 2018-07-07 CT

    • S/P operation. Presence of incisional hernia. Focal fat stranding of abdominal wound.

  • 2018-06-28 Surgical pathology Level III

    • Soft tissue, site?, debridement — Ulcer with granulation tissue

  • 2018-04-26 Surgical pathology Level VI

    • Pathologic diagnosis
      • Descending colon, left hemicolectomy — Adenocarcinoma, moderately differentiated
        
      • Resection margins: Free
        
      • Lymph nodes, mesocolic, dissection — Metastatic adenocarcinoma (2/16)
      • Pathology stage: pT4aN1b(cMx); Stage IIIB at least
    • Microscopic examination
      • Histology: Adenocarcinoma
        
      • Histology Grade: Moderately differentiated
      • Depth of invasion: Mesocolic soft tissue
        
      • Angiolymphatic invasion: Present
        
      • Perineural invasion: Present
        
      • Discontinuous extramural tumor extension: Not identified
        
      • Serosal margin status of colon: Involved
        
      • Lymph nodes metastasis, mesocolic: Metastatic adenocarcinoma (2/16) (No. Positive / No. Total)
      • Extranodal involvement: Present
        
      • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)

[consultation]

• 2023-02-03 Radiation Oncology
  • A
    • In the past 2 wks, he sufferred from Lt neck enlarging LAPs compression with severe Lt arm and scapular pain. CT-simulation will be arranged on 20230208.
    • Plan to deliver 20 Gy/ 4 fx to the Lt neck LAPs. The dose schedule to the spine mets will be adjusted according to the dose distribution and constraint by then.
    • RT will start around 20230209.
• 2022-12-14 Radiation Oncology
  • A
    • Paraaortic enlarging LAPs have caused mild lower limbs edema already. Palliative RT is indicated. CT-simulation will be arranged on 20231219.
    • Plan to deliver 40~45 Gy/ 20~25 fx to the paraaortic LAPs. RT will start around 2022/12/21 or 22.
  • 2022-12-12 Radiation Oncology
    • Q
      • for CT guide biopsy of liver
      • This 60-year-old man, a patient of colon cancer with liver mets progression and he was admitted for C/T. The abdominal CT showed hepatic tumor progression. We need expertise to evaluate his condition thanks!
    • A
      • According to the clinical history and imaging findings, biopsy is indicated.
  • 2022-09-27 Radiation Oncology
    • A
      • Mr. Hsu, a 60-year-old man with history of Descending colon adenocarcinoma pT4aN1bM0 stage IIIB s/p T-loop colostomy, left hemicolectomy, closure of colostomy and FOLFOX chemotherapy in 2018. Metastatic colonic adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA post segmental hepatectomy on 2019/06/05. RFA for S6/7 metastases at VGHTPE on 2019/12/26. status during palliative C/T with liver metastases and abdominal LAPs progression.
      • The Lt upper back and shoulder pain and soreness has been noted since one month ago. Bone scan on 20220916 revealed prominently increased activity in some upper T-spines. Bone metastases should be considered first.
      • Palliative RT to the upper T-spine metastases is indicated. CT-simulation will be arranged today. Plan to deliver 30 Gy/ 10 fx to the site mentioned above. RT will start around 20220928 or 20220929. Thank you very much.
  • 2022-08-11 Colorectal Surgery
    • Q
      • for suspected fistular
      • This 60-year-old man, a patient of colon cancer with liver mets progression and Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease S/P C/T. He was admitted due to dyspnea & bak pain on 8/4 22 night abdominal wound poor healing & pus discharge for one week. pus discharge and stool passage via poor healing wound was noted suspected fistular related. We need expertise to evaluate his condition thanks!
    • A
      • The patient was case of colon cancer with liver and LN metastasis
      • Colo-cutaneous fistula was noted
      • PE: Abd: soft; no peritoneal sign; no abdominal pain
      • Imp: Colon cancer s/p op with enterocutaneous fistula
      • Suggestion:
        • Cover with colostomy bag and may contact stoma nurse if needed
        • Keep on palliative chemotherapy
  • 2022-03-15 Ophthalmology
    • Q
      • For left eye reddish for days
      • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted for chemotherapy. He compalined of left eye reddish for days. We need expertise to evaluate his condition. thanks!
    • A
      • S
        • For redness, FBS os for 1 week
        • OPHx: trichiasis s/p epilation od 2wk ago
        • PHx: DM, colon cancer with liver & lung mets progression under Erbitux, FOLFIRINOX
        • NKA
      • O
        • BCVA: OD 0.6(0.9X-0.25/-0.50X40) OS 0.3(0.5X0/-0.50X5)
        • PT: 20/18mmHg
        • Pupil: 3mm, light reflex +, no RAPD
        • Eyelash: entropion with trichiasis os
        • Conj: np od, inferior injected os
        • K: clear ou, inferior spks os
        • A/C: deep/clear ou
        • Lens: ns+ ou
        • Fundus: c/d 0.4, one CWS near disc od, one blot hemorrhage and CWS os
      • A:
        • Entropion with corneal abrasion os
        • Mild diabetic retinopathy ou
      • P:
        • Control blood sugar
        • Sinomin 1gtt QID os + Tetracycline oint HS os + tapping inferior eyelid os
        • OPH OPD f/u for entropion and f/u cotton-wool spot at disc os

[surgical operation]

• 2019-06-05
  • Segmental hepatectomy
  • Secondary liver malignant neoplasm
• 2018-06-27
  • Colon cancer s/p op with enterocutaneous fistula
• 2018-06-22
  • Malignant colon neoplasm, desc
  • 8.5 Fr. B. braun port, left cephalic vein, cut-down method.
• 2018-05-01
  • D-colon cancer obstruction post op
  • Smoe necrotic tissue at colostomy opened wound
  • Debridement and closure and set a penrose drain
• 2018-04-25
  • D-colon cancer obstruction s/p colostomy
  • D-colon cancer with complete obstruction 744cm
  • Peristoma dense adhesion with omentum and small intestine
• 2018-04-10
  • D-colon cancer obstruction
  • Severe dilatation of T-colon and short mesentary
  • Asites (+)

[chemotherapy]

• 2023-03-20 - irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5290mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-03-01 - cetuximab 250mg/m2 100mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5280mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-02-06 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5400mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2023-01-04 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5300mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2022-12-14 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5300mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

  • 2022-11-25 - cetuximab 250mg/m2 480mg 2hr + oxaliplatin 60mg/m2 115mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5450mg 46hr (FOLFOXIRI Zhang_ShouYi)

    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg IVD + granisetron 2mg + acetaminophen 500mg PO

  • 2022-11-08 - cetuximab 250mg/m2 490mg 2hr + oxaliplatin 60mg/m2 118mg 2hr + irinotecan 150mg/m2 295mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

  • 2022-10-20 - cetuximab 250mg/m2 485mg 2hr + oxaliplatin 60mg/m2 116mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 775mg 2hr + 5-Fu 2800mg/m2 5430mg 46hr (Zhang_ShouYi)

  • 2022-08-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 180mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

  • 2022-09-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

  • 2022-08-26 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5520mg 46hr (Zhang_ShouYi) patient asked to add oxaliplatin back.

  • 2022-08-12 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

  • 2022-07-21 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

  • 2022-07-01 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

  • 2022-06-14 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi) FOLFIRI

  • 2022-05-24 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 185mg/m2 370mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

  • 2022-04-27 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

  • 2022-03-29 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

  • 2022-03-15 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

  • 2022-02-10 - cetuximab 400mg/m2 700mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

  • 2022-01-14 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 170mg/m2 330mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

  • 2021-12-22 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 160mg/m2 300mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

  • 2021-12-01 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

  • 2021-11-11 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5345mg 46hr (Zhang_ShouYi) FOLFOXIRI

  • 2021-09-28 ~ 2021-11-09 - Stivarga (regorafenib 40mg/tab) 4# QD D1-21 Q4W

  • 2021-09-03 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

  • 2021-08-20 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5640mg 46hr (Zhang_ShouYi)

  • 2021-07-29 - oxaliplatin 70mg/m2 140mg 2hr + leucovorin 400mg/m2 805mg 2hr + 5-Fu 2800mg/m2 5660mg 46hr (Zhang_ShouYi)

  • 2020-08-24 - bevacizumab 5mg/kg 200mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

  • 2020-07-27 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

  • 2020-06-29 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5460mg 46hr (Zhang_ShouYi)

  • 2020-06-15 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

  • 2020-05-28 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 160mg/m2 300mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

  • 2020-05-07 - bevacizumab 300mg 90min + irinotecan 120mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + 5-Fu 400mg/m2 650mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1-2 (Liu_JunHuang)

  • 2020-04-20 - bevacizumab 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 560mg 2hr + 5-Fu 400mg/m2 560mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1 (Liu_JunHuang)

  • 2020-04-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1 (Liu_JunHuang)

  • 2020-03-16 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

  • 2020-03-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

  • 2020-02-17 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

  • 2020-02-03 - irinotecan 270mg 1.5hr + leucovorin 400mg/m2 760mg 0hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

  • 2020-01-13 - oxaliplatin 85mg/m2 2hr + leucovorin 200mg/m2 380mg 0hr + 5-Fu 400mg/m2 684mg 15min D1-2 + 5-FU 1000 mg 20hr D1-2 (Liu_JunHuang)

  • 2019-12-06 ~ 2019-12-28 - capecitabine

  • 2019-06-12 - FOLFIRI + bevacizumab

  • 2019-05-28 - FOLFIRI + bevacizumab

  • 2019-05-07 - FOLFIRI + bevacizumab

  • 2019-04-20 - FOLFIRI + bevacizumab

  • 2019-04-03 - FOLFIRI + bevacizumab

  • 2019-03-16 - FOLFIRI + bevacizumab

  • 2019-03-02 - FOLFIRI + bevacizumab

  • 2019-02-17 - FOLFIRI + bevacizumab

  • 2019-02-03 - FOLFIRI

  • 2019-01-03 - FOLFIRI

  • 2018-06-08 ~ 2018-06-18: capecitabine

221128

[assessment]

• The control of blood sugar is better than it was during the last hospital stay.
• As far as the active prescription is concerned, there is no problem.

221109

[assessment]

• The patient continues to have poor blood sugar control despite treatment with acarbose, metformin, and vildagliptin (2 data points over 244 mg/dL on 2022-11-08 and 2022-11-09). SGLT2 inhibitors such as Canaglu (canagliflozin), Forxiga (dapagliflozin) or Jardiance (empagliflozin) might be added to help manage diabetes.

220913

[assessment]

• Although the patient is currently receiving 3 classes of oral antidiabetic medications (metformin, sitagliptin, and dapagliflozin), his blood sugar remains high (381mg/dL on 2022-09-12 17:35, 302mg/dL on 2022-09-13 06:46); HbA1c of 8.4 (2022-08-26 lab), mild diabetic retinopathy has been confirmed (2022-03-15 ophthalmology).
• Starting basal insulin (e.g., Toujeo (insulin glargine)) at 0.1 unit/kg/day or 10 units/day is recommended.

220722

[assessment]

• Irinotecan 180 mg/m2 in current regimen is considered a normal dose range for patients with ALT/AST 43/44, BUN 10 (2022-07-21).
• There is a history of T2DM in this patient. The most recent HbA1c record dates from 2019, and the AC blood sugar readings have been 271, 327, and 267 since this hospitalization. As there is no hypoglycemic agent in active prescriptions, metformin 500 mg BID is recommended.

220315

[assessment]

• CT and MRI in mid January 2022 showed the disease progressed compared to previous images.
• CEA readings since July 2021 at intervals of two to three months showed a peak in November 2021 (1261ng/mL) and a slight fall in February 2022 (886ng/mL), possibly caused by the introduction of FOLFOXIRI from November 2021 (ongoing).

701459963

230321

[diagnosis]

• Malignant neoplasm of left ovary
• Left ovary mixed mucinous and aclear cell carcinoma, pT1c3N0M0, stage IC3, post debulking (ATH + BSO + BPLND + artial omentectomy) on 2022/11/18

[past history]

• Past hx: denied
• Surgical hx:
  • 2022/11/18 ebulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND) + enterolysis
  • 2202/12/07 port implantaion, left cephalic vein

[allergy]

• NKDA     

[family history]

• denied family history

[exam findings]

• 2023-02-18 SONO - abdomen
  • mild fatty liver
  • right renal cyst
• 2023-02-16 Nerve Conduction Velocity, NCV
  • Findings
    • The NCV study showed (1) Prolonged distal motor latency, decreased SAP amplitude, slowing sensory conduction velocity in bilateral median nerves. (2) Decreased CMAP amplitude in left median nerve. The F wave study showed no response in left median nerve. The H reflex was within normal limits. The QST study showed abnormal heat and cold sensation in upper and lower limbs.
  • Conclusion
    • The above finding suggest entrapment neuropathy in bilateral median nerves at wrist and small fiber disease. Advise clinical correlation.
• 2023-02-09 Brainstem auditory evoked potentials, BAEP
  • Findings: Normal waveforms, amplitudes, peak latencies, interpeak intervals following click stimulaion to each ear.
  • Conclusion: This is a normal BAEP study.
• 2023-02-16 Neurosonology
  • Mild atherosclerosis in left CCA bifurcation and left CCA.
  • Adequate total VA flow volume (234 ml/min).
• 2023-01-27 MRI - brachial plexus
  • Indication
    • Ovary cancer
    • acute left upper arm pain and left upper limb weakness on 2022/11/21
    • had tenderness point
    • no trauma history
    • 2022/12/15 improving
  • Without- and with-contrast MRI of brachial plexus, including axial, coronal and oblique sagittal T1WI and T2WI (with 3 mm or 4 mm thickness) reveal:
    • Hypertrphic degeneration of C-spine, esp C5-6-7.
    • No abnormality along the course of left brachial plexus.
    • A well-defined non-enhancing cystic lesion infiltrating along muscles at left shoulder joint, including subacromion region, indicating degenerative joint disease.
    • S/P Port-A device at left chest wall.
  • IMP: No evidence of brachial plexus lesion. Cervical spondylosis.
• 2023-01-27 MRI - C-spine
  • Findings:
    • General bulging disc with central focal protrusion causing mild spinal canal stenosis and bilateral mild neuroformainal narrowing at C4-5.
    • Decreased vertebral body height, end-plate degeneration, general bulging disc with central disc protrusion, posterolateral osteophytes and enlarged facets causing spinal canal stenosis, cord compression and bilateral moderate neuroforaminal narrowing at C5-6-7.
    • No intramedullary abnormality.
    • No abnormal enhancement.
  • IMP: Cervical spondylosis with spinal canal stenosis and neuroforaminal narrowing, esp C5-6-7.
• 2022-12-09 Nerve Conduction Velocity, NCV
  • Findings
    • The NCV study showed (1) Prolonged distal motor latency in bilateral median nerves. (2) Marked decreased CMAP in left median nerve. (3) Slowing sensory conduction velocity in bilateral median nerve. The F wave study showed prolonged latency in left median nerve. The EMG study showed normal findings in left FDI, left brachioradialis and left biceps brachii muscle. The H reflx was normal.
  • Conclustion
    • The above findings suggest left median neuropathy, left cervical radiculopathy and entrapment neuropathy in right median nerve at wrist. Advise clinical correlation.
• 2022-12-07 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 24 dB HL; LE 23 dB HL
  • bil normal to moderate SNHL (sensory neural hearing loss)
• 2022-11-28 MRI - upper arm
  • Partial-thickness intrasubstance tear of supraspinatus tendon
  • Supraspinatus and infraspinatus tendinosis and calcific tendinitis
• 2022-11-26 Shoulder LT
  • Calcified left rotator cuff tendinitis
• 2022-11-26 CXR
  • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, T-spine.
  • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
  • a small nodular opacity over Lt midlung zone?
• 2022-11-26 Gynecologic ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2022-11-21 Patho - soft tissue tumor, extensive resection
  • Diagnosis:
    • Ovary, left, oophorectomy —- mucinous carcinoma with focal clear cell carcinoma; AJCC 8th edition: pStage IC, pT1c2N0(if cM0), FIGO Stage IC2 or pStage IC, pT1c3N0(if cM0), FIGO Stage IC3; please correlate with the clinical presentation
      
    • Ovary, right, oophorectomy —- negative for malignancy
    • Fallopian tube, bilateral, salpingectomy —- negative for malignancy
    • Uterus, corpus, total hysterectomy —- negative for malignancy
    • Uterus, cervix, total hysterectomy —- negative for malignancy
    • Uterus, endometrium, total hysterectomy —- negative for malignancy
    • Omentum, omentectomy —- negative for malignancy
    • Lymph node, left iliac, dissection —- negative for malignancy (0/7)
    • Lymph node, left obturator, dissection —- negative for malignancy (0/10)
    • Lymph node, right iliac, dissection —- negative for malignancy (0/6)
      
    • Lymph node, right obturator, dissection —- negative for malignancy (0/7)
  • Gross description:
    • Procedure (select all that apply): debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND)
      
    • Specimen Integrity
      • Specimen Integrity of Right Ovary (if applicable): Capsule intact
      • Specimen Integrity of Left Ovary (if applicable): Capsule ruptured
      • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
      • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
    • Tumor Site: Left ovary
    • Ovarian Surface Involvement (required only if applicable): Absent
    • Fallopian Tube Surface Involvement (required only if applicable): Absent
    • Tumor Size
      • F2022-00552
        • Greatest dimension (centimeters): 7.5 cm
        • Additional dimensions (centimeters): 7.3 x 2.8 cm
    • Specimen size:
      • S2022-20527
        • right ovary: 2.3 x 1.8 x 0.3 cm;
        • right tube: 5.6 cm in length and 0.5 cm in diameter;
        • left tube: F2022-00552: 4.6 cm in length and 0.3 cm in diameter;
        • uterus: 8.6 x 5.6 x 4.8 cm, 135 g; Cervix: 3.8 x 3.5 x 2.8 cm; Endometrial cavity: 4.0 x 3.8 x 0.2 cm; Several leiomyomas, measuring up to: 1.1 x 1.0 x 0.8 cm
        • omentum: 14.7 x 10.5 x 2.0 cm
    • Sections are taken and labeled as:
      • F2022-00552: Representative sections are taken and labeled as: FsA1-3, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: left fallopian tube; X2: adnexal soft tissue; X3-6: left ovary.
      • S2022-20527: A1: cervix; A2-3: endometrium; A4: leiomyoma; A5: right ovary and fallopian tube; A6: left adnexal soft tissue; A7: posterior wall; B1-2: omentum; C1-2: lymph node, left iliac; D1-2: lymph node, left obturator; E1-2: lymph node, right iliac; F: lymph node, right obturator.
  • Microscopic Description:
    • Histologic Type: Mucinous carcinoma with focal clear cell carcinoma; The immunohistochemical stains reveal PAX8(+), WT-1(-), PR(-), Napsin A(focal +), p53(aberrant expression +)
    • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
      • (Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.)
      • WHO Grading System: G2: Moderately differentiated
    • Implants (required for advanced stage serous/seromucinous borderline tumors only): not applicable
    • Other Tissue/ Organ Involvement (select all that apply): Not identified
    • Largest Extrapelvic Peritoneal Focus (required only if applicable): Cannot be determined
    • Peritoneal/Ascitic Fluid: N2022-04283: suspicious
      
    • Regional Lymph Nodes: left iliac: 0/7; left obturator: 0/10; right iliac: 0/6; right obturator: 0/7
    • Additional Pathologic Findings: Leiomyoma and adenomyosis are seen.
• 2022-11-18 Body fluid cytology - ascites
  • suspicious for malignancy;
    
  • few clusters of suspicious cells with high nuclear/cytoplasmic ratio present.
• 2022-11-18 Frozen section
  • Ovary, left, oophorectomy —- adenocarcinoma
• 2022-11-17 Colonoscopy
  • Diverticulum, descending colon
  • Internal hemorrhoid
• 2022-11-17 Panendoscopy
  • Diagnosis
    • Reflux esophagitis LA Classification grade AEsophageal phleboectasia, middle esophagus
    • Superficial gastritis
  • Suggestion
    • No endoscopic evidence of primary malignancy in UGI tract
• 2022-11-16 ECG
  • Sinus bradycardia
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2022-11-10 Gynecologic ultrasonography
  • suspected pelvis mass: 92 x 47 mm (RI: 0.38)
  • ascites

[surgical operation]

• 2022-11-18 debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND) + enterolysis

[chemotherapy]

• 2023-03-20 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
• 2023-02-24 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
• 2023-02-07 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
• 2023-01-18 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
• 2022-12-28 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
• 2022-12-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3

[note]

First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tube, and peritoneal cancer https://www.uptodate.com/contents/first-line-chemotherapy-for-advanced-stage-iii-or-iv-epithelial-ovarian-fallopian-tube-and-peritoneal-cancer

• General principles
  • The standard approach to treatment for women requiring first-line chemotherapy for EOC is to use a platinum agent with a taxane. For women with optimally reduced disease (<1 cm of residual disease), there are two options: intravenous (IV) chemotherapy alone or a combination of IV and intraperitoneal (IP) chemotherapy (IV/IP therapy). Women with suboptimally reduced disease (≥1 centimeter of residual disease) are not candidates for IP therapy due to limited penetration into larger tumors. These women should therefore receive IV treatment.
• Women with optimally cytoreduced disease
  • IV/IP therapy versus IV therapy alone
    • Comparative data
      • For women with optimally cytoreduced disease (no residual or less than 1 cm of residual disease) who have not received neoadjuvant treatment, IV/IP therapy is an appropriate option. Some UpToDate experts prefer IV/IP treatment for optimally cytoreduced disease, while others prefer IV therapy, particularly given that other treatment options including bevacizumab and maintenance therapy with PARP inhibitors are also often included.
    • Preferred IV/IP therapy regimen
      • The most commonly used intravenous/intraperitoneal (IV/IP) regimen comes from GOG 172 and consists of six cycles of
        • IV paclitaxel (135 mg/m2 over 24 hours) on day 1
        • IP cisplatin (100 mg/m2 in a liter of normal saline) on day 2
        • IP paclitaxel (60 mg/m2) on day 8
      • We typically use the above regimen, with the exception of reducing cisplatin to 75 mg/m2, which was the regimen used in GOG 252.
    • Preferred IV therapy regimen
      • For patients with optimally cytoreduced disease in whom intravenous (IV) therapy will be administered, choice of agents and scheduling is the same as for those with suboptimally cytoreduced disease, and is discussed below.
  • Incorporation of HIPEC
    • For patients who undergo neoadjuvant chemotherapy and have an optimal surgical result (ie, residual disease <1 cm), incorporation of HIPEC is discussed separately.
• Women with suboptimally cytoreduced disease
  • For patients with suboptimally cytoreduced EOC (epithelial ovarian cancer), we suggest IV treatment rather than IV/IP therapy.
  • Choice of agents
    • For women requiring first-line chemotherapy for EOC, the standard IV regimen utilizes platinum and taxane agents. For select patients at higher risk of recurrence (eg, those with pleural effusions or ascites who lack a BRCA mutation), we suggest the addition of bevacizumab, which is administered with chemotherapy and continued as maintenance therapy.
    • Although cisplatin and/or docetaxel are sometimes used in this setting, we prefer carboplatin plus paclitaxel. Our rationale is based on the following:
      • We prefer carboplatin rather than cisplatin because multiple trials have consistently demonstrated that carboplatin produces equivalent response rates and survival outcomes to cisplatin, but is associated with less toxicity.
      • Although both paclitaxel and docetaxel (the most commonly used taxanes for EOC) can be administered along with carboplatin in this setting, we prefer paclitaxel because it is less myelosuppressive than docetaxel. However, a consideration between these two taxanes can be individualized based on their differing toxicities. For paclitaxel, these include a higher risk of neuropathy, myalgias, and weakness compared with docetaxel; for docetaxel, these include a higher risk of neutropenia, hypersensitivity reactions, and nausea and vomiting.
      • We prefer to treat for a maximum of six cycles rather than more because there are no data that treatment beyond six cycles improves outcomes, although further treatment increases the risk of treatment-related toxicities. The administration of further treatment for patients who respond (or do not progress) after six cycles of first-line therapy (ie, maintenance therapy) is covered below.

[assessment]

• Some patients with type 1 or type 2 diabetes have a paradoxically high GFR early in their disease course (ie, “glomerular hyperfiltration”). Glomerular hyperfiltration is usually defined as GFR approximately 20 percent or more above that in age-matched, healthy controls without diabetes. In younger individuals, the usual threshold for hyperfiltration is considered 120 to 140 mL/min/1.73m2, whereas in older adults it may be closer to 100 to 120 mL/min/1.73m2. In studies of patients with diabetes that measured GFR, hyperfiltration was associated with greater risks of albuminuria progression and kidney function decline. The kidney protective effects of renin angiotensin system (RAS) and sodium-glucose cotransporter 2 (SGLT2) inhibitors are thought to be mediated, at least in part, by reductions in glomerular hyperfiltration.
  • 2023-03-15 eGFR 155.56
    
  • 2023-03-09 eGFR 134.22
    
  • 2023-02-22 eGFR 144.16
    
  • 2023-02-15 eGFR 151.57
    
  • 2023-02-07 eGFR 147.78
    
  • 2023-02-01 eGFR 128.28
    
  • 2023-01-17 eGFR 144.16
    
  • 2023-01-12 eGFR 155.56
• No HbA1c readings or blood glucose levels are accessible in HIS5. It is advised to examine whether the patient has developed type 2 diabetes.

221229

[assessment]

• According to the 2022-12-28 lab results, the readings were grossly within the normal range, and no dosage adjustment is necessary.
• Primarily a distal sensory neuropathy, may occur with paclitaxel. Neuropathy can present as a mixture of paresthesias and dysesthesias, including burning, numbness, tingling, and shooting pains, typically in a stocking-glove distribution. Prior to the chemotherapy, 2022-12-09 nerve conduction velocity test suggested neuropathy, 2022-12-07 pure tone audiometry resulted bilateral normal to moderate sensory neural hearing loss. While severe symptoms are unusual, peripheral neuropathy often leads to subsequent dose reductions in many patients.
• Carboplatin has also been associated with ototoxicity (1%, UpToDate). Although peripheral neuropathy occurs infrequently, the incidence of peripheral neuropathy is increased in patients >65 years of age and those who have previously received cisplatin treatment (not this case).
• Please keep an eye out for signs of exacerbated adverse reactions as always.

700035817

230320

{not completed}

He was admitted for hemoptysis with blood clot from oral and nasal cavity for more than a week. History of NPC and CT imaging revealed possible tumor recurrence in Jan 2022.

[exam findings]

• 2023-03-16 CT - neck
  • Chief Complaints: Tongue swealling and left face redness
  • CT scans of the neck from the level of hard palate to the level of infraclavicular region using a 64-sliced multi-detector row volumetric CT after intravenous injection of 100 c.c. iodinated contrast agent.
  • Coronal reformation was performed. The slice thickness is 5 mm.
  • Findings:
    • Known a case of nasopharyngeal cancer S/P treatment. Large lobulated heterogeneous enhancing lesion over nasopharyngeal space with involvement of left parapharyngeal space and nasal cavity, favor malignancy.
    • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
    • Large amount of loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
    • S/P tracheostomy.
    • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
• 2023-03-16 CXR
  • S/P tracheostomy in place.
  • S/P Port-A infusion catheter insertion.
  • Ground glass opacity in bilateral lower lungs.
• 2023-03-16, 2022-12-28, -12-10 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Abnormal ECG
• 2023-01-05 CXR
  • S/p tracheal tube placement with its tip in place.
  • Tortous aorta with calcification is noted.
  • Senile fibrotic change is noted at lung fields.
• 2022-12-22 CT - abdomen
  • History and indication: Respiratory failure
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P gastrostomy. Mild small bowel ileus.
    • Bil. pleural effusion with adjacent lung consolidation. Some nodules in bil. lungs.
    • Right adrenal nodule (9mm). Hyperplasia of left adrenal gland.
    • Right renal cysts (up to 8mm).
    • Normal appearance of liver, spleen, pancreas.
    • Wall thickening of gallbladder with stone (6mm).
    • Patency of portal vein.
    • Fracture of left femoral neck.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac, coronary arteries.
    • S/P Port-A infusion catheter insertion. S/P tracheostomy in place. S/P foley catheter indwelling.
  • IMP:
    • S/P gastrostomy. Mild small bowel ileus.
    • Bil. pleural effusion with adjacent lung consolidation. Some nodules in bil. lungs.
    • Wall thickening of gallbladder with stone (6mm).
    • Fracture of left femoral neck.
• 2022-12-22 Patho - colon biopsy
  • Colorectum, hepatic flexure, s/p biopsy(A) — Granulation tissue
  • Colorectum, hepatic flexure, s/p biopsy(B) — Hyperplastic polyp
• 2022-12-16 CT - abdomen
  • The rectum and sigmoid colon show distension and hard feces retention. please correlate with clinical condition.
  • Chronic cholecystitis is highly suspected.
    • The differential diagnosis include gallbladder cancer.
    • Please correlate with sonography.
  • There are few soft tissue nodules in LLL of the lung.
    • Please correlate with chest CT.
  • Hyperplasia of bilateral adrenal gland are noted.
• 2022-11-05 ECG
  • Sinus tachycardia
  • Left anterior fascicular block
  • Abnormal ECG
• 2022-08-23 CT - neck
  • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
  • Presence of soft tissue swelling over the region of right face and neck with diffuse fat stranding.
  • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
  • Total occlusion of right ICA and upper-middle part of CCA.
  • Presence of soft tissue swelling over right neck, carotid space, and skull base, recurrent tumor with infection?
  • Old right fronto-temporal insult with brain tissue loss due to ICH.
  • S/P tracheostomy in position.
  • S/P Port-A infusion catheter insertion at right jugular/subclavian region.
  • Suggest clinical correlation and previous films comparison.
• 2022-05-06 CT - neck
  • Indication: NPC cT4bNx, s/p CCRT + adjuvant PF
  • With and Without contrast Neck CT showed
    • s/p tracheostomy
    • s/p graft stent at the right CCA and right ICA with total occlusion.
    • soft tissue swelling over right neck, carotid space, and skull base, suspected recurrent tumor with infection?
    • mucosal thickening in the bilateral frontal, bilateral ethmoidal, sphenoidal and bilateral maxillary sinuses. Wall thickening in the walls of the bialteral paranasal sinuses was noted.
    • old insult in the right parietal lobe
  • IMP: soft tissue swelling over right neck, carotid space, and skull base, suspected recurrent tumor with infection?
• 2022-05-05 CXR
  • S/P tracheostomy
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
• 2022-04-16 Chest PA/AP view
  • S/P tracheostomy.
  • S/P port-A insertion via right subclavian vein.
  • Right lower lung infiltrates.
  • No cardiomegaly.
  • Intimal calcification of thoracic aorta.
• 2022-04-16 KUB
  • Calcifications in the pelvic cavity, could be due to phleboliths.
  • Non-specific bowel gas pattern.
  • Mild lumbar spondylosis.
  • Old fractures at left proximal femur.
• 2022-01-13 Patho - polyps, inflammatory nasal/sinonasal
  • Labeled as “Granulation tissue at nasopharynx”, biopsy — benign squamous mucosa lined tissue with granulation tissue.
  • Labeled as “Granulation tissue at soft palate, poterior pharyngeal wall”, biopsy — squamous cell carcinoma, granulation tissue and necrotic tissue.
    • IHC stain: p16 (-).
  • Labeled as “Granulation tissue around stoma”, biopsy — necrotic tissue.
• 2022-01-11 CT - CTA, brain (head, neck)
  • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
  • Total occlusion of right ICA and upper-middle part of CCA.
  • But seems with well blood collateral circulation to right ICA, MCA from left AcomA.
  • Presence of soft tissue swelling over right neck, carotid space, and skull base, recurrent tumor with infection?
  • Old right fronto-temporal insult with brain tissue loss due to ICH.
  • S/P tracheostomy in position.
  • S/P Port-A infusion catheter insertion at right jugular/subclavian region.
• 2021-04-26 KUB
  • Osteopenia of the bony structure is noted.
  • The psoas shadow is clear.
  • Degenerative change of the bony structure with marginal osteophyte formation is identified.
  • Stool impaction at the abdominal cavity is noted.
  • Phlebolith at pelvic cavity is also found.
  • Suggest clinical correlation
• 2021-04-18 Sinuses
  • Water’s view of the paranasal sinuses showed
    • obliteration of the bilateral paranasal sinuses
    • no evidence of destructive bone lesions
• 2021-04-18 Neck soft tissue
  • s/p tracheostomy
    
  • increased soft tissue thickness in the prevertebral soft tissue
  • s/p stenting at the right neck
• 2021-04-18 CT - neck
  • s/p tracheostomy.
  • s/p stenting at the right ICA and right CCA with air in the luminal region
  • Diffuse soft tissue densities in nasalpharynx, oropharynx; and bilateral retropharyngeal, right carotid and right masticator spaces with diffuse subcutaneous fatty infiltrates and abscess formation in the right masticator space. Recurrent tumor with abscess, or stent extravasation? Suggest clinical correlation.
  • bilateral CPS.
• 2020-12-06 CT - abdomen, pelvis
  • PE abdomen: Muscle guarding
  • Without contrast Abdomen CT showed
    • unremarkable change in the solid organs, such as liver, pancreas, spleen, and both kidneys, except multiple GB stones, up to 22mm in the largest one.
    • gastrostomy
  • IMP: GB stones.
• 2020-12-04 Bronchoscopy
  • Bronchitis
  • Tracheomalasia
  • Profuse purulent bronchorrhea s/p bronchial toilet
  • suspected nasopharyngeal tumor with nearly total obstruction
• 2020-11-17 Nasopharyngoscopy
  • NPC s/p treatment
  • Trachea granulation
• 2020-10-28 Whole body PET scan
  • In comparison with the previous study on 2018/12/19, glucose hypermetabolism in the right nasopharyngeal wall disappears, indicating NPC with good response to previous therapy. However, there is a new lesion of glucose hypermetabolism in the left vocal cord in this study, suggesting tumor recurrence with hypopharynx involvement.
    
  • Glucose hypermetabolism in the left level II cervical lymphh nodes, probably reactive change in response to locoregional inflammation.
    
  • Glucose hypermetabolism in the right pleura and right axillary lymph nodes, the nature is to be determined (inflammation/ infection process, NPC with distant metastasis, or others ?), suggesting follow-up.
  • Glucose hypermetabolism in the right neck, suggesting s/p tracheostomy with inflammation/infection process.
  • Glucose hypermetabolism in hepatic flexure of colon, bilateral shoulders, and left hip, probably benign in nature.
  • Nasopharyngeal cancer s/p treatment with tumor recurrence, rcT4NxM0-1, stage IVA at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2020-10-18 CT - neck
  • S/P tracheostomy.
  • S/P vascular stenting in right CCA with intraluminal and perivascualr air densities, suspected infection/inflammation.
    
  • R/O tumor recurrence in nasalpharynx, oropharynx and carotid and masticator spaces (mainly in right side), with cellulitis? Suggest clinical correlation.
  • Multiple enlarged lymph nodes in neck, mediastinum and right axillary regions.
• 2020-09-09 CT - CTA, brain (head, neck)
  • Total occlusion from the right proximal CCA to the cavernous ICA with air in the stent graft. suspected inflammatory process.
• 2020-05-27 CT - abdomen, pelvis
  • findings
    • There is an ill-defined mild poor enhancing lesion measuring 3.4 x 1.4 cm in S4 of the liver (Srs:3, Img:23) that may be abscess? please correlate with clinical condition and sonography.
    • There are several gallstones, the size ＜ 1.8 cm), but no evidence of wall thickening, distension or surrounding fatty stranding.
    • Mild swelling of the pancreatic head is suspected. Please correlate with amylase and lipase level.
    • Left adrenal hyperplasia shows stationary.
    • Hyperdense hard Fecal material in the S-colon and rectum.
    • Status post feeding gastrostomy.
    • There is no focal abnormality in the biliary system, spleen & both kidney.
    • There is no ascites or lymphadenopathy.
    • There is no bowel wall thickening, and no bowel obstruction.
      
    • There is no evidence of intrinsic or extrinsic bladder mass.
    • The abdominal aorta and IVC are grossly unremarkable.
    • There is no focal lesion in the mesentery and omentum.
  • IMP:
    • Liver abscess is suspected. please correlate with clinical condition and sonography.
• 2020-01-06 Carotid angiography bilat
  • IMP: Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding.
• 2020-01-05 Embolization (TAE) - neuro
  • Indication: Massive bleeding from the oral cavity
  • Angiography of bilateral ECA shows oozing of the mucosa at right side supplied by branches of rigth ECA and active bleeding is found at left side by left ECA.
  • Embolization was done with fine gelatine sponge from bilateral ECAs till decreased blood flow.
• 2020-01-05 Carotid angiography bilat
  • Right distal CCA blow-out with one pseudo-aneurysm formation. Suggest covered-stent insertion.
• 2020-01-05 CT - lung/pleura (chest and upper abdomen) (with and without contrast)
  • Ind: hemoptysis, suspected lung hemorrhage, suspected NPC with tumor bleeding
  • Imp:
    • probably oozing or bleeding at hypopharyngeal region.
    • single nodule at left apical lung. suggest follow up.
    • s/p gastrostomy.
    • s/p tracheal tube placement with its tip in place.
  • 2019-11-25 Abdominal Ultrasonography
    • liver parenchyma disease/ incomplete exam of liver
    • gallstones, GB wall thickening
    • pancreas masked
    • spleen not seen
  • 2019-11-25 Phleborheograph, PRG
    • Venous thrombosis at right internal jugular vein; patent right external jugular vein; patent right subclavian vein.
  • 2019-11-13 CT - sinuses for navigator
    • Increased soft tissue in the bilateral posterior nostrils and the nasopharynx. Nature?
      
    • CPS
  • 2019-11-05 Nasopharyngolaryngoscopy
    • finding: bi sinus s/p FESS, right choana total synechiae (fibrosis between septum, right inferior T and nasal floor), left NP whitish mass, biopsy done
    • diagnosis
      • NPC s/p treatement
      • Nasopharyngeal lesion, suspect post-RT necrosis, suspected tumor recurrence
  • 2019-10-08 Nasopharyngolaryngoscopy
    • finding: right choana synechiae, left NP mass with whitish exudate coating
    • diagnosis
      • Nasopharyngeal lesion, suspect post-RT necrosis, suspected tumor recurrence
      • suggest debridement/excision of nasopharyngeal lesion + choana-plasy +- FESS for CPS
  • 2019-09-20 Repetitive stimulation test
    • Blink Reflex Studies
    • The repetitive stimulation study at frequency of 2Hz showed no typical decremental responses in the examined muscles.
    • Sympathetic Skin Response (SSR)
  • 2019-09-06 MRA - brain
    • General brain atrophy.
    • Hydrocephalus.
    • Bilateral chronic paranasal sinusitis.
    • Bilateral mastoiditis.
  • 2019-08-30 CT - brain
    • Brain atrophy.
    • Paranasal sinusitis, nasal polyps and mastoiditis.
    • Nasopharyngeal and oropharyngeal lesion. DDX: prolapse of nasal polyps, nasopharyngeal tumor. Suggest ENT check up.
  • 2019-07-26 MRI - nasopharynx
    • post-CCRT change with dissue swelling in the bilateral nasopharynx, oropharynx, amd hypopharyn; and anterior neck. Please f/u 3 months later.
  • 2019-05-24 CT - abdomen
    • Senile fibrotic change is noted at lung fields. Some bronchovascular bundle infiltration at right lower lobe is found.
    • Gallstones with borderline wall thickening but the GB is not distended.
  • 2019-05-15 Myocardial perfusion SPECT with persantin
    • Probably attenuating artifact or mild myocardial ischemia at the inferoseptal wall of LV.
    • No post-stress dilatation of the left ventricle.
  • 2019-05-15 Carotid phonoangiograph, CPA
    • Sonographic diagnosis:
      • Mild to moderate atherosclerosis in Rt CCA.
      • Imcomplete study due to poor temporal windows for transcranial insonation.
      • Partial venous thrombus formation or venous stasis was noted in Rt IVJ with blood flow.
      • Adequate total VA flow volume (126 ml/min), indicating absence of Vertebrobasilar insufficiency.
    • Advise clinical correlation.
  • 2018-12-20 MRI - nasopharynx
    • Image staging(AJCC,8th edition): NPC, T1N1Mx, stage II.
  • 2018-12-19 Whole body PET scan
    • Glucose hypermetabolism in the right nasopharyngeal wall, compatible with the primary lesion of nasopharyngeal cancer.
    • Glucose hypermetabolism in the right level II and III cervical lymph nodes, suggesting cancer with regional lymph node involvement.
    • Mild glucose hypermetabolism in the left level IIa cervical lymphh nodes, reactive change in response to locoregional inflammation may show such a picture.
    • Glucose hypermetabolism in both lobes of the thyroid gland, inflammatory change is more likely. Please correlate with other work-up studies if further evaluation is warranted.
    • Nasopharyngeal cancer, cT1N1M0, stage II (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2018-12-10 Surgical pathology level IV
    • Nasopharynx, left, biopsy — Non-keratinizing squamous cell carcinoma
    • The sections show non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of sheets and scattered spindle-shaped neoplastic cells in lymphoid stroma.
    • IHC: CK(+), p63(+).

[consultation]

• 2023-03-17 Ear Nose Throat

  • Q
    • This is a 68 years old man had history of (1) NPC cT4bNx, s/p CCRT + adjuvant PF, with long term ventilator status under hospice care, Diabetes mellitus, Hypertension, Reflux esophagitis and duodenal ulcer, Chronic obstructive pulmonary disease, Hypothyroidism, Right distal common carotid artery pseudoaneurysm status post transcatheter arterial chemoembolization and stent insertion, Old intracerebral hemorrhage, Old myocardial infarction, Right internal jugular vein thrombosis, Enlarged prostate.
    • This time he was admitted due to Tongue swealling and left face redness for 2 days.
    • CT done at ER reported:
      • Known a case of nasopharyngeal cancer S/P treatment. Large lobulated heterogeneous enhancing lesion over nasopharyngeal space with involvement of left parapharyngeal space and nasal cavity, favor malignancy.
      • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
      • Large amount of loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
    • Lab with leukocytosis and bandemia, admission under the impression of progression of NPC with deep neck infection with abscess formation, cannot rule out tumor necrosis.
    • Emperic treatment with brosym was prescribed. The patient’s family request for further surgical treatment for possible symptom relief.
    • We need your expertise for further evaluation of possibilites of surgical drainge of abscess, thank you!
  • A
    • 68 y/o man
      • NPC s/p treatment
      • Oropharyngeal cancer noted since 2022-01 (biopsy of oropharynx on 2022-01-12: squamous cell carcinoma)
      • No further treatment for oropharyngeal cancer
      • Neck CT on 2022-03-16 revealed loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
    • Suggest antibiotics teatment
      • I & D not recommended because the CT finding was related to his tumor necrosis with 2nd infection (I&D: Incision and Drainage)
      • I will discuss with his family

• 2023-03-17 Infectious Disease

  • Q
    • Emperic treatment with brosym was prescribed.
  • A
    • This is a case of oropharyngeal & hypopharyngeal abscess with sepsis.
    • Hx NPC s/p op, C/T, ventilator dependent, DM, HCVD.
    • Antibiotcs with meropenem 1g iv q8h is suggested.
    • Please consider debridement.
    • Collect B/C and pus for culture.
    • Please adjust antibiotic according to culture results and clinical conditions.

• • 2021-12-08 ENT
    • Minimal oozing from tracheal wound
    • Portable fiber through tracheal tube: patent airway, no active bleeding site
    • Local treatment done
    • Suggestion:
      • Curam + Paran for Rt. facial cellulitis
      • ENT OPD f/u if needed
  • 2021-05-06 ENT
    • we had changed the trachea already this night but I could not help him to clean the cerumen because the patuient could noy obey our order and he is too heavy that the nurse was hard to move his head
    • we suggested back yo our OPD for crumen removed
  • 2021-05-03 Family Medicine
    • The patient is a case of NPC. This time, he was admitted due to deep neck infection with abscess formation. Due to poor prognosis, we were consulted for further evaluation.
    • When I visited, the patien lied on bed. I asked the nurse about the family’s decision for hospice care. The nurse said that the patient’s wife still need to take the message to other family members. And they didn’t make decision. As a result, I arranged hospice combine care for the patient.
    • Assessment
      • Indication for hospice combine care : NPC with severe infection
      • ECOG 4
  • 2021-04-19 Radiation Oncology
    • Q
      • This 67 year old man is a case of NPC, old CVA, tracheostomy with vewntilation. He suffer form deep neck infection with abscess formation. We need your expertise for pigtail drainage!
    • A
      • According to the clinical condition and imaging findings, drainage is indicated.
  • 2021-04-18 ENT
    • Impression: Deep neck infection with abscess formation, nasopharyngeal carcinoma.
    • Plan:
      • Surgical intervention at the moment is not appropriate owing to high mortality and morbidity rate.
      • Please arrange admission to INFECTION IPD for broad-spectrum antibiotic treatment.
    • Already told the patient to consider hospice care.
  • 2021-03-30 ENT
    • Local finding via portable fiberoscopy:
      • Bil. nasal mucopus and cannot see N-P well, favor post-RT CPS
      • Rt. auricle swelling and EAC cerumen impaction
      • Diffused redness and swelling of Rt. facial, neck and shoulder skin
    • Imp
      • Favor diffused soft tissue infection, suspected post-R/T caused poor circulation
    • Suggestion
      • Keep current Abx
      • If no improvement or even progression, may consider CT for r/o abscess formation
  • 2020-12-24 Rehabilitation
    • Assessment
      • Acute respiratory failure with ventilator support
      • NPC s/p CCRT with airway stenosis s/p tracheostomy
      • Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding s/p TAE with stent
      • COPD with AE
      • DM
      • HTN
      • old CVA with bedridden status
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation programs
    • Goal: recondition, improve endurance and muscle strength, remove endo tube
  • 2020-10-26 Radiation Oncology
    • Assessment: Non-keratinizing squamous cell carcinoma of the nasopharynx, stage cT1N1M0 (stage II), s/p CCRT.
    • Plan: There is no tissue proven of the suspicious area at the present. ENT further evaluation was suggested.
  • 2020-03-18 Mental Health
    • Psychiatric impression
      • Depressive DISORDER WITH SUICIDE ATTEMPT
      • ADJUSTMENT DISORDER WITH DEPRESSED MOOD,
    • Psychiatric history
      • This 66-year-old male patient was brought to this ER due to self-remove trachia this morning. According to his wife, notable depressed mood and insomnia with initial type since diagnosed with NPC. However, his depression was progressed in recent 3 months since he suffered form hemiparesis due to hemoregic stroke. He also note cooperative for rehabilitation and other treatment. Few and nearly no interpersonal interaction. Previosly, he had self-remove trachia during hospitalization.
      • GIVEN-UP COMPLEX, HELPLESSNESS AND HOPELESSNESS
    • Medical history:
      • Nasopharyngeal, left, non-keratinizing squamous cell carcinoma, cT1N1M0, stage II, with right neck LNs, s/p CCRT and Chemotherapy. Intake form grastostomy
      • Diabetes Mellitus type II.
      • Chronic obstructive pulmonary disease.
      • Right distal common carotid artery pseudoaneurysm status transcatheter arterial chemoembolization and stent on 2020/01/06.
    • Suggestion:
      • prevent suicide, well inform the risk and prevention to his family
      • emotional support
      • correct his medical problem as your expertise
      • may give Mirtapine 1# hs for his depression
      • arrange psychiatric OPD follow up
  • 2020-01-12 General and Gastroenterological Surgery
    • Inform the family members (his wife) of the CT results of the brain, and inform that if the anticoagulant continues to be used, it may aggravate the cerebral hemorrhage, but if the anticoagulant is not used, the stent placed in the aneurysm may be blocked.
  • 2020-01-07 Neurology
    • impression: left hemiplegia, suspect R hemisphere subcortical infarction
    • suggestion:
      • agree with current dual antiplatelet agent therapy if no contraindication such as active bleeding
      • arrange brain MRA (without contrast) for stroke survey (consider contrast enhancement for brain metastasis survey)
  • 2020-01-07 Family Medicine
    • When I visited patient, he lied on the bed and his consicousness was drowsy. Interminttent oozing from oral and trochea were found. Tachycardia was found (HR: 120-130/minute). Breathing sound showed no rhonchi or no wheezing. CT on 20200105 showed tumor local invasion and angiography on 20200106 showed no pneudoaneurym formation. Stent for carotid bleeding was done at that time. Due to NPC with local invasion and persisted bleeding, we will arrange hospice combine care for patient first. If his family prefer to receive palliative care, we will discuss with family about further management or PCU admission issue. If family still want to receive aggressive treatment/management, we will keep current combine care first.
  • 2020-01-07 Infectious Disease
    • Bleeding is the major problem now.
    • Despite there is leukocytosis, no definite infection is found at the present time.
    • Because of repeated embolization, temporary coverage of staphylococci, including MRSA/MRSE possibility, is acceptable.
    • Empirical anti-fungal therapy seems not necessary for him.
    • Please repeat CxR film to see if there is newly-developed pneumonia or not.
  • 2020-01-07 Radiation Oncology
    • We have arranged emergent angiography for this patient 20200106 19:00, which revealed right distal CCA blowout, with active bleeding from pseodoaneurysm. Two stents were placed crossing distal CCA and proximal ICA. No more active bleeding is noted after stenting.
    • Medication: Plavix and Bockey 1# QD at least 3 month, after 3 month Bockey 1# QD life long.
  • 2020-01-07 ENT
    • Local finding: Oozing from oral cavity but cannot see the bleeding origin
    • No epistaxis nor bleeding from tracheostomy
    • s/p 10 pieces Bosmin gauze compression, but may still need TAE again
  • 2020-01-04 ENT
    • Scope: should suspect bleeding from tracheal or lung
      • Yellowish mass over bil. nasopharynx, suspected pus (CPS) or tumor
      • Cannot passed the scope into hypopharynx.
    • However, the patient was using tracheal tube “without” side hole -> less likely from nasal or oral cavity
    • Suggestion: consult chest men for lung CT or bronchoscopy

• surgical operation

  • 2022-01-12
    • Surgery
      • debride the granulation tissue
      • change gastrostomy tube 20fr for him
    • Finding
      • grandulation tissue around the gastrostomy
  • 2022-01-12
    • Surgery
      • Stomaplasty    
      • Biopsy of oropharynx and nasopharynx mucosal lesion       
    • Finding
      • Granulation around the stoma except inferior part    
      • Yellowish semisolid necrotic substance at soft palate, posterior pharyngeal wall, and bilateral nasopharynx; Diffuse mucosal edema and touch bleeding was noted at above areas  
  • 2020-11-11 excision - granuloma around gastrostomy, easy bleeding(+), pain(+)
  • 2020-04-29 Stomaplasty
    • Surgery
      • Stomaplasty + Nasopharyngeal lesion biopsy
    • Finding
      • Stoma stenosis with granulation formation.
      • Whitish exudate like lesion at bilateral nasopharynx.
  • 2021-04-28
    • Surgery
      • Incision and drainage of right masticator space
    • Finding
      • Much bloody discharge and few pus over right masticator space
  • 2020-04-02
    • Surgery
      • laparoscopic gastrostomy
    • Finding
      • NPC
      • difficulty in NG tube insertion
  • 2020-01-06 Embolization (TAE) - neuro
    • Indication: Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding.
    • TAE was done with two 8x50 mm stent graft (Viabahn Endoprothesis, overlapped on distal CCA), no more contrast leak after this procedure.
    • Imp: Post stent grafting of the large right CCA pseudoaneurysm.
    • Medication: Plavix and Bockey 1# QD at least 3 month, after 3 month Bockey 1# QD life long.
  • 2019-11-20 Nasopharyngeal necrosis and right choana atresia
  • 2019-08-27 Tracheostomy for respiratory failure
    • neck shortness and stiffness, tracheostomy done with Shily #6
  • 2019-06-10 Jejunostomy - Nasopharyngeal cancer post op, for feeding jejunostomy creation
  • 2017-12-26 R’t soft palate tumor
    • 1.3x2mm granular lesion at right soft palate

230317

[drug identification]

The medication you are requesting drug identification for is Eltroxin, which contains levothyroxine at a dose of 0.05mg.

This medication is used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone.

The medication will be sent back to the ward by an in-hospital porter.

220505

[assessment]

• Lab data on 2022-05-04 showed PT 10.6 sec, INR 1.02, APTT 40.4 sec, Fibrinogen 474.5 mg/dL, D-dimer 982 ng/mL(FEU).
• Aspirin, warfarin, vitamin K antagonists, DOACs records found in NHI PharmaCloud.
• Tranexamic acid 500mg IVD Q8H has been prescribed since 2022-05-05.
• Hemoptysis no longer appears in the problem list. No issue with current medication.

701252793

230320

[diagnosis] - 2023-03-17 admission note

• Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck
• Neoplasm of uncertain behavior of brain, unspecified
• Other cerebrovascular disease
• Dizziness and giddiness
• Other localized visual field defect, unspecified eye
• Diffuse large B-cell lymphoma, extranodal and solid organ sites
• Personal history of other infectious and parasitic diseases
• Chronic obstructive pulmonary disease, unspecified
• Gout, unspecified

[exam findings]

• 2023-02-07 MRI - brain
  • No brain infarct was seen. Marked shrinkage of left thalamus and left occipital lesion. Marked regression of peri-tumoral edema.
• 2022-10-12 MRI - brain
  • Clinical information: Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma. Primary NHL (Diffuse large B cell lymphoma) of brain
  • Findings
    • Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), marked shrinkage of left thalamus lesion (from 29mm to 12mm). But marked progression of lateral lesions (abutting left occipital horn) (from 15mm to 31mm).
    • Prominent peri-tumoral edema over left thalams and temporal lobe.
• 2022-07-13 Body Fluid Cytology - CSF
  • Negative
  • Smears show some small lymphocytes, plasma cells, and monocytes.
• 2022-07-12 Whole body PET scan
  • A glucose hypermetabolic lesion in the left deep temporal lobe of the cerebrum, compatible with lymphoma.
  • Mild glucose hypermetabolism in a focal area in the left anterior upper chest wall. Inflammation may show this picture.
  • Increased FDG accumulaton in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
• 2022-07-11 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
  • Section shows piece(s) of bone marrow with 60 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
• 2022-07-09 CXR
  • Atherosclerotic change of aortic arch
• 2022-07-04 CT - lung/mediastinum/pleura
  • No tumor or LAPs in the neck, chest, and upper abdomen.
• 2022-07-04 CXR
  • Ground glass opacity in bilateral lower lungs.
• 2022-06-23 Patho - brain biopsy
  • Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma
    
  • Immunohistochemical stain profiles:
    • CD20(diffuse+), CD3 (scant + at T- cells), Bcl-2(+), Bcl-6(+), CD56(-), GFAP(-), Ki-67 index: >90%, cyclin D1(-).
    • MUM-1(+), C-MYC(+)
• 2022-06-23 Frozen Section
  • Brain, periventricular lesion, frozen section — hypercellular round blue cell-type neoplasm
• 2022-06-21 CT - brain for navigator
  • Findings
    • An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt.
    • Mild dilated right lateral ventricle.
  • Impression:
    • intra-axial tumor, d/d lymphoma or high grade glioma.
• 2022-06-20 MRA - brain
  • Left temporal lobe-basal ganglion tumor with mass effect.
  • D/D: lymphoma, metastases, GBM. Infectious process is unlikely.
• 2021-04-29 SONO - kidney
  • Right renal stone 0.44 cm
• 2020-09-21 Bronchodilator Test
  • diagnosis: COPD
  • conclusion: normal spirometry

[consultation]

• 2022-10-20 Radiation Oncology
  • Q
    • The 56 y/o man has primary brain diffuse large B cell lymphoma, CD20 (diffuse+), CD3 (scant + at T- cells), Bcl-2(+), Bcl-6(+), CD56(-), GFAP(-), Ki-67 index: >90%, cyclin D1(-). Lugano stage 1E. IELSG score 2 (CSF protein elevated and deep lesions).
    • Due to brain lesion in progress, so we need your help for RT assessment. Thanks!
  • A
    • The patient’s history was reviewed and patient was examined.
    • S: For radiotherapy due to CNS lymphomas s/p chemotherapy.
      • PI: The patient has primary brain diffuse large B cell lymphoma, Lugano stage 1E. IELSG score 2 (CSF protein elevated and deep lesions) s/p chemotherapy (2022-07-14 ~ 2022-10-21). Due to brain tumor progression, he was referred for radiotherapy.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (quit); Smoking (+); Betel nut (-).
        • Personal Hx: DM(-); HTN(-)
        • Previous RT Hx: (-)
    • O: ECOG: 1
      • PE: meck and bil SCF: neg; no motor dysfunction.
      • CXR (2022-06-20): Clean lung fields based on plain image. Normal shape and size of heart. No abnormal mediastinal interfaces, stripes, and lines. Normal appearance of both hila. Costophrenic angles are preserved. Unremarkable of visible trachea
      • MRI of brain (2022-06-20): Left temporal lobe - basal ganglion tumor with mass effect. D/D: lymphoma, metastases, GBM. Infectious process is unlikely.
      • Operation (2022-06-23): Left periventricular tumor for stereotactic biopsy. [Finding]: 1. An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt; intra-axial tumor, d/d lymphoma or high grade glioma; Infectious process.
      • Pathology (S2022-10048, 2022-06-29): Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma
      • CT scan of lung (2022-7-4): no tumor or LAPs in the neck, chest, and upper abdomen.
      • Pathology (S2022-11023, 2022-07-12): Bone marrow, iliac, biopsy — Negative for malignancy.
      • PET (2022-07-12): A glucose hypermetabolic lesion in the left deep temporal lobe of the cerebrum, compatible with lymphoma.
      • CSF (2022-07-13): negative
      • MRI of brain (2022-10-12): 1. Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), Left temporal lobe-basal ganglion (abutting left occipital horn) (from 15mm to 31mm). 2. Prominent peri-tumoral edema over left thalams and temporal lobe.
    • A: Diffuse large B cell lymphoma of the left temporal lobe-basal ganglion area, Lugano stage 1E, s/p chemotherapy, with gross residual tumor.
    • P: Radiotherapy is indicated for this patient with the following indicators: gross residual tumor
      • Goal: curative
      • Treatment target and volume: brain
      • Technique: 2D and VMAT/IGRT
      • Preliminary planning dose: 3060cGy/17 fractions of the whole brain, and 4500cGy/25 frcations of the CNS lymphoma area.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2022-10-26.
• 2022-07-20 Nephrology
  • Q
    • The 55 y/o man has primary CNS lymphoma post HD-MTX and Mabtherapy treatment.
    • Due to AKI with elevated P and Mg, but no oliguria or SOB, so we need your help for management. Thanks!
  • A
    • Lab:
      • BUN 96, Cr 1.09 -> 9.71, Na 133, K 3.5, Mg 3.2, P 7.6, Ca 2.3
    • Impression:
      • AKI stage 3 suspect methotrexate induced
      • primary CNS lymphoma post HD-MXT and Mabthera
    • Suggestion
      • check urinalysis
      • check vein gas
      • IV hydration with urinary alkalinzation; could also prescribe furosemide
      • Follow up VBG and urinalysis in the following day
      • check I/O and body weight qd
      • avoid nephrotoxic agents
      • indication of dialysis has been explained to the patient and family.
    • We will follow up the case. Thank you very much for your consultation.
• 2022-07-11 Ophthalmology
  • Q
    • The 55 y/o man has primary CNS lymphoma with right eye blurred vision, so we need your help for management.
  • A
    • O
      • bv od > os, no floaters ou
      • oph denied
      • BCVA od 0.2(0.4x-1.25/-1.50x175) os 0.2(0.2x-0.75/-2.50x180)
      • PT 20/20
      • k clear ou
      • ac d/cl ou
      • lens clear ou
      • conj np ou
      • f’d c/ d 40% ou, media clear no vitritis ou
    • A
      • no ocular involvement ou currently
    • P
    • suggest control underlying disease+inform the symptoms/ signs and opd f/u afterward
• 2022-06-20 Neurosurgery
  • Q
    • Stroke symptoms (sudden slurred speech/unilateral limb paresthesia/sudden visual impairment) > symptom onset more than 4.5 hours or relieved, right limb and visual field incoordination for two weeks
  • A
    • A case of 55 y/o male; progressive headache (night pain)/blurred vision/gait disturbance for 2 weeks;
    • Drug hx: nil
    • A brain MRI/MRA showed A well-defined irregular-shaped mass with T1-hypointensity, T2-hyperintensity, diffusion restriction and vivid enhancement involving left deep temporal lobe and basal ganglion, associating with perifocal white matter edema and causing mass efect on laterla ventricles and midline structures. Lymphoma is first considered. D/D: metastases, GBM.
    • P: admit for tumor survey; Stereotactic biopsy indicated; HIV?; Explained;

[surgical operation]

• 2022-06-23
  • Surgery
    • Left periventricular tumor for stereotactic biopsy
  • Finding
    • An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt; intra-axial tumor, d/d lymphoma or high grade glioma; Infectious process
    • 3 strips/ 2 targets were apllied for tumor biopsy;
    • Frozen section: lymphocyte/ vascular structure/ inflammation cell?; Favor malignancy. Perminent report will be followed;
    • Culture also sent.
  • Remark: FROZEN SECTION INITIAL DIAGNOSIS: Brain, periventricular lesion, frozen section — hypercellular round blue cell-type neoplasm

[C/T history]

C1D1 (#1) HD-MTX (8000mg/m2) on 2022/7/14, C1D2 Leucovorin (100 mg/m2) q6h until serum methotrexate <0.05 mmol/L and C1D3 Mabthera (375mg/m2) = 750mg on 2022/7/16. Rolican + HS hydration for AKI correct after HD-MTX. Feburic 80mg/tab (Febuxostat) 1# qod for prevent elevated uric acid.

C1D14 (#2) HD-MTX (due to AKI history, so change to 4000mg/m2) on 22022/8/09, Leucovorin 100mg q6h, Mabthera on 2022/8/11. Colchine and dexamethaxone for gouty arthritis treatment on 2022/8/17.

C2D1 (#3) HD-MTX (4g/m2), Covorin, Mabthera on 2022/8/24-8/26. C2D14(#4) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/12-9/14. C3D1 (#5) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/26-9/28.

2022/10/13 brain MRI: 1. Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), marked shrinkage of left thalamus lesion (from 29mm to 12mm). But marked progression of lateral lesions (abutting left occipital horn) (from 15mm to 31mm). 2. Prominent peri-tumoral edema over left thalams and temporal lobe. C3D15 (#6) HD-MTX (8g/m2), Covorin, Mabthera on 2022/10/21-23.

He received the radiotherapy on 2022/11/2 -2022/12/6 with 3060cGy/17 fractions ofthe whole brain, and 4500cGy/25 fractions of the CNS lymphoma area.

C4D1 (#7) HD-MTX (8g/m2), Covorin,Mabthera on 2023/1/6-8. Followed up MRI of brain was performed on 2023/2/8 revealed No brain infarct was seen. Marked shrinkage of left thalamus and left occipital lesion. Marked regression of peri-tumoral edema.

This time, he was admitted for C4D15 (#8) chemotherapy HD MTX/Covorin/Mabthera on 2023/3/17.

[chemoimmunotherapy]

• 2023-03-17 - methotrexate 8000mg/m2 16000mg NS 800mL 6hr D1 + rituximab 375mg/m2 745mg NS 500mL 8hr D3
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + NS 250mL] D2
• 2023-01-06 - methotrexate 8000mg/m2 16000mg NS 800mL 6hr D1 + rituximab 375mg/m2 745mg NS 500mL 8hr D3

  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + NS 250mL] D2

  • 2022-10-21 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3

    • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3

  • 2022-09-26 - methotrexate 4000mg/m2 7950mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3

    • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3

  • 2022-09-12 - methotrexate 4000mg/m2 7980mg 6hr D1 + rituximab 375mg/m2 748mg 8hr D3

    • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3

  • 2022-08-24 - methotrexate 4000mg/m2 7880mg 6hr D1 + rituximab 375mg/m2 740mg 8hr D3

    • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3

  • 2022-08-09 - methotrexate 4000mg/m2 7900mg 6hr D1 + rituximab 375mg/m2 744mg 8hr D3

    • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3

  • 2022-07-14 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 750mg 8hr D3

    • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3

[note]

methotrexate (https://www.uptodate.com/contents/methotrexate-drug-information 2022-07-20)

• Dosing: Adult
  • Primary CNS lymphoma, newly diagnosed (off-label use):
    • IV:
      • 8 g/m2 over 4 hours (followed by leucovorin rescue) every 14 days until complete response or a maximum of 8 cycles; if complete response, follow with 2 consolidation cycles at the same dose every 14 days (with leucovorin rescue), followed by 11 maintenance cycles of 8 g/m2 every 28 days (with leucovorin rescue) (Batchelor 2003)
    • R-MPV regimen:
      • 3.5 g/m2 over 2 hours on day 2 every 2 weeks (in combination with rituximab, vincristine, procarbazine, and leucovorin [with intra-Ommaya methotrexate 12 mg between days 5 and 12 of each cycle if positive CSF cytology]) for 5 to 7 induction cycles followed by reduced-dose whole brain radiotherapy and then cytarabine (Morris 2013; Shah 2007) or autologous stem cell transplant (Omuro 2015)
    • R-MP regimen (patients >=65 years of age):
      • 3 g/m2 over 4 hours on days 2, 16, and 30 of a 42-day cycle (in combination with rituximab, procarbazine, and leucovorin) for 3 cycles (Fritsch 2017)
    • MT-R regimen:
      • 8 g/m2 once every 2 weeks (adjusted for creatinine clearance and in combination with leucovorin, temozolomide, and rituximab) for 7 doses, then followed by high-dose consolidation chemotherapy (Rubenstein 2013)
      • 3.5 g/m2 on weeks 1, 3, 5, 7, and 9 (in combination with leucovorin, temozolomide, and rituximab), followed by whole-brain radiotherapy and then post-radiation temozolomide (Glass 2016).
• Dosing: Kidney Impairment: Adult
  • Regimen-specific dosage adjustments:
    • Primary CNS lymphoma, high dose methotrexate (usual methotrexate dose: 8 g/m2 over 4 hours with leucovorin rescue [Gerber 2007]); CrCl is measured or can be calculated using the Cockcroft-Gault equation (Gerber 2007): IV:
      • CrCl >=100 mL/minute: No methotrexate dosage adjustment necessary.
      • CrCl 50 to 99 mL/minute: Calculate dose using percentage reduction of CrCl below 100 mL/minute. Example: If CrCl is 80 mL/minute, adjust dose to 0.8 x 8 g/m2 = 6.4 g/m2.
      • CrCl <50 mL/minute: Avoid methotrexate use.

leucovorin (https://www.uptodate.com/contents/leucovorin-drug-information 2022-07-20)

• Dosing: Adult
  • Methotrexate-rescue, high-dose methotrexate:
    • Initial: Oral, IM, IV: 15 mg (~10 mg/m2); start 24 hours after beginning methotrexate infusion; continue every 6 hours for 10 doses, until methotrexate level is <0.05 micromolar. Monitor hydration and electrolyte status, as well as urine alkalinization. Adjust dose per institutional protocol or as follows:
      • Normal methotrexate elimination (serum methotrexate level ~10 micromolar at 24 hours after administration, 1 micromolar at 48 hours, and <0.2 micromolar at 72 hours):
        • Oral, IM, IV: 15 mg every 6 hours for 60 hours (10 doses) beginning 24 hours after the start of methotrexate infusion.
      • Delayed late methotrexate elimination (serum methotrexate level remaining >0.2 micromolar at 72 hours and >0.05 micromolar at 96 hours after administration):
        • Continue leucovorin calcium 15 mg (oral, IM, or IV) every 6 hours until methotrexate level is <0.05 micromolar.
      • Delayed early methotrexate elimination and/or acute renal injury (serum methotrexate level >=50 micromolar at 24 hours, or >=5 micromolar at 48 hours, or a doubling of serum creatinine level at 24 hours after methotrexate administration):
        • IV: 150 mg every 3 hours until methotrexate level is <1 micromolar, then 15 mg every 3 hours until methotrexate level is <0.05 micromolar.
  • Methotrexate overdose, inadvertent:
    • Note: Begin as soon as possible after overdose.
    • Oral, IM, IV: 10 mg/m2 every 6 hours until the methotrexate level is <0.01 micromolar. If serum creatinine is increased >50% above baseline 24 hours after methotrexate administration, if 24 hour methotrexate level is >5 micromolar, or if 48 hour methotrexate level is >0.9 micromolar, increase leucovorin dose to 100 mg/m2 IV every 3 hours until the methotrexate level is <0.01 micromolar.
  • Methotrexate overexposure, high-dose methotrexate:
    • Leucovorin nomogram dosing for high-dose methotrexate overexposure (off-label dosing; generalized dosing derived from reference nomogram figures, refer to each reference [Bleyer 1978; Bleyer 1981; Widemann 2006] or institution-specific nomogram for details):
      • At 24 hours:
        • For methotrexate levels of >=100 micromolar at ~24 hours, leucovorin calcium is initially dosed at 1,000 mg/m2 IV every 6 hours.
        • For methotrexate levels of >=10 to <100 micromolar at 24 hours, leucovorin calcium is initially dosed at 100 mg/m2 IV every 3 or 6 hours.
        • For methotrexate levels of ~1 to 10 micromolar at 24 hours, leucovorin calcium is initially dosed at 10 mg/m2 IV or orally every 3 or 6 hours.
      • At 48 hours:
        • For methotrexate levels of >=100 micromolar at 48 hours, leucovorin calcium is dosed at 1,000 mg/m2 IV every 6 hours.
        • For methotrexate levels of >=10 to <100 micromolar at 48 hours, leucovorin calcium is dosed at 100 mg/m2 IV every 3 hours.
        • For methotrexate levels of ~1 to 10 micromolar at 48 hours, leucovorin calcium is dosed at 100 mg/m2 IV every 6 hours or 10 mg/m2 IV or orally to 100 mg/m2 IV every 3 hours.
      • At 72 hours:
        • For methotrexate levels of ≥10 micromolar at 72 hours, leucovorin calcium is dosed at 100 to 1,000 mg/m2 IV every 3 to 6 hours.
        • For methotrexate levels of ~1 to 10 micromolar at 72 hours, leucovorin calcium is dosed at 10 mg/m2 IV or orally to 100 mg/m2 IV every 3 hours.
        • For methotrexate levels of ~0.1 to 1 micromolar at 72 hours, leucovorin calcium is dosed at 10 mg/m2 IV or orally every 3 to 6 hours.
      • If serum creatinine is increased >50% above baseline, increase the standard leucovorin calcium dose to 100 mg/m2 IV every 3 hours, then adjust according to methotrexate levels above.
      • Follow methotrexate levels daily, leucovorin calcium may be discontinued when methotrexate level is <0.1 micromolar.
      • Some regimens use the following equation when calculating the leucovorin calcium dose (if the methotrexate plasma concentration is >5 micromolar) (Ramsey 2018):
        • Plasma methotrexate concentration (micromolar) x body weight (kg)
• Warnings/Precautions
  • Disease-related concerns:
    • Anemias: Leucovorin is inappropriate treatment for pernicious anemia and other megaloblastic anemias secondary to a lack of vitamin B12; a hematologic remission may occur while neurologic manifestations progress.
    • Renal impairment: Leucovorin is excreted renally; the risk for toxicities may be increased in patients with renal impairment.
  • Concurrent drug therapy issues:
    • Fluorouracil: Leucovorin may increase the toxicity of 5-fluorouracil; deaths from severe enterocolitis, diarrhea, and dehydration have been reported (in elderly patients); granulocytopenia and fever have also been reported.
    • Sulfamethoxazole-trimethoprim: The combination of leucovorin and sulfamethoxazole-trimethoprim for the acute treatment of Pneumocystis jirovecii pneumonia in patients with HIV infection has been reported to cause increased rates of treatment failure.
  • Other warnings and precautions:
    • Folic acid antagonist overdose: When used for the treatment of accidental folic acid antagonist overdose, administer as soon as possible.
    • Methanol toxicity: Leucovorin is the reduced form of folic acid; leucovorin is rapidly converted to tetrahydrofolic acid derivatives, which are the storage forms of folate in the body. Because leucovorin does not require metabolic reduction, it is the preferred form of folate in the treatment of methanol toxicity. Administration during methanol toxicity is especially important in patients with chronic alcohol use disorder as these patients may have chronic folate deficiency. Clinicians should note that leucovorin is an adjunctive therapy and should never be used as the sole intervention in the management of methanol toxicity (AACT [Barceloux 2002]).
    • Methotrexate overdose: When used for the treatment of a methotrexate overdose, administer IV leucovorin as soon as possible. Monitoring of the serum methotrexate concentration is essential to determine the optimal dose/duration of leucovorin; however, do not wait for the results of a methotrexate level before initiating leucovorin. It is important to adjust the leucovorin dose once a methotrexate level is known. The dose may need to be increased or administration prolonged in situations in which methotrexate excretion may be delayed (eg, ascites, pleural effusion, renal insufficiency, inadequate hydration). Never administer leucovorin intrathecally.
    • Methotrexate rescue therapy: Methotrexate serum concentrations should be monitored to determine dose and duration of leucovorin therapy. Dose may need to be increased or administration prolonged in situations where methotrexate excretion may be delayed (eg, ascites, pleural effusion, renal insufficiency, inadequate hydration). Never administer leucovorin intrathecally.

[assessment]

• The patient’s height is 175cm, weight is 80kg, and his lab results from 2023-03-20 showed serum Cre 1.38mg/dL, eGFR 56.65, and CrCl 63~68mL/min.
• The recommended dosing for methotrexate in adult patients with CNS lymphoma whose CrCl is 50 to 99 mL/minute is to calculate the dose using the percentage reduction of CrCl below 100 mL/minute. For example, if CrCl is 65 mL/minute, the dose should be adjusted to 0.65 x 8 g/m2 = 5.2 g/m2.

230220

[assessment]

• The patient’s serum creatinine levels have decreased to nearly the upper limit of normal.
  • 2023-02-02 Creatinine 1.30 mg/dL
    
  • 2023-01-20 Creatinine 1.54 mg/dL
    
  • 2023-01-16 Creatinine 1.41 mg/dL
    
  • 2023-01-13 Creatinine 1.95 mg/dL
    
  • 2023-01-10 Creatinine 2.09 mg/dL
    
  • 2023-01-09 Creatinine 2.02 mg/dL
    
  • 2023-01-08 Creatinine 1.99 mg/dL
    
  • 2023-01-07 Creatinine 1.36 mg/dL
    
  • 2023-01-06 Creatinine 1.01 mg/dL

230110

[assessment]

• Methotrexate induced acute renal failure is typically nonoliguric and is reversible in almost all cases. Plasma creatinine levels usually peak within the first week and return toward baseline levels within 1 to 3 weeks. The patient’s renal function is decreasing at a much slower rate over time, which is a positive sign that creatinine almost reaches its peak level.

  • 2023-01-10 Creatinine 2.09 mg/dL
    
  • 2023-01-09 Creatinine 2.02 mg/dL
    
  • 2023-01-08 Creatinine 1.99 mg/dL
    
  • 2023-01-07 Creatinine 1.36 mg/dL
    
  • 2023-01-06 Creatinine 1.01 mg/dL
    
  • 2023-01-10 eGFR 35.09
    
  • 2023-01-09 eGFR 36.50
    
  • 2023-01-08 eGFR 37.13
    
  • 2023-01-07 eGFR 57.61
    
  • 2023-01-06 eGFR 81.22
    
  • 2023-01-10 BUN 27 mg/dL
    
  • 2023-01-09 BUN 27 mg/dL
    
  • 2023-01-08 BUN 26 mg/dL
    
  • 2023-01-07 BUN 21 mg/dL
    
  • 2023-01-06 BUN 17 mg/dL

• The likelihood of MTX-induced renal dysfunction in patients receiving high dose MTX can be minimized (but not eliminated) by hydration both to maintain a high urine flow and to lower the concentration of MTX in the tubular fluid and by alkalinization of the urine to a pH above 7.0. Raising the urine pH from 5.0 to 7.0 increases the solubility of MTX 10-fold.

• It is customary to begin the MTX infusion only after the urine pH is >= 7.0 and to maintain it in this range until plasma MTX levels have declined to less than 0.1 microM.

• Urinary alkalinization is most easily accomplished by adding ampules of sodium bicarbonate to each liter of IV fluid hydration. This accomplishes both fluid hydration and urinary alkalinization. A typical choice is IV D5W with 100 to 150 mEq of sodium bicarbonate per liter, administered by continuous infusion at 125 to 150 mL/hour. A cation concentration of 80.5 mEq/L is roughly equivalent to one-half normal saline. The amount of bicarbonate in each liter and the IV fluid composition can then be modified according to the urine pH and serum sodium.

• An alternative oral protocol for sodium bicarbonate can be started with 3000 mg (300mg/tab * 10 tablets) Q6H, and can be escalated the frequency to Q4H as needed; once the urine pH is greater than 7, the 24 hour daily dose can then be lowered and divided into four doses, every six hours.

230109

[assessment]

• Lab data indicated that the patient’s renal function is deterioating

  • 2023-01-09 Creatinine 2.02 mg/dL
    
  • 2023-01-08 Creatinine 1.99 mg/dL
    
  • 2023-01-07 Creatinine 1.36 mg/dL
    
  • 2023-01-06 Creatinine 1.01 mg/dL
    
  • 2023-01-09 eGFR 36.50
    
  • 2023-01-08 eGFR 37.13
    
  • 2023-01-07 eGFR 57.61
    
  • 2023-01-06 eGFR 81.22
    
  • 2023-01-09 BUN 27 mg/dL
    
  • 2023-01-08 BUN 26 mg/dL
    
  • 2023-01-07 BUN 21 mg/dL
    
  • 2023-01-06 BUN 17 mg/dL

• In this male patient, who is 56 y/o, Cre 2.02 mg/dL and weighs 82 kg, the estimated CrCl is 47 mL/min. The self-carried Baraclude (entecavir) for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours. QODAC is preferred.

• Methotrexate is greater 80% excreted as the unchanged drug and is primarily excreted in the urine. Leucovorin 100mg IVD Q6H has been administered since 2023-01-08 06:05.

• Serum MTX levels are declining at an apparent rate.

  • 2023-01-08 22:39 3.549 umol/L
  • 2023-01-07 22:36 17.473 umol/L
    • ref Toxic:
      • 24 hr > 10 umol/L
      • 48 hr > 1 umol/L
      • 72 hr > 0.1 umol/L

• If the patient is still able to urinate normally, furosemide may be an option for helping the excretion of methotrexate. For patients with an eGFR greater than 30 mL/minute/1.73m2, furosemide does not require dosage adjustment.

220720

[assessment]

• The dosage of leucovorin 200mg Q6H used immediately following methotrexate has been adjusted to 400mg Q6H as of 2022-07-20. Leucovorin is excreted renally, however there are no dosage adjustments provided in manufacturer’s labeling for kidney impairment patients.
• Items in the active prescription that should be addressed if kidney function is altered.
  • Keppra (levetiracetam)
    • The manufacturer’s labeling recommends estimating CrCl using the Cockcroft-Gault formula adjusted for BSA as follows: CrCl (mL/minute/1.73 m2) = CrCl (mL/minute)/BSA (m2) x 1.73.
      • CrCl 80 to 130 mL/minute/1.73 m2: 500 mg to 1.5 g every 12 hours.
      • CrCl 50 to <80 mL/minute/1.73 m2: 500 mg to 1 g every 12 hours.
      • CrCl 30 to <50 mL/minute/1.73 m2: 250 to 750 mg every 12 hours.
      • CrCl 15 to <30 mL/minute/1.73 m2: 250 to 500 mg every 12 hours.
      • CrCl <15 mL/minute/1.73 m2: 250 to 500 mg every 24 hours (expert opinion).
  • Baraclude (entecavir)
    • Daily-dosage regimen preferred.
      • CrCl >=50 mL/minute: No dosage adjustment necessary.
      • CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours.
      • CrCl 10 to <30 mL/minute: Administer 30% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 72 hours.
      • CrCl <10 mL/minute: Administer 10% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 7 days.
  • Furosemide
    • eGFR >30 mL/minute/1.73 m2: No dosage adjustment necessary.
    • eGFR <=30 mL/minute/1.73 m2: Higher doses may be required to achieve desired diuretic response due to decreased secretion into the tubular fluid. However, single doses >160 to 200 mg IV (or oral equivalent) are unlikely to result in additional diuretic effect (Brater 2011).
• CrCl is 10 mL/min and eGFR is 7 mL/min for this patient based on Cockcroft-Gault formula, CKD-EPI equation and 2022-02-20 updated lab data.

701469357

230320

[lab data]

2023-03-17 Anti-HBc Nonreactive
2023-03-17 Anti-HBc-Value 0.18 S/CO
2023-03-17 Anti-HCV Nonreactive
2023-03-17 Anti-HCV Value 0.17 S/CO
2023-02-03 Anti-HCV Nonreactive
2023-02-03 Anti-HCV Value 0.10 S/CO
2023-02-03 HBsAg Nonreactive
2023-02-03 HBsAg (Value) 0.49 S/CO
2023-02-03 Anti-HBs 1.12 mIU/mL
2023-02-02 MTBC PCR NOT DETECTED
2023-02-02 MTBC PCR Value <11.8 CFU/ml

[exam findings]

• 2023-03-12 CT - abdomen
  • Clinical history: 51 y/o male patient with cough, headache, chills, fever since this morning, mild nausea, loose stool
  • With and without contrast enhancement CT of abdomen - whole:
    • S/P feeding jejunostomy.
    • Thickening wall at the middle/distal third esophagus, c/w esophageal cancer, with ulceration at left lateral wall with adjacent lung consolidation.
    • Left pleural effusion.
    • There are enlarged lymph nodes in bilateral SCF, pretracheal, subcarina, around GE junction, r/o metastatic lymph nodes.
    • Left renal cyst, 0.8cm.
    • Unremarkable change of the liver, spleen, pancreas and right kidney.
  • Impression:
    • S/P feeding jejunostomy.
    • Esophageal cancer with ulceration and adjacent left lung consolidations, left pleural effusion.
    • Multiple metastatic lymph nodes in lower neck, mediastinum and upper abdomen.
• 2023-03-12 CXR
  • S/P port-A insertion via left subclavian vein.
  • Increased bilateral lung markings.
  • No cardiomegaly.
  • Thoracic spondylosis.
• 2023-02-17 Patho - gingival/oral mucosa biopsy
  • Diagnosis:
    • Uvula, wide excision (S2023-2822A) with frozen section (F2023-65) — poorly differentiated carcinoma and sarcomatoid carcinoma.
    • Hypopharyngeal tumor, wide excision (S2023-2822B) — squamous cell carcinoma in situ (CIS), < 1 mm from unspecified margin.
    • Uvula: pT1 pNx (if cM 0); pStage: I.
    • Hypopharynx: pTis pNx (if cM0); pStage: 0.
  • Macroscopic examination
    • Surgical Procedure(s): uvula: wide excision with frozen section. Hypopharynx: wide excision.
    • Specimen Type:
      • Main location: S2023-2822A: uvula; B: hypopharynx.
      • Other part(s) included: F2023-00065A: posterior margin; B: anterior margin.
      • Lymph node dissection: no.
    • Specimen Integrity: intact
  • Microscopic examination
    • Histologic Type: 01: uvular tumor: poorly differentiated carcinoma and sarcomatoid carcinoma. 02. hypopharyngeal tumor: carcinoma in situ (CIS).
    • Histologic Grade: 01: uvular tumor: G3: Poorly differentiated
    • Microscopic Tumor Extension: (specify) submucosa.
    • Margins (obtained from the main resection specimen):
      • Margins uninvolved by invasive carcinoma, uvular tumor:
        • Distance from closest margin: gin and posterior margin. 4 mm. Anterior margin and posterior margin. NOTE: This distance does not include the size of frozen section specimens.
      • Margins uninvolved by squamous cell carcinoma in situ (left hypopharynx)
        • Distance from closest margin: 1 mm. Unspecified margin
    • Lymph-Vascular Invasion: not identified
    • Perineural Invasion: not identified
    • Neck Lymph Nodes: no lymph node submitted.
• 2023-02-11 MRI - larynx
  • p16(+) Oropharnx
    • Impression (Imaging stage): T: 0(T_value) N: 2c(N_value) M: 0(M_value) STAGE: IVA(Stage_value)
• 2023-02-08 Nasopharyngoscopy
  • whitish lesion over posterior side of uvula, smooth NPx, granular lesion over left hypopharynx
• 2023-02-04 MRI - brain
  • MRI of the brain in multiplanar projections, multisequences imaging acquisition without and with IV Gd-DTPA administration shows:
  • Imp: No brain nodule or metastasis. Mild cortical brain atrophy.
• 2023-02-04 Pure Tone Audiometry
  • PTA:
    • Reliability FAIR
    • Average RE 38 dB HL, LE 43 dB HL
    • Bil normal to moderatly severe SNHL
• 2023-02-03 Whole body PET scan
  • Glucose hypermetabolism involving the middle to lower portions of the esophagus, compatible with primary esophageal malignancy.
  • Glucose hypermetabolism in a left upper paratracheal lymph node, some bilateral supraclavicular lymph nodes and a lymph node in the upper abdomen near EG junction. Metastatic lymph nodes may show this picture.
  • Mild glucose hypermetabolism in a focal area in the middle lobe of right lung. Inflammation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Glucose hypermetabolism in the uvula, hypopharynx, nasopharynx, bilateral parotid glands, some bilateral upper neck lymph nodes, soft palate and bilateral tonsils. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
• 2023-02-02 Tc-99m MDP whole body bone scan
  • Increased activity in the lower T-spines and L4-5 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
• 2023-02-02 Patho - larynx biopsy
  • Labeled as “hypopharynx”, biopsy — squamous cell carcinoma in situ (CIS).
• 2023-02-02 Patho - nasopharyngeal/oropharyngeal biopsy
  • Labeled as “uvula”, bronchoscopic biopsy — Sarcomatoid carcinoma.
  • Section shows diffuse infiltration of spindle shaped neoplastic cells.
  • IHC stain: Vimentin (diffuse +), CK (focal +), p16 (-).
• 2023-02-01 Patho - esophageal biopsy
  • Soft palate, left, biopsy — Squamous cell carcinoma in situ
• 2023-02-01 Cardiopulmonary Exercise Testing
  • summary:
    • low exercise capacity ( VO2 75%, WR 76%)
    • low stroke volume response during exercise
    • normal HR response slope
    • normal ventilatory function ( FVC 102%, FEV1 94%)
    • No SpO2 desaturation during exercise
    • Poor expiratory muscle strength (MIP 77%, MEP 51%)
    • Health-related quality of life, CAT= 0, good
  • suggestions:
    • treat underlying condition
    • for low stroke volume response, suggest to intake adequate fluid, may survey cardiac function
    • arrange pulmonary rehab with exercise training after operation
    • low risk for operation
• 2023-01-30 CT - chest
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2023-01-30 Patho - esophageal biopsy
  • Esophagus, 30 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated (G2)
  • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation and tumor necrosis are evident.
• 2023-01-28 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Highly suspected esophageal cancer, M-L/3, s/p biopsy
    • Incomplete study
  • Suggestion
    • Admission for parenteral nutrition and staging.
    • Watch out for refeeding syndrome.

[radiotherapy]

[chemotherapy]

• 2023-03-16 - cisplatin 80mg/m2 130mg NS 500mL 4hr + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-2 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

701473264

230316

[drug interaction]

• Histamine H2 Receptor Antagonists may decrease the absorption of dasatinib. Dasatinib prescribing information states histamine H2 receptor antagonists (H2RAs) should not be coadministered with dasatinib due to the risk of reduced dasatinib concentrations and efficacy. Given the longer-term acid suppression achieved with H2-antagonist or proton pump inhibitor therapy, the manufacturer suggests the use of antacids (with 2-hour dose separation) if acid-reducing therapy is required. The likely mechanism for this apparent interaction is impaired absorption of dasatinib, which does appear to display pH-sensitive solubility, due to the increase in gastric pH caused by a H2-receptor antagonist.

• Currently, the patient is prescribed Sprycel (dasatinib) and Ulstop (famotidine) with a QD and BID frequency, respectively. These medications are being administered at the same time of 09:00. To prevent any potential drug interactions, it is recommended to shift the administration time of one of the medications to a time that does not overlap with the other medication.

700180610

230315

[exam findings]

• 2023-02-20 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (76 - 29) / 76 = 61.84%
    • M-mode (Teichholz) = 61
  • Adequate LV systolic function with normal resting wall motion
  • Trivial MR and trivial TR
  • Preserved RV systolic function
• 2023-02-01 whole body bone scan with SPECT
  • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, some T- and L-spine, bilateral shoulders, S-I joints, and hips, in whole body survey.
  • IMPRESSION:
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, S-I joints, and hips.
• 2023-01-30 Her-2/neu in situ hybridization
  • RESULT OF HER2/NEU IN SITU HYBRIDIZATION: BREAST
    • Negative: There is NO amplification of HER2 detected
    • METHOD AND DETAILS:
      • Number of observers: 1
      • Number of invasive tumor cells counted: 20
      • Average number of HER2 gene copy signal per cell: 1.8
      • Average number of CEP17 gene copy signal per cell: 2
      • HER2/CEP17 ratio: 0.9
      • Heterogeneous signals: Absent
      • Origin slide and block number: S2023-1401
      • Specimen: Formalin-fixed paraffin embedded breast tumor
      • Adequacy of sample for evaluation: Yes
      • Method of in situ hydridization: CISH (Ventana HER2 dual ISH DNA probe cocktail assay, Roche compancy)
    • INTERPRETATION CRITERIA (ASCO/CAP scoring criteria 2018)
      • Amplified:
        • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number >=4.0
        • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=6.0 signals/cell
      • Not amplified:
        • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number <4.0
        • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=4.0 and <6.0 signals/cell
        • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number <4.0
  • RESULT OF HER2/NEU IN SITU HYBRIDIZATION : LYMPH NODE
    • Negative: There is NO amplification of HER2 detected
    • METHOD AND DETAILS:
      • Number of observers: 1
      • Number of invasive tumor cells counted: 20
      • Average number of HER2 gene copy signal per cell: 1.8
      • Average number of CEP17 gene copy signal per cell: 2
      • HER2/CEP17 ratio: 0.9
      • Heterogeneous signals: Absent
      • Origin slide and block number:S2023-1402
      • Specimen: Formalin-fixed paraffin embedded breast tumor
      • Adequacy of sample for evaluation: Yes
      • Method of in situ hydridization: CISH (Ventana HER2 dual ISH DNA probe cocktail assay, Roche compancy)
    • INTERPRETATION CRITERIA (ASCO/CAP scoring criteria 2018)
      • Amplified:
        • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number >=4.0
        • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=6.0 signals/cell
      • Not amplified:
        • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number <4.0
        • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=4.0 and <6.0 signals/cell
        • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number <4.0
• 2023-01-30 Patho - breast biopsy (no need margin)
  • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • IHC stains (using block: S2023-1401): ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: equivocal (score=2+), Ki-67(50%), E-cadherin (+). An additional report of Her2 DISH will be followed.
• 2023-01-30 Patho - lymphnode biopsy
  • Lymph node, right axillary, core biopsy — Invasive carcinoma, no special type, NST.
  • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.
  • IHC stains (using block: S2023-1401): ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: equivocal (score=2+), Ki-67(50%), E-cadherin (+). An additional report of Her2 DISH will be followed.
• 2023-01-30 CT - chest
  • Indication: Unspecified lump in breast
  • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images, and oblique sagittal reconstructed images of the Rt breast shows:
    • chest wall: a large Rt breast solid soft-tissue tumor (93mm in longest axial dimension) with surrounding linear opacities (lymphatic drainage) and skin involvement, and many metastatic lymph nodes at Rt axilla.
    • Lungs: normal appearance of bilateral lungs.
    • Mediastinum and hila: no enlarged LN or mass.
      • the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
    • Visible abdominal contents: a low density focus (24mm) in the uterus, cystic lesion or necrotic myeoma.
      • mltiple stones with collapsed gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • no enlarged lymph node. no ascites..
    • Visualized bones: unremarkable.
  • Impression:
    • Rt breast cancer with Rt axillary LNs metastasis T4N1
• 2023-01-20 SONO - breast
  • Findings
    • Parenchymal pattem
      • Loosely (inhomogeneously) sonodense
    • Focal sonographic lesion
      • right breast huge tumor, with skin involvement, heteogenous, > 10cm, favor malignancy
      • LAP(+)
  • Diagnosis
    • Highly suspicious of malignancy,with sonographic positive axillary LAP
  • Treatment
    • Core-needle biopsy
  • Suggestion and Plan
    • Regular OPD follow-up
    • BI-RADS 5 - Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken

[chemotherapy]

• 2023-03-14 - doxorubicin 60mg/m2 100mg NS 100mL 10min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-20 - doxorubicin 60mg/m2 100mg NS 100mL 10min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

Granocyte (lenograstim 250ug/vial) CGRAN01 - 2023-03-02 ~ 2023-03-04 - 250ug QD SC - IPD 2023-03-02

[assessment]

• On 2023-01-30, the Her-2/neu in situ hybridization results indicated a negative status for both breast and lymph nodes.
• On 2023-03-02, a grade 4 neutropenia event was observed in the patient with a WBC count of 930/uL and Neutrophil count of 18%. Following the administration of three consecutive days of lenograstim since that day, no further episodes of neutropenia have been observed up to the present time.
• Please prescribe Baraclude (entecavir) 0.5mg tablets, one tablet daily, for the patient’s underlying hepatitis B virus infection.

700541242

230315

{Malignant neoplasm of body of stomach; gastric antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy}

[diagnosis] - 2023-02-04 discharge note

• Gastric  antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy
• Hepatits B, anti-HBC:positive

[past history]

• Hypertension
• right shoulder s/p operation 7+ years ago at NTUH                                        

[allergy]

• NKDA                             

[family history]

• Denied family history of cancer and mental diseases.
• No members of the family with diabetes.  

[exam findings]

• 2023-01-25 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • S/p port-A placement with its tip at left brachiocephalic vein
  • Emphysematous change over both lungs.
  • Osteopenia of the bony structure is noted.
• 2023-01-25 CT - abdomen
  • s/p subtotal gastrectomy.
  • Minimal ascites in the abdominal cavity is found.
• 2023-01-25 ECG
  • Normal sinus rhythm
  • Nonspecific T wave abnormality
  • Abnormal ECG
• 2023-01-02 CT - abdomen
  • History and indication: gastric cancer wt peritoneal seeing, pT4aN0M1, stage IV
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P gastric operation.
    • Bronchiectasis at RML, RLL and LLL.
    • Retroversion of uterus.
    • Atherosclerosis of aorta.
  • IMP:
    • S/P gastric operation. No evidence of tumor recurrence.
    • Bronchiectasis at RML, RLL and LLL.
  • 2023-01-02 CXR
    • Borderline cardiomegaly
    • Scoliosis of the T-spine with convex to right side.
  • 2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30 Body fluid cytology - ascites and others
    • Negative
  • 2022-08-01, -07-29, -07-27, -07-26, -07-24 CXR
    • Ground glass opacities in bil. lungs.
  • 2022-07-24 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Suboptimal study due to much blood and blood clot were noted upon entering stomach.
      • Post subtotal gastrectomy with Billroth II anastomosis
      • Suspicious gastrojejunal anastomosis site ulcers, Forrest calssification IIa and Ib, s/p hemostasis with submucosal epinephrine injection and clipping
    • Suggestion
      • NPO
      • High dose PPI use
      • suggest second-look endoscopy
  • 2022-07-20 CXR
    • Pneumoperitoneum.
    • Right catheterization to SVC in position.
    • Left catheterization to SVC in position.
    • S/P NG tube indwelling.
    • Ground glass opacity in bilateral lower lungs and RUL.
    • Blunted bilateral costophrenic angles.
  • 2022-07-19 Patho - stomach subtotal/total
    • pathologic diagnosis
      • Stomach, subtotal gastrectomy — Poorly cohesive carcinoma, signet-ring cell type
      • Margins, bilateral cutting ends, subtotal gastrectomy — Free of tumor invasion
      • Lymph nodes, D2 LN dissection — Negative for malignancy (0/47)
      • Omentum, subtotal gastrectomy — Metastatic carcinoma
      • AJCC Pathologic staging — pT4aN0M1, stage IV
    • microscopic examination
      • Histologic type: Poorly cohesive carcinoma, signet-ring cell type (Lauren classification: diffuse type)
      • Histologic grade: Poorly differentiation (G3)
      • Depth of tumor invasion: Tumor invades the serosa
      • Margins: All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 2 mm from radial margin
      • Perineural invasion: Present
      • Lymphovascular space invasion: Absent
      • Regional lymph nodes: Negative for malignancy (0/47)
        • 0/7 (LN 1), 0/7 (LN 3), 0/1 (LN 4), 0/3 (LN 5), 0/3 (LN 6), 0/26 (LN 7, 8, 9, 11p, 12a), 0 (LN14v) (Number of LN involved/Number of LN examined)
      • Duodenum: Involved by carcinoma
      • Omentum: Metastatic carcinoma
      • Additional pathologic findings: Reactive gastropathy
      • Pathologic Staging: pT4aN0M1 (stage IV)
      • IHC (S2022-10770): HER2 (negative, score=1+)
      • Ascites Cytology: Negative
  • 2022-07-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (91.5 - 28.5) / 91.5 = 68.85%
      • Normal chamber size
      • Adequate LV and RV systolic function
      • AV sclerosis with trivial AR, trivial MR, TR and PR
      • No regional wall motion abnormalities
  • 2022-07-08 Double contrast upper GI series
    • Findings
      • Normal appearance of the esophagus.
      • There is no evidence of abnormal mucosal pattern at the stomach.
      • Intact EG junction.
      • The gastric angle is intact.
      • Decreased peristasis with poorly opacified gastric pylorous.
    • Imp:
      • Decreased peristasis with poorly opacified gastric pylorous.
  • 2022-07-07 MRI - upper abdomen
    • Suboptimal study due to motion.
    • Hepatic hemangioma. S4/8
    • Enhanced mucosa at gastric pylorous is found. Nature?
  • 2022-07-07 Patho - stomach biopsy
    • Stomach, pyloric ring, biopsy — Poorly cohesive carcinoma with signet-ring cell differentiation
    • Microscopically, the sections show a picture of poorly cohesive carcinoma with signet-ring cell differentiation characterized by individual tumor cells infiltratiion. Immunohistochemistry of CK(+) and Her2 (-, Dako score 1+) for tumor. Besides, mild intestinal metaplasia is also noted.
  • 2022-07-06 SONO - abdomen
    • Diagnosis: Hepatic hemangima, right lobe
  • 2022-07-06 Esophagogastroduodenoscopy, EGD
    • Esophagus: Confluent mucosal breaks more than 75% with fagile mucosa and superficial ulcers were noted from EC junctiob to 25cm below the incisors.
    • Stomach: Upon entry, much food debris was noted in stomach. Mucosal swelling was noted at pylori ring, causing pylori stricture that the scope could not pass through. Biopsy *6 was performed the pylori ring.
    • Duodenum: Not checked
    • Diagnosis
      • Incomplete study
      • Reflux esophagitis, LA D, with ulcers formation, suspected vomiting related
      • Pylori stricture, s/p biopsy
    • Suggestion
      • Please pursue pathology report
  • 2022-07-05 CT - abdomen
    • Addendum Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T4a(T_value) N:N1(N_value) M:M0(M_value) STAGE:III(Stage_value)
  • 2022-07-05 ECG
    • Normal sinus rhythm
    • ST & T wave abnormality, consider inferior ischemia
    • ST & T wave abnormality, consider anterolateral ischemia
    • Prolonged QT

[consultation]

• 2022-07-13 General and Gastrointestinal Surgery
  • Q
    • This 69 years old female has the history of hypertension
    • This time, she came to ER for persisit vomit with dizzness in recently 2 weeks, she ver been to LMD but invain. She denied fever or chills, dyspnea or chest pain , abdomen pain, tarry or bloody stool passage recently. She also denied TOCC history.
    • At ER, physical exammination revealed abdomen soft without tenderness and acitve bowel sound. Lab data showed impaird renal function, hyponatremia hypokalemia and the Non-contrast CT of abdomen-pelvis revealed: Bronchiectasis at RML, RLL and LLL. Distention of stomach and dilatation of esophagus. Retroversion of uterus. Initial NG was placed at ER and coffee ground was noted and gastric juice showed OB 3+. KCAL fluid was given to correct hypokalemia. Under the impresion of Vomit, hypokalemia, she was admitted to GI wrd for further management.
      
    • EGD was perfromed and reported Incomplete study Reflux esophagitis, LA D, with ulcers formation, suspected vomiting related Pylori stricture, s/p biopsy. The pathology reported Poorly cohesive carcinoma with signet-ring cell differentiation. we need your expertise. Thanks~
  • A
    • please arrange heat echo for pre-op survey
    • TPN for nutrition support
    • we will take over for this case
    • further operation will arrange on next week

[surgical operation]

• 2022-07-18 Radical subtotal gastrectomy and B-II gastrojejunostomy
  • Tumor visible at antrum at lesser curvature of antrum
  • Ring-like tumor about 3cm width at pyloric antrum
  • cT4aN1M0

[chemoimmunotherapy]

• 2023-02-21 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + leucovorin 400mg/m2 470mg NS 250mL 2hr + fluorouracil 2000mg/m2 2350mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-02 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2000mg/m2 2300mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

  • 2023-01-09 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr

    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg

  • 2022-12-22 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2400mg/m2 2840mg 46hr

    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg

  • 2022-12-08 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr

    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg

  • 2022-11-17 - oxaliplatin 40mg/m2 47mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2360mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg

  • 2022-10-25 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2370mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg

  • 2022-09-13 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg

  • 2022-08-30 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg

  • 2022-08-08 - mitomycin-C 15mg/m2 20mg 2hr D2-3 + [fluorouracil 500mg/m2 645mg IP 1hr D1-5 + gentamicin 40mg IP 1hr D1-5 + sodium bicarbonate 2800mg IP 1hr D1-5]

[assessment]

• According to available lab data since 2022-07-05 in HIS5, the patient has experienced frequent occurrences of hyponatremia, hypopotassemia, hypokalemia, and hypomagnesemia. However, during the same time frame, there have been few instances of hyper- or hypophosphatemia.

• The patient began receiving FOLFOX treatment in August 2022, and the use of carboplatin in this treatment regimen can be associated with hyponatremia, hypokalemia, hypomagnesemia, and hypocalcemia.

• It is recommended to continue monitoring the patient’s electrolyte levels and prescribe supplements as needed. If it becomes challenging to maintain a balance of electrolytes through supplementation, it may be necessary to consider reducing the dose of carboplatin or switching to a different regimen.

230222

[assessment]

• A low serum magnesium level of 1.6mg/dL (2023-02-21) has been observed, and the patient has been prescribed MgSO4 injections and MgO tablets appropriately.
• Apart from hypomanesia, the patient’s other laboratory readings were within normal limits, and their vital signs have remained stable throughout this hospitalization.

230110

[assessment]

• There has been a frequent low level of magnesium in the patient’s blood for months, this hospital currently has only magnesium oxide tablets available for oral administration, so it is recommended to continue prescribing MgO when he is discharged.

• MgO should be taken with food and at least 240mL of water (absorption: oral up to 30%). Patients might be educated that whole grains, legumes, and dark-green leafy vegetables are dietary sources of magnesium.

221209

[assessment]

• As multiple body fluid (primarily ascites) cytological studies (2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30) did not reveal evidence of malignancy, intraperitoneal chemotherapy was discontinued while systemic FOLFOX is continued.

• The lab serum magnesium levels indicated a frequent deficiency of serum magnesium in this patient.

  • 2022-12-08 Mg (Magnesium) 1.4 mg/dL
    
  • 2022-11-16 Mg (Magnesium) 1.7 mg/dL
    
  • 2022-10-17 Mg (Magnesium) 2.0 mg/dL
    
  • 2022-10-14 Mg (Magnesium) 1.5 mg/dL
    
  • 2022-10-11 Mg (Magnesium) 1.8 mg/dL
    
  • 2022-10-03 Mg (Magnesium) 1.8 mg/dL

• For the magnesium sulfate prescription will expire on the weekend, a lab data renewal may assist in determining whether the magnesium supplement should continue to be administered.

221026

[assessment]

• Body weight has decreased by almost 10 kg in the last 3 months (33.1kg 2022-10-25 <- 42.8kg 2022-07-27 gastrectomized), and a low albumin level (3.2 g/dL 2022-10-25) could indicate malnutrition. Long-term survival may be adversely affected by malnutrition after gastrectomy for gastric cancer (ref: Impact of Malnutrition After Gastrectomy for Gastric Cancer on Long-Term Survival. Ann Surg Oncol. 2018;25(4):974-983. doi:10.1245/s10434-018-6342-8)

• It is advisable to begin strict nutritional follow-up as soon as possible after surgery in order to prevent a sharp weight loss in the early postoperative phase when most of the dietary problems arise.

• Vitamin B12 injections might be required, as well as multivitamins and minerals.

• As this patient’s weight is approximately equivalent to that of a ten-year-old child, the dosage might need to be adjusted accordingly.

220913

[drug interaction]

• Metoclopramide might enhance the CNS depressant effect of lorazepam. The patient should be monitored for signs of increased CNS depressant effects (e.g. somnolence, drowsiness).

700909334

230315

[diagnosis]

• Malignant neoplasm of overlapping sites of corpus uteri
• Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV with obstructive Lt lung collapse; ECOG = 3.
• Secondary malignant neoplasm of retroperitoneum and peritoneum
• Thalassemia, unspecified
• Gastrointestinal hemorrhage, unspecified
• Allergy, unspecified, initial encounter
• Dysthymic disorder
• Insomnia due to other mental disorder
• Constipation, unspecified
• Chronic viral hepatitis B without delta-agent

[past history]

• uterus leiomyosarcoma with bone meta, liver and lung metastases s/p OP, pazopanib target therapy with progression and chemotherapy (cisplatin and ifosphamide).
• Metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilaterla salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence, status post transvaginal tumor excision on 2017/12/25 status post 6 courses of adjuvant chemotherapy with Paclitaxel plus Carboplatin (20180105~0430) with lung metastases and bone metastases, status post 5 courses of chemotherapy with Cisplatin, Ifosfamide and Mensna (20211110~1224) at Tri-service General Hospital, under current radiation therapy.
• Gastro-esophageal reflux disease with esophagitis, LA grade D
• Thalassemia
• Positive infection of COVID-19 on 2022/05/16

[exam findings]

• 2023-03-09 CT - brain
  • Clinical information: This 62 y/o female patient has the history of metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence
  • Cranial CT scans from the vertex to the mid-maxillary level were performed with i.v. contrast injection.
  • Impression:
    • One enhancing nodular lesion (7mm) over right parietal lobe, favor a metastatic lesion.
    • The size of the lateral and third ventricles appears normal.
    • The posterior structures including the brain stem, cerebellum and CP angles look normal.
• 2023-02-08 CTA - chest
  • Indication: Malignant neoplasm of overlapping site
  • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images and coronal slab MIP PA images shows:
  • Comparison was made with previous CT dated on 2022/12/08
    • Lungs: extensive heterogeneous consolidation with air-bronchograms at left perihilar lung region and multiple randomly distributed pulmonary nodules of varying sizes due to metastases.
    • Mediastinum and hila: enlarged LNs in the Rt hilum and intrapulominary LLL.
    • Aorta: normal caliber of thoracic aorta.
    • Central pulmonary arteries: normal caliber and well opacification
    • Heart: normal in size of cardiac chambers.
    • Pleura: small Lt effusion extending to major fissure, Rt pleural metastasis and thickening.
    • Chest wall and visible lower neck: unremarkable.
    • Visible abdominal-pelvic contents:
      • multiple large metastatic hepatic tumors, small metastatic tumors at left kidney and Rt adrenal gland, and a large metastatic tumor at RUQ of abdomial cavity. a large tumor at pelvic cavity involving adjacent organs.
      • small ascites is visible.
  • Impression: Leiomyosarcoma of uterus with multiple sites of metastases, in progression as compared with the previous CT on 2022/12/08
• 2023-02-08 CXR
  • Extensive heterogeneous consolidation in left perihilar lung region and multiple randomly distributed pulmonary nodules of varying sizes due to metastases
  • Port-A catheter inserted into superior RA via left subclavian vein.
  • Diffuse hepatomegaly.
  • Normal heart size.
• 2023-02-02 CXR
  • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
  • S/P metalic autosuture at left lower lung.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
• 2023-01-25 CXR
  • Cardiomegaly is noted.
  • S/p port-A placement with its tip at Superior vena cava.
  • Mass like lesion at left upper lobe with nodular lesions at both lungs is found.
• 2023-01-04
  • A nodular opacity projecting in the left upper lung is suspected. Please correlate with CT.
  • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
  • S/P metalic autosuture at left lower lung.
• 2022-12-13
  • Multiple nodules at bil. lungs.
  • Patch density at LUL.
• 2022-12-08 CT - chest
  • Indication: Leiomyosarcoma s/p C/T
  • Chest and Abdominal CT with and without enhancement revealed:
    • Chest:
      • S/p port-A placement with its tip at Superior vena cava.
      • Nodular lesions at both lungs up to 3.6cm at right lower lobe is found. In comparison with CT dated on 2021-09-21, the lesion enlarged.
      • Left hilar infiltration is found.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • s/p ATH and BSO.
      • Soft tissue nodule at right pelvic side wall up to 4.6cm in largest dimension. In progression.
      • Soft tissue mass near uncinate process of the pancreas is found. The lesion enlarged.
      • Low density lesions at both lobes of liver up to 6.4cm in largest dimension is found. In enlargement.
      • The urinary bladder is well distended without soft tissue lesion.
      • Right adrenal enlargment up to 3.09cm is found. In progression. Suggest clinical correlation
  • Imp:
    • s/p ATH and BSO.
    • Residual tumor at pelvis about 4.6cm with liver, lung, right adrenal and uncinate process meta. In progression.
• 2022-11-15 CXR
  • Progression of left pleural effusion as compare with CXR on 2022-09-21. Suggest clinical correlation.
  • S/P port-A insertion via left subclavian vein.
  • Multiple lung tumors, suspected lung metastasis, progression.
• 2022-09-21 CT - abdomen
  • History: uterine leiomyosarcoma
    • 20220330 CT from TSGH: a heterogeneous mass 14 cm in the RUQ of abdomen,surround by C-loop of duodenum. Suspected metastasis.
    • 20220524 CC:UGI bleeding, gastroscopy:One 2cm ulcerative mass covering with fresh blood just distal to papilla. Patho:metastatic uterus leiomyosarcoma,
    • 20220623 CT:R/O metastases at pancreatic head and duodenum with duodeno-colon fistula.
  • Indication: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis; ECOG 2. s/p palliative RT on 2022/06/07.
  • MD CT (64 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • Prior CT identified a metastasis measuring 3.3 cm in S6 of the liver is noted again, mild decreasing in size to 3 cm.
      • However, There are two newly-developed poor enhancing masses measuring 4.3 cm in S4/5/8 and 1.2 cm in S7 of the liver that are c/w newly-developed metastases.
    • Prior CT identified multiple metastases on both lower lung are noted again, mild increasing in size.
    • Prior CT identified metastasis in between the pancreatic head and duodenum is noted again, marked decreasing in size.
    • S/P hysterectomy.
    • There is mild left pleural effusion.
    • There is a poor enhancing lesion measuring 1.2 cm in left kidney middle pole, nature? Please correlate with sonography.
    • Others
      • There is no focal abnormality in the gallbladder, biliary system, spleen & right kidney.
        
      • There is no ascites or lymphadenopathy.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • Two newly-developed liver metastases in S4/5/8 and S7.
    • Multiple lung metastases show mild increasing in size.
    • Prior CT identified metastasis in between the pancreatic head and duodenum is noted again, marked decreasing in size.
• 2022-09-21, -08-15 CXR
  • Multiple lung tumors, suspected lung metastasis.
  • Regression of left pleural effusion as compare with CXR on 2022-08-15, -07-19.
• 2022-07-19 CXR
  • Total white-out of left lung and mediastinum shift to left side is noted that may be left lung collapse?
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • There are few nodular opacity projecting in both lung hat may be metastases. Please correlate with CT.
• 2022-06-28 Abdomen Decubitus LT
  • Left Pleura effusion and left lung volume decrease.
• 2022-06-28 CXR
  • Left pleural effusion.
  • Deviation of trachea.
  • Multiple nodules at right lung.
• 2022-06-23 CT - abdomen
  • History and indication: metastatic uterus leiomyosarcoma
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P hysterectomy.
    • Left pleural effusion with adjacent lung collapse. Multiple nodules in right lung.
    • A poor enhancing tumor (3.3cm) at S6 of liver.
    • Suspected metastases at pancreatic head and duodenum with duodeno-colon fistula.
  • IMP:
    • S/P hysterectomy.
    • Left pleural effusion with adjacent lung collapse. Lung and liver metastases. Suspected metastases at pancreatic head and duodenum with duodeno-colon fistula.
• 2022-05-24 Patho - stomach biopsy
  • Duodenum, just distal to papilla, biopsy (A) — Leiomyosarcoma.
  • IHC stains: desmin (+), CD117 (-), CD34 (-), dog-1 (-), CK (-), melan-A (-), Ki-67: 90%.
  • Section shows 1 piece(s) of benign duodenal tissue and 1 piece of neoplastic spindle cell tumor with markedly enlaged and hyperchromatic nuclei.
• 2022-05-24 Colonoscopy
  • No active bleeder nor blood clot was noted during this exam, but few tarry stool residual was noted
  • Diverticula, cecum and ascending colon
  • Mild internal hemorrhoid
• 2022-05-24 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Duodenal ulcerative tumor, 2nd portion, s/p biopsy (A)
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric polyps, body, s/p biopsy (B)
    • Gastric erosion, middle body, PW site, s/p biopsy (C)
  • Suggestion
    • Suggest Abdominal CT with contrast (if not contraindicated) to DDx the duodenal lesion.
    • Keep high dose PPI therapy for 3-5 days
    • If acitive bleeding, consider angiography for embolization and surgical intervention. Endoscopic treatment is NOT suitable for such bleeding lesion.
    • Pursue the result of pathology report
• 2022-04-13 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA grade D
    • Superficial gastritis
    • Incomplete study
  • Suggestion
    • Consider temporary NG tube for decompression
    • PPI use for severe reflux esophagitis
    • Consider 2nd look endoscopy if active bleeding or persistent tarry stool
• 2022-04-11 ECG
  • Sinus tachycardia
  • Right atrial enlargement
  • Rightward axis
  • Pulmonary disease pattern
  • Abnormal ECG
• 2022-04-11 Abdomen -Standing (Diaphragm)
  • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
• 2021-03-23 CT (performed at another hospital?)
  • There are several small nodules (maximal size: about 1.7 cm) in all lobes (im:87) showing no change in size in comparison with the prior study obtained on 2020-12-02, lung metastasis is suspected. Suggest get tissue diagnosis
  • Multiple hypodense lesions in the spleen. Suggest correlate with abdomen CT study

[consultation]

• 2023-01-05 Oral and Maxillofacial Surgery
  • Q
    • This is a 62-year-old female who has the underlying disease of the following below: 1. Metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilaterla salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence, status post transvaginal tumor excision on 2017/12/25 status post 6 courses of adjuvant chemotherapy with Paclitaxel plus Carboplatin (20180105-0430) with lung metastases and bone metastases, status post 5 courses of chemotherapy with Cisplatin, Ifosfamide and Mensna (20211110-1224) at Tri-service General Hospital, under current radiation therapy. 2. Gastro-esophageal reflux disease with esophagitis, LA grade D 3. Thalassemia 4. Positive infection of COVID-19 on 2022/05/16.
    • For throbbing pain in upper left tooth, we need your further evaluation and management. (throbbing pain consists of recurring achy pains, may also experience pounding, beating, or pulsing pain.)
  • A
    • deep caries of tooth 26 was noticed.
    • But due to unstable hemodynamic status, Hb = 3.1 g/dL, blood transfusion was performed at ward
    • we suggested symtpom relief/pain relief (NSAID if no contraindicated/gastric ulceration)
• 2022-07-01 Radiation Oncology
  • Q
    • The 62 y/o female has metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. This time she has left lung collapse with SOB, patient asks for RT for treamtent.
  • A
    • Diagnosis: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis s/p to RUQ tumor from 2022-04-27 to 2022-06-07 with duodeno-tumor fistula and intermittent tumor bleeding; left pleural effusion with adjacent lung collapse, due to tumor obstruction of left main bronchus; ECOG = 2.
    • Suggest: Radiotherapy.
      • Goal: Palliative.
      • RT Plan may be designed as the following one:
        • Target & Volume: Metastatic tumor at left main bronchus.
        • Technique: VMAT & IGRT (OBI).
        • Dose & Fractionation: 2400cGy/6 fractions.
        • Expected benefits: about 60-70% chance to open the left bronchus, improve breathing, and last for about 1-2 months.
    • Plan: Palliative R/T is suggested for tumor obstruction. Possible toxicity (malaise, radiation esophagitis and pneumonitis) is told. CT simulation is arranged on 2022-07-04 15:30pm. Treatment will be started on next Tuesday or Wednesday if feasible.
      • Hospice care is also suggested. It has been recommended that family members be prepared for the best and the worst. Infection, bleeding, and other metastases may pose a threat at any time to the patient. Get to know the wisdom of letting go at the right time and adapt anticipatory grief accordingly.
• 2022-06-30 Family Medicine
  • Q
    • The 62 y/o female has metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. This time she has left lung collapse with SOB and abdomen CT with duodeno-colon fistula, can’t do the surgical intervention. Due to terminal stage, so we need your help for share care. Thank you.
  • A
    • When I visited, the patient lied on bed and her caregiver stood by her. She still wanted to receive palliative radiotherapy. After discussion, I decided to arrange hospice combine care for this patient.
    • Current condition: 62 y/o metastatic uterus leiomyosarcoma
    • Indication for hospice combine care: metastatic uterus leiomyosarcoma
• 2022-06-28 General and Gastroenterological Surgery
  • Q
    • The 62 y/o female has metastatic uterus leiomyosarcoma with liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. Due to abdomen CT showed metastases at pancreatic head and duodenum with duodeno-colon fistula. So we need your help for surgical indication management. Thank you.
  • A
    • S: Gastroenterological SurgeryDue to UGI bleeding, surgical intervention is consulted.
    • O:
      • vital signs: stable, no fever
        
      • HEENT: pale conjunctiva, OU
      • abdomen: soft, ovoid, normal bowel sound, RUQand epigastric tenderness, no rebounding pain
        
      • lab data: see chart
    • A: uterus leiomyosarcoma with multiple metastases,suspect duodeno-colon fistula and UGI bleeding
    • P:
      • Please arrange panendoscopy and colonoscopy for bleeding source and duodeno-colon fistula and possible hemostasis
      • Please use high dose PPI and keep blood transfusion if onging GI bleeding
      • If UGI bleeding is not well control after medication, blood trasfusion, and GI scope hemostasis, TAE is preferred than operation in stage IV case.
• 2022-06-27 Gastroenterology
  • Q
    • The 62 y/o female has metastatic uterus leiomyosarcoma with liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. Due to abdomen CT showed metastases at pancreatic head and duodenum with duodeno-colon fistula and stool ob 4+ with anemia Hb: 6.6d/dL. So we need your help. Thanks!
  • A
    • EGD on 20220524 showed a duodenal ulcerative tumor in 2nd portion, which was compatible with the CT finding
    • But the colonoscopy at the same time did not showed evidence of fistula
    • CT scan (20220623) reported a large tumor located between duodenum and pancreatic head region with suspicious duodeno-colonic fistula. Though, intraperitoneal free air accumulated below liver could not be ruled out.
    • Imp: Duodenal or pancreatic head tumor (suspected metastasis) with duodeno-colonic OR duodeno-peritoneal fistula
    • Suggestion:
      • Consult GS for surgical indication
      • Keep on PPI for the sign of UGI bleeding due to the duodenal tumor
• 2022-04-25 Radiation Oncology
  • A
    • Diagnosis: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis; ECOG = 3.
    • Suggest: Radiotherapy.
      • Goal: Palliative.
      • RT Plan may be designed as the following one:
        • Target & Volume: RUQ tumor.
        • Technique: VMAT.
        • Dose & Fractionation: 2500-3000cGy/10-12 fractions.
        • Expected benefit: about 30-40% chance to improve tumor bleeding and obstruction, lasting for about 1-2 months.
    • Plan: Palliative R/T is suggested for tumor obstruction and bleeding. Possible toxicity (malaise, vomiting, radiation gastritis and enteritis) is told. CT simulation is arranged on 20220426 16:00pm. Treatment will be started on Wednesday if feasible.
      • It is recommended that the patient’s spouse and children make an appointment with me to listen to the explanation of the condition and discuss the treatment goals; it is recommended to continue to arrange the hospice ward.

[radiotherapy]

s/p palliative RT on 2022/06/07 (RUQ tumor), 2022/07/18 (left hilum), 2022/08/05 (left hilum), 2022/10/21 (liver, SBRT), 2023/01/02 (LUL).

• 2023-01-03 ~ 2023-01-19 - 2500cGy/10 fractions (15 MV photon) to duodenal tumor
• 2022-12-12 ~ 2023-01-02 - 4500cGy/15 fractions (6 MV photon) to LUQ tumors
• 2022-10-11, -13, -17, -19, -21 - 5000cGy/5 fractions (15 MV photon) to liver tumors over right lobe
• 2022-08-01 ~ 2022-08-16 - 4200cGy/12 fraction (6 MV photon) to L main bronchus tumor & other 2 tumors
• 2022-07-05 ~ 2022-07-18 - 2400cGy/6 fractions (6 MV photon) to left main bronchus tumor
• 2022-04-27 ~ -05-06, -05-15 ~ -06-01, -06,07 - 3000cGy/15 fractions (15MV photon) to RUQ tumor

[immunotherapy]

• 2023-03-14 - nivolumab 3mg/kg 200mg NS 100mL 30min
  • diphenhydramine 30mg + NS 250mL
• 2023-02-20 - nivolumab 3mg/kg 200mg NS 100mL 30min
  • diphenhydramine 30mg + NS 250mL
• 2023-02-03 - nivolumab 3mg/kg 200mg NS 100mL 30min
  • diphenhydramine 30mg + NS 250mL
• 2023-01-09 - nivolumab 3mg/kg 100mg NS 100mL 30min
  • diphenhydramine 30mg + NS 250mL
• 2022-12-19 - nivolumab 3mg/kg 200mg NS 100mL 30min
  • diphenhydramine 30mg + NS 250mL

[assessment]

• Based on the available data, this patient’s HGB level has consistently remained below the lower limit of normal and requires blood transfusions to prevent it from dropping further.
  • 2023-03-13 HGB 6.4 g/dL
    
  • 2023-03-08 HGB 7.4 g/dL
    
  • 2023-03-02 HGB 8.2 g/dL
    
  • 2023-02-15 HGB 8.0 g/dL
    
  • 2023-02-08 HGB 9.3 g/dL
    
  • 2023-02-02 HGB 8.7 g/dL
    
  • 2023-01-31 HGB 10.1 g/dL
    
  • 2023-01-25 HGB 7.7 g/dL
    
  • 2023-01-25 HGB 6.6 g/dL
    
  • 2023-01-17 HGB 8.5 g/dL
    
  • 2023-01-09 HGB 8.9 g/dL
    
  • 2023-01-07 HGB 7.9 g/dL
    
  • 2023-01-04 HGB 3.1 g/dL
    
  • 2022-12-18 HGB 10.5 g/dL
    
  • 2022-12-15 HGB 4.9 g/dL
    
  • 2022-12-13 HGB 8.8 g/dL
    
  • 2022-12-07 HGB 6.5 g/dL
    
  • 2022-11-15 HGB 6.1 g/dL
    
  • 2022-10-18 HGB 6.4 g/dL
    
  • 2022-09-20 HGB 7.2 g/dL
    
  • 2022-08-30 HGB 7.9 g/dL
    
  • 2022-08-16 HGB 6.9 g/dL
    
  • 2022-07-19 HGB 11.3 g/dL
    
  • 2022-07-10 HGB 9.1 g/dL
    
  • 2022-07-06 HGB 7.1 g/dL
    
  • 2022-06-28 HGB 8.4 g/dL
    
  • 2022-06-26 HGB 6.6 g/dL
    
  • 2022-06-23 HGB 8.9 g/dL
    
  • 2022-06-21 HGB 8.9 g/dL
    
  • 2022-06-15 HGB 6.8 g/dL
    
  • 2022-06-07 HGB 8.8 g/dL
    
  • 2022-05-30 HGB 10.0 g/dL
    
  • 2022-05-27 HGB 9.3 g/dL
    
  • 2022-05-26 HGB 9.4 g/dL
    
  • 2022-05-25 HGB 5.1 g/dL
    
  • 2022-05-23 HGB 9.6 g/dL
    
  • 2022-05-22 HGB 5.8 g/dL
    
  • 2022-05-21 HGB 9.6 g/dL
    
  • 2022-05-17 HGB 10.8 g/dL
    
  • 2022-05-12 HGB 9.4 g/dL
    
  • 2022-05-05 HGB 8.0 g/dL
    
  • 2022-04-27 HGB 10.0 g/dL
    
  • 2022-04-25 HGB 10.3 g/dL
    
  • 2022-04-24 HGB 8.3 g/dL
    
  • 2022-04-24 HGB 9.7 g/dL
    
  • 2022-04-18 HGB 7.9 g/dL
    
  • 2022-04-14 HGB 8.0 g/dL
    
  • 2022-04-12 HGB 6.8 g/dL
    
  • 2022-04-08 HGB 11.4 g/dL
    
  • 2021-05-04 HGB 10.4 g/dL
    
  • 2020-09-09 HGB 10.0 g/dL
• This patient has received nivolumab immunotherapy 5 times since 2022-12-19 and has undergone multiple rounds of radiotherapy between late April 2022 and late January 2023. It is unlikely that anemia can be solely attributed to nivolumab, as hematologic immune-related adverse events from nivolumab occur less frequently and the exact mechanism of anemia is unknown. However, they are typically non-dose-related. The anemia in this patient may also be caused by other factors, such as the multiple rounds of radiotherapy she has undergone.

230314

[assessment]

• Advanced uterine leiomyosarcoma (ULMS) remains an incurable disease in most cases, and despite new drug approvals, improvements in overall survival have been modest at best. Microsatellite instability and/or high tumor mutational burden are distinctly uncommon in uterine LMS, perhaps explaining the lack of activity of immunotherapy agents observed in phase II trials in LMS.

  • ref:
    • Immunotherapy with single agent nivolumab for advanced leiomyosarcoma of the uterus: Results of a phase 2 study. Cancer. 2017;123(17):3285-3290. doi:10.1002/cncr.30738
    • Pembrolizumab in advanced soft-tissue sarcoma and bone sarcoma (SARC028): a multicentre, two-cohort, single-arm, open-label, phase 2 trial [published correction appears in Lancet Oncol. 2017 Dec;18(12 ):e711] [published correction appears in Lancet Oncol. 2018 Jan;19(1):e8]. Lancet Oncol. 2017;18(11):1493-1501. doi:10.1016/S1470-2045(17)30624-1

• Based on the available lab data in HIS5 since 2020-09-09, the patient’s HGB level has never reached the lower limit of normal. In 2023, the patient has received her 7th blood transfusion during this hospitalization.

• There is no medication reconciliation issue found in the patient.

230221

[assessment]

• 2023-02-08 CT showed disease progression compared to 2022-12-08 CT.
• The patient has had a relatively low blood pressure of around 100/70 and a slightly elevated resting heart rate of around 90 during her hospital stay. Adequate hydration may be beneficial in this situation.

230203

[assessment]

• Tramectedin is an alkylating agent approved for the treatment of unresectable or metastatic soft tissue sarcomas (liposarcomas or leiomyosarcomas). It is a temporary purchase item in this hospital and could be a subsequent option if nivolumab becomes less effective. For patients previously treated unresectable/metastatic liposarcoma or leiomyosarcoma: IV 1.5 mg/m2 as a continuous infusion over 24 hours once every 3 weeks; continue until disease progression or unacceptable toxicity.
  • ref:
    • Efficacy and Safety of Trabectedin or Dacarbazine for Metastatic Liposarcoma or Leiomyosarcoma After Failure of Conventional Chemotherapy: Results of a Phase III Randomized Multicenter Clinical Trial. J Clin Oncol. 2016;34(8):786-793. doi:10.1200/JCO.2015.62.4734
    • Doxorubicin alone versus doxorubicin with trabectedin followed by trabectedin alone as first-line therapy for metastatic or unresectable leiomyosarcoma (LMS-04): a randomised, multicentre, open-label phase 3 trial. Lancet Oncol. 2022;23(8):1044-1054. doi:10.1016/S1470-2045(22)00380-1
    • The Role of Trabectedin in Soft Tissue Sarcoma. Front Pharmacol. 2022;13:777872. Published 2022 Feb 23. doi:10.3389/fphar.2022.777872

220415

{tube feeding}

• All the oral drugs can be administered with a nasogastric tube.
• The coadministration of fentanyl, diphenhydramine, and estazolam may enhance the CNS depressant effect, please observe for signs of slowed or difficult breathing, and/or sedation.

701388511

230315

{not completed}

{angioimmunoblastic T cell lymphoma, high grade with neck, inguinal, retroperitoneal LN metastases and generalized skin rashes, Lugano stage III, PS:0}

[lab data]

• PSA
  • 2022-08-08 PSA 8.100 ng/mL
    
  • 2022-07-15 PSA 7.360 ng/mL

[exam findings]

• 2022-08-08 Patho - prostate needle biopsy
  • Prostate, right, needle biopsy — Prostatic adenocarcinoma (Gleason score = 7 = 4 +3 ) involving 3 of 6 strips of prostatic tissue by the number of involved strips or 50 % by the involved volume of the specimen.
  • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
  • Histologic Type: Prostatic adenocarcinoma
  • Histologic Grade: Gleason score = 7 = 4 + 3
  • Tumor Quantitation: For needle biopsy: Proportion of prostatic tissue involved by tumor: 3 of 6 strips of prostatic tissue by the number of strips or 50 % by the volume of the specimen.
• 2022-08-08 Patho - prostate needle biopsy
  • Prostate, left, PSA = 7.360, needle biopsy — stromal and glandular hyperplasia with multiple foci of chronic inflammation. All prostatic glands are 34betaE12 (+) and AMACR (-) with IHC stains.
• 2022-06-10 SONO - neck
  • Some LNs in bil. neck.
• 2022-05-12 PET scan (at Cardinal Tien Hospital)
  • Malignant lymphoma with bilateral sides of neck LNs, submental LNs, mediastinal LNs, bilateral axillary LNs, hepatoduodenal ligament LNs, retroperitoneal LNs, bilateral iliac chain LNs and bilateral inguinal LNs involvement.
• 2022-05-11 Patho - neck (at Cardinal Tien Hospital)
  • high grade lymphoma, favor T-cell lymphoma, angioimmunoblastic T cell lymphoma is compatible.
  • CD3:(+/diffuse), BCL:(+/diffuse), CD20(-), CD10(+), CD4(+), CD21(+) for follicular dendritic cells, CD8(+), EBV(-), MIB-1: highly increasing proliferative index for tumor cells.
• 2022-05-05 SONO - abdomen (at Cardinal Tien Hospital)
  • fatty liver, hepatic cyst, GB wall thickening, Intra abdominal LN, renal cyst and splenomegaly.
• 2022-04-28 CT - neck (at Cardinal Tien Hospital)
  • extensive lymphadenopathy at bilateral neck, upper mediastinum on 2022/4/28.
• Initial presentation
  • body weight loss 10kg in one month and neck lymphadenopathy

[chemoimmunotherapy]

• 2022-08-14 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5
• 2022-07-25 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + prednisolone 60mg/m2 40mg TID D1-5
• 2022-07-04 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5
• 2022-06-10 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5

[family meeting minutes]

• In the family meeting, the attending physician Dr. Gao explained the process and precautions of autoPBSCT to the patient and his family members (sister and brother-in-law). The patient expressed his willingness to fully cooperate. However, the patient has been married before and his only daughter is currently studying in the United States and is unaware of her father’s medical condition.

• The patient’s family support may be insufficient before and after the scheduled transplantation. The nursing station will assist in coordinating caregiver arrangements. The attending physician reminded the patient to inform his daughter about his condition, and the patient indicated his understanding.

701313188

230314

[diagnosis] - 2023-03-13 admission note

• Diffuse large B-cell lymphoma, extranodal and solid organ sites
• Localized swelling, mass and lump, neck
• Chronic sinusitis, unspecified
• Temporomandibular joint disorder, unspecified

[past history]

Medical history: HTN, Chronic rhinosinusitis

Operation history: - glaucoma - s/p Parotidectomy, left、submandibular gland tumor excision, left - s/p Port-A insertion, L’t after L’t cephalic vein exploration         

[allergy]

• NKDA     

[family history]

Denied family history

[exam findings]

• 2023-02-17 SONO - abdomen
  • Liver cysts
  • Gallbladder adenomyomatosis
  • Splenomegaly
• 2023-02-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (131 - 54) / 131 = 58.78%
    • 2D (M-simpson) = 59
  • Mildly dilated LV with mild hypokinesia of inferior wall, mid-to-apical posterior wall; preserved LV systolic function.
  • Normal RV systolic function.
  • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
  • Aortic valve sclerosis; midl MR; trivial TR.
  • Mildly dilated aoartic root and proximal ascending aorta (35 mm)
• 2023-02-14 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Negative for malignancy.
• 2023-02-10 CXR
  • Solitary pulmonary nodule at RUL.
• 2023-02-09 Whole body PET scan
  • Glucose hypermetabolism in a left posterior upper neck lymh node and in the right submandibular gland. Lymphoma should be watched out.
  • Glucose hypermetabolism in a focal area in the region about left aspect of soft palate and in the region about right posterior gingiva. The nature is to be determined (inflammation? lymphoma?). Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in the left parotid and left submandibular areas. Post-operative inflammation may show this picture.
  • Mild glucose hypermetabolism in some bilateral neck level II lymph nodes, in a focal area in the left anterior upper chest and in a focal area in the lower lobe of left lung. Inflammatory process is more likely.
  • Increased FDG accumulation in both kidneys, bilateral ureters and colon. Physiological FDG accumulation may show this picture.
• 2023-01-27 Patho - salivary gland resection
  • DIAGNOSIS:
    • A: Salivary gland, left parotid, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
    • B: Salivary gland, left parotid, inferior pole of deep lobe, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
    • C: Salivary gland, left parotid, superior pole of deep lobe, parotidectomy — Negative for malignancy
    • D: Salivary gland, left parotid, superior margin, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
    • E: Salivary gland, left submandibular gland, excision — Diffuse large B-cell lymphoma, non-GCB type
    • F: Lymph node, left, level Ib, dissection — Diffuse large B-cell lymphoma, non-GCB type
    • G: Salivary gland, left residual submandibular gland, excision — Diffuse large B-cell lymphoma, non-GCB type
    • F2023-00041
      • Parotid gland, left, biopsy — Diffuse large B-cell lymphoma, non-GCB type
  • GROSS DESCRIPTION:
    • A: Specimen submitted in formalin consists of a piece of left parotid gland weighing 28.0 gm and measuring 4.7 x 4.7 x 2.5 cm. On cut, there is a gray, solid tumor measuring 4.0 x 3.0 x 1.7 cm. The tumor is involving the anterior, superior, inner resection margins, and 1.2 cm, 0.7 cm, and 0.1 cm away from the posterior, inferior, and outer resection margins. The parenchyma elsewhere is unremarkable. Representative sections are taken and labeled as A1-6: tumor (A1: superior: ink black, outer: ink green, inner: ink yellow; A2: inferior: ink black, outer: ink green, inner: ink yellow; A3: anterior; A4: posterior).
    • B: Specimen submitted in formalin consists of 3 pieces of tan, irregular tissue measuring up to 1.8 x 1.0 x 0.3 cm. All for section in a cassette B.
    • C: Specimen submitted in formalin consists of 3 pieces of tan, irregular tissue measuring up to 0.8 x 0.6 x 0.2 cm. All for section in a cassette C.
    • D: Specimen submitted in formalin consists of a piece of tan, irregular tissue measuring 1.4 x 0.8 x 0.6 cm. All for section in a cassette D.
    • E: Specimen submitted in formalin consists of a piece of left submandibular gland tissue measuring 5.0 x 3.0 x 2.4 cm. On cut, there is a gray, solid tumor measuring 3.7 x 3.0 x 2.4 cm. The tumor is involving the peripheral resection margin. Representative sections are taken and labeled as: E1-2: the same level.
    • F: Specimen submitted in formalin consists of 4 level Ib lymph nodes, measuring up to 1.1 x 0.7 x 0.5 cm. All for section in a cassette F.
    • G: Specimen submitted in formalin consists of a piece of left residular submandibular gland tissue measuring 1.8 x 1.4 x 0.6 cm. On cut, there is a gray, solid tumor almost involving the whole specimen. The tumor is involving the peripheral resection margin. The specimen is bisected and all for section in a cassette G.
      
    • F2023-00041
      • Specimen submitted in fresh consists of a piece of tan, irregular tissue measuring 0.7 x 0.3 x 0.2 cm. All for section in a cassette for frozen examination.
  • MICROSCOPIC DESCRIPTION:
    • A: Sections show salivary gland with diffusely infiltration of large lymphoid cells. The immunohistochemical stains reveal CD3(-), CD20(+), BCL2(+), BCL6(-), CD10(-), MUM1(+), Cyclin D1(-), and c-MYC(-). The Ki-67 is about 20-30%. The results are consistent with diffuse large B-cell lymphoma, non-GCB type.
      
    • B: Section shows salivary gland with infiltration of large lymphoid cells.
    • C: Section shows salivary gland without infiltration of large lymphoid cells.
    • D: Section shows salivary gland with infiltration of large lymphoid cells.
    • E: Sections show salivary gland with diffusely infiltration of large lymphoid cells.
    • F: Section shows 4 lymph nodes with infiltration of large lymphoid cells.
    • G: Section shows salivary gland with diffusely infiltration of large lymphoid cells.
    • F2023-00041
      • Section shows salivary gland with diffusely infiltration of large lymphoid cells and marked crushed artifact.
• 2022-12-20 CT - neck
  • CT scans of the neck from the level of hard palate to the level of infraclavicular region using a 64-sliced multi-detector row volumetric CT after intravenous injection of 100 c.c. iodinated contrast agent.
  • Coronal reformation was performed. The slice thickness is 5 mm.
  • Findings:
    • One well-defined nodular lesion (3.6cm) within left parotid gland, showing homogeneous enhancement. May be a benign mixed tumor. Suggest tissue proof.
    • The oral cavity shows no evidence of focal lesion.
    • The mouth floor and submandibular regions are normal. No focal lesion is identified.
    • Relative hypertrophy of left submandibular gland.
    • The thyroid appears normal in size and enhancement.
    • Effacement of left pyriform sinus.
• 2022-12-19 Nasopharyngoscopy
  • Findings: synechia between R middle T and septum; bilateral middle T polypoid change with clear to whitish mucus; smooth nasopharynx, oropharynx, hypopharynx.
  • Diagnosis/Conclusion: chronic rhinosinusitis

[chemoimmunotherapy]

• 2023-03-13 - rituximab 375mg/m2 646mg NS 500mL 8hr D1 + [cyclophosphamide 750mg/m2 1292mg NS 250mL 30min + liposome doxorubicin 30mg/m2 52mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min] D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CDOP)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2023-02-16 - rituximab 375mg/m2 646mg NS 500mL 8hr D1 + [cyclophosphamide 750mg/m2 1292mg NS 250mL 30min + liposome doxorubicin 30mg/m2 52mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min] D2 + prednisolone 60mg/m2 20# as 7#, 7#, 6# TID PO D2-6 (R-CDOP)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2

[assessment]

• The patient’s underlying hypertension is well controlled with Exforge (amlodipine 5mg + valsartan 160mg) currently and there were no medication reconciliation issues.

701328032

230314

[diagnosis] - 20221219 admission note

• Malignant neoplasm of stomach, unspecified
• Mixed hyperlipidemia
• Chronic gastric ulcer without hemorrhage or perforation
• Ulcer of esophagus without bleeding

[exam findings]

• 2022-12-22 Body fluid cytology - ascites
  • atypia
• 2022-12-14 CXR
  • Atherosclerosis of the aorta.
• 2022-11-14 CXR
  • Ground glass opacity in bilateral lower lungs.
  • Left pleural effusion.
• 2022-11-11 Patho - gallbladder (benigh lesion)
  • Gallbladder, laparoscopic cholecystectomy — acute cholecystitis, compatible with cholelithiasis
• 2022-11-11 Patho - stomach biopsy
  • Diagnosis:
    • Stomach, antrum, partial gastrectomy — Poorly differentiated adenocarcinoma
    • Lymph node 1, dissection — Metastatic adenocarcinoma ( 1 / 5 )
    • Lymph node 3, dissection — Metastatic adenocarcinoma ( 2 / 2 )
    • Lymph node 4, dissection — Metastatic adenocarcinoma ( 3 / 7 )
    • Lymph node 5, dissection — Metastatic adenocarcinoma ( 1 / 1 )
    • Lymph node 6, dissection — Metastatic adenocarcinoma ( 3 / 6 )
    • Lymph node, unspecified, dissection — Metastatic adenocarcinoma ( 2 / 7 )
    • Lymph node 14, dissection — Negative for malignancy ( 0 / 1 )
    • Omentum, omentectomy — Negative for malignancy
    • AJCC 8th edition pathology stage:pT4aN3a(if cM0); AJCC stage IIIB
  • Gross Description:
    • Procedure: Partial gastrectomy, distal
    • Tumor Site: Antrum
    • Tumor Size: 5.5x 4.2 cm
    • Gross configuration - For advanced carcinoma (Borrmann classification): Type III: Ulcerated with poorly defined infiltrative margins
    • Sections are taken and labeled as: F2022-530FS:margin, A1:D-margin, A2-12:tumor, B:LN1, C:LN3, D:LN4, E:LN5, F:LN6, G1-2:lymph node, H:LN14, I:omentum
  • Microscopic Description:
    • Histologic Type
      • Adenocarcinoma
      • Lauren classification of adenocarcinoma: Intestinal type
    • Histologic Grade: G3: Poorly differentiated
    • Tumor Extension: Tumor invades the serosa (visceral peritoneum)
    • Margins
      • Proximal margin: uninvolved by invasive carcinoma
      • Distal margin: uninvolved by invasive carcinoma
      • Radial margin: involved by invasive carcinoma
    • Lymphovascular Invasion: present
      
    • Perineural Invasion: present
      
    • Regional Lymph Nodes
      • Number of lymph nodes examined/involved: 12 / 29
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
      • Primary Tumor (pT)
        • pT4a: Tumor invades the serosa (visceral peritoneum)
      • Regional Lymph Nodes (pN)
        • pN3a: Metastasis in seven to 15 regional lymph nodes
      • Distant Metastasis (pM) (required only if confirmed pathologically in this case)
        • Not applicable
    • Additional Pathologic Findings
      • None identified
      • Intestinal metaplasia
    • Ancillary Studies : None
    • Comment(s): None
• 2022-11-05 CT - chest
  • A nodule at RML. Emphysema at bil. lungs.
  • Gastric antral cancer with outlet obstruction and regional LAP.
  • Left adrenal tumor (1.7cm).
  • Gallbladder stones (up to 1.3cm).
  • A calcified spot (6mm) at right subphrenic region.
• 2022-11-01 Flow Vlume Test
  • mild obstructive impairment
• 2022-10-31 Patho - stomach biopsy
  • Stomach, antrum, biopsy — Adenocarcinoma, moderately differentiated
  • The secvtions show a picture of adenocarcinoma, moderately differentiated, composed of cuboidal neoplastic cells, arranged in tubular and papillary patterns with desmoplastic stromal reaction. Mucosal ulcer is present.
• 2022-10-31 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Advanced gastric cancer with obstruction, Borrmann type III, antrum, s/p biopsy*3
    • Reflux esophagitis LA grade D
    • Incomplete study
  • Suggestion
    • NG decompression
    • Follow up pathology result
• 2022-10-28 ECG
  • Normal sinus rhythm
  • Right bundle branch block
  • Abnormal ECG
• 2022-10-26 CT - abdomen
  • History: hunger epigastric pain for months, being told to have one huge ulcer at antrum, tissue proved adenocarcinoma (2022-10-04) refer to GS Dr.
  • Findings:
    • There is circumferrential asymmetrical wall thickening at the gastric antrum, measuring 1.5 cm in the maximal wall thickness that is c/w adenocarcinoma (T3).
      • In addition, There are five enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament that may be metastatic nodes (N2).
    • There are several gallstones (< 1.5 cm) and mild wall thickening of the gallbladder.
    • There is a calcification 7 mm at S8 of the liver dome that is c/w old granuloma.
    • There is a mass lesion in left adrenal gland, measuring 1.8 cm in size, -2 HU at non-enhanced CT and 42 HU at portal venous phase images.
      • Adenoma of left adrenal gland is highly suspected.
      • Follow up is indicated.
    • Abdominal aorta shows atherosclerosis andectasia 2.2 cm.
    • A renal cyst measuring 0.8 cm in left upper pole is noted. Please correlate with sonography.
    • There is a small soft tissue nodule in RML of the lung, measuring 3 mm in size at lung window setting (Srs:302 Img:7).
      • Follow up chest CT 6 months later is indicated.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T3 (T_value) N:N2 (N_value) M:M0 (M_value) STAGE:III(Stage_value)

[surgical operation]

• 2022-11-10
  • Surgery
    • radical subtotal gastrectomy with D2 dissection
    • HIPEC with Oxalip (300mg/M2) at 42 degree C 60 mins
  • Finding
    • distal gastric cancer with multiple LN alpable
    • peritoneal seeding+
    • serosa++

[chemotherapy]

• 2023-03-13 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2400mg 3880mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-17 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 625mg NS 250mL 2hr + fluorouracil 2400mg 3770mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-03 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 625mg NS 250mL 2hr + fluorouracil 2400mg 3770mg NS 500mL 46hr (FOLFOX Q2W)
  • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-20 - oxaliplatin 60mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2000mg 3200mg NS 500mL 46hr + [docetaxel 30mg/m2 20mg + cisplatin 30mg/m2 20mg + gentamicin 20mg + sodium bicarbonate 1400mg] IP 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-11-10 - oxaliplatin 300mg/m2 510mg IP 1hr (HIPEC)

[assessment]

• Based on the available lab data, serum Ca levels are stably lower than the normal range. If PTH secretion is insufficient to act on kidney, bone, and intestines, hypocalcemia may occur (hypoparathyroidism). No PTH lab data available. As the serum albumin concentration is also below normal, the low calcium level could also be due to a reduction in serum albumin levels.

• Even when potassium supplements are taken intermittently, serum K readings remain below normal range since December 2022. An acute increase in hematopoietic cell production is associated with potassium uptake by the new cells and this may lead to hypokalemia. Administration of vitamin B12 or folic acid to treat a megaloblastic anemia or use of granulocyte-macrophage colony-stimulating factor (GM-CSF) to treat neutropenia are the most common scenarios in which this occurs.

230104

[assessment]

• Based on the available lab data, serum Ca levels are stably lower than the normal range. If PTH secretion is insufficient to act on kidney, bone, and intestines, hypocalcemia may occur (hypoparathyroidism). No PTH lab data available. As the serum albumin concentration is also below normal, the low calcium level could also be due to a reduction in serum albumin levels.

• Even when potassium supplements are taken intermittently, serum K readings remain below normal range since Dec 2022. An acute increase in hematopoietic cell production is associated with potassium uptake by the new cells and this may lead to hypokalemia. Administration of vitamin B12 or folic acid to treat a megaloblastic anemia or use of granulocyte-macrophage colony-stimulating factor (GM-CSF) to treat neutropenia are the most common scenarios in which this occurs.

221220

[assessment]

• Cancer multidisciplinary team meeting (2022-12-06) concluded the treatment for the case: arrange further CCRT and keep IP C/T.
• This patient is admitted for mFOLFOX chemotherapy as arranged. Based on lab data (2022-12-19), the chemotherapy was not contraindicated.
• There were low levels of albumin (3.1g/dL 2022-12-19) and prealbumin (13.85mg/dL 2022-11-21). They might indicate a short-term impairment in energy intake and the effectiveness of nutritional support.
• As a diagnosis item, mixed hyperlipidemia is listed, however no associated medication is prescribed, and recent lab data show that triglyceride levels have returned to normal.
  • 2022-11-21 Triglyceride (TG) 109 mg/dL
    
  • 2022-11-14 Triglyceride (TG) 111 mg/dL
    
  • 2022-11-08 Triglyceride (TG) 156 mg/dL

700978784

230313

[diagnosis] - 2023-03-12 admission note

• Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]
• Unspecified B-cell lymphoma, lymph nodes of head, face, and neck
• Type 2 diabetes mellitus with diabetic nephropathy

[edu opinion] - 2023-03-12 admission note

History - Orbital lymphoma more commonly presents in the middle-age and the elderly. - Slowly progressing, and typically painless.

Signs - Conj: the typical lesion is salmon or flesh-pink color - Orbit, eyelid: when palpable, the masses are firm. - Lacrimal gland: an “S-shaped” mass due to the lateral location of the lacrimal gland - Proptosis - Ptosis and decreased levator function may indicate superior orbital and levator muscle involvement, and motility should also be measured if the patient complains of diplopia. - Signs are more commonly unilateral

Symptoms - Many lesions are asymptomatic but depending on the location of the mass, patients can complaint of exophthalmos, pain or diplopia, as well of conjunctival, eyelid, orbital or lacrimal gland mass.

Differential diagnosis - Benign lymphoproliferative lesions - Lymphoid hyperplasia - Systemic lymphoma - Metastasis - Amelanotic melanoma - Epithelial tumors - Inflammatory and infectious lesions - Orbital pseudotumor - Cavernous hemangioma    

[past history]

• DM
• Hyperlipidemia
• Mucosa‐associated lymphoid tissue (MALT) lymphoma over kidney and urinary system s/p radiotherapy 

[allergy]

• NKDA

[exam findings]

• 2023-03-09 2D transthoracic echocardiography

(145 - 47) / 145 - M-mode (Teichholz) = 68 - Prominent concentric LV hypertrophy and mild RV hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; moderately dilated LA. - Dilated LV with normal LV and RV systolic function. - Aortic valve sclerosis and mild aortic root calcification; mild MR; mild PR.

• 2023-03-07, 2022-12-20 ECG
  • Normal sinus rhythm
  • Moderate voltage criteria for LVH, may be normal variant
• 2023-02-21 Patho - bone marrow biopsy
  • PATHOLOGIC DIAGNOSIS
    • Bone marrow, iliac creast, biopsy — Free from lymphoma involvement
  • Immunohistochemical stains:
    • MPO: positive for myeloid series
    • CD71: positive for erythroid series
    • CD61: positive for megakaryocytes
    • CD34 and CD117: positive for blast
    • CD20: positive for B-cell
    • CD3: positive for T-cell
• 2023-02-17 Patho - colon biopsy
  • Polypoid colonic lesion, cecum, biopsy — Non-specific chronic colitis
• 2023-02-17 SONO - nephrology
  • Chronic renal parenchymal disease, mild to moderate degree
  • Right renal cysts
• 2023-01-27 CT - chest
  • Indication:
    • Unspecified B-cell lymphoma, lymph nodes of head, face, and neck
    • Type 2 diabetes mellitus with diabetic nephropathy
  • MDCT (80-detector rows, Aquilion Prime SP, was performed with 2.5 mm lung window,5 mm soft-tissue window slice thickness)
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • Minimal interstitial infiltration over both lungs is found.
      • Patent airway is found.
      • There is no evidence of destructive bone lesion.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Mild left hydronephrosis and hydroureter is found.
      • Right renal stone is found.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • The GB is well distended without soft tissue lesion
  • IMp: Minimal interstitial infiltration over both lungs
• 2023-01-20 Patho - stomach biopsy
  • Stomach, low body and antrum, biopsy— chronic gastritis with intestinal metaplasia and Helicobacter infection
  • Stomach, cardia, biopsy— inflammatory polyp with Helicobacter infection
• 2023-01-18 Whole body PET scan
  • Glucose hypermetabolism in the left orbital fossa (Deauville score 5), compatible with lymphoma with tumor recurrence.
    
  • Glucose hypermetabolism in bilateral mediastinal and bilateral pulmonary hilar lymph nodes (Deauville score 4-5), tumor recurrence should be considered, suggesting biopsy for further investigation.
    
  • Glucose hypermetabolism in a lymph node in the right retromolar region (Deauville score 4) and in the gastric region (Deauville score 4), the nature is to be determined (reactive or recurrent nodes, or other nature ?), suggesting follow-up.
  • Increased FDG uptake in the rectal region, the nature is to be determined also, suggesting colon fibroscopy exam. for investigation.
    
  • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
  • B-cell lymphoma s/p treatment with tumor recurrence, rc-stage II at least, by this F-18 FDG PET scan.
• 2023-01-02 Patho - soft tissue nontumor/mass/lipoma/debridement
  • PATHOLOGIC DIAGNOSIS
    • Orbital, left, biopsy — Small B-cell lymphoma, compatible with extranodal marginal zone lymphoma
      
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Small B-cell lymphoma, compatible with extranodal marginal zone lymphoma, composed of small to medium-sized, slightly irregular nuceli with abundant pale cytoplasm and monocytoid appearance
      
    • Pathologic Extent of Tumor: To adjacent adipose tissue
    • Additional Pathologic Findings: None identified
      
    • Immunophenotyping: CD3(-), CD20(+), CD5(-), CD23(focal+), CD43(-), Cyclin D1(-)
• 2022-12-20 Nasopharyngoscopy
  • polyp over right middle meatus, mucopus over right inferor meatus and left chona, polyp over nasopharynx, fair vocal fold movement
• 2022-12-14 CT - orbits
  • With and Without contrast CT of the bilateral orbital cavities showed
    • An irregular-margined soft tissue lesion, about 38.7mm, with attachment to the anterior aspect of the left IR muscle. Mild enhancement was noted.
    • The anterior and lateral bony walls of right maxillary sinus were thickened.
    • The mucosal thickening in the bilateral ethmoidal, sphenoidal and right maxillary sinuses with destruction of the medial wall of the right maxillary sinus. Some calcified spots within the right maxillary sinus were noted.
  • IMP:
    • Suspected inflammatory tumor in the left orbital cavity or hemangioma (less likely).
    • Suspected infectious process or tumor in the right maxillary sinus.
• 2022-12-14 Nasopharyngoscopy
  • smooth nasopharynx, oropharynx, hypopharynx
  • nasal polyp over right middle meatus, no obvious mucopus noticed
  • post-nasal dripping over nasopharynx
• 2018-10-31 SONO - abdomen
  • Diagnosis
    • Fatty liver,mild to moderate
    • Suspected renal cysts,bil
    • Pancreas not shown
    • Suboptiaml examination of liver due to Poor echo window
  • Suggestion
    • OPD follow up
    • Follow liver function test and AFP
    • Small liver lesion may be masked by bowel gas, especially liver dome

[consultation]

• 2022-12-14 Ear Nose Throat
  • Q
    • Pain noted around left eye, no blurring of vision
    • Redness +, Swelling +, Local Heat +
    • Past History: DM, HTN
    • Surgical history: Denied
    • Drug allergy: Denied
  • A
    • S
      • Left eye pain and periorbital swelling for 2 months
      • Phx: type 2 DM, dyslipidemia, gout
      • no visual loss, diplopia, facial pain, epistaxis, foul smelling, epistaxis, nasal obstruction, rhinorrhea
    • O
      • Local finding: bilteral pale and boggy inferior turbinates
      • Scope:
        • smooth nasopharynx, oropharynx, hypopharynx
        • nasal polyp over right middle meatus, no obvious mucopus noticed
        • post-nasal dripping over nasopharynx
      • CT: sinusitis over bilateral sphenoid sinus and right maxillary sinus, mass lesion over left infra-orbital region
    • A
      • Impression: Right maxillary sinusitis
    • P
      • Nasonex for right side sinusitis
      • Survey and management of right eye lesion as ophthalmalogist suggested
      • ENT OPD f/u a week later
      • Well education
      • if diplopia, visual loss noticed, back to ER soon
• 2022-12-14 Ophthalmology
  • Q
    • Pain noted around left eye, no blurring of vision
    • Redness +, Swelling +, Local Heat +
    • Past History: DM, HTN
    • Surgical history: Denied
    • Drug allergy: Denied
  • A
    • S: left periorbital swelling for 1-2 month, no BV, no diplopia, no pain
      • PHx: DM, hyperlipidemia, ophx denied, nka
    • O
      • WBC 6740, CRP 0.8
      • BCVA OD 0.6x-1.75/-2.25x75 OS 0.6x-3.0/-1.0x100
      • PT: 15/18 mmHg
      • pupil: 3mm+/+, 3mm+/+, no rapd
      • palpation : no tenderness
      • Hertel exophthalmometer: 12>–120–<16
      • EOM: mild limitation at lower left gaze os
      • conj: mild chemosis os
      • K: cl ou
      • AC: deep and clear ou
      • LenS: NS + ou
      • F’d: no infiltration, no whitish nor lelvated lesion, no vessel compromise , macula ok, no break ou
    • A: orbital tumor with proptosis, os cause to be determied, lymphoma?
    • P:
      • please consult ENT for sinus lesion
      • explain to the patient, the lesion might be benign or malignant, further survey is needed
      • inform the risk of disesae progression and IOP elevation, if difficulty on opening eye and progressive pain, come back to ER asap
      • opd f/u on W2

[chemoimmunotherapy]

• 2023-03-13 - rituximab 375mg/m2 674mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID D2-6
  • [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D2
• 2023-02-21 - rituximab 375mg/m2 674mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID D2-6
  • [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D2

[assessment]

• On 2023-03-12, a self-paid G-CSF filgrastin 150ug SC was administered due to leukopenia (WBC count of 2.73K/uL, marked with asterisks in the following table) observed on the same day. The event occurred approximately 3 weeks since the patient’s first R-CHOP treatment started on 2023-02-21. This is longer than the usual 1-2 week timeframe for WBC nadir after chemotherapy. However, it cannot be entirely ruled out that there may be other unidentified factors that are affecting the patient’s WBC count.
  • 2023-03-13 WBC 7.91 x10^3/uL
    
  • 2023-03-12 WBC 2.73 x10^3/uL *
  • 2023-03-03 WBC 4.72 x10^3/uL
    
  • 2023-02-19 WBC 3.89 x10^3/uL
    
  • 2023-02-03 WBC 6.99 x10^3/uL
    
  • 2023-01-12 WBC 9.84 x10^3/uL

701455299

230310

[exam findings]

• 2022-12-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (82 - 26) / 82 = 68.29%
    • M-mode (Teichholz) = 68.4
  • Adequate LV, RV systolic function with normal wall motion
  • Impaired LV relaxation
• 2022-11-14 Patho - breast simple/partial mastectomy
  • Diagnosis:
    • Breast, right, partial mastectomy — Invasive carcinoma of no special type, grade 2
    • Skin, right breast, partial mastectomy — Negative for malignancy
    • Lymph node, SLN, right axilla, SLNB — Negative for malignancy (0/2)
    • AJCC 8th edition pathology stage:pT1cN0(if cM0); Anatomic stage IA; AJCC prognostic stage IA
  • Gross Description
    • Procedure
      • Partial mastectomy
    • Lymph node sampling (if lymph nodes are present in the specimen)
      • Sentinel lymph node(s)
    • Specimen laterality
      • Right
    • Sections are taken and labeled as:
      • F2022-533FSA1-2: margins,
      • F2022-533FSB: SLN,
      • F2022-533A1-8: tumor and skin,
  • Microscopic Description
    • For Invasive Carcinoma
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma (mm): 15 mm
      • Histologic grade (Nottingham histologic score): grade II (score7)
      • Extent of tumor (required only if the structures are present and involved)
      • Skin involvement: Absent
        
      • Chest wall invasion deeper than pectoralis muscle: Absent
        
    • For Ductal Carcinoma In Situ
      • Tumor size (mm): 6 mm
      • Nuclear grade: 2
      • Architectural pattern: Comedo and Non-comedo
      • Tumor necrosis: Present
    • Margins:
      • Negative, Closest margin (7 mm from closest margin)
    • Nodal status: Negative
    • No. examined: 2
    • No. macrometastases (>2 mm): 0
    • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells):0
    • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
    • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
      • In the Breast: N/A
      • In the Lymph nodes: N/A
    • Immunohistochemical Study: Reference: S2022-17911
• 2022-11-11 Frozen Section
  • Margin, right breast, frozen section — Free
  • SLN, axilla, right, frozen section — Negative for malignancy (0/2)
• 2022-11-11 Lymphoscintigraphy
  • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
  • IMPRESSION: Probably a sentinel lymph node at the right axillary region.
• 2022-10-25 Tc-99m MDP whole body bone scan with SPECT
  • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the maxilla, lower T-spine, some L-spines, bilateral shoulders, sternoclavicular junctions and hips in whole body survey.
  • IMPRESSION:
    • Increased activity in the lower T-spine and some L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
• 2022-10-24 CT - chest
  • Indication: Malignant neoplasm of unspecified site of right female breast, Unspecified lump in breast
  • MDCT (256-detector rows, GE Revolution, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images and axial slab MIP images, and oblique coronal reconstructed images of the Rt breast shows:
    • Lungs: normal appearance of bilateral lungs.
    • Mediastinum and hila: no enlarged LN or mass.
      • the trachea and main bronchi are normallly identified without endobronchial lesion.
    • Vessels:
      • the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
    • Heart: normal in size of cardiac chambers.
    • Pleura: unremarkable.
      • Chest wall and visible lower neck: an enhancing nodular lesion with mild lobulated contour (15mm in longest dimension) in inferior central aspect of Rt breast. multiple low density ovalm or round shaped lesions within the breast too measuring up to 3.1cm. no enlarged LNs in axilla.
    • Visible abdominal-pelvic contents: diffuse wal thickening of distal half body and fundal part with sessile luminal nodular lesions of the gall bladder.
      • unremarkable of the liver, spleen, both adrenal glands, pancreas, kidneys, uterus, U-bladder, and small and large bowels.
      • no enlarged lymph node. no ascites.
    • Visualized bones: unremarkable.
  • Impression:
    • Rt breast tumor (15mm) and multiple cysts.
    • Gall tumor.
• 2022-10-17 Patho - breast biopsy (no need margin)
  • DIAGNOSIS:
    • A. Breast, right, nipple, core biopsy — Fibroadenoma
    • B. Breast, right, 6 o’clock, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
  • MICROSCOPIC DESCRIPTION:
    • A. Section shows fragments of breast tissue with fibroadenoma.
    • B. Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
• 2022-10-17 SONO - breast
  • Treatment: core needle biopsy
  • Suggestion and Plan:
    • Right breast 6’region tumor, suspected malignancy, suggest biopsy.
    • Right nipple region cystic tumor, suspected intraductal papilloma, suggest biopsy.
    • Multiple bilateral breast cysts.
  • BI-RADS:
    • Category 4c: highly suspicious abnormality-biopsy should be considered.
• 2022-10-17 Mammography
  • Indication: breast lump was noted during regular healthy examination.
  • No previous mammography is available for comparison.
  • Mammography of bilateral breasts with craniocaudal (CC) and mediolateral oblique (MLO) views shows:
    • Composition: The breast tissue is heterogeneously dense, and this may decrease the sensitivity of mammography.
    • Multiple oval nodules with obscured margin at bilateral breasts, suggest ultrasound correlation.
    • An irregular mass shadow at right lower central breast, 6’ region, superimposed with microcalcifications and associated with mild architectural distortion. Suggest ultrasound correlation and may consider biopsy.
    • No enlarged axillary lymph nodes.
  • Final assessment:
    • BI-RADS category 0, Need additional imaging evaluation.
    • Suggest ultrasound correlation for bilateral breast masses, especially right 6’ region mass.

[consultation]

• 2022-11-11 Rehabilitation
  • Q
    • This 43 y.o lady denied systemic disease, op history on contraceptive for 10 years. 5 months before admission, noted solid tumor on 7 o’clock of right breast. Futher investigation was done. Right breast biopsy showed invasive carcinoma no special type, NST. IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
      • 2022/10/17 Mamography : BI-RADS category 0, Need additional imaging evaluation.
      • 2022/10/17 Breast sono : 1. Right breast 6’region tumor, r/o malignancy, suggest biopsy. 2. Right nipple region cystic tumor, r/o intraductal papilloma, suggest biopsy.3. Multiple bilateral breast cysts.
      • 2022/10/24 Chest + Abd CT : Rt breast tumor (15mm) and multiple cysts. Gall tumor.
      • 2022/10/25 Bone scan : Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • She is admitted for partial masmectomy + SLND possible ALND.
    • We need your expertse opinion and set up rehabilitation program for post masmectomy and axillary lymph node dissection.
  • A
    • Physical examination
      • 2022/11/10 14:15 T/P/R: 36.5 degree celsius / 66bpm / 17bpm BP:118/56mmHg
      • Consciousness: clear
      • Cognition: intact
      • MP: RUE/RLE: 5/5, LUE/LLE: 5/5
      • Functional status: ID
      • ADLs: ID
      • Hand and arm circumference (R/L,cm):
        • Elbow joint above 5cm 23/23.5
        • Elbow joint below 5cm 21/21
    • Imp
      • Breast, right Invasive carcinoma, no special type, NST. IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
      • Unspecified lump in breast
    • OP: right partial masmectomy + SLND possible ALND on 2022/11/11.
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
      • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[surgical operation]

• 2022-11-11
  • Surgery
    • partial mastectomy and SLNB
  • Finding
    • right 6/1 tumor, about 1.5cm in diameter, frozen: margin free
    • SLNB: negative of malignancy, 0/2
  • Procedure
    • Under ETGA, we harvested the SLNB under gamma-detecter assisted. The frozen section showed negative of malignancy. Then we performed wide excision for right breast tumor. Then frozen section of margin showed negative of malignancy. After one J-vac drain was left, then we closed the wound layer by layers.

[chemotherapy]

• 2023-02-20 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-30 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-03 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-12 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

• Currently, there are no observed leukopenia symptoms. However, the time serial data of the WBC count showed a downtrend, with the nadir (marked with an asterisk in the following table) indicating a obvious decrease in accordance with the treatment cycle. To avoid over-suppressing the recovery of WBC, it may be beneficial to consider reducing the dose of epirubicin.
  • 2023-03-08 WBC 7.12 x10^3/uL
    
  • 2023-03-02 WBC 0.79 x10^3/uL *
  • 2023-02-16 WBC 7.56 x10^3/uL
    
  • 2023-02-09 WBC 1.13 x10^3/uL *
  • 2023-01-30 WBC 5.90 x10^3/uL
    
  • 2023-01-12 WBC 2.27 x10^3/uL *
  • 2023-01-03 WBC 5.95 x10^3/uL
    
  • 2022-12-20 WBC 2.23 x10^3/uL *
  • 2022-12-12 WBC 4.79 x10^3/uL
    
  • 2022-10-22 WBC 5.16 x10^3/uL

230220

[assessment]

• The WBC count reached its lowest point approximately 7-10 days after the previous chemotherapy treatment in this patient, as indicated by the time relationship between the chemotherapy dates and the lab data recorded at this hospital.

• Epirubicin can cause neutropenia (in 54% to 80% of patients; with grades 3/4 in 11% to 67%; nadir occurring at 10 to 14 days and recovery by day 21) and leukopenia (in 50% to 80% of patients; with grades 3/4 in 2% to 59%). ref: UpToDate

• The prophylactic administration of G-CSF after chemotherapy may be considered around one week after treatment. Another option to consider is to moderately reduce the dose of epirubicin.

• Cyclophosphamide use may lead to hemorrhagic cystitis, which can cause pyelitis, ureteral disease (ureteritis), and hematuria. Therefore, please closely monitor for any signs of these possible adverse reactions. Mesna can be used for the prevention of cyclophosphamide-induced hemorrhagic cystitis in cancer patients. Patients who have difficulty emptying their bladders are at a higher risk of developing bladder toxicity. If there is a clinical concern, a bladder ultrasound should be performed, and if there is a high post-void residual, the use of mesna is also appropriate for such patients.

700130863

230309

{S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019-09-11 s/p post-Op adjuvant chemotherapy FOLFOX finishing in 2020-04 with periotneal seeding s/p laparoscope rt diaphram tumor excision 2021-06-09}

[past history]

• Left thyrioid goiter for 3-4 years with follow up at Taipei City Hospital FuYou Branch

• Gastric polyp, body s/p biopsy (biopsy: Hyperplastic polyp) in 2019/08

• past operation

  • S/P ovarian cystectomy 30+ years ago
  • S/P tubal ligation surgery 30+ years ago

• double cancer

  • Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11.
  • RUL cancer, adenocarcinoma,pT1NoMi(cMx), stage IA1 if cM0, status post 3D VATS RUL lobectomy + RLND on 2019/09/30.
  • Left port-a implantation was done on 2019/10/07.
  • Lung, right upper lobe, lobectomy 2019/09/11 pathology showed minimally invasive adenocarcinoma, pT1miN0(cMx), Stage IA1 if cM0.

[lab data]

• 2021-07-19 All-RAS mutations assay
  • S2021-8200
  • There was no variant detected in the KRAS/NRAS gene.
• 2021-06-30 BRAF mutations assay
  • S2021-08200
  • There was no variant detected in the BRAF gene.
• 2021-06-25 EGFR
  • S2021-08200
  • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen.
• 2021-06-29 Anti-HBc Reactive
  
• 2021-06-29 Anti-HBc-Value 1.89 S/CO
  
• 2021-06-10 Anti-HBs 33.61 mIU/mL
  
• 2021-06-10 HBsAg Nonreactive
  
• 2021-06-10 HBsAg (Value) 0.40 S/CO
  
• 2021-06-10 Anti-HCV Nonreactive
  
• 2021-06-10 Anti-HCV Value 0.22 S/CO

[exam findings]

• 2023-01-30 PET scan
  • Glucose-hypermetabolism lesions in the perirectal region and in bilateral inguinal lymph nodes are new compared with the previous study on 2021-05-17, the nature is to be determined, suggesting biopsy for investigation.
    
  • Glucose-hypermetabolism in bilateral mediastinal lymph nodes and bilateral pulmonary hilar lymph nodes, probably reactive nodes.
    
  • Glucose-hypermetabolism in the left adrenal region, probably benign or malignant tumor of the left adrenal gland.
    
  • Increased FDG accumulation in the left kidney and ureter, suggesting left GU tract obstruction (resulting from perirectal tumor ?).
    
  • A glucose hypometabolism lesion in the right upper lung, compatible with right lung cancer s/p treatment.
• 2023-01-12 Sigmoidoscopy
  • Left lateral rectal wall scar , suspect extrarectal tumor with regression
• 2023-01-09 KUB
  • S/P double J catheter insertion in place, left side.
  • Non-specific bowel gas pattern.
  • Calcifications in LUQ, r/o left renal stones.
  • Lumbar spondylosis.
• 2023-01-09 Body fluid cytology - urine
  • 32 cc yellow clear urine — Atypia, favor reactive change
• 2023-01-08 CXR
  • Opacification in right upper lung, stationary.
• 2023-01-05 ECG
  • Normal sinus rhythm
  • S1-S2-S3 pattern, consider pulmonary disease, RVH, or normal variant
  • Left anterior fascicular block
  • Abnormal ECG
• 2022-12-28 CT - abdomen
  • History:
    • 20190902 CT abdo: S-colon cancer, cT3N2aM0 s/p LAR n 2019/09/11 s/p post-Op adjuvant C/T wt FOLFOX finishing in 2020/04,
    • 20190826 CT lung: an irregular GGO 16 mm with central solid component (5mm) in RUL. path: Minimal invasive adenocarcinoma, pT1miNoMo, pStage:IA1
    • 20210531 CT: Multiple metastases at peritoneal cavity.
    • 20211203 CT: Omentum metastases S/P C/T show stable disease.
  • MD CT (Aquilion Prime SP) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images with axial and coronal reformated isotropic images were obtained in non-contrast scan and portal venous phase scan after IV contrast injection.
  • FINDINGS - Comparison: prior CT dated 2022/06/10.

    • Prior CT identified a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion is noted again, marked decreasing in size and poor margination.

      • Tumor seeding S/P C/T with partial response is highly suspected.

    • S/P LAR with autosuture retention over the sigmoid colon.

      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.

    • Liver and renal cysts (up to 2.4cm).

    • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change. please correlate with clinical history.

    • Others

      • There is no focal lesion in mediastinum.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen.
      • There is no ascites or lymphadenopathy.
      • There is no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
  • IMP
    • Tumor seeding in the rectum S/P C/T show partial response. please correlate with clinical condition.
    • Multiple omentum metastases S/P C/T show stable disease.
• 2022-10-27 Anoscopy
  • Mixed hemorrhoid and posterior fissure
• 2022-09-29 CT - abdomen
  • History and indication: Sigmoid cancer with peritoneal seeding and local recurrence s/p OP, s/p R/T, s/p C/T
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Mild regression of peritoneal seeding.
    • Liver and renal cysts (up to 2.4cm).
    • Normal appearance of spleen, pancreas, adrenals.
    • Normal appearance of gallbladder.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral lungs.
  • IMP:
    • Mild regression of peritoneal seeding.
• 2022-09-23, -09-21 KUB
  • Fecal material store in the colon.
  • S/P LAR with autosuture retention over the sigmoid colon.
• 2022-09-03 Foot LT
  • left 5th metatarsal neck fracture
  • acceptable alignment with few callus
• 2022-06-10 CT - abdomen, pelvis
  • Findings:
    • There is a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion, measuring 3.2 x 2.1 cm in size.
      • Tumor seeding is highly suspected.
      • The differential diagnosis include rectal cancer.
    • S/P LAR with autosuture retention over the sigmoid colon.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.
    • Liver and renal cysts (up to 2.4cm).
    • There is no focal lesion in mediastinum.
      • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change. please correlate with clinical history.
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen.
    • There is no ascites or lymphadenopathy.
    • There is no bowel obstruction.
      
    • The abdominal aorta and IVC are grossly unremarkable.
      
    • There is no evidence of intrinsic or extrinsic bladder mass.
      
  • IMP:
    • Tumor seeding in left lateral anterior aspect of the rectum with left uterine cervix and vaignal invasion is suspected. The differential diagnosis include rectal cancer. please correlate with clinical condition.
    • Multiple omentum metastases S/P C/T show stable disease.
• 2022-03-20 ECG
  • Normal sinus rhythm
  • Left anterior fascicular block
• 2022-03-11 CT - abdomen, pelvis
  • FindingsFINDINGS:
    • S/P LAR with autosuture retention over the sigmoid colon.
    • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.
    • Liver and renal cysts (up to 2.4cm).
    • There is no focal lesion in mediastinum.
    • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change. please correlate with clinical history.
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen.
    • There is no ascites or lymphadenopathy.
    • There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable.
      
    • There is no evidence of intrinsic or extrinsic bladder mass.
  • IMP:
    • Multiple omentum metastases S/P C/T show stable disease.
• 2021-12-03 CT
  • Multiple omentum metastases S/P C/T show stable disease.
• 2021-09-03 CT
  • Multiple omentum metastases S/P C/T show stable disease.
  • Metastasis or post-operative change in left upper pelic wall?
• 2021-06-09 Patho - colon ca s/p at 2018 with intraabd recurrent, including bilat diaphragm, T-colon stomach surface and rt liver surface
  • Tumor, R’t diaphragm, biopsy - Metastatic colonic adenocarcinoma
  • IHC: CK7(-), CK20(+), CDX2(+) and TTF-1(-) for tumor.
  • IHC: EGFR (+, weakly); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+)
  • According to clinical information and above histopathologic findings, it indicated a case of metastatic colonic adenocarcinoma.
• 2021-05-31 CT - whole abdomen, pelvis
  • S/P colon operation. Multiple metastases at peritoneal cavity.
• 2021-05-17 Whole body PET scan
  • Glucose-hypermetabolism in the right mediastinal lymph nodes, probably recurrent lung cancer with regional lymph nodes involvement.
    
  • Glucose-hypermetabolism in the left mediastinal lymph nodes and left pulmonary hilar lymph nodes, probably reactive nodes or recurrent lung cancer with regional lymph nodes involvement.
    
  • Glucose-hypermetabolism in bilateral adrenal regions, probably recurrent lung cancer with bilateral adrenal glands metastases.
  • Glucose-hypermetabolism in peritoneal lymph nodes in the epigastric region, right hypochondriac region, and bilateral lumbar regions of abdomen, probably recurrent colon cancer with peritoneal metastases.
    
  • S-colon cancer s/p treatment with tumor recurrence, rcTxNxM1c, stage IVC (AJCC 8th ed.); right lung cancer s/p treatment with tumor recurrence, rcTxN2-3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
• 2021-05-14 MRI - MR Cholangiography (MRCP)
  • Multiple cysts on both hepatic lobes.
• 2019-08-26 CT - lung cancer screening (Low-dose CT)
  • RUL lung cancer TmiNOMO stage IA1
• 2019-10-09 Patho - Uterus, cervix, biopsy
  • Chronic cervicitis with reactive aypia
  • IHC, the epithelial cells are negative for p16 and ki-67 proliferation index <5%.
• 2019-10-01 Patho - Lung, right upper lobe, lobectomy
  • Minimally invasive adenocarcinoma
    
  • Lymph nodes, group 2+4, 7, 11; RLND - No metastatic carcinoma
    
  • pTNM Pathology stage: pT1miN0(cMx), Stage IA1 if cM0
• 2019-09-12 Patho - Malignant sigmoid colon neoplasm
  • Sigmoid colon, LAR - Adenocarcinoma, moderately differentiated
  • Lymph node, mesocolic, dissection - Positive for tumor metastasis (4/16) with extracapsular extension (3/4)
  • AJCC pathologic stage - pT4bN2aMx, stage IIIC at least
• 2019-09-02 CT - liver, spleen, biliary duct
  • T3N2aMx
• 2019-08-29 Whole body PET scan
  • A glucose hypermetabolic lesion in the sigmoid colon, compatible with colon malignancy.
  • A faint glucose hypermetabolic lesion in the upper lobe of right lung. The nature is to be determined.
  • Glucose hypermetabolism in the right pulmonary hilar region. The nature is to be determined.
  • Mild glucose hypermetabolism in the left lobe of the thyroid gland.
• 2019-08-26 Patho - colon, sigmoid or rectosigmoid junction, biopsy
  • Ademocarcinoma
  • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).

[consultation]

• 2022-12-10 Dermatology
  • Q
    • This 80-year-old woman patient is a case of S-colon cancer, cT3N2aM0, stage IVC s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy with FOLFOX finishing in 2020/04 with periotneal seeding s/p laparoscope right diaphram tumor excision on 2021/06/09 s/p palliative chemotherapy with FOLFIRI from 2021/07/01~2022/07/27 and Avastin from 2021/10/08~2022/07/27 with tumor seeding in left lateral anterior aspect of the rectum with left uterine cervix and vaignal invasion s/p radiotherapy to anal tumor s/p palliative chemotherapy with Erbitux/FOLFIRI from 2022/09/08. She was adnmitted for chemotheraopy with Erbitux/FOLFIRI(C4D1).
    • This time, for right thumb nail gap redness, swelling with pain, suspected paronychia.
  • A
    • This patient suffered from dyskeratotic nails for months and erytheamtous patches for days
    • Imp:
      • Tinea unguim
      • Asteatotic dermatitis
    • Suggestion:
      • Excelderm solution (sulconazole) x 4 BT/Bid
      • Mycomb (nystatin, neomycin, triamcinolone acetonide, gramicidin) x 4 tubes/bid
• 2022-08-27 Psychosomatic Medicine
  • Q
    • This 79-year-old woman patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy wt FOLFOX finishing in 2020/04 with periotneal seeding s/p laparoscope rt diaphram tumor excision on 2021/06/09. He was admitted for palliative chemotherapy. This time, for depression, anxiety. Now, for evaluate drug therapy. Thank you.   
  • A
    • This 79-year-old woman, our YiDe Mama. She was diagnosed as colon cancer in 2018. She could tried hard to cope with it, untill 2021/5, she developed RLQ pain and exams revealed relapse and metastesis of cancer. She started to develop low and anxious mood, unspokable distress, lack of pleasure and poor appetite, and rumination of negative thoughts. Psychiatrist was consulted in 2021/11 and she also started a conseling with onco-psychologist. The mood condition has been partially improved under mirtazapine 30mg 1# HS, however she still percieved low and tense mood (invisible stress all day), lack of appetite, preoccupation on the somatic distress, ruminated thoughts about the intrafamilial issue (worried that her daughters will not get along well), some demoralize feelings about treatment (she feels that chemotherapy is a long way off, and there is no hope). She tried to cope with walking outside with daughter and watching TV show but lack of true pleasure.
    • She denied obvious impairment on cognitive function, denied sleep problem nor suicidal ideation.
    • MSE: Low and anxious mood, inner tension, ruminated and negative thoughts, hopelessness and demoralized feelings. lack of pleasure and motivation.
    • IMP: Depressive disorder
      • suspected Adjustment disorder with depressive mood
    • Suggestion:
      • Keep mirtazapine 30mg 1# HS.
      • Add sulpiride 50mg 1# HS for adjuctive therapy of depression.
      • Carthasis and empathy. Psychoeducation to the family and the patient.
      • Arrange PSY OPD follow up.
• 2021-11-18 Mental Health
  • Clinical impression:
    • Depressive disorder
    • Adjusment disorder
  • Clinical course:
    • This 78-year-old female patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis s/p post-Op C/T with periotneal seeding s/p laparoscope rt diaphram tumor excision. She was admitted for chemotherapy with Avastin/FOLFIRI(C5D1).
    • We were consult for depressed mood and poor appetite.
    • According to past medical record, during admission in July for chemotherapy, psychiatric department was consulted once for panic symptoms, but no further OPD follow up.
    • At bedside, the patient is conscious clear, lying on the bed resting, with her daugher at the bedside. She started to percieved dysphoric and low mood since she was diagnosed with cancer on 2018, but she tried hard to modify her mindset and cope with the distress, and able to maintain acceptable mood. Until this year 2021-05, she suffered from right lower abdominal pain, and PET scan found metastatis of the cancer, and started to recieved treatment again.
    • Recently, she noted that she began to be easily irritable and dysphoric, unspoken stressfulness feeling, high inner tention, decrease of reward sensation and low mood, decrease appetite, negative thoughts, sleep disturbance (poor maintainence, unstable), got worse in recnent 2 weeks.
    • She received psychotherapy in recent half year, feel better at first, but noticing unable to control now.
  • MSE:
    • Kempt, polite. Frowning and distressful look. Sometimes she smiles when talk about the people who support her so much.
    • Coherent and relevant speech, articulate
    • Fair attention lasting
    • Depressed mood, low drive and energy, fatigue
    • Ruminated thought
    • Denied hopeless or helplessness, denied suicide ideation
    • Poor appetite and insomnia
  • Suggestion:
    • Psychoeducaiton and emotional support
    • Add mirtapine (30) 1#HS for depressive mood, enhacing appetite. Eurodin 1#HS for insomnia
    • Arrange psychiatric OPD follow up
• 2021-07-20 Mental Health
  • Psychiatric impression:
    • Panic attack
    • Suspected anxiety disorder
  • Psychiatric history:
    • This 78-year-old female patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy (FOLFOX) finishing in 2020/04 and peritoneal seeding s/p laparoscope Rt. diaphragm tumor excision 2021/06/09. Palliative chemotherapy with FOLFIRI(Campto 90mg/m2, LV 400mg/m2, 5FU 2400mg/m2)(C1D15) was done during 2021/07/15~2021/07/17. We were consult for anxiety. According to the patient, she suffered from episodic chest tightness, dizziness, general weakness, tremors and feeling loss of control since early July. She also perceived low mood and negative thinking intermittently for several weeks. During this admission, frequent experience of chest tightness, hands tremor, limb numbness and parathesia (hot and cold sensation). She feeling frustration form physical discomfort and these panic like symptoms.
  • MSE:
    • Coherent and relevant speech
    • Fair attention lasting
    • Depressed mood, low drive and energy, fatigue
    • Ruminated thought
    • Denied hopeless or helplessness, denied suicide ideation
    • Poor appetite and insomnia with terminal type under stilnox
  • Suggestion:
    • Psychoeducaiton and emotional support
    • Add mirtapine (30) 0.5mg HS
    • Arrange psychiatric OPD follow up
• 2021-06-09 Hemato-Oncology
  • Q
    • for chemotherapy
    • This is a 78y/o female with past history of 1) Adenocarcinoma of sigmoid colon with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11, s/p post-Op adjuvant C/T wt FOLFOX finishing in 2020/4; 2) Bilateral thyroid tumors status post bilateral thyroidectomy on May 26, 2020; 3) Minimal invasive adenocarcinoma of lung over RUL, s/p VATS segmentectomy + RLND, pT1miN0M0, stage IA1 on 2019/09/30; 4) s/p ovarian cystectomy; 5) s/p tubal ligation surgery 30+ years ago.
    • This time she was visited our OPD due to LLQ abdominal pain for about 3 months, which several examination were arranged, MRI on 5/14 showed multiple cysts on both hepatic lobes;
    • Whole body PET scan on 5/18 revealed 1. Glucose-hypermetabolism in the right mediastinal lymph nodes, probably recurrent lung cancer with regional lymph nodes involvement. 2. Glucose-hypermetabolism in the left mediastinal lymph nodes and left pulmonary hilar lymph nodes, probably reactive nodes or recurrent lung cancer with regional lymph nodes involvement. 3. Glucose-hypermetabolism in bilateral adrenal regions, probably recurrent lung cancer with bilateral adrenal glands metastases. 4. Glucose-hypermetabolism in peritoneal lymph nodes in the epigastric region, right hypochondriac region, and bilateral lumbar regions of abdomen, probably recurrent colon cancer with peritoneal metastases. 5. S-colon cancer s/p treatment with tumor recurrence, rcTxNxM1c, stage IVC (AJCC 8th ed.); right lung cancer s/p treatment with tumor recurrence, rcTxN2-3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
    • Abdominal CT on 5/31 showed Multiple metastases (up to 2.4cm) at peritoneal cavity. Therefore under impression of multiple tumor recurrance and metastases, she was admitted to GS ward on 6/3.
    • She received operation with laparoscopic and showed multiple tumor seedind was noted right diaphragm (2) and right liver surface, gasric antrum surface(1), left diaphragm (2). T-colon (3) left lower quadrant (1), PCI: 9/39 and liver metas was noted. So further percedure with laparoscope right diaphram tumor excision and HIPEC with Oxalip 300mg/M2(408mg) for 60mins was processed successfully on 6/9. We need your help for further chemotherapy evaluation of 5FU since 6/10. Thanks for your time!!
  • A
    • Patient examined and Chart reviewed. A case of sigmoid colon cancwer is noted. I am conslted for further management.
    • My suggestions would be:
      • Please prescribe the 5-FU as follows: 5-FU 1200 mg/m2 NS 500 mL IVD 24 hours for 2 days, LV 120 mg/m2 in NS 500 mL IVD 24 hours for 2days.
      • Please arrange my OPD appointment after being discharged.
      • Any issue, please let me know.
• 2020-03-30 Colorectal Surgery
  • Q
    • This 77 years old famale patient has history denocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 108/09/11 (Bloody stool on 108/8) under chemotherapy as FOLFOX. Due to hemorrhoid with bleeding bother her, so we need your help for management.
  • A
    • We had visited the patient that she was a case of mild mixed hemorrhoids.
    • PE:
      • No induration, no redness, no perianal pain
      • No palpable mass around low rectum, no obvious bloody clot on gloves
    • IMP:
      • Mild mixed hemorrhoids, no obvious external hemorrhoid
    • Suggest:
      • Alcos-anal ointment was considered
      • Change habit of stool passage
      • Education about sitz bath and have more water/fiber food
      • Arrange CRS OPD if she still have hemorrhoidal problems

[surgical operation]

• 2023-01-09
  • Surgery
    • Ureterorenoscopic exam & double-J stenting (tumor stent), left.        
  • Finding
    • Left lower and upper ureter stricture and kinking.
• 2021-06-09
  • Surgery
    • Laparoscope rt diaphram tumor excision
    • HIPEC with oxalip 300mg/m2 for 60 mins
  • Finding
    • right diaphragm (2) and right liver surface
    • gasric antrum surface (1), left diaphragm (2). T-colon (3) left lower quadrant (1)
    • PCI: 9/39 and liver mets
    • ascite: nil
• 2020-05-26
  • Surgery
    • L’t lobectomy + right partial thyroidectomy
  • Finding
    • enlargement of left thyroid gland with multiple goiter lesions and trachea deviation noted
    • some goiter lesions over right thyroid gland also noted
• 2019-09-30 Thoracoscopic Lobectomy
• 2019-09-11 Laparoscopic anterior resection and anastomosis, sigmoid colon resection, tumor

[chemoimmunotherapy]

• 2023-03-08 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-24 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-02-06 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2023-01-13 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-12-09 - irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-25 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-11-07 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-10-07 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-09-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-09-08 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
• 2022-08-26 - irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-08-12 - irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-07-27 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-07-15 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-06-29 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-06-17 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
• 2022-06-01 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-05-20 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-05-06 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-04-24 - irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-04-08 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-03-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-03-11 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-02-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-02-07 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2022-01-14 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-12-30 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-12-15 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-12-03 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-11-17 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-11-05 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-10-22 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 175mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-10-08 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-09-20 - irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
• 2021-09-03 - irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
• 2021-08-20 - irinotecan 120mg/m2 140mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
• 2021-07-15 - irinotecan 120mg/m2 140mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
• 2021-07-01 - irinotecan 90mg/m2 120mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
• 2021-06-10 - leucovorin 120mg/m2 165mg 24hr D1-2 + 5-Fu 1200mg/m2 1635mg 24hr D1-2
• 2021-06-09 - oxaliplatin 300mg/m2 408mg 90min
• 2021-04-13 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
• 2021-03-30 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
• 2021-03-16 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
• 2021-03-02 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
• 2021-02-14 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
• 2021-01-31 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
• 2021-01-09 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

==========

2023-03-09

• The patient has been diagnosed with major depressive disorder and a sleep disorder and is currently receiving regular follow-up care from our psychologist. The medications Lexapro (escitalopram) and Mirtapine (mirtazapine) are appropriately added to her active drug list and there are no issues with reconciliation.
• Lab data showed that her TSH and T4 levels have been within the normal range for the past six months. Her hypothyroidism is being well-managed with a weekly dosage of 850ug of Eltroxin (levothyroxine).
• New glucose-hypermetabolism lesions detected in perirectal region and bilateral inguinal lymph nodes in 2023-01-30 PET scan. Nature of lesions unknown. In addition, the PET result also revealed that glucose-hypermetabolism has been detected in bilateral mediastinal and pulmonary hilar lymph nodes, which are likely reactive nodes. (The patient underwent a 3D VATS RUL lobectomy and RLND on 2019-09-30, for her adenocarcinoma in the RUL, which was classified as pT1NoMi(cMx), stage IA1 if cM0.)
• There are no issues with the current prescription.

2022-06-30

• CT images on 2022-06-10 showed a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vaginal invasion. A number of small soft tissue nodules were identified in the omentum (mets) and were still stable in size as compared to prior CTs under FOLFIRI (administered since 2021-07). Therefore, the newly developed lesion might be different from the original in some respects.

2022-06-02

• The patient received FOLFOX during 2020-01 to 2020-04 and has been receiving FOLFIRI since 2021-06 (plus bevacizumab since 2021-10).
• A time series of CT scans showed that the size of omentum mets stayed stable from 2021-09 to 2022-03-11 (most recent). The regimen is considered to be effective at keeping the disease stable.
• Hypothyroidism is still an active problem and Eltroxin (levothyroxine) can be found in recent PharmaCloud records. It is recommended that levothyroxine be prescribed as a self-carried item until the problem is resolved.

2022-03-11

• the last exam report is dated on 2021-12-23, no updated image; CEA, CA199 readings remain stable around 9ng/mL, 53U/mL, respectively; most WBC and CBC items and all the liver, kidney function tests (reported on 2022-03-09) were in normal range; the systolic blood pressure was slightly higher (159mmHg) at 13:14 2022-03-11.
• the underlying diseases are treated with the drugs in the current medication list without issue.

2022-02-08

• according to time-serial CT images, CEA, CA199 readings, the disease remains stable in recent months under current regimen.
• no drug allergy recorded in database, no issue found with active medication.

2021-08-13

[loss of appetite]

visiting the patient (with her daughter accompanied) at around 16:20 on 2021-08-13.

S:

• the patient does not feel like to eat these days.

O:

• poor appetite, not eat much.
• cachexia still in problem list.

A:

• chemo not applied yet since this hospitalization, not chemo induced poor appetite for sure, could be psychogenic.
  • psychological counselor had visited the patient on 2021-08-09.
• some appetite stimulant could be of help.

Suggestion

• Megejohn (megestrol 160mg/tab) PO QD could be an option to serve as appetite stimulant.
  • dronabinol and oxandrolone are not available in the hospital.

701443048

230309

[exam findings]

• 2023-01-09, 2022-12-13, -12-06, -11-22 CXR
  • Increased infiltration over RLL. May be active infection.
  • S/P port-A catheter insertion.
  • S/P tracheostomy.
  • S/P N-G tube insertion.
• 2022-11-03 Patho - colon biopsy
  • Distal transverse colon, biopsy — Ulcer
• 2022-11-01 PD-L1 IHC 28-8
  • PD-L1 Immunostaining Result
    • Tumor cell (TC) staining assessment: TC < 1%
    • Percentage of 28-8 expressing tumor cells (%TC): 0%
• 2022-10-21 MRI - nasopharynx
  • Indication: Malignant neoplasm of tongue, unspecified
  • Findings
    • invasive tumors with heteorogeneous enhancement in the bilateral oropharynx, posterior tongue, oral tongue, mouth floor, left buccogingical mucosa, the mendible, left pterygoid plates, lower lip with the largest axis, about 111mm.
    • enlarged lymph nodes in the bilateral submandibular spaces
    • a nodular lesion about 25mm in the left thyroid gland.
  • IMP: invasive oral cavity cancer, in progression.
• 2022-10-18 Patho - colon biopsy
  • Large intestine, descending, biopsy —- ulcer with non-specific colitis
• 2022-10-06 Nasopharyngoscopy
  • Granulation over mouth floor, left gingival sulcus, left tonsillar fossa, tongue base (almost contacted lingual side of epiglottis), bulging of R posterior phayrngeal wall, cystic formation? over R AE fold, fair vocal cord movement
• 2022-10-05 CT - abdomen
  • History: Recurrent squamous cell carcinoma of tongue, cT4aN0M0, stage IVA
  • Findings:
    • There is distension with fluid and gas collection of the entire colon. please correlate with clinical condition.
    • A renal cyst measuring 1.5 cm in right middle pole is noted.
    • There minimal effusion in right posterior basal CP angle.
• 2022-10-03 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • PEG insertion site (wound) at AW of lower body, without presence of the PEG tube, suspected buried bumper syndrome
    • Bilious substance in stomach
    • Oral cancer
  • Suggestion
    • No bloody substance or active bleeder in UGI tract. Please survey other bleeding source, such as LGI bleeding.
    • Consider CT scan to confirm the location of the PEG. Remove the PEG tube and then revision should be done If buried bumber syndrome or migration of PEG is confirmed.
• 2022-09-12 ECG
  • Sinus tachycardia
  • ST & T wave abnormality, consider inferior ischemia
  • ST & T wave abnormality, consider anterolateral ischemia
• 2022-08-12 Patho - gingival/oral mucosa biopsy
  • Labeled as “left lower gingiva”, incisiaonal biopsy — squamous cell carcinoma.
  • IHC stains: p16 (-), CK5/6 (+), p40 (+).
• 2022-08-10 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed hot areas in the mandible, and increased activity in the skull base, bilateral sternoclavicular junctions, shoulders, and S-I joints, in whole body survey.
  • IMPRESSION:
    • Hot areas in the mandible, the nature is to be determined (dental problem, cancer with local bone involvement, or other nature ?), suggesting further evaluation and follow-up with bone scan in 3 months.
    • Suspected benign lesions in the skull base, bilateral sternoclavicular junctions, shoulders, and S-I joints.
• 2022-08-09 MRI - nasopharynx
  • Oropharyngeal Cancer (p16-) Staging Form
  • For Oropharyngeal Carcinoma (p16-)
    • 20. PRIMARY TUMOR:
      • T4 : Moderately advanced or very advanced local disease
        • T4a : Moderately advanced local disease: Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible
    • 14. REGIONAL LYMPH NODES:
      • N1 : Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension and ENE(−)
    • 13. DISTANT METASTASIS:
      • M0 : No distant metastasis (in this study)
  • AJCC 8th edition Staging status: T4aN1M0
• 2022-08-08 SONO - abdomen
  • incomplete exam of liver
  • pancreas obscured

[consultation]

• 2023-03-09 Family Medicine
  • Q
    • For hospice care for pain control and and aromatherapy and lymphatic massage
    • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. immunotherapy with OPDIVO and CCRT at our hospital since 08/16/2022 (The treatment process has been listed in detail in the progress note). ECOG: 3. However, anemia, hypoalbuminemia and mild electrolyte imbalance and swelling of face were noted. We need your help for combined hospice care for pain control and and aromatherapy and lymphatic massage, Thanks !!
  • A
    • 41 y/o gentleman advanced tongue cancer
    • pain control now
      • Fentanyl 2 large Q3D, Oxynorm (5) 2# q4H, MXL (60) 1# Q12H
    • VAS 5~ 7
    • may add lyrica for neuropathic pain
    • adjust morphine as required
    • Our sahre care would follow up.
• 2023-03-07 Nephrology
  • Q
    • For severe hyponatremia and unbalance electrolye
    • Because of severe hyponatremia, we need your help, Thanks!!
  • A
    • We visited the patient at the bedside and evaluated his condition. His consciousness was clear, speech was coherent, no respiratory distress, no convulsions and no focal neurological symptoms were noted, and his four limbs were not edematous. He denied having drunk excessive free water or urinated in larger amount than usual.
    • His blood test showed a steep decline in serum Na levels over the course of hospitalization, but we require more data to determine the nature of hyponatremia.
      • 2023-03-06 Na (Sodium) 109 mmol/L
        
      • 2023-02-27 Na (Sodium) 126 mmol/L
        
      • 2023-02-24 Na (Sodium) 129 mmol/L
        
      • 2023-02-20 Na (Sodium) 132 mmol/L
        
    • Our advices are as follows
      • Adequate hydration with isotonic saline, and avoid 3% hypertonic saline unless patient exhibit severe neurological symptoms
      • Monitor serum Na at least Q12H, changes in serum Na levels should not exceed 4-6mEq/L within 24 hours or osmotic demyelination syndrome (ODS) may develop
      • Monitor urine output amount and neurological symptoms
      • Check serum osmolality, TSH, fT4, ACTH (8am), Cortisol (8am)
      • Check urine osmolality, Na, Cre
    • Please feel free to contact us should you require further assistance.
• 2023-02-27 Ear, Nose, and Throat
  • Q
    • For nasal bleeding management.
    • This 41-year-old Philippine male patient was a case of recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVa.
    • MRI revealed tumor had involved to posterior pharyngeal walls. We need your help for nasal bleeding management. Thanks.
  • A
    • S
      • L nasal bleeding even after bosmin gauze compression
      • a case of Recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVA with cuffed-tracheostomy (Rota)
    • O
      • Left anterior nasal bleeding
      • trismus and oropharynx invisible, but no blood noticed from oral cavity
      • scope can not be performed due to active bleeding even under bosmin gauze
      • no more bleeding after merocel packing over left common meatus
    • A
      • Left epistaxis
    • P
      • no more bleeding after merocel packing over left common meatus
      • suggest abx usage for merocel insertion
      • may contact us for merocel removal 5-7 days later
• 2023-02-21 Infectious Disease
  • Q
    • For severe leukocytosis
    • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. immunotherapy with OPDIVO and CCRT at our hospital since 08/16/2022. ECOG: 3. However, anemia, hypoalbuminemia and mild electrolyte imbalance were noted.
    • Because of severe leukocytosis (CRP:12.19, WBC: 17680) and sputum culture revealed Pseudomonas aeruginosa 2+ and Achromobacter xylosoxidans 2+, we need your help, Thanks !!
• 2023-01-12 Cardiology
  • Q
    • For severe hypertension
    • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. Immunotherapy with OPDIVO and CCRT at our hospital since 2022-08-16. ECOG: 3. However, Anemia . hypoalbuminemia and mild electrolyte imbalance were noted . Because of severe hypertension recently, we need your help, Thanks !!
  • A
    • S
      • This 41 y/o male patient is a case of squamaous cell tongue cancer s/p OP and C/T with recurence. He was admitted for palliative chemotherapy. He also had previous history of bronchial asthma and no longer attack in the previous 2 years. High BP was recorded after hospitalization. Now we are consulted for adjusting anti-HTN medications.
    • O
      • BP: 160_190/80110+ mmHg, HR:80~110 BPM
      • Current anti-HTN medications: olmetec 1# BID use
      • 20221024 EKG: sinus tachycardia
      • 20230111 BUN/CR:12/0.55, ALT:8, K:3.1
    • Suggestion:
      • Please add adapin (nifedipine 30mg) 1# QD and nebilet (nebivolol 5mg) 1/2 # QD for better BP and HR control.
      • If elevated BP is still recorded 3~5 days later, then push up adapin to 1 # BID, and push up nebilet to 1# QD if no bronchial asthma happens after nebilet treatment.
      • Change olmetec to micardis (telmisartan) 1# QD if above treatment is unsatisfactory for BP control.
• 2022-11-22 Radiation Oncology
  • Q
    • For radiation therapy
    • This is a 41-year-old male Fillipino patient , he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy and imunotherapy.
      • Anti-neoplastic therapy:
        • Palliative chemotherapy with #3 Erbitux 400mg/M^2 + #2a 90% TPF (Taxotere 36mg/M^2, Cisplatin 36mg/M^2, 5-Fu 900mg/M^2, Leucovorin 90mg/M^2) on 2022/09/07 - 2022/09/09.
        • Palliative chemotherapy with #4 Erbitux 400mg/M^2 + #2b 60% TPF (Taxotere 24mg/M^2, Cisplatin 24mg/M^2, 5-Fu 600mg/M^2, Leucovorin 60mg/M^2) on 2022/09/30 - 2022/10/02.
        • Palliative chemotherapy with #5 Erbitux 250mg/M^2 + #3a 70% Taxotere 28mg/M^2 on 2022/11/01.
        • Palliative chemotherapy with #6 Erbitux 250mg/M^2 + #3b 70% Taxotere 28mg/M^2 on 2022/11/11.
          
        • Immunotherapy with #1 OPDIVO 160mg on 2022/11/07. 2022/11/22.
  • A
    • S: For palliative radiotherapy due to recurrent left tongue cancer.
    • O
      • PI: This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left oral tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Philippines. Because of recurrent squamous cell carcinoma of tongue, he was admitted for palliative chemotherapy and immunotherapy.
        • Previous RT Hx (2021-11-15 ~ 2021-12-31, St. Luke’s Medical Center, Phippines): 6000cGy/30 fractions of the (GTVp+0.1cm+ entire tongue, base of tongue, alveolar ridge, epiglottis, bilateral retrostyloid, level IB, II, III, IV, V, and modified level VI and left level IA nodes, + margins), 7000cGy/35 fractions of the [(GTVp(heterogenous enhancing mass, left hemitongue extending to the right side) + margin), + prechemotherapy level IIA, bilateral; level IB, right]+ margin] + margin.
          
      • ECOG: 3
      • PE: oral cavity: protruding tumor mass over anterior tongue border and low gum; poor hearing function; on oxygen inhalation.
      • MRI (2022-08-09): stage T4a(5.3cm, right tongue base; left tonsillar fossa, oropharyngeal wall), N1(right level I, single lymphadenopathy)M0.
      • Bone scan (2022-08-10): Hot areas in the mandible, the nature is to be determined (dental problem, cancer with local bone involvement, or other nature ?)
      • Pathology (S2022-13232, 2022-08-16): Labeled as “left lower gingiva”, incisiaonal biopsy — squamous cell carcinoma. IHC stains: p16 (-), CK5/6 (+), p40 (+).
      • CXR (2022-10-07): No cardiomegaly. No active lung lesion. Normal bony contour. S/P port-A catheter insertion.
      • MRI (2022-10-21): 1. invasive tumors with heteorogeneous enhancement in the bilateral oropharynx, posterior tongue, oral tongue, mouth floor, left buccogingical mucosa, the mendible, left pterygoid plates, lower lip with the largest axis, about 111mm. 2. enlarged lymph nodes in the bilateral submandibular spaces. 3. a nodular lesion about 25mm in the left thyroid gland. Imp: invasive oral cavity cancer, in progression.
    • A:
      • Squamous cell carcinoma of left oral tongue, stage cT3N0M0, stage III, s/p partial glossectomy on 2015/07.
      • Squamous cell carcinoma of left oral tongue, stage cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy and definitive radiotherapy in Philippines, with progression, s/p palliative chemotherapy and immunotherapy.
    • P: Palliative radiotherapy is indicated for this patient with the following indicators: tumor progression
      • Goal: pallaition
      • Treatment target and volume: tumor over left oral tongue to low gum and peripheral involved area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 3000cGy/15 fractions
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be arranged.
• 2022-10-28 Thoracic Surgery
  • Q
    • This 41-year-old Philippine male patient was a case of recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVa. MRI revealed tumor had involved to oropharyngeal walls. However, he had suddened onset severe dyspnea and stridor were found. Acute respiratry failure were highly suspected, we need your for tracheotomy tube insertion. Thanks !!
  • A
    • The patient had buccal ca. s/p CCRT with fibrotic neck
    • Progressive dyspnea noted since last night
    • Tracheostomy may be considered but very high risk of life threatening
    • Consult ANE Dr for evaluation
    • Prepare ICU bed
• 2022-10-12 Dermatology
  • Q
    • However, patient complained of itching skin lesion suspected fungal infection in right inguinal was noted for a while. We need your expertise and further management. Thanks !!
  • A
    • The patient had sufferred from erythematous to blackwish palques over bilateral inguinal area with staellite active borders.
      
    • Under the impression of intertrigo eczema with seocndary candidiasis infesation.
    • The following sugeetion:
      • Zalain (sertaconazole) 1 tube topical bid use over large area of invloved area
      • Please keep the affected area dry and clean, add Mycomb (nystatin, triamcinolone, neomycin, gramicidin) 1 tube topical bid use on the active scaling lesions of bilateral inguinal area.
• 2022-10-03 Gastroenterology
  • Q
    • However, blood stool since 2022-10-02 was noted. Anemia (Hb: 7.9) and tachycardia this morning. Because of suspected GI bleeding. We need your further evaluation and suggestion. Thanks !!
  • A
    • S
      • The 41-year-old man has left tongue cancer, cT3N0M0, stage III, s/p glossectomy and chemotherapy at Philippines. Due to further treatment of recurrent left tongue cancer, he transfered to Taiwan for further management. He just received chemotherapy, finished on 2022-09-30 but bloody stool with tarry was noted. Therefore, we are consulted for further management.
    • O
      • PE
        • conscious: clear
        • chest: smooth breath pattern under room air
        • abdomen: soft and flat
        • extremity: warm
      • Lab
        • Hb: 10.8 -> 7.9
        • Plt: 515k -> 542k
      • 20221003 EGD
        • Diagnosis:
          • Reflux esophagitis LA Classification grade A
          • Superficial gastritis
          • PEG insertion site (wound) at AW of lower body, without presence of the PEG tube, r/o buried bumper syndrome
          • Bilious substance in stomach
          • Oral cancer
        • Suggestion:
          • No bloody substance or active bleeder in UGI tract. Please survey other bleeding source, such as LGI bleeding.
          • Consider CT scan to confirm the location of the PEG. Remove the PEG tube and then revision should be done If buried bumber syndrome or migration of PEG is confirmed.
    • Impression
      • Tarry stool with blood clot, lessly like Upper GI tract bleeding by 20221003 EGD, need to rule out Lower GI tract bleeding
    • Suggestion
      • Due to the patient unable oral intake and dysfunction PEG, please use Ducolax 2PC BID + Cleanse enema, then arrange Colonscopy
      • If massive bleeding again or unstable hemodynamic status, please arrange CTA or TAE
      • Due to PEG dysfunction, after bleeding subsided, discuss with GS for further management.
• 2022-09-28 Infectious Disease
  • Q
    • This 40-year-old male Fillipino patient who sufferred from recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVA and under process in palliative chemotherapy treatment. Leukocytopenia, anemia, hypoalbumin and electrolyte imbalance were noted during this chemotherapy course.
    • Current problem: his central line culture showed GNB, we need your further evaluation and suggestion. Thanks !!
  • A
    • S: The patient’s condition was as your description.
    • O: 2022-09-25 B/C: GNB
    • Suggestion:
      • Antibiotics with finibax 500mg iv q8h for GNB sepsis is suggested.
      • DC tapimycin
      • Please remove or exchange the CVP
      • Check CXR
• 2022-09-07 Metabolism and Endocrinology
  • Q
    • However, his thyroid function showed T3 46.195ng/dl, T4 4.076, free T4 1.388 and TSH 1.3. We need your further evaluation and suggestion. Thanks !!
  • A
    • S
      • This 40-year-old male, with past history of squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino, was admitted due to recurrent squamous cell carcinoma of tongue and for palliative chemotherapy. We were consulted for abnormal TFT.
    • O
      • HR: 119
      • Possible related medication: Thyroxine 50 mcg 1# QDAC for 2 months until now (according to his family)
      • AST/ALT: 50/85
      • BUN/Cr: 13/24
      • Na: 137, K: 3.7
      • TSH/FT4: 1.300/1.388
      • T3: 46.195
      • ATPO, ATG, TSH receptor Ab: unavailable
      • ACTH/Cortisol: unavailable
      • ECG: sinus tachycardia (8/8)
    • A
      • Sick euthyroid syndrome
      • R/I radiation related primary hypothyroidism
    • Suggestions
      • Keep thyroxine 50 mcg 1# QDAC as before
      • Check ATPO, ATG in the next lab
      • Recheck TSH/FT4 2 weeks later or Meta OPD follow, including thyroid ultrasound
      • Contact us if needed. I’d like to follow up this patient.
• 2022-08-12 Gastroenterology
  • Q
    • However, his Anti-HCV (+) and value showed 1.20 were noted. We need your further evaluation and suggestion. Thanks !!
  • A
    • check Bil(D), a-Fetoprotein, HCV RNA PCR (quantitative)
    • Well explained to the patient low incidence of HCV reactivation during or after chemotherapy according to previous reports
    • GI OPD f/u for treatment

[chemoimmunotherapy]

• 2023-03-09 - methotrexate 30mg/m2 50mg NS 100mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
• 2023-02-21 - pembrolizumab 200mg NS 100mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
• 2023-02-16 - docetaxel 32mg/m2 50mg NS 100mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
• 2023-02-09 - docetaxel 32mg/m2 50mg NS 100mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
• 2023-01-31 - pembrolizumab 200mg NS 100mL 1hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
• 2023-01-30 - methotrexate 30mg/m2 50mg NS 100mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
• 2023-01-03 - cetuximab 250mg/m2 420mg 1hr + cisplatin 40mg/m2 70mg in saline 0.9% 500mL 2hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-12-28 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr

  •                 diphenhydramine 30mg + granisetron 1mg

• 2022-12-20 - cetuximab 250mg/m2 420mg 1hr + cisplatin 40mg/m2 70mg in saline 0.9% 500mL 2hr (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-12-09 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr

  •                 diphenhydramine 30mg + granisetron 1mg

• 2022-12-06 - cetuximab 250mg/m2 400mg 1hr + docetaxel 40mg/m2 60mg in saline 0.9% 100mL 1hr
  • dexamethasone 4mg + granisetron 1mg
• 2022-11-24 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 45mg in saline 0.9% 100mL 1hr
  • dexamethasone 4mg + granisetron 1mg
• 2022-11-22 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr

  •                 diphenhydramine 30mg + granisetron 1mg

• 2022-11-10 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 45mg in saline 0.9% 100mL 1hr
  • dexamethasone 4mg + granisetron 1mg
• 2022-11-07 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr

  •                 diphenhydramine 30mg 

• 2022-11-01 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 48mg in saline 0.9% 100mL 1hr
  • dexamethasone 4mg + granisetron 1mg
• 2022-09-30 - cetuximab 250mg/m2 400mg 1hr + docetaxel 24mg/m2 40mg in NS 100mL 1hr + cisplatin 24mg/m2 40mg in NS 300mL 3hr + [leucovorin 60mg/m2 100mg + fluorouracil 600mg/m2 1000mg] in NS 1000mL 22hr
  • dexamethasone 4mg + diphenhydramine 30mg
• 2022-09-07 - cetuximab 250mg/m2 400mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-08-23 - cetuximab 250mg/m2 440mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-08-16 - cetuximab 400mg/m2 700mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

[assessment - appetite stimulant]

• The patient reached his lowest recorded weight of 52.6kg on 2023-01-13, before slightly increasing to 54.6kg on 2023-02-24. The patient is currently receiving nutrition through a nasogastric tube and it is recommended to provide sufficient calories, protein, and other nutrients.

• Previously in another pharmacist note, megestrol was recommended as an appetite stimulant, but if the patient cannot tolerate it and there is still a need for an appetite stimulant, Pilian (cyproheptadine 4mg/tab) might be also considered as an off-label alternative for decreased appetite due to chronic disease. The recommended dosage for Pilian is an initial 2mg four times per day for one week, followed by 4mg four times per day.

  • ref:
    • Cyproheptadine is an effective appetite stimulant in cystic fibrosis. Pediatr Pulmonol. 2004;38(2):129-134. doi:10.1002/ppul.20043
    • Long-term trial of cyproheptadine as an appetite stimulant in cystic fibrosis. Pediatr Pulmonol. 2005;40(3):251-256. doi:10.1002/ppul.20265

• Quetiapine might then be considered as a last resort to increase weight, but it comes with the cost of dyslipidemia.

[assessment - pain control]

• MXL (morphine 60mg/cap) 1# Q12H, fentanyl transdermal patch 50ug/h 2# Q3D, OxyNorm (oxycodone 5mg/cap) 2# Q4H have been properly prescirbed to deal with the backgroud pain.

• NG tube OxyNorm administration: pour the small granules out of the OxyNorm capsules, dissolve them in drinking water, and pass them through the feeding tube.

• If the patient still experiences breakthrough pain with a high VAS score, the addition of PRN morphine might be considered.

230210

[assessment]

• HGB 11.3 g/dL 2023-02-09 <- 6.5 g/dL 2023-02-06, in this case, anemia has been mitigated.

• Platin- and taxel-based treatments have been administered to the patient.

  • Cisplatin-induced neuropathy was more similar to neuropathy in patients receiving oxaliplatin than in those receiving paclitaxel. The cisplatin and oxaliplatin groups exhibited the coasting phenomenon and more prominent upper extremity symptoms than lower extremity symptoms during chemotherapy administration weeks. In contrast, paclitaxel-treated patients did not, on average, exhibit the coasting phenomenon; additionally, lower extremity symptoms were more prominent during the weeks when paclitaxel was administered. ref: Cisplatin-associated neuropathy characteristics compared with those associated with other neurotoxic chemotherapy agents (Alliance A151724) [published correction appears in Support Care Cancer. 2021 Nov;29(11):7129-7130]. Support Care Cancer. 2021;29(2):833-840. https://doi.org/10.1007/s00520-020-05543-5
  • Cisplatin-induced peripheral neuropathy (CIPN) is a frequent serious dose-dependent adverse event that can determine dosage limitations for cancer treatment. CIPN severity correlates with the amount of platinum detected in sensory neurons of the dorsal root ganglia (DRG). After cisplatin-induced DNA damage, p21 appears as the most relevant downstream factor of the DDR in DRG sensory neurons in vivo, which survive in a nonfunctional senescence-like state. ref: Cisplatin-induced peripheral neuropathy is associated with neuronal senescence-like response. Neuro Oncol. 2021;23(1):88-99. https://doi.org/10.1093/neuonc/noaa151

• 2020 ASCO guidelines suggest that clinicians may offer duloxetine to patients with chemotherapy-induced peripheral neuropathy, and 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for treatment of neuropathic pain in this setting. ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325. https://doi.org/10.1200/jco.20.01399

  • Duloxetine for adult patients with chemotherapy-induced peripheral neuropathy: Oral initial 30 mg once daily for 1 week, then 60 mg once daily. Ref: Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial. JAMA. 2013;309(13):1359-67. doi:10.1001/jama.2013.2813 https://doi.org/10.1001/jama.2013.2813
  • There is Cymbalta (duloxetine 30mg/cap) available in the stock. According to the patient’s lab results of 2023-02-09, his liver and kidney function have not deteriated, so no dose adjustment is required. Cymbalta 1# QD is recommended to mitigate his neuropathy.

• The platinum agents cisplatin and carboplatin are used both as single agents and to form the backbone for most combination regimens to treat metastatic and recurrent head and neck cancers. Although carboplatin is often considered to be less systemically effective than cisplatin in head and neck cancer, there is little direct evidence. Carboplatin may be preferred in some cases since it is associated with less neurotoxicity, nephrotoxicity, ototoxicity, and nausea and vomiting compared with cisplatin, although carboplatin causes more myelosuppression.

  • Compared to TPF (docetaxel, cisplatin, fluorouracil) induction chemotherapy, CT (carboplatin, paclitaxel) induction chemotherapy had at least similar if not better LRC and PFS in patients while having less renal toxicity. Thus, CT induction chemotherapy may benefit patients with locally advanced HNSCC by facilitating adequate chemoradiation regimens that enhanced disease control. ref: Comparison of carboplatin-paclitaxel to docetaxel-cisplatin-5-flurouracil induction chemotherapy followed by concurrent chemoradiation for locally advanced head and neck cancer. Oral Oncol. 2014;50(1):52-58. https://doi.org/10.1016/j.oraloncology.2013.08.007

[duplicate note]

• As the note has already been responded to, please disregard this duplicate note generated by the system.

230130

[assessment]

• Since the patient has lost more than 10kg of body weight over the past 5 months (64.4kg 2022-09-17 -> 52.6kg 2023-01-13), possibly as a result of tumor-induced cachexia, it is recommended that the patient consume more and/or receive more intensive nutritional support. The addition of some appetizers, such as megestrol, might be beneficial.

• Metoclopramide has been prescribed. The use of Emend (aprepitant) for antiemetic effect might be considered if nausea and/or vomiting is observed.

701472893

230309

[exam findings]

• 2023-03-01 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with myeloproliverative neoplasm and see description
  • The sections show normocellular marrow (30%). The M/E ratio about 2:1 in MPO and CD71 immunostains. Increased numbers of small to enlarged CD61+ megakaryocytes with occasional hyperchromatic nuclei, arragned in loose clusters are present. No left shift of myeloid series and erythroid precursors. A few CD34+ and/or CD117+ immature cells in interstitium, account for <3% of nucleated cells can be found. Loose network of reticulin with many intersections (MF-1) in reticulin stain. The finding is compatible with myeloproliferative neoplasm. The differential diagnosis including prefibrotic/early primary myelofibrosis and essential thrombocythemia. Suggest bone marrow smear evaluation, genetic study and clinic correlation.
• 2023-03-01 CT - brain
  • Indication: Thrombocythemia with dizziness, R/O CVA
  • IMP: No evidence of intracranial lesion.
• 2023-02-24 CT - abdomen
  • CC: abdominal pain, diarrhea once and vomit > 3 times since last night
    • no fever, headache (+), no family had similar symptom
  • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There are multiple hyperdense lesions in the stomach, duodenum, and small intestine that may be food materials.
      • please correlate with clinical condition.
    • There are two poor enhancing lesion 2 cm and 1.8 cm in the uterus that may be myomas. In addition, there is a cystic lesion 2.1 cm in left adnexa that may be left ovarian cyst.
      • Please correlate with GYN. sonography.
    • Others
      • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidneys.
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
  • Impression:
    • There are two poor enhancing lesion 2 cm and 1.8 cm in the uterus that may be myomas.
    • In addition, there is a cystic lesion 2.1 cm in left adnexa that may be left ovarian cyst.
    • Please correlate with GYN. sonography.

[consultation]

• 2023-02-08 Ear Nose Throat
  • Q
    • This 43-year-old woman patient is a case of Thrombocythemia with dizziness. Now, for evaluate ear examine of dizziness. Thank you.
  • A
    • S:
      • intermittent Vertigo for 1 month
      • when lying down and getting up from the bed in the morning and at night?
      • Duration: 50 mins
      • First attack: this time
      • Headache(+) for 1 month
      • Tinnitus(-), Hearing loss(-), aural fullness(-)
      • N/V and abdominal pain since last Thursday, improved now nausea or vomiting now, but still intermittent vertigo and headache
      • PHx: denied
      • Allergy: denied
    • O:
      • Ear drums: intact
      • No spontaneous, positional , positioning nystagmus
      • Finger nose finger : ok
      • Romberg test : ok
      • Tandem gait : ok
      • Dix-Hallpike test: Bil negative
      • Supine roll test: Bil negative
    • A: Vertigo, cause?
      • central origin can’t be ruled out
    • P:
      • Please rule out central lesion due to thrombocythemia
      • Brain image study: had arranged
      • Treat thrombocythemia as your expertise
      • may consider diphenidol and nicametate citrate
      • ENT/Neuro OPD f/u

700070871

230307

{Diffuse large B-cell lymphoma, stage IV, with bilateral lung and adrenal gland metastasis. triple hit, IPI:4}

[diagnosis] - 2022-08-04 Discharge diagnosis

• Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
• Diffuse large B-cell lymphoma, stage IV, with bilateral lung and adrenal gland metastasis. triple hit, IPI:4.
• Acute respiratory failure post intubation on 111-06-16
• Pneumonia due to Pseudomonas and Oxacillin-resistant Staphylococcus aureus (ORSA)
• Anemia, unspecified
• Gastrointestinal hemorrhage, unspecified
• Diarrhea, postive of stool GDH
• Chronic viral hepatitis B without delta-agent
• Constipation, unspecified
• Other forms of stomatitis
• Port-A catheter insertion 2022/6/30
• Fistulotomy and debridement on 2022/8/3

[exam findings]

• 2023-01-27 CT - chest
  • Indication
    • Dyspnea, unspecified
    • Secondary malignant neoplasm of unspecified lung
  • MDCT (80-detector rows, Aquilion Prime SP, was performed with 2.5 mm lung window,5 mm soft-tissue window slice thickness)
  • Chest CT without IV contrast ehnancement shows:
    • Chest:
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • MInimal dense opacity over right lower lobe, left lower lobe and left peripheral lung is found.
      • No evidence of bilateral pleural effusion.
      • Calcified coronary arteries is found.
      • Dense calcified lymph nodes at mediastinal and both hilar region is found.
    • Visible abdomen:
      • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
      • The GB is well distended without soft tissue lesion
      • Suggest clinical correlation
  • Imp:
    • MInimal dense opacity over right lower lobe, left lower lobe and left peripheral lung is found.
    • Calcified lymph nodes at mediastinum and bilateral pulmonary hilum.
• 2023-01-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (97 - 33) / 97 = 65.98%
    • M-mode (Teichholz) = 65
  • Adequate LV systolic function with normal resting wall motion
  • Mild MR and mild TR
  • LV diastolic dysfunction, Gr 1
  • Preserved RV systolic function
• 2023-01-11, 2022-12-05 CXR
  • multiple nodules in both lungs, in regression
• 2023-01-11 ECG
  • Normal sinus rhythm
  • Nonspecific T wave abnormality
• 2023-01-11 Spirometry
  • normal standard spirometry
  • negative BDT (back diffusion technique)
  • normal DLCO (diffusing capacity of the lungs for carbon monoxide)
• 2022-10-25 CT - neck
  • Indication:
    • triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
  • Head and Neck CT with and without IV contrast administration shows: (Comparison: 2022/07/03 CT)
    • Head and Neck
      • A large mass lesion, can be confluent LAPs, in right middle low lateral neck.
      • Regressed size from 95x80x60 mm to 77x57x37 mm (RL-AP-CC). [CC: Cranial-caudal; RL: Right-left; AP: Anterior-Posterior]
      • After IV contrast administration shows well or heterogenous enhancement of the mass or LAPs with central necrosis.
    • Thorax:
      • Presence of multiple lung nodules/masses.
      • One enlarged LN in right paratracheal space, seems with central necrotic change. With unknown size change, not scanned on last CT study, 2022/07/03 CT.
      • Several LAPs in AP window and pretracheal space.
    • Abdomen and pelvis:
      • One enlarged LN in anterior part of celiac root. With unknown size change, not scanned on last CT study, 2022/07/03 CT.
      • No evident other abnormal enlarged lymph node in paraaortic space or iliac chain.
  • IMP: Decreased right neck LAPs when compared with 20220703 CT as mentioned above.
• 2022-08-03 Patho - fissure/fistula
  • Anus, fistulotomy — Anal fistula with abscess
  • Section shows piece(s) of cutaneous-colonic junctional tissue with one fistula surrounded by abscess composed of debri and diffuse acute as well as chronic inflammation.
• 2022-07-31 CXR
  • a mass shadow in over the Rt neck, in regression
  • multiple nodules in both lungs, in regression
• 2022-07-26 PET
  • Mildly increased FDG uptake in a large focal area in the right neck, compatible with lymphoma of low FDG uptake.
  • Mildly increased FDG uptake in multiple lymph nodes on both sides of the diaphragm as mentioned above and Increased FDG uptake in multiple focal areas in bilateral lung fields. Lymphoma can not be ruled out. Please correlate with other clinical findings for further evaluation.
  • Mildly increased FDG uptake in the bone marrow of bilateral thighs. The nature is to be determined (bone marrow hyperplasia? lymphoma of low FDG uptake?). Please also correlate with other clinical findings for further evaluation.
  • Increased FDG accumulation in the intestine and both kidneys. Physiological FDG accumulaiton may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2022-07-21 Patho - intestine
  • Large intestine, ICV, biopsy —- ulcer with non-specific colitis
  • Small intestine, terminal ileum, biopsy —- ulcer with chronic inflammation
• 2022-07-21 SONO
  • Right neck heteroechoic tumor with some necrosis
• 2022-07-03 CT
  • No evidence of intracranial hemorrhage.
  • A large mass (8.1cm) at right neck.
  • Some patchy densities at bil. upper lungs.
• 2022-06-24 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (95.9 - 33.9) / 95.9 = 64.65%
    • M-mode (Teichholz) = 64.7
  • Adequate LV systolic function with no regional wall motion abnormality at resting state
  • Mild to moderate tricuspid regurgitaition and mild mitral regurgitation
  • Dilated LA and IVC; mildly thick IVS and LVPW (IVC = inferior vena cava; IVS = interventricular septum; LVPW = left ventricular posterior wall)
  • Mild pulmonary hypertension
• 2022-06-23 Patho - bone marrow biopsy
  • Bone marrow, biopsy — No evidence of lymphoma involvement and see description.
  • The sections show normocellular marrow (35%). M/E ratio = 4:1. The myeloid cells show maturation. The megakaryocytes are increased in number with a few small megakaryocytes. No focal lymphoid aggregation. Scattered CD34+ and/or CD117+ immature cells, account for 3% of marrow cells can be found. There is no evidence of lymphoma involvement in CD3 and CD20 immunostains. Suggest further bone marrow smear evaluation and clinic correlation.
• 2022-06-21 Patho - lymph node region resection
  • Tissue, neck, right, incisional biopsy — Diffuse large B cell lymphoma, GCB
    
  • Immunohistochemical stain profiles: CD20(+), CD3 (focal+ at background T-cells), Bcl-2(+), Bcl-6(+), MUM-1(-), CK(-), CD56(-), CD10(+), Cyclin D1(-), C-MYC(+).
• 2022-06-17 Patho - lymphnode biopsy
  • Labeled as “Right neck lymph node”, SONO guided biopsy — B cell lymphoma, high grade.
  • IHC stains: CK (-), CD56 (-), CD3 and CD20: a predominant B cell sub-population, Bcl-2 (+), bcl-6(+), MUM-1(-), Ki-67: 95%, CD10 (-), cyclin-D1 (equivocal), CD23 (-), CD30 (-), C-myc (+, focally >30%), a pattern, in favor of diffuse large B cell lymphoma, double-expressor.
• 2022-06-16 CXR
  • Diffuse nodular lesions at both lungs is found.
• 2022-06-16 CT - neck
  • Neck lymphadenopathy with lung meta and extensive lymphadenopathy, suggest biopsy.
• 2022-06-16 CT - lung
  • Huge right neck lymphadenopathy with bilateral lung meta, adrenal meta and mediastinal, bilatral axillary and paraaortic lymphadenopathy, please check neck, oral pharyngeal region for primary tumor.
• 2022-06-16 CXR
  • Patch density at bil. lungs.

[consultation]

• 2023-02-13 Vascular Surgery
  • Q
    • This 53 year old male is a case of triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
    • Will prepare autoPBSCT this time, we need your expertise for hickman insertion on 2023/02/16, thanks.
  • A
    • For BMT preparation, insertion of perm-cath will be scheduled on 20230216. Thanks for your consultation.
• 2023-02-13 Oral and Maxillofacial Surgery
  • Q
    • This 53 year old male is a case of triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
    • Will receive autoPBSCT on 20230224, we need your expertise for oral examination, thanks
  • A
    • after examining the intraoral condition and taking radiographic study, no pathology was noticed neither hopeless tooth was noticed
    • Plaque deposition over upper dentition was noticed.
    • Plan:
      • Teach him how to reinforce oral hygiene
• 2022-11-21 Vascular Surgery
  • Q
    • A case of triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
    • will receive PBSC harvest on 20221206 ~ 20221209, we need your expertise for double lumen insertion on 20221205, thanks
  • A
    • I have had the pleasure of involving with the patient’s care. In brief, He is a 53 year old male seen in consultation for opinion regarding treatment options for double lumen cath insertion for PRBC harvest access.
    • The pt’s hx/Dx was noted for Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
    • Lab/CXR reviewed.
    • SUGGESTION & PLAN:
      • D/L insertion will be arranged on R’t side on 2022/12/05 under LA 8AM
      • please prepare a 16cm D/L (double lumen catheter) to bring to OR.
• 2022-08-01 Colorectal Surgery
  • Q
    • The 53 y/o neck diffuse large B cell lymphoma case s/p R-DA-EPOCH at MICU. Due to a carbuncle over left buttock without discharge for 2-3 days. PS was consulted and who assessment of abscess just located nearby anus and it is likely anal fistula with anal abscess, so we need your help. Thanks!
  • A
    • We’ll go to see the patient tomorrow morning
• 2022-08-01 Reconstructive and Plastic Surgery
  • Q
    • The 53 y/o neck diffuse large B cell lymphoma case s/p R-DA-EPOCH at MICU. Due to a carbuncle over left buttock without discharge for 2-3 days, so we need your help for management. Thanks!
  • A
    • abscess just located nearby anus
    • it is likely anal fistula with anal abscess
    • plan and suggestion:
      • please consult CRS for this problem
      • sitz bath with warm water after stool passage
• 2022-06-24 Gastroenterology
  • Q
    • For HBV evaluation
    • This is a 53 years old man, a case denided Diabetes, Hypertension or heart disease history. This time, he suffered from shortness of breath was noted since today. right neck swelling for 6 months. so he went to ER for help. At ER, conscious clear, vital sign showed BP:163/91mmHg; HR:139; BT:36.3; RR:20; SPO2:88%, follow up Lab data showed leukocytosis (wbc:16930 CRP:11.55). chest films revealed diffuse nodular lesions at both lungs is found. chest CT revealed huge right neck lymphadenopathy with bilateral lung mets, adrenal mets and mediastinal, bilatral axillary and paraaortic lymphadenopathy, please check neck, oral pharyngeal region for primary tumor.Because of dyspnea, desaturation progression, emergent intubation with ventilator support and then transfer to ICU for further care.
    • After admission. B cell lymphoma was diagnosis. HbsAg(-), Anti-Hbc reactive. We sinecerely need your help. Thanks a lot.
  • A
    • O
      • Abdominal echo: nil
      • ALT:15 , BUN:20, Cr:0.45
      • HBsAg(-), Anti-HBsAb:(-), Anti-HBc:(+), Anti-HCV(-)
    • Impression
      • Resolved HBV infection
      • Diffuse large B cell lymphoma, triple hit, IPI:4, stage IV
    • Suggestion
      • We will prescribe Baraclude 0.5mg QD (GFR>50 QD, GFR 30-49 QOD, GFR 15-29 Q3D, GFR<15 or HD QW)
      • Arrange abdominal sonography after transfer to general ward
      • Regular/close monitor liver function
      • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication
• 2022-06-23 Hemato-Oncology
  • Q
    • For B cell lymphoma evaluation
  • A
    • Impression:
      • Diffuse large B cell lymphoma, triple hit, IPI:4, stage IV
      • Acute respiratory failure s/p intubation on 20220617
      • Bilateral lung pneumonia, sputum culture yeild Pseudomonas aeruginosa on 20220617
    • Suggestion:
      • Bone marrow aspiration and biopsy for further staging. Arrange PET after remove endo.
      • We had well explaint to his brother and will arrange R-COP for cyto-reduction. Please watch for tumorlysis syndrome
      • Check HbsAg, AntiHCV, Anti Hbc
      • We may take over this case after remove endo with stable condition.
      • Thanks for your consultation. If there is any problem, please feel free to let us know
• 2022-06-20 Anesthesiology
  • Q
    • For pre-op evaluation
  • A
    • Condition: Stable V/S Cons. clear, previous walking ok but now weakness and tired, no dyspnea, chest tightness or leg edema, fighting with ventilator
    • EKG: ST
    • CXR: a huge mass shadow in over the Rt neckmultiple nodules and several large massses of variable sizes in both lungs due to metastases. Cardiomegaly, Tortous aorta with calcification, Osteopenia, Senile fibrotic change
    • Neck CT: Neck lymphadenopathy with lung meta and extensive lymphadenopathy, suggest biopsy
    • Lung CT: Huge right neck lymphadenopathy with bilateral lung meta, adrenal meta and mediastinal, bilatral axillary and paraaortic lymphadenopathy, please check neck, oral pharyngeal region for primary tumor.
    • Airway: adequate open
    • ASA3
      • NOTE: AMERICAN SOCIETY OF ANESTHESIOLOGY PATIENT CLASSIFICATION STATUS
        • ASA I
          • Normal healthy Pt
        • ASA II
          • Pt with mild systemic disease; no functional limitation–eg, smoker with well-controlled HTN
        • ASA III
          • Pt with severe systemic disease; definite functional impairment–eg, DM and angina with relatively stable disease, but requiring therapy
        • ASA IV
          • Pt with severe systemic disease that is a constant threat to life–eg, DM + angina + CHF; Pts have dyspnea on mild exertion and chest pain
        • ASA V
          • Unstable moribund Pt who is not expected to survive 24 hours with or without the operation
        • ASA VI
          • Brain-dead Pt whose organs are removed for donation to another
        • E
          • Emergency operation of any type, which is added to any of the 6 above categories, as in ASA II E
    • Plan:
      • High risk of aspiration, sepsis, shock
      • Anes. plan and risk was told to him at bedside and brother at door of SICU
      • Resucitation will be procedured if emergence condition.
      • We will arrange ETGA
      • Correct underly dx as your expertise.
      • Follow onetouch q6h when nil per os if DM or high risk of hypoglycemia
• 2022-06-20 ENT
  • Q
    • For A huge indurated mass (over 10cm in largest dimension) with partial skin erosion (2*2cm) over right lateral-posterior neck without tendeness.
  • A
    • CT: right neck lymphadenopathy with bilateral lung meta, adrenal meta and mediastinal, bilatral axillary and paraaortic lymphadenopathy
    • PE:
      • Oral: N-P
    • Scope: unable to evaluate due to saliva pooling
    • Imp: R neck lympahdenopathy with metastasis, origin?
    • Plan:
      • Arrange excisional biopsy for tissue proof on 20220621 On call.
• 2022-06-16 Oral and Maxillofacial Surgery
  • Q
    • shortness of breath was noted since today
    • right neck swelling for 3 month
    • Hx of NIL
  • A
    • This is a 53-year-old male who felt a little hard to breath and went to our ER for help
    • PMH: denied
    • S: I felt a little hard to breath
    • O: BP:163/91; P:139; T:36.3; R:20;
      • Con’s: E4V5M6
      • SpO2:88%
      • Extraoral finding:
        • mass (width 4 fingers, length 9 fingers) over his right neck was noted (it was so small 3 months ago)
    • A: tumor of right neck
    • P:
      • Physical exam and explain the findings to the patient.
      • Consult Hemato-Oncology for further survey
• 2022-06-16 ENT
  • Q
    • shortness of breath was noted since today
    • right neck swelling for 3 month
    • Hx of NIL
  • A
    • O
      • Local finding:
        • No stridor but shortness of breath
        • Fair oral cavity and oropharynx
        • A huge indurated mass (over 10cm in largest dimension) with partial skin erosion (2*2cm) over right lateral-posterior neck without tendeness.
      • Portable nasopharyngoscopy: smooth nasopharynx, oropharynx and hypopharynx; patent airway through subglottic level; no vocal palsy.
      • Neck and Chest CT Report: A huge solid mass measuring up to 12cm in greatest dimention over right posterior-lateral neck with partial liquid component, along with bilateral multiple pulmonary/mediastinal nodular/mass lesion.
    • Impression:
      • Suspect malignancy, pulmonary origin with multiple metastasis should be primarily considered.
    • Plan:
      • Closely monitor airway condition.
    • Suggest consult Chest Physician or Hemato-oncologist for further evaluation and management.

[surgical operation]

• 2022-12-05
  • Surgery
    • D/L insertion (RIJV approach, 16cm)  
• 2022-08-03
  • Surgery
    • Fistulotomy and debridement
  • Finding
    • Inflammation and swelling over left perianal region with much pus was drained. Debridement and irrigation using H2O2 was done.
• 2022-06-21
  • Surgery
    • Incisional biopsy of right neck mass
  • Finding
    • Right neck indurated mass, measuring up to 12cm in greatest dimention

[chemoimmunotherapy]

• 2022-12-19 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
  • premed - dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
• 2022-11-21 - rituximab 375mg/m2 600mg 8hr D1 + methylprednisolone 500mg 1hr D2-6 + etoposide 40mg/m2 63mg 1hr D1-5 + cisplatin 25mg/m2 39mg 18hr D1-5 + cytarabine 2000mg/m2 3160mg 2hr D6 (R-ESHAP)
  • premed - dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + palonosetron 250ug D1-6
  • R-ESHAP - https://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/cancer-drugs/drugs/r-eshap
    • R - rituximab (ri-tuk-si-mab)
    • E - etoposide (ee-top-o-side)
    • S - solu-medrone (sol-you-med-rone), you commonly hear it called methylprednisolone
    • HA -high dose cytarabine (sye-ta-ra-bin), also known as Ara C
    • P - cisplatin (sis-pla-tin)
• 2022-10-25 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
  • premed - dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
• 2022-09-16 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
  • premed - dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
• 2022-08-18 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
  • premed - dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
• 2022-07-11 - rituximab 375mg/m2 600mg 6hr D1 + prednisolone 60mg/m2 5mg/tab 19tab BID D1-5 + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 15mg 24hr D1-4 + vincristine 0.4mg/m2 0.5mg 24hr D1-4 + cyclophosphamide 750mg/m2 1200mg D5 (R-DA-EPOCH)
  • premed - dexamethasone 4mg D1 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D1 + famotidine 20mg D1
• 2022-06-23 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1260mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 tmg/tab 10tab BID D1-6 (R-COP)
  • premed - dexamethasone 4mg D1 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D1
  • R-CVP - http://nssg.oxford-haematology.org.uk/lymphoma/documents/lymphoma-chemo-protocols/L-82-r-cvp.pdf
    • INDICATION: Non-Hodgkin lymphoma.
    • Omit rituximab if CD20-negative.
• G-CSF
  • Granocyte (lenograstim 250mg SC) 2022-11-04, -05, -07 (20221104 OPD)
  • Granocyte (lenograstim 250mg SC) 2022-11-01, -02, -03 (20221023 IPD)
  • Granocyte (lenograstim 250mg SC) 2022-09-26, -27, -28 (20220926 OPD)
  • Granocyte (lenograstim 250mg SC) 2022-09-20, -21, -22 (20220913 OPD)
  • Granocyte (lenograstim 250mg SC) 2022-08-30, -31, -09-01 (20220830 OPD)
  • Granocyte (lenograstim 250mg SC) 2022-08-24, -25 (20220818 IPD)

[problem list / assessment / plans]

Problem 1# triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, HCT-CI score: 0, IPI score: 4, High risk group, PS: 1 Assessment： autoPBSCT on 2023/02/24 (D0) Plan =>Blood transfusion with LPRBC (ZhaoGuang) and LRP (ZhaoGuang) for anemia and thrombocytopenia (In this context, “ZhaoGuang” refers to a leukocyte reduction process in which blood products such as LPRBC and LRP are exposed to ultraviolet light to inactivate leukocytes. This is done to reduce the risk of transfusion-related reactions and complications.) =>Nincort and Mycostatin 5ml QID for mucositis =>PPN with Oliclinomel was administered for poor appetite from 3/2 =>AutoPBSCT on 2023/02/24(D0),infusion time 10:11AM-10:17AM;10:19AM-10:26AM, (12/6 CD34: 5.49x10^6/kg and 12/5 CD34: 4.05x10^6/kg, total 9.54x10^6/kg)   =>Baktar 2tab QD for PJP prevention =>Prophylaxis antibiotivcs with Cravit 1.5tab from 2/16-23,antifungas with Fluconazole 300mg QD IVD from 2/16-23,then shifted to Tienam,Targocid from 2/24-3/2 then shifted to Zyvox from 3/2(D6) and Mycamine from 2/24(D12),pending blood culture =>Conditioning regimen for autologous PBSCT with BuCyE was administered on 2023/2/17-22 =>Adequate hydration =>Oral surgerist was consulted for oral examination =>CVS was consulted for Hickman insertion on 2/16 =>closely monitor clinical condition  

[assessment - Improvement in WBC Count Trend Observed]

• Today (2023-03-07) marks the 11th day since autoPBSCT. Based on recent lab data, there is a noticeable upward trend in WBC count over these two days, indicating a return to the normal range.
  • 2023-03-07 D11 WBC 4.87 x10^3/uL
    
  • 2023-03-06 D10 WBC 2.51 x10^3/uL
    
  • 2023-03-05 D 9 WBC 0.91 x10^3/uL
    
  • 2023-03-04 D 8 WBC 0.28 x10^3/uL
    
  • 2023-03-03 D 7 WBC 0.04 x10^3/uL
    
  • 2023-03-02 D 6 WBC 0.01 x10^3/uL
    
  • 2023-03-01 D 5 WBC 0.01 x10^3/uL
    
  • 2023-02-27 D 3 WBC 0.01 x10^3/uL
    
  • 2023-02-26 D 2 WBC 0.02 x10^3/uL
    
  • 2023-02-24 D 0 WBC 0.11 x10^3/uL
    
  • 2023-02-22 D-2 WBC 1.16 x10^3/uL
    
  • 2023-02-20 D-4 WBC 1.22 x10^3/uL
    
  • 2023-02-16 D-8 WBC 1.08 x10^3/uL

230215

[preparation and administration of mesna]

• Mesna can be dissolved in 0.9% normal saline (NS) or 5% dextrose in water (D5W).

• As the patient weighs 60kg, the scheduled (since 2023-02-21) dose of mesna is 12mg/kg, which means that 720mg of mesna should be dissolved in the aforementioned solvent no less than 50mL (final concentration no more than 20 mg/mL).

• To ensure optimal administration, it is recommended that the injection lasts for no less than 30 minutes.

700588033

230307

[exam findings]

• 2023-01-16 CT - abdomen
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Abdominal CT with and without enhancement revealed:
    • s/p ATH.
    • The soft tissue mass at left pelvic sidewall is not visualized in the study. However,
    • Increased intestinal gas is found.
    • No evidence of free air is noted at the subphrenic region.
    • Non-specific bowel gas at abdominal cavity is found.
    • The liver, spleen, pancreas, both kidneys and adrenals are intact.
    • There is no evidence of paraarotic LAPs.
    • There is no ascites accumulation at abdominal cavity.
    • Visible chest
    • Normal heart size.
    • The lung fields are clear.
    • No pleural effusion is found.
    • Suggest clinical correlation
  • Imp:
    • s/p ATH.
    • Dirty appearance of the pelvis mesetery is found. Suspected residual tumor activity.
• 2023-01-06, 2022-12-09 CXR
  • A nodular opacity projecting in the right middle lung is suspected. Please correlate with CT.
• 2023-01-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 32) / 88 = 63.64%
    • M-mode (Teichholz) = 63
  • Dilated LA
  • Adequate LV, RV systolic function with normal wall motion
  • LV hypertrophy, Impaired LV relaxation
• 2022-11-09 Patho - soft tissue tumor, extensive resection
  • DIAGNOSIS:
    • A. Labeled as “01 left pelvic tumor”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
    • B. Labeled as “02 omentum tumor”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
    • C. Labeled as “03 para-rectal tumor (in CDS)”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
    • D. Labeled as “04 right peritoneal tumor”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
  • MICROSCOPIC DESCRIPTION:
    • A. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
    • B. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
    • C. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
    • D. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
• 2022-11-09 Body fluid cytology
  • 35 cc brown turbid ascites
    
  • The smears show many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
• 2022-10-18 CT - abdomen
  • Clinical history: 45 y/o female patient with right side Ovarian (high-grade serous carcinoma) , pT3cN1a, stage IIIC s/p debulking surgery, s/p chemotherapy with Carboplatin + paclitaxel + Avastin (2021/10/01~2022/01/14 6 cycles).
  • With and without contrast enhancement CT of abdomen–whole:
    • S/P hysterectomy.
    • Left obturator region hypodense lesion, 1.3cm, stationary.
    • Soft tissue lesion, 1.8cm in left pelvic cavity, anterior to left psoas muscle.
    • Unremarkable change of the liver, spleen, pancreas and both kidneys.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
    • Subpleural nodule in right lower lung, nature?
  • Impression:
    • S/P hysterectomy.
    • Stationary left pelvic cavity tumors.
    • Right lower lung subpleural nodule, nature?
• 2022-10-17 Gynecologic ultrasonography
  • ATH + BSO
• 2022-09-01 CT - abdomen
  • History and indication:
    • ROV cancer, stage IIIC s/p debulking surgeryeating and self voiding, defecation
  • IMP:
    • S/P hysterectomy.
    • A cystic lesion (1.1cm) at left pelvic cavity.
    • Grade 4 fatty liver.
• 2022-08-12 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA grade A
  • Superficial gastritis
  • Gastric erosions, antrum
• 2022-06-09 Gynecologic ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2022-04-19 CXR
  • A nodular opacity projecting in the right middle lung is suspected. Please correlate with CT.
• 2022-03-11 CT - abdomen
  • History:
    • 20210821 G-I OPD refer. SONO: pelvic mass and Ascites, BW LOSS 7 KG/2-3 MO,
    • 20210821 ERCT: suspected ovarian cancer with massove ascites
    • 20210827 debulking surgery:ROV cancer, pT3cN1a, pstage IIIC
  • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
  • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
  • Findings:
    • S/P hysterectomy
    • There is a cystic lesion measuring 3 cm in left pelvic sidewall that may be lymphocele? please correlate with clinical condition.
    • Others
      • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
  • IMP:
    • S/P hysterectomy.
    • Lynmphocele 3 cm in left pelvic sidewall is suspected. please correlate with clinical condition.
• 2022-03-08 CT - chest
  • stationary of a well-defined RLL-S6 solid nodule (8 mm) as compared with previous CT study on 2021/12/06
• 2021-12-16 Gynecologic ultrasonography
  • ATH + BSO
  • No obvious uterine or ovarian lesion
• 2021-12-06 CT - chest
  • stationary of a well-defined RLL-S6 solid nodule (8 mm) and regression lobular/centriolobular ground-glass opacities in RUL-S2 as compared with previous CT study on 2021/09/25.
• 2021-09-25 CT - chest
  • Right lower lobe nodule. In regression. Meta is not likely.
  • Right upper lobe ground glass nodules with bronchial distribution. suspected recent inflammation. Suggest closely follow up.
• 2021-08-30 Patho - soft tissue tumor, extensive resection
  • PATHOLOGIC DIAGNOSIS
    • Ovarian mass, R’t, frozen + debulking surgery — High-grade serous carcinoma
      
    • Fallopian tube, R’t, ditto — Tumor present
      
    • Endometrium, uterus, debulking surgery — Free from tumor, proliferative phase
      
    • Myometrium, uterus, ditto — Tumor invasion and leiomyomas
      
    • Endoervix, uterus, ditto — Tumor present at serosa with myometrial invasion
      
    • Cervix, uterus, ditto — Free from tumor
      
    • Ovary. L’t, ditto — Tumor present
      
    • Fallopian tube, L’t, ditto — Tumor present at serosa area
      
    • Omentum ttissue, excision — Tumor present
      
    • Pelvic (in Douglous) mass, excision — Tumor present
      
    • R’t peritoneal mass, excision — Tumor present
      
    • Lymph node, R’t iliac, dissection — Tumor metastasis (1/6) without extracapsular extension (0/1)
      
    • Lymph node, R’t obturator, ditto — Free from tumor metastasis (0/3)
      
    • Lymph node, L’t iliac, ditto — Tumor metastasis (1/8) without extracapsular extension (0/1)
      
    • Lymph node, L’t obturator, ditto — Tumor metastasis (2/2) without extracapsular extension (0/2)
      
    • AJCC Pathologic staging: pT3cN1a, if cM0; stage IIIC
      
  • MICROSCOPIC EXAMINATION
    • Histologic type: high-grade serous carcinoma
      
    • Histologic grade: high grade
      
    • Contralateral ovary involvement: present
      
    • Tumor side ovarian surface involvement: present
      
    • Contralateral ovary involvement: present
      
    • Right tube involvement: present
      
    • Left tube involvement: present at serosal layer
      
    • In situ adenocarcinoma in right ＆/or left fallopian tube: absent
      
    • Right adnexa soft tissue involvement: present
      
    • Left adnexa soft tissue involvement: present
      
    • Pelvic soft tissue involvement: present
      
    • Uterine serosa involvement: present
      
    • Omentum involvement: present
      
    • Uterine Cervix involvement: absent
      
    • Endocervix: tumor involved serosal and myometrial area, without endocervical glands invasion
      
    • Endometrium involvement: absent
      
    • Myometrium involvement: present at post endocervical region
      
    • Lymph nodes metastasis: tumor metastasis (4/19) without extracapsular extension (0/4) in total number
      
    • Immunohistochemistry: CK (+), WT-1 (+), PAX-8 (+), P53 (aberrant expression) and Napsin-A (-) for tumor
      
    • Ascites cytology: negative
• 2021-08-21 CT - abdomen
  • suspected ovarian cancer with massove ascites
• 2021-08-21 Gynecologic ultrasonography
  • Pelvic mass, suspected bilateral ovarian tumor, malignancy was highly suspected
• 2021-08-21 SONO - abdomen
  • Diagnosis
    • Pelvic cystic tumor, huge
    • massive Ascites
  • Suggestion
    • GYN OPD visit

[consultation]

• 2021-08-21 Obstetrics and Gynecology
  • A
    • S
      • This 44 y/o female suffered from abodminal fullness and poor appetite for one mth. She visited our GI OPD and was noted to have pelvic mass and ascites and was referred to ER.
      • BW LOSS 7 KG/2-3 MO,NO BLOODY STOOL
      • PH: NIL NKDA
    • O
      • P1, C/Sx１
      • LMP: 07/20+
      • MC: regular
      • PV: Discharge: mucoid, whitish, mild amount
      • VP: smooth, no motion tender
      • Adx and ut: unclear due to distend abdomen
      • Echo: pelvic mass, bil, malignancy was highly suspected
    • Imp
      • Ascites, cause to be determined
      • Pelvic mass, suspected ovarian cancer, origin to be determined
    • P
      • Please keep w/u other cause of ascites and origin of pelvic mass, eg. GI origin
      • Please contact us if other GYN lesion noted in the following study
      • Please also check CA 15-3 and gyneco-oncological OPD f/u for further management

[surgical operation]

• 2022-11-08
  • Surgery: debulking surgery (left pelvic tumor + omentum tumor + pararectal tumor + right pelvic tumor excision) + enterolysis
• 2021-08-27
  • Surgery: debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + peritoneal tumor excision) + enterolysis

[chemoimmunotherapy]

• 2023-03-06 - bevacizumab 800mg NS 250mL 1.5hr + liposome doxorubicin 30mg/m2 55mg D5W 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-02-06
• 2023-01-06
• 2022-12-09
• 2022-10-17 - bevacizumab 15mg/kg 1200mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-09-20
• 2022-08-30
• 2022-08-11
• 2022-07-21
• 2022-06-27
• 2022-06-07
• 2022-05-12 - bevacizumab 15mg/kg 900mg NS 250mL 1.5hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
• 2022-04-20
• 2022-03-25
• 2022-03-07
• 2022-02-11
• 2022-01-14 - bevacizumab 15mg/kg 900mg NS 250mL 1.5hr + paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 6 600mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2021-12-24
• 2021-12-03
• 2021-11-12
• 2021-10-22
• 2021-10-01 - no bevacizumab

700378861

230306

[exam findings]

• 2023-03-01 SONO - chest
  • Pleural effusion, minimal, bilatera
  • Consolidation, LLL and RLL
• 2023-02-27, -02-25, -02-23, -02-20, -02-17 CXR
  • S/P nasogastric tube insertion
  • S/P CVP line insertion from left jugular vein and the tip located at SVC.
  • Atherosclerotic change of aortic arch
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Linear and nodular infiltration over both lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Borderline cardiomegaly
• 2023-02-23 KUB
  • Fecal material store in the colon.
  • Ascites is highly suspected. Please correlate with sonography.
• 2023-02-22 CT - brain
  • Indication: Myelodysplastic Syndrome
  • IMP: No evidence of intracranial lesion.
• 2023-02-22 SONO - abdomen
  • GB wall thickening, possibly secondary to hepatitis or ascites
  • Parenchymal renal disease
  • Left renal cyst
  • Ascites
  • Pleural effusion
  • suboptimal echo window
• 2023-02-17 MRI - L-spine
  • Indication: Myelodysplastic Syndrome. bilateral lower limbs weakness
  • Impression:
    • Degenerative spinal and disc disease.
    • Favor intramuscular hematomas in right psoas muscle.
• 2023-02-08 SONO - chest
  • Symptoms:
    • Internal jugular vein narrowing or thrombosis.
    • Peripheral vein narrowing
  • Indication:
    • Risky in bleeding, thrombosis, vessel narrowing.
  • Clinical Diagnosis
    • COVID-19 pneumonia with ARDS.
    • MDS with severe pancytopenia
  • Echo Diagnosis
    • Right side
      • Internal jugular vein and common carotid artery confirmed by echo probe compression, Doppler velocity detection.
      • Internal jugular vein compress: lumen narrowing, velocity increasing.
      • Internal jugular vein lumen narrowing and velocity increase during inspiration.
      • Cross-sectional probe: lumen area: 0.66cm in diameter
      • Thrombosis: No
• 2023-02-02 CT - abdomen
  • History and indication: SOB
  • IMP: Ground glass opacities at bil. lungs. Some LNs at mediastinum. Pericardial and pleural effusion.
• 2023-01-12 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • diverticulum : the second portion of duodenum
  • Suggestion
    • PPI therapy
    • OPD follow-up
• 2021-09-30 Patho - bone marrow biopsy
  • PATHOLOGIC DIAGNOSIS
    • Bone marrow, biopsy — Compatible with myelodysplastic syndrome with excess blasts (MDS-EB-1)
      
    • MICROSCOPIC EXAMINATION
      • The sections show normocellular marrow (25%). M/E ratio = 2:1 in CD71 amd MPO stains. The megakaryocytes are not remarkable.
        
      • Slightly increased CD138+ mature plasma cells (5%) in interstitium.
        
      • Increased CD34+ blasts, account for 9% of marrow cells. Only few CD117+ immuture cells. the finding is compatible with myelodysplastic syndrome with excess blasts (MDS-EB-1). Suggest further bone marrow smear evaluation and clinic correlation.
• 2019-08-12 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (119 - 37) / 119 = 68.91%
    • LVEF = 69
    • M-mode (Teichholz) = 69
  • Normal LV systolic function with normal wall motion.
  • Normal LV diastolic function.
  • Normal RV systolic function.
  • Mild MR; mild TR; mild PR.
  • No vegetation was found by TTE.
  • Flat IVC, consider hypovolemia.
• 2019-08-11 CT - abdomen
  • Indication: Suspected liver abscess.
  • Impression:
    • No intraabdominal abscess
    • Left renal cyst
    • Prominent pancreatic tail

[consultation]

• 2023-02-24 Nephrology
  • Q
    • For Hyernatremia evaluation
    • The 63-year-old man had past history with MDS with RAEB s/p vidasa. This time, he was visited ER due to dyspnea and progressed since 20230202, the chest film manifasted bilateral ground glass opacity with severe pneumonia patch noted. Abomen CT showed left renal cyst and pleural effusion with pericardial. He was admited due to bilateral lung pneumonia with respiratory failure s/p intubation and COVID-19 infection.
    • The lab showed Hyernatremia, Na (blood): 160 -> 163 -> 171 mmol/L, Na (urine): 32 mmol/L, K (blood): 2.5 -> 3.2 mmol/L, K (urine): 18.8 mmol/L, Osmolality (blood): 340mOsn/kg, Osmolality (urine): 236mOsm/kg, Urine SG: 1.006, U/O: 2807.3+ lossml/day(2023/02/20), 1560ml/day(2023/02/21), so we need your help for Hyernatremia evaluation, thanks a lot!!
  • A
    • Patient seen with history reviewed. We are consulted for hyernatremia.
    • pitting edema 2+
    • Lab
      • 2023-02-22 Na(Urine) 46 mmol/L
        
      • 2023-02-22 Urine osmolarity 281 mOsm/Kg
      • 2023-02-22 Na (Sodium) 171 mmol/L
        
      • 2023-02-21 Na (Sodium) 163 mmol/L
        
      • 2023-02-20 Na (Sodium) 160 mmol/L
        
      • 2023-02-17 Na (Sodium) 141 mmol/L
        
      • 2023-02-13 Na (Sodium) 141 mmol/L
        
      • 2023-02-22 BUN 40 mg/dL
        
      • 2023-02-20 BUN 32 mg/dL
        
      • 2023-02-17 BUN 31 mg/dL
        
      • 2023-02-13 BUN 45 mg/dL
    • U/O
      • 2023-02-20 U/O 2807+loss
      • 2023-02-21 U/O 1560
    • Impression
      • hypernatremia, suspected osmotic diuresis
    • Suggestion
      • estimated free water deficit: 8.5L
      • correct hypernatremia with adequate free water (in diet and IVF), since pleural effusion and pitting edema were noted
      • monitor sodium level closely, sodium level decrease should not exceed 8mmol/L/d
      • record I/O
• 2023-02-20 Infectious Disease
  • Q
    • For antibiotic evaluation
    • The 63-year-old man had past history with MDS with RAEB s/p vidasa. This time, he was visited ER due to dyspnea and progressed since 2023/02/02, the chest film manifasted bilateral ground glass opacity with severe pneumonia patch noted. Abomen CT showed left renal cyst and pleural effusion with pericardial. He was admited due to bilateral lung pneumonia with respiratory failure s/p intubation and COVID-19 infection.
    • The lab showed leucopenia, pancytopenia due to MDS, Lenograstim and Tapimycin, Mycamine for blood culture: Candida, sputum culture: PDR-K. oxytoca, so we need your help for antibiotic evaluation, thanks a lot!!
  • A
    • keep present antibiotic Rx, and adjust to culture data later
    • monitor CRR
• 2023-02-08 Gastroenterology
  • Q
    • After admission, he received ventilator support, empiric antibiotics with Tapimycin and Cravit was prescribed for pneumonia treatment, Decan 6 mg IVD QD (2/2-2/10) and DC Remdisivir due to liver failure. LPRBC and LRP were tranfused for anemia and pancytopenia. We need your expert to evaluate his condition and give us advise with hepatitis. Thank a lot
  • A
    • B (-) C (-)
    • Impression
      • Abnormal liver function test, resolving, r/p sepsis related, r/o shock liver (The liver function test was abnormal but it is improving. This could be related to the recent sepsis the patient had and we need to rule out shock liver.)
    • Plan:
      • Arrange abdominal sonography when transfer to a general ward after isolation
      • Check Anti HAV IgM
      • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
      • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication
      • Silymarin 1#~2# TID (The National Health Insurance will reimburse when the levels of GOT and GPT are greater than or equal to twice the normal values.)

[chemotherapy]

• 2022-05-10 - Vidaza (azacitidine) 230mg SC
• 2022-01-17 - Vidaza (azacitidine) 260mg SC
• 2022-01-10 - Vidaza (azacitidine) 260mg SC
• 2021-12-13 - Vidaza (azacitidine) 260mg SC
• 2021-12-06 - Vidaza (azacitidine) 260mg SC
• 2021-11-15 - Vidaza (azacitidine) 260mg SC
• 2021-11-08 - Vidaza (azacitidine) 260mg SC

[assessment]

• The patient’s renal function has declined, as evidenced by a decrease in creatinine clearance based on Cockcroft-Gault formula to 33mL/min as of 2023-03-06.

  • 2023-03-06 Creatinine 2.37 mg/dL
    
  • 2023-03-03 Creatinine 1.79 mg/dL
    
  • 2023-02-27 Creatinine 1.54 mg/dL
    
  • 2023-03-06 eGFR 29.54
    
  • 2023-03-03 eGFR 40.84
    
  • 2023-02-27 eGFR 48.58

• In patients with a CrCl between 25 and 50 mL/min, a recommended dose of 1g Q12H for meropenem is advised, compared to the intended dose of 1g Q8H.

• By the way, there is no dosage adjustment necessary for any degree of kidney dysfunction for micafungin use. And there are no dosage adjustments for nystatin provided in the manufacturer’s labeling for patients with kidney Impairment.

700701354

230306

{Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.}

[lab data]

• HBsAg 2022-06-04 Reactive, Value 4.62 S/CO
  
• Anti-HCV 2022-06-04 Nonreactive, Value 0.10 S/CO
  
• Anti-HBc 2022-06-04 Reactive, Value 7.96 S/CO
  
• Anti-HBc IgM 2022-06-04 Nonreactive, Value 0.12 S/CO

[exam findings]

• 2023-02-22 CT - chest
  • Squamous cell carcinoma of upper to middle esophagus, cT3N3M0 stage IVA for esophageal cancer follow-up
  • MDCT (128-detector rows, iCT Philips,was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
  • Comparison was made with previous CT dated on 2022/11/07
    • Lungs: basal segmental consolidation and volume loss of LLL. long subpleural lines at RLL, may be fibrosis.
      • extensive ground-glass opacity at RML and centrilobular nodular opacities at RUL.
    • Mediastinum and hila: s/p left main bronchial stenting.
      • asymmetric wall thickness with luminal dilatation of upper to middle third thoracic esophagus, seem in progression as compared with CT on 2022/08/08. enlarged subcarinal LNs in visceral space, in progression
      • filling defects in pulmonary arteries (distal main, intrapulmonary lobar and segmental/subsegmentsl branches)
    • Heart: normal in size of cardiac chambers.
    • Pleura: small Lt-sided effusion.
      • opacification of veins in the chest wall and mediastinum
    • Visible abdominal contents:
      • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • no enlarged lymph node.
    • Visualized bones: unremarkable.
  • Impression:
    • proression of esophageal cancer with regional LN metastasus and newly developed pulmonary embolism and LLL consolidation/volume and pleural effusion as compared with CT on 2022/11/07
• 2023-02-21 ECG
  • Sinus tachycardia
  • Incomplete right bundle branch block
  • Septal infarct, age undetermined
  • Inferior injury pattern
  • ACUTE MI / STEMI
• 2023-02-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 25) / 93 = 73.12%
    • M-mode (Teichholz) = 73
  • Normal LV filling pressure; possibly impaired RV relaxation.
  • Normal LV and RV systolic function.
  • Mild aortic valve sclerosis; mildly dilated aortic root.
  • Sinus tachycardia.
• 2023-02-19, -02-02 ECG
  • Sinus tachycardia
• 2023-01-26 Laryngoscopy
  • Findings
    • left nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, no gross tumor found at hypopharynx, small airway
  • Conclusion
    • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
    • supraglottic swelling
• 2023-01-20 CXR
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Left hemi-diaphragm elevation is noted, which may be due to eventration.
• 2023-01-09 Esophagogastroduodenoscopy, EGD; Endoscopic Retrograde CholangioPancreatography, ERCP
  • Findings
    • Supraglottic swelling and posterior hypopharynx ulcer was noted.
    • A stricuture was noted at posterior hypopharynx. The regular EGD scope could not be inserted into esophageal inlet.
    • Using guidewire(Jagwire Revolution 0.025in x450cm) and balloon dilatation with CRE ballooin (15-18 mm, 3 ATM) was performed under fluroscopy.
    • After dilatation, the regular EGD scope still could not be inserted pass through the stricture due to the angulation at the stricture site.
  • Diagnosis
    • Hypopharyngeal stricture, s/p endoscopic balloon dilatation
  • Suggestion
    • Repeat CRE balloon dilatation
• 2023-01-08 CXR
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • Linear fibrosis or discoid atelectasis in LLL of the lung?
• 2022-12-30 CXR
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2022-12-27 Laryngoscopy
  • Findings
    • right nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, no gross tumor found at hypopharynx, yellowish sputum accumulation at bi hypopharynx, patent airway but small
  • Conclusion
    • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
    • supraglottic swelling
• 2022-12-19 SONO - abdomen
  • probable liver parenchymal disease
  • pancreas obscured
  • spleen not seen: obscured?
• 2022-12-19 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Esophageal inlet stricture, s/p endoscopic balloon dilatation
  • Suggestion
    • Suboptimal effect of the balloon dilatation was noted in this procedure.
    • Repeat dilatation is indicated.
• 2022-12-13 Patho - stomach biopsy
  • Stomach, mid-body, PW, biopsy — inflammatory polyp. No H.pylori present
• 2022-12-12 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Esophageal inlet stricture, suspected cancer stenosis s/p CRE balloon dilatation
    • C/W esophageal cancer, 20cm to 35cm below incisor
    • Gastric polyp, mid-body, PW, s/p biopsy, suspected adenoma
    • Superficial gastritis & hiatus hernia
    • Reflux esophagitis LA Classification grade A
  • Suggestion
    • Arrange CRE balloon dilatation again and placement of esophageal stent on 20221219.
• 2022-12-06 CT - brain
  • Imp: No brain nodule or metastasis. Mild cortical brain atrophy.
• 2022-12-05 Esophagography
  • Esophagography revealed obstruction of cervical esophagus with chocking.
• 2022-12-01 CXR
  • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
  • Atherosclerotic change of aortic arch
• 2022-11-29 Laryngoscopy
  • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
• 2022-11-16, -11-04, -10-19, -09-30 CXR
  • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Lung volume decrease of left lower lung is suspected.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2022-11-07 CT - chest
  • residual subsegmental atelectasis at basal segments of LLL.
  • suspect progression of esophageal tumor as compared with CT on 20220808.
• 2022-11-02 SONO - neck (lymph node)
  • Findings
    • Multiple LNs in left middle and left lower neck, with size up to 0.4cm in length at left.
    • No abnormal fluid collection.
  • Imp
    • Multiple small left neck LNs.
• 2022-10-24 MRI - larynx
  • Remarkly regressed right hypopharyngeal tumor.
  • Multiple abnormal enlarged lymph nodes in left low neck and supraclavicular fossa were noted, suggest check sonography.
    
  • Severe artifacts at left upper face,neck and oral cavity was noted, this can mask details.
  • Highly suspected regrowth of upper thoracic esophageal tumor/CA, was noted.
• 2022-09-22 Laryngoscopy
  • Findings：
    • right nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, mucus coating on supraglottis and bi hypopharynx, no gross tumor found at hypopharynx
  • Conclusion:
    • hypopharyngeal cancer s/p CCRT, no evidence of tumor recurrence
• 2022-09-07, -09-02 CXR
  • Atherosclerotic change of aortic arch
  • Lung volume decrease of left lower lung is suspected.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2022-09-05 ECG
  • Sinus tachycardia
  • Rightward axis
  • Borderline ECG
• 2022-08-25 Laryngoscopy, Stroboscopy
  • hypopharyngeal cancer s/p CCRT
• 2022-08-08 CT - chest
  • Findings
    • Lungs: residual atelectasis at basal segments of LLL. normal appearance of LUL and Rt lung.
    • Mediastinum and hila: s/p left main bronchial stenting. decrease wall thickness and luminal dilatation of lower third esophagus compared with CT on 20220604. small LNs in visceral space.
    • Pleura: trace Lt-sided effusion or thickening or nodule.
  • Impression:
    • Regression of lower third esophageal tumor as compared with CT on 20220604. LLL basal segmental atelectasis.
• 2022-08-02, -07-04 CXR
  • Atherosclerotic change of aortic arch
  • Lung volume decrease of left lower lung is suspected.
• 2022-07-07 Abdomen - standing (diaphargm)
  • Left hemi-diaphragm elevation is noted, which may be due to left lower lung volume decrease .
• 2022-06-23 CXR
  • Lt pleural effusion and consolidation and volume loss over Lt lower lobe
  • post Lt main bronchial stent placement, with expansion of atelectatic left lung
• 2022-06-15 CXR
  • Lt pleural effusion and consolidation and volume loss over Lt lower lobe
• 2022-06-13 CXR
  • regression Lt pleural effusion and consolidation and volume loss over Lt lower lobe
• 2022-06-08 CXR
  • Atherosclerotic change of aortic arch
  • Lung volume decrease of left lower lung is suspected.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
  • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
• 2022-06-08 Bronchoscopy
  • Nasal mucosal lesion, favor mucocele
  • Orolaryngeal wall tumor invasion
  • Endobronchial tumors invasion of whole left main bronchus, combined with severely external compression with LM near-total obstruction.
• 2022-06-06 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (30 - 4) / 30 = 86.67%
  • Normal LV systolic function with normal wall motion.
  • Normal LV diastolic function.
  • Normal RV systolic function.
  • Aortic valve calcificaiton with no AS and AR; mild MR; trivial TR.
  • LV chamber obliteration and flat IVC, consider hypovolemia.
• 2022-06-04 CT - CTA, chest
  • CTA of chest revealed:
    • Wall thickening of subcarinal esophagus. Left pleural effusion. Partial consolidation at left lung. A patchy density at RLL.
    • S/P jejunostomy.
    • Hyperplasia of left adrenal gland.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Wall thickening of subcarinal esophagus. Left pleural effusion. Partial consolidation at left lung. A patchy density at RLL. No evidence of pulmonary embolism.
• 2022-05-26 Electrocardiogram, EKG
  • Incomplete right bundle branch block
• 2022-05-25 Nasopharyngoscopy
  • Scope: smooth NPx, oropharynx
  • post. pharyngeal wall ulcerative lesion s/p biopsy, wound healed
  • saliva and mucus pooling, aspiration+
• 2022-05-05 Patho - larynx biopsy
  • Labeled as “Hypopharyngeal lesion”, punch biopsy — squamous cell carcinoma.
  • IHC stains: CK5/6 (+), p40 (+), p16 (+, >70%).
  • Specimen submitted in formalin consists of 2 piece(s) of tan, irregular tissue measuring 0.2 x 0.2 x 0.1 cm.
• 2022-05-02 Miniprobe Endoscopic Ultrasound
  • Diagnosis
    • Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement
    • Gastric polyp, body, PW, s/p biopsy
    • Reflux esophagitis, LA grade A
    • Hiatal hernia
    • Superficial gastritis, body
  • Suggestion
    • suggest consult ENT for biopsy of hypopharynx lesion
    • Pursue pathology report
• 2022-05-02 Nasopharyngoscopy
  • smooth nasopharynx and oropharynx;
  • small whitish lesion over left pyriform sinus;
  • bulging over right pyriform sinus;
  • posterior hypopharyngeal wall ulcerative lesion;
  • fair vocal cord movement.
• 2022-04-29 Tc-99m MDP whole body bone scan
  • Mildly increased activity in the lower C-spine, some T- and L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2022-04-28 MRI - brain
  • No evidence of brain metastasis.
  • Mild general brain atrophy.
• 2022-04-28 Abdominal Ultrasonography
  • Diagnosis
    • Hepatic lesion, S3, 1.22cm, suspected falciform ligament or hemangioma
    • Suspected calcified spot, left kidney
  • Suggestion
    • Please correlate with other image study for liver lesion
• 2022-04-19 Whole body PET scan
  • Glucose hypermetabolism involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in some right neck level II lymph nodes, a left submandibular lymph node, a left supraclavicular lymph node and a right paratracheal lymph node. The nature is to be determined (inflammatory process? metastases of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism involving the posterior pharyngeal wall of the hypopharynx. Hypopharyngeal malignancy should be considered.
  • Glucose hypermetabolism in a left neck level II lymph node and a left neck level IV lymph node. Metastatic lymph nodes may show this picture.
• 2022-04-13 Patho - esophageal biopsy
  • Esophagus, 25 to 28 cm, biopsy — Squamous cell carcinoma, moderately differentiated
  • The specimen submitted consists of multiple small pieces of gray-tan soft tissue, labeled esophagus, 25 to 28 cm, measuring up to 0.2 x 0.1 x 0.1 cm. All for section and labeled S2020-05275 FS.
  • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident.
• 2022-04-09 CT - lung/mediastinum/pleura
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Soft tissue mass at middle to lower third esophagus up to 7.5cm in length is found. Esophageal cancer is considered. In comparison with CT dated on 2021-08-27, the lesion progressed.
      • Small lymph nodes are found at AP window and paratracheal region.
      • The lung fields are clear.
      • Patent airway is found.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • Suggest clinical correlation
  • Imp:
    • Suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression.
    • Mediastinal lymphadenopathy
• 2021-08-30 Patho - esophageal biopsy
  • Esophagus, middle, 25 to 30 cm, biopsy — High-grade dysplasia (severe dysplasia)
    
  • The sections show high-grade (severe) dysplasia, composed of squamous epithelium with hyperkeratosis, parakeratosis, acanthosis, cellular atypia and atypical mitotic figures. Changes extend to upper-third of the epithelium. Suggest closely follow up.
• 2021-08-27 CT - lung/mediastinum/pleura
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Calcified coronary arteries is found.
      • The lung fields are clear.
      • Patent airway is found.
      • No evidence of bilateral pleural effusion.
      • There is no evidence of esophageal wall thickening.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • The GB is well distended without soft tissue lesion
      • Suggest clinical correlation
  • Imp: no evidence of esophageal wall thickening in the study.
• 2020-12-29 Patho - esophageal biopsy
  • Esophagus, middle, biopsy — high-grade dysplasia
    
  • Microscopically, it shows high-grade dysplasia with aacanthosis and dysplastic change of the epithelial cells.
• 2020-12-29 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade AEsophageal lesion, middle esophagus s/p biopsy (B)
  • Superficial gastritis, antrum
  • Gastric polyp, GC of body s/p biopsy (A)
• 2019-11-13 CT - mediastinum
  • Comparison: prior CT dated on 2017/11/27
    • Chest
      • No enlarged LNs in the mediastinum, supraclavicular fossa, and hilars.
      • Normal appearance of visible thoracic aorta, central pulmonary arteries, and cardiac chmabers.
      • No pleural effusion or nodule.
      • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric juncntion.
      • A tiny subupleural nodule at LUL. normal appearance of the LLL and Rt lung.
      • Unremarkable of the chest wall.
    • Visible abdomen
      • Unremarkable of the liver, spleen, pancreas, both kidneys, GB, and adrenal glands.
      • No enlarged LN.
      • No ascites in the abdominal cavity.
    • Visible bones
      • Mild marginal spurs of multiple vertebral bodies.
  • Impression:
    • esophageal cancer,T2N2M0, s/p compeleted CCRT with no obvious recurrent tumor or luminal narrowing based on this CT study.
• 2018-07-03 Bone densitometry - hip
  • Hip BMD performed by DXA revealed:
    • Hip, BMD is 0.660 gms/cm2, about 1.5 SD below the peak bone mass (78%) and 0.6 SD below the mean of age-matched people (89%).
  • IMP: osteopenia
• 2017-11-27 CT - lung/pleura, chest and upper abdomen
  • Findings
    • Chest:
      • No enlarged LNs in the mediastinum, supraclavicular fossa, and hilars.
      • Normal appearance of aorta, pulmonary arteries, and cardiac chmabers.
      • No pleural effusion.
      • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric juncntion.
      • Two tiny subupleural nodule at LUL srs5 img10
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys, GB, and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • No ascites in the abdominal cavity.
  • Impression:
    • esophageal cancer, T2N2M0, s/p compeleted CCRT without obvious recurrent tumor or luminal narrowing based on CT study.
• 2017-03-06 CT - lung/pleura, chest and upper abdomen
  • Findings
    • Chest:
      • No enlarged LNs in the mediastinum, supraclavicular fossa, and hila.
      • Normal appearance of aorta, pulmonary arteries, and cardiac chmabers.
      • No pleural effusion.
      • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric jucntion.
      • Two tiny subupleural nodule at LUL
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • The GB is well distended without soft tissue lesion
      • Suggest clinical correlation
  • Impression:
    • esophageal cancer, T2N2M0, s∕p compeleted CCRT without obvious recurrent tumor or luminal narrowing based on CT study.

[consultation]

• 2023-02-21 Cardiology
  • Q
    • This 61-year-year-old male has the medical history of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up.
    • Chemotherapy with Docetaxel + Leucovorin + Fluorouracil + Cisplatin was started on 2022/12/21. C2D1 for Docetaxel + Leucovorin + Fluorouracil + Cisplatin was on 2023/01/09. C2D15 chemotherapy with Docetaxel + Leucovorin + Fluorouracil + Cisplatin was on 2023/01/09.
    • This time, he suffered from intermittent and progressive chest tightness and chest pain for 2 day. He denied fever, chills, abdominal pain, or dysuria. He visited our ER for management. During ER, vital sign showed BP:114/69, PR:122, BT:36.7 degree Celsius, RR:20. Lab data showed negative cardiac enzyme abnomality, but CRP was elevated. CXR showed focal increased density in the right lower lung field. Under the impression of pneumonia, he was admitted for further management.
    • He complatins chest pain, chest tightness, short of breathing, 12 lead EKG: II, III, aVF ST elevate, follow-up right side 12 lead EKG showed acut MI/ STEMI, so we need your help, thanks a lot!!
  • A
    • The patient was examined and hx was reviewed.
    • O
      • nsp chest tightness and chest pain;
        • aggravated productive cough with wheezing+ in recent days;
      • CxR: elevated L’t diaphragm, suspected LLL consolidation;
      • 2D echo showed preserved LV systolic function; no evidence of segmental asynergy.
    • Imp
      • Sinus tachcyardia, possibly due to underlying infection (possibly L’t pneumonia); no evidence of STEMI now.
    • Suggestion
      • Treat L’t pneumonia and bronchospasm firstly.
      • Check thyroid function for tachycardia survey.
• 2023-01-09 Gastroenterology
  • Q
    • For esophagus balloon dilation
    • This 60-year-year-old male has the medical history of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up. He was found esphagus relapse and suspicious hypopharyngeal involvement by PES was done on 2022/04/13 and nasopharyngoscopy 2022/05/02.
    • He received 6 courses CCRT with PF from 2022/06/02 ~11/04. Radiotherapy from 2022/05/30~7/27.
    • This time, he was admitted for exam and chemotherapy on 2023/01/08.
    • He under went CRE balloon dilatation again on 2022/12/19 which showed esophageal inlet stricture.
    • Thus we need your expertise for his balloon dilatation at this admission. Thanks a lot!
  • A
    • 60M, A case of 1) Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. 2) Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0. 3) Squamous cell carcinoma of the middle third esophagus. We are consulted for CRE balloon dilatation.
    • S+O:
      • conscious status: clear
      • HEENT: dysphagia, including drinking water
      • chest: smooth breath sound
      • abdomen: soft and flat
      • Lab
        • WBC: 4700
        • Hb: 11
        • Plt: 208
        • AST/ALT: 30/26
        • INR: 1
        • PT: 10.3
      • EGD(2022/12/19):
        • Esophageal inlet stricture, s/p endoscopic balloon dilatation
    • A:
      • Esophageal squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence.
      • Esophageal inlet stricture
      • quamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.
    • P:
      • We will arrange EGD for endoscopic balloon dilatation evaluation.
• 2022-12-13 Thoracic Surgery
  • Q
    • He underwent jejunostomy surgery on 2022/05/06 by doctor Hsieh. The patient complaint about redness around Jejunostomy with leakage recently. We need your help for further evaluation. Thank you very much.
  • A
    • Dear Dr. Wan, I will visit the patient and educate about wound care. Thanks for your consultation!!
• 2022-12-02 Gastroenterology
  • Q
    • The patient was unable to swallow even water. We need your help for further evalution of esophageal stent. Thank you very much.
  • A
    • Image
      • 2022/11/07 - asymmetric wall thickness and luminal dilatation of upper to middle third thoracic esophagus, seem in progression as compared with CT on 8/8. small LNs in visceral space
    • Impression
      • Dysphagia, suspicious obstruction of recurrent esophageal cancer
    • Suggestion
      • Please arrange Esophagography first to evalute the level of esophagus obstruction, then contact us for further management about esophageal stent placement
      • We would arrange EGD for tthis patient.
• 2022-11-07 Rehabilitation
  • A
    • Assessment
      • Squamous cell carcinoma of upper to middle esophagus, cT3N3M0 stage IVA
      • Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0
      • Carrier of viral hepatitis B
      • constipation
      • Dysphagia due to esophageal tumor progression
    • Plan
      • The patient is not suitable for swallowing training
      • Food and water cannot pass down the esophagus, they will go back retrogradely and cause aspiration or choking
• 2022-07-08 Dental Clinic
  • Q
    • For dental evaluation and management
    • This is a 60-year-old man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up. This time he has suffered from progressive dysphagia and weight loss of 8 kg in 1 month. In hematology OPD, chest CT was arranged and showed suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression and mediastinal lymphadenopathy. He was extracting the teeth (14, 27, 28, 38, 45), and he received CCRT with PF. The family request consult dentistry for dental evaluation and management. Thanks a lot.
  • A
    • #11-#13 The dental bridge is loose, it is recommended to use interdental brushes to maintain oral hygiene.
    • A diagnostic certificate issued by an oral and maxillofacial surgery department is required.
  • 2022-06-09 Infectious Disease
    • A
      • Assessment
        • Consultation for Mepem antibiotic
        • 60-year-old esophageal cancer male patient has received recent chemotherapy
        • High fever yesterday afternoon despite Cravit use for left lung pneumonia.
        • Aspiration pneumonia is the first impression.
        • Sputum culture normal flora only.
        • Cravit is replaced by Mepem yesterday evening.
      • Suggestion:
      • 1. Continue Mepem for one week first.
      • 2. Check blood culture report, repeat sputum culture.
  • 2022-06-08 Family Medicine
    • Q
      • The patient and family request to combine hospice care (NHI card annoted DNR), so we need your help, thanks a lot!!
    • A
      • 60 y/o gentleman advanced esophageal cancer. admitted for CCRT
      • Our share care would follow up.
  • 2022-05-26 Thoracic Surgery
    • Q
      • This 60 y/o man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up.
      • Recurrent upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA status post jejunostomy and port-A catheter implantation on 2022-05-06.
      • The patient’s jejunostomy was done under your servise on 2022-05-06. This time, he was admitted due to acute epiglottitis. After admission, antibiotic with Cravit was given. The patient suffered from cold sweating and palpitation while G-tube feeding, and some yellowish discharge from jejunostomy for 4-5 days. NPO was told since last night. We request your consultation for further evaluation.
    • A
      • I have visited the patient and educated about care of jejunostomy. Thanks for your consultation!!!
  • 2022-05-10 Oral and Maxillofacial Surgery
    • Q
      • This is a 60-year-old man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up. This time he has suffered from progressive dysphagia and weight loss of 8 kg in 1 month. In hematology OPD, chest CT was arranged and showed suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression and mediastinal lymphadenopathy.
      • Upper GI panendoscpope showed one lumen-obstructive tumor was noted from 25 to 30 cm and biopsy was done. Pathology revealed moderately differentiated squamous cell carcinoma. He was referred to our CS OPD. PET scan revealed a glucose hypermetabolic lesion involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis.Endoscopic biopsy proved Esophageal squamous cell carcinoma at middle/lower third esophagus. However, his EUS showed Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement.
      • We consult ENT Dr. Lan for hypopharynx lesion, nasopharngoscopy biopsy show squamous cell carcinoma.
      • After admission, we arranged WBBS, brain MRI, abd. sono, EUS and bronchoscope, for cancer work-up. On 2022-05-06, he underwent feeding jejunostomy + port-A insertion. We kept nutrition supplement with jejunostomy feeding since 2022-05-07 and increased calories gently. We also consulted ONCO and for further manegement.
      • Impression: upper to middle esophagus squamous cell carcinoma,cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma.
      • We need to consult you for for pre-RT dental evaluation and management.
    • A
      • This is a 60-year-old man suffered from upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma. We were consulted for Pre-radiotherapy dental evaulation
      • O:
        • Hopeless teeth of tooth 14, 27, 28, 38, 45
        • Poor oral hygiene with full mouth gingivitis.
      • P:
        • Explain the finding to patient and his son.
        • Please prescribed Cefa 1g IV Q8H for prophhylaxis.
        • We were arranged further extraction for him .
        • OPD follow up.
  • 2022-05-09 Radiation Oncology
    • The patient’s history was reviewed and patient was examined.
    • S:
      • For radiotherapy due to recurrent esophageal carcinoma and hypopharyngeal carcinoma.
      • PI: The patient was a case of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up. He suffered from progressive dysphagia since 2021 with body weight loss of 8 kg in 1 month. After a series of work-up, the impression was upper to middle esophageal squamous cell carcinoma, cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma. On 2022-05-06, he underwent feeding jejunostomy + port-A insertion. Nutrition supplement with jejunostomy feeding since 2022-05-07 and increased calories gently.
      • Family history: (father: esophageal cancer).
      • Cancer site specific factors: Alcohol (quit); Smoking (quit); Betel nut (quit).
      • Personal Hx: DM(-); HTN(-); HBV(+)
    • O:
      • ECOG: 1
      • PE: neck and bil SCF: neg.
      • Pathology (2013-02-01; S2013-01656): Esophagus, esophagocardiac junction to 32 cm below incisor, biopsy — squamous cell carcinoma.
      • Esophagography (2013-02-22): lower esophageal cancer.
      • CXR (2013-02-18): neg.
      • Chest CT (2013-02-08): Soft tissue mass at lower third esophagus near EG junction up to 5*3.55cm with central necrotic part is found. There is no evidence of mediastinal LAP, however, some lymph nodes (3-4) around EG junction is noted. Esophageal cancer at lower third esophagus. T2N2M0 in the study. Stage IIIa.
      • PET scan (2013-02-20): Glucose hypermetabolism lesion in the esophagus, L/3, probably primary esophagus malignancy; hypermetabolism lesion in the right subcarinal region of mediastinum, probably reactive node or malignancy with lymph nodes metastasis. Staging: TxNxM0.
      • RT (2013-3-11 ~ 2013-4-15): 4500cGy/25fractions of the low third esophageal tumor to peripheral lymphatic area.
      • CT scan of mediastinum (2013-07): resolution of intraluminal mass in lower third of esophagus; post treatment change involving M/3 esophagus?
      • Pathology (S2021-11415, 2021-08-31): Esophagus, middle, 25 to 30 cm, biopsy — High-grade dysplasia (severe dysplasia).
        
      • CT scan of lung (2022-04-09): Suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression. Mediastinal lymphadenopathy.
      • UGI pandendoscopy (2022-04-13): One lumen-obstructin tumor was noted from 25 to 30 cm, s/p biopsy*8 (A). Lugol solution was applied. Area of sliver color sign was noted at 23-25cm. Biopsy was done. (A). One depressed lesion with loss of vasculature was noted at hypopharynx. Diagnosis: Esophageal cancer, s/p biopsy (A) + (B). Hypopharynx lesion, suspected metastatic lesion
      • Pathology (S2022-06234, 2022-04-14): Esophagus, 25 to 28 cm, biopsy — Squamous cell carcinoma, moderately differentiated
      • PET (2022-04-19): 1. Glucose hypermetabolism involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis. 2. Mild glucose hypermetabolism in some right neck level II lymph nodes, a left submandibular lymph node, a left supraclavicular lymph node and a right paratracheal lymph node. The nature is to be determined (inflammatory process? metastases of low FDG uptake?). 3. Glucose hypermetabolism involving the posterior pharyngeal wall of the hypopharynx. Hypopharyngeal malignancy should be considered. 4. Glucose hypermetabolism in a left neck level II lymph node and a left neck level IV lymph node. Metastatic lymph nodes may show this picture.
      • CXR (2022-04-27): a focal Rt-sided convexity of the azygoesophageal recess interface, raise suspicious of esophageal tumor. Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch. Clean lung fields based on plain image. Normal shape and size of heart. Marginal spurs of multiple vertebral bodies of T-L spine due to spondylosis. Normal appearance of both hila
      • MRI of brain (2022-04-28): No evidence of brain metastasis. Mild general brain atrophy.
      • Abd sono (2022-04-28): Hepatic lesion, S3, 1.22cm, suspected falciform ligament or hemangioma. Suspected calcified spot, left kidney.
      • Bone scan (2022-04-29): no evidence of bone metastasis.
      • Miniprobe EUS for UGI (2022-05-02): 1. Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement. 2. Gastric polyp, body, PW, s/p biopsy. 3. Reflux esophagitis, LA grade A. 4. Hiatal hernia. 5. Superficial gastritis, body.
      • Operation (2022-5-6): Feeding jejunostomy + port A
      • Pathology (S2022-07892, 2022-5-9): Labeled as “Hypopharyngeal lesion”, punch biopsy — squamous cell carcinoma. IHC stains: CK5/6 (+), p40 (+), p16 (+, >70%).
    • A:
      • Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence.
      • Squamous cell carcinoma of the hypopharynx, p16 (+).
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: recurrent esophageal carcinoma and hypopharyngeal carcinoma.
      • Goal: curative (if double primary), or palliation (if metastatic chypopharyngeal carcinoma).
      • Treatment target and volume: hypopharyngeal tumor, bilateral neck, to recurrent esopharyngeal tumor area.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: probably 5000cGy/25 fractions of the esophageal tumor, bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor to involved neck nodal lesions (if hypopharyngeal carcinoma is 2nd primary).
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 10:30, 2022-05-11.
      • Please consult Dental department for pre-RT dental evaluation and management.
  • 2022-05-05 Hemato-Oncology
    • Impression:
      • Recurrent upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA
      • Hypopharynx tumor suspect SCC s/p biopsy, pending pathology
    • Suggestion
      • For recurrent esophagus cancer, SCC, systemic therapy is indicated (such as 5-FU/capecitabine + oxaliplatin[self-paid]/cisplatin) or clinical trial if available
      • Schedueled feeding jejunostomy + port-A had arranged
    • Thanks for your consultation. We will discuss with patient. If there is any problem, please feel free to let us known
  • 2022-05-02 ENT
    • A
      • Local finding: fair oral cavity and oropharynx
      • Scope: smooth nasopharynx and oropharynx; small whitish lesion over left pyriform sinus; bulging over right pyriform sinus; posterior hypopharyngeal wall ulcerative lesion; fair vocal cord movement.
      • Impression: hypopharyngeal malignancy cannot be ruled out
      • Plan: Biopsy for tissue proof may be required.

[surgical operation]

• 2022-10-26 Removed port-A and insert new one. Revision of jejunostomy.
• 2022-06-13 Tracheal stent inseriton.
• 2022-05-06 Feeding jejunostomy

[radiotherapy]

• 2022-05-30 ~ 2022-07-27 - 5000cGy/25 fractions (15MV and 6MV photon) of the hypopharyngeal tumor to bilateral neck, and 7000cGy/35 fractions of the reduced hypopharyngeal tumor to bilateral involved neck nodal area.

[chemoimmunotherapy]

• 2023-02-02 - docetaxel 40mg/m2 65mg NS 200mL 1hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 250mL 2hr + fluorouracil 1000mg/m2 1735mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 65mg NS 500mL 4hr D3
  • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
• 2023-01-09 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
  • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
• 2022-12-20 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
  • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
• 2022-12-01 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
  • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
• 2022-11-04 - cisplatin 75mg/m2 130mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
• 2022-09-30 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
• 2022-09-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
• 2022-08-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
• 2022-07-04 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
• 2022-06-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)

[note]

• Esophageal and Esophagogastric Junction Cancers NCCN guidelines version 4.2022, 20220907
  • DEFINITIVE CHEMORADIATION (NON-SURGICAL) p51
    • Fluorouracil and cisplatin
      • Cisplatin 75-100 mg/m2 IV on Day 1
      • Fluorouracil 750-1000 mg/m2 IV continuous infusion over 24 hours daily on Days 1-4
      • Cycled every 28 days for 2 cycles with radiation followed by 2 cycles without radiation
    • ref: Minsky BD, Pajak TF, Ginsberg RJ, et al. INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combinedmodality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy. J Clin Oncol 2002;20:1167
  • PERIOPERATIVE CHEMOTHERAPY (Only for adenocarcinoma of the thoracic esophagus or EGJ) p50
    • Fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) - (4 cycles preoperative and 4 cycles postoperative)
      • Fluorouracil 2600 mg/m2 IV continuous infusion over 24 hours on Day 1
      • Leucovorin 200 mg/m2 IV on Day 1
      • Oxaliplatin 85 mg/m2 IV on Day 1
      • Docetaxel 50 mg/m2 IV on Day 1
      • Cycled every 14 days
    • ref: Al-Batran S-E, Homann N, Pauligk C, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastrooesophageal junction adenocarcinoma (FLOG4): a randomised, phase 2/3 trial. Lancet 2019;393:1948-1957.
• Concurrent Chemoradiotherapy with Docetaxel, Cisplatin, and 5-fluorouracil Improves Survival of Patients with Advanced Esophageal Cancer Compared with Conventional Concurrent Chemoradiotherapy with Cisplatin and 5-fluorouracil. J Cancer. 2018;9(16):2765-2772. Published 2018 Jul 16. doi:10.7150/jca.23456
  • All patients underwent chemotherapy and radiotherapy concurrently.
  • In the CF-RT group, cisplatin (70 mg/m2) was administered via intravenous drip infusion on day 1, and 5-FU (700 mg/m2) via continuous intravenous drip infusion on days 1-5.
  • In the DCF-RT group, docetaxel and cisplatin (both 50 mg/m2) were administered via intravenous drip infusion on day 1, and 5-FU (500 mg/m2) via continuous intravenous drip infusion on days 1-5.
  • Patients underwent 2 cycles of chemotherapy during radiotherapy when no deterioration in overall health or occurrence of adverse events was verified.
  • Patients with severe neutropenia were immediately administered granulocyte-colony stimulating factor (G-CSF).

[assessment]

• 2023-03-05 lab data CRP 5.25mg/dL.

• 2023-03-05 sputum gram’s stain result showed:

  • G(+) Cocci 3+: There is a high amount of gram-positive cocci bacteria present in the sample being analyzed.
  • GNB 3+: There is a high amount of gram-negative bacilli bacteria present in the sample being analyzed.
  • Neutrophil/LPF <10 and/or Epithelial cell/LPF >25: This may indicate that the sample was not collected properly and that there is a risk of contamination.

• As the staining results may suggest a possibility of contamination, it may be necessary to collect a new sample.

• Moxifloxacin with an antibacterial spectrum encompassing both aerobic gram-negative and gram-positive strains, as well as anaerobic bacteria, can be used for pneumonia, community-acquired, outpatients with comorbidities and inpatients as an alternative agent. It is not recommended to be used in patients with risk factors for P. aeruginosa (ATS/IDSA [Metlay 2019]; File 2020). Based on the normal liver and kidney function lab results on 2023-03-05, the current dosage of 400 mg once daily is appropriate and does not require any adjustments.

230202

[assessment]

• Lab data on 2023-02-01 were grossly normal. There is no problem with the active prescription, except for the anticipated less effective use of Boren-C by tube-feeding.

230109

[tube feeding]

• Broen-C (bromelain + L-cysteine) is an enteric-coated tablet designed to prevent the destruction of the bromelain enzyme by gastric juice.

• Bromelain is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. ref: Mala T, Anal AK. Protection and Controlled Gastrointestinal Release of Bromelain by Encapsulating in Pectin-Resistant Starch Based Hydrogel Beads. Front Bioeng Biotechnol. 2021;9:757176. Published 2021 Oct 29. doi:10.3389/fbioe.2021.757176

• There are no other drugs in the inventory that contain bromelain.

221219

[assessment]

• It has been arranged on 20221219 for a CRE (controlled radial expansion) balloon dilatation and placement of an esophageal stent due to obstruction of cervical esophagus.
• Medication is sometimes responsible for clogged feeding tubes. To prevent clogs and other related issues, there are general tips for giving medication through a feeding tube:
  • Administer each medication separately.
  • Stop the feeding and flush the tube with water before and after medication administration.
  • Crush only those medications which are immediate-release. Sustained-release and enteric-coated medications don’t dissolve well and may not absorb properly when crushed.
  • Use liquid medications when available.
  • Dilute liquid medications to prevent clogging and gastrointestinal upset, like diarrhea.

221212

[tube feeding]

• Except for Broen-C, all oral medications in the active prescription can be administered by nasogastric tube.
• In order to prevent the bromelain enzyme from being destroyed by gastric juice, Broen-C (bromelain + L-cysteine) is designed as an enteric-coated tablet.

221202

[assessment]

• As a result of the CT result obtained on 2022-11-07, it appears that the esophageal tumor has progressed. It was then decided to change the regimen from [cisplatin + fluorouracil] to [docetaxel + leucovorin + fluorouracil + cisplatin], which was initiated during this hospitalization.
• Neither a non-trivial adverse reaction nor an issue with the active prescription have been observed.

221201

{tube feeding}

• With the exception of Boren-C, all other drugs in the active prescription can be administered via nasogastric tube.
• As an enteric-coated tablet, Boren-C is designed to prevent gastric acids from destroying its key ingredient, bromelain enzyme.

221003

[assessment]

• The underlying condition HBV is currently being managed with Vemlidy (tenovofir) without any problems.

220930

[assessment]

• Broen-C (bromelain + L-cysteine) is an enteric coated tablet that should not be administered through a nasogastric tube. Right now, there is no single ingredient bromelain item in stock, however, Actein (acetylcysteine 200 mg/pk) has also been prescribed and may act in part as cysteine.

220905

[assessment]

• As Harnalidge (tamsulosin 0.4mg PO QDAC) is not intended for use with nasogastric tubes, it is recommended to replace it with Urief (silodosin 8mg PO QD).
• Broen-C (bromelain + L-cysteine) is formulated as an enteric coated tablet and is not intended for nasogastric tube feeding. Currently, there is no single ingredient bromelain item available in inventory, however, Actein (acetylcysteine 200mg/pk) is available and could partially serve as cysteine.

220606

[assessment]

• Initially diagnosed in 2013, this patient now suffers from recurrent esophageal squamous cell carcinoma of cT3N3M0 stage IVA. He has begun receiving CCRT since late May 2022.
• Additionally, the patient carries viral hepatitis B, which is treated with Vemlidy (tenofovir alafenamide) 25mg PO QDCC.

700081806

230303

[exam findings]

• 2023-02-27 Patho - gingival/oral mucosa biopsy
  • Bone, chin, removal — Osteitis and osteonecrosis
• 2022-09-20 MRI - nasopharynx
  • Indication: Recurrence SCC of mandibular gingiva
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
  • Pulse sequences:1. Precontrast: sagittal and axial, coronal T1WI, coronal T2WI images, axial T2WI 2. Post contrast: axial, coronal T1WI. Slice thickness: 3-5 mm
  • Comparison: 2022/05/13 MRI
    • Post fat-containing flap reconstruction surgery with clips/sutures retention and/or bony defect at left mandible, bucco-gingival region.
    • No evident abnormal enlarged lymph node in the visible neck.
    • No obvious abnormal enhancement after contrast medium administration.
    • No obvious gingival nodule or mass was found, though early shallow lesion is hard to be defined on this study.
• 2022-09-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
  • Tissue blocks/unstained slides received labeled as: S2022-15310
  • TC >= 1% and < 5%
  • Percentage of PD-L1 expressing tumor cells (%TC): 1%
• 2022-09-12 Patho - soft tissue biopsy / simple excision (non lipoma)
  • Skin lesion, chin, frozen and excision — Squamous cell carcinoma, moderately differentiated
  • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated characterized by solid tumor nests show enlarged, pleomorphic nuclei infiltrate in the stroma with keratin formation.
• 2022-09-09 CT - facial bone
  • Indication
    • SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
    • SCC of left lower gingival (T1N0M0 stage I) s/p OP with tongue flap .
    • SCC of lower lower gingival (T4N0M0 stage IV) s/p OP with fibula flap reconstruction
    • During CCRT
    • The STSG wound of left fibula region was healing in progress .
    • Multiple ulceration of left floor of the mouth
    • A little swelling of chin region .
  • Protocol: 2.5mm slice thickness, axial scan and coronal/ sagittal reconstruction
  • Without contrast fical bone CT showed
    • The neck airway was unremarkable.
    • Suspicious a break at the metallic plate of the left posterior mandible.
    • Post-operation change at left buccal region, mandile and maxilla.
    • No neck LAP
  • IMp: suspicious a break at the metallic plate of the left posterior mandible.
• 2022-07-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
  • Tissue blocks/unstained slides received labeled as: S2022-09325A1
  • Tumor cell (TC) staining assessment: TC < 1%
• 2022-06-09 Patho - oral cancer (wide excision without lymph node)
  • PATHOLOGIC DIAGNOSIS
    • Mandibular gingiva, left, wide excision — Squamous cell carcinoma
    • Lymph nodes, llevel 3, right, LN dissection — Negative for malignancy (0/1)
    • Bone, mandible, segmental mandibulectomy — Involved by carcinoma and free margin
    • Pathology stage: rpT4aN0(cM0); Stage IVA
  • MACROSCOPIC EXAMINATION
    • Surgical Procedure(s): Wide excision + segmental mandibulectomy + LN dissection
    • Specimen Type:
      • Main location: Left mandibular gingiva
      • Lymph node dissection: Yes, right level III
    • Specimen Integrity: intact
    • Specimen Size: 7.2 x 4.2 x 3.5 cm with skin 3.9 x 3.2 cm, mandible bone, 7.2 cm in length, and three teeth
    • Tumor Site: Mandibular gingiva; Laterality: Left
    • Tumor Focality: Single focus
    • Tumor Size: 2.0 x 1.0 x 0.8 cm
      • Depth of Invasion: 8 mm
    • Mucosal Surface : Ulcerated
    • Gross Tumor Extension: Tumor invades bone
    • Representative parts are taken for section and labeled: A1= tumor + anterior margin of mouth floor, A2= tumor + upper lip, A3= tumor + mouth floor, A4= tumor + buccal mucosa, A5= tumor + skin, A6= lower lip, A7= posterior area of molar, A8= mandible bone. B= level 3 lymph node. F2022-00263 FSA= mouth floor, left, FSB= mouth floor, right
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Squamous cell carcinoma
    • Histologic Grade: G2 (moderate differentiated)
    • Microscopic Tumor Extension: To mandible bone
    • Margins: Margins free, Distance from closest margin: 0.5 cm (anterior margin of mouth floor)
    • Lymph-Vascular Invasion: Not identified
    • Perineural Invasion: Not identified
    • Neck Lymph Nodes: Negative (0/1)
      • Number of LN examined: 1 (right level 3)
      • Number of LN metastasis: 0
    • Mandibule bone margin: Free of tumor
    • Surgical margins received for frozen section, including mouth floor, right and mouth floor left: Free of tumor
• 2022-05-13 MRI - nasopharynx
  • Indication:
    • SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
    • SCC of left lower gingival s/p OP with tongue flap .
    • A ganuloma like mass was noted of left commisure region with bleeding tendancy s/p CO2 laser surgery on 2022/04/25. Pathology report: SCC
  • Imaging protocol: 3-5mm slice thickness; coronal T1 & T2, sagittal T1, axial T1 & T2FS & DWI/ADC, axial and coronal T1FS+C images
  • Neck MRI without/with Gadolinium-based contrast enhancement shows:
    • magnetic suceptibility artifacts from dental prosthesis obscure the image details in oral cavity.
    • postoperative change at left buccal region, left neck, and left submandibular space.
    • ill-defined enhancing mass lesion (largest diameter about 3.3cm) at left lower gingiva and oral commisure, with invasion to mandibular bone causing cortex destruction and bone marrow signal change, and probably also invasion to left inferior alvealar nerve. T4a disease is compatible.
    • no enlarged cervical lymphadenopathy.
  • Impression:
    • Recurrent left lower gingival cancer, image staging favor T4aN0.
    • Postoperative change at left buccal region and left neck.
  • Imaging Report Form for Oral Cavity Carcinoma
    • Impression (Imaging stage) : T:T4a(T_value) N:0(N_value) M:____(M_value) STAGE:IVA(Stage_value)
• 2022-05-10 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a faint hot spot in the midline lower frontal area of the skull and increased activity in the mandible, sacrum, bilateral shoulders and right sternoclavicular junction in whole body survey.
  • IMPRESSION:
    • Increased activity in the mandible. The nature is to be determined (dental problem? malignancy with local bone invasion?). Please correlate with other clinical findings for further evaluation.
    • Mildly increased activity in the sacrum. Degenerative change may show this picture.
    • A faint hot spot in the midline lower frontal area of the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and right sternoclavicular junction, compatible with benign joint lesions.
• 2022-04-25 Patho - gingival / oral mucosa biopsy
  • Oral cavity, left lower gingival, incisional biopsy — moderately differentiated squamous cell carcinoma
  • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests and sheets of non-keratinizing tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
  • Immunohistochemical stain reveals p16(-).
• 2021-11-15 Patho - gingival/oral mucosa biopsy
  • PATHOLOGIC DIAGNOSIS
    • Tumor, left lower gingiva, wide excision — Squamous cell carcinoma
      
    • Resection margins, ditto — Tumor present at one of peripheral margins
      
    • Lymph node — N/A
      
    • AJCC Pathologic staging — pT1, if cN0 and cM0, stage I
      
  • MACROSCOPIC EXAMINATION
    • Surgical Procedure(s): wide excision
      
    • Specimen Type:
      • Main location: left lower gingiva
        
      • Other part(s) included: N/A
        
      • Lymph node dissection: NO
        
    • Specimen Integrity: Intact
      
    • Specimen Size: 1.0 x 0.7 x 0.4 cm
      
    • Tumor Site: left gingiva
      
    • Tumor Focality : solitary
      
    • Tumor Size: 0.4 cm
      • Tumor thickness (for pT1 and pT2 tumors only): 0.1 cm
        
    • Mucosal Surface: ulcerative tumor
      
    • Gross Tumor Extension (specify) : can not be assessed
  • MICROSCOPIC EXAMINATION
    • Histologic Type: squamous cell carcinoma
      
    • Histologic Grade: G2, moderately differentiated
      
    • Microscopic Tumor Extension: 0.1 cm
      
    • Margins: tumor present at one of peripheral margins , < 0.1 cm from base
      
    • Lymph-Vascular Space Invasion: absent
      
    • Perineural Invasion: absent
      
    • Neck Lymph Nodes: N/A
      
    • Immunohistochemistry: CK5/6(+), P63(+), P53(+) and P16(-) for tumor
• 2021-11-12 MRI - nasopharynx
  • History:
    • Squamous cell carcinoma of left buccal mucosa ,pT1N0M0 post of operation (2012)
    • Squamous cell carcinoma of left upper gingiva, pT1N0(cM0) post of operation (2017)
    • A verrucous like mass was noted of left lower gingival about 0.5 cm in diameter. Pathological report: Squamous cell carcinoma in situ at least.
  • Imaging protocol: 3-5mm slice thickness; coronal T1 & T2, sagittal T1, axial T1 & T2FS & DWI/ADC, axial and coronal T1FS+C images
  • Neck MRI without/with Gadolinium-based contrast enhancement shows:
    • magnetic suceptibility artifacts from dental prosthesis obscure the image details in oral cavity.
    • postoperative change at left buccal region, left neck, and left submandibular space.
    • the primary lesion at left lower gingiva is not obviously seen in this image study. No mandibular bone invasion is noted.
    • no enlarged cervical lymphadenopathy.
  • Impression:
    • Left lower gingival cancer, image staging favor T1N0.
    • Postoperative change at left buccal region and left neck.
  • Imaging Report Form for Oral Cavity Carcinoma
    • Impression (Imaging stage) : T:T1(T_value) N:0(N_value) M:M0(M_value) STAGE:I(Stage_value)
• 2021-11-04 Patho - gingival/oral mucosa biopsy
  • Gingiva, left lower, incisional biopsy — Squamous cell carcinoma in situ at least
    
  • The sections show squamous cell carcinoma in situ at least, composed of squamous epithelium with hyperkeratosis, parakeratosis, acanthosis, keratin pearls, marked cellular atypia and atypical mitotic figures. Changes involving the whole thickness of the epithelium. No stromal component can be found, and squamous cell carcinoma can not be excluded. Suggest excision.
• 2021-04-24 MRI - nasopharynx
  • Indication: SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I). follow up.
  • IMP: C/W left buccal cancer s/p operation without recurrence. Stationary as compared with MRI on 20190907.
• 2021-04-06 Patho - fissure/fistula
  • Anus, fistulotomy and hemorrhoidectomy — hemorrhoid and consistent with anal fistula
• 2020-04-07 Whole body PET scan
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2019-09-07 MRI - nasopharynx
  • For oral cancer follow up. SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
  • IMP: C/W left buccal cancer s/p operation, without recurrence. Stationary as compared with MRI on 20190126.
• 2019-01-26 MRI - nasopharynx
  • For oral cancer follow up. SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
  • IMP: C/W left buccal cancer s/p operation, without recurrence. Stationary as compared with MRI on 20180629.
• 2018-06-29 MRI - nasopharynx
  • bilateral neck LNs, stationary.
• 2017-12-20 MRI - nasopharynx
  • prominent buccal mucosa in the right inferior buccal region. Nature? bilateral neck LNs, stationary.
• 2017-08-09 MRI - nasopharynx
  • Left buccal CA, post OP with neck LNs dissection. No tumor recurrence. Small bilateral neck LNs, stationary.
• 2017-05-04 Surgical pathology Level VI
  • PATHOLOGIC DIAGNOSIS
    • Gingiva, upper, left, wide excision — Squamous cell carcinoma
    • Lymph nodes, level V, left neck, dissection — No metastatic carcinoma (0/3)
    • Pathology stage: pT1N0(cMx)
  • MACROSCOPIC EXAMINATION
    • Surgical Procedure(s): Wide excision + neck dissection
    • Specimen Type:
      • Main location: Left upper gingiva
      • Other part(s) included: Bone of left maxilla
      • Lymph node dissection: Yes (specify): Left neck level V
    • Specimen Integrity: Intact
    • Specimen Size: 3.5 x 2.4 x 2.0 cm
      • Additional dimensions (maxilla bone): 3.0 x 1.5 x 1.0 cm
    • Tumor Site: Left upper gingiva
    • Tumor Focality: Single focus
    • Tumor Size: Greatest dimension: 0.5 cm
      • Additional dimensions (if available): 0.5 x 0.3 cm
      • Tumor thickness (for pT1 and pT2 tumors only): 3 mm
    • Mucosal Surface: Intact
    • Gross Tumor Extension: To subepithelial connective tissue
    • Representative parts are taken for section and labeled as: A1= anterior palatal, A2= palatal gingiva, A3= posterior buccal, A4= superior buccal, A5= anterior buccal, A6= bone, B= level V LN, C= left maxilla bone.
    • The specimen received for frozen section consists of four pieces of gray red soft tissue, labeled cheek mucosa, maxillary site, anterior margin, posterior margin; measuring 0.6 x 0.4 x 0.3 cm, 0.7 x 0.5 x 0.4 cm, 0.4 x 0.3 x 0.2 cm, 0.5 x 0.3 x 0.2 cm; respectively. All for paraffin section and labeled as: S2017-06679FS.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Squamous cell carcinoma
    • Histologic Grade: G2 (Moderately differentiated)
    • Microscopic Tumor Extension: To subepithelial connective tissue
    • Margins: Free, Distance from closest margin: 3 mm (superior buccal margin)
    • Lymph-Vascular Invasion: Not identified
    • Perineural Invasion: Not identified
    • Neck Lymph Nodes:
      • Ipsilatera (specify)l: level V
      • Number examined: 3
      • Number involved: 0
    • Left maxilla bone: Free of tumor
    • Margins for frozen section, including cheek mucosa, maxillary site, anterior margin, posterior margin: Free of tumor
• 2017-04-29 MRI - nasopharynx
  • Left buccal CA, post OP with neck LNs dissection. No tumor recurrence. Small bilateral neck LNs, stationary.
• 2017-04-26 Whole body bone scan
  • No evidence of bone metastasis.
  • Suspected benign lesions in the lower frontal area of the skull, maxilla, mandible, sacrum, bil. shoulders, elbows, and knees.
• 2017-04-19 Surgical pathology Level IV
  • Left maxilla, biopsy — Squamous cell carcinoma IHC stain p16 (-)

[consultation]

• 2022-06-24 Radiation Oncology
  • A
    • A: Squamous cell carcinoma of the left mandibular gingiva, stage rpT4aN0(cM0), Stage IVA; s/p operation (Wide excision of the malignant tumor of left mandibular gingiva plus segmental mandibulectomy. Intermaxillary fixation. Complicated extraction of tooth 31, 41, 42. Left fibula osseocutaneous free flap reconstruction. STSG (16*5cm) from the left thigh for wound closure of the left calf).
    • P: Radiotherapy is indicated for this patient with the following indicators: stage rpT4aN0(cM0)
      • Goal: curative
      • Treatment target and volume: left mandibular gingiva tumor bed, peripheral, to bilateral neck
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the left mandibular gingiva tumor bed, peripheral, to bilateral neck, and 6000cGy/30 fractions of the left mandibular gingiva tumor.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2022-06-30.

[radiotherapy]

[chemoimmunotherapy]

• 2023-03-03 - cetuximab 250mg/m2 400mg 2hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-02-16 - cetuximab 250mg/m2 400mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 200mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-01-16 - cetuximab 400mg/m2 700mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 200mL 3hr
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-12-26 - docetaxel 40mg/m2 70mg NS 150mL + cisplatin 32mg/m2 60mg NS 150mL 3hr + leucovorin 80mg/m2 150mg & fluorouracil 800mg/2 1500mg NS 1000mL 22hr
  • dexamethasone 4mg + diphenhydramine 30mg
• 2022-12-12
• 2022-11-21
• 2022-11-11
• 2022-10-18
• 2022-10-11
• 2022-09-27
• 2022-09-19
• 2022-08-16
• 2022-08-09
• 2022-07-26
• 2022-07-19

[assessment]

• Lab data

  • 2023-03-03 CRP 3.90 mg/dL
    
  • 2023-02-27 CRP 0.34 mg/dL
    
  • 2023-02-23 CRP 0.68 mg/dL
    
  • 2023-02-16 CRP 0.57 mg/dL
    
  • 2023-03-03 WBC 20.65 x10^3/uL
    
  • 2023-02-27 WBC 1.34 x10^3/uL
    
  • 2023-02-23 WBC 1.67 x10^3/uL
    
  • 2023-02-16 WBC 5.48 x10^3/uL
    
  • 2023-03-03 HGB 10.4 g/dL
    
  • 2023-02-27 HGB 7.3 g/dL
    
  • 2023-02-23 HGB 8.2 g/dL
    
  • 2023-02-16 HGB 8.8 g/dL
    
  • 2023-03-03 PLT 198 x10^3/uL
    
  • 2023-02-27 PLT 210 x10^3/uL
    
  • 2023-02-23 PLT 230 x10^3/uL
    
  • 2023-02-16 PLT 249 x10^3/uL

• According to recent lab results, there is no longer leukopenia observed, but instead an overboosted WBC count accompanied by an elevated CRP reading (G-CSF administered on 2023-02-27). Please be aware of any signs of infection or inflammation. Anemia has gradually improved, and there is no observed thrombocytopenia.

• The patient received injectable Amsulber (ampicillin + sulbactam) from 2023-02-23 to 2023-03-02 and has been taking oral Soonmelt (amoxicillin + clavulanic acid) since 2023-03-03. However, there has been no recent culture result available for the patient.

• The laboratory results from 2023-02-28 also showed 4+ stool occult blood, which could be a possible cause of the anemia. It would be beneficial to rule out gastrointestinal bleeding before discharging the patient.

701269031

230303

[diagnosis]

• Bilateral high grade serous ovarian carcinoma, cT3N1bM1, stage IV s/p bilateral oophorectomy, hysterectomy and chemotherapy, recurrent with peritoneal seeding s/p chemotherapy with Taxol/Carboplatin from 2023/02/10 ongoing.

[present illness]

• This 69-year-old married woman had past history of bilateral high grade serous ovarian carcinoma stage IV (T3cN1bM1) s/p bilateral oophorectomy, hysterectomy and chemotherapy.
• According to the patient, she had lived in Shanghai for 20 years. Two years ago (2021?), she went to hospital in Shanghai due to distended abdomen and abdominal pain for two months.
• She was diagnosed with bilateral high grade serous ovarian carcinoma stage IV (T3cN1bM1). She received surgery to remove bilateral side of ovarian and received chemotherapy (paclitaxel/carboplatin/bevacizumab) for 14 times.
• This time, she came to our hospital for the second opinion due to elevated CA125 level in recent months. Tumor marker as CA125 510.5 U/ml, CEA 6.8 ng/ml, CA199 46.63 U/ml.

[past history]

• Bilateral high grade serous ovarian carcinoma, cT3N1bM1, stage IV
• Covid-19 virus identified 2022/12/28
• Bilateral oophorectomy and hysterectomy
• Cervical carcinoma in situ (partially resection) 20 years ago         

[allergy]

• NKDA         

[Family History]

• Father had DM
• She denied cancer history in her family

[lab data]

• 2023-01-11 Anti-HBc Nonreactive
  
• 2023-01-11 Anti-HBc-Value 0.13 S/CO
  
• 2023-01-11 Anti-HBs 3.73 mIU/mL
  
• 2023-01-11 HBsAg Nonreactive
  
• 2023-01-11 HBsAg (Value) 0.39 S/CO
  
• 2023-01-11 Anti-HCV Nonreactive
  
• 2023-01-11 Anti-HCV Value 0.08 S/CO

[exam findings]

• 2023-02-09 Hearing Test
  • Reliabilty Fair
  • PTA
    • R’t : 16 dB HL
    • L’t : 15 dB HL
    • Bil WNL except 8k Hz.
• 2023-01-20 MRI - brain
  • Indication: Ovarian cancer s/p OP and chemotherapy, with recurrence over peritoneum seeding
  • IMP: No evidence of intracranial lesion.
• 2023-01-19 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the nasal bone, L3-4 spines, bilateral shoulders, left elbow and bilateral hips in whole body survey.
  • IMPRESSION:
    • Mildly increased activity in the L3-4 spines. Degenerative change may show this picture.
      
    • Increased activity in the nasal bone. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, left elbow and bilateral hips, compatible with benign joint lesions.
• 2023-01-18 PET scan
  • There was increased FDG uptake in the surface of the right lobe of liver (SUVmax early: 7.24, delay: 7.37), in the surface or sub-diaphragm of the left lobe of liver (SUVmax early: 10.73, delay: 11.82), celiac lymph nodes (SUVmax early: 5.60, delay: 7.06), left para-aortic space lymph nodes (SUVmax early: 10.31, delay: 11.92), lymph nodes in the LLQ (SUVmax early: 11.90, delay: 12.74) and RLQ (SUVmax early: 10.59, delay: 11.47) of abdomen, and spleen (SUVmax early: 4.63, delay: 4.89). In addition, increased FDG uptake was also noted in several left mediastinal lymph nodes (SUVmax early: 7.27, delay: 6.51), and bilateral pulmonary hilar lymph nodes (SUVmax early: 3.74, delay: 6.05).
  • IMPRESSION:
    • Glucose hypermetabolism lesions in n the surface of the right lobe of liver, in the surface or sub-diaphragm of the left lobe of liver, celiac lymph nodes, left para-aortic space lymph nodes, lymph nodes in the LLQ and RLQ of abdomen, and spleen, highly suspected recurrent tumor with peritoneal seeding, suggesting further investigation and follow-up.
      
    • Glucose hypermetabolism in the left mediastinal lymph nodes, the nature is to be determined (reactive or metastatic lymph nodes or other nature ?), suggesting further investigation.
      
    • Glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, probably reactive nodes.
    • Ovarian cancer s/p treatment with tumor recurrence and peritoneal seeding, rc-stage IVB, by this F-18 FDG PET scan.
• 2023-01-17 CT - abdomen
  • S/P hysterectomy and oophorectomy.
  • GB stone.
  • Hypodense nodule, 0.68cm in the liver dome, suspected liver metastasis. DDx: subphirenic seeding.

[chemotherapy]

• 2023-03-02 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
• 2023-02-10 - paclitaxel 140mg/m2 200mg NS 250mL 3hr + carboplatin AUC 4 450mg NS 250mL 2hr
  • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

[G-CSF]

• 2023-02-21 ~ 2023-02-23 Granocyte (lenograstim) 250ug SC QD

[assessment]

• Although most patients with high-grade serous carcinoma (HGSC) initially respond to platinum-based chemotherapy, the large majority of patients will relapse. ref: ESMO-ESGO consensus conference recommendations on ovarian cancer: pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease†. Ann Oncol. 2019;30(5):672-705. doi:10.1093/annonc/mdz062
  • There are no validated predictive markers of primary platinum refractory or resistant disease.
  • Defects in HR repair are associated with improved outcome/PFS following platinum-based chemotherapy.
  • The time elapsed since last platinum chemotherapy represents a continuum of probability of response to further chemotherapy.
• In potentially platinum-responsive patients previously exposed to bevacizumab, platinum-based rechallenge followed by PARPi maintenance therapy is effective irrespective of BRCA mutation and HRD status. Olaparib, niraparib and rucaparib can also be considered for use as monotherapy in patients with recurrent disease who have received several previous lines of treatment. ref: How to sequence treatment in relapsed ovarian cancer. Future Oncol. 2021;17(3s):1-8. doi:10.2217/fon-2020-1122
  • The patient initiated a new series of cycles with paclitaxel and carboplatin from 2023-02-10.
• According to the National Health Insurance drug reimbursement regulations, PARP inhibitors (olaparib, niraparib) can be used for maintenance therapy in patients with ovarian, tubal, or primary peritoneal cancer who meet all of the following conditions for up to two years:
  • Used after responding to first-line platinum-based chemotherapy.
  • Patients have germline or somatic BRCA1/2 pathogenic or suspected pathogenic mutations.
  • FIGO stage III or IV disease.
• According to the National Health Insurance drug reimbursement regulations, patients with malignancies who have experienced leukopenia with a white blood cell count less than 1000/uL or neutrophil count (ANC) less than 500/uL after receiving chemotherapy, can use short-acting injection of granulocyte colony-stimulating factor (G-CSF) such as filgrastim or lenograstim.
  • It has been planned to administer Granocyte (lenograstim) once daily for 3 consecutive days, starting from 2023-03-03.

230302

[assessment]

• The condition of leukopenia has been resolved after administering lenograstim for 3 consecutive days (2023-02-21 ~ 2023-02-23)
  • 2023-03-01 WBC 4.19 x10^3/uL
    
  • 2023-02-20 WBC 1.48 x10^3/uL

700052706

230302

[exam findings]

• 2023-02-14 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the maxilla, mandible, middle T-spines, some L-spines, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
  • IMPRESSION:
    • In comparison with the previous study on 2022/08/18, the lesions in the middle T-spines are slightly more evident. Degenerative change in slightly more severe status is more likely. Please correlate with other imaging modalities for further evaluation.
    • No prominent change is noted in other bone lesions.
• 2023-02-13 SONO - abdomen
  • mild fatty liver (incomplete exam of liver)
  • fatty infiltration of pancreas
• 2023-02-01 Patho - gingival/oral mucosa biopsy
  • Labeled as “right mandibular gingiva near tooth of #43”, incisional biopsy — squamous cell carcinoma.
  • IHC stain: p16 (-).
• 2023-01-20 MRI - nasopharynx
  • History: previous MRI showed an enlarged lymph node (14 mm) at right surpaclavicular fossa. He had received a series of operations on 2022-09-09 at the right buccal mucosa, retromolar trigone area and soft palate.
  • Without- and with-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness＝3 mm, gap＝1 mm), sagittal T1WI (thickness＝4 mm, gap＝1 mm), and axial T1WI and T2WI with FS (thickness＝5 mm, gap＝1 mm), and post-contrast coronal T1WI with FS (thickness＝ 3 mm, gap＝1 mm) and axial T1WI with FS (thickness＝5 mm, gap＝1mm) show:
    • Post-operation change at bilateral buccal regions, with flap reconstruction at left part of palate and buccal region.
    • S/P lymph node dissection on both sides of the neck.
    • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
    • A 14-mm lymph node at right supraclavicular fossa, and a 7.5-mm one at left supraclavicular fossa. Stationary as compared with MRI on 20220817.
    • Atrophy with fatty degeneration of left parotid gland.
    • New lesions with diffuse heterogeneous enhancement along right pterygopalatine fossa and pterygoid muscles and temporalis mcsules near right pterygoid plate. Abnormal enhancement also noted along post-operated right posterior buccal region. D/D: recurrence or inflammatory process.
      
  • IMP:
    • C/W oral cancer s/p treatment, with highly suspicious recurrence along right pterygopalatine fossa and pterygoid plate.
    • Bilateral supraclavicular lymph nodes, stationary as compared with MRI on 20220817.
• 2022-09-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
  • PD-L1 Immunostaining Result, S2022-15256A1
    • Tumor cell (TC) staining assessment: TC >= 1% and < 5%
    • Percent of PD-L1 expression in tumor cells (TC): 1%
• 2022-09-12 Patho - oral cancer (wide excision without lymph node)
  • Diagnosis
    • Buccal mucosa, right, wide excision —- Squamous cell carcinoma, moderately differentiated, AJCC 8th edition: pStage I, pT1Nx(if cM0)
    • Buccal mucosa, right, posterior tumor margin, re-excision —- Mild dysplasia
    • F2022-00419
      • FsA: Palatoglossal fold, resection margin, biopsy — Negative for malignancy
      • FsB: Oropharynx, resection margin, biopsy — Negative for malignancy
      • FsC: Posterior margin, resection margin, biopsy — Severe dysplasia, at least
      • FsD: Upper posterior margin, resection margin, biopsy — Negative for malignancy
      • FsE: Inferior posterior margin, resection margin, biopsy — Negative for malignancy
      • FsF: Middle inferior margin, resection margin, biopsy — Negative for malignancy
      • FsG: Anterior margin, resection margin, biopsy — Negative for malignancy
      • FsH: Inferior tumor margin, resection margin, biopsy — Negative for malignancy
  • Microscopic examination
    • Histologic Type: Squamous cell carcinoma,
      
    • Histologic Grade: G2: Moderately differentiated,
      
    • Microscopic Tumor Extension: (specify) submucosa
    • Margins (obtained from the main resection specimen): …
    • Lymph-Vascular Invasion: not identified
    • Perineural Invasion: not identified
    • Neck Lymph Nodes: not received
      
    • Extranodal extension: not received
      
    • Additional Pathologic Findings: The posterior tumor margin reveals focal residual squamous epithelium with mild dysplasia.
    • F2022-00419 Sections of the 8 specimens show squamous mucosa and salivary glands without malignancy. Severe dysplasia is seen in posterior margin specimen.
• 2022-08-18 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the maxilla, mandible, middle T-spine, some L-spines, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
  • IMPRESSION:
    • In comparison with the previous study on 2017/11/14, the lesions in some L-spines are slightly more evident. Degenerative change in slightly more severe status may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Other bone lesions are either stationary or a little less evident, possibly more benign in nature.
• 2022-08-17 MRI - nasopharynx
  • C/W oral cancer s/p treatment without evidence of recurrence. Stationary as compared with MRI on 20220304.
• 2022-08-17 SONO - abdomen
  • renal cyst, bilateral
  • most pancreas masked by gas
• 2022-08-03 Patho - gingival/oral mucosa biopsy
  • Labeled as “right buccal mucosa”, incisional biopsy — verrucous carcinoma with high grade dysplasia.
  • IHC stain: p16 (-).
• 2022-03-04 MRI - nasopharynx
  • C/W oral cancer s/p treatment without evidence of recurrence. An enlarged lymph node (14 mm) at right surpaclavicular fossa. Stationary as compared with MRI on 20210715.
• 2021-07-15 MRI - nasopharynx
  • C/W oral cancer s/p treatment without evidence of recurrence. An enlarged lymph node (14 mm) at right surpaclavicular fossa. Stationary as compared with MRI on 20200916.
• 2020-09-16 MRI - nasopharynx
  • post-OP change in left maxilla floor, hard palate, upper bucco-gingival regions.
  • No local tumor recurrence.
  • No neck LAP.
• 2020-08-30 CT - abdomen
  • dilated small bowels. suspected small bowel ileus
• 2020-03-09 MRI - nasopharynx
  • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows: (comparison: 2019/10/18 MRI)
    • Post fat-containing flap reconstruction surgery with clips/sutures retention and/or bony defect of left maxilla floor, hard palate, upper bucco-gingival region. No obvious focal mass or nodule, stationary.
    • Post LNs dissection with clips retention with metallic artifact and/or soft tissue or muscle defect, left.
    • Post resection of left submandibular gland.
    • No evident abnormal enlarged lymph node in the visible neck.
    • Presence of thick fluid accumulation and thickened mucoperiosteum in the bilateral paranasal sinuses.
    • No obvious abnormal enhancement after contrast medium administration.
  • Impression:
    • Stationary post OP change in left maxilla floor, hard palate, upper bucco-gingival regions. No local tumor recurrence. No neck LAP.
• 2019-10-22 Surgical pathology level VI
  • Pathologic Diagnosis
    • Buccal mucosa, right, wide excision — Squamous cell carcinoma
    • Resection margins, the same as above and frozen section — Free of tumor invasion
    • Lymph node, submandibular and submental gland, dissection — Free of tumor metastasis (0/5)
    • Lymph node, superficial Level II, the same as above — Free of tumor metastasis (0/2)
    • Lymph node, parotid area, dissection — Free of tumor metastasis (0/1)
    • Lymph node, Level III, dissection — Free of tumor metastasis (fat only)
    • AJCC Pathologic staging — pT1N0Mx, at least stage I.
  • Microscopic Examination
    • Histologic Type: Squamous cell carcinoma
    • Histologic Grade: G1: Well differentiated
    • Microscopic Tumor Extension: 0.35 cm in thickness
    • Margins: Free, less than 0.1 cm from base, 0.1 cm from posterior margin, 0.6 cm from anterior margin, 0.5 cm from superior margin and 0.5 cm away from inferior margin
    • Lymph-Vascular Space Invasion: absent
    • Perineural Invasion: Present
    • Neck Lymph Nodes: free from tumor metastasis (0/8)
    • Salivary gland, submandibular and submental gland LN: chronic sialoadenitis
• 2019-10-18 MRI - nasopharynx
  • Post-operation change without evidence of recurrence. No evidence of right lower buccogingival lesion based on this study.
• 2019-10-02 Surgical pathology level IV
  • Right buccal mucosa, biopsy — Squamous cell carcinoma, well differentiated.
  • IHC stain: p16 (-)
• 2019-05-02 MRI - nasopharynx
  • CC: He is an oral cancer patient and received 3 cycles of induction chemotherapy followed by cancer operations and CCRT. CCRT ended on 2018-02-01. He complains of dry mouth and pain at his left lower lip area occasionally. The patient became anxious and sought medical attention at both Shuang Ho Hospital and Far Eastern Memorial Hospital, where they received cryotherapy treatment (2018-11-01).
  • Cancer Site-Specific Factors
    • Betel nut chewing [present]: 20 nuts per day, for the past 20 years.
    • Smoking [present]: 20 cigarettes per day, for the past 20 years.
    • Alcohol consumption [none].
  • Indication:
    • S: He is an oral cancer patient and received 3 cycles of induction chemotherapy followed by cancer operations and CCRT. CCRT ended on 2018-02-01.
    • O: cheilis of both oral commissure combined with fungus infection are noted. leukoplakia of the right palatoglossal fold is still present after injection treatment. chronic abnormal erythymatous lesion on the inner surface of lower lip near left oral commissure are still noted.
    • A: SCC of left maxillary gingiva with bone invasion (cT4aN1M0 before) (2017/11/17 OP) (pT4aN0M0)
    • P:
      • check BUN and creatinine before MRI examination
      • arrange MRI with contrast to evaluate undermining tumor status
  • IMP
    • Post OP in left maxilla floor, hard palate, upper bucco-gingival regions. No local tumor recurrence. No neck LAP.
• 2018-11-01 MRI - nasopharynx
  • Post flap reconstruction surgery in left maxilla floor, hard palate, bucco-gingival regions. No local tumor recurrence. No neck LAP.
• 2018-03-06 MRI - nasopharynx
  • Post flap reconstruction surgery in left maxilla floor, hard palate, bucco-gingival regions.
• 2017-11-20 Surgical pathology level VI
  • Pathologic Diagnosis
    • Gum, left upper, wide excision — Squamous cell carcinoma, moderately differentiated, with invasion to maxillary sinus, s/p induction chemotherapy
  • Microscopic Examination
    • Histologic Type: Squamous cell carcinoma, s/p induction chemotherapy; The immunohistochemical stain of p16 is negative.
      
    • Histologic Grade: G2: Moderately differentiated
    • Microscopic Tumor Extension: (specify) maxillary sinus
• 2017-11-14 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the left aspect of the maxilla, middle T-spine, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
  • IMPRESSION:
    • Increased activity in the left aspect of the maxilla. Malignancy with local bone invasion should be watched out. Please correlate with other clinical findings for further evaluation.
    • Increased activity in the middle T-spine. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • A hot spot in the inferolateral aspect of right orbital area of the skull and some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral sternocalvicular junctions, hips and knees, compatible with benign joint lesion.
• 2017-11-13 MRI - nasopharynx
  • Indication: SCC of left maxillary gingiva with bone invasion (cT4aN2bM0)
  • Impression:
    • Residual left maxillary gingiva tumor with bone involvement, in regression
    • compared with previous brain MRI study.
    • paranasal sinusitis.
    • no cervical enlarged LNs.
• 2017-08-14 Nerve Conduction Velocity, NCV
  • The NCV study showed (1) Prolonged distal motor latency and slowing of sensory nerve conduction velocity in bilateral median nerves. (2) Slowing of motor nerve conduction velocity in left ulnar nerve across elbow. (3) Decreased CMAP amplitude and slowing of motor conduction velocity in left peroneal nerve. (4) Decreased SAP amplitude in left ulnar nerve.
  • The F wave study showed prolonged latency in all sampled nerve of lower limbs. The H reflex showed prolonged latency of left side. The above findings suggest bilateral lumbosacral polyradiculopathy and entrapment neuropathy of bilateral median nerves at the wrist and left ulnar nerve across elbow. Advise careful clinical correlation.
• 2017-08-12 MRA - brain
  • Indication: SCC of left maxillary gingiva with bone invasion
  • Impression:
    • Essential normal brain MR study.
    • Left chronic paranasal sinusitis

[chemotherapy]

• 2023-02-22 - cetuximab 250mg/m2 460mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + [leucovorin 100mg/m2 180mg + fluorouracil 1000mg/m2 1800mg + NS 1000mL] 22hr D2 (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2023-02-15 - cetuximab 400mg/m2 740mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + [leucovorin 100mg/m2 180mg + fluorouracil 1000mg/m2 1800mg + NS 500mL] 22hr D2 (TPF Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
• 2022-08-30 ~ 2023-02-09 - UFT (tegafur + uracil) KUFT01 2# BID
• 2017-10-26 ~ 2017-11-16 - UFT 2# BID

[assessment]

• Leukopenia was observed in the patient, with a count of 1.97 K/uL, on 2023-02-27. This occurred 5 days after the patient received the second cycle of chemoimmunotherapy (cetuximab + TPF).
• This patient also took UFT from 2022-08-30 to 2023-02-09. As UFT has been discontinued for some time, it is less likely to be the cause of the recent leukopenia.
• According to the National Health Insurance medication reimbursement regulations, patients with malignant diseases who have experienced leukopenia (less than 1000/uL) or neutropenia (ANC less than 500/uL) after receiving chemotherapy are eligible to use short-acting granulocyte colony-stimulating factor (G-CSF) injections, such as filgrastim or lenograstim.
• Self-paid G-CSF may be considered by the patient as an option to rapidly increase his white blood cell count.

700280118

230302

[exam findings]

• 2023-02-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (132 - 56) / 132 = 57.58%
    • M-mode (Teichholz) = 58
  • Dilated LV, Ao
  • Adequate LV, RV systolic function with normal wall motion
  • Thick LVPW, Impaired LV relaxation
• 2023-01-13 SONO - right knee
  • Right knee joint fluid. The differential diagnosis includes, but is not limited to hemarthrosis, gouty arthropathy.
• 2023-01-03 Patho - bone marrow biopsy
  • PATHOLOGIC DIAGNOSIS
    • Bone marrow, biopsy — Myelodysplastic syndrome with excess blasts (RAEB-1)
    • Immunohistochemical stains:
      • MPO: positive for myeloid series
      • CD71: positive for erythroid series
      • CD61: positive for megakaryocytes
      • CD117: positive for blast
      • CD34: positive for blast
      • CD138: positive for plasma cell
    • Histochemical stain:
      • Reticulin: increased reticulin fibers
  • Microscopically, the sections show pictures as follows:
    • Hypercellularity for his age >90%
    • M/E ratio about 2-3/1, proliferation with left shift maturation of myeloid and erythroid series
    • Proliferative megakaryocytes with nuclear dysplasia and clustering, accompanied by grade 2 (MF-2) reticulin/collagen fibrosis
    • Increased blast (5-9%)
    • Scater distribution of plasma cells
    • Myelofibrosis and osteosclerosis
    • According to all above histopathologic findings, it is suggestive of myelodysplastic syndrome with excess blasts, compatible with RAEB-1 and myelofibrosis. Please correlate with clinical and bone marrow smear findings for conclusive diagnosis.
• 2022-12-28 SONO - abdomen
  • Splenoemgaly
• 2022-07-25 Patho - stomach biopsy
  • Stomach, lower body, biopsy — Chronic erosive gastritis, Helicobacter Pylori: NOT present
• 2022-07-25 SONO - abdomen
  • splenomegaly, mild to moderate
  • pancreas almost not shown
• 2022-07-25 Esophagogastroduodenoscopy, EGD
  • Reflux esophagitis LA Classification grade A
  • Gastric ulcer, multiple, shallow, lower body, s/p biopsy
  • Hiatal hernia
• 2022-06-17 Patho - gingival/oral mucosa biopsy
  • Labeled as “right buccal mucosa”, excisional biopsy — verrucous hyperplasia, involving un-oriented and unspecified excisional side margin.
• 2021-11-01 MRI - nasopharynx
  • History: a tongue cancer at the right side was noted and he had received cancer surgeries on 2021-07-07. suspected SCC of right floor of mouth (cT2N2bM0)
  • Indication:
    • S: He is cheek cancer (2016-09) and tongue cancer (2017-03). He finished 3 cycle of induction chemothrapy followed by surgery to remove oral cancer (2016-06).
      
    • O: Toothace due to gingivitis of residual teeth and residual roots of #22 is noted. red color change on the left palatlglossal fold is noted.
      
    • A:
      • Verrucous carcinoma of right tongue border (2017-03-15)
      • SCC of left buccal mucosa, lower gingiva and retromolar area, size about 5 cm with suspicous lymph node involment and skin invasion near oral commissure (cT3N1M0 preChemo) (2016-06) (pT2N0M0 postChemo)
    • P:
      • BUN and creatinine before the MRI examination
      • arrange MRI examination to evaluate the underming tumor status
  • Impression:
    • Post OP at right tongue and mouth floor, no obvious focal residual mass
    • Post OP at left bucco-gingival region with neck LNs dissection.
    • No local tumor recurence.
    • No neck LAP.
• 2021-07-08 Patho - oral cancer (wide excision + lymph node)
  • Oral cavity, right mouth floor, wide excision — Well differentiated squamous cell carcinoma
• 2021-06-03 Patho - gingival/oral mucosa biopsy
  • Labeled as “right floor of mouth and tongue”, incisional biopsy — Squamous cell carcinoma, well differentiated.
  • IHC stains: CK5/6 (+), p40 (+), p16 (-).
• 2021-05-19 Tc-99m MDP bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, S-I joints, hips, right knee, and left ankle.
• 2021-05-18 MRI - nasopharynx
  • Post OP at left bucco-gingival region with neck LNs dissection. No local tumor recurence. No neck LAP.
  • No obvious discernible right mouth floor lesion. Stationary and hard to define right tongue or mouth floor tumor? after comparing with 2020/02/11 MRI, need clinical correlation. (revised on 2021/06/10)
• 2021-02-11 MRI - nasopharynx
  • Post-operation change without evidence of recurrence. Stationary as compared with MRI on 20190402.
• 2020-02-05 Patho - gingival/oral mucosa biopsy
  • Right floor of mouth? biopsy — Verrucous hyperplasia. Please excise entire lesion for further patholoigcal evaluation.
• 2019-04-02 MRI - nasopharynx
  • Post-operation change without recurrence. Stationary as compared with MRI on 20180828.
• 2018-10-02 Surgical pathology level IV
  • Oral cavity, right, buccal mucosa, laser remove — Verrucous carcinoma — margin free
• 2018-08-28 MRI - nasopharynx
  • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
• 2018-01-03 MRI - nasopharynx
  • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
• 2017-06-22 MRI - nasopharynx
  • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
• 2017-03-15 Surgical pathology level IV
  • Tongue, right border, wide excision —- Verrucous carcinoma
    
  • Pathology stage: pStage I, pT1 Nx (cMx)
• 2017-01-03 MRI - nasopharynx
  • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.

[consultation]

• 2021-06-23 Hemato-Oncology
  • Q
    • This is a 51-year-old male who had medical history of squamous cell carcinoma of left bucco-gingival region with retromolar extension and possible anterior skin invasion, cT4aN1M0 status post induction chemotherapy and surgery, ypT2N0M0 in 2016 and several cancer surgeries for verrucous carcinoma of tongue and right buccal mucosa thereafter. He didn’t return to OPD follow-up until this time with a painless malignant tumor with firm texture on the right floor of mouth and ventral tongue. After thorough tumor work-up, he was diagnosed with squamous cell carcinoma of right floor of mouth, cT2N2bM0. This time, he was admitted for surgical intervention. However, his platelet count was lower than average (50x10^3/uL) without any underlying known cause and coagulation defiency. Therefore, we need your expertise for further survey of idiopathic thrombocytopenia.
  • A
    • The 51 y/o male, a pt of L bucco-gingival SCC wt retromolar extension and possible anterior skin invasion, cT4aN1M0 s/p post induction chemotherapy and surgery, ypT2N0M0 in 2016 and several cancer surgeries for verrucous carcinoma of tongue and right buccal mucosa, was noted to have thrombocytopenia just before Op in June 2021.
    • The definite diagnosis of thrombocytopenia is to be under further investigation.
    • Image
      • Abd sono (20210520): splenomegaly.
    • Lab data
      • Hb (20210622):15.6, MCV:95.0, MCHCL34.5, plt:50K, WBC:3600
      • Hb (20210517):15.9, MCV:96.0, MCHC:34.6, plt:51K, WBC:4270
      • LFT & RFT (20210622): normal
      • HBsAg & antti-HCV (20210519): negative.
    • Dx: Thrombocytopenia, cause ? R/I splenomegaly related R/I idiopathic thromcytopenic purpura (ITP) R/I autoimmune related
    • Medical advice:
      • By Tracing his medical history, thrombocytopenia has been noted recently in May & June 2021.
        • Abd CT (20210520) showed splenomeagly. Splenomegaly related thrombocytopenia seems to be likely cause of thrombocytopenia.
      • May check Rheumatoid factor & ANA to exclude possible autoimmune dz. But autoimmune dz very rarely occurs in male pt. 
        • By clinical pictures, hematologic dz, TTP with toxic S/S, or DIC by infection were less likely to be the causes of thrombocytopenia of this pt. 
        • Splenomegaly related thrombocytopenia seems to be likely cause of thrombocytopenia if RF & ANA show negative.
      • If RF or ANA shows positive, may consult rheumatologist for further Tx. Tx of underlying autoimmune Dz may improve thrombocytopenia or may try prednisolone 1mg/kg/day for 2 weeks. If no response, splenectomy or IVIG or immunosuppressant (eg: Azathioprin, cyclophosphamide or Vincristine ) may be tried.
      • The current platelet count 50 K/uL is safe for this pt if no trauma happens. If platelet count requirement for Op is above 100K /uL, may consider platelet transfusion wt single donor ( pheresis ) platelet transfusion which is more effective to elevate platelet count & may less induce autoAb that will cause poor response to next platelet transfusion in the future.
        • But it is hard for pt wt splenomegaly related thrombocytopenia to elevate plt count by plt transfusion.

[chemotherapy]

• 2023-03-01 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7

• 2023-02-02 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7

• 2021-05-17 ~ 2021-07-05 UFT (tegafur + uracil) KUFT01

[assessment]

• Lab data

  • WBC
    • 2023-03-01 WBC 21.51 x10^3/uL
      
    • 2023-02-27 WBC 3.45 x10^3/uL
      
  • HGB
    • 2023-03-01 HGB 7.4 g/dL
      
    • 2023-02-27 HGB 9.3 g/dL
      
  • PLT
    • 2023-03-01 PLT 16 x10^3/uL
      
    • 2023-02-27 PLT 3 x10^3/uL
      
    • 2023-02-26 PLT 7 x10^3/uL
      
    • 2023-02-24 PLT 17 x10^3/uL
      
    • 2023-02-22 PLT 12 x10^3/uL
      
    • 2023-02-19 PLT 6 x10^3/uL
      
    • 2023-02-17 PLT 4 x10^3/uL
      
    • 2023-02-15 PLT 1 x10^3/uL
      
    • 2023-02-14 PLT 2 x10^3/uL
      
    • 2023-02-13 PLT 1 x10^3/uL
      
    • 2023-02-12 PLT 1 x10^3/uL
      
    • 2023-02-11 PLT 1 x10^3/uL
      
    • 2023-02-10 PLT 1 x10^3/uL
      
    • 2023-02-09 PLT 1 x10^3/uL
      
    • 2023-02-09 PLT 1 x10^3/uL
      
    • 2023-02-08 PLT 7 x10^3/uL
      
    • 2023-02-08 PLT 3 x10^3/uL
      
    • 2023-02-07 PLT 2 x10^3/uL
      
    • 2023-02-06 PLT 1 x10^3/uL
      
    • 2023-02-04 PLT 3 x10^3/uL
      
    • 2023-02-03 PLT 1 x10^3/uL
      
    • 2023-02-02 PLT 2 x10^3/uL
      
    • 2023-02-01 PLT 3 x10^3/uL
      
    • 2023-01-30 PLT 5 x10^3/uL
      
    • 2023-01-18 PLT 6 x10^3/uL
      
    • 2023-01-16 PLT 7 x10^3/uL
      
    • 2023-01-13 PLT 10 x10^3/uL
      
    • 2023-01-11 PLT 9 x10^3/uL
      
    • 2023-01-10 PLT 6 x10^3/uL
      
    • 2023-01-08 PLT 5 x10^3/uL
      
    • 2023-01-06 PLT 3 x10^3/uL
      
    • 2023-01-05 PLT 5 x10^3/uL
      
    • 2023-01-03 PLT 15 x10^3/uL
      
    • 2023-01-02 PLT 7 x10^3/uL
      
    • 2022-12-31 PLT 7 x10^3/uL
      
    • 2022-12-27 PLT 9 x10^3/uL
      
    • 2022-12-27 PLT 7 x10^3/uL
      
    • 2022-07-13 PLT 15 x10^3/uL
      
    • 2022-03-29 PLT 24 x10^3/uL
      
    • 2021-07-12 PLT 44 x10^3/uL
      
    • 2021-07-09 PLT 74 x10^3/uL
      
    • 2021-07-07 PLT 125 x10^3/uL
      
    • 2021-07-06 PLT 153 x10^3/uL
      
    • 2021-07-05 PLT 77 x10^3/uL
      
    • 2021-06-22 PLT 50 x10^3/uL
      
    • 2021-05-17 PLT 51 x10^3/uL

• According to the lab data on 2023-03-01, leukopenia has improved in the patient. However, anemia is still progressing, and blood transfusion might be necessary.

• Erythropoiesis-stimulating agents (ESAs) have been recommended as an effective treatment option for lower-risk MDS, including biosimilar epoetin alfa. ref: Epoetin alfa for the treatment of myelodysplastic syndrome-related anemia: A review of clinical data, clinical guidelines, and treatment protocols. Leuk Res. 2019;81:35-42. doi:10.1016/j.leukres.2019.03.006

• In addition to leukopenia and anemia, the patient has been experiencing thrombocytopenia for years with no substantial improvement. Therefore, increased risk of bleeding should be carefully monitored and managed.

• Thrombocytopenia is a significant problem in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Eltrombopag, a thrombopoietin receptor agonist, has shown potential clinical activity in MDS and AML clinical trials. Studies have shown that eltrombopag is well tolerated and clinically effective in both low-risk and higher-risk MDS and AML patients. ref: Eltrombopag reduces clinically relevant thrombocytopenic events in higher risk MDS and AML. Lancet Haematol. 2018;5(1):e6-e7. doi:10.1016/S2352-3026(17)30229-6

• There was another study evaluated the safety and efficacy of Eltrombopag in low to intermediate risk myelodysplastic syndromes (MDS) patients. The primary efficacy endpoint was hematologic response at 16-20 weeks, and 44% of the patients responded. The safety profile was consistent with previous studies, and Eltrombopag was effective in restoring hematopoiesis in these patients. ref: Eltrombopag monotherapy can improve hematopoiesis in patients with low to intermediate risk-1 myelodysplastic syndrome. Haematologica. 2020;105(12):2785-2794. Published 2020 Dec 1. doi:10.3324/haematol.2020.249995

701201523

230302

[diagnosis]

• Small cell B-cell lymphoma, lymph nodes of head, face, and neck
• Relapsed small lymphocytic lymphoma involving multiple lymph nodes as of bil. neck, axillary regions, mediastinum, peritoneal cavity, pelvi cavity, retroperitoneum and bil. inguinal regions ,Lugano stage IV, PS:1
• Essential (primary) hypertension
• Chronic viral hepatitis B without delta-agent

[exam findings]

• 2022-12-12 ECG
  • Sinus rhythm with 1st degree A-V block
• 2022-11-25 CT - chest
  • Lymphadenopathy at left lower neck. Statioanry.
  • Lymphadenopathy at mesenterric and paraaortic region. In progression.
• 2022-07-29 CT - chest
  • Extensive lymphadenopathy at bilateral lower neck, axillary, and mesenterric region. Stationary in size.
• 2022-04-15 CT - chest
  • Lymphadenopathy at left supraclavicular region and bilateral axillary region, paraaortic and mesenterric region. In regression.
• 2022-01-06 CT - chest
  • Lymphadenopathy at bilateral thoracic inlet and axillary, mediastinal and abdominal paraaortic and paracaval region. In regression.
• 2021-10-19 CXR
  • Atherosclerotic change of aortic arch.
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
• 2021-10-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (74 - 19) / 74 = 74.32%
    • M-mode (Teichholz) = 74
  • Normal LV systolic function with normal wall motion.
  • Normal LV diastolic function.
  • Normal RV systolic function.
  • Aortic valve sclerosis with no AS and AR; mild MR; moderate TR; mild PR.
• 2021-10-06 CT - chest
  • advanced malignant lymphoma involving both sides of diaphgram, stationary as compared with previous CT study on 2021/04/13
• 2021-04-13 CT - chest
  • advanced malignant lymphoma involving neck both sides of diaphgram, seem stationary as compared with previous CT study on 2020/12/22
• 2020-12-22 CT - chest
  • advanced malignant lymphoma involving neck, axillary regions, mediastinum, and abdomen (both sides of diaphgram), stationary as compared with previous CT study on 2020/07/15
• 2020-07-15 CT - chest
  • advanced malignant lymphoma involving neck, axillary regions, mediastinum, and abdomen (both sides of diaphgram), stationary as compared with previous CT study on 2019/12/05
• 2019-12-17 Surgical patholgoy Level IV
  • Clinical diagnosis: Lymphoma, other named variants, LN of head face and neck;
  • Pathological diagnosis:
    • Bone marrow, iliac, biopsy — Lymphoma involvement.
    • IHC stains: CD3 and CD20 show monoclonality. CD5 (+), CD23 (+).
  • Microsopic description
    • Section shows one piece of bone marrow with 50% cellularity and M:E ratio of approximately 5:1. There is a predominant subpopulation of small lymphoid cells.
    • IHC stains: CD3 and CD20 show monoclonality. CD5 (+), CD23 (+), compatible with clinical history of small lymphocytic lymphoma.
• 2019-12-05 CT - abdomen
  • Enlarged LNs at bil. neck, axillary regions, mediastinum, peritoneal cavity, pelvi cavity, retroperitoneum and bil. inguinal regions c/w lymphoma.
• 2019-11-01 PET
  • There was mildly or faintly increased FDG uptake involving multiple lymph nodes (SUVmax early: 1.10, delay: 1.15) including multiple bilateral neck, bilateral supraclavicular and axillary lymph nodes, some mediastinal, abdominal and bilateral inguinal lymph nodes. There was increased FDG uptake in the nasopharynx (SUVmax early: 1.94) and stomach (SUVmax early: 2.84, delay: 1.79).
  • IMPRESSION:
    • Mild or faint glucose hypermetabolism involving multiple lymph nodes as mentioned above. Lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the nasopharynx and stomach. The nature is to be determined (inflammatory process? other nature?). Please also correlate with other clinical findings for further evaluation.

[chemoimmunotherapy]

• 2023-03-01 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2023-01-06 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2022-12-13 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2022-03-08 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2022-02-08 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2022-01-03 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2021-12-07 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2021-11-09 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2021-10-19 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2

[assessment]

• This patient with Small cell B-cell lymphoma was treated with a total of six cycles of R-COP regimen from 2021-10 to 2022-03. However, during regular CT follow-up on 2022-11-25, progression of lymphadenopathy was observed in the mesenteric and paraaortic regions. As a result, the patient was rechallenged with R-COP from 2022-12 onwards.

• The lab results from 2023-03-01 indicated that there were no notable abnormalities in the patient’s liver and kidney functions or blood cell counts. And the TPR panel revealed that the patient’s vital signs and blood pressure were stable.

• Entecavir is prescribed to suppress the replication of the hepatitis B virus with no issue.

700207892

230301

[present illness] - 2023-02-27 admission note

• The 44 year old woman has history of
  • Renal stone /p ESLW once and /p URS on 2018
  • Small lymphocytic lymphoma / chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV under Leukeran (chlorambucil) 2mg 1# qd treatment on 2021/05 ~ 2022.

[past history]

• medication history:
  • small lymphocytic lymphoma/ chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV, ECOG:  1
• operation history:
  • Renal stone s/p ESLW and URS
  • anal fissure and mixe dhemorhroids s/p operation
  • right thigh intramascular abscess s/p debridement                    

[allergy]

• NKDA     

[family history]

• no family history of DM, CAD, CVA and cancer

[exam findings]

• 2022-10-13 Patho - abscess
  • Labeled as “right thigh soft tissue”, clinical history of chronic lymphocytic leukemia, debridement — chronic inflammation.
  • IHC stains: CD3 and CD20 show no predominant sub-population.
• 2022-10-08 MRI - lower extremity
  • Indication: Small lymphocytic lymphoma / chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV
  • MRI of lower extremity without/with Gadolinium-based contrast enhancement shows:
    • swelling of right anterior thigh muscle (mainly rectus femoris) with a rim-enhancing intramuscular mass lesion (about 3.1x2.4x4.5cm) with central necrosis. Marked adjacent subcutaneous fat stranding and superficial fascial fluid collection is noted. An intramuscular abscess is first considered. Suggest follow up after treatment to exclude lymphoma involvement.
    • clustered enlarged inguinal lymph nodes.
    • no abnormal bone marrow edema nor hyperemia.
  • Impression:
    • Favor an intramuscular abscess (about 3.1x2.4x4.5cm) at right anterior thigh. Suggest follow up after treatment to exclude lymphoma involvement.
• 2022-08-23 Patho - fissure/fistula
  • Anus, PIS — Anal fissure
• 2022-08-12 Abdomen - standing (diaphragm)
  • There is hepatosplenomegaly. please correlate with clinical condition
• 2022-06-29 CT - abdomen
  • Indication: intermittent, whole abdominal dull pain for 3 days
  • IMP:
    • no evidence of free abdominal air.
    • a nodular lesion, about 14mm, in the spleen. Nature?
• 2022-06-04 CT - brain
  • Clinical information: Cranial CT scans from the vertex to the mid-maxillary level were performed without i.v. contrast injection.
  • Impression:
    • The brain shows normal grey and white matter attenuation without evidence of focal lesion. There is no intracranial hemorrhage seen.
    • The size of the lateral and third ventricles appears normal.
    • The posterior structures including the brain stem, cerebellum and CP angles look normal.
• 2021-05-27 Patho - bone marrow biopsy
  • Bone marrow, iliac, biopsy — Small lymphocytic lymphoma / chronic lymphocytic leukeima
    
  • The sections show hypercellular marrow (>90%) for her age with small lymphocytes proliferation. Immunohistochemistry of CD20(+), CD3(-), CD5(+), CD23(+), Bcl2(+), CD34(-), CD61 showed adequate megakaryocyte, CD71 showed mild decreas of erythroid series and MPO showed decreased myeloid series. Clinical correlation is advised.
• 2021-05-25 CT - abdomen
  • Lymphoma in paraaortic, iliac and pelvic cavity, inguinal regions. Progression.
  • Splenomegaly with splenic nodule, progression, suspected lymphoma.
• 2021-01-05 CT - abdomen
  • Splenomegaly.
  • Lymphadenopathy at paraaortic and mesenterric region. Stable.
• 2020-09-25 CT - abdomen
  • Lymphoma S/P C/T show stable disease.
• 2020-07-01 Whole body PET scan
  • Glucose hypermetabolism in bilateral cervical lymph nodes, bilateral axillary lymph nodes, pelvis, and bilateral inguinal lymph nodes, lymphoma should be the first considered.
    
  • Glucose hypermetabolism in bnilateral palatine tonsils, reactive change resulting from locoregional inflammation may show such a picture.
  • Lymphoma (if proved), stage III at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
• 2020-06-12 Patho - lymphnode biopsy
  • Lymph node, right inguinal, excision —– Small lymphocytic lymphoma / chronic lymphocytic leukemia
    
  • Histology type: B-cell neoplasms: B-lymphoblastic lymphoma/leukemia
    
  • Immunohistochemical stain profiles: CD20(+), CD3(-), CD5(+), BCL2(+), CD23(+), CD43(+), SOX11(-), Cyclin D1(-), BCL6(-), CD10(-). The Ki-67 is about 15%.
• 2020-06-12 CT - abdomen
  • Lymphoma is highly suspected.
  • The differential diagnosis include metastases.
• 2020-06-10 Patho - bone marrow biopsy
  • clinical diagnosis: D72.829 Elevated white blood cell count, unspecified
    
  • Bone marrow, iliac, biopsy — B cell lymphoma.
  • IHC stains: CD34: 1%; MPO: approximaltely: 10%; LCA (+, 80-90%); CD20: a predominant monoclonal subpopuation. CD3: few.
    
  • Additional IHC stains: bcl-2 (diffuse +++), bcl-6 (-), CD23 (+++), cyclin-D1 (-).
  • The IHC pattern is that of a small lymphocytic lymphoma / chronic lymphocytic leukeima.
    
  • Section shows one piece of bone marrow with 60-70 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes and a predominant subpopulation of small round blue cells. Megakaryocytes are adequate in number. B cell lymphoma.
• 2020-06-09 CXR
  • A nodular opacity projecting in the left upper lung is suspected that may be left 1st rib cartilage calcification or true lesion? Follow up is indicated. Otherwise, Please correlate with CT.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.

[chemoimmunotherapy]

• 2023-02-27 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1450mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2023-01-30 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2023-01-04 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2022-12-13 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2022-11-07 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
  • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
• 2021-05-26…2021-07-04 - Leukeran (chlorambucil 2mg/tab) KLEUK BID PO

[G-CSF]

• Granocyte (lenograstim) CGRAN01
  • 2022-11-29 ~ 2022-11-30 250ug SC 2022-11-17 IPD
  • 2022-08-27 ~ 2022-08-26 250ug SC 2022-08-12 IPD
• G-CSF (filgrastim) CGCSF01
  • 2023-02-27 150ug SC 2023-02-27 IPD self-paid
  • 2022-08-12 300ug SC 2022-08-12 IPD

[assessment]

• It is recommended avoiding the administration of filgrastim from 24 hours before to 24 hours after the administration of cytotoxic chemotherapy, due to the potential sensitivity of rapidly dividing myeloid cells to the cytotoxic effects of chemotherapy.

• Filgrastim was administered on 2023-02-27 and chemotherapy is scheduled to be administered on 2023-03-01, with one day in between. Our administration pattern for the patient helps to uphold this principle without an issue.

700853234

230301

[exam findings]

• 2023-02-27 CXR
  • small Lt hemithorax, decreased pulmonary vascularity, and small hilum, due to fibrotic and bronchiectatic change
  • extensive mixed consolidation and hazy increased opacity over Rt lower lung zone
  • pathological compression fracture of multiple vertebral bodies
  • compression fracture of L2 vertebral body priop vertebroplasty
• 2023-02-07 Tc-99m MDP whole body bone scan with SPECT
  • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the skull, multiple C-, T- and L-spines, bilateral multiple ribs and bilateral pelvic bones.
  • IMPRESSION: The scintigraphic findings suggest multiple bone metastases.
• 2023-02-03 MRI - spine
  • Diffuse bony metastases involving C2-T12 vertebral bodies and bilateral ribs. LUL lesion, suspected metastases.
  • Diffuse bony metastases involving vertebral column (T10-S1) and iliac bones. Recent compression fratucre of L1 vertebral body, pathologic? S/P VP at L4 vertebral body.
• 2023-02-03 ECG
  • Sinus tachycardia with Premature atrial complexes
• 2023-02-01 T-spine AP + Lat
  • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s).
  • Presence of thoracic-lumbar spinal kyphosis, mild.
• 2023-02-01 KUB + L-spine Lat
  • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
  • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s).
  • Post percutaneous vertebroplasty of the visible lumbar or thoracic spine at L4.
• 2022-09-21 CT - abdomen
  • History: abdominal pain and cramp for 1 m. poor appetite. diarrhea but small amount 3-4/day. blood stool (-).
    • 20220426 colonoscopy: R/O A-colon cancer with obstruction. pathology: Signet-ring cell carcinoma
      
    • 20220504 CT：T4bN2aM0, cSTAGE:IIIC
    • 20220511 S/P right hemicolectomy:Advanced A-colon CA wt peritoneal seeding, pT4aN2bM1c , stage IVC
  • Indication: A-colon cancer S/P C/T for FU
  • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • S/P right hemicolectomy
    • There is minimal ascites in the cul-de-sac.
    • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left lower pole.
    • Prior CT identified two confluent cystic dilatation lesion in LUL and LLL of the lung are noted again, stationary.
      • Bronchiectasis are highy suspected.
    • Others
      • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • S/P right hemicolectomy.
    • There is no evidence of tumor recurrence.
• 2022-09-21 CXR
  • Fibrosis of left upper lung is noted. Please correlate with clinical history to rule out old inflammatory process.
  • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
• 2022-05-12 Patho - colon segmental resection for tumor
  • PATHOLOGIC DIAGNOSIS
    • Ascending colon, right hemicolectomy — Signet-ring cell carcinoma
    • Resection margins, bilateral, ditto — Free of tumor
    • Lymph node, mesocolic, dissection — Tumor metastasis (14/18) with extracapsular extension (7/14)
    • Appendix, right hemicolectomy — Appendiceal wall invasion
    • Omentum tissue, ditto — Signet-ring cell carcinoma
    • AJCC pathologic stage — pT4aN2bM1c, stage IVC
  • MACROSCOPIC EXAMINATION
    • Operation procedure: right hemicolectomy
    • Specimen site: Ascending colon, terminal ileum and appendix
    • Specimen size: (a) A-colon: 22.5 cm in length, up to 5.2 cm in diameter with some omentum tissue, (b) Terminal ileum: 6.5 cm in length, 2.7 cm in diameter; (c) Appendix: 3.4 cm in length, 0.3 cm in diameter
    • Tumor size: 6.9 x 4.8 cm
    • Tumor location: 15 and 6.5 cm away from bilateral resection margins
    • Tumor appearance: protruding mass
    • Depth of invasion grossly: visceral peritoneum
    • Representative sections as A1: ileum + colonic margin, A2: appendix, A3: tumor + radial margin, A4-A6: tumor + serosal layer, A7-A8: tumor, A9-A12: lymph nodes, A13: omentum nodules
  • MICROSCOPIC EXAMINATION
    • Histology: signet-ring cell carcinoma with abundant mucin production
    • Histology Grade: G3, poorly differentiated
      
    • Depth of invasion: visceral peritoneum
    • Angiolymphatic invasion: present
    • Perineural invasion: present
    • Discontinuous extramural tumor extension: not identified.
    • Circumferential (radial) margin of rectosigmoid: involved
    • Lymph node metastasis, mesocolic: tumor metastasis (14/18)
    • Lymph node metastasis, IMA / SMA: N/A
    • Extranodal involvement: Present (7/14)
    • Pathological TNM Stage: pT4aN2bM1c
    • Type of polyp in which invasive carcinoma arose: N/A
    • Omentum tissue: tumor deposition
    • TNM descriptors: N/A
      
    • Tumor regression grading S/P CCRT: N/A
    • Appendix: appendiceal wall invasion
• 2022-05-10 CT - chest
  • post infectios or inflammatory fibroticalcified change of lungs
  • with bronchiectasis/bronchiolitis and volume loss especially left lung.
• 2022-05-10 Flow volume chart
  • mild restrictive impairment
• 2022-05-09 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (74 - 15) / 74 = 79.73%
    • M-mode (Teichholz) = 79.5
  • Preserved LV and RV systolic function with normal wall motion
  • Grade 1 LV diastolic dysfunction
  • Mild MR, TR and PR
• 2022-05-04 CT - abdomen
  • History: abdominal pain and cramp for 1 m. poor appetite. diarrhea but small amount 3-4/day. blood stool (-).
    • 20220426 colonoscopy: R/O colon cancer with obstruction at hepatic flexture. pathology: Signet-ring cell carcinoma
      
  • Indication: colon cancer, hepatic flexure for staging
  • Findings:
    • There is asymmetrical wall thickening with whole layer involvement and irregular outer margin at the ascending colon, ileo-cecal valve and terminal ileum, measuring 7.5 cm in length. The adjacent omentum shows fatty stranding and suspicious soft tissue nodules.
      • Adenocarcinoma of the ascending colon with direct invasion the adjacent omentum (T4b) is highly suspected.
      • In addition, There is are four enlarged nodes in the adjacent mesocolon (N2a).
    • There is minimal ascites in the cul-de-sac.
    • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left lower pole.
    • There are two confluent cystic dilatation lesion in LUL and LLL of the lung that may be bronchiectasis? Please correlate with chest CT.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
• 2022-04-26 Patho - colon biopsy
  • Colon, hepatic flexure, biopsy — Signet-ring cell carcinoma
    
  • Section shows pieces of colonic tissue with invasive signet-ring cells.
  • The immunohistochemical stains reveal CK7(-) and CK20(+), EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • Please correlate with the clinical presentation and image study to exclude other primary origin.
• 2022-04-26 Colonoscopy
  • Suspected colon cancer, hepatic flexure, s/p biopsy
  • Suspected lumen stricture, hepatic flexure
  • Mixed hemorrhoid
• 2018-02-12 MRI - L-spine
  • Recent compression fracture of L4 vertebral body
  • Mild central HIVD, L3-L4.
  • Disc bulge with fissure of posterior annulus, L4-L5
  • Disc bulge with tear fissure, L2-L3.

[surgical operation]

• 2022-05-11
  • Surgery: Right hemicolectomy        
  • Finding: large A-colon cancer withmesentary LN enlargement R/O Omental carcinomatosis and tumor seeding on viceral peritoneum
• 2018-02-13
  • Diagnosis: L4 compression fracture
  • PCS code: 64160B

[chemoimmunotherapy]

• 2022-10-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3170mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2022-09-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 535mg NS 250mL 2hr + fluorouracil 2400mg/m2 3220mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2022-08-22 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 535mg NS 250mL 2hr + fluorouracil 2400mg/m2 3235mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2022-08-03 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3240mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2022-07-18 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3240mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2022-06-27 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
• 2022-06-09 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

[assessment]

• A blood transfusion may be considered in light of the patient’s HGB level of 8.6 g/dL, PLT count of 31K/uL, and 4+ stool occult blood in 2023-02-28 lab results.

• The sputum culture result 2023-02-28 revealed the presence of 1+ gram-positive cocci and 2+ gram-negative bacilli. Levofloxacin has been prescribed appropriately to target and treat these strains.

701462331

230301

[present illness]

• The 72-year-old men has had history of
  • Hypertension for more than 5 years under regular medication treatment at CGMH
  • Coronary artery disaeae post stent for more than 10 years under regular medication treatment at CGMH
  • Gallbladder stone
  • Hyperlipidemia for more than 5 years under regular medical treatment at CGMH
  • Right clavicle fracture s/p plating, union on 2003/10/27
  • Diagnosis lung cancer in ECKH (En Chu Kong Hospital) 2022/11/23, status post Tarceva (erlotinib) since 2022/11/25, change to Giotrif (afatinib) since 2022/12/08.

[past history] - 2023-02-25 admission note

• Hypertension for more than 5 years under regular medication treatment at CGMH.
• Coronary artery disaeae post stent for more than 10years under regular medication treatment at CGMH.
• Gallbladder stone.
• Hyperlipidemia for more than 5 years under regular medical treatment at CGMH.
• Right clavicle fracture s/p plating, union on 2003/10/27.
• COVID-19 infection on 2022/06     

[allergy]

• NKDA

[family history]

• There is no family history of cancer, mental diseases or asthma.
• No members of the family with diabetes.   

[exam findings]

• 2023-02-25 - CXR
  • Ground glass opacity in bilateral lower lungs.
• 2023-02-01 CT - chest
  • Indication: Lung adenocarcinoma with lung to lung mets, cT4N3M1a, TTF-1 (+)
  • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
  • Comparison was made with previous CT )other hospital) dated on 2022/11/16
    • Lungs: diffus reticular and small nodules opacities over both lungs, with subpleural ground glass opacity over Rt lower lobe.
    • Mediastinum and hila: extensive lymphadenopathy in the visceral space and left anterior prevascular space and both hila/ small calcifiecations are noted, may be sequela of previous TB infection
      • extensive coronary arterial calcification.
    • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: trace Rt-sided effusion.
    • Chest wall and visible lower neck: small LNs at Lt supraclavicular fossa.
    • Visible abdominal contents: gall bladder stone (20mm).
      • no focal lesion in visible portion of liver, spleen, both adrenal glands, pancreas, and both kidneys.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression: RLL cancer with lung to lung (hematogeneous, lyphaphatic routes) and mediastinal-hilar LNs metastases in regression compared with CT on 2022/11/16, and suspect RLL fibrosis extensive 3V-CAD
• 2023-02-01, -01-19, -01-05, 2022-12-22, -12-01 CXR
  • There are multiple nodular opacities projecting at both lung that are c/w lung to lung metastases after correlate with CT.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
• 2022-12-01 Patho - lung transbronchial biopsy
  • Lung, RB7a, TBLB — adenocarcinoma, moderately differentiated
  • Sections show acinar glandular cells infiltrating in a fibrotic stroma. The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
• 2022-12-01 Cell Block
  • Indication: multiple metastatic lung nodules, ADC proved by CGMH, but origin unknown
  • Result: Malignancy
  • Smears and cell block show clusters of pleomorphic tumor cells. The immunohistochemical stains reveal CK(+), TTF-1(+), and Calretinin(-). The results are consistent with meatstatic adenocarcinoma from lung. Please correlate with the clinical presentation.
• 2022-12-01 Bronchoscopy
  • Chronic rhinitis with post-nasal drip
  • Multiple mucosa anthrocosis change
  • No any visible endobronchial lesion
  • RB7 para- and peribronchial lesion, s/p TBLB.

[medication]

• 2022-12-08 ~ undergoing - Giotrif (afatinib 30mg/tab) KGIOT03 QDAC
• 2022-11-25 ~ 2022-12-?? - Tarceva (erlotinib)

[assessment]

• Based on the patient’s medication history of erlotinib followed by afatinib, it can be inferred that the disease is likely positive for EGFR exon 19 deletion or L858R, S768I, L861Q, and/or G719X mutations.

• The patient had Grade 1 diarrhea which responded well to Smecta treatment (bowel movement of 3 times each day on 2023-02-27 and 2023-02-28). Additionally, the patient also experienced Grade 2 dermatitis and onychomycosis, which are currently being treated externally with tetracycline. If severe or prolonged diarrhea is not responding to antidiarrheal agents, GILOTRIF should be withheld to prevent dehydration and renal failure. In addition, GILOTRIF should be discontinued for life-threatening cutaneous reactions. Severe bullous, blistering, and exfoliating lesions occurred in 0.2% of patients. Severe and prolonged cutaneous reactions also require withholding of GILOTRIF.

• After ground glass opacity was detected in bilateral lower lungs on the chest X-ray 2023-02-25, and G(+) Cocci were identified from sputum culture 2023-02-26, the afatinib treatment was temporarily suspended until the lung symptoms were relieved.

• The current prescription is without any issue.

700838300

230224

[diagnosis] - 2023-02-23 admission note

• Invasive carcinoma, no special type of right breast cT1bN0M0, stage IA, IHC stains: ER (+), PR(+), Her2/neu: (-).
• Malignant neoplasm of unspecified site of right female breast
• Mastodynia
• Essential (primary) hypertension
• Insomnia, unspecified
• Constipation, unspecified

[past history] - 2022-12-08 admission note

• The patient has history of hypertension under medication treatment.
• history of operation: s/p bilateral mammoplasty.
• G2P0SA2
• Breast feeding (-)
• menarche : 13y/o
• menopause: y/o
• Hormone therapy: (+) due to In Vitro Fertilization
• Family history of breast cancar: NIL       

[lab data]

• 2022-08-29 HBsAg Negative
  
• 2022-08-29 HBsAg Value 0.524
  
• 2022-08-29 Anti-HCV Negative
  
• 2022-08-29 Anti-HCV Value 0.0352
  
• 2022-08-29 Anti-HBc Nonreactive
  
• 2022-08-29 Anti-HBc-Value 0.19 S/CO
  
• 2022-06-29 Anti-ENA Scl-70 Ab <0.6 EliA U/ml
  
• 2022-06-29 Anti Jo-1 antibody <0.3 EliA U/ml
  
• 2022-06-29 Anti-ENA SS-A(Ro) <0.3 EliA U/ml
  
• 2022-06-29 Anti-ENA SS-B(La) <0.3 EliA U/ml
  
• 2022-06-29 ANA Negative

[exam findings]

• 2022-12-19 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 22) / 89 = 75.28%
    • M-mode (Teichholz) = 76
  • Normal chambers sizes
  • Normal LV and RV systolic function.
  • Typical mitral valve prolapse ( anterior leaflet); mild PR.
  • poor apical echo window due to previous mammloplasty procedure.
• 2022-12-10 CT - chest
  • Indication: Invasive carcinoma, no special type of right breast cT1bN0M0, stage IA, IHC stains: ER (+), PR(+), Her2/neu: (-).
  • Chest CT with and without IV contrast ehnancement shows:
    • S/p port-A placement with its tip at Superior vena cava.
    • s/p op. over right axillary region is found. Some fibrotic mass like lesion at op region. Regional lymph nodes are also found.
    • Calcified dot at uncinate process of the pancreas is found.
  • Imp:
    • Right axillary soft tissue mass with lymph nodes.
    • Calcified dot at uncinate proces of the pancreas.
• 2022-10-05 Pap Smear Test (for cervical cancer screening)
  • Atypical squamous cells (ASC-US)
• 2022-08-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (72.1 - 26.8) / 72.1 = 62.83%
    • M-mode (Teichholz) = 62.8
  • Normal AV with no AR
  • Normal MV with no MR
  • Normal LV chamber size and wall thickness
  • Preserved LV and RV systolic function
  • Mild PR, trivial TR, normal IVC size
• 2022-08-11 Patho - breast biopsy
  • PATHOLOGIC DIAGNOSIS
    • Tumor, right breast, frozen+ partial mastectomy —- Invasive carcinoma of no special type
    • Resection margins, frozen section — Free, closest 0.2 cm at upper side of 1 o’clock margin
      • 12 o’clock margin, recut — Free of tumor invasion
    • Skin, ditto — Free of tumor invasion
    • Lymph node, R’t axillary SLN, frozen section — Tumor metastasis (2/4) without extracapsular extension (0/2)
      • Lymph node, R’t level I, dissection — Free of tumor metastasis (0/14)
      • Lymph node, R’t level II, dissection — Free of tumor metastasis (0/7)
    • Cyst, R’t chest wall, excision — Epidemal cyst
    • AJCC Pathologic Anatomic Stage — pT1cN1a, if cM0, stage IIA; Prognostic Stage — Stage IA
  • MICROSCOPIC EXAMINATION
    • Histologic type: Invasive carcinoma of no special type with focal ductal carcinoma in situ, low grade
    • Size of invasive carcinoma: 1.1 x 0.9 cm
    • Histologic grade (Nottingham histologic score): Grade I (score 5) including (A) Tubule formation: score 2; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1]. Besides, focal ductal carcinoma in situ, low grade arranged in cribriform pattern is also noted
    • Margins: Free, closest 0.2 cm away from upper side of 1 o’clock, 2.6 cm from 12 o’clock, 1.1 cm from 3 o’clock, 2.6 cm from 9 o’clock, 2.4 cm from 6 o’clock and 0.5 cm from base
    • Nodal status:
      • R’t axillary SLNs: Tumor metastasis (2/4) without extracapsular extension (0/2)
      • R’t level I: Free of tumor metastasis (0/14)
      • R’t level II: Free of tumor metastasis (0/7)
    • Treatment Effect: N/A
    • Lymphovascular space invasion: present
    • Perienural invasion: Not identified
    • Immunohistochemistry: Please refer to S2022-11514
• 2022-08-11 Frozen Section
  • Margins, right breast, frozen section — Free, closest margin 0.3 cm at 12 o’clock and 0.2 cm at upper side of 1 o’clock margin
  • Sentinel lymph nodes, right axilla, ditto — Tumor metastasis (2/4)
• 2022-08-11 Lymphoscintigraphy
  • Finding
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
  • Impression
    • Probably a sentinel lymph node at the right axillary region.
• 2022-07-28 Tc-99m MDP whole body bone scan with SPECT
  • Mildly increased activity in lower L-spines. Degenerative change may show this picture.
  • Increased activity in the maxilla. Dental problem may show this picture.
  • Some faint hot spots in the anterior aspect of bilateral rib cages and increased activity in the nasal bon. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
  • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral elbows, hips and knees, compatible with benign joint lesions.
• 2022-07-25 SONO - abdomen
  • Calcified spots in the liver.
  • Liver cysts.
    
  • Gallbladder stone.
• 2022-07-18 Patho - breast biopsy
  • Breast, right, 1/3 tumor, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains: ER (+, 100%, strong intensity), PR(+, 100%, strong intensity), Her2/neu: negative(score=1+), Ki-67(<10 %), p53 (<10%).
• 2022-06-28 SONO - breast
  • Diagnosis
    • Bil. fibroadenomas as described
    • Suspected right breast tumor (#2)
    • S/P bil. mammoplasty
  • Suggestion
    • tissue study
  • BI-RADS:
    • suspicious abnormality, biopsy should be considered
• consultation
  • 2022-08-16 Dermatology
    • Q
      • For dermatitis
      • This 41 y/o female a case of right breast cancer. She underwent right partial mastectomy + ALND on 20220811. She has noted dermatitis at forehead, without itch. We need your expertise for dermatitis evaluation and treatment.
    • A
      • The patient had sufferred from facial and scalp erythematous papules
        
      • Under the impression of seborrheic dermatitis
      • The following sugeetion:
        • Topysm lotion 2 bot. topical bid use on the scalp lesions.
        • Rinderon-V cream 1 tube topical bid use on the facial and post-aucurial area.

[surgical operation]

• 2022-08-11
  • Surgery
    • right partial mastectomy and ALND (axillary lymph node dissection)
    • tumor excision
  • Finding
    • right 1/3 tumor, about 1cm in diameter
    • SLNB (sentinel lymph node biopsy): positive of malignancy, 2/4
    • epidermoid cyst over right chest wall, LIQ, no infection

[chemoimmunotherapy]

• 2023-02-23 - doxorubicin 60mg/m2 95mg NS 100mL 10min + cyclophosphamide 600mg/m2 945mg NS 500mL 1hr (AC, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2023-01-31 - doxorubicin 60mg/m2 95mg NS 100mL 10min + cyclophosphamide 600mg/m2 950mg NS 500mL 1hr (AC, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-28 - doxorubicin 60mg/m2 94mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 500mL 1hr (AC, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-12-08 - docetaxel 75mg/m2 115mg NS 250mL 1hr + cyclophosphamide 600mg/m2 945mg NS 500mL 1hr (post-Op adjuvant TC)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-11-17 - docetaxel 75mg/m2 118mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant TC)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-10-26 - docetaxel 75mg/m2 118mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant TC)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• 2022-09-23 - docetaxel 60mg/m2 90mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant)
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
• G-CSF (granulocyte colony stimulating factor)
  • 2022-12-17, -18, -19 (20221217 OPD)
  • 2022-11-26, -27, -28 (20221126 OPD)
  • 2022-11-20, -21, -22 (20221117 IPD)
  • 2022-10-29, -30, -31 (20221026 IPD)
• Low WBC data points
  • 2022-12-17 WBC 1.29 *10^3/uL
    
  • 2022-11-26 WBC 2.59 *10^3/uL
    
  • 2022-10-04 WBC 1.34 *10^3/uL

[assessment]

• The most common sequelae, or aftereffects, of axillary lymph node dissection (ALND 2022-08-11) are arm lymphedema, numbness, and limited shoulder mobility.

• For patients with lymphedema (ie, International Society of Lymphology - ISL stage I, II, III), there is a recommendation to measure blood pressure in the contralateral arm, particularly in any setting in which blood pressure is being closely repeatedly or continuously monitored.

• The effectiveness of these treatments in patients with established breast cancer-associated lymphedema (BCAL) is summarized below.

  • For patients with mild lymphedema (ISL stage I), it is suggested physiotherapy in the form of manual lymphatic drainage and compression garments, rather than more intensive therapy. Manual lymphatic drainage (MLD) is a massage-like technique that is typically performed by specially trained physical therapists, but a self-help maneuver (simple lymphatic drainage) has also been used for mild cases. Light pressure is used to mobilize edema fluid from distal to proximal areas.
  • For patients with moderate-to-severe lymphedema (ISL stages II to III) and no contraindications, it is suggested intensive physiotherapy, usually in the form of complete decongestive therapy, rather than less intense therapy. Complete decongestive therapy (CDT) refers to a two-phase (treatment phase, maintenance phase) multicomponent technique that is designed to reduce the degree of lymphedema and to maintain the health of the skin and supporting structures.
  • Patients with severe lymphedema (ISL stage III) may also benefit from intermittent pneumatic compression (IPC) in addition to CDT. IPC (also called sequential pneumatic compression) devices employ a plastic sleeve or stocking that is intermittently inflated over the affected limb. Most pneumatic compression pumps sequentially inflate a series of chambers in a distal-to-proximal direction.

• This (2023-02-24) morning, there was a decrease in blood pressure by 10mmHg resulting in a reading of 96/57, which should be noted. If the blood pressure continues to decrease, the administration of Concor (bisoprolol 5mg) may be suspended.

• No medication reconciliation issues were found during this hospital stay, and the recently prescribed drugs disclosed in the NHI PharmaCloud System have been accurately prescribed as self-carried items that cover the patient’s underlying conditions.

221209

[assessment]

• 2D transthoracic echocardiography performed on 2022-12-19 and 2022-08-29 did not demonstrate deteriorations in heart function.

221118

[assessment]

• Docetaxel has been associated with adverse dermatologic reactions: Alopecia (56% to 76%, can be permanent), dermatological reaction (20% to 48%; severe dermatological reaction: 5%), nail disease (11% to 41%). There have also been reports of adverse reactions associated with cyclophosphamide: Alopecia, changes in nails, dermatitis, erythema multiforme, erythema of skin, hyperhidrosis, palmar-plantar erythrodysesthesia, pruritus, skin abnormalities related to radiation recall, skin blister, skin rash, skin toxicity, Stevens-Johnson syndrome (Assier-Bonnet 1996), toxic epidermal necrolysis (Sasak 2016), urticaria (Thong 2002).
• It is not recommended to immediately reduce the dose of chemotherapy once a mild adverse reaction has been observed in order to gain expected therapeutic effect. Skin symptoms are currently treated with drugs prescribed by dermatologists.
• The underlying conditions of hypertension, constipation, mastodynia, and insomnia are all appropriately treated with appropriate medication without a problem.

221006

[assessment]

• A rise in serum creatinine has been observed over the last three months, while the patient has been taking several NSAIDs, including Tonec (aceclofenac), Arcoxia (etoricoxib), and Volna-K (diclofenac). If NSAIDs are required for myositis and/or mastodynia, the renal function should be routinely monitored.
  • 2022-10-04 Creatinine 0.70 mg/dL
    
  • 2022-09-23 Creatinine 0.64 mg/dL
    
  • 2022-08-10 Creatinine 0.55 mg/dL
• For this patient with ER(+), PR(+) and HER2(-) breast cancer, the current adjuvant chemotherapy might be followed by endocrine therapy (e.g., aromatase inhibitor or tamoxifen).

700851656

230224

[exam findings]

• 2023-02-17 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
• 2023-02-17 ECG
  • Normal sinus rhythm
  • Minimal voltage criteria for LVH (left ventricular hypertrophy), may be normal variant
  • Borderline ECG
• 2022-09-23 SONO - nephrology
  • chronic parenchymal renal disease
• 2022-01-28 Merchant view (patella 45 0) Rt
  • No lateral subluxation or lateral tilting of the patella
  • Patellofemoral osteoarthritis
  • Sperner classification: 4
• 2022-01-28 Knee Rt standing AP and Lat views
  • Severe osteoarthritis of right knee with valgus deformity
  • Ahlback calcification: grade 4
• 2021-11-04 Patho - colorectal polyp
  • Mid transverse colon, polypectomy — Tubular adenoma, low grade
  • Proximal transverse colon, polypectomy — Tubular adenoma, low grade
• 2021-07-02 SONO - nephrology
  • chronic parenchymal renal disease
  • distended urinary bladder
• 2021-06-28 CT - abdomen
  • Bilateral kidney atrophy
  • Lumbar spondylosis
• 2020-12-24 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Duodenal ulcer scars, bulb
    • Superficial gastritis, antrum, s/p CLO
    • Reflux esophagitis LA Classification grade A
  • Suggestion
    • PPI use
    • Pend for CLO
• 2020-08-01 SONO - abdomen
  • Diagnosis
    • liver parenchyma disease
    • gallstones, GB wall thickening
    • suspect renal parenchyma disease
  • Suggestion
    • correlate with kidney echo
• 2020-07-30 CXR
  • Increased bilateral lung markings.
  • Cardiomegaly.
  • Intimal calcification of thoracic aorta.
• 2020-07-29 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 45.4) / 104 = 56.35%
    • M-mode (Teichholz) = 56.3
  • Dilated LA
  • Adequate LV,RV systolic function with normal wall motion
  • LV hypertrophy, Impaired LV relaxation
  • Mild MR, TR, AR, PR
  • Mild Pulmonary HTN
• 2020-07-28 CXR
  • Mild increased infiltration in both lungs
  • No pleural lesion
  • Borderline enlarged cardiac sihoutte
• 2020-05-08 SONO - nephrology
  • chronic parenchymal renal disease
• 2020-04-30 CXR
  • Increased bilateral lung markings.
  • Borderline cardiomegaly.
  • Intimal calcification of thoracic aorta.
• 2020-04-30 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Left ventricular hypertrophy
  • Nonspecific ST abnormality
  • Abnormal ECG

[assessment]

• Based on the available lab data in HIS5, the patient’s HGB level has been consistently below the lower limit of normal since May 2020. The most recent HGB level recorded on 2023-02-23 was 7.4g/dL. It is recommended to closely monitor the patient’s ability to oxygenate.

• For patients with chronic kidney disease-related anemia (2023-02-07 Ferritin 731.6ng/mL), the initiation of epoetin alfa or its biosimilars is generally recommended when Hb levels fall below 10 g/L, according to the Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. Reference: KDIGO clinical practice guideline for anemia in chronic kidney disease, published in Kidney Int Suppl in 2012;2(suppl):279-335.

• Please evaluate if the detected bacteriuria (2023-02-24 lab result) indicates an asymptomatic UTI or not. Asymptomatic bacteriuria is common, but most patients with asymptomatic bacteriuria have no adverse consequences and derive no benefit from antibiotic therapy. With few exceptions, nonpregnant patients should not be screened or treated for asymptomatic bacteriuria.

701296927

230224

{not completed}

[diagnosis]

• K-ras wild type Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV.

[past history]

• Denied history of Hypertension        

[allergy]

• NKDA

[family history]

• There is no family history of cancer

[exam findings]

• 2023-01-02, 2022-12-20, -12-15 Abdomen - Standing (Diaphragm)
  • Ascites is noted.
  • S/P clips projecting at RUQ and LMQ abdomen, and pelvis.
  • Spondylosis of the L-spine is noted.
  • 2023-01-02 Partial Small bowel obstruction with partial resolving is suspected. Follow up is indicated.
  • 2022-12-20 Partial Small bowel obstruction is suspected. Please correlate with CT.
  • 2022-12-15 Small bowel obstruction is suspected. Please correlate with CT.
• 2022-12-14 CT - abdomen
  • CC: Abd fullness for 2+ weeks, poor appetite,
  • Past History: Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV, hemicolectomy at TSGH on 2021-05-13.
  • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is massive ascites and soft tissue lesions in the omentum and mesentery.
      • Carcinomatosis is highly suspected. Please correlate with ascites cytology.
    • There is suggestive tumor seeding in splenic flexure colon, causing marked dilatation of the proximal colon and small intestine.
      • Tumor seeding in the splenic flexure colon induce mechanical colonic obstruction is highly suspected. Please correlate with clinical condition and colonoscopy.
    • There are multiple metastatic nodes in the celiac trunk, para-aortic space and para-cava space that are c/w metastatic nodes.
    • There are two kissing poor enhancing lesions in S4/8 of the liver that are c/w liver metastases.
    • Abdominal aorta shows atherosclerosis, aneurysm 3.2 cm and mild intramural thrombus formation.
    • A calcification 7 mm in S4 liver is noted that is c/w old granuloma.
    • There are several renal stones on both kidney and the largest one measuring 0.6 cm in right middle pole.
      • There are several renal cysts on both kidney and the largest one measuring 1.1 cm in size at right upper-middle pole.
    • S/P LAR with autosuture retention over the sigmoid colon.
    • S/P cholecystectomy.
      
    • Others
      • There is no focal abnormality in the biliary system, pancreas, and spleen.
      • The IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
  • Impression:
    • Carcinomatosis is highly suspected. Please correlate with ascites cytology.
    • Tumor seeding in the splenic flexure colon induce mechanical colonic obstruction is highly suspected. Please correlate with clinical condition and colonoscopy.
    • Multiple metastatic nodes in the celiac trunk, para-aortic space and para-cava space.
    • Two metastases in S4/8 of the liver.
• 2022-12-14 KUB
  • Increased air in distended loops of small bowel over abdomen and pelvicr ,could be adhesive or mechanical ileus.
  • Abdominal ascites
  • Surgical clips over the abdomen
• 2022-12-14 ECG
  • Sinus tachycardia
  • Possible Septal infarct, age undetermined
  • Abnormal ECG
• 2022-10-14 Anoscopy
  • Stool color: normal
  • Rectal mucosa: normal
  • Anal canal: abnormal
  • Impression: 2022-05-20 DRE/anoscopy: mixed morrhoids with perianal skin erosion(+)
• 2022-10-01 CT - abdomen
  • Colon cancer s/p operation. Increased soft tissues at left abdominal cavity suspected tumor seeding.
  • A poor enhancing nodule (1.1cm) at pancreatic tail.
• 2022-06-13 CT - abdomen
  • Very faint soft tissue nodule at left subphrenic region about 0.74cm in largest dimension.In comparison with CT dated on 2022-03-11, the lesions are stationary.
  • s/p cholecystectomy
  • s/p LAR.
• 2022-03-21 Anoscopy
  • Hemorrhoid and anterior anal fissure
• 2022-03-11 CT - abdomen
  • Two soft tissue nodules in LUQ omentum measuring 8 mm and 5 mm that may be post-operative change.
  • The differential diagnosis include tumor seeding but less likely.
• 2022-02-21 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed faint hot spots in the left rib cage, and increased activity in the maxilla, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees, in whole body survey.
  • IMPRESSION:
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the left rib cage, maxilla, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees.
• 2021-12-06 CT - abdomen
  • Colon cancer s/p operation. No evidence of tumor recurrence.
  • Wall edema of colon r/o colitis. Focal small bowel ileus.
• 2021-08-26 CT - abdomen
  • Colon cancer s/p operation. No evidence of tumor recurrence.
• 2021-06-10 Whole body PET scan
  • Glucose hypermetabolism in multiple abdominal bilateral paraaortic lymph nodes, compatible with metastatic lymph nodes.
  • Glucose hypermetabolism in some left supraclavicular lymph nodes. Metastatic lymph nodes should be watched out. Please correlate with other clinical findings for further evaluation.
  • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes and in a small focal area in the upper lobe of right lung. The nature is to be determined (inflammatory process? other nature such as metastases?). Please follow up other imaging modalities for further evaluation.
  • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.

[consultation]

• 2022-12-21 Orthopedics
  • Q
    • The patient is an 63-year-old man with a history of K-ras wild type Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV, Hypertension.
    • He presented with left knee painful since yesterday, progression when movement. Suspect OA knee.
    • Follow-up knee bil. x-ray today. We need your further evaluation and management.
  • A
    • S: 63 male
    • Dx: Left knee OA, grade II
    • O
      • No open fracture
      • Intact N/V
    • Plan:
      • OPD f/u
      • Pain management with pain killers
      • RICE (Rest, Ice, Compression, and Elevation)
• 2022-01-04 Infectious Disease
  • Q
    • The 61 y/o man has watery diarrhea per day for 2-3 weeks and went to PoJen General Hospital for colonscopy /p biopsy. Thus, he sent to TSGH for future management and D- and Sigmoid PD adenocarcinoma with invading to the visceral peritoneaum, pT4aN2b, stage IIIC at least, lymphovascular invasion (+), perineural invasion (+) (LN met 11/16 and 5/11) at least post hemicolectomy at TSGH by GS Chan DChung on May 13, 2021.
    • port-A insertion on 2021-06-09. PET was performed on 2021-06-11 which showed There was increased FDG uptake in some left supraclavicular lymph nodes (SUVmax early: 8.27, delay: 10.54), in a small focal area in the upper lobe of right lung (SUVmax early: 3.30, delay: 5.38), in bilateral pulmonary hilar lymph nodes (SUVmax early: 4.86, delay: 6.77) and in multiple abdominal bilateral paraaortic lymph nodes (SUVmax early: 7.50, delay: 13.69). Besides, there was increased FDG accumulation in both kidneys and bilateral ureters. Radiotherapy with 4500cGy/25 fractions were done. Under the diagnosis of Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV.
    • He received chemotherapy with
      • C1D1 FOLFIRI on 2021/06/11-13.
      • C1D15 Avastin plus FOLFIRI on 2021/06/25-27.
      • C2D1 Avastin plus FOLFIRI on 2021/07/12-14.
      • C2D15 Avastin plus FOLFIRI on 2021/07/27-29
      • C3D1 Avastin plus FOLFIRI on 2021/08/10-12
      • C3D15 Avastin plus FOLFIRI on 2021/08/23-25.
      • => Followed CT of abdomen on 2021/08/26 which revealed Colon cancer s/p operation. No evidence of tumor recurrence.
      • C4D1 Avastin plus FOLFIRI on 2021/09/06-09/08
      • C4D15 FOLFIRI on 2021/9/27-29.
      • C5D1 Avastin plus FOLFIRI on 2021/10/12-14.
      • C5D15 Avastin plus FOLFIRI on 2021/10/26-28.
      • C6D1 Avastin plus FOLFIRI on 2021/11/10-12.
      • C6D15 Avastin plus FOLFIRI on 2021/11/23-25
    • RT 4500cGy/25 fractions at primary tumor bed, peripheral, to regional lymphatic including pelvic area started from 2021/11/11.
    • clostridium difficileGDH as well as Toxin A/B, which showed GDH and Toxin A/B all positive on Dec,2021 although cultural results showed no infection signs.
    • He was admitted for scheduled chemotherapy this time, however still severe diarrhea and clostridium difficileGDH andToxin A/B, which still showed GDH and Toxin A/B all positive. we need your expertise for further management,thanks
  • A
    • The patient’s condition was as your description.
      • RT 4500cGy/25 fractions at primary tumor bed, peripheral, to regional lymphatic including pelvic area started from 2021/11/11.
      • clostridium difficile GDH as well as Toxin A/B, which showed GDH and Toxin A/B all positive on Dec, 2021.
    • Clostridium difficile associated diarrhea was impressed.
    • Suggestion:
      • Vancomycin 125 mg po qid is suggested for 10 days.
      • Please keep contact isolation
• 2021-09-06 Radiation Oncology
  • A
    • A: Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon, AJCC pathological staging pT4aN2b(cM0), stage IIIC at least, s/p operation.
    • P: Radiotherapy is indicated for this patient with the following indicators: D-S colon cancer, stage pT4aN2b(cM0), stage IIIC, wth visceral peritoneum invasion and tumor focal attach to the nearest circumferential margin.
      • Goal: curative
      • Treatment target and volume: primary tumor bed, peripheral, to regional lymphatic including pelvic area.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions.
      • The patient’s family is going to apply the details of medical records. I would like to view those including preoperative CT scan image to clarify the tumor location and then make a decision.
      • RTC: in one week

[radiotherapy]

[chemoimmunotherapy]

• 2023-02-23 - ramucirumab 8mg/kg 400mg NS 250mL 1hr + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4560mg NS 500mL 46hr (Cyramza + FOLFOX, Q2WK)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-02-03 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2023-01-15 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2022-12-30 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2022-12-16 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

• 2022-06-13 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• … … ..

• 2022-03-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

• … … ..

• 2021-06-11 - irinotecan 180mg/m2 310mg D5W 250mL 90min + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2800mg/m2 4830mg NS 500mL 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL

[assessment]

• There is a possible trend towards leukopenia as the patient’s WBC count has gradually decreased over time.

  • 2023-02-23 WBC 3.44 x10^3/uL
    
  • 2023-02-10 WBC 2.83 *10^3/uL
    
  • 2023-02-03 WBC 3.09 *10^3/uL
    
  • 2023-01-27 WBC 4.43 *10^3/uL
    
  • 2023-01-15 WBC 4.05 *10^3/uL
    
  • 2023-01-12 WBC 5.79 *10^3/uL
    
  • 2022-12-29 WBC 5.29 *10^3/uL
    
  • 2022-12-26 WBC 7.99 *10^3/uL

• The patient’s HbA1c levels have slowly increased and warrant attention.

  • 2023-02-20 HbA1c 6.1 %
    
  • 2022-12-06 HbA1c 5.8 %
    
  • 2022-09-05 HbA1c 5.7 %

• Diarrhea seems to have improved as there was no bowel movement recorded on 2023-02-23.

• The medications recently prescribed for the patient are in accordance with the records in the NHI PharmaCloud System, and have been correctly prescribed as self-carried items during this hospital stay to cover his underlying conditions. No issues related to medication reconciliation have been identified.

230116

[assessment]

• Based on the records, bowel movements were 2, 2, 1 over the past three days. No further diarrhea has been observed; loperamide might not be continued. (The drug has not been refilled after the original prescribed expired.)
• Blood sugar levels remain at 90 mg/dL, they are in good control.

700174936

230223

[past history]

• Medical history:

  • Heart: hypertension and dyslipidemia for 10+ years under medical control
  • Other medical:
    • Insomnia, but does not use sleeping pills
    • Asymptomatic gallbladder stones

• Surgical: operation for endometriosis x3, 10+ years ago (open abdominal x1 + hysteroscopic x2)

• Menstrual history: G0P0, Last menstrual period:2022/8/2

  • Menarche at the age of 13 years old
  • Menstrual cycle:Duration/Interval:7-14days/28days
  • Amount: moderate —> changed to menstruation 1 time per year for the past 3 years

• Has regular Pap smear examination (most recent 2022/08/03)

[allergy]

• NKDA         

[family history]

• Mother had hysterectomy, but the patient doesn’t know why
• Mother has thalasemia anemia and hypertension

[exam findings]

• 2022-12-30 - CT - abdomen
  • History: Left ovary cancer of clear cell carcinoma s/p Laparoscopic hysterectomy + BSO + bilateral pelvic lymphadenectomy on 2022/09/22, pT1aN0; stage IA; FIGO stage IA
  • MD CT (iCT 256 slices) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • S/P hysterectomy
    • Severe fatty liver, grade 5, is noted.
    • The gallbladder shows stones and mild wall thickening. please correlate with clinical condition.
    • There is a soft tissue enhancing lesion in left adrenal gland, measuring 1.3 x 0.9 cm in size, that may be adenoma. please correlate with clinical condition.
    • Others
      • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
  • Impression:
    • S/P hysterectomy
    • Severe fatty liver, grade 5, is noted.
    • The gallbladder shows stones and mild wall thickening. please correlate with clinical condition.
    • Left adrenal adenoma is highly suspected. please correlate with clinical condition.
• 2022-10-19 Gynecologic Ultrasonography
  • Suspected LT skin sub? cyst: 16mm x 11mm
  • ATH + BSO
• 2022-09-23 Patho - uterus (with or without SO) neoplastic
  • PATHOLOGIC DIAGNOSIS
    • Ovary, left, BSO — Clear cell carcinoma
    • Lymph nodes, pelvic, bilateral, BPLND — Negative for malignancy (0/15)
    • AJCC 8 th edition, Pathology stage: pT1aN0; stage IA; FIGO stage IA
  • MACROSCOPIC EXAMINATION
    • Procedure: Laparoscopic hysterectomy + BSO + BPLND
    • Specimen Size:
      • Multiple pieces, up to 7.5 x 2.2 x 0.5 cm (Lt ovary, received for frozen section), multiple pieces up to 2.5 x 2.0 x 1.5 cm (Lt ovary), 5.5 x 1.2 x 0.7 cm (Lt tube), 4.5 x 3.2 x 2.5 cm (Rt ovary), 4.5 x 1.5 x 0.9 cm (Rt tube), 12.0 x 7.0 x 5.0 cm and 100 gm (uterus)
    • Specimen Integrity
      • Right ovary: Capsule intact
      • Left ovary: Fragmented
      • Right fallopian tube: Serosa intact
      • Left fallopian tube: Serosa intact
    • Tumor Site: Left ovary
    • Ovarian Surface Involvement: Absent
    • Fallopian tube Surface Involvement: Absent
    • Tumor Size: Cannot be assessed (about 5-6 cm in dimension)
    • Lymph Nodes: Four groups including left iliac, left obturator, right iliac, right obturator
    • Representative parts are taken for section and labeled as: F2022-00449FS and A1-A3, A4, A6 = left ovary, A5 = left tube. S2022-16185A = left iliac LNs, B = left obturator LNs, C = right iliac LNs, D = right obturator LNs, E1 = cervix, E2-E7 = uterine corpus, E8-E9 = endometrium, E10-E11 = right ovary, E12 = right fallopian tube, F1-F2 = left ovary.
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Clear cell carcinoma
    • Histologic grade: High-grade
    • Implants: Not identified
    • Other Tissue/Organ Involvement: Not identified
    • Peritoneal Fluid: Not submitted
    • Regional Lymph Nodes: All lymph nodes negative for tumor cells
      • number of lymph node examined: 2 (left iliac), 7 (left obturator), 1 (right iliac), 5 (right obturator)
      • number with metastases >10 mm: 0
      • number with metastases 10mm or less: 0
      • number with isolated tumor cells (<=0.2mm): 0
    • Pathologic Stage
      • Primary Tumor: pT1a (tumor limited to one ovary)
      • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
      • Distant Metastasis: Not applicable
    • FIGO Stage: Stage IA
    • Lymphovascular invasion: Absent
    • Perineural invasion: Absent
    • Additional Pathologic Findings:
      • Cervix: Chronic cervicitis with squamous metaplasia
      • Endometrium: Endometrial polyp with endometrial hyperplasia
      • Myometrium: Leiomyoma and adenomyosis
      • Ovary, right: Endometrosis
      • Fallopian tube, left: Unremarkable
      • Fallopian tube, right: Hydrosalpinx and hemosalpinx
• 2022-09-22 Frozen Section
  • Ovary, left, frozen section — Malignant, clear cell carcinoma can be considered
• 2022-09-21 ECG
  • Marked sinus bradycardia
  • Septal infarct, age undetermined
  • Nonspecific ST abnormality
• 2022-08-20 Gynecologic Ultrasonography
  • Suspected LT ovarian mass with (papillary 24x23mm)
  • Uterine myoma
• 2022-08-03 Mammography
  • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
  • BI-RADS: Category 1: negative. - annual screening.

[surgical operation]

• 2022-09-22
  • Surgery
    • Diagnosis: Left ovarian tumor suspected malignancy for staging surgery.    
    • Operation: Laparoscopic gynecologic oncology staging surgery (Laparoscopic hysterectomy + BSO + bilateral pelvic lymphadenectomy)   - Finding
    • Left ovarian tumor, suspected malignancy.
    • Frozen: clear cell carcinoma
    • Uterus: irregular shape due to multiple uterine myomas with size 9x8cm, there was dense adhesion with bladder, peritoneum due to previous endometriosis surgery before, adhesiolysis was performed smoothlt.
    • LOV: 6x7x5xcm , capsule intact , smooth surface, with yellowish mucus fluid content and necrotic tissues found within the ovary .
    • ROV: 3x3x2 cm , grossly normal
    • Fallopian tube: bilateral grossly normal
    • CDS: invisible due to tumor mass occupied
    • Ascites: bloody , about 10 ml
    • Bilateralpelvic lymph nodes: normal(+), enlarged(-), indurated(-)
    • Omentum: not seen
    • Liver: grossly normal & smooth
    • Appendix: grossly normal.
    • After the operation, check the bleeder and spray the arista on both pelvic lymph nodes lesion
    • Estimated blood loss: 300 ml
    • Blood transfusion: nil
    • Complication: nil  

[chemoimmunotherapy]

• 2023-02-22 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2023-01-30 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2022-12-28 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2022-12-07 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2022-11-14 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
• 2022-10-21 - paclitaxel 175mg/m2 260mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL

[assessment]

• The patient exhibited severely elevated blood pressure of 228/122 at 19:17 on 2023-02-22, which should be noted as it indicates that her blood pressure was unstable.

• The patient’s 2023-02-22 lab results showed generally normal readings, and she is tolerating the treatment well.

• The active prescription for the patient’s underlying conditions, including hypertension, chronic viral hepatitis B, and hypomagnesemia, has been prescribed without an issue.

221024

• exam findings
  • 2022-10-19 Gynecologic Ultrasonography
    • Suspected LT skin sub? cyst: 16mm x 11mm
    • ATH + BSO
  • 2022-09-23 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left, BSO — Clear cell carcinoma
      • Lymph nodes, pelvic, bilateral, BPLND — Negative for malignancy (0/15)
      • AJCC 8 th edition, Pathology stage: pT1aN0; stage IA; FIGO stage IA
    • MACROSCOPIC EXAMINATION
      • Procedure: Laparoscopic hysterectomy + BSO + BPLND
      • Specimen Size:
        • Multiple pieces, up to 7.5 x 2.2 x 0.5 cm (Lt ovary, received for frozen section), multiple pieces up to 2.5 x 2.0 x 1.5 cm (Lt ovary), 5.5 x 1.2 x 0.7 cm (Lt tube), 4.5 x 3.2 x 2.5 cm (Rt ovary), 4.5 x 1.5 x 0.9 cm (Rt tube), 12.0 x 7.0 x 5.0 cm and 100 gm (uterus)
      • Specimen Integrity
        • Right ovary: Capsule intact
        • Left ovary: Fragmented
        • Right fallopian tube: Serosa intact
        • Left fallopian tube: Serosa intact
      • Tumor Site: Left ovary
      • Ovarian Surface Involvement: Absent
      • Fallopian tube Surface Involvement: Absent
      • Tumor Size: Cannot be assessed (about 5-6 cm in dimension)
      • Lymph Nodes: Four groups including left iliac, left obturator, right iliac, right obturator
      • Representative parts are taken for section and labeled as: F2022-00449FS and A1-A3, A4, A6 = left ovary, A5 = left tube. S2022-16185A = left iliac LNs, B = left obturator LNs, C = right iliac LNs, D = right obturator LNs, E1 = cervix, E2-E7 = uterine corpus, E8-E9 = endometrium, E10-E11 = right ovary, E12 = right fallopian tube, F1-F2 = left ovary.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Clear cell carcinoma
      • Histologic grade: High-grade
      • Implants: Not identified
      • Other Tissue/Organ Involvement: Not identified
      • Peritoneal Fluid: Not submitted
      • Regional Lymph Nodes: All lymph nodes negative for tumor cells
        • number of lymph node examined: 2 (left iliac), 7 (left obturator), 1 (right iliac), 5 (right obturator)
        • number with metastases >10 mm: 0
        • number with metastases 10mm or less: 0
        • number with isolated tumor cells (<=0.2mm): 0
      • Pathologic Stage
        • Primary Tumor: pT1a (tumor limited to one ovary)
        • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IA
      • Lymphovascular invasion: Absent
      • Perineural invasion: Absent
      • Additional Pathologic Findings:
        • Cervix: Chronic cervicitis with squamous metaplasia
        • Endometrium: Endometrial polyp with endometrial hyperplasia
        • Myometrium: Leiomyoma and adenomyosis
        • Ovary, right: Endometrosis
        • Fallopian tube, left: Unremarkable
        • Fallopian tube, right: Hydrosalpinx and hemosalpinx
  • 2022-09-22 Frozen Section
    • Ovary, left, frozen section — Malignant, clear cell carcinoma can be considered
  • 2022-09-21 ECG
    • Marked sinus bradycardia
    • Septal infarct, age undetermined
    • Nonspecific ST abnormality
  • 2022-08-20 Gynecologic Ultrasonography
    • Suspected LT ovarian mass with (papillary 24x23mm)
    • Uterine myoma
  • 2022-08-03 Mammography
    • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative. - annual screening.
• surgical operation
  • 2022-09-22
    • Surgery
      • Diagnosis: Left ovarian tumor suspected malignancy for staging surgery.    
      • Operation: Laparoscopic gynecologic oncology staging surgery (Laparoscopic hysterectomy + BSO + bilateral pelvic lymphadenectomy)     - Finding
      • Left ovarian tumor, suspected malignancy.
      • Frozen: clear cell carcinoma
      • Uterus: irregular shape due to multiple uterine myomas with size 9x8cm, there was dense adhesion with bladder, peritoneum due to previous endometriosis surgery before, adhesiolysis was performed smoothlt.
      • LOV: 6x7x5xcm , capsule intact , smooth surface, with yellowish mucus fluid content and necrotic tissues found within the ovary .
      • ROV: 3x3x2 cm , grossly normal
      • Fallopian tube: bilateral grossly normal
      • CDS: invisible due to tumor mass occupied
      • Ascites: bloody , about 10 ml
      • Bilateralpelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: not seen
      • Liver: grossly normal & smooth
      • Appendix: grossly normal.
      • After the operation, check the bleeder and spray the arista on both pelvic lymph nodes lesion
      • Estimated blood loss: 300 ml
      • Blood transfusion: nil
      • Complication: nil  
• chemoimmunotherapy
  • 2022-10-21 - paclitaxel 175mg/m2 260mg 3hr + carbopatin AUC 5 580mg 2hr

[assessment]

• The patient has just undergone her first treatment with paclitaxel/carboplatin and her TPR and blood pressure are stable.
• The active prescription does not present a problem.

701468007

230223

[past history] - 2023-02-22 admission note

• The patient had no systemic diseases, including endocrine、CNS、CV
• history of operation:
  • s/p abdominal total hysterectomy (ATH) for 20+ y/o ago
  • s/p Urethovesicopexy
  • s/p bilateral cataract
  • s/p rectal biopsy on 2023/02/01
  • s/p L’t port-A on 2023/02/15
• Denied recent traveling history
• Blood transfusion history: NIL
• Occupational function (premorbid)：OK。
• Regular medications or herb：no            

[allergy]

• NKDA

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[lab data]

• 2023-02-12 HBsAg Nonreactive
  
• 2023-02-12 HBsAg (Value) 0.44 S/CO
  
• 2023-02-12 Anti-HBc Reactive
  
• 2023-02-12 Anti-HBc-Value 7.26 S/CO
  
• 2023-02-12 Anti-HCV Nonreactive
  
• 2023-02-12 Anti-HCV Value 0.11 S/CO

[exam findings]

• 2023-02-03 MRI - pelvis
  • CC: She sufferred from constipation for 2 months. This time, anal pain and anal bleeding after defecation developed recently. Digital examination: swelling anorectal region, 7 o’clock rupture.
    • 20230117 sigmoidoscopy: perianal swelling and extensive ulcerative lesion over 6-8 o’clock. Suspected anorectal ulcer
  • MR Imaging of the abdomen was performed on a 1.5 T superconducting magnet and phase arrayed body coil. Patient kept in supine position.
    
  • Scanning protocol:
    • Axial plane: spin echo T1WI, diffusion weighted images, Non-Fat-saturation FSE T2WI, and HASTE T2WI
    • Coronal and sagittal plane: Non-Fat-saturation FSE T2WI,
      
    • Dynamic study: Fat saturated T1WI with IV Gd-DTPA 0.1mmol/Kg and images were obtained at 70 second.
  • Findings:
    • There is circumferrential asymmetrical wall thickening at the rectum and aus, with right lateral exophytic growing measuring 4 cm in size. The cranial-caudal dimension of the rectal lesion is measured about 8 cm in length.
      • The fat plane between this mass and right levator ani muscle shows obliteration that is c/w direct invasion.
      • In addition, the rectal mass shows poterior extension to the perineum.
      • Squamous cell carcinoma of the anorectum with right levator ani muscle invasion (T3) is highly suspected.
      • Please correlate with biopsy.
    • There are five enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w regional metastatic nodes.
      • The largest one measuring 1.3 cm.
      • In addition, There are several enlarged nodes in bilateral inguinal area that are also c/w regional metastatic nodes (N1a).
    • Others
      • There is no focal lesion in the urinary bladder and vaginal.
      • There is no evidence of ascites.
      • The visible artery and vein show unremarkable finding.
  • IMP:
    • Squamous cell carcinoma of the anorectum with right levator ani muscle invasion is highly suspected. Please correlate with biopsy.
    • According to American Joint Committee on Cancer (AJCC) staging system, 9th edition for anal cancer: T3N1aM0, stage:IIIC
• 2023-02-02 CT - abdomen
  • History and indication: anorectal ulcer
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Wall thickening of rectum with adjacent tissue invasion, regional LAP and perforation. Colonic diverticula.
    • Some calcifications in bil. breasts.
    • Hyperplasia of left adrenal gland.
    • Some LNs at bil. inguinal regions.
    • S/P hysterectomy. Suspected left ovary cyst (1.8cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • Addendum Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N1a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
• 2023-02-02 Patho - colon biopsy
  • Anorectum, biopsy — squamous cell carcinoma, moderately differentiated
  • Section shows pieces of squamous mucosa with invasive squamous cell carcinoma.
  • The immunohistochemical stains reveal CK5/6(+), p40(+), CDX2(-), and CD56(-). The results are supportive for the diagnosis.
• 2023-01-31 ECG
  • Sinus rhythm with Premature atrial complexes
  • Left axis deviation
  • Right bundle branch block
• 2023-01-17 Sigmoidoscopy
  • Findings
    • 30cm to S colon, diverticulosis of S colon.
    • perianal swelling and extensive ulcerative lesion over 6~8 o’clock.
  • Diagnosis
    • anorectal ulcer, easily bleeding, pt complain better
  • Suggestion
    • repeat 1 month later.
  • Complication
    • No immediate complication
• 2023-01-13 CXR
  • Cardiomegaly is noted.
• 2023-01-13 ECG
  • Normal sinus rhythm with sinus arrhythmia
  • Left axis deviation
  • Right bundle branch block
  • Abnormal ECG

[SOAP]

• 2023-02-10 Radiation Oncology
  • CCRT is indicated but old age. CT-simulation will be arranged on 20230215. Plan to deliver 45 Gy/ 25 fx to the pelvis (including inguinal, int & ext iliac lymphatic drainage area). Then boost the anal tumor and LAPs to 54 Gy/ 30 fx.

[chemotherapy]

• 2023-02-22 - mitomycin-C 10mg/m2 16mg NS 50mL 5min D1(&D29) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-3 (5FU + mitomycin + RT)
  • [dexamethasone 4mg + NS 250mL] D1-3
• ref
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3839500/
  • https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Colorectal/Fluorouracil-Mitomycin-Radiotherapy.pdf
  • https://www.macmillan.org.uk/cancer-information-and-support/treatments-and-drugs/mitomycin-and-fluorouracil
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4963381/
  • https://www.nccn.org/professionals/physician_gls/pdf/anal_blocks.pdf

[assessment]

• The use of 5-fluorouracil/mitomycin or capecitabine/mitomycin in combination with radiation for the treatment of anal cancer was considered (2023-02-10). A population-based study found that capecitabine/mitomycin and fluorouracil/mitomycin given concurrently with radiation achieved similar disease-free survival (DFS) and anal cancer-specific survival (ACSS). As such, substituting capecitabine for infusional 5-FU may be a viable option for patients and healthcare providers who prefer to avoid the potential complications and inconvenience of a central infusional device. (Reference: “A comparison between 5-fluorouracil/mitomycin and capecitabine/mitomycin in combination with radiation for anal cancer.” J Gastrointest Oncol. 2016;7(4):665-672. doi:10.21037/jgo.2016.06.04)

• The mitomycin and fluorouracil with concurrent radiation (FUMIR) regimen was ultimately chosen for the patient. There are multiple variations of this regimen. The standard administration of 5-FU involves a continuous infusion over 4 days, specifically on Day 1-4 and 29-32. (ref: Mitomycin and Fluorouracil With Concurrent Radiation (FUMIR) Regimen for Anal Cancer. Hosp Pharm. 2013;48(6):464-469. doi:10.1310/hpj4806-464). Due to the patient’s advanced age, a 3-day infusion was utilized during this hospitalization, with a weekend break in between.

• Lab results 2023-02-22 revealed that the CBC, WBC DC, Na, K, liver and kidney function were grossly normal, indicating no significant abnormalities.

• In the review of systems section of the admission note (2023-02-22, yesterday), it was documented that the patient had been experiencing constipation for a period of two months, as well as anal bleeding with pain. The prescription of sennoside has been appropriately made. If anal bleeding persists, the addition of tranexamic acid may be considered as a potential treatment option.

• A summary of the compatibility of mitomycin with various intravenous solutions is listed as following: mitomycin is not compatible with D5W, Dextrose 3.3% in sodium chloride 0.3%, and Dextrose 5% in water. Compatibility with D10W, D5LR, D5NS, 1/2NS, D5W-1/2NS and Ringer’s Injection is untested. IV compatibility with Normal saline (Sodium chloride 0.9%) is variable; Lactated Ringer’s Injection, Sodium chloride 0.4%, Sodium chloride 0.6%, and Sodium lactate 1/6 M is compatible.

700184828

230222

[past history]

• Medical history:
  • Hypertension
  • Goiter
  • Gall bladder stone
  • Mixed hyperlipidemia
  • Left adrenal hemanigioma status post laparoscopic adrenalectomy
  • Diabetes, suspicious subclinical Cushing.
  • Acom aneurysm rupture s/p TAE at ShuGuang Hospital in ShangHai, 20160326
  • Non rupture right MCA aneurysm.
• Operative history:
  • Left adrenal hemanigioma status post laparoscopic adrenalectomy
  • Acom aneurysm rupture s/p TAE at ShuGuang Hospital in ShangHai, 20160326
  • Port-A insertion on 2022-10-13
• Neoadjuvent chemotherapy with
  • Lipo-dox 35mg/m2 + Endoxan 600mg/m2 since 2022/10/22~2022/12/26.
  • Taxotere 75mg/m2 since 2023/01/31~ .
  • Herceptin 600mg SC + Perjeta 420mg for 6 cycles since 2023/01/31~

[allergy]

• NKDA                 

[family history]

• There is no family history of mental diseases or asthma.
• Father: lung cancer; Mother: hypertension.

[exam findings]

• 2023-01-31 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 21) / 80 = 73.75%
    • M-mode (Teichholz) = 73
  • Preserved LV and RV systolic function with normal wall motion
  • Mildly dilated LA, grade 1 LV diastolic dysfunction
  • Mild MR, TR
• 2022-10-14 Patho - breast biopsy (no need margin)
  • Breast, left, biopsy — fibroadenoma
  • Microscopically, the breast shows fibroadenoma composed of intracanalicular growth pattern of elongated and branching mammary ductules surrounded by fibrous stroma.
• 2022-10-13 SONO - neck (lymph node)
  • Sonography of neck revealed some LNs in bil. neck.
• 2022-10-12 SONO - breast
  • Diagnosis
    • uncertain breast tumor, in favor of benign
    • fibroadenoma (FA) suspect malignancy from PET
  • Suggestion and Plan
    • regular OPD follow-up.
    • A breast tumor located at L’t (1, 0) noted from sonography.
    • We use 16 guage needle to puncture the tumor for 3 times.
• 2022-09-30 Whole body PET scan
  • There was increased FDG uptake in multiple focal areas in the right breast (SUVmax early: 18.22, delay: 20.27), in multiple right axillary lymph nodes (SUVmax early: 17.81, delay: 24.89), in a small focal area in the left breast (SUVmax early: 17.33, delay: 23.16), in a focal area in the right parotid gland (SUVmax early: 7.93, delay: 7.69), in some bilateral neck lymph nodes (SUVmax early: 5.17, delay: 6.25) and in the right adrenal gland (SUVmax early: 7.32, delay: 9.92).
  • IMPRESSION:
    • Multiple glucose hypermetabolic lesions in the right breast, compatible with multiple malignant breast tumors.
    • A small glucose hypermetabolic lesion in the left breast. Breast malignancy should be watched out. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in multiple right axillary lymph nodes, suggesting metastatic lymph nodes.
    • A glucose hypermetabolic lesion in the right parotid gland. Some kind of parotid lesion may show this picture. Please correlate with other clinical findings for further evaluation
    • Mild glucose hypermetabolism in some bilateral neck lymph nodes. Inflammation is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Glucose hypermetabolism in the right adrenal gland. Either hyperplasia or adenoma may show this picture. Please also correlate with other clinical findings for further evaluation
• 2022-09-29 Patho - breast biopsy (no need margin)
  • Lymph node, right axillary, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains (using block: S2022-16632): ER (-, 0%), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67( 70%), E-cadherin (+).
  • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.
• 2022-09-29 Patho - breast biopsy (no need margin)
  • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
  • IHC stains (using block: S2022-16631): ER (-, 0%), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67( 70%), E-cadherin (+).
  • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
• 2022-09-27 Mammography
  • Screening digital mammography of both breasts with MLO and CC views:
  • Old mammographic study: 2013-08-09 (BIRADS 1)
  • Impression:
    • Dense breast. Right breast tumors with enlarged right axillary lymph nodes, suspected malignancy with lymph nodes metastasis.
  • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.

[chemoimmunotherapy]

• 2023-02-21 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 133mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2023-01-31 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr + docetaxel 75mg/m2 132mg NS 250mL 1hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
• 2022-12-26 - cyclophosphamide 600mg/m2 1046mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2022-12-05 - cyclophosphamide 600mg/m2 1048mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2022-11-14 - cyclophosphamide 600mg/m2 1048mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
• 2022-10-22 - cyclophosphamide 600mg/m2 1053mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
  • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

[assessment]

• There are currently no bowel movement records for this hospital stay in HIS5. However, the records from the patient’s previous hospital stay (between 2023-01-31 and 2023-02-01) indicated that the patient had one bowel movement per day.

• According to the review of systems in the admission note for this hospital stay, the patient experienced diarrhea and had 8 to 9 bowel movements per day.

• It might be noted that docetaxel is known to cause gastrointestinal adverse reactions, including diarrhea (with a frequency of 23% to 43%, and severe diarrhea occurring in 6% or less of cases), and the incidence of diarrhea with pertuzumab and trastuzumab is 60% (ref: UpToDate).

• The use of loperamide is recommended as a means of alleviating diarrhea and Loperamide (2mg/cap) is available in this hospital.

• Loperamide usage: Oral, Initial: 4 mg, followed by 2 mg every 2 to 4 hours or after each loose stool; for diarrhea persisting >24 hours, administer 2 mg every 2 hours (or 4 mg every 4 hours). Continue until 12 hours have passed without a loose bowel movement. Doses >16 mg/day may not provide benefit; consider alternative therapy for diarrhea persisting >=48 hours.

700348666

230221

This patient passed away at 10:19, 2022-11-03.

701470008

230221

[lab data]

2023-06-26 CMV viral load assay Target not detecetedIU/mL
2023-06-19 CMV viral load assay Target not detecetedIU/mL
2023-06-12 CMV viral load assay Target not detecetedIU/mL

2023-03-14 CMV IgM Nonreactive
2023-03-14 CMV IgM Value 0.57 Index
2023-03-14 CMV_IgG Reactive
2023-03-14 CMV_IgG Value 393.8 AU/mL

2023-02-16 FLT3-D835 Undetectable
2023-02-15 BCR/abl Undetectable
2023-02-15 PML-RARA Undetectable
2023-02-13 FLT3/ITD Undetectable
2023-02-13 NPM1 Undetectable

2023-02-04 Anti-HBc Nonreactive
2023-02-04 Anti-HBc-Value 0.21 S/CO
2023-02-04 Anti-HBs 1.78 mIU/mL
2023-02-04 Anti-HCV Nonreactive
2023-02-04 Anti-HCV Value 0.09 S/CO
2023-02-04 HBsAg Nonreactive
2023-02-04 HBsAg (Value) 0.36 S/CO
2023-02-04 Anti-HBc IgM Nonreactive
2023-02-04 Anti-HBc IgM Value 0.10 S/CO

[exam findings]

• 2023-07-03 Patho - bone marrow biopsy
  • Bone marrow, iliac bone, biopsy — Compatible with AML with partial remission at least, see description
    • Immunohistochemical stains:
      • MPO: positive for myeloid series
      • CD117: negative for blast
      • CD34: positive for blast
      • CD61: positive for megakaryocyte
      • CD71: positive for erythroid series
      • CD68: positive for monocyte
  • MACROSCOPIC EXAMINATION
    • The specimen submitted consisted of one strip of bone marrow tissue measuring 2.2 x 0.2 x 0.2 cm in size, fixed in B-5 solution. Grossly, it was tan in color and bony hard in consistence. All embedded for sections after short decalcification.
  • MICROSCOPIC EXAMINATION
    • Hypocellularity for her age, 30%
    • M/E ratio about 1.5/1, largely normal maturation of myeloid and erythroid series
    • Adequate megakaryocytes with focal mononucleation and hyposegmentation
    • Some scatter large nucleated cells, which IHC shows CD34(-) / CD117(+) / CD68(+/-, equivocal), maybe residual blast or erythroid precursor
    • According to all histopathologic finding, it is compatible with acute myeloid leukemia with partial remission at least. Clinical or smear correlation is needed for conclusive diagnosis due to histologic limitation. Closely follow up.
• 2023-02-09 CXR
  • Enlargement of cardiac silhouette.
• 2023-02-06 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Compatible with acute myeloid leukemia with maturation
  • The sections show hypercellular marrow (95%). M/E ratio = 3:1 in CD71 immunostain. The marrow space is partially replaced by a population of medium to large-sized immature cells with round to oval nucleus and prominent nucleoli.
  • IHC, increased CD34+ and or CD117+ blasts, constitue 40% of marrow cells. Most blasts are also positive for MPO and a few blasts are positive for CD68. The finding is compatible with acute myeloid leukemia with maturation. Suggest bone marrow smear evaluation and clinic correlation.
• 2023-02-06 Gynecologic Ultrasonography
  • EM: 6.7mm.
• 2023-02-02 CXR
  • Increase bilateral lung markings.

[MedRec]

• 2023-07-06 Progression Note
  • Problem #1: Acute myeloid leukemia, 46,XX[20], status post induction chemotherapy with I3A7 on 2023/02/13-19, consolidation chemotherapy with hige dose Ara-C on 2023/04/12-15, 2023/06/02-05
    • Assessment: pending for bone marrow biopsy
  • Plan:
    • Followed bone marrow aspiration and biopsy on 2023/7/3 and pending
    • Family meeting on 2023/07/06 10:30, explained the current condition and further chemotherapy, alloPBSCT
    • closely monitor clinical condition
  • Medical team explained the current changes in the patient’s disease and future treatment direction:
    • The patient was diagnosed with Acute Myeloid Leukemia in 2023-02. Induction chemotherapy (I3A7) was given from 02/13 to 02/19. A follow-up bone marrow biopsy on 02/24 showed partial remission. Starting from 04/11/2023, the patient has been receiving consolidation treatment (High dose Ara-C) in two courses.
    • The initial white blood cell count was 100,000, indicating a poorer prognosis. The recent bone marrow biopsy during this hospitalization showed that complete remission has not yet been achieved. We discussed the subsequent treatments and the possibility of allogeneic peripheral blood stem cell transplant.
    • The patient’s sister will have HLA-ABC DR DQ typing performed for compatibility matching.
    • We explained and presented the consent form for matching from the Tzu Chi Stem Cell Registry.

[consultation]

• 2023-02-06 Obstetrics and Gynecology
  • Q
    • This is a 29-year-old female with history of GERD. She denied systemic diseases, operation history or allergic history. She is ADL independent. This time, she suffered from abdominal distension for 1 months, accompanying with exertional dyspnea and bilateral lower limb edema for 5 days. Her dyspnea exacerbated during walking, and relieved during resting. She denied fever, chills, shortness of breath, dysuria, or abdominal pain. She visited local clinic first, and lab data revealed severe leukocytosis (92720) and anemia with HgB: 4.7. Then, she was transfered to Cardinal Tien Hospital. In order of further examination and survey, she was transfered to our ER due to leukocytosis, suspected leukemia. During ER, her vital sign showed BP:132/72, PR:123, BT:35.9 degree celsius, RR:18. Lab data showed severe leukocytosis (103.39 10^3/uL), anemia (HgB: 4.9 g/dL), thrombocytopenia (PLT: 52 10^3/uL). KUB and CXR showed negative findings. LPRBC 2U was transfused for her anemia.
    • Under the impression of anemia and abdominal distension, suspected acute leukemia, she was admitted for further hematological survey.
    • We strongely need your expertise for ceasing menstrural period due to severe thrombocytopenia (20230206 PLT: 78000/ul). Thank you very much.
  • A
    • S/O
      • SEX(+), LMP:2022/12/18 (moderate amount. irregular period, duration: 3~5 days)
      • NDKA
      • PHx: denied GYN history or family history GYN history. 2022/09 covid-19 infection.
      • Medication or hormone use: denied any hormone use before.
      • CC: for leukemia treatment.
      • PV: no lifting pain. clear discharge.
      • TVS (transvaginal ultrasound):
        • Uterus: AFV, 81X40 mm
        • EM:6.7 mm
        • ROV:27x12 mm
        • LOV:16x15 mm
    • Suggestion and plan:
      • Check pregnancy test. (Irregular menstrual cycle. )
      • Leuplin 3M 11.25 mg syringe SC ST for 1 dose
      • For long-acting Leuplin, one dose can last for three months, and at most two doses can last for six months. Patients have been informed that each dose will cost about TWD 10000 at their own expense.
      • The patient has been taught that Leuplin takes time to act, if there is still menstruation or heavy bleeding this month, oxytocin and transamin can be used (please contact obstetrics and gynecology).

[chemotherapy]

• 2023-07-07 - [fludarabine 30mg/m2 46mg NS 500mL 30min + cytarabine 2000mg/m2 3000mg NS 500mL 4hr] D1-5 (FLAG Q4W)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
• 2023-06-02 - cytarabine 3000mg/m2 4500mg NS 500mL 4hr Q12H D1-4 (HD Ara-C Q4W)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-4
• 2023-04-12 - cytarabine 1500mg/m2 2190mg NS 500mL 3hr Q12H D1-4 (HD Ara-C Q4W)
  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-4
• 2023-02-13 - idarubicin 10mg/m2 14mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 145mg NS 500mL 24hr D1-D7 (idarubicin/cytarabine 3+7 Q4W)
  • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3

CYTARABINE (ARA-C) HIGH DOSE - Consolidation chemotherapy for AML in remission — https://nssg.oxford-haematology.org.uk/myeloid/protocols/ML-4-cytarabine-ara-c-3g-m2.pdf

ACUTE MYELOID LEUKAEMIA - CYTARABINE (3000mg/m2) — https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/AML/Cytarabine3000.pdf

==========

2023-07-07

• In this hospital stay, the patient’s chemotherapy regimen has been augmented with the addition of fludarabine. I prepared information sheets for the patient on fludarabine and cytarabine and brought them to the ward. I visited her around 13:20 on 2023-07-07. Both the patient and her mother were present; the patient was standing and seemed to be reaching for something, and I observed that she was in good spirits. I highlighted the key points and potential side effects on the medication sheets with a colored marker, verbally informed both of them, and asked them to let our medical team know as soon as possible if they notice any suspected adverse drug reactions. I also left them with the contact information for the medication consultation window for their future reference.
• During the visit, the patient’s mother asked about the results of the bone marrow biopsy performed on 2023-07-03. I informed her that questions regarding the patient’s condition and treatment strategy should be addressed to the attending physician. It is up to Dr Gao to disclose this information to the patient’s family as clinically necessary.

2023-02-11

• Dr. Wan asked how long the stability of cytarabine lasts this morning. After calling the original supplier, the manufacturer said that the physical and chemical stability can be longer, but the microbiological stability is as shown in the package insert.
• The content of this article “An 1H NMR study of the cytarabine degradation in clinical conditions to avoid drug waste, decrease therapy costs and improve patient compliance in acute leukemia” (Anticancer Drugs. 2020;31(1):67-72. doi:10.1097/CAD.0000000000000850) is the result of using Ara-C test instead of Cytosar.

700057920

230220

• diagnosis - 2022-11-03 discharge
  • recurrent cholangiocarcinoma measuring 0.7 cm in S4, 0.9 cm in S8 and 1.2 cm in S3 of the liver are suspected. Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery, stage IV
  • Intrahepatic bile duct carcinoma status post laparoscopic S6-7 resection on 2020/09/30. ECOG:0, stage IV
  • chronic viral hepatitis B without delta-agent
  • liver cirrhosis, HBV related. Child A
• exam findings
  • 2022-11-14 Ascites tapping
    • 2700mL
  • 2022-11-01 PTCD (Percutaneous Transhepatic Cholangial Drainage) revision
    • Obstruction of the PTCD catheter.
    • Revision of the catheter smoothly.
  • 2022-10-26 CT - abdomen
    • History and Indication:
      • 20080128 CT: HCC in S6 S/P partial segmentectomy
      • 20200826 AFP and CEA: normal, MRI:HCC 4.8 cm in S7 is suspected.
        • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
      • 20201002 Liver, S6-7 resection: cholangiocarcinoma
        • pT1aNx; Stage IA at least
      • 20220330 CEA, CA199, and AFP: normal.
    • IMP:
      • Recurrent cholangiocarcinoma in S4 of the liver S/P C/T shows stable disease.
      • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, and aortocaval space S/P C/T show stable disease.
        • Multiple metastatic nodes in the mesentery S/P C/T show partial response.
          
      • Carcinomatosis is highly suspected.
        • Please correlate with ascites cytology.
        • In addition, there is marked increased the volume of the ascites.
        • please correlate with clinical condition.
  • 2022-09-26 Endoscopic Retrograde CholangioPancreatography, ERCP
    • diagnosis
      • Failed to reach major papilla
      • CBD stricture s/p PTCD
      • Duodenal stenosis, proximal 2nd portion and SDA
      • Duodenitis and duodenal tumor with ulcer
    • suggestion
      • PPI
  • 2022-09-05 KUB
    • S/P PTCD catheter implantation via left lobe IHD approach and the tip located at S2/3 IHD?
    • Fecal material store in the colon. -Mild ascites is suspected. Please correlate with sonography.
  • 2022-08-24 CT - abdomen
    • Recurrent cholangiocarcinoma in S4 of the liver S/P C/T shows partial response.
    • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, and aortocaval space S/P C/T show partial response.
      • Multiple metastatic nodes in the mesentery show progressive disease.
        
    • Carcinomatosis is highly suspected.
      • Please correlate with ascites cytology.
  • 2022-06-15 CT - abdomen
    • One recurrent cholangiocarcinoma measuring 1.6 cm in S4 of the liver is suspected.
    • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery S/P CT show partial response.
    • There is ascites in the abdomen and pelvis with smuddgy appearance at the perihepatic omentum area.
    • Please correlate with ascites cytology to R/O carcinomatosis?
  • 2022-05-09 Endoscopic Retrograde CholangioPancreatography, ERCP
    • Failed Cholangiography due to inablity to reach major papilla
    • CBD stricture s/p PTCD
    • Duodenal stenosis, proximal 2nd portion and SDA
    • Duodenitis and duodenal tumor with ulcers
  • 2022-04-29 Percutaneous Transhepatic Cholangiography and Drainage, PTCD
    • Dilatation of the biliary tree (by US images).
    • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
    • No procedure-related complication during the whole procedure.
  • 2022-04-28 SONO - abdomen
    • Diagnosis
      • Liver tumor, c/w recurrent cholangiocarcinoma, S3 and S7
      • Dilated CBD & bilateral IHD
      • Lymphadenopathy at pancreatic head area
      • Splenomegaly, moderate
      • Ascites, left retroperitoneal
    • Suggestion
      • ultrasound follow up ascites.
  • 2022-04-22 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • Liver tumor, c/w recurrent cholangiocarcinoma, S3 and S7
      • suspicious,subphrenic abscess or biloma , S7 area.
      • Prominent bilateral IHD and MPD
      • suspiciosu, Renal stone, right
      • lymphadenopathy at pancreatic head area
      • Splenomegaly, moderate
      • Ascites, left retroperitoneal
      • CBD, GB, pancreatic body masked
    • Suggestion
      • ultrasound follow up ascites.
  • 2022-04-20 Patho - lymphnode biopsy
    • Lymph node, hepatic hilum, EUS FNB — Compatible with metastatic cholangiocarcinoma
    • The sections show a picture of adenocarcinoma, composed of nests and cords of large pleomorphic neoplastic cells with focal glandular differentiation. Extensive tumor necrosis and moderate neutrophil infiltration are present.
    • IHC shows: CK7(+, focal), CK20(-), Arginase-1(-) and Hepatocyte(-). The finding is compatible with metastatic cholangiocarcinoma.
  • 2022-04-20 Patho - liver biopsy needle/wedge
    • Liver, EUS FNB — Adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma, recurrent
    • The sections show a picture of adenocarcinoma, composed of nests and cords of large pleomorphic neoplastic cells with focal glandular differentiation. Tumor necrosis, hemorrhage, and neutrophil infiltration are present.
    • IHC shows: CK7(+, focal), CK20(-), Arginase-1(-) and Hepatocyte(-). The finding is compatible with recurrent cholangiocarcinoma.
  • 2022-04-20 Endoscopic Ultrasonography, EUS
    • Diagnosis
      • Hepatic tumor, S4, s/p CH-EUS and FNB, suspect cholangiocarcinoma
      • Lymphadenopathy, hepatic hilum, s/p CH-EUS and FNB, suspect metaplastic lesion
      • Ascites
    • Suggestion
      • pursue pathological result
  • 2022-04-01 CT - abdomen
    • Three recurrent cholangiocarcinoma measuring 0.7 cm in S4, 0.9 cm in S8 and 1.2 cm in S3 of the liver are suspected. Please correlate with MRI.
    • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery.
  • 2022-01-03 CT - abdomen
    • Liver tumor s/p operation with a biloma formation (3.5x7.9cm). A LN (1.5cm) at hepatic hilar region.
  • 2021-10-15 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • post partial right hepatectomy.
      • Calcified spot of liver, S4/7 area.
      • GB, pancreatic body and tail masked by gas.
      • Left hepatic lobe hypertrophy
      • Much colon gas.
    • Suggestion
      • semi-annual ultrasound follow up.
  • 2021-07-19 SONO - abdomen
    • Diagnosis
      • Liver cirrhosis
      • Status post S6/7 liver segmentectomy
      • Hepatic calcified spots
      • Fatty pancreas
    • Suggestion
      • keep follow up
  • 2021-04-30 CT - abdomen
    • History and Indication: FL + HCC + HBV , normal LFT
      • 20080128 CT: HCC in S6 S/P partial segmentectomy
      • 20200826 AFP and CEA: normal, MRI:HCC is highly suspected.
        • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
      • 2020/10/02 Liver, S6-7 resection: cholangiocarcinoma
        • pT1aNx; Stage IA at least
    • IMP:
      • S/P near total right hepatectomy. There is no evidence of tumor recurrence.
      • Biloma in right surgical margin shows decreasing in size to 4 x 2.2 cm.
  • 2021-02-25 Hearing Test
    • Tymp bil type A
    • ART bil WNL
    • PTA:
      • Reliability FAIR
      • Average RE 11 dB HL, LE 13 dB HL
      • bil normal to mild SNHL
    • SRT RE 10 dB HL, LE 10 dB HL
    • WDS RE 96 % at MCL, LE 96 % at MCL
  • 2021-02-03 SONO - abdomen
    • Diagnosis
      • Liver cirrohis
      • Propable post op related biloma, right lobe
      • C/w post liver segmentectomy
    • Suggestion
      • keep follow up
  • 2020-12-30 Patho - soft tissue
    • Labeled as “an erythematous nodules with heat and itching on left chest for 1 months -> suspected cutaneous metastasis of HCC or cholangiocarcinoma”, skin biopsy — marked perivascular lymphocytic inflammation.
    • IHC stains: CD3 and CD20: no predominant subpopulation. No metastatic carcinoma.
      
  • 2020-12-09 SONO - abdomen
    • Diagnosis
      • C/w post liver segmentectomy
      • Propable post op related bilioma,right lobe
      • Poor assessment of biliary tract and PV
      • Pancreas not shown
      • Suboptimal examination of liver due to poor echo window
    • Suggestion
      • OPD f/u
      • Please correlate with other image
      • Follow liver function test and AFP
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
  • 2020-11-09 CT - abdomen
    • Impression: Liver tumor s/p operation with a biloma formation (3.5x7.9cm). No evidence of tumor recurrence.
  • 2020-10-02 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS:
      • Liver, S6-7, segmental hepatectomy — Intrahepatic cholangiocarcinoma
        
      • Pathologic Staging: pT1aNx; Stage IA at least
        
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Intrahepatic cholangiocarcinoma
        
      • Histologic Grade: Poorly differentiated (G3)
        
      • Tumor Growth Pattern: Mass-forming
        
      • Tumor Necrosis: Present
        
      • Tumor Extension: Tumor confined to hepatic parenchyma
        
      • Large Vessel Invasion: Not identified
      • Small Vessel Invasion: Not identified
        
      • Perineural Invasion: Not identified
        
      • Pathologic Staging (pTNM): Stage IA at least (pT1aNx)
        
      • Margins
        • Parenchymal Margin: Free, 2.5 cm from closest margin
          
        • Hepatic Capsule: Involved by invasive carcinoma
          
      • Additional Pathologic Findings: None identified
        
      • Hepatitis (specify type): Hepatitis B
        
      • Ishak Modified HAI Grading: Score=2 (interphase hepatitis=0/4, confluent necrosis=0/6, focal necrosis=0/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
        
      • Ishak Staging: F2 (Corresponding Metavir F2, periportal fibrosis)
        
      • Fatty Change: Present (＜5%)
        
      • IHC: Hepa-1(-), Arginase-1(-), CK7(+), CK19(+), CD56(-)
        
  • 2020-09-21 Visceral Angiography 2 vessels
    • DSA of celiac trunk and common hepatic artery with post-angiography CTAP study via right common femoral artery puncture revealed:
      • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
      • Liver cirrhosis.
      • Patency of portal vein.
      • A hypervascular tumor at right hepatic lobe. A marginal enhancing nodule at S4 of liver r/o hemangioma. Some vascular blushes at right hepatic lobe r/o vascular shunting.
      • Post-angiography CTAP images also revealed a perfusion defect (5.9cm) at right hepatic lobe.
      • No procedure-related complication during the whole procedure.
    • IMP: Right liver tumor (5.9cm), HCC is first considered. Left liver hemangioma (1.1cm).
  • 2020-09-21 SONO - abdomen
    • Diagnosis
      • Liver tumor, nature?
      • Parenchymal liver disease
      • HCC s/p S5 resection
    • Suggestion
      • Please follow sonography in 3-6 mon
      • Please check tumor, hepatitis markers and LFTs q3-6 mon
  • 2020-08-26 MRI - abdomen
    • History and Indication: FL + HCC + HBV , normal LFT and AFP
      • BWL 8 kg in 6 mon after exercise
      • 20080128 CT: HCCs in S6 S/P partial segmentectomy
      • 20200826 AFP and CEA: normal
    • Findings:
      • There is a well-defined, mild heterogeneous mass 4.8 x 3.5 cm in S7 of the liver. The main tumor shows hypointensity on T1WI, moderate hyperintensity on T2WI, and marked hyperintensity on DWI. During dynamic study, this tumor shows contrast enhancement in arterial phase and contrast washout in portal and delayed phase images.
        • The central area shows even higher intensity than the peripheral main tumor on T2WI and contrast enhancement in delayed phase images.
        • HCC is highly suspected.
        • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
      • S/P partial resection of S6 liver.
      • There are one enlarged node in hepatoduodenal ligament measuring 3 x 1.3 cm and several enlarged nodes in celiac trunk area, showing bright on DWI that may be metastatic nodes.
        • The differential diagnosis include benign reactive nodes.
  • 2020-07-28 Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t: 13 dB HL
      • L’t: 11 dB HL
    • Bil WNL except L’t 8k Hz
    • Tymp
      • Bil Type A
    • ART
      • Bil WNL.
• surgical operation
  • 2020-09-30
    • Surgery
      • S6-7 resection
      • laparoscope IOE
    • Finding
      • 5.5 x 5.0 x 5.0 cm well define tumor at S7
• chemoimmunotherapy
  • 2022-11-22 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4370mg 46hr
  • 2022-11-02 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 725mg 2hr + fluorouracil 2400mg 4370mg 46hr
  • 2022-10-11 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr
  • 2022-09-05 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr
  • 2022-08-16 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr # The chemotherapy Q2W shift to Q3W due to neutropenia.
  • 2022-07-27 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4360mg 46hr
  • 2022-07-08 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4360mg 46hr
  • 2022-06-13 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2200mg 3990mg 46hr
  • 2022-05-23 - fluorouracil 225mg/m2 400mg 24hr D1-3
  • 2022-05-16 - fluorouracil 225mg/m2 400mg 24hr D1-5
  • 2022-05-10 - fluorouracil 225mg/m2 400mg 24hr D1-3
  • 2022-05-04 - fluorouracil 225mg/m2 400mg 24hr D1-3

[assessment]

• The recently prescribed drugs that were disclosed in the NHI PharmaCloud System have been appropriately prescribed during this hospital stay.
• No medication reconciliation issues have been found in the patient.

221122

[assessment]

• The HGB level was 7.7 g/dL on 2022-11-21, and a transfusion of LPRBC 2U is scheduled.

700545433

230220

{DLBCL}

[diagnosis] - 2022-07-31 discharge diagnosis

• Diffuse large B-cell lymphoma, lymph nodes of multiple sites
• Diffuse large B cell lymphoma, Non-germinal center type,multiple lymph nodes on both sides of the diaphragm as mentioned above and multiple focal areas in bilateral lung fields involvement,Lugano stage IV,IPI score:4,PS:2
• Hypertension
• Type 2 diabetes mellitus without complications
• Hyperlipidemia

[lab data]

• 2022-07-18 Amikacin <2.5 ug/mL
  
• 2022-06-02 HCV RNA-PCR Target Not Detected IU/mL
  
• 2022-06-01 EB VCA IgM Negative Ratio
  
• 2022-06-01 EB VCA IgM Value 0.2
  
• 2022-06-01 HBsAg Nonreactive
  
• 2022-06-01 HBsAg (Value) 0.67 S/CO
  
• 2022-06-01 Anti-HCV Reactive
  
• 2022-06-01 Anti-HCV Value 2.98 S/CO
  
• 2022-06-01 Anti-HBc Nonreactive
  
• 2022-06-01 Anti-HBc-Value 0.18 S/CO
  
• 2022-05-30 EB VCA IgG Positive Ratio
  
• 2022-05-30 EB VCA IgG Value 7.2 Ratio
  
• 2022-05-30 EBNA-IgG Positive Ratio
  
• 2022-05-30 EBNA-IgG Value 2.5 Ratio
  
• 2022-05-30 HSV 1 IgM Negative Ratio
  
• 2022-05-30 HSV 1 IgM Value 0.18 Ratio
  
• 2022-05-30 HSV 2 IgM Negative Ratio
  
• 2022-05-30 HSV 2 IgM Value 0.04 Ratio
  
• 2022-05-27 MTBC PCR NOT DETECTED
  
• 2022-05-27 MTBC PCR Value <131 CFU/ml
  
• 2022-05-26 CMV IgM Nonreactive
  
• 2022-05-26 CMV IgM Value 0.21 Index
  
• 2022-05-26 CMV_IgG Reactive
  
• 2022-05-26 CMV_IgG Value 1701.6 AU/mL
  
• 2022-05-26 HIV Ab-EIA Nonreactive
  
• 2022-05-26 Anti-HIV Value 0.04 S/CO

[exam findings]

• 2023-02-15 Whole body PET scan
  • There was increased FDG uptake in soft tissue in the upper and middle abdomen (SUVmax early: 18.32, delay: 27.37), and in the right lobe of the liver (SUVmax early: 17.88, delay: 26.98). In addition, increased FDG accumulation was also noted in bilateral kidneys and colon.
  • IMPRESSION:
    • The old lesions of glucose-hypermetabolism in bilateral neck and supraclavicular lymph nodes, bilateral axillary lymph nodes, mediastinal lymph nodes, pelvic lymph nodes, bilateral inguinal lymph nodes, and in multiple focal areas in bilateral lung fields disappear or come to very faint compared with the previous study on 2022-06-02.
      
    • However, old lesions of glucose-hypermetabolism in the upper and middle abdomen (Deauville score 5) become more evident, and there are several new lesions of glucose-hypermetabolism in the right lobe of the liver (Deauville score 5) in this study.
      
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • Diffuse large B-cell lymphoma s/p treatment with dissociated response to current therapy, by this F-18 FDG PET scan.
• 2023-02-13 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot area in the sternum, and increased activity in the maxilla, mandible, some C-, T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
  • IMPRESSION:
    • A hot spot in the sternum and increased activity in the maxilla, the nature is to be determined (post-traumatic change, lymphoma or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the mandible, some C-, T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees.
• 2023-02-10 Patho - liver biopsy needle/wedge
  • liver, CT-guided biopsy — Diffuse large B-cell lymphoma
  • The sections show a picture of diffuse large B-cell lymphoma with following features:
    • Specimen: Liver
    • Procedure: CT-guided biopsy
    • Tumor site: Liver
    • Histologic type: Diffuse large B-cell lymphoma
    • IHC: CD3(-), CD20(+), CK(-), and CD56(-)
• 2023-02-01 CT - abdomen
  • History and indication: abdominal pain
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A poor enhancing lesion (4.0cm) in pancreatic body with SMA, splenic artery and splenic vein invasion. Some LNs at mesentery. A poor enhancing tumor (4.0cm) at right hepatic lobe.
    • Wall thickening of rectum.
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • A poor enhancing lesion (4.0cm) in pancreatic body with SMA, splenic artery and splenic vein invasion suspected malignancy. Liver and LNs metastases.
    • Wall thickening of rectum. Suggest coloscopy study.
• 2023-01-30 KUB
  • Spondylosis of the L-spine is noted.
• 2023-01-28 KUB
  • Calcified dot(s) is found at right paravertebral region, ureter stone(s) is most likely.
  • Stool impaction at the abdominal cavity is noted.
  • Phlebolith at pelvic cavity is also found.
• 2023-01-27 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (39 - 13) / 39 = 66.67%
    • M-mode (Teichholz) = 66.7
  • Dilated aortic root
  • Concentric LV hypertrophy
  • Adequate LV and RV systolic function
  • Possibly impaired LV relaxation
  • AV sclerosis with mild AR, mild MR, TR and PR
  • No regional wall motion abnormalities
• 2023-01-26 ECG
  • Normal sinus rhythm
  • Septal infarct, age undetermined
  • Abnormal ECG
• 2023-01-26 KUB
  • Compression fracture of L2.
  • Stool retention in the bowel.
  • Atherosclerosis of the aorta.
• 2023-01-18 KUB + AP & lat. LS-spine
  • Mild compression fracture of L1 vertebral body
  • Atherosclerosis of abdominal aorta and bilateral common and external iliac arteries.
• 2023-01-02 CT - chest
  • Indication: malignant lymphoma in both sides of diaphram with lung involvement suspected LUL cancer with lung to lung metastases and distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases
  • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Comparison was made with previous CT dated on 2022/09/04
    • Lungs: stationary of reticular opacities at Lt lung and a small noodule at RUL-S2 compared with CT on 2022/09/04.
      • mild paraspinal fibrosis of RLL, stable.
    • Mediastinum and hila: no enlarged LN or mass.
    • Vessels:
      • mild calcified plaques of the LAD coronary artery.
      • Aorta: normal caliber, moderate atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers. minimal calcified aortic valves.
    • Pleura:no effusion.
    • Chest wall and visible lower neck: no enlarged lymphadenopathy.
    • Visible abdominal contents:
      • stationary residual of lymphadenopathy in mesentery root compared with CT on 2022/09/14.
      • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • no bowel wall thickening in visible colonic segments and small bowel.
  • Impression:
    • post treatment change in lung and a a RUL 3mm nodule, and minimal residual small LNs at mesentery rootm as compared with CT on 2022/09/14
• 2022-10-03, -07-14 CXR
  • Few nodular opacity projecting in both lung show mild resolving?
  • Spondylosis of the T-spine
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
• 2022-09-14 CT - chest
  • near complete resolution of an irregular soft-tissue mass at LLL and multiple nodules in both lungs and significant regression of lymphadenopathy in both sides of diaphgram as compared with CT on 2022/05/30
• 2022-07-29 ECG
  • Normal sinus rhythm
  • Septal infarct, age undetermined
  • Abnormal ECG
• 2022-07-12 KUB
  • Radiopaque spot(s) at right renal region suspected renal stone(s).
  • Radiopaque density in left paraspinal portion suspected U/3 ureter stone.
  • Degeneration and spondylosis of L-S spine.
• 2022-07-11 CT - brain
  • Brain atrophy.
• 2022-06-30 ECG
  • Normal sinus rhythm
  • Anteroseptal infarct, age undetermined
  • T wave abnormality, consider lateral ischemia
• 2022-06-28 CXR
  • Few nodular opacity projecting in both lung show mild resolving?
  • Spondylosis of the T-spine
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
• 2022-06-02 Patho - lung wedge biopsy
  • Lung, side?, CT-guide biopsy —- diffuse large B cell lymphoma
  • Sections show alveolar lung tissue with infiltration of large pleomorphic tumor cells.
  • The immunohistochemical stains reveal CK(-), CD3(-), and CD20(+). The Ki-67 is about > 90%. The results are supportive for diffuse large B cell lymphoma.
• 2022-06-02 Whole body PET scan
  • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm as mentioned above.
  • Prominently increased FDG uptake in multiple focal areas in bilateral lung fields. Lymphoma should be considered first.
    
  • Mildly to moderately increased FDG uptake in two focal areas in the region about left lobe of the thyroid gland. The nature is to be determined (some kind of benign or malignant thyroid lesion? lymphoma?). Please correlate with other clinical findings for further evaluation.
• 2022-06-01 2D transthoracic echocardiography
  • Concentric LV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
  • Normal LV and RV systolic function.
  • Aortic valve sclerosis.
  • Dilated aortic root and proximal ascending aorta (35 mm).
  • Prominent epicardial and pericardial fat.
• 2022-05-30 CT - lung/mediastinum/pleura
  • malignant lymphoma in both sides of diaphram with lung involvement suspected LUL cancer with lung to lung metastases and
  • distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases, suggest tissue sampling.
• 2022-05-30 SONO - abdomen
  • mild to moderate fatty liver (suboptimal exam of liver)
  • fatty infiltration of pancreas
• 2022-05-27 Patho - lymph node region resection
  • Labeled as “Right level Ib lymph nodes”, excision biopsy — diffuse large B cell lymphoma. Non-germinal center type.
  • IHC stains: CD3 (focal +), CD20 (diffuse +), bcl-2 (diffuse +), bcl-6 (+, > 30%), MUM-1 (+, 90%), CD15 (+), CD30 (-), CD10 (-), c-myc: (+, <10%), Ki-67: 90%.
• 2022-05-25 CXR
  • Multiple nodular opacities over both lungs. Suggest check CT scan to rule out metastases.
  • Degenerative joint disease of T-spine with marginal osteophytes.
• 2022-05-16 Patho - lymphnode biopsy
  • Lymph nodes, L’t neck level V, excisional biopsy — Extensive coagulative necrosis with atypical B-cell proliferation
  • The large lymph node shows extensive, ring-like coagulative necrosis, 70-80% (unlikely geographic necrosis) with some nuclear debris, ghost cells, histiocytes and a few neutrophils as well as medium or large-size atypical lymphocytes in central, non-necrotic area. No granuloma is found. Immunohistochemistry of CK(-), CD3(+, scatter), CD20 (+) at subcapsular area and (-) at central area, CD68(+, scatter) and CD30(-). The three small lymph nodes show reactive change due to normal distribution of B and T-cell. The histopathologic finding and IHC stains is inconsistent with Kikuchi lymphadenitis, but infectious lymphadenitis or malignant lymphoma can not be excluded entirely due to suboptimal specimen with extensive necrosis. However, serology analysis (EBV or others) and repeat lymph node excision is advised for further evaluation. Closely follow up.
• 2019-09-16 Knee Bilat. standing
  • Osteoarthritis change of both knees with joint space narrowing and marginal spur formation, more severe on right side. Osteopenia of visible bones.
• 2019-01-26 CT - abdomen
  • Focal ileus of small and large bowel.
  • Wall thickening of gastric antrum. Distention of stomach.
• 2019-01-24 SONO color transcranial, carotid phonoangiograph, CPA
  • Minimal atherosclerosis in bilateral CCA bifurcations.
  • Adequate total VA flow volume (107 ml/min).
  • Poor bilateral temporal windows for transcranial insonation.
  • Increased RI in bilateral VA, indicating distal stenosis.
  • Increased PI in right VA, indicating distal stenosis.

[consultation]

• 2023-02-15 Psychosomatic Medicine
  • Q
    • The 77 y/o female patient with history of DM, HTN, hyperlipidemia. Under the diagnosis of Diffuse large B cell lymphoma, Non-germinal center type, multiple lymph nodes on both sides of the diaphragm as mentioned above and multiple focal areas in bilateral lung fields involvement, Lugano stage IV, IPI score:4, PS:2.
    • She received the C1 chemotherapy R-COP on 2022/06/08. C2 R-CHOP (Epirubicin 80mg/m2) on 2022/06/29-30. C3 R-CHOP (Epirubicin 80mg/m2) on 2022/07/29-30. C4 R-CHOP (Epirubicin 80mg/m2) on 2022/08/18-19. C5 R-CHOP (Epirubicin 80mg/m2) on 2022/9/11-12. C6 R-CHOP (Epirubicin 80mg/m2) on 2022/10/3-4.
    • The patient reported feeling very down lately, with physical discomfort and a lack of energy throughout the body. It has consulted with a psycho-oncologist who suggested a referral.
  • A
    • Psychiatric impression:
      • Acute depressive state
      • r/o adjustment recation with depressive features
      • r/o persistent depressive disorder, current major depressive episode
    • Symptoms and course:
      • This is a 77 y/o female patient admitted under the diagnosis of: Diffuse large B cell lymphoma, Non-germinal center type. We were consulted for her recent depressed mood.
      • According to the patient herself and the care-giver, since she was diagnosed of the disease about 1+ year ago, she had frequently visited the hospital with multiple treatment courses, that she developed depressed mood, preoccupied over her unfortunate, negative thinking, hopeless feelings. She claimed transient suicide ideation but not prominent without plan or attempt. When she was at home, she would try to relax herself and her mood would improve.
      • However, this admission, she suffered from greater pain, that she got more dysphoric with poor appetite, and also occaisonal sleep disturbance at night, sleepiness in the daytime.
    • Suggestion:
      • Suicide risk assessment: low to moderate: denied current ideation, without plan or attempt, care-giver(+), chronic disease
      • Provide psychoeducation for suicide prevention, and emotion catharsis, the patient and care-giver could understand
      • Brintellix (vortioxetine 10mg) 1# HS for the depressed mood
      • Arrange PSY OPD f/u
• 2022-07-14 Infectious Disease
  • Q
    • The 77 y/o woman has diffuse large B cell lymphoma stage IV, who was admitted for neutropenic fever. Due to B/C yield Staphylococcus haemolyticus, so we need your help for antibiotic assessment. (20220714 WBC 14000/uL under GCSF 300 mcg treatment) Thanks!
  • A
    • Assessment:
      • Neuropenic fever with S. haemolyticus bacteremia
      • UTI
    • Suggestion:
      • Recommend antibiotic Rx with Targocid or Vancomycin + Amikin 500mg iv Qd
      • Check B/C from Port-A, if positive, may arrange echocardiography to rule out Infective Endocarditis (IE)
      • Monitor CRP
• 2022-06-02 Radiation Oncology
  • Q
    • The 76 y/o female, she has right neck mass post biopsy and report showed diffuse large B cell lymphoma. Due to lung suspect a tumor, so we need your help for biopsy. Thanks!
  • A
    • This is a case of lung masses, suspected lung cancer or lymphoma. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
• 2022-06-01 Gastroenterology
  • Q
    • The 76 y/o female, she has right neck mass post biopsy and report showed diffuse large B cell lymphoma. Due to postive of HCV, so we need your help. Thank you.
  • A
    • O
      • ALT 82
      • bil(t) 0.23
      • HbsAg(-)
      • anti-HbcAb(-)
      • anti-hcv ab(+)
      • abdominal echo: mild to moderate fatty liver(suboptimal exam of liver), fatty infiltration of pancreas
      • CT: normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
    • P
      • Check HCV viral load
        • If HCV RNA is detected, check HCV genotyping, and then discuss about treatment of direct antiviral agent.
      • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
      • Well explained to the patient low incidnece of HCV reactivation during or after chemotherapy according to previous reports
      • GI OPD f/u for treatment
• 2022-06-01 Hemato-Oncology
  • Q
    • for diffuse large B cell lymphoma
    • This is a 76 y/o female patient with history of DM, HTN, hyperlipidemia. This time, she came to our hospital due to right neck mass noted for 3 months. Other painful LNs were also noted at R’t level V , L’t level V and Bil. axillary, R’t inguinal region. Neck CT was done and revealed a nodular lesion (28mm) and another small one over right submandibular region, favor enlarged nodes. Also, due to lab data when admission showed elevated WBC and CRP, infection doctor was consulted, and antibiotic with ceftriaxone and Amikacin were suggested. Blood culture was also done and grew K.p. Abd. sono was done, and there’s no liver abscess noted.
    • She received right level Ib lymph nodes excision on 20220526, and the pathology showed diffuse large B cell lymphoma. She also received lung CT due to bil. lung nodules noted by CXR. Chest CT revealed an irregular soft-tissue mass (40 mm) at LLL, multiple nodules of variable sizes throughout both lungs, extensive lymphadenopathy in para-aortic region and mesentery root. Malignant lymphoma in both sides of diaphram with lung involvement or LUL cancer with lung to lung metastases and distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases were impressed. Therefore, we need your expertise for further evaluation and management.
  • A
    • Impression:
      • Diffuse large B cell lymphoma, non-germinal center type, triple hit, IPI score:3 (age, stage, extranodal)
      • Suspected LLL cancer with lung to lung metastases
    • Suggestion:
      • Arrange LLL lung CT guide biopsy for suspected lung cancer with lung to lung meta
      • Arrange PET scan for lymphoma work up, bone marrow is indicated
      • Check CEA, SCC, HbsAg, Anti Hbc, Anti HCV
      • Arrange Port A insertion
      • Arrange 2D heart echo
• 2022-05-26 Infectious Disease
  • Q
    • According to the blood culture on 20220525 revealed GNB. General infection can not be rule out. We request your consultation for further management.
  • A
    • A patient of DM, HTN, hyperlipidemia. High fever developed and GNB sepsis was noted. In series of patients with immune-deficient fever, infection has been identified as the cause of the fever in 60% or more of cases. In at least some cases, however, the diagnosis has been presumptive, based on a favorable clinical response to antimircobial therapy, rather than on the result of definitive tests. Infection caused by pyogenic bacteria are the most common cause of fever. The generally respond well to antibiotic therapy, whether or not the etiologic microorganism is isolated. Anti-microbiologic coverage with parenteral Rocephin 2.0 gm qd or Fortum 1.0 gm q8h +- plus AMK 500 mg qd is recommended. The antimicrobial regimen can be modified once the results of the culture and susceptibility tests are available.

[chemoimmunotherapy]

• 2022-08-18 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP)
• 2022-07-29 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP, vincristine not available then)
• 2022-06-29 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP)
• 2022-06-08 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-COP)

701182757

230220

[exam findings]

• 2023-02-17 SONO - chest
  • left lower lung consolidation
  • left side pleural thickening with trivial amount of pleural effusion, no thoracentesis wad done due to high risk
• 2023-02-09, -02-02 KUB
  • Scoliosis of L-spine with convex to left side.
  • Fecal material store in the colon.
  • Calcified uterine fibroid in rihgt middle pelvis.
  • Ascites is highly suspected. Please correlate with sonography.
• 2023-02-02 CXR
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Scoliosis of the T-spine with convex to right side.
    
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • Linear and nodular opacities on right lung are noted. please correlate with clinical condition or CT.
• 2023-01-04 CXR
  • Cardiomegaly is noted.
  • Tortous aorta with calcification is noted.
  • S/p port-A placement with its tip at Superior vena cava.
  • Right pleural effusion is found.
• 2022-12-26 Lower leg RT
  • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography.
• 2022-12-26 L-spine AP+Lat. (including sacrum)
  • S/P nasogastric tube insertion
  • scoliosis of L-spine with convex to left side
  • Ueterine fibroid is noted.
• 2022-12-26, -12-22, -12-15, -12-12, -12-08, -12-06, -12-05, -12-03 CXR
  • S/P nasogastric tube insertion
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • Linear infiltration on both lung are noted. please correlate with clinical symptom to rule out inflammatory process.
• 2022-11-29 CT - abdomen
  • Clinical history: 75 y/o female patient with follicular lymphoma.
  • With and without contrast enhancement CT of abdomen - whole:
    • Diffuse multiple enlarged lymph nodes in the mediastinum, bilateral neck, right axillar regions, paraaortic regions and mesentery, progression
    • Paraspinal and prevertebral soft tissue with necrosis (T9-12 levels), could be due to lymphoma post treatment.
    • Focal soft tissue in right abdominal wall.
    • There are uterine tumors, some with dense calcifications, suspected uterine myomas.
    • Unremarkable change of the liver, spleen, pancreas and both kidneys.
    • Diffuse right pleural thickening.
  • Impression:
    • Diffuse right pleural thickening.
    • Diffuse lymphoma (from neck to chest and adomen) with progression.
    • Uterine tumors some with calcifications, suspected myomas.
• 2022-11-29 SONO - chest
  • Right thorax: partial lung consolidation was noted; no pleural effusion
  • Left thorax: no pleural effusion.
• 2022-11-28 CXR
  • S/P nasogastric tube insertion
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Borderline cardiomegaly
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • Linear infiltration over right lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, Please correlate with CT.
• 2022-11-08 SONO - chest
  • Right thorax: minimal amount pleural effusion; thoracocentesis was not performed.
• 2022-11-07 CXR
  • S/P nasogastric tube insertion or S/P ventricular-peritoneal shunt insertion ?
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • There is scoliosis of the T-spine with convex to right side.
  • Right pleura effusion.
• 2022-11-04 Peripheral Vascular Test - vein, lower limbs
  • Clinical diagnosis: edema
  • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
    • Lower limbs R_CFV R_SFV R_PV R_PTV R_SV L_CFV L_SFV L_PV L_PTV L_SV
    • Spontaneous signal N N N N N T T A T T
    • Respiratory changes N N N N N T T A T T
    • Cough response N N N N N T T A T T
    • Compression study N N N N N T T N N N
  • Report:
    • Right side:
      • SVC: 13.7 mmHg ; 15.1 mmHg ;
      • MVO/SVC: 100 % ; 99 % ;
      • Average MVO/SVC: 99 %
    • Left side:
      • SVC: 2.4 mmHg ; 4.5 mmHg ;
      • MVO/SVC: 100 % ; 98 % ;
      • Average MVO/SVC: 99 %
    • Thrombus at L’t CFV, SFV, PV, LSV
    • Varicose vein : None
  • Conclusion:
    • C/W acute to subacute DVT involved the left CFV, PFV, proximal SFV and proximal LSV with partial recanalization. The left middle to distal SFV, left popliteal vein and left PTV were patent with loss of respiratory change and cough response due to upstream outflow venous obstruction.
    • There was no evidence of DVT detected at right leg deep venous system.
    • The right saphenofemoral venous junction (LSV) and bilateral saphenopopliteal venous junction (SSV) were competent without venous reflux.
    • The measured MVO/SVC ratio at right leg was 99%, indicated no venous stenosis or obctruction at right iliofemoral venous system.
    • Although the measured MVO/SVC ratio at left leg was 99%, the SVC at left leg was very low, compatible with outflow venous obstruction.
• 2022-11-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 9) / 53 = 83.02%
    • M-mode (Teichholz) = 83
  • Septal and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
  • Normal LV and RV systolic function.
  • Mild aortic valve sclerosis.
  • Mild aortic root calcification with sessile atheromas.
  • Prominent epicardial fat.
• 2022-11-02 CTA - chest
  • Indication: suspected Pulmonary embolism
  • Findings
    • Chest:
      • Pulmonary embolism at both sides of the main pulmonary artery and its branches more on right side is found.
      • Right pleural effusion is found.
      • Calcified coronary arteries is found.
      • Right pleural thickening is found and consolidation over right lower lobe is found.
      • Lymphadenopathy at right paratracheal region is found.
      • S/p port-A placement with its tip at Superior vena cava.
    • Visible abdomen:
      • The GB is well distended without soft tissue lesion
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
  • Imp: Pulmonary embolism at both sides of the pulmonary artery.
• 2022-11-02 SONO - chest
  • pleural effusion, minimal, right
  • consolidation, RLL
• 2022-10-31 ECG
  • Normal sinus rhythm
  • Possible Left atrial enlargement
  • Abnormal QRS-T angle, consider primary T wave abnormality
• 2022-10-31 CXR
  • Consolidation in right lung
  • Right pleural fluid
• 2022-10-17 MRI - brain
  • Indication: consciousness disturbance suspected brain mets
  • Findings
    • Generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • The interhemispheric fissure is centered on the midline.
    • Sella and pituitary are normal. The parasellar structures are unremarkable.
    • There are no abnormalities in the cerebellopontine angle areas on both sides.
    • There are no abnormalities in the calvarium.
    • A left temporal base tumor mass up to 15 mm, DDx: meningioma or lymphoma?
      
    • Well and heterogenous enhancement after contrast administration was noted of this tumor mass.
      
  • Imp:
    • Brain atrophy.
    • A left temporal base tumor mass, DDx: meningioma or lymphoma?
• 2022-10-14 CT - abdomen
  • History and indication:
    • 20190604 PET: Lymphoma in right paraspinal retroperitoneal space
    • 20190613 CT; Soft tissue tumors (up to 4.6x10.6cm) at spleen, right paraspinal region and retroperitoneum. follicular lymphoma s/p C/T ＆ R/T.
  • FINDINGS - Comparison: prior chest CT dated 2022/09/27.
    • Prior CT identified diffuse and marked thickening of Rt parietal and visceral pleura (involving hemidiaphgram) is noted again, mild increasing in size.
      • In addition, prior CT identified enlarged LNs in the paratracheal space and subcarinal space are noted again, increasing in size that is c/w progressive disease.
    • Prior CT identified left middle paraspinal soft-tissue mass around the descending thoracic aorta and thickening of Rt pericardium is noted again, stationary.
    • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, stationary.
    • Uterine tumors with some calcifications (up to 3.8cm) suspected myomas and fibroids.
    • Small renal cysts (up to 5mm).
    • Atherosclerosis of the aorta and coronary arteries.
    • Others
      • There is no focal abnormality in the gallbladder, biliary system, and pancreas.
      • There is no ascites.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion in the mesentery and omentum.
  • IMP:
    • Prior CT identified diffuse and marked thickening of Rt parietal and visceral pleura (involving hemidiaphgram) is noted again, mild increasing in size.
      • In addition, prior CT identified enlarged LNs in the paratracheal space and subcarinal space are noted again, increasing in size that is c/w progressive disease.
    • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, stationary.
• 2022-10-03 Patho - pleural/pericardial biopsy
  • Pleura, right, decortication — high grade B-cell lymphoma (please see microdescription)
  • Specimen submitted in formalin consists of multiple tissue fragments measuring up to 7.5 x 3.2 x 0.2 cm. Representative sections are taken and labeled as A1-3.
  • Sections show fibroadipose tissue with diffuse infiltration of intermediate to large size lymphoid cells.
  • The immunohistochemical stains reveal CD3(-), CD20(+), BCL2(+), BCL6(+), CD10(+), cMYC(+), and MUM1(-). The Ki-67 is about 70%. The results are in favor of Grade 3B follicular lymphoma or GCB type diffuse large B-cell lymphoma.
• 2022-09-28 Cell block
  • Right pleural effusion: Suggestive of lymphoma involvement
    
  • 7 cc red cloudy pleural effusion
    
  • The smears and cell block show small to intermediate size of lymphocytes with cleaved nucleus and nucleoli. According to clinical information and cytomorphologic findings, it is suggestive of follicular lymphoma involvement.
• 2022-09-27 CT - chest
  • Indication: Recurrent follicular lymphoma with right lung pleural effusion
  • Findings - Comparison was made with previous CT dated on 2022/09/20
    • diffuse and marked thickening of Rt parietal and visceral pleura (nvolving hemidiaphgram) with residual loculated effusion s/p pigtail drain placement (its pigtail segment is within lung parenchyma).
    • lungs compressive Rt lung volume loss (especially RML and RLL).
      • a subpleural lobular consolidation at S6 and minimal ground-glass opacities at basal segments of LLL.
    • Mediastinum and hila: enlarged LNs the visceral space especially subcarinal space and left middle paraspinal soft-tissue mass around the descending thoracic aorta.
      • small pericardial effusion and thickening of Rt pericardium.
    • Vessels:
      • extensive calcified plaques of the LAD and LCX coronary arteries.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Heart: normal in size of cardiac chambers.
    • Visible abdominal-pelvic contents: .
      • several small bilateral renal cysts.
      • unremarkable of the liver, spleen, both adrenal glands, pancreas, and no enlarged lymph node. .
      • Extensive atherosclerotic change of the abdominal aorta.
  • Impression:
    • recurrent follicular lymphoma with pleural, lung, hemidiaphgram, and descending aortic involvment, and mediastinal LAP.
    • regression of Rt pleural effusion with loculations, and malposition of pigtail drain.
• 2022-09-26 Cell block
  • Suggestive of lymphoma involvement
    
  • 12 cc red cloudy right pleural effusion
    
  • The smears and cell block show mainly B lymphocytes with small to intermediate size of atypical lymphocytes with cleaved nucleus and nucleoli.
  • Immunocytochemistry shows CD20(+), CD3(-), Bcl-2(+), Bcl-6(+, focal) and CD10(+, focal) for lymphocytes. According to clinical information and cytomorphologic findings, it is suggestive of follicular lymphoma involvement.
• 2022-09-20 CT - abdomen
  • Clinical history: 75y/o female patient with Recurrent follicular lymphoma at para-spinal region, Lugano stage II. Owing to poor appetite suspected peritonal seeding related.
  • Findings
    • Diffuse lobulated tumors in the pleura and pleural effusion with collapsed right lung, progression as compare with CT study on 2022-07-22.
    • R/O bilateral renal cysts, <1cm.
    • Unremarkable change of the liver, spleen, pancreas.
    • No enlarged lymph node in the paraaortic region.
    • No ascites.
    • There are uterine tumors, some with dense calcifications, up to 4cm, suspected uterine myomas.
  • Impression:
    • Progression of right plueral tumors and pleural effusion, right lung collapse, could be due to recurrent lymphoma with progression.
    • Uterine tumors, suspected uterine myomas.
• 2022-09-16 MRI - T-spine
  • Indication: recurrent follicular lymphoma with low back pain
  • Findings
    • Abnormal enhancement in T10 and T11 vertebral body (esp T10), para-aoritc soft tissue lesions, right paraspinal soft tissue lesion at T9-12 levels, left paraspinal soft tissue lesionat T6-7 levels, and intraspinal lesion causing spinal cord compression at T7-10 levels (most severe at T10), indicating metastases.
    • Right massive pleural effusion.
    • End-plate degeneraiton, disc collapse with general bulging, posterolaterla osteophytes and enlarged facets causing diffuse spinal canal stenosis and neuroforaminal narrowing at at C2-3-4-5-6-7-T1.
    • No intramedullary lesion.
  • IMP: Bony metastases at T10 and T11 vertebral body and bilateral paraspinal metastases (left T6-7 and left T9-12) with intraspinal invasion and cord compression (T7-10).
• 2022-09-16 CXR
  • Atherosclerotic change of aortic arch
  • There is scoliosis of the T-spine with convex to right side.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
• 2022-09-13 Abdomen, standing (diaphragm)
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Scoliosis of L-spine with convex to left side
  • Fecal material store in the colon.
• 2022-08-16 Whole body PET scan
  • Glucose hypermetabolism involving the upper abdominal right paraaortic area, pleura of right lower lung field, right paraspinal area and adjacent T10 spine. Recurrent lymphoma may show this picture.
  • A glucose hypermetabolic lesion in the wall of the descending aorta. The nature is to be determined (lymphoma? inflammatory process?). Please correlate with other clinical findings for further evaluation.
• 2022-08-02 Patho - omentum biopsy
  • Pathologic diagnosis
    • Para-spinal tumor, CT-guided biopsy — Follicular lymphoma, compatible with recurrence
  • Macroscopic description
    • Operation procedure: CT-guided biopsy
    • Topology: Para-spinal tumor
      
    • Specimen size and number: one strip of tumor tissue measured 0.5 x 0.1 x 0.1 cm in size
  • Microscopic description
    • Histology type: follicular lymphoma
    • Histology description: B-cell lymphoma characterized by proliferative small lymphoid cells.
    • Immunohistochemistry shows CK(-), CD3(-), CD20(+), Bcl-2(+), CD10(+), Bcl-6(+), CD23(+) and Cyclin-D1(-) for tumor. According to all histopathologic findings and past history, it is compatible with recurrent follicular lymphoma.
• 2022-07-22 CT - abdomen
  • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, mild increasing in size.
• 2022-01-24 CT - abdomen
  • History and indication: Follicular lymphoma grade I, lymph nodes of head, face, and neck
  • Impression:
    • Stationary condition of spleen lesions.
    • Total regression of retroperitoneal tumors.
    • Mild progression of right paraspinal lesions.
• 2021-08-09 CT - abdomen
  • Stationary condition of spleen lesions.
  • Total regression of right paraspinal and retroperitoneal tumors.
• 2021-02-19 CT - abdomen
  • Follicular lymphoma of right paraspinal area and retroperitoneal space s/p C/T ＆ R/T show complete response.
  • Follicular lymphoma of the spleen s/p C/T ＆ R/T show near complete response.
• 2020-09-07 CT - abdomen
  • Much regression of spleen lesions.
  • Total regression of right paraspinal and retroperitoneal tumors.
• 2020-03-03 CT - abdomen
  • Much regression of spleen, right paraspinal and retroperitoneal tumors.
• 2019-12-31 CT - abdomen
  • Much regression of spleen, right paraspinal and retroperitoneal tumors.
• 2019-12-12 MRI - C-spine
  • Indication:
    • 72 y/o, a pt of follicular lymphoma stage II Dx in May 2019 at TaiAn Hospital, s/p definitive C/T wt R-COP or R-CHOP IV Q3W x 6 finishing in Oct 2019 and R/T (15 frac) to paraspinal tumor bed from 20191113 to 20191203 by Dr JingMin Huang.
    • 20191203: right distal hand numbness for yrs with recent deterioration; neckpain also noted; clumsiness over rigth UE with weakness / eaasily lost holding things; no night pain
  • IMP:
    • Cervical spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp C7-T1 with right HIVD and compressive myelopathy.
• 2019-09-04 Whole body PET scan
  • Glucose hypermetabolic lesions in the abdomen as mentioned above with extension to the right lower back region come to significantly less prominent compared with the previous study on 2019/06/04, indicating partial response to current therapy.
    
  • Mild and symmetric glucose hypermetabolism in bilateral pulmonary hilar regions, probably inflammatory process or physiological uptake of FDG.
• 2019-06-13 CT - abdomen
  • Soft tissue tumors (up to 4.6x10.6cm) at spleen, right paraspinal region and retroperitoneum.
• 2019-06-04 Whole body PET scan
  • Glucose hypermetabolic lesions in the abdomen as mentioned above with extension to the right lower back region, compatible with malignancy such as lymphoma. Please correlate with other clinical findings for further evaluation.
  • Mild and symmetric glucose hypermetabolism in bilateral pulmonary regions. Inflammatory process is more likely.

[consultation]

• 2022-11-17 Rehabilitation
  • A
    • Assessment
      • Follicular lymphoma, stage II s/p chemotherapy
      • Pleural effusion in other conditions classified elsewhere
      • Shortness of breath
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation programs
      • Goal: recondition, improve endurance and muscle strength
• 2022-11-04 Cardiology
  • Q
    • Consultation for management of pulmonary embolism.
    • This is a 75 year-old female patient with history of follicular lymphoma at para-spinal region, Lugano stage II, s/p definitive C/T wt R-COP or R-CHOP regimen finishing in Oct 2019 & R/T (15 fr) to paraspinal tumor bed completed in Dec 2019. This time, she was admitted due to dyspnea for 3 days. She appeared in general weakness and fatigue.
      • CXR done in ER : right-sided pleural effusion; however, chest echo showed only minimal fluid; therefore, tapping was not done.
      • PE : bilateral coarse breathing sound, swollen and cold left lower limb. SpO2 was able to be maintined by nasal cannula 3L for now.
      • Lab data : leukocytosis with neutrophilic predominance
      • WBC: 19.4 K
      • Neutrophil: 90%
      • D-dimer: >10000
      • NT-proBNP: 1896
      • Chest CTA was done on 20221102, which showed pulmonary embolim.
    • We have started 3 days of SC enoxaparin from 11/3, and have arranged lower limb Doppler sonography and cardiac echo. We need your expertise for this patient’s pulmonary embolism management.
  • A
    • This is a 75 year-old female patient with history of follicular lymphoma at para-spinal region, Lugano stage II,
    • This patient suffered from lobulated pleural effusion, s/p VATS decortication + close drainage. at 2022/09. According to this patient, she suffered rom dyspnea and also ntoed to have left lower limb swelling for 1~2 months. Currently, her left lower limb showed no obvious erythema or swelling or edema, however, the diameter was obvious larger than right side. She had history of cancer and also in semi-bedridden status.
      • Chest CT: right side pulmonary embolis, possible some small pulmonary embolism at left upper lobe branch, no RA dilatation
    • Impression:
      • compatible with pulmoanry embolism, beween submasive(trop-I) to low risk, suspected left chronic DVT related
    • Suggestion:
      • agree with Clexane Q12H use, ( BW 47kg, Creatine 1.10)
        • May transition to NOAC after 1 week of clexane injection
        • e.g. Apixaban 5mg 1# BID or Edoxaban 60mg 1# QD or Rivaroxaban 15mg 1# BID (EINSTEIN–PE study, higher dose and may go with higher bleeding risk in this patient)
      • Due to left lower limb swelling was noted, but clinical condition not favor acute DVT, may consider chronic DVT or may-thurner syndrome or retroperitoneal fibrosis
        • => please arrange lower limb echo (for DVT survey) and echocardiography (for pulmonary embolism PEPSI score)
      • This patinet had higher risk for recurrence (bed-ridden / cancer) and may consider long term NOAC use
        • If other cause was worry, may consider search for autoimmune and coagulation profile ( but might not change clinical decision)
        • => protein C/ protein S, anti-phospholipid antibody syndrome profile, C3,C4, lupus anticoagulant
• 2022-10-18 Radiation Oncology
  • A
    • S: For radiotherapy due to high grade follicular lymphoma with brain metastasis.
      • PI: The patient suffered from change of personality during admission. Brain MRI (2022-10-17) showed a left temporal base tumor mass, suspicious meningioma or lymphoma? For radiotherapy.
    • A: Follicular lymphoma of the spleen, right paraspinal region and retroperitoneum, stage II, s/p chemotherapy, with partial response, s/p radiotherapy, with tumor progression including brain metastasis.
    • P: Radiotherapy is indicated for this patient with the following indicators: brain metastasis.
      • Goal: palliation
      • Treatment target and volume: brain
      • Technique: 2D and VMAT/IGRT
      • Preliminary planning dose: 1400cGy/7 fractions of the whole brain, and 3000cGy/15 fractions of the metastatic brain tumor.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy was already started at 1330, 2022-10-18.
• 2022-10-06 Infectious Disease
  • Q
    • The 75 y/o woman has recurrent follicular lymphoma with right pleural effusion malignant. Due to rectal swab showed VRB, so we need your management.
  • A
    • Hx review as mentioned above and Lab data check
    • Suggestion:
      • May stop Targocid, shift to zyvox for this immunocompromised pt with increasing CRP
      • repeat B/C, monitor CRP
• 2022-10-05 Psychosomatic medicine
  • Q
    • The 75 y/o woman has recurrent follicular lymphoma with right pleural effusion malignant. Due to several delirum with aggressive behavior, so we need your management. Thanks!
  • A
    • Psychiatric impression:
      • Acute agitated state
        • suspected adjustment reaction
        • suspected acute delirium
        • suspected dementia with BPSD
      • Depressive disorder
    • Symptoms and course:
      • This is a 75 y/o female patient with underlying lymphoma with right pleural effusion admitted for palliative C/T s/p 20220930 VATS decortication, and was just tranferred out from ICU at 20221005 afternoon. According to the patient, her family and side information collected:
      • Upon visit, she showed clear consciousness, alert, but very guarded and defensive attitude, irritable mood, angry, hostile attitude towards the medical team and her family. Speech were rather coherant and relevant, no obvious psychosis were noted currently.
      • Orientation:
    • Suggestion:
      • Anxicam 0.5amp IM/ Bini-U 0.5amp IM PRNQ6H if severe agitation
      • Add Utapine 1# HS, and give utapine 1# PRNHS if still irritable and sleep disturbance. Keep the xanax 1# BID for anxious mood.
      • Close monitor the vital signs, respiratory patterns after the PRN injection and medication, regularly follow up EKG
      • Further survey and treat her possible physical condition: infection, pain, urine retention…
      • Acute intervention, suicide risk assessment: moderate: denied past suicide idea or attempt; fair family support and accompany, but now in great distress and anger, impulsive
      • Suicide prevention is adviced.
• 2022-09-29 Thoracic Surgery
  • Q
    • The 75 y/o woman has recurrent follicular lymphoma, least stage III. Due to right pleural effusion with loculations, so we need help for chest tube insertion assessment. Thanks!
  • A
    • I have visited the patient and reviwed the images. I will arrange right VATS decortication this week. Thanks for your consultation!!
• 2022-09-17 Neurosurgery
  • Q
    • The 75 y/o woman has recurrent follicular lymphoma with bony metastases at T10 and T11 vertebral body and bilateral paraspinal metastases (left T6-7 and left T9-12) with intraspinal invasion and cord compression (T7-10). We need your help for surgycal intervention. Thanks!
  • A
    • suggest medication treatment for the recurrent follicular lymphoma with bony metastasis first.

[chemotherapy]

• 2022-11-30 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + bendamustine 70mg/m2 100mg NS 250mL 90min D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + acetaminophen 500mg PO

[tube feeding]

• Keppra: In this hospital, there is a liquid form of Keppra oral solution (levetiracetam 100mg/mL, 300mL per bottle) that is suitable for tube feeding.

• OxyNorm: Pour the small granules out of the OxyNorm (oxycodone 5mg/cap) capsules, dissolve them in drinking water, and administer them through a tube feeding.

• OxyContin: OxyContin (oxycodone 10mg controlled-release tablet) is a long-acting formulation. Grinding the tablet will destroy the controlled-release design and cannot maintain long-lasting effects. Its use is not recommended for tube feeding.

221006

{drug interaction}

• Morphine (8mg IVD PRNQ6H currently) is contraindicated when used concurrently with monoamine oxidase inhibitors (MAOIs, linezolid 600mg IVD Q12H currently).

• There is a possibility that monoamine oxidase inhibitors may enhance the adverse/toxic effects of morphine. Please monitor any possible adverse reactions carefully.

700936681

230216

[assessment]

• Cisplatin is assciated with the potential hematologic and oncologic side effects as the following (ref: UpToDate)
  • Anemia may occur in up to 40% of patients receiving the treatment.
  • Leukopenia may occur in 25% to 30% of patients, with the lowest levels (nadir) typically occurring between days 18 and 23 of treatment. White blood cell counts typically recover by day 39. The incidence and severity of leukopenia may be related to the dose of the treatment.
  • Thrombocytopenia may also occur in 25% to 30% of patients, with the lowest levels (nadir) typically occurring between days 18 and 23 of treatment. Platelet counts typically recover by day 39. The incidence and severity of thrombocytopenia may be related to the dose of the treatment.
• Reducing the dosage of cisplatin (which is dose-dependent) can alleviate thrombocytopenia. Although the patient’s decrease in neutrophils and hemoglobin is not as significant as the decrease in platelets, platelet transfusions may trigger immune responses, infections, and other complications. Therefore, a balance between the expected therapeutic effect and adverse reactions should be sought while considering treatment options. One possible approach is to first reduce the cisplatin dosage to a level where the patient’s platelet count can still recover, and then proceed with further consideration.

230126

{Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and Rt retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30}

[past history]

• Hepatitis B carrier
• Acoustic neuroma
• NPC
• Liver metastasis s/p SBRT on 20180209
• R/I recurrence of NPC by surgical excision at TuCheng ChangGung Hospital on 2022-01-21 by vice president Dr. Wei FuQuan.
  • Pathology: Brain, CP angle, Rt, carcinoma, metastatic.
  • Positive: AE1/AE3, EMA, p40; negative EBV, Hep-par-1, PR, S100; Ki67 100%.
  • Plan: Refer to LK-CGMH for evaluation of proton therapy.

[exam findings]

• 2023-01-06 MRA - brain
  • History: This 53 years old male patient had past history of hepatitis B carrier; suffered from right abducens palsy with right tinnitus and head heaviness for months and progressively deterioration.
  • With- and without-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial FLAIR images and axial DWI; using 4 mm thickness for sagittal section and 5 mm thickness for the others) revealed
    • an multi-lobulted extraaxial tumor, about 29.7mm, in the right IAC and right CPA with invasion to the right pons. Severe perifocal edemea was noted. Due to rapid progression, malignent change was considered.
    • post-OP change in the right occipital lobe and right cerebellar hemisphere.
  • IMP: an extra-axial tumor with intra-axial invasion in the right IAC and right CPA
• 2023-01-06 CXR
  • Tortous aorta with calcification is noted.
  • Emphysematous change over both lungs.
• 2022-10-04 MRI - brain
  • Clinical information: Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and Rt retropharyngeal LAP metastasis s/p CCRT
  • Findings:
    • Still presence of the enhancing lesions at right CP angle and IAC, associating with perifocal edema in right cerebellum, as compared with MRI on 2022/07/07.
    • Mildly dilated ventricles.
    • Moderate periventricular small vessel disease. NO acute ischemic infarct.
• 2022-07-07 MRI - brain
  • Indication: Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and Rt retropharyngeal LAP metastasis s/p CCRT PF
  • Without- and with-contrast multiplanar MRI studies of the brain (including axal and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
    • Regressive change of the enhancing lesion at right CP angle and IAC, associating with perifocal edema in right cerebellum, as compared with MRI on 20220315.
    • General enlargement of ventricles and cisterns, indicating general brain atrophy.
    • Multiple small well-defined FLAIR-hyperintensities at deep cerebral white matters, indicating leukoaraiosis.
    • Post-operation change at right sub-occipital neck.
    • No abnormal intensity at nasopharynx.
  • IMP: Right CPA/IAC tumor s/p treatment, with residual lesion. Suggest close follow-up.
• 2022-03-18 ENT Hearing Test
  • PTA
  • Reliability FAIR
  • Average RE >120 dB HL; LE 55 dB HL.
  • RE profound SNHL
  • LE mild to profound SNHL
• 2022-03-17 MRI - nasopharnyx
  • Right IAC and CPA tumor, stationary as compared with MRI on 20223015. Metastatic LAP with ENE at right neck.
• 2022-03-15 MRI - brain
  • Right CP (cerebellopontine) angle and IAC (internal auditory canal) mass, regressed size and perifocal edema, when compared with 20220108 MRI.
  • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
• 2022-01-08 MRI - posterior fossa, brain stem
  • A multi-lobuled lesion in the right IAC and right CPA with severe mass effect on the right brain stem, marked increase in size.
• 2022-01-03 Tc-99m MDP whole body bone scan
  • A hot spot in the left aspect of the maxilla, the nature is to be determined (dental problem or other nature?), suggesting follow-up with bone scan in 3-6 months for investigation.
  • Suspected benign lesions in the mandible, some C-, T- and L-spine, right sternoclavicular junction, bilateral shoulders, S-I joints, and hips.
• 2021-10-06 SONO - abdomen
  • There are several hepatic cysts in right lobe and the largest one measuring 1 cm in size at segment 8.
    
  • A renal cyst 1.35 cm on right kidney middle pole is noted.
• 2021-06-30 MRI - posterior fossa, brain stem
  • Right CP angle and IAC mass, slightly regressed size DDx: Neuroma, meningioma or metastasis.
  • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
• 2020-12-30 MRI - brain
  • Tumor at right CPA and IAC. Mild enlargement as compared with MRI on 20201126. Suspected metastasis. Meningioma or Schwannoma is less likely.
• 2020-11-26 SONO - abdomen
  • Right liver cysts and calcification. Left renal cyst and bil. renal stones.
• 2020-11-26 MRI - nasopharynx
  • C/W NPC s/p treatment without local recurrence, but with a metastatic lesion involving right IAC and CPA
• 2020-04-15 SONO - abdomen
  • There are several hepatic cysts in right lobe and the largest one measuring 1.08 cm in size at segment 8.
  • A renal cyst 1.27 cm on right kidney middle pole is noted.
• 2020-04-15 MRI - nasopharynx
  • C/W NPC s/p treatment without evidence of recurrence. An enhancing lesion in right IAC and cochlea. Suspected post-RT neuropathy. Metastasis is unlikely. Stationary as compared with previous MRIs.
• 2019-09-26 MRI - liver, spleen
  • Post RT change of right lobe liver.
  • Hepatic simple cysts.
• 2019-05-20 MRI - nasopharynx
  • C/W NPC s/p treatment with complete remission and no evidence of recurrence. Stationary as compared with MRI on 20190108.
• 2019-05-20 SONO - abdomen
  • Liver cysts.
  • Right renal stone.
  • Right renal cyst.
• 2019-01-08 MRI - nasopharynx
  • Right NPC, post CCRT. No evidence local recurrent tumor. No neck LAP.
• 2019-01-08 SONO - hepatobiliary
  • There are several hepatic cysts in right lobe and the largest one is measured about 0.91 cm in size at segment 8.
    
  • A renal cyst 1.33 cm on right kidney middle pole is noted.
• 2018-09-05 Whole body PET scan
  • In comparison with the previous study on 20180118, the glucose hypermetabolic tumor in the liver dome had disappeared in this study, suggesting response to current treatment.
  • Glucose hypermetabolism in the right alveolar process of the maxilla had been stationary since the previous study, suggesting benign conditions such as dental inflammatory lesion.
  • Moderate glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change in response to locoregional inflammation may show such a picture. Please correlate with clinical findings and keep follow-up, however, to exclude the possibility of more significant clinical problems.
• 2018-08-21 MRI - upper abdomen
  • Liver metastasis in segment 4/8 dome Status post R/T with inflammatory fibrosis is highly suspected.
• 2018-05-21 CT - abdomen
  • Much regression of liver dome lesion.
• 2018-01-24 CT - abdomen
  • A poor enhancing nodule (1.7cm) at liver dome c/w metastases.
• 2012-07-12 Pathology
  • Nasopharynx, right: Non-keratinizing carcinoma, undifferentiated (WHO-2B).

[consultation]

• 2023-01-31 Rehabilitation
  • Q
    • Brain MRI on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA. Now, he was admitted for concurrent chemoradiotherapy. This time, for evaluate “limb and bedside rehabilitation exercises”
  • A
    • Physical examination
      • 2023/01/31 13:10 T/P/R: 35.8℃ / 84bpm / 20bpm BP:145/89mmHg
      • Body weight: 56.2
        
      • Consciousness: clear
      • Cognition: intact, oriented, could follow orders
      • Speech: no aphasia, no obvious dysarthria
      • Swallowing: oral diet
      • Sphincter: urinary and stool continence
      • MP: RUE/RLE: 3/2-3, LUE/LLE: 3/2-3
      • Functional status: could sit up under modA with fair-poor sitting balance
      • BADL: needs mod assistance
      • MRS: 4 (need follow-up)
    • Assessment
      • Malignant neoplasm of nasopharynx
      • Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and right retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of extra-axial tumor with intra-axial invasion
      • Fever
      • Chronic viral hepatitis B without delta-agent
      • Gout
    • Plan
      • Rehabilitation programs: Bedside first PT, OT rehabilitation programs
      • Goal: Ambulation with/without device ID, BADL ID
• 2023-01-19 Family Medicine
  • Q
    • Brain MRA on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA. Now, under brain tumor radiotherapy, for combined care need your evaluate. Thank you.
  • A
    • 63 y/o gentaleman advanced NPC for brain palliative RT .
    • Our share care would follow up.
• 2023-01-09 Radiation Oncology
  • Q
    • This 63-year-old man patient is a case of Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and right retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of extra-axial tumor with intra-axial invasion.
    • This time, General weakness and difficulty in urinating for one week and vomiting after excercis for three days. Brain MRA on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA. Now, for evaluate brain tumor radiotherapy. Thank you.
  • A
    • S
      • This 63-year-old man patient is a case of nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and right retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy (72 Gy/36 fx) on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p SRS (14 Gy) on 2020/12/31 s/p surgical resection on 2022/1/21, s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of extra-axial tumor with intra-axial invasion. This time, progressive general weakness and difficulty in urinating for one week and vomiting after exercise has been noted for three days. Brain MRA on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA.
        
      • Previous RT: as above; s/p SBRT to single liver metastasis on 2018/2/09.
    • O
      • General Condition-ECOG: 2.
      • PE, 2023/01/09: No neck or SCF LAPs. General motor weakness; on bed ambulation.
      • Pathology, 2022/01/21: Rt CP angle, metastatic carcinoma.
      • Images:
        • Brain MRI, 2023/01/06: a multi-lobulated extraaxial tumor, about 29.7mm, in the right IAC and right CPA with invasion to the right pons. Severe perifocal edema was noted. Due to rapid progression, malignant change was considered. Post-OP change in the right occipital lobe and right cerebellar hemisphere. IMP: an extra-axial tumor with intra-axial invasion in the right IAC and right CPA
        • CXR, 2023/01/06: No lung metastasis; no pneumonia.
        • EBV DNA titer, 2022/11/16: Equivocal.
          
    • Diagnosis: Nasopharyngeal carcinoma, cT4N1M0, stage IV, s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p SRS on 2020/12/31 s/p surgical resection on 2022/1/21, s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of Rt CP angle tumor with invasion to the right pons; ECOG =2.
    • Plan: Palliative RT to Rt CP angle tumor for 4400cGy/20 fx is suggested for locoregional control. CT simulation was arranged on 2023/01/10, 09:30am. Possible radiation toxicity (white matter injury and pons injury) is told. Diet education is given. Poor prognosis is expected due to limited radiation dose.

[surgical operation]

• 2022-01-21 at TuCheng ChangGung Hospital

[radiotherapy]

• 2018-01-30 ~ 2018-02-09 - 5000cGy/5 fractions (6 MV photon) to metastatic tumor at liver dome
• 2012-07-31 ~ 2012-09-17 - CCRT was performed on 2012/07/31, 2012/08/07, 2012/08/14, 2012/08/21, 2012/08/28, 2012/09/04, 2012/09/11. RT completed on 2012/09/17.

[chemotherapy]

• 2023-02-03 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-01-27 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-01-18 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-01-12 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
  • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-09-29 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-08-30 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-08-04 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-07-08 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-05-25 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-04-22 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-03-18 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
  • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

[assessment]

• Recent lab data showed a significant downward trend in PLT, indicating that the patient has developed thrombocytopenia. Please closely monitor the patient for any signs of bleeding.
  • 2023-02-13 PLT 45 *10^3/uL
    
  • 2023-02-10 PLT 59 *10^3/uL
    
  • 2023-02-03 PLT 81 *10^3/uL
    
  • 2023-01-27 PLT 128 *10^3/uL
    
  • 2023-01-18 PLT 260 *10^3/uL
    
  • 2023-01-12 PLT 292 *10^3/uL
• Actively bleeding patients with thrombocytopenia should be transfused with platelets immediately to keep platelet counts >50K/uL in most bleeding situations including disseminated intravascular coagulation (DIC), and >100K/uL if there is central nervous system bleeding. (ref: Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. 2009;145(1):24-33. doi:10.1111/j.1365-2141.2009.07600.x)

220805

{Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and Rt retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30}

• exam finding
  • 2022-07-07 MRI - brain
    • Right CPA/IAC tumor s/p treatment, with residual lesion. Suggest close follow-up.
  • 2022-03-18 ENT Hearing Test
    • PTA
    • Reliability FAIR
    • Average RE >120 dB HL; LE 55 dB HL.
    • RE profound SNHL
    • LE mild to profound SNHL
  • 2022-03-17 MRI - nasopharnyx
    • Right IAC and CPA tumor, stationary as compared with MRI on 20223015. Metastatic LAP with ENE at right neck.
  • 2022-03-15 MRI - brain
    • Right CP angle and IAC mass, regressed size and perifocal edema, when compared with 20220108 MRI.
    • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
  • 2022-01-08 MRI - posterior fossa, brain stem
    • A multi-lobuled lesion in the right IAC and right CPA with severe mass effect on the right brain stem, marked increase in size.
  • 2022-01-03 Tc-99m MDP whole body bone scan
    • A hot spot in the left aspect of the maxilla, the nature is to be determined (dental problem or other nature?), suggesting follow-up with bone scan in 3-6 months for investigation.
    • Suspected benign lesions in the mandible, some C-, T- and L-spine, right sternoclavicular junction, bilateral shoulders, S-I joints, and hips.
  • 2021-10-06 SONO - abdomen
    • There are several hepatic cysts in right lobe and the largest one measuring 1 cm in size at segment 8.
      
    • A renal cyst 1.35 cm on right kidney middle pole is noted.
  • 2021-06-30 MRI - posterior fossa, brain stem
    • Right CP angle and IAC mass, slightly regressed size DDx: Neuroma, meningioma or metastasis.
    • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
  • 2020-12-30 MRI - brain
    • Tumor at right CPA and IAC. Mild enlargement as compared with MRI on 20201126. Suspected metastasis. Meningioma or Schwannoma is less likely.
  • 2020-11-26 SONO - abdomen
    • Right liver cysts and calcification. Left renal cyst and bil. renal stones.
  • 2020-11-26 MRI - nasopharynx
    • C/W NPC s/p treatment without local recurrence, but with a metastatic lesion involving right IAC and CPA
  • 2020-04-15 SONO - abdomen
    • There are several hepatic cysts in right lobe and the largest one measuring 1.08 cm in size at segment 8.
    • A renal cyst 1.27 cm on right kidney middle pole is noted.
  • 2020-04-15 MRI - nasopharynx
    • C/W NPC s/p treatment without evidence of recurrence. An enhancing lesion in right IAC and cochlea. Suspected post-RT neuropathy. Metastasis is unlikely. Stationary as compared with previous MRIs.
  • 2019-09-26 MRI - liver, spleen
    • Post RT change of right lobe liver.
    • Hepatic simple cysts.
  • 2019-05-20 MRI - nasopharynx
    • C/W NPC s/p treatment with complete remission and no evidence of recurrence. Stationary as compared with MRI on 20190108.
  • 2019-05-20 SONO - abdomen
    • Liver cysts.
    • Right renal stone.
    • Right renal cyst.
  • 2019-01-08 MRI - nasopharynx
    • Right NPC, post CCRT. No evidence local recurrent tumor. No neck LAP.
  • 2019-01-08 SONO - hepatobiliary
    • There are several hepatic cysts in right lobe and the largest one is measured about 0.91 cm in size at segment 8.
      
    • A renal cyst 1.33 cm on right kidney middle pole is noted.
  • 2018-09-05 Whole body PET scan
    • In comparison with the previous study on 20180118, the glucose hypermetabolic tumor in the liver dome had disappeared in this study, suggesting response to current treatment.
    • Glucose hypermetabolism in the right alveolar process of the maxilla had been stationary since the previous study, suggesting benign conditions such as dental inflammatory lesion.
    • Moderate glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change in response to locoregional inflammation may show such a picture. Please correlate with clinical findings and keep follow-up, however, to exclude the possibility of more significant clinical problems.
  • 2018-08-21 MRI - upper abdomen
    • Liver metastasis in segment 4/8 dome Status post R/T with inflammatory fibrosis is highly suspected.
  • 2018-05-21 CT - abdomen
    • Much regression of liver dome lesion.
  • 2018-01-24 CT - abdomen
    • A poor enhancing nodule (1.7cm) at liver dome c/w metastases.
  • 2012-07-12 Pathology
    • Nasopharynx, right: Non-keratinizing carcinoma, undifferentiated (WHO-2B).
• history
  • Hepatitis B carrier
  • Acoustic neuroma
  • NPC
  • Liver metastasis s/p SBRT on 20180209
  • R/I recurrence of NPC by surgical excision at TuCheng ChangGung Hospital on 2022-01-21 by vice president Dr. Wei FuQuan.
    • Pathology: Brain, CP angle, Rt, carcinoma, metastatic.
    • Positive: AE1/AE3, EMA, p40; negative EBV, Hep-par-1, PR, S100; Ki67 100%.
    • Plan: Refer to LK-CGMH for evaluation of proton therapy.
• surgical operation
  • TuCheng ChangGung Hospital
• radiotherapy
  • 2018-01-30 ~ 2018-02-09 - 5000cGy/5 fractions (6 MV photon) to metastatic tumor at liver dome
  • 2012-07-31 ~ 2012-09-17 - CCRT was performed on 2012/07/31, 2012/08/07, 2012/08/14, 2012/08/21, 2012/08/28, 2012/09/04, 2012/09/11. RT completed on 2012/09/17.
• chemotherapy
  • 2022-08-04 - cisplatin 80mg/m2 130mg 24hr D1 + fluorouracil 1000mg/m2 1700mg 22hr D1-4
  • 2022-07-08 - cisplatin 80mg/m2 130mg 24hr D1 + fluorouracil 1000mg/m2 1700mg 22hr D1-4
  • 2022-05-25 - cisplatin 80mg/m2 130mg 24hr D1 + fluorouracil 1000mg/m2 1700mg 22hr D1-4
  • 2022-04-22 - cisplatin 80mg/m2 130mg 24hr D1 + fluorouracil 1000mg/m2 1700mg 22hr D1-4
  • 2022-03-18 - cisplatin 80mg/m2 130mg 24hr D1 + fluorouracil 1000mg/m2 1700mg 22hr D1-4

[assessment]

• The patient had a marginally high uric acid level (2022-07-05 7.7 mg/dL) prior to last chemotherapy, which could be followed up in order to determine the need for an uric acid lowering drug (e.g. febuxostat).
• EBV DNA PCR results on 2022-01-17 indicated equivocal 120 copies/mL, which could be updated as well.
• There is no issue with active prescriptions.

220425

[assessment]

• For nonkeratinizing and/or undifferentiated histology, consider testing for EBV in tumor and blood. The EBV DNA load may reflect prognosis and change in response to therapy.
• Stereotactic proton radiosurgery might be effective in treating brain metastases. reference: Proton Stereotactic Radiosurgery for Brain Metastases. https://pubmed.ncbi.nlm.nih.gov/29976494/
• 5-Fu plus cisplatin has been the current regimen since 2022-03-18. PD-1 inhibitors (e.g. pembrolizumab or nivolumab) might be an additional treatment option for cancers that are recurrent, unresectable, or metastatic (without surgery or radiation therapy).
• Chronic viral hepatitis B is managed with Baraclude (entecavir) currently.

700143756

230214

[diagnosis] - 2023-01-16 admission note

• Synchronous cancer in the cecum and rectosigmoid colon, cT4aN2aM0, stage IIIC with partial obstruction and reginal lymph node metastasis s/p chemotherapy with FOLFOX from 2022/10/24 and status post robotic low anterior resection on 2022/12/20
• Malignant neoplasm of sigmoid colon
• Chronic viral hepatitis B without delta-agent
• Hypokalemia
• Constipation, unspecified
• Cachexia
• Insomnia, unspecified
• Anemia due to antineoplastic chemotherapy

[past history]

• Denied history of Hypertension, DM, asthma, cancer.
• Denied any operation, accident and other medical history.                    

[allergy]

• NKDA                     

[family history]

• Father: colon cancer.
• Mother: brain cancer.

[lab data]

• 2022-08-23 Anti-HBc Reactive
  
• 2022-08-23 Anti-HBc-Value 7.67 S/CO
  
• 2022-08-23 Anti-HBs 1.00 mIU/mL
  
• 2022-08-23 HBsAg Reactive
  
• 2022-08-23 HBsAg Value 23.83 IU/mL

[exam findings]

• 2023-01-03 CXR
  • staple line and hazy areas of increased opacity over Lt upper lung zone due to post op change
  • marginal spurs of multiple vertebral bodies due to spondylosis.
• 2022-12-22 CXR
  • S/P Port-A infusion catheter insertion.
  • Right subphrenic air.
  • Presence of ileus.
  • S/P left side chest tube insertion.
  • S/P operation.
  • Right subcutaneous emphysema.
• 2022-12-20 Patho - colon segmental resection for tumor
  • Diagnosis
    • Large intestine, rectum, robotic low anterior resection —- Adenocarcinoma, moderately differentiated, s/p CCRT
      
    • Resection margins: circumferential: involved
      
    • Lymph node, mesocolic, dissection —- Negative for malignancy (0/15)
    • Lymph node, IMA / SMA, dissection —- Not received
    • AJCC 8th edition Pathology stage: ypStage IIB, ypT4aN0(if cM0)
      
    • F2022-00614 Lung, LUL, wedge resection —- Negative for malignancy
  • Gross Description:
    • Operation procedure: robotic low anterior resection
    • Specimen site: rectum
      
    • Specimen size: 8.8 cm in length
      
    • Tumor size: 4.1 cm in length, annularly ulcerated
    • Tumor location: 2.7 cm and 2.0 cm away from the two resection margins, respectively
      
    • Depth of invasion grossly: visceral peritoneum
    • Mucosa elsewhere: congestion
      
    • Macroscopic Tumor Perforation: Not identified
    • Macroscopic Intactness of Mesorectum (if applicable): Complete
    • Sections are taken and labeled as: A1: colon, non-tumor; A2-6: tumor; A7-10: lymph node, mesocolic; B: proximal cutend; C: distal cutend.
    • F2022-00614 - The specimen submitted in fresh consists of a piece of lung tissue, measuring 9.3 x 2.0 x 1.4 cm and weighing 8g. On cutting, a fibrotic and calcified nodule measuring 0.5 x 0.4 x 0.3 cm is seen and 0.5 cm away from the resection margin. The parenchyma elsewhere is congested. The nodule is all for section in a cassette for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: resection margin; X2: lung, near nodule; X3-4: lung.
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
      
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Involved
        
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Present
    • Tumor Budding: Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose: tubulovillous adenoma
    • Tumor Deposits: Not identified
    • Regional Lymph Nodes: 0/15
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply): y (posttreatment)
        • Primary Tumor (pT): pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
        • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
        • Distant Metastasis (pM): if cM0
    • Additional Pathologic Findings (select all that apply): None identified
    • Tumor regression grading S/P CCRT: Modified Ryan scheme: Tumor regression score: 2, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response).
    • F2022-00614 - Sections show lung with a calcified and fibrotic nodule. No malignancy is seen.
    • Addendum: The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
• 2022-12-19 CXR
  • Ground glass opacity in left lung.
• 2022-12-19 Frozen Section
  • Preliminary diagnosis: Lung, LUL, biopsy — Calcified fibrotic nodule
• 2022-12-19 ECG
  • Moderate voltage criteria for LVH, may be normal variant
  • Nonspecific T wave abnormality
• 2022-11-29, -11-24 KUB
  • S/P intrauterine contraceptive device retention over the pelvis
  • Fecal material store in the colon.
• 2022-11-24 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (92 - 19) / 92 = 79.35%
    • M-mode (Teichholz) = 79
  • Indeterminated LV filling pressure and impaired RV relaxation.
  • Normal LV and RV systolic function.
  • Suspected bicuspid aortic valve with mild to moderate aortic stenosis (AVA= 1.45 cm2 by Doppler method); mild AR; mild MR; mild TR and mild PR.
  • Dilated aortic root and proximal ascending aorta ( 34 mm) with mild calcification.
• 2022-11-22 CXR
  • Solitary pulmonary nodule at LLL.
• 2022-11-22 CT - abdomen
  • History and indication: A case of RS cancer s/p CCRT
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Stable condition of R-S colon cancer and LAP. Some nodules in bil. lungs.
    • Wall thickening of cecum.
    • Small liver and renal cysts.
    • Atherosclerosis of aorta, iliac arteries.
    • An IUD in the pelvic cavity.
  • IMP:
    • Stable condition of R-S colon cancer and LAP. Some nodules in bil. lungs.
    • Wall thickening of cecum.
• 2022-11-22 Colonoscopy
  • Rectosigmoid cancer partial obstruction s/p CCRT
  • The scope can’t pass through due to lumen narrowing
• 2022-10-17 Bronchodilator Test
  • Rectosigmoid cancer partial obstruction s/p CCRT
  • The scope can’t pass through due to lumen narrowing
• 2022-08-30 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
• 2022-08-29 ECG
  • Normal sinus rhythm
  • Minimal voltage criteria for LVH, may be normal variant
  • Nonspecific ST and T wave abnormality
• 2022-08-29 CXR
  • Atherosclerotic change of aortic arch
  • Tortuosity of thoracic aorta
  • Enlargement of cardiac silhouette.
  • Spondylosis of the T-spine
• 2022-08-17 CT - abdomen
  • History: 76 y/o female
    • 20220726 FOBT positive at Far Eastern Polyclinic of Far Eastern Medical Foundation
    • 20220810 colonoscopy: An annular tumor mass obstructs the lumen at this level about 10-15 cm from the anal verge and the scope cannot pass through this stenotic lesion.
    • 20220816 pathological result: adenocarcinoma
  • Indication: Sigmoid colon cancer for staging
  • Findings:
    • There is segmental lobulated wall thickening measuring 6 cm in length and 1.8 cm in the maximal wall thickness at the rectal-sigmoid colon with irregular contour and lumen narrowing that is c/w adenocarcinoma （T4a) of the rectal-sigmoid colon with partial obstruction.
      • The fat plane between sigmoid colon lesion and the uterine cervix area shows obliteration that may be tumor invasion or attachment? Please correlate with MRI.
      • In addition, There are four enlarged nodes in left perirectal space that may be metastatic nodes (N2a).
    • Another lobulated soft tissue mass-like lesion in the cecum and proximal ascending colon is suspected.
      • Please correlate with colonoscopy to R/O Synchronous cancer.
    • There is a well-defined poor enhancing lesion 6 mm at S8 dome of the liver that may be cyst?
      • The differential diagnosis include metastasis?
      • However, it is too small to characterize. Follow up is indicated.
    • There is a well-defined ovoid-shaped poor enhancing lesion at right inguinal area, measuring 2.3 x 1.3 cm in size and 5HU in CT density.
      • Benign reactive node or cystic lesion is highly suspected. Please correlate with sonography.
    • There is a small nodule 4 mm at LUL of the lung.
      • Follow up is indicated.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T4a (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
• 2022-08-11 Patho - colon biopsy
  • DIAGNOSIS: Intestine, large, RS colon, 10-15 cm from anal verge, biopsy — adenocarcinoma
  • Description: The specimen submitted consists of 4 pieces of tissues measuring up to 0.4 x 0.3 x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic. All for section.
  • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, tumor necrosis and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • NOTE: IHC stain for MSI will be followed.
• 2022-08-10 Colonoscopy
  • Findings
    • Using Olympus CF-H260AL, endoscopic examination of rectum and colon was done and the scope is placed up to the level of RS junction. An annular tumor mass obstructs the lumen at this level about 10-15 cm from the anal verge and the scope cannot pass through this stenotic lesion. Bx x 4 done. Internal hemorroid is noticed.
    • Internal hemorrhoid was noted.
  • Diagnosis
    • Colon cancer, RS junction s/p Bx
    • Internal hemorrhoid
    • Incomplete CFS exam

[consultation]

• 2022-11-25 Thoracic Surgery
  • Q
    • This is a 76 year-old woman who denied having any history. According the patient, she suffered from mucous stools was pink like, abdomen flatulence, and difficult defecation since half year ago. And she came to the local clinic (Far Eastern Polyclinic), the fecal occult blood test positive noticed, so referred to our GI OPD for further assessment.
    • Colonscopy (2022/08/10) showed: 1. Colon cancer, RS junction s/p Bx. 2. Internal hemorrhoid. Abdomen CT showed: 1. Adenocarcinoma of the sigmoid colon with suspicious uterine cervix invasion is suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T4a(or4b)N2aM0, stage:IIIC. 2. Synchronous cancer in the cecum and proximal ascending colon is suspected on 2022/08/17. The RS colon biopsy — adenocarcinoma.
    • The radiotherapy starts from 2022/08/26, RT finished on 2022/10/12. CCRT with 5-FU (Covorin 20mg/m2, 5-Fu 225mg/m2) QW, (C1) on 2022/9/1-2022/9/2, 2022/9/5-2022/9/7, 2022/09/22-2022/09/23, 2022/09/26-2022/09/28. Chemotherapy with FOLFOX (Oxalip 85mg/m2, Covorin 400mg/m2, 5-Fu 400mg/m2、5-Fu 2400mg/m2) was given on 2022/10/24(C1D1), 2022/11/07(C1D15). Surgery will be arranged on 20221207 or later.
    • Due to CT image (2022/11/22) showed some nodules in bil. lungs, we need your consultation for evaluation. Thanks a lot!!!
  • A
    • LUL nodule was noted. I will arrange VATS LUL wedge resection.

[surgical operation]

• 2022-12-19
  • Surgery
    • Robotic low anterior resection        
  • Finding
    • Advanced rectal cancer s/p CCRT with anterior pelvic peritoneal invasion
• 2022-12-19
  • Surgery
    • VATS LUL wedge resection.
  • Finding
    • One small nodule was noted over LUL, size about 0.5cm in diameter.
    • Frozen section: benign lesion.
    • One 20 Fr. straight chest tube was inserted via left 6th ICS.

[radiotherapy]

• 2022-08-26 ~ 2022-10-06 - 5040cGy/28 fractions (15 MV photon) to rectosigmoid tumor, LAPs and cecal tumor.

[assessment]

• 2023-12-13 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (w/o 5-FU bolus)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-01-16 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-11-07 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2023-10-24 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
• 2022-09-26 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-3
• 2022-09-22 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-2
• 2022-09-05 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-3
• 2022-09-01 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-2 (CCRT)
  • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-2

[assessment]

• A leukocytopenia event was observed (2023-02-02 WBC 1.86K/uL, Neutrophil 42% => ANC 780/uL) and the previously scheduled chemotherapy was cancelled on that day. FOLFOX is being administered without a 5-FU bolus this time. It is important to monitor the patient’s WBC count to determine whether leukocytopenia recurs.

230117

[assessment]

• Except for urticaria, the underlying conditions listed in the problem list are appropriately treated with corresponding medications.

• As a premedication, a single shot diphenhydramine is used in the current chemotherapy regimen, however, the newer, second generation H1 antihistamines are recommended as first-line therapy for urticaria. These newer drugs are minimally sedating, are essentially free of the anticholinergic effects that can complicate use of 1st generation agents, have few significant drug-drug interactions, and require less frequent dosing compared with first-generation agents. It is recommended to initialize a 2nd generation antihistamine at standard therapeutic dose:

  • cetirizine, 10mg once daily
  • levocetirizine, 5mg once daily
  • fexofenadine, 180mg once daily
  • loratadine, 10mg once daily
  • desloratadine, 5mg once daily

220926

• lab data
  • 2022-08-23 Anti-HBc Reactive
    
  • 2022-08-23 Anti-HBc-Value 7.67 S/CO
    
  • 2022-08-23 Anti-HBs 1.00 mIU/mL
    
  • 2022-08-23 HBsAg Reactive
    
  • 2022-08-23 HBsAg Value 23.83 IU/mL
• exam finding
  • 2022-08-30 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-08-29 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH, may be normal variant
    • Nonspecific ST and T wave abnormality
  • 2022-08-29 CXR
    • Atherosclerotic change of aortic arch
    • Tortuosity of thoracic aorta
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-08-17 CT - abdomen
    • History: 76 y/o female
      • 20220726 FOBT positive at Far Eastern Polyclinic of Far Eastern Medical Foundation
      • 20220810 colonoscopy: An annular tumor mass obstructs the lumen at this level about 10-15 cm from the anal verge and the scope cannot pass through this stenotic lesion.
      • 20220816 pathological result: adenocarcinoma
    • Indication: Sigmoid colon cancer for staging
    • Findings:
      • There is segmental lobulated wall thickening measuring 6 cm in length and 1.8 cm in the maximal wall thickness at the rectal-sigmoid colon with irregular contour and lumen narrowing that is c/w adenocarcinoma （T4a) of the rectal-sigmoid colon with partial obstruction.
        • The fat plane between sigmoid colon lesion and the uterine cervix area shows obliteration that may be tumor invasion or attachment? Please correlate with MRI.
        • In addition, There are four enlarged nodes in left perirectal space that may be metastatic nodes (N2a).
      • Another lobulated soft tissue mass-like lesion in the cecum and proximal ascending colon is suspected.
        • Please correlate with colonoscopy to R/O Synchronous cancer.
      • There is a well-defined poor enhancing lesion 6 mm at S8 dome of the liver that may be cyst?
        • The differential diagnosis include metastasis?
        • However, it is too small to characterize. Follow up is indicated.
      • There is a well-defined ovoid-shaped poor enhancing lesion at right inguinal area, measuring 2.3 x 1.3 cm in size and 5HU in CT density.
        • Benign reactive node or cystic lesion is highly suspected. Please correlate with sonography.
      • There is a small nodule 4 mm at LUL of the lung.
        • Follow up is indicated.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
  • 2022-08-11 Patho - colon biopsy
    • DIAGNOSIS: Intestine, large, RS colon, 10-15 cm from anal verge, biopsy— adenocarcinoma
    • Description: The specimen submitted consists of 4 pieces of tissues measuring up to 0.4 x 0.3 x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic. All for section.
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, tumor necrosis and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • NOTE: IHC stain for MSI will be followed.

[assessment]

• The CT of the abdomen on 2022-08-17 revealed possible synchronous cancer (rectal-sigmoid colon, cecum, and proximal ascending colon), a liver S8 dome lesion, and a LUL nodule.
• Patients with synchronous colorectal carcinoma have a higher proportion of microsatellite instability cancer than patients with a solitary colorectal carcinoma. Also, limited data have revealed that in many synchronous colorectal carcinomas, carcinomas in the same patient have different patterns of microsatellite instability status, p53 mutation and K-ras mutation. (ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4051920/ ). Pathology (2022-08-11) IHC MSI results (for the rectal-sigmoid colon specimen) are not yet available.

701334097

230214

{not completed}

[exam findings]

• 2023-02-08, -02-05, -01-31 CXR

  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Pleura effusion of right and left costal-phrenic angle S/P pigtail catheter implantation at right CP angle?
  • 2023-02-08 - Patchy consolidation of both lung zone are noted. please correlate with clinical condition to R/O Bronchopneumonia.
  • 2023-02-05 - Linear infiltration over both lung zone are noted. please correlate with clinical condition.
  • 2023-01-31 - Increased lung markings on both lower lung are noted. Please correlate with clinical condition.

• 2023-02-05 CT - brain

  • Brain atrophy

• 2023-02-03 MRI - brain

  • No evidence of intracranial lesion.

• 2023-02-03 Electroencephalography, EEG

  • This is an abnormal EEG suspecting bilateral central epileptogenic activities intermittent diffuse slow waves at bilateral central and temporal area
  • A few sharpy contour waves or spikes over bilateral central area.
  • Please correlate clinially

• 2023-02-03 Peripheral Vascular Test - vein, lower limbs

  • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
  • Bilateral long saphneous vein engorgement (from thigh to leg), left side more severe; connecting to bilateral engorged posterior tibial veins by perforator veins at leg level

• …

• …

• …

  • 2022-01-06 Patho - colon segmental resection for tumor
    • pathology diagnosis
      • Rectum, Hartmann’s operation – Adenocarcinoma, moderately differentiated
        
      • Resection margins, Hartmann’s operation – Free of carcinoma
        
      • Lymph nodes, mesocolorectal, Hartmann’s operation — Metastatic adenocarcinoma (1/12)
        
      • Specime labeled pelvic tumor margin, biopsy — Necrosis and granulation tissue and free of carcinoma
        
      • T-colon colostomy, closure of colostomy — Free of carcinoma
        
      • Pathology stage: ypT3N1a(cM0); Stage IIIB
    • microscopic examination
      • Histology: Adenocarcinoma
        
      • Histology Grade: Moderately differentiated
        
      • Depth of invasion: Perirectal soft tissue
        
      • Angiolymphatic invasion: Not identified
        
      • Perineural invasion: Present
        
      • Tumor cell budding: Intermediate
        
      • Circumferential (radial) margin of rectum: Uninvolved, 2 mm from the margin
        
      • Lymph node metastasis, mesocolorectal: Metastatic adenocarcinoma (1/12)
      • Extranodal involvement: Absent
        
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): ypT3 (Tumor invades pericolorectal tissues)
          
        • Regional Lymph Nodes (pN): ypN1a (one regional lymph node positive)
          
        • Distant Metastasis (pM): cM0
          
      • Type of polyp in which invasive carcinoma arose: Not identified
        
      • Additional pathologic findings: None identified
        
      • Tumor regression grading S/P CCRT: Partial response (score 2)
        
      • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
        
      • Specime labeled pelvic tumor margin: Necrosis and granulation tissue, and free of carcinoma
        
      • T-colon colostomy: Free of carcinoma
  • 2021-12-28 CT - abdomen, pelvis
    • Rectosigmoid colon cancer, size decreased.
    • Decreased size of pericolic lymph nodes.
    • Status post T-colostomy.
    • Right hydronephrosis and hydroureter.
    • Tiny subpleural nodules (<0.5cm) at basal LLL. Suggest close follow up.
  • 2021-12-28 Colonoscopy
    • compatible with colon cancer, 8cm AAV, with near lumen obstruction.
  • 2021-09-16 CT - abdomen, pelvis
    • Imaging stage: T3N2aM0, stage IIIB

• lab data

  • 2022-02-24
    • All RAS mutation not detected
    • BRAF mutation not detected

• surgical operation

  • 2022-01-05
    • surgery
      • Hartmann’s operation and closure of T-loop colostomy
    • finding
      • Advanced rectal cancer obstruction s/p CCRT and the tumor was firmly fixed to the pelvic cavity , clinically can’t be resected completely
  • 2021-09-17
    • surgery
      • T loop colostomy        
    • finding
      • Rectal cancer with obstruction, cT3N2aM0 stage IIIB
      • RUQ stoma with stent

• radiotherapy

  • 2021-09-28 ~ 2021-11-04 - pelvis: 45 Gy/ 25 fx. R-S colon tumor and LAPs: 50.4 Gy/ 28 fx

• chemoimmunotherapy

  • 2022-02-22 ~ undergoing - FOLFOX plus bevacizumab
  • 2021-11-29 ~ 2022-02-07 - FOLFOX
  • 2021-10-04 ~ 2021-11-01 - 5-Fu + LV (CCRT)

230206

[assessment]

• 2023-01-23 urine culture found Candidas abicans 50000 colony count CFU/cc. Treatment of candidemia and invasive candidiasis in nonneutropenic patients could be an echinocandin (1. caspofungin 70 mg IV loading dose, then 50 mg IV daily; 2. micafungin 100 mg IV daily; 3. anidulafungin 200 mg IV loading dose, then 100 mg IV daily. Items 2 and 3 are not necessary to be dose adjusted for any degree of kidney impairment and they are available in this hospital.) is recommended as initial therapy. (ref: https://www.uptodate.com/contents/image?imageKey=ID%2F87676)

• 2023-01-13 anaerobic culture of the perineuim was found to contain Bacteroides thetaiotaomicron 3+ that was sensitive to metronidazole and ampicillin/sulbactam. It is not necessary to adjust dose for metronidazole if CrCl is greater than 10, while for ampicillin/sulbactam, CrCl is greater than 30. Keep metronidazole use is recommended.

• If Keppra (500mg Q12H) is not demonstrated to be effective for seizure control, valproate (no dosage adjustment necessary if CrCl >= 10 mL/min) or carbamazepine (no dosage adjustment necessary for kidney impairment) might be added.

  • Depakine (valproic acid) is available in tabet, oral solution and injection forms.
  • Carbamazepine might cause hyponatremia, which might be a desired side effect to mitigate the patient’s hypernatremia (2023-02-05 Na 152 mmol/L).

230130

{compatible solutions to mitigate hypernatremia that do not rely on saline}

Following is a list of the selected injectable medications in the active prescription and their compatibility with non-saline-based solutions according to MicroMedex.

• Benamine (diphenhydramine hydrocholoride)
  • D5W (Dextrose 5% in water)
    • IV compatible
  • D10W (Dextrose 10% in water)
    • IV compatible
  • D5LR (Dextrose 5% in lactated Ringers)
    • IV compatible
• Flucon (fluconazole)
  • D5W (Dextrose 5% in water)
    • IV compatible
  • D10W (Dextrose 10% in water)
    • IV not tested
  • D5LR (Dextrose 5% in lactated Ringers)
    • IV not tested
• Furosemide
  • D5W (Dextrose 5% in water)
    • IV compatible
  • D10W (Dextrose 10% in water)
    • IV compatible
  • D5LR (Dextrose 5% in lactated Ringers)
    • IV compatible
• Metronidazole
  • D5W (Dextrose 5% in water)
    • IV compatible
  • D10W (Dextrose 10% in water)
    • IV not tested
  • D5LR (Dextrose 5% in lactated Ringers)
    • IV not tested

Use potassium supplements if necessary

• Potassium phosphates
  • D5W (Dextrose 5% in water)
    • IV compatible
  • D10W (Dextrose 10% in water)
    • IV compatible
  • D5LR (Dextrose 5% in lactated Ringers)
    • IV not compatible

220408

[assessment]

• Having been firmly embedded in the pelvic cavity, the tumor could not be surgically resected fully (2022-01-05).
• The patient receives FOLFOX since 2021-11-29 (plus bevacizumab since 2022-02-22) s/p T loop colostomy (2021-09-17) and CCRT (late Sep to early Nov 2021).
• According to laboratory data reported on 2022-04-06, there were no obvious abnormalities; however, elevations in ALT (60 U/L) and AST (64 U/L) should be addressed, as these two readings had been normal prior to the this last examination.
• As metoclopramide is one of the potentially hepatotoxic drugs, some silymarin as supplementation might be an optional add-on to mitigate the potential hepatotoxicity.
  • reference
    • Hepatotoxicity by Drugs: The Most Common Implicated Agents. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4783956/
    • A Pilot Study of Silymarin as Supplementation to Reduce Toxicities in Metastatic Colorectal Cancer Patients Treated With First-Line FOLFIRI Plus Bevacizumab. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8420909/

701277175

230213

[assessment]

WBC returned to 5.05K/uL on 2023-02-12, neutropenia not observed.

230106

• diagnosis - 20230105 admission note
  • Malignant neoplasm of unspecified site of left female breast
  • Left breast invasive carcinoma with left axillary LN enlargement and bone metastasis, ER (+), PR (-), Her2 (+), stage IV, PS 1
  • Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes
  • Secondary malignant neoplasm of bone
• exam finding
  • 2022-10-17 CT - chest
    • Indication: left breast invasive carcinoma with left axillary LN enlargement and BONE Metases ER (+), PR (-), Her2 (+), stage IV, PS 1
    • MDCT (128 256-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows: (Comparison was made with previous CT dated on 20220702)
      • Lungs: s/p RUL operative with septal line and surrounding opacity along the interalobar fissures, and septal thickening and subpleural edema along minor fissure. septal line and septal thickening at RML too.
        • there is subpleural and reticulation at basal segments of RLL.
    • Impression:
      • post op change in RUL and RML, in regression as compared with previous CT on 20220702.
      • suspect early fibrosis in RLL.
  • 2022-07-05 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/02/11, no prominent change is noted in the previous faint hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones, suggesting stable condition.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • 2022-07-04 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A(minimal)
      • Superficial gastritis, body, s/p CLO test
      • Gastric erosions, antrum
      • Gastric polyps, fundus and AW site of high body, r/o fundic gland polyps
      • Duodenal shallow ulcer, bulb, AW site
    • Suggestion
      • Pursue CLO test result
  • 2022-07-02 CT - chest
    • S/P mastectomy at left side
    • S/p port-A placement with its tip at SUPERIOR VENA CAVA
    • post op. change over right upper lobe
  • 2022-06-20 Abdomen - standing (diaphragm)
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • S/P Mastectomy, left.
  • 2022-06-14 MTBC (Mycobacterium tuberculosis complex) PCR
    • Undetectable
  • 2022-05-30, -05-27 CXR
    • Port-A catheter inserted into RA via right subclavian vein.
    • s/p right chest tube in place, its tip directed superiorly projecting over 5th rib
    • extensive hazy areas of increased opacity over Rt upper lung zone
  • 2022-05-27 Patho - lung wedge biopsy
    • DIAGNOSIS:
      • A: Lung, RML, wedge resection — organizing pneumonia
      • B: Lymph node, right, group 7, dissection — negative for malignancy (0/1)
      • C: Lymph node, right, group 9, dissection — negative for malignancy (0/1)
      • D: Lymph node, right, group 11, dissection — negative for malignancy (0/3)
      • E: Lymph node, right, group 12, dissection — negative for malignancy (0/1)
      • F2022-00248: Lung, RUL, segmentectomy — Non-necrotizing granulomatous inflammation with organizing pneumonia
  • 2022-05-26 Pulmonary Flow Volume Loop
    • Normal ventilation
  • 2022-04-22 CT - lung/mediastinum/pleura
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • S/P mastectomy at left side.
        • Spiculated nodule at right upper lobe up to 1.9cm in largest dimension is found. Another fissural based lesion at right middle lobe up to 1.4cm in largest dimension. In comparison with CT dated on 2021-12-17, the lesions are new. Suggest correlate with PET or other exam.
        • No evidence of bilateral pleural effusion.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • Non-specific bowel gas at abdominal cavity is found.
      • Imp:
        • S/P mastectomy at left side.
        • New spiculated nodule at right upper lobe and right middle lobe, the nature of the lesions should be further characterized or closely follow up. (mets is less likely but primary tumor or inflammation cannot be excluded.)
  • 2022-02-11 Tc-99m MDP whole body bone scan - In comparison with the previous study on 20210924, no prominent change is noted in the previous hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones, suggesting stable condition. - Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • 2022-01-20 Patho - breast simple/partial mastectomy
    • Breast, left, simple mastectomy (s/p chemotherapy) — No residual tumor
    • Pathology stage: ypT0N0(if cM0)
  • 2022-01-19 Lymphoscintigraphy
    • No sentinel lymph node in the left axillary region or left ant. chest wall is delineated throughout the whole study.
  • 2022-01-11 SONO - breast
    • Clinical left breast s/p C/T.
    • Right breast cysts and fibroadenomas. Suggest follow up.
    • BIRADS 6 - proven malignancy
  • 2021-12-17 CT - chest
    • No evidence of recurrent/residual tumor at both sides of the breast and other region.
  • 2021-09-24 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20210427, the previous hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones are less evident. Bone metastases with some resolution may show this picture. Please correlate with other clinical findings for further evaluation.
    • Increased activity in the maxilla in stationary status. Dental problem and/or sinusitis may show this picture.
  • 2021-09-06 CT - chest
    • resolution of Lt breast tumor and metastatic axillary and supraclavicular lymphadenopathy as compared with CT on 20210423.
    • minimal paraspinal fibrosis in RLL of lung.
  • 2021-04-30 CT - brain
    • No intracranial lesion based on this study.
  • 2021-04-27 Tc-99m MDP whole body bone scan
    • Multiple hot spots in the skull, anterior aspect of bilateral rib cages and bilateral iliac bones. Bone metastases should be watched out if no definite traumatic event is noted. Please correlate with other clinical findings for further evaluation.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • 2021-04-26 Patho - lymphnode biopsy
    • Lymph node, left axilla, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains (using block S21-6478): ER (+, strong intensity, 70%), PR(-), Her2/neu: positive(score=3+), Ki-67(50%), p53 (<5%).
    • Section shows fragments of tissue with irregular neoplastic ducts infiltration.
  • 2021-04-26 Patho - breast biopsy
    • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains (using block S21-6477): ER (+, strong intensity, 70%), PR(+, weak intensity,5%), Her2/neu: positive(score=3+), Ki-67(80%), p53 (10%).
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2021-04-26 SONO - breast
    • Left breast tumors with axillary lymph nodes, suspected malignancy with lymph nodes metastasis.
    • BI-RADS5
  • 2021-04-23 CT - nect
    • Suspect left breast tumor with left axillary lymphadenopathy. Several small lymph nodes at left supraclavicular region.
    • Suggest further breast ultrasound correlation and tissue proof if needed.
• surgical operation
  • 2022-01-19 Simple mastectomy and SLNB (Sentinel Lymph Node Biopsy)
    • No palpable and visible tumor over L`t breast UOQ.
    • Sentinel nodes biopsy was done
    • Simple mastectomy was done.
    • L’t big toe nail bed redness & loosen wit hpus discharge.
• chemoimmunotherapy
  • 2023-01-05 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
  • 2022-10-18 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
  • 2022-09-18 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
  • 2022-08-22 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
  • 2022-07-25 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
  • 2022-06-20 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
  • 2022-04-27 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
  • 2022-04-01 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 130mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-03-10 - docetaxel 75mg/m2 120mg 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-02-16 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-12-28 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-11-25 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-11-02 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-10-05 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-08-27 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 120mg 1hr D2
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
  • 2021-07-29 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-07-02 - trastuzumab 600mg SC 5min D1 + pertuzumab 840mg 1hr D1 + decetaxel 75mg/m2 120mg 1hr D2
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
  • 2021-06-01 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2021-05-05 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg
• medication
  • Xgeva (denosumab) CXGEV01
    • 2022-09-01 120mg Q1M SC OPD
    • 2022-06-20 120mg ST SC IPD 2022-06-19
    • 2022-05-06 120mg Q1M SC OPD
    • 2022-04-01 120mg ST SC IPD 2022-03-31
    • 2022-02-25 120mg Q1M SC OPD
    • 2022-01-06 120mg Q1M SC OPD
    • 2021-12-02 120mg Q1M SC OPD

[assessment]

• CT scan results from 2022-10-17 and bone scan results from 2022-07-05 indicate that the disease has remained non-progressive, indicating that the current regimen is still effective.
• The lab results for 2023-01-05 were normal, and the vital signs during this stay in the hospital were stable.

220919

[objective]

• exam finding
  • 2022-04-22 CT - lung/mediastinum/pleura
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • S/P mastectomy at left side.
        • Spiculated nodule at right upper lobe up to 1.9cm in largest dimension is found. Another fissural based lesion at right middle lobe up to 1.4cm in largest dimension. In comparison with CT dated on 2021-12-17, the lesions are new. Suggest correlate with PET or other exam.
        • No evidence of bilateral pleural effusion.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • Non-specific bowel gas at abdominal cavity is found.
        • Suggest clinical correlation
    • Imp:
      • S/P mastectomy at left side.
      • New spiculated nodule at right upper lobe and right middle lobe, the nature of the lesions should be further characterized or closely follow up. (mets is less likely but primary tumor or inflammation cannot be excluded.)
  • 2022-02-11 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20210924, no prominent change is noted in the previous hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones, suggesting stable condition.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • 2022-01-20 Patho - breast simple/partial mastectomy
    • Breast, left, simple mastectomy (s/p chemotherapy) — No residual tumor
    • Pathology stage: ypT0N0(if cM0)
  • 2022-01-19 Lymphoscintigraphy
    • No sentinel lymph node in the left axillary region or left ant. chest wall is delineated throughout the whole study.
  • 2022-01-11 SONO - breast
    • Clinical left breast s/p C/T.
    • Right breast cysts and fibroadenomas. Suggest follow up.
    • BIRADS 6 - proven malignancy
  • 2021-12-17 CT - chest
    • No evidence of recurrent/residual tumor at both sides of the breast and other region.
  • 2021-09-24 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20210427, the previous hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones are less evident. Bone metastases with some resolution may show this picture. Please correlate with other clinical findings for further evaluation.
    • Increased activity in the maxilla in stationary status. Dental problem and/or sinusitis may show this picture.
  • 2021-09-06 CT - chest
    • resolution of Lt breast tumor and metastatic axillary and supraclavicular lymphadenopathy as compared with CT on 20210423.
    • minimal paraspinal fibrosis in RLL of lung.
  • 2021-04-30 CT - brain
    • No intracranial lesion based on this study.
  • 2021-04-27 Tc-99m MDP whole body bone scan
    • Multiple hot spots in the skull, anterior aspect of bilateral rib cages and bilateral iliac bones. Bone metastases should be watched out if no definite traumatic event is noted. Please correlate with other clinical findings for further evaluation.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • 2021-04-26 Patho - lymphnode biopsy
    • Lymph node, left axilla, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains (using block S21-6478): ER (+, strong intensity, 70%), PR(-), Her2/neu: positive(score=3+), Ki-67(50%), p53 (<5%).
      
    • Section shows fragments of tissue with irregular neoplastic ducts infiltration.
  • 2021-04-26 Patho - breast biopsy
    • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains (using block S21-6477): ER (+, strong intensity, 70%), PR(+, weak intensity,5%), Her2/neu: positive(score=3+), Ki-67(80%), p53 (10%).
      
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2021-04-26 SONO - breast
    • Left breast tumors with axillary lymph nodes, suspected malignancy with lymph nodes metastasis.
    • BI-RADS5
  • 2021-04-23 CT - nect
    • Suspect left breast tumor with left axillary lymphadenopathy. Several small lymph nodes at left supraclavicular region.
    • Suggest further breast ultrasound correlation and tissue proof if needed.
• surgical operation
  • 2022-01-19 Simple mastectomy and SLNB (Sentinel Lymph Node Biopsy)
    • No palpable and visible tumor over L`t breast UOQ.
    • Sentinel nodes biopsy was done
    • Simple mastectomy was done.
    • L’t big toe nail bed redness & loosen wit hpus discharge.     
• chemoimmunotherapy
  • 2021-07-02 ~ undergoing - docetaxel + trastuzumab + pertuzumab
  • 2021-05-05 ~ 2021-06-01 - docetaxel
  • 2021-12-02, 2022-01-06, 2022-02-25 - Xgeva (denosumab)

[assessment]

• The patient was diagnosed with hormone receptor and Her2 positive breast cancer with bone mets. Mastectomy with SLNB was performed on 2022-01-19. Her chemoimmunotherapy with docetaxel began in May 2021, then trastuzumab and pertuzumab were added since July 2021.
• She also received three denosumab injections for the bone mets on 2021-12-02, 2022-01-06, and 2022-02-25. Tc-99m MDP scan on 2022-04-22 showed that bone mets were stable.
• The lab results of 2022-04-27 revealed no noticeable abnormalities. No issue with current prescription.

220428

[assessment]

• The patient was diagnosed with hormone receptor and Her2 positive breast cancer with bone mets. Mastectomy with SLNB was performed on 2022-01-19. Her chemoimmunotherapy with docetaxel began in May 2021, then trastuzumab and pertuzumab were added since July 2021.
• She also received three denosumab injections for the bone mets on 2021-12-02, 2022-01-06, and 2022-02-25. Tc-99m MDP scan on 2022-04-22 showed that bone mets were stable.
• The lab results of 2022-04-27 revealed no noticeable abnormalities. No issue with current prescription.

700380439

230210

[diagnosis] - 2022-12-02 admission note

• Malignant neoplasm of lower third of esophagus
• Bacteremia
• Other specified bacterial agents as the cause of diseases classified elsewhere
• Gastro-esophageal reflux disease with esophagitis
• Secondary malignant neoplasm of other specified sites
• Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
• Urinary tract infection, site not specified
• Enterococcus as the cause of diseases classified elsewhere
• Cardiomegaly
• Rheumatic disorders of both mitral and tricuspid valves
• Gastritis, unspecified, without bleeding
• Pneumonia due to Pseudomonas

[past history]

• denied systemic diseases
• hyperthyroidism years ago? without follow up and medicine
• SCC of esophagus of middle to lower third esophagus with gastric involvement, ycT3N1M1, stage IVB.   

[family history]

• There is no family history of cancer, hypertension, mental diseases or asthma.
• No members of the family with diabetes.

[exam findings]

• 2023-02-10 CT - abdomen
  • History: esophageal cancer S/P C/T
    • 20210118 chest CT：interval regression of esophageal tumor and metastatic LN at Rt supraclavivular fossa, but new regional metastatic mediastinal LAP, progression of retroperitoneal LAP and lung metastases, new hepatic metastasis, as compared with CT on 2022/10/28.
  • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is newly-developed massive ascites and omentum cake that is c/w carcinomatosis.
      • Please correlate with ascites cytology.
      • In addition, There are newly-developed ill-defined poor enhancing masses on both hepatic lobes that are c/w liver metastases.
    • Prior CT identified multiple lung metastases are noted again, mild increasing in size that is c/w progressive disease.
    • Prior CT identified metastatic nodes in the gastrohepatic ligament, celiac trunk and para-aortic space are noted again, mild increasing in size that is c/w progressive disease.
    • Prior CT identified regional metastatic node in right lower para-esophageal mediastinum 2 cm is noted again, mild increasing in size to 2.5 cm.
    • There are several renal cysts on both kidney and the largest one measuring 2 cm in size at right umiddle pole.
    • Others
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery.
  • Impression:
    • Carcinomatosis and liver metastases (newly-developed).
    • Multiple lung metastases show progressive disease.
    • Metastatic nodes in the gastrohepatic ligament, celiac trunk and para-aortic space show progressive disease.
    • Metastatic regional node shows progressive disease.
• 2023-01-18 CT - chest
  • Indication: esophageal cancer, S/P chemotherpaycheck chest C.T.
  • MDCT (128-detector rows, iCT Philips,was performed with 0.625 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
  • Comparison was made with previous CT dated on 2022/10/26
    • Lungs:
      • extensive, bilateral, upper lobes predominant, destructive centrilobular emphysema and subpleural paraseptal emphysema/bulla, in the lungs.
      • Multiple randomly distributed pulmonary nodules of varying sizes
      • due to metastases. reticular opacities at LLL and lingula.
    • Mediastinum and hila: a new necrotic lymphadenopathy in Rt paraesophageal region, subcarinal space.
      • Diffuse wall thickening from middle to lower third esophagus, in regression.
    • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
    • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: no effusion or nodule.
    • Chest wall and visible lower neck: regression mestatatic LAP at Rt supraclavicular fossa..
    • Visible abdominal contents: s/p percutsneous gastrostomy.
      • interval increase in size metastatic lymphadenopathy at para-aortic region near celiac trunk, with invasion to the pancreas.
      • multiple small hepatic cysts and small metastatic tumors are found. several small bilateral renal cysts.
  • Impression:
    • interval regression of esophageal tumor and metastatic LN at Rt supraclavivular fossa, but new regional metastatic mediastinal LAP, progression of retroperitoneal LAP and lung metastases, new hepatic metastasis, as compared with CT on 2022/10/28.
• 2023-01-02 CXr
  • A nodular opacity projecting in the left lower lung is suspected. Please correlate with CT.
  • S/P port-A implantation.
  • Atherosclerotic change of aortic arch
  • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
• 2022-11-02 Patho - esophageal biopsy
  • Labeled as “lower esophagus”, biopsy — Ulcer.
  • IHC stains: CK highlights surface squamous mucosa. P40 (-).
  • Section shows surface squamous mucosa, abundant cell debris and acute inflammatory exudates.
• 2022-11-02 Patho - esophageal biopsy
  • Stomach, PW of upper body, biopsy — Ulcer, H pylori NOT present.
  • Section shows benign gastric mucosal tissue and ulcer debris with chronic inflammation. H. pylori NOT present.
  • NOTE: Since malignancy is clinically suspected, further work up or repeat biopsy might be considered.
• 2022-11-02 SONO - abdomen
  • Liver cyst, both lobe
• 2022-11-02 Miniprobe Endoscopic Ultrasound
  • Indication: Esophageal cancer, s/p CCRT, for restaging
    • Esophageal cancer staging
    • Symptoms: Nil
    • Dysphagia
    • Pre-EUS diagnosis: Esophageal cancer
  • Endoscopic findings:
    • With NBI-ME, no lesion nor brownish area was noted above epiglottis or at bilateral pyriform sinuses. With whitelight endoscopy, an easily touch-oozing scar was noted at 29cm below the incisors, causing luminal stenosis. The magnified endoscope could not pass through the stenotic site. With NBI-ME, non-specifc JES-IPCL pattern was noted over the scar and focal JES-IPCL B1 pattern was noted near the scar. We changed the scope to ordinary GIF scope and could pass through the stenotic site with resistance. A PEG tube was noted at AW of lower body. A healing ulcer with surrounding fold convergence was noted at PW of upper body, s/p biopsy(A). A kissing scar was noted at duodenal bulb. Chromoendoscopy with lugol solution showed circumferential LVL with pink-color sign from EC junction to 29cm below the incisors, s/p biopsy(B).
  • EUS findings:
    • With UM-2R, EUS showed 4th layer destruction, at least 3cm in length by miniprobe measurement. A 6.1mm hypoechoic lesion was noted near EC junction.
  • Diagnosis:
    • C/W esophageal cancer, middle to lower esophagus, EUS restaging at least cT3N1, s/p biopsy(B)
    • Gastric ulcer, PW of upper body, H2, Forrest III, suspected malignancy but improved, s/p biopsy(A)
    • PEG in situ
    • Duodenal ulcer scar, bulb
  • Suggestion:
    • Consider to correlate to other image studies and pursue pathology report
• 2022-10-31 Tc-99m MDP whole body bone scan with SPECT
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, L-S junction, left sternoclavicular junction, bilateral shoulders, S-I joints, hips, and knees.
• 2022-10-29 MRI - brain
  • Findings
    • mild dilated intraventricular and extraventricular CSF spaces
    • some white matter gliosis in the bilateral frontal lobes
  • IMP: no evidence of brain metastasis.
• 2022-10-28 CT - chest
  • Indication: esophageal cancer
  • Findings
    • Chest:
      • Diffuse wall thickening from middle to lower third esophagus is found.
      • Severe Emphysematous change over both lungs is found.
      • Nodular lesion at subpleural region of right lower lobe up to 0.7cm and left lower lobe up to 0.5cm is found. These nodules are new.
      • S/p port-A placement with its tip at Superior vena cava.
      • Mild pericardial effusion is found.
      • No evidence of bilateral pleural effusion.
      • Lymphadenopathy at supraclavicular region is found. In regressionn.
    • Visible abdomen:
      • s/p gastrostomy. -Lymphadenopathy at retroperitoneum near celiac trunk is found. In enlargement. -The GB is well distended without soft tissue lesion -The liver, spleen, pancreas, both kidneys and adrenals are intact. -There is no evidence of paraarotic LAPs. -Suggest clinical correlation
    • Imp:
      • Severe COPD.
      • Esophageal cancer with regression.
      • NEw Right lower lobe and left lower lobe nodules. suspected lung meta.
      • Lymphadenopathy at supraclavicular region, in regression.
      • Lymphadenopathy at retroperitoneum, in enlargement.
• 2022-10-28 Nasopharyngoscopy
  • Bil. few thick mucus and nasal cavity, suspected chronoic rhinosinusitis.
• 2022-10-27 Body fluid cytology - bronchial washing
  • Atypia
• 2022-10-27 Whole body PET scan
  • Glucose hypermetabolism involving the lower portion of the esophagus and cardia of the stomach, compatible with primary malignancy involving these regions.
  • Glucose hypermetabolism in multiple lymph nodes in the right lower neck, right paratracheal, precarinal, gastric cardiac and abdominal left paraaortic regions. Metastatic lymph nodes may show this picture.
  • A glucose hypermetabolic lesion in the segment IVb of the liver. Liver metastasis should be watched out.
  • Some glucose hypermetabolic lesions in bilateral lung fields. The nature is to be determined (inflammation? metastases?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG uptake/accumulation in the left neck muscle, bilateral kidneys, ureters and colon. Physiological FDG uptake/accumulation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
• 2022-10-27 Bronchoscopy
  • nasal mucosa chronic inflammation
  • No evidence of trachea or LLL bronchus invasion of esophageal cancer
  • COPD AE during scopy
  • Diffuse proximal airways mucus impaction
• 2022-10-26 CXR
  • Increased lung volume and areas of hyperlucency and decreased upper lung vascular markings due to severe emphysematous change of both lungs upper lung predominance
  • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
• 2022-09-16 CXR
  • Atherosclerotic change of aortic arch
  • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to suspected old inflammatory process.
• 2022-08-10 KUB
  • S/P gastrostomy.
  • Radiopaque spot(s) at left renal region suspected renal stone(s).
  • Intact bony structure(s).
• 2022-08-04 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (134 - 43) / 134 = 67.91%
    • M-mode (Teichholz) = 67.8
  • Dilated LV, Ao
  • Adequate LV, RV systolic function with normal wall motion
  • LV hypertrophy, Impaired LV relaxation
  • Mild MR, TR
• 2022-08-01 Tc-99m MDP whole body bone scan with SPECT
  • Several faint hot spots in the right rib cage, and increased activity in some T- and L-spine, and L-S junction, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
  • Suspected benign lesions in the maxilla, left sternoclavicular junction, bilateral shoulders, and S-I joints.
• 2022-07-30 CT - chest
  • Indication: esophageal tumor, lower esophagus
  • Findings
    • Chest:
      • Dilated upper esophagus with soft tissue occupying middle to lower esophagus about 10.3cm in largest dimension.
      • Lymphadenopathy at right lower neck, paratracheal, paraesophageal, gastric cardiac and retroperitoneal region.
      • There is no evidence of destructive bone lesion.
      • Severe Emphysematous change over both lungs.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Multiple hepatic cysts are found at both lobes of liver is found.
      • The spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
    • Suggest clinical correlation
  • Imp:
    • Esophageal cancer at lower third esophagus and extensive lymphadenopathy. Suggest further treatment.
    • Severe Emphysematous change over both lungs.
  • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2022-07-29 Patho - esophageal biopsy
  • Esophagus, 30-40 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
  • Esophagus, 40-42 cm below the insicors, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation and tumor necrosis are evident.
  • Stomach, cardia, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections show a picture of squamous cell carcinoma, composed of gastric mucosal tissue with nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.

[consultation]

• 2022-10-28 ENT
  • Q
    • This 63-year-old man has squamous cell carcinoma of middle to lower third esophagus, with caria involvement, cT3N3M0, stage IVA. He underwent neoadjuvant CCRT and visited our oncologist OPD for regular follow-up. This time, he was admitted for cancer restaging. Due to nasal mucosa lesion noted during bronchoscope on 2022-10-27. Thus we need your professional evaluation and suggestion. Thank you very much.
  • A
    • Local finding via scope (PACS):
      • Bil. few thick mucus and nasal cavity, suspected chronoc rhinosinusitis
      • No obvious abnormal lesion was noted via this exam
    • Suggestion:
      • OPD f/u for his chronoc rhinosinusitis is enough
• 2022-08-05 Radiation Oncology
  • A
    • A: Squamous cell carcinoma of the M-L/3 esophagus, with gastric involvement, stage cT3N3M0.
    • P: CCRT is indicated for this patient with the following indicators: esophageal cancer with gastric involvement, stage cT3N3M0.
      • Goal: palliation
      • Treatment target and volume: esophageal tumor, peripheral involved and regional involved nodal lesions.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5040cGy/28 fractions of the esophageal tumor, peripheral involved and regional involved nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-08-09.
• 2022-08-02 Hemato-Oncology
  • Q
    • For CCRT surveillance
    • This is a 63 y/o male with history of hyperthyroidism (subclinical?) without medical treatment.
    • He was admitted for tumor work-up and treatment due to unintentional BW loss, esophageal and gastric tumor noted via PES on 20220728.
    • Pathological study showed squamous cell carcinoma. We sincerely need your expertise for CCRT evaluation and management.
  • A
    • This 63-year-old man was consulted and evaluated for esophageal cancer and CCRT
    • A:
      • esophagel cancer, with partial obstruction.
    • Recommendation:
      • CCRT is indicated for this patient
      • suggest port-A implantation and feeding jejumstomy for nutrition

[surgical operation]

• 2022-08-08 laparoscopic gastrostomy and port-A implantation

[chemoimmunotherapy]

• 2023-01-02 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-12-02 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-11-11 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-09-16 - [NS 500mL 2hr + cisplatin 75mg/m2 120mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-D4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
• 2022-08-19 - [NS 500mL 2hr + cisplatin 75mg/m2 120mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-D4 (CCRT)
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[assessment]

• After the last round of chemotherapy (in early Jan 2023), he suffered from severe diarrhea for seven days and poor intake of food.
• Chest CT images (2023-01-18) and abdomen CT images (2023-02-10) indicated that the disease is progressive.
• A subsequent line treatment with paclitaxel 50 mg/m2 and carboplatin AUC 2 weekly for 5 weeks could be considered optionally.

230103

[assessment]

• As part of the admission diagnosis, COPD with (acute) exacerbation is present, however, the Sp02 remains at no less than 94% according to vital sign records in this hospitalization.
• Here are a few signs to watch for: diffuse wheezing, distant breath sounds, barrel-shaped chest, tachypnea, tachycardia, use of accessory muscles, brief and fragmented speech, inability to lie supine, profound diaphoresis, agitation, and an asynchrony between respiration and chest and abdominal movements.
• In the event that exacerbations occur:
  • Inhaled beta agonist: Albuterol 2.5 mg diluted to 3 mL via nebulizer or 2 to 4 inhalations from metered dose inhaler (MDI) every hour for 2 or 3 doses; up to 8 inhalations may be used for intubated patients, if needed.
  • Short-acting muscarinic antagonist (anticholinergic agent): Ipratropium 500 micrograms (can be combined with albuterol) in 3 mL via nebulizer or 2 to 4 inhalations from MDI every hour for 2 to 3 doses.
  • Intravenous glucocorticoid (eg, methylprednisolone 60 mg to 125 mg IV, repeat every 6 to 12 hours).
• A slightly low level of serum Na, K, and Mg was found in the 2023-01-02 lab result. Corresponding supplements were administered.

701463803

230210

[exam findings]

• 2023-01-20 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, lower C-spine, middle and lower T-spines, some L-spines, bilateral shoulders, hips and knees in whole body survey.
  • IMPRESSION:
    • Increased activity in the lower C-spine, middle and lower T-spines and some L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
• 2023-01-18 ECG
  • Possible Left atrial enlargement
  • Left axis deviation
  • Nonspecific T wave abnormality
• 2022-12-30 SONO - abdomen
  • Findings:
    • The liver shows normal in size and echogenicity without focal lesion.
      • Portal vein flow: patent.
      • Bile ducts: not dilated.
    • The gallbladder appears normal in wall thickness and size.
      • There is no evidence of stone, polyp or sludge.
        
    • The pancreatic head and body shows normal in size and texture.
      • The pancreatic tail is obscured by overlying bowel gas.
    • The spleen shows normal in size and echogenicity without focal lesion.
    • Abdominal aorta and IVC show unremarkable finding.
    • There is no evidence of para-aortic lymphadenopathy or ascites.
    • Both kidney show normal echopattern and size.
      • There is no evidence of stone or hydronephrosis.
  • Impression:
    • Normal sonographic study of the hepatobiliary system.
• 2022-12-23 Patho - breast mastectomy with regional lymph nodes
  • PATHOLOGIC DIAGNOSIS
    • Breast, left, modified radical mastectomy — Invasive carcinoma of no special type
    • Resection margin, breast, left, modified radical mastectomy — Free
    • Lymph node, level I and level II, left axilla, modified radical mastectomy — Metastatic carcinoma (1/12)
    • AJCC 8 th edition, Pathology stage: pT4bN1a(cM0); Anatomic stage IIIB; Prognostic stage IIIB
  • MACROSCOPIC EXAMINATION
    • Breast Size: 18 x 12 x 5.0 cm
    • Skin Size: 11.5 x 4.5 cm
    • Nipple: Not retracted
    • Tumor Size: 3.5 x 3.0 x 2.5 cm
      
    • Resection Margin: Free, 0.1 cm from the deep margin
    • Lymph nodes, left axillary: Level 1 and level 2
    • Representative parts are taken for section and labeled: A1=lateral margins, A2-A8= tumor, B1-B4= left axillary LN, level I, C= left axillary LN, level II
  • MICROSCOPIC EXAMINATION
    • Histologic type: Invasive carcinoma of no special type
    • Size of invasive carcinoma: 3.5 x 3.0 x 2.5 cm
      
    • Histologic grade (Nottingham histologic score): Grade 2 (score= 6)
    • Skin involvement with ulcer: Present
    • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
    • Margins: Negative; Closest margin (1 mm from deep margin)
    • Nodal status: Positive (level I 1/11; level II 0/1)
      • number of lymph node examined: 11 (level I), 1 (level II)
      • number with macrometastases (>2mm): 1 (level I)
      • number with micrometastases (>0.2~2mm and/or >200 cells): 0
      • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
    • Extranodal extension: Not identified
    • Treatment Effect: No presurgical neoadjuvant therapy received
    • Lymphovascular invasion: Presnt
    • Perineural invasion: Present
  • IMMUNOHISTOCHEMICAL STUDY (at Kaohsiung Armed Forces General Hospital)
    • ER (Ab): Positive (90%, 3+)
    • PR (Ab): Negative
    • HER-2/Neu (Ab): Negative
    • Ki-67: 5%
• 2022-12-21 CT - chest
  • Indication: Malignant neoplasm of central portion of left female breast
  • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
  • Chest CT with and without IV contrast ehnancement shows:
    • Chest:
      • Lymphadenopathy at left axillary region is found.
      • Soft tissue mass at left breast up to 2.8cm is found.
      • Minimal atelectatic change at right middle lobe is found.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp:
    • Left breast cancer with left axillary lymphadenopathy
• 2022-12-21 ECG
  • Normal sinus rhythm
  • Left anterior fascicular block
  • Abnormal ECG
• 2022-12-21 Spirometry
  • Mild restrictive ventilatory impairment
• 2022-12-21 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (92.4 - 23.4) / 92.4 = 74.68%
    • M-mode (Teichholz) = 74.7
  • Adequate LV, RV systolic function with normal wall motion
  • Impaired LV relaxation
  • Mild MR, TR
• 2022-12-20 External Eye Photography
  • cataract

[chemotherapy]

• 2023-02-10 - Endoxan (cyclophosphamide) 600mg/m2 836mg NS 500mL 1hr + Lipo-Dox (liposome doxorubicin) 35mg/m2 48mg dextrose 5% 250mg 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
• 2023-01-19 - Endoxan (cyclophosphamide) 600mg/m2 823mg NS 500mL 1hr + Lipo-Dox (liposome doxorubicin) 35mg/m2 48mg dextrose 5% 250mg 2hr
  • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
• package insert
  • Endoxan: WBC > 2500
  • Lipo-Dox: ANC > 1500

[assessment]

• 2023-02-09 WBC 1.74 *10^3/uL, Neutrophil 52.4%, Band 0.0% => ANC 912/mm3 grade 3 neutropenia. In the case of grade 3 neutropenia, chemotherapy is not recommended.
• If the patient’s granulocyte count needs to be increased within a short period of time, 250ug of Granocyte (lenogastin) or 150ug of G-CSF (filgrastim) is recommended for two or three consecutive days. However, please do not administer G-CSF in the period 24 hours before to 24 hours after administration of cytotoxic chemotherapy because of the potential sensitivity of rapidly dividing myeloid cells to cytotoxic chemotherapy.
• It is suggested to closely monitor any signs of infection.

700702162

230206

[diagnosis] - 20230203 admission note

• Intrahepatic bile duct carcinoma
• Malignant neoplasm of larynx, unspecified
• Cholangiocarcinoma s/p weekly chemotherapy with Gemzar/CDDP * 8 doses (4 cycles) in TP-VGH (last dose on 2022/06/09), PD with spleen metastasis, stage IV on 2022/06/23 s/p plliative chemotherapy with FOLFOX from 2022/08/12 ~ 2022/10/21 for 5 cycles with liver metastasis s/p Target therapy with Lenvatinib (self pay) from 2022/11/16
• Chronic viral hepatitis B without delta-agent
• Essential (primary) hypertension

[past history]

• Larynnx cancer (SCC), stage Tis, diagnosis at Cardinal Tien Hospital s/p radiotherapy at NTUHon 2017-04 ~ 2017-06
• HBV under HBs(+) noted 30+ y/o, Hepatitis flare 2012-04 ~ (HBVDNA 1.36*7iu/ml) HBs(+>250iu/ml) HBe(-) antiHBe(+). PegIFN (Roche), 2012-09-12 ~ NHI 2012/09/14 ~ 2013/01 ETV NHI 2013/01/04 ~, self-paid 4/wk 2016/01/05 ~
• DM with diet control 60 y/o~
• Hypertension regular Olmetec 20mg 1# po QD tx 55 y/o~
• Vocal cord SCC 28 y/o Cardinal Tien Hospital post R/T NTUH 2017/04 ~ 06    

[allergy]

• Naproxen (KNAPO02): skin rash
• Trimethoprim, Sulfamethoxazole (KBAKT01): slight ???

[exam findings]

• 2023-02-03 KUB
  • Scoliotic alignment of the lumbar spine is found.
  • Phlebolith at pelvic cavity is also found.
• 2023-02-03 CXR
  • Nodular lesion at right central lung is found.
• 2023-01-31 CT - abdomen
  • History and indication: Intrahepatic cholangiocarcinoma
  • Findings
    • Some hypodense lesions (up to 3.3cm) in liver. A small enhancing tumor (1.6cm) at liver dome with venous wash out pattern. S/P right hepatic lobe operation. Grade 4 fatty liver.
    • Multiple nodules in bil. lungs.
    • Wall thickening of A-colon. Minimal ascites.
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • Duodenal diverticulum.
    • Normal appearance of gallbladder.
    • Patency of portal vein.
    • Intact bony structures.
    • No enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
  • IMP:
    • A recurrent tumor (1.6cm) at liver dome.
• 2022-10-24 CT - abdomen
  • Indication:
    • Intrahepatic bile duct carcinoma with splenic mets s/p OP and RFA
    • Malignant neoplasm of larynx, unspecified
  • Abdominal CT with and without enhancement revealed:
    • Abdomen
      • s/p right hepatic op.
      • Several low density lesions scattered at both lobes of liver is found up to 3.53cm at S4. Liver meta is considered. In comparison with CT dated on 2020-08-10, progession of the tumors are found.
      • Lymphadenopathy at hepatic hilum, mesenterric region and gastrohepatic ligment and paraaortic region is found.
      • MInimal ascites is found.
      • The GB is well distended without soft tissue lesion
      • The urinary bladder is well distended without soft tissue lesion.
      • The spleen, pancreas, both kidneys and adrenals are intact.
    • Visible chest
      • Normal heart size.
      • The lung fields are clear.
      • No pleural effusion is found.
  • Imp: Multiple liver meta with lymphadenopathy in the abdominal cavity.
• 2020-08-10 CT - liver, spleen, biliary duct, pancreas
  • History and indication: cancer F/U
  • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
  • With and without-contrast CT of abdomen-pelvis revealed:
    • A small enhancing tumor (1.1cm) at liver dome with venous wash out pattern. S/P right hepatic lobe operation. Grade 4 fatty liver.
    • Normal appearance of spleen, pancreas, adrenals and kidneys.
    • Duodenal diverticulum.
    • Normal appearance of gallbladder.
    • Patency of portal vein.
    • Intact bony structures.
    • No ascites, nor enlarged lymph node.
    • No obvious extraluminal free air.
    • No abnormal density of heart.
    • Atherosclerosis of aorta, iliac arteries.
    • No abnormal density at bilateral basal lungs.
  • IMP:
    • A recurrent tumor (1.1cm) at liver dome. S/P right hepatic lobe operation. Grade 4 fatty liver.
• 2020-06-03 Patho - liver partial resection
  • Diagnosis
    • Liver, S7, resection — Cholangiocarcinoma
  • Gross Description:
    • Procedure: S7 partial hepatectomy, 7 x 6 x 3 cm, 70 gms
      
    • Tumor Focality: Solitary
      
    • Tumor Site: Right lobe S7
      
    • Tumor Size: 2.2 x 2.0 x 1.8 cm , 2.0 cm away from closest margin
      
    • Non-tumorous part: cirrhotic
      
    • Gallbladder: size: not received.
      
    • Sections are taken and labeled as: A1-2: tumor with margins; A3-4: tumor; A5: non-tumor.
      
  • Microscopic Description:
    • Diagnosis: Intrahepatic cholangiocarcinoma
      
    • Histologic Grade: G2: Moderately differentiated
      
    • Tumor Growth Pattern: Mass-forming
      
    • Tumor Extension: Tumor confined to hepatic parenchyma
      
    • Parenchymal Margin Uninvolved by invasive carcinoma
      
    • Bile duct Margin Uninvolved by invasive carcinoma
• 2020-05-19 Visceral Angiography 2 vessels
  • DSA of celiac trunk, common hepatic artery and SMA with post-angiography CTAP study via right common femoral artery puncture revealed:
    • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
    • Patency of portal vein.
    • A faint enhancing tumor at right hepatic lobe.
    • Post-angiography CTAP images also revealed a perfusion defect (2.5cm) at right hepatic lobe. Left liver cyst (5mm).
    • No procedure-related complication during the whole procedure.
  • IMP: Right liver tumor, HCC is first considered.
• 2020-05-15 CT - liver, spleen, biliary duct, pancreas
  • Indication:
    • 2015-08-14 HBV
    • 2020-05-12 US: susp tumor 17mm, > CT HBs(+) noted 30+y/o, HBe(-) antiHBe(+)
    • Vocal cord SCC 28y/o at Cardinal Tien Hospital and post R/T at NTUH 2017/4~6
    • FH: senior brother HBs + Cholangioca died 58y/o.
  • Findings:
    • There is an ill-defined hypodense mass lesion measuring 1.8 x 1.3 cm in S6 of the liver subcapsule area. During dynamic study, this mass shows mild contrast enhancement in arterial phase images and contrast washout in portal venous phase and delayed phase images.
      • HCC is highly suspected. The differential diagnosis include cholangiocarcinoma.
      • Please correlate with AFP and contrast enhanced dynamic MRI.
    • A hepatic cyst measuring 0.4 cm in S3 is suspected. Please correlate with sonography.
    • There is a diverticulum measuring 2.9 cm in the medial aspect of duodenum 2nd portion, near the ampulla of Vater area. Please correlate with clinical condition.
  • Imaging Report Form for Cholangiocarcinoma
    • Impression (Imaging stage): T:T1a (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:IA(Stage_value)
• 2020-05-04 SONO - abdomen
  • Diagnosis
    • Fatty liver, mild
    • Parenchymal liver disease, mild
    • Liver tumor, hypoechoic, nature indeterminate (1.7 cm, right lobe)
    • Suspected tiny GB polyps
  • Suggestion
    • Correlate with CT or MR
    • Check AFP
• 2019-11-05 SONO - abdomen
  • Findings
    • Smooth liver surface. Small anechoic lesion about 0.5cm was noted at left lobe.
    • No gall stone. Small polyp about 0.2cm was noted on the gallbladder wall. No CBD dilatation.
  • Diagnosis
    • Liver cyst, left lobe
    • Gallbladder polyp
• 2019-04-03 SONO - abdomen
  • Findings
    • Increased brightness, far attenuation and increased hepatorenal contrast
    • A few cysts were detected and the largest one 0.7 cm in size, was at S5
    • 2/3 pancreas was mask by bowel gas
    • Increased brightness of pancreas
  • Diagnosis
    • Fatty liver, mild
    • Fatty infiltration of pancreas
    • Liver cysts
• 2018-09-19 SONO - abdomen
  • Findings
    • Increased brightness of echotexture. One 0.70cm anechoic cystic lesion with posterior enhancement at S5.
    • One 0.35cm hyperechoic lesion within GB lumen. No dilatation of CBD.
  • Diagnosis
    • Fatty liver, mild
    • Hepatic cyst, right
    • GB polyp
• 2018-03-23 SONO - abdomen
  • Findings
    • Size normal; Surface smooth; Edge sharp; Vessel well-defined; Echotexture: increased hepatorenal echocontrast; One hypoechoic lesion about 0.8cm was found at the right anterior segment
    • One hyperechoic lesion about 0.4 cm in the GB; Normal GB wall thickness; No biliary tract dilatation
  • Diagnosis
    • Fatty liver,mild
    • Suspected liver cyst,right
    • Suspecetd GB polyp
    • Pancreas not shown
• 2017-09-21 SONO - abdomen
  • Findings
    • bright echo appperance with increased hepatorenal contrast, mild
    • obliteration of portal tract; a 0.77-cm anechoic lesion at seg5
    • a 0.48-cm polyp in GB ; no biliary tract dilatation.
  • Diagnosis
    • mild fatty liver
    • liver cyst
    • GB polyp
• 2017-03-22 SONO - abdomen
  • Indication: Hepatitis
  • Findings
    • Mildly bright liver echo comparing with renal cortex.
    • A 8-mm cyst in liver, right lobe.
    • A 6-mm polyp in GB. No biliary dilatation.
    • pancreas ~60% visible
  • Diagnosis
    • Mild fatty liver + Right Liver cyst
    • GB polyp

[consultation]

• 2023-01-17 Dermatology
  • Q
    • This 64-year-old male patient has past history of 1) Larynnx cancer (SCC), stage Tis, diagnosis at Cardinal Tien Hospital s/p radiotherapy at National Taiwan University Hospital on 2017/04 ~ 2017/06; 2) HBV under ETV (4/wk) tx (self-paid), 3) Hypertension, he was regularly followed up at OPD. According for his statement, abdominal sonography on 2020/05/04 showed 1) Fatty liver, mild; 2) Parenchymal liver disease, mild; 3) Liver tumor, hypoechoic, nature indeterminate (1.7 cm, right lobe); 4) Suspected tiny GB polyps. Further Abdominal CT was perfromed on 2020/05/17 and revealed 1) HCCs 1.8 x 1,3 cm in S6 of the liver is highly suspected. The differential diagnosis include cholangiocarcinoma. Alpha-feto-protein (AFP) was 3.0ng/dl on 2020/05/04. Angio CT on 2020/05/15 also revealed a perfusion defect (2.5cm) at right hepatic lobe. Left liver cyst (5mm).
    • Cholangiocarcinoma s/p weekly chemotherapy with Gemzar/CDDP * 8 doses (4 cycles) in TP-VGH (last dose on 2022/06/09). Liver tumor biopsy on 2020/06/03 and pathology showed cholangiocarcinoma. PD in new lesion over spleen based on the findings of CT on 2022/06/24.
      
    • He was transfer to our hospital for further treatment. The patient has been informed again palliative chemotherapy with FOLFOX (Oxalip 85mg/m2 and 5HT3 are not covered by NHI) on 2022/08/12. Palliative chemotherapy with FOLFOX (Oxalip 85mg/m2 self pay, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) on 2022/8/12(C1D1), 2022/08/26(C1D15), 2022/09/13(C2D1), 2022/10/05(C2D15), 2022/10/21(C3D1). Abdominal CT on 2022/10/24 showed multiple liver metastases with lymphadenopathy in the abdominal cavity. Target therapy with Lenvatinib (self pay) from 2022/11/16. Now, he was admitted to ward for target therapy with Lenvatinib (self pay).        
    • For Lenvatinib related side effect of hand, we need your further evaluation and management.
  • A
    • The patient had sufferred from mutiple erythematous plaques with thick scales and erosion.
      
    • Under the impression of hand-foot syndrome after chemotherapy and target therapy.
      
    • The following sugeetion:
      • Tetracycline onit 2 tube topical bid use on the wound and erosive lesions first.
      • Sinphraderm cream (urea 100mg/gm) 1 tube topical QN use after body clean for skin mositurization and keratolytic effect.
        
      • If new erythema lesions development, consider Topysm cream (fluocinonide) 1 tube topical bid use for anti-inflammation.
        • Fluocinonide is a high potency corticosteroid commonly used topically for a number of inflammatory skin conditions. ref: https://go.drugbank.com/drugs/DB01047
• 2020-05-18 Radiation Oncology
  • Q
    • for arrange angiography with CTAP (computed tomography arterial portography)
    • This 61 year-old male of DM, HBV.
    • Abdominal CT showed HCCs 1.8 x 1,3 cm in S6 of the liver is highly suspected. The differential diagnosis include cholangiocarcinoma. Please correlate with AFP and contrast enhanced dynamic MRI. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition, CT staging of HCC: T1N0Mx, Staging: I.
  • A
    • According to the clinical condition and imaging findings, angiography with CTAP study is indicated.

[chemotherapy]

• 2022-10-21 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3
• 2022-10-05 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-09-13 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-08-26 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
• 2022-08-12 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

[medication]

• Lenvima (lenvatinib) KLENV02
  • 2022-11-16 ~ undergoing 10mg QD
• Baraclude (entecavir) KBARA01
  • 2022-11-02 ~ undergoing 0.5mg QDAC
  • 2020-08-21 ~ + 84 days 0.5mg QDAC

[assessment]

• 2023-02-06 lab data showed low Na, low K, low Mg, low Ca in the blood, Nako No.5 electrolyte solution has been provided appropriately.
• Due to the patient’s blood pressure level staying at 90/50 for the past two days, it is not necessary to lower his blood pressure further. Please temporarily hold the self-carried Olmetec (olmesartan).
• Please follow up with the patient to determine whether the hand-foot syndrome is improving, if not, topical tetracycline, Sinphraderm (urea), and Topysm (fluocinonide) can be applied again.

230118

[assessment]

• Because lenvatinib has a moderate to high emetic potential, the antiemetic agent metoclopramide has also been prescribed appropriately in combination with lenvatinib.
• Lenvatinib’s dermatologic adverse reactions include: alopecia (12%), palmar-plantar erythrodysesthesia (27% to 32%), skin rash (14% to 21%). The developed hand-foot syndrome has been referred to a dermatologist and topical tetracycline, Sinphraderm (urea), and Topysm (fluocinonide) have been prescribed to mitigate the symptoms.
• As the patient has a history of hypertension, and lenvatinib is also associated with hypertension (45% to 73%; severe hypertension: 3%), it is recommended that blood pressure be closely monitored.

700151650

230203

{not completed}

[exam findings]

• 2023-02-02 Tc-99m MDP whole body bone scan
  • Mildly increased activity in the middle and lower T-spines, some L-spines and sacrum. Degenerative change may show this picture.
  • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
  • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral wrists, hip and right knee, compatible with benign joint lesion.
  • No prominent bone abnormality was noted elsewhere.
• 2023-02-02 SONO - chest
  • Echo diagnosis:
    • pleural effusion
  • Suggestion:
    • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
    • Check bleeding, if bleed from pig tail tube, please call Dr.
    • CxR follow up pig tail tube position.
• 2023-02-01 Bronchoscopy
  • no endobronchial mass,
  • s/p bronchial washing via RML, sent for TB culture, TB PCR and cytology
• 2023-01-31 SONO - thyroid gland
  • Normal size of the thyroid gland.
  • Some hypoechoic nodules (up to 0.67cm) in left thyroid gland.
  • Some LNs at bil. neck.
• 2023-01-19 Cell block
  • PATHOLOGIC DIAGNOSIS
    • Positive for malignancy
    • Immunocytochemistry show TTF-1(+), CK7(+), Napsin-A(+), CK20(-) and CDX-2(-), compatible with metastatic pulmonary adenocarcinoma
      
    • The smears and cell block show lymphocytes, mesothelial cells and many hyperchromatic atypical epithelial clusters with focal tubular arrangement, compatible with metastatic adenocarcinoma.
• 2023-01-19 SONO - chest
  • Echo diagnosis:
    • Pleural effusion
  • Suggestion:
    • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
• 2023-01-18 CT - chest
  • Findings
    • lungs:
      • a spiculated tumor at mediobasal segment of RLL (31mm in axial dimension) invading adjacent pericardium.
      • partial atelectasis of RML.
      • innumberable randomly distributed pulmonary small nodules of varying sizes due to lung to lung metastases.
      • moderate Rt pleural effusion.
    • Mediastinum and hila:
      • extensive lymphadenopathy in the visceral space, with central necrosis in subcarinal LAP.
    • Aorta:
      • normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
    • Heart:
      • normal in size of cardiac chambers.
      • mild calcified mitral annulus
    • Chest wall and visible lower neck:
      • suspect metastatic LAP aty Lt supraclavicular fossa.
    • Visible abdominal contents:
      • normal appearance of gall bladder.
      • a small Rt hepatic measurig 10mm.
  • Impression: RLL cancer T4N3M1a(E1)
  • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:M1a(M_value) STAGE:____(Stage_value)
• 2023-01-17 CXR
  • diffuse miliary lesions in both lungs with xonsolidation and volume reduce over Rt lower lung zone and Rt pleural effusion, miliary tuberculosis or metastasis
  • Mild dextroscoliosis of the T-spine
    
  • Thoracic aortic arch calcified atheriosclerotic plaque
• 2023-01-12 Merchant view (patella 45 0) Bil :
  • Lateral subluxation of the patella, Rt
  • Patellofemoral osteoarthritis
  • Sperner classification: 3, 3
• 2023-01-12 Knee BIL standing AP and Lat
  • Moderate to severe osteoarthritis of both knees, Rt > Lt
  • Ahlback calcification: grade 4, 3
• 2022-08-15 Peripheral Vascular Test - Vein, lower limbs
  • Significant venous reflux at left saphenofemoral junction with varicose change of left LSV from upper to lower leg level (Tortuous change at lower leg level). Slow venous return flow at left popliteal vein; atleast two perforator veins connecting the left PTV and LSV at left proximal to middle lower leg level were detected.
  • Slow venous return flow at left popliteal vein; atleast three perforator veins connecting the right PTV and LSV at right proximal to distal lower leg level were detected.
  • No evidence of venous thrombosis at bilateral lower limbs venous systems.
  • The ratios of MVO and SVC of bilateral legs were within normal limits.
• 2022-08-02 ENT Hearing Test
  • Reliabilty Fair to Poor, 50dB
  • PTA
    • R’t : 73 dB HL, moderately severe to profound mixed type HL
    • L’t : 68 dB HL, moderately severe to profound SNHL
  • Tymp
    • R’t : Type A
    • L’t : Type As.
• 2022-08-02 Nasopharyngoscopy
  • Findings
    • bil clear nasal cavity; smooth NPx, oropharynx, hypopharynx, no vocal lesion
    • a few whitish discharge coating on pharyngeal wall
  • Conclusion
    • chronic pharyngitis and rhinitis

701456943

230202

[diagnosis] - 2023-01-12 discharge note

• Adenocarcinoma of rectosigmoid junction status post laparoscopic low anterior resection on 2022/11/03, pT3N2aM0(6/17), stageIIIB
• Constiplation

[Past History]

• DM under metformin
• Adenocarcinoma of rectosigmoid junction status, cT3N2bM0, status post laparoscopic low anterior resection on 2022/11/03, pT3N2aM0(6/17), stageIIIB, LVI(+), PNI(-), CRM(-), EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+) , stageIIIC    

[Family History]

• His mother had colon cancer and DM
• His younger brother had colon cancer; one of his elder sister had lung adenocarcinoma; one of his elder sister had gastric cancer
• He denied other systemic diseases

[lab data]

• 2022-10-20 HBsAg (NM) Negative
  
• 2022-10-20 HBsAg Value (NM) 0.424
  
• 2022-10-20 Anti-HBs (NM) Positive
  
• 2022-10-20 Anti-HBs value (NM) 197
  
• 2022-10-20 Anti-HCV (NM) Negative
  
• 2022-10-20 Anti-HCV Value (NM) 0.0365

[exam findings]

• 2022-12-02 Anoscopy
  • Mixed hemorrhoids with congestion
• 2022-11-04 All RAS + BRAF mutation
  • ALL-RAS:
    • Detected (KRAS codon 12 GGT>GAT, p.G12D)
  • BRAF:
    • There was no variant detect in the BRAF gene.
• 2022-10-28 Patho - colon segmental resection for tumor
  • Diagnosis:
    • Intestine, large, RS colon, Laparoscopic low anterior resection — Moderately differentiated adenocarcinoma
    • Distal cut-end: Free
    • Proximal cut-end: Free
    • Lymph node, regiona, dissection — Metatstaic adenocarcinoma (6/17)
    • AJCC 8th edition pathology stage: pT3N2a(if cM0); AJCC stage IIIB
  • Gross Description:
    • Procedure: Laparoscopic low anterior resection
    • Tumor Site: RS colon
    • Tumor Size: 5 x 4 cm.
      
    • Macroscopic Tumor Perforation: Not identified
    • Macroscopic Intactness of Mesorectum (if applicable): Complete
    • Sections are taken and labeled as:A:distal cut end, B1-3:LNs, B4-10:tumor, C:proximal cut end
  • Microscopic Description:
    • Histologic Type: Adenocarcinoma
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
    • Margins
      • Proximal margin: Uninvolved
      • Distal margin: Uninvolved
      • Radial or Mesenteric Margin: Uninvolved
      • Distance of tumor from margin: 4 cm
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Not identified
    • Tumor Budding:
      • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2)
      • Low score (0-4)
    • Type of Polyp in Which Invasive Carcinoma Arose:Not identified
    • Tumor Deposits: Not identified
      • Specify number of deposits: N/A
    • Regional Lymph Nodes:
      • Number of Lymph Nodes Involved/Examined: 6/17
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors (required only if applicable) (select all that apply)
      • m (multiple primary tumors) r (recurrent) y (posttreatment)
        • Primary Tumor (pT)
          • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN)
          • pN2a: Four to six regional lymph nodes are positive
        • Distant Metastasis (pM):
          • N/A
    • Additional Pathologic Findings (select all that apply): None identified
    • Ancillary Studies: Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
    • Comment(s): None
• 2022-10-28 Sigmoidoscopy
  • Diagnosis
    • A fungating tumor lesion (3-4cm in size) is located at rectosigmoid junction (15cm AAV)
    • A middle rectal diverticulum
  • Suggestion
    • suggest operation
• 2022-10-21 CT - abdomen
  • History: passage of bloody stool, change in bowel habit, decrased stool caliber for weeks. tumor of RS-colon at YongHe local clinics.
  • Findings:
    • There is segmental wall thickening of the recto-sigmoid colon, measuring 1.3 cm in the maximal wall thickness that is c/w adenocarcinoma (T3).
      • In addition, There are seven enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w metastatic nodes (N2b).
    • There is a small poor enhancing lesion measuring 5 mm in S2 of the liver that may be cyst? Please correlate with sonography.
    • There is no focal lesion in both lung and mediastinum.
  • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:T3 (T_value) N:N2b (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)

[surgical operation]

• 2022-10-03
  • Surgery
    • Laparoscopic low anterior resection     
  • Finding
    • A fungating 4-5cm tumor is located at RS-colon. Some adhesions over small bowel and S-colon mesentery was found, and adhesiolysis was done.    
    • Radical proctectomy (low anterior resection) with total mesorectal excision was carried out smoothly. Blood loss was about 30ml.    
    • Anastomosis was achieved using endo GIA 601+ 451/ green, + CDH-33 + TISSEEL 4ml. Air test is ok.     
    • A drain in pelvis, 4DF 3g was applied for prevent adhesions.  

[radiotherapy]

• 2022-12-05 ~ 2023-01-13 - completed RT to the pelvis: 45 Gy/ 25 fx. The rectal tumor bed: 54 Gy/ 30 fx.

[chemotherapy]

• 2023-02-01 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 2hr + fluorouracil 2400mg/m2 4100mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
• 2023-01-09 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 2hr + fluorouracil 2400mg/m2 4100mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
• 2022-12-19 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
• 2022-12-05 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg

[assessment]

• The lab results (2023-02-01) were grossly normal.
• Metformin (prescribed by a local clinic) is not included on the active medication list despite the fact that the patient has a history of diabetes.
• If there are no contraindications, the addition of metformin is recommended to maintain stable blood sugar control.

700508887

230201

[potential drug interactions]

• Flunarizine (patient-carried) is cocommitant with clonazepam, diphenhydramine, estazolam and fexofenadine currently.

• According to the flunarizine product monograph (https://www.aapharma.ca/downloads/en/PIL/2021/Flunarizine_PM_EN.pdf), use of CNS depressants, including alcohol, should be avoided during treatment with flunarizine due to the risk of excessive sedation.

• There is also an antivertigo preparation available in stock known as Nilasen (betahistine 24mg/tab), which has a lower risk of drug interaction than flunarizine and can be considered as a 1# daily dosage alternative.

230112

• diagnosis
  • 2023-01-11 admission note - Acute lymphoblastic leukemia not having achieved remission
  • 2022-12-21 OPD assessment - MDS is considered with Karyotype: 45~46,XX,+1,der(1;16)(q10;p10)[cp7]/46,XX[7]
  • 2022-12-09 OPD assessment - MDS is considered
• past history - 20230111 admission note
  • Myelodysplastic syndrome diagnosed on 2022-12-05 by BM biopsy
  • Hypertension for years, with medication (Aprovel) control and regular follow-up at Cardinal Tien Hospital
  • Hyperlipidemia for years, with medication (Livalo) control and regular follow-up at Cardinal Tien Hospital
  • Thrombocytopenia since 2015, and regular follow-up at Cardinal Tien Hospital
• allergy
  • NKDA
• family history
  • Mother: Hypertension.
  • Deny any cancer history
• exam findings
  • 2023-01-11 CXR
    • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage.
  • 2022-12-05 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Normal cellularity with presence of blasts; Suspicious for myelodysplastic syndrome
      • NOTE: Correlation with peripheral blood test, bone marrow smear, flow cytometry, molecular genetic study and clinical findings is recommended.
    • Microscopically, it shows normal cellularity for age (40%), 3:1 of M:E ratio and presence of trilineage marrowe component. Occasional megakaryocytes are seen. Blasts are highlighted by CD34 and CD117 (<20%).
    • Immunohistochemical stain reveals MPO (focal +), CD71(focal+), CD20(focal+), CD138(focal+), CD10(-) and TdT(-).
  • 2022-12-02 CXR
    • cardiomegaly; mediastinal widening

230111

There is no specific pharmacist shift handover to follow in this patient.

[drug identification]

• A request has been made for us to identify drugs for 3 items.
• In total, 3 items have been identified as follows, with 0 item remaining unidentified.
  • Doxynin (doxycycline 100mg)
  • Welizen (famotidine 20mg)
  • Flamquit (diclofenac potassium 50mg)
• These drugs will be sent back to ward by the in-hospital porter.

701352128

230201

[diagnosis] - 2023-02-01 discharge note

• Gastric cancer with liver metastasis status post total gastrectomy with D2 and dissection, S2-3 left lateral segmentectomy, S6-7 partial hepatectomy and S4-8 alcohol injection on 2021-12-16, stage IV.
• Chronic viral hepatitis B without delta-agent, 2022/12/23 Anti-HBc: postive

[lab data]

• 2022-12-26 HBV-DNA-PCR Target Not Detected IU/mL
  
• 2022-12-23 Anti-HBc Reactive
  
• 2022-12-23 Anti-HBc-Value 4.82 S/CO
  
• 2021-12-13 HBsAg Nonreactive
  
• 2021-12-13 HBsAg (Value) 0.32 S/CO

[exam findings]

• 2023-01-31 CT - abdomen
  • Clinical history: 70 y/o male patient with Gastric cancer (pathology showed poorly adenocarcinoma) with outlet obstruction.
  • Impression:
    • S/P total gastrectomy.
    • Ascites with pleural effusion and basal lung atelectasis, progression.
    • Minimal pericardial effusion.
• 2022-10-12 CT - abdomen
  • History and Indication:
    • 20211206 Gastroscopy at Yonghe Cardinal Tien hospital: gastric cancer at the antrum induce gastric outlet obstruction.
    • 20211214 sono: A 1.7 cm hypoehcoic lesion at S2
    • 20211215 CT: gastric cancer & liver metas? cT4aN3aM1, csTAGE:IVB
    • 20211217 S/P total gastrectomy: pT4aN3bM1, pstage:IV
  • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings - Comparison: prior CT dated 2022/03/16.
    • There is ascites in pre-hepatic space, perisplenic space, and the pelvis.
      • S/P total gastrectomy.
      • S/P total resection of S2-3 and tumor enucleation of S6/7 of the liver.
    • Prior CT identified three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver are not noted again that are c/w metastases S/P C/T with complete response.
    • Prior CT identified A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is not noted again.
    • Others
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • There is ascites in pre-hepatic space, perisplenic space, and the pelvis.
• 2022-06-23 CT - abdomen
  • History and indication: Gastric cancer with liver metastasis
  • IMP:
    • Gastric cancer s/p operation. Minimal ascites in pelvic cavity.
    • Much regression of liver lesions.
• 2022-03-16 CT - abdomen
  • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • S/P total gastrectomy.
    • S/P total resection of S2-3 and tumor enucleation of S6/7 of the liver.
    • There are three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver that may be metastases? The largest one measuring 1.1 cm in S4.
    • A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is noted.
      • Primary lung cancer is suspected.
      • The differential diagnosis include Metastasis.
      • Follow up is indicated.
  • Impression:
    • There are three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver that may be metastases? The largest one measuring 1.1 cm in S4.
    • A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is noted.
      • Primary lung cancer is suspected.
      • The differential diagnosis include Metastasis.
      • Follow up is indicated.
• 2021-12-20 Upper GI series
  • S/P gastrectomy. No evidence of contrast medium leakage.
  • Normal contour and mucosal pattern of the esophagus.
  • Right CVP inserted to SVC in position.
  • Compression fracture of spine.
• 2021-12-17 Patho - liver partial resection
  • PATHOLOGIC DIAGNOSIS
    • Liver, S2-3, partial hepatectomy — Metastatic adenocarcinoma, stomach origin
      
    • Liver, S6-7, partial hepatectomy — Metastatic adenocarcinoma, stomach origin
      
  • MACROSCOPIC EXAMINATION
    • Procedures: Partial hepatectomy of S2-3 and S6-7
      
    • Specimen Size: 12 x 5.0 x 4.0 cm and 130 gm (S2-3); 3.0 x 2.0 x 1.2 cm (S6-7)
      
    • Tumor Focality: Multiple; number: 3 (S2-3) and 1 (S6-7)
      
    • Tumor Site: S2-3 and S6-7
      
    • Tumor Size: 1.4 x 1.2 cm, 1.2 x 0.9 cm, 0.2 x 0.2 cm (S2-3), and 0.8 x 0.6 cm (S6-7), respectively
      
    • Large vessel involvement: Not identified
      
    • Non-tumorous part: Not cirrhotic
      
    • Sections are taken and labeled as: A1-A4= S2-3 tumors, B1-B2= S6-7 tumor
      
  • MICROSCOPIC EXAMINATION
    • Diagnosis: Metastatic gastric adenocarcinoma
      
    • Histologic grade: Poorly differentiated
      
    • Tumor growth pattern: Infiltrating
      
    • Tumor pseudocapsule: Absent
      
    • Tumor necrosis: Present
      
    • Parenchymal margin: Uninvolved by carcinoma
    • Vascular invasion: Present
      
    • Perineural invasion: Not identified
      
    • Non-neoplastic liver parenchyma: Mild lymphocytic portal
• 2021-12-17 Patho - stomach subtotal/total (tumor)
  • PATHOLOGIC DIAGNOSIS
    • Stomach, total gastrectomy — Mixed tubular adenocarcinoma and poorly cohesive carcinoma
      
    • Margins, bilateral cutting ends, total gastrectomy — Free of tumor invasion
      
    • Lymph nodes, D2 LN dissection — Metastatic adenocarcinoma (46/60)
      
    • Omentum, omentectomy — Free of tumor invasion
      
    • AJCC Pathologic staging — pT4aN3bM1, stage IV
      
  • MACROSCOPIC EXAMINATION
    • Specimen type: Stomach, lymph nodes, omentum
      
    • Specimen size: (a) Stomach: 31.5 cm along the greater curvature and 16.0 cm along the lesser curvature (b) Omentum: 35 x 22 x 5 cm
      
    • Number of lesions: Solitary
      
    • Tumor site: Antrum to cardia, lesser curvature, 3.5 cm from distal margin
      
    • Tumor size: 12.5 x 11.0 cm
      
    • Tumor configuration: Ulcerative tumor
      
    • Representative sections as follows: A1= distal cut end, A2-A5= tumor with lesser curvature LNs, A6-A7= tumor at antrum, A8= tumor at body, A9-A10= tumor at fundus and cardia, B1-B2= omentum, C= esophageal margin, D1-D4= LN 1, E1-E2= LN 2, F1-F5= LN 4, G1-G2= LN 5, H1-H2= LN 6, I1-I4= LN 7,8,9,11,12a,16, J1-J2= LN 10, K1-K2= LN 14. F2021-00500FS= esophageal cut end received for frozen section
      
  • MICROSCOPIC EXAMINATION
    • Histologic type: Mixed tubular adenocarcinoma and poorly cohesive carcinoma (Lauren classification: mixed type)
      
    • Histologic grade: Poorly differentiation (G3)
      
    • Depth of tumor invasion: Tumor invades the serosa
      
    • Margins: All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin: <1 mm from radial margin
        
    • Perineural invasion: Present
      
    • Lymphovascular space invasion: Present
      
    • Regional lymph nodes: Metastatic adenocarcinoma (46/60) 8/8 (lesser curvature LNs), 0/1 (omentum LN), 12/14 (LN 1), 0 (LN 2), 14/14 (LN 4), 1/2 (LN 5), 4/5 (LN 6), 4/8 (LN 7, 8, 9, 11, 12a, 16), 0/1 (LN 10), 3/7 (LN 14) (Number of LN involved/Number of LN examined)
      
    • Extracapsular extension: Present
      
    • Omentum: Free of tumor invasion
      
    • Additional pathologic findings: Liver metastasis (S2021-18735)
      
    • Pathologic Staging: pT4aN3bM1, stage IV
      
    • IHC: HER2(Negative, score= 0)
      
    • Esophageal margin (including frozen section specimen): Free of carcinoma
• 2021-12-15 CT - abdomen
  • History and Indication:
    • 20211206 Gastroscopy at Yonghe Cardinal Tien hospital: gastric cancer at the antrum induce gastric outlet obstruction.
    • 20211214 sono: A 1.7 cm hypoehcoic lesion at S2
  • Findings:
    • There is an ill-defined poor enhancing mass measuring 1.5 cm in S2 dome of the liver at portal venous phase images and suggestive enhancement in delayed phase images.
      • In addition, there are two lesions measuring 0.5 cm in S4 and 0.7 cm in S5, showing similar feature.
      • Metastases are highly suspected.
      • The differential diagnosis include hemangioma.
      • Please correlate with MRI.
    • There is wall thickening at the gastric antrum measuring 1.3 cm in wall thickness. Please correlate with gastroscopy.
      • In addition, there are seven enlarged nodes in the gastrohepatic ligament, celiac trunk, and hepatoduodenal ligament that may be metastatic nodes.
  • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T4a (T_value) N:N3a (N_value) M:M1 (M_value) STAGE:IVB(Stage_value)
• 2021-12-15 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (84.4 - 24.6) / 84.4 = 70.85%
    • M-mode (Teichholz) = 70.9
  • Normal chamber size
  • Adequate LV and RV systolic function
  • Possibly impaired LV relaxation
  • AV sclerosis with mild AR, mild MR, TR and PR
  • No regional wall motion abnormalities
• 2021-12-14 Patho - stomach biopsy
  • Stomach, prepyloric antrum, biopsy— poorly differentiated adenocarcinoma with focal signet-ring cell differentiation
    
  • Microscopically, it shows poorly differentiated adenocarcinoma composed of proliferation of neoplastic cells arranged in solid to glandular architecture, and focal signet-ring cell diffferentiation.
• 2021-12-14 SONO - abdomen
  • Hepatic tummor, nature to be determinated
• 2021-12-14 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Suboptimal study due to much semi-fluid residue retention
    • Ulcerative tumor, preplyoric antrum and probable low body, s/p biopsy x6
  • Suggestion
    • Pursue biopsy result
• 2021-12-13 Spirometry
  • normal spirometry

[consultation]

• 2021-12-24 Radiation Oncology
  • Q
    • This 69 y/o male with history of gastric with liver meta then s/p total gastrectomy with LN D2+ dissection and S23 resection + S6-7 partial hepatectomy + S4-8 alcohol injection on 2021/12/16. Pathology showed Mixed tubular adenocarcinoma and poorly cohesive carcinoma. pT4aN3bM1, stage IV. after well improved of general condition and well oral intake, further management of CCRT will plaining. We need your help for RT evaluation. Thanks you!!
  • A
    • A: Mixed tubular adenocarcinoma and poorly cohesive carcinoma of the stomach, AJCC Pathologic staging — pT4aN3bM1, stage IV, with liver metastases, s/p total gastrectomy with LN D2+ dissection, S23 resection, S6-7 partial hepatectomy, S4-8 alcohol injection.
      
    • P: Radiotherapy is indicated for this patient with the following indicators: stage pT4aN3bM1
      • Goal: palliation
      • Treatment target and volume: gastric tumor bed, peripheral involved including regional lymphatic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the gastric tumor bed, peripheral involved including regional lymphatic area
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and would like to receive radiotherapy, The treatment planning of radiotherapy will be started at 8:30, 2022-01-10.

[surgical operation]

• 2021-12-16
  • Surgery
    • total gastrectomy with LN D2+ dissection
    • S23 resection
    • S6-7 partial hepatectomy
    • S4-8 alcohol injection
  • Finding
    • gastric ca lesser curvature cardia to lowewr antrum with multiple LN enlarge
    • serosa+
    • seeding-
    • multiple liver tumor
    • S2-3 at least 3 nodle 0.2, 0.8 1.2cmS6-7 0.8cm
    • S6-7 0.8 cm
    • S4-8 0,8 x 0.6cm in deep central parancyhma

[radiotherapy]

• 2022-01-19 ~ 2022-03-02 - 4500cGy/25 fractions (15 MV photon) of the gastric tumor bed, peripheral involved including regional lymphatic area.

[chemotherapy]

• 2023-01-30 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4775mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-12-22 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4770mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-12-09 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4740mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-11-25 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4740mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-11-09 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-10-24 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4760mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-09-27 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4760mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-08-24 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-08-10 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-07-27 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-07-08 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-06-22 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-06-06 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-05-23 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-05-03 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-04-19 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-03-29 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-03-15 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
• 2022-03-01 - fluorouracil 225mg/m2 380mg 24hr D1-2
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-02-21 - fluorouracil 225mg/m2 380mg 24hr D1-5
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-02-14 - fluorouracil 225mg/m2 390mg 24hr D1-5
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-02-07 - fluorouracil 225mg/m2 390mg 24hr D1-5
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-01-24 - fluorouracil 225mg/m2 390mg 24hr D1-5
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• 2022-01-19 - fluorouracil 225mg/m2 390mg 24hr D1-3
  • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

701460262

230201

[diagnosis] - 2023-02-01 discharge note

• Malignant neoplasm of cervix uteri, unspecified
• Squamous cell carcinoma, keratinizing, moderately differentiated of the uterine cervix, stage pT1a2 (III), with negative margin (HPV related), s/p laparoscopic assisted vaginal hysterectomy, with local recurrence.
• Type II diabetes mellitus

[lab data]

• 2022-11-29 HBsAg (NM) Negative
  
• 2022-11-29 HBsAg Value (NM) 0.775
  
• 2022-11-29 Anti-HBc Nonreactive
  
• 2022-11-29 Anti-HBc-Value 0.19 S/CO
  
• 2022-11-29 Anti-HCV (NM) Negative
  
• 2022-11-29 Anti-HCV Value (NM) 0.0347

[exam findings]

• 2022-11-21 MRI - pelvis
  • Clinical history: 42 y/o female patient with cervical CIN 3 and ov tumor said s/p hysterectomy in Keelung CGMH in 2020 , patho revealed cervical cancer (SCC, stage Ia2, patho Number S2020G-15625A), 2021 stump revealed VaIN 3 (S2021G-12951) -> local LASER was done. 2022/11/10 vaginal bleeding, suggest IVRT (intravaginal radiotherapy) if residual cancer tissues noted. next – ask the patient to bring the reports from previous hospital, + MRI + SCC + CEA check.
  • Impression:
    • S/P hysterectomy.
    • Recurrent tumors in the vaginal stump with colon and urinary bladder adhesion/involvement.
    • Cystic lesions, 2.35cm in left pelvic cavity.
• 2022-11-10 Gynecologic ultrasonography
  • s/p ATH
  • Suspcted Rt Ovarian cyst
• 2021-11-04 Pathology - vagina biopsy (Keelung CGMH)
  • S2021G-12951A: vagina biopsy — vaginal intraepithelial neoplasia III (VaIn III) — P16(+), suggestive high risk HPV infection.
• 2020-10-29 Pathology (Keelung CGMH)
  • S2020G-15625A: uterus, cervix, laparoscopic assisted vaginal hysterectomy — squamous cell carcinoma, keratinizing, moderately differentiated, pT1a2, wth negative margin (HPV related)
• 2020-10-26 Pathology (Keelung CGMH)
  • S2020G-15625: uterus, cervix, laparoscopic assisted vaginal hysterectomy — squamous cell carcinoma, keratinizing, moderately differentiated, pT1a1, wth negative margin (HPV related)

[surgical operation]

• 2020 Laparoscopic Assisted Vaginal Hysterectomy, LAVH (Keelung CGMH)

[radiotherapy]

• 2022-12-09 ~ - at 4500cGy/25 fractions (15 MV photon) of the pelvic area.

[chemotherapy]

• 2023-01-30 - cisplatin 70mg/m2 115mg 4hr D1 + fluorouracil 1000mg/m2 1660mg 24hr D1 (CCRT)
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + granisetron 2mg D1
• 2022-12-15 - cisplatin 70mg/m2 115mg 4hr D1-4 + fluorouracil 1000mg/m2 1660mg 24hr D1-4 (CCRT)
  • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + granisetron 2mg D1

700978478

230131

[diagnosis] - 2022-10-01 discharge

• Squamous cell carcinoma of upper third esophagus cT2N2M0,stage IIA
• Essential (primary) hypertension
• Type 2 diabetes mellitus without complications
• Unspecified viral hepatitis B without hepatic coma
• Hyperuricemia without signs of inflammatory arthritis and tophaceous disease
• Hypomagnesemia
• Constipation, unspecified

[exam findings]

• 2022-12-23, -12-20, -12-19, -12-16, -12-15, -12-14 CXR
  • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
  • Right internal jugular central venous catheter with tip in the superior cavo-atrial junction
  • s/p right chest tube in place, its tip directed superomedially, projecting over hilar shadow
  • Rt shift of trachea s/p esophagectomy and gastric tube reconstruction s/p gastric tube placement
  • Platelike lung atelectasis over Lt lower lung zone
• 2022-12-13 Patho - esophagus subtotal/total resection
  • Diagnosis
    • Esophagus, upper third, VATS McKeown esophagectomy —- Squamous cell carcinoma, moderately differentiated, s/p CCRT
    • Stomach, cardia, partial gastrectomy —- Negative for malignancy
    • Thoracic duct, right, excision —- Negative for malignancy
    • Resection margin: Negative for malignancy; cutend of proximal esophagus: Negative for malignancy
    • Lymph node, upper paraesophageal, specimen 1, dissection —- Negative for malignancy (0/1)
    • Lymph node, peri-gastric, specimen 1, dissection — Negative for malignancy (0/11)
    • Lymph node, right, group 2+4, dissection —- Negative for malignancy (0/15)
    • Lymph node, left, group 4, dissection —- Negative for malignancy (0/3)
    • Lymph node, right, group 7, dissection —- Negative for malignancy (0/3)
      
    • Lymph node, right, lower paraesophageal, dissection —- Negative for malignancy (0/0)
    • Left recurrent laryngeal nerve and lymph node, dissection —- Negative for malignancy (0/3)
    • Lymph node, left group 9, dissection —- Negative for malignancy (0/0)
      
    • AJCC 8 th edition pT N M Pathology stage: ypStage I, ypT2N0(if cM0)
  • Gross Description:
    • Procedure: VATS McKeown esophagectomy; Size: Esophagus: 10.0 cm in length with a portion of gastric tissue measuring 2.6 cm in length.
    • Tumor Site: upper esophagus
    • Relationship of Tumor to Esophagogastric Junction: Tumor is entirely located within the tubular esophagus and does not involve the esophagogastric junction
    • Tumor Size: 2.2 x1 .5 cm
      
    • Sections are taken and labeled as: A1-2: Distal gastric resection margin; A3: stomach; A4: esophagus;A5: EG junction; A6-9: tumor; A10: lymph node, upper paraesophageal; A11: lymph node, middle paraesophageal;A12: lymph node, lower paraesophageal; A13-14: lymph node, perigastric; B1-2: lymph node, right group 2+4; C: lymph node, left group 4; D1-2: lymph node, right group 7; E: right thoracic duct; F: lymph node, right lower paraesophageal; G: left recurrent laryngeal nerve and artery; H: proximal cutend of esophagus; I: lymph node, left group 9.
      
  • Microscopic Description:
    • Histologic Type: Squamous cell carcinoma, s/p CCRT
    • Histologic Grade: G2: Moderately differentiated
    • Tumor Extension: Tumor invades the muscularis propria
    • Margins: All margins are uninvolved by invasive carcinoma, dysplasia, and intestinal metaplasia
      • Distance of invasive carcinoma from closest margin (millimeters or centimeters): 1 mm
      • Specify closest margin: serosal
      • Proximal resection margin: 1.1 cm
      • Distal resection margin: 9.1 cm
    • Treatment Effect: Present, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response, score 2)
      
    • Lymphovascular Invasion: Present
      
    • Perineural Invasion: Not identified
    • Regional Lymph Nodes: please see diagnosis
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • TNM Descriptors: y (posttreatment)
      • Primary Tumor (pT): pT2: Tumor invades the muscularis propria
      • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
      • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
    • Additional Pathologic Findings: Acute inflammation is seen on serosa.
• 2022-11-26 MRI - brain
  • IMP: no evidenceof brain tumors.
• 2022-11-25 Tc-99m MDP whole body bone scan
  • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the lower C-spine, lower T-spine, L4-5 spines, bilateral shoulders, sternoclavicular junctions, hips and knees in whole body survey.
  • IMPRESSION:
    • In comparison with the previous study on 2022/09/16, no prominent change is noted, suggesting no definite evidence of bone metastasis.
    • Increased activity in the lower C-spine, lower T-spine and L4-5 spines. Degenerative change may show this picture.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2022-11-24 Bronchoscopy
  • Normal airways, no evidence of esophageal cancer invasion
  • COPD with some sputum in dependent airways
  • Chronic rhinitis
• 2022-11-23 Patho - esophageal biopsy
  • PATHOLOGIC DIAGNOSIS
    • Esophagus, upper, 23 cm, biopsy — Squamous cell carcinoma, moderately differentiated
    • Esophagus, upper, 26 cm, biopsy — Chronic esophagitis
    • Esophagus, lower, 35 cm, biopsy — Chronic esophagitis
  • MICROSCOPIC EXAMINATION
    • The sections of specimen (1) show a picture of chronic esophagitis, composed of squamous epithelium with congestion, basal cell hyperplasia, elongation of papillae, moderate inflammatory cells infiltration, and reactive atypia of epithelial cells.
    • The sections of specimen (2) show a picture of squamous cell carcinoma, moderately differentiated, composed of nests of polygonal to oval-shaped neoplastic cells with stroma invasion. Keratin formation is present.
    • The sections of specimen (3) show a picture of chronic esophagitis, composed of squamous epithelium with congestion, parakeratosis, basal cell hyperplasia, elongation of papillae, and mild inflammatory cells infiltration.
• 2022-11-23 Miniprobe Endoscopic Ultrasound
  • Diagnosis
    • Esophageal cancer, 23cm, EUS staging at least cT2N2, s/p biopsy(C)
    • Lugol voiding area, r/o dysphagia, 35cm, s/p biopsy(A)
    • Lugol voiding area, r/o dysphagia, 26cm, s/p biopsy(B)
    • Gastric subepithelial lesion, fundus, r/o lipoma
  • Suggestion
    • Consider to correlate to other image studies and pursue pathology report
• 2022-11-23 Cardiopulmonary Exercise Test
  • conclusion
    • maximal exercise
    • low exercise capacity (VO2 59%, WR 75%)
    • low stroke volume response during exercise
    • normal ventilatory function (FEV1/FVC, FVC 87%, FEV1 81%)
    • No SpO2 desaturation during exercise
    • normal respiratory muscle strength (MIP 101%, MEP 79%)
    • Health-related quality of life, CAT= 12, poor, cough, sputum, chest tightness predominant
  • suggestions:
    • treat underlying condition, treat cough, sputum, chest tightnes
    • survey and treat cardiac function
    • Adequate fluid intake to keep adequate stroke volume
    • suggest exercise training after operation
    • low risk for operation
• 2022-11-22 PET scan
  • In comparison with the previous study on 2022/09/14, the glucose hypermetabolism in the upper portion of the esophagus and some bilateral paratracheal lymph nodes is less evident.
    
  • Mild glucose hypermetabolism in bilateral pulmonary hilar regions, in bilateral shoulders and in the soft tissues around bilateral hips. Inflammation may show this picture.
  • Increased FDG accumulation in the colon and both kidneys, probably physiological accumulation of FDG.
  • No prominent abnormal focal FDG uptake was noted elsewhere.
• 2022-09-20 Pure Tone Audiometry, PTA
  • Reliability FAIR
  • Average RE 36 dB HL; LE 39 dB HL
  • R’t normal to severe SNHL.
  • L’t normal to severe SNHL but have ABG at 1k Hz.
  • 4k Hz notch was noted in both ears.
• 2022-09-17 MRI - brain
  • No evidence of brain metastases.
• 2022-09-16 Tc-99m MDP
  • No definite evidence of bone metastasis.
  • Increased activity in the lower C-spine, lower T-spine and L4-5 spines. Degenerative change may show this picture.
  • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
• 2022-09-15 Cardiopulmonary Exercise Testing
  • Conclusion
    • maximal exercise
    • low exercise capacity (VO2 73%, WR 67%)
      • normal stroke volume response during exercise
      • normal ventilatory function (FVC 83%, FEV1 82%)
      • Health-related quality of life, CAT = 13, poor
  • Suggestions
    • treat underlying condition
    • suggest exercise training
    • low risk for operation
• 2022-09-14 Whole body PET scan
  • A glucose hypermetabolism lesion in the esophagus, U/3, compatible with the primary esophageal cancer.
    
  • Glucose hypermetabolic lesions in bilateral mediastinal space, suspected cancer with regional lymph nodes metastases.
    
  • Glucose hypermetabolism in bilateral pulmonary hilar regions and in a right level II-III cervical lymph node, probably reactive nodes.
  • Glucose hypermetabolism in the right palatine tonsil, probably chronic inflammation process.
    
  • Increased FDG accumulation in the colon, probably physiological uptake of FDG.
    
  • Upper esophageal cancer with two regional lymph nodes metastases, cTxN1M0, by this F-18 FDG PET scan.
• 2022-09-14 Bronchoscopy
  • no endobronchial lesion
• 2022-09-13 ECG
  • Sinus rhythm with 1st degree A-V block
  • Incomplete right bundle branch block
• 2022-09-13 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 26) / 80 = 67.50%
    • M-mode (Teichholz) = 66
  • Preserved LV and RV systolic function with normal wall motion
  • Grade 1 LV diastolic dysfunction
• 2022-08-24 CT - chest
  • Imaging Report Form for Esophageal Carcinoma
  • Impression (Imaging stage): T:T2(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
• 2022-08-23 Patho - esophageal biopsy
  • Esophagus, 22-30 cm below incisors, biopsy — Squamous cell carcinoma, moderately differentiated
  • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei with subtle desmoplastic stromal reaction. Keratin formation is evident.
• 2022-08-22 SONO - abdomen
  • mild tomoderate fatty liver (suboptimal exam of liver)
  • mild gallbladder wall thickening
• 2022-08-22 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Segmental esophageal lesion, suspected advanced esophageal cancer, 22-30 cm below incisors, s/p biopsy
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis
    • The examination was suboptimal due to patient’s intolerance
  • Suggestion
    • Pursue pathology result
    • CT scan is indicated

[consultation]

• 2022-09-21 Hemato-Oncology
  • Q
    • This is a 55 year-old male, with underlying disease of (1) diabetes mellitus (2) hypertension. He suffered from dysphagia and odynophagia for one month. According to himself, he could swallow solid food, but there were foreign body sensation while food intake. No body weight loss, no fever, no cough. He then came to our gastrointestine clinic for help. Panendoscopy was done and and showed segmental esophageal lesion, further biopsy proven squamous cell carcinoma. Chest CT also done and revealed left lateral esophageal wall thickening with luminal narrowing at upper third of thoracic esophagus. Therefore, he was refferd to chest surgery clinic for further evaluation. After admission, we arranged PET, EUS, brain MRI, WBBS, bronchoscope and CPET for cancer work-up. On 2022-09-19, he underwent port-A insertion.
    • Impression: Upper thoracic esophageal cancer, cT2N2M0, Squamous cell carcinoma, moderately differentiated
    • We need to consult you for CCRT. Thanks a lot!
  • A
    • Impression:
      • Upper thoracic esophageal cancer, cT2N2M0, stageIII, Squamous cell carcinoma, moderately differentiated
      • Occult hepatitis B (anti Hbc positive)
    • Suggestion:
      • We will discuss with patient about CCRT, thanks for your referal
      • May arrange 24hr urine CCR and PTA auditory test
      • May arrange our OPD after discharge or transfer to our ward
      • If there is any problem, please feel free to let us known

[surgical operation]

• 2022-12-12
  • Surgery
    • 3D VATS esophagectomy + gastric tube reconstruction.
  • Finding
    • One tumor was noted over U/3 of esophagus, s/p CCRT
    • One 24 Fr. straight chest tube was inserted via right 9th ICS.

[radiotherapy]

• 2022-09-26 ~ undergoing? at 3240cGy/18 fractions of the esophageal tumor, peripheral including regional nodal area.

[chemoimmunotherapy]

Esophageal and Esophagogastric Junction Cancers, NCCN Evidence Blocks, 2022-09-07, Version 4.2022, ESOPH-F 5 OF 17, p49 = Principles of Systemic Therapy > Regimens and Dosing Schedules > Other Recommended Regimens

• Fluorouracil and cisplatin
  • Cisplatin 75-100 mg/m2 IV on Days 1 and 29
  • Fluorouracil 750-1000 mg/m2 IV continuous infusion over 24 hours daily on Days 1-4 and 29-32
  • 35-day cycle

Administration

• 2023-01-30 - cisplatin 75mg/m2 135mg 24hr + fluorouracil 1000mg/m2 1800mg 24hr D1-4 (PF4)
  • dexamethasone 8mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg 10min] post cisplatin
• 2022-10-21 - cisplatin 75mg/m2 135mg 24hr + fluorouracil 1000mg/m2 1800mg 24hr D1-4 (PF4)
  • dexamethasone 8mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3
• 2022-09-26 - cisplatin 75mg/m2 135mg 24hr + fluorouracil 1000mg/m2 1800mg 24hr D1-4 (PF4)
  • dexamethasone 8mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3

[assessment]

• Despite MgO PO, MgSO4 IV supplementation during hospitalization, this patient had several months of hypomagnesemia according to lab data. It is recommended that supplementation continue following discharge.

221025

[assessment]

• The current two-drug cytotoxic regimen (fluorouracil + cisplatin) is preferred for patients with advanced disease because of lower toxicity.
• The underlying conditions of hypertension, type 2 diabetes, hyperuricemia are well managed with patient-carried medications based on blood pressure, finger stick measurements and lab data.
• Hypomagnesemia (1.4mg/dL 2022-10-24) is treated with MgSO4 injection.
• The active prescription is not subject to any issues.

700999046

230131

[assessment]

• In response to anemia (2023-01-27 HGB 7.5g/dL), LPRBC 2U was transfused on 2023-01-28 to treat the condition.

• Cold hemagglutination was observed in 2023-01-27 lab data.

  • Cold agglutinins regularly occur during the course of two infections: 1. M. pneumoniae (primary atypical pneumonia), 2. Epstein-Barr virus (infectious mononucleosis). Case reports have described cold agglutinins in the setting of other viral infections such as HIV, rubella virus, influenza viruses, COVID-19 infection, or varicella-zoster virus (chickenpox). Not all individuals with these infections who develop cold agglutinins will have clinically significant hemolysis. For those who do, it usually occurs approximately two weeks after onset of the primary infection, diminishes as the infection begins to resolve, and is gone within two to three months.
  • Cold agglutinins have also been described in individuals with autoimmune disorders such as systemic lupus erythematosus (SLE) and rheumatoid arthritis.

701431422

230130

[exam findings]

• 2023-01-28 CXR
  • S/P pace-maker implantation.
  • Enlargement of right hilum.
  • Atherosclerosis of the aorta.
• 2023-01-27 CT - abdomen
  • Indication:
    • He received pancreatic ca stage I operation (Nov. 2022) at VGH.
    • He was recommended to receive TS-1
    • Night fever was noted since Dec. 16, 2022.
    • Fever, nature ? (20230113)
  • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
  • Findings:
    • There is a lobulated cystic lesion with enhancing wall at left anterior subphrenic space, measuring 14 x 6 x 4 cm (width x depth x cranial-caudal length).
      • Pseudocyst is highly suspected.
      • The differential diagnosis include abscess.
      • please correlate with clinical condition.
    • There are two lobulated cystic lesion in right and left para-colic gutter space, measuring 1.9 x 2.6 x 3.2 cm and 1.7 x 2.3 x 3,8 cm, respectively.
      • Pseudocysts are highly suspected.
        
    • There is another cystic lesion with enhancing wall at the midline pelvis, measuring 5 x 4 cm.
      • Pseudocyst is also suspected.
    • There is ascites in right perihepatic space,
    • S/P Whipple operation and S/P cholecystectomy.
    • There is mild left Pleura effusion.
    • Others
      • There is no focal abnormality in the biliary system, spleen & both kidney.
        
      • There is no evidence of lymphadenopathy.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
  • Impression:
    • Pseudocyst (14 x 6 x 4 cm) in left anterior subphrenic space is highly suspected.
      • The differential diagnosis include abscess. please correlate with clinical condition.
    • Three lobulated cystic lesions in bilateral para-colic gutter space and midline pelvis are noted.
      • Pseudocysts are highly suspected.
• 2023-01-16 ECG
  • Atrial-paced rhythm
  • Nonspecific ST and T wave abnormality
  • Abnormal ECG
• 2023-01-13 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • Scoliosis of the T-spine with convex to right side.

[assessment]

• Despite having a pacemaker implanted, the patient’s heart rate doubled from 64 (2023-01-29 20:03) to 144 (2023-01-30 08:50).

• Runaway pacemaker occurs when the pacemaker’s pulse generator discharges at a rate above its preset upper limit. The malfunction lies entirely within the pulse generator. It should be suspected if pacemaker dysrhythmias occur at rates greater than 130 beats/min or the upper rate limit if this is known. ref: Tachycardia in the presence of a pacemaker. Postgrad Med J. 2004;80(940):119-122. doi:10.1136/pmj.2002.004036q

701433000

230130

[lab data]

• 2022-07-21 Anti-HBc Reactive
  
• 2022-07-21 Anti-HBc-Value 7.05 S/CO
  
• 2022-07-21 Anti-HBs 10.17 mIU/mL
  
• 2022-07-21 Anti-HCV Nonreactive
  
• 2022-07-21 Anti-HCV Value 0.07 S/CO

[exam findings]

• 2023-01-28 Elbow LT
  • Left elbow X-ray shows
    • Permeative change of proximal radius is found. Fracture line is also found. Pathological fracture is considered.
    • Regional soft tissue swelling is identified.
• 2023-01-28 KUB
  • Phlebolith at pelvic cavity is found.
• 2023-01-28 CXR
  • Cardiomegaly is noted.
  • Nodular lesion at both lungs is found.
  • The trachea is deviated to right side is found.
• 2023-01-16, -01-10 CXR
  • Widening of the left upper mediastinum causing right lateral deviation of the trachea is noted. Please correlate with CT.
  • Borderline cardiomegaly
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • Few nodular opacity projecting at both lung are noted that are c/w metastases after correlate with CT.
• 2023-01-04 CT - chest
  • Findings - Comparison was made with previous CT dated on 20220624
    • Lungs:
      • multiple randomly distributed pulmonary nodules of varying sizes up to 26mm at RUL due to metastases.
      • septal thickening over medial Rt upper lobe.
    • Mediastinum and hila: resolution of M/3 esophageal tumor, with mild wall thickening.
      • extensive lymphadenopathy in the visceral space and left anterior prevascular space, with tracheal and thyroid gland invasion and encasing Ly common carotid artery
      • small pericardial effusion.
    • Pleura: minimal bilateral effusion.
    • Visible lower neck: metastatic LAPs in left deep cervical space,
    • Visible abdominal-pelvic contents:
      • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • no enlarged lymph node. no ascites.
    • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
  • Impression:
    • m/3 esophageal cancer with resolution of primary tumor but pogression of lung and distant LNs metastases compared with 2022-06-24
• 2023-01-03 Neck Soft tissue X-rays
  • Swelling of prevertebral soft tissue at C4-6 level.
  • Straightening alignment of cervical spine.
  • Degenerative change of the spine with marginal spur formation.
• 2023-01-03 CXR
  • Pulmonary nodules at right lung.
• 2022-10-26 Patho - lung transbronchial biopsy
  • Trachea, central, bronchoscopic biopsy —- acute and chronic inflammation — negative for malignancy
• 2022-10-14, -09-21, -09-07, -09-01 CXR
  • Widening of the left upper mediastinum causing right lateral deviation of the trachea is noted. Please correlate with CT.
  • Borderline cardiomegaly
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
• 2022-08-25 CXR
  • No active lung lesion.
  • No cardiomegaly.
  • T-spine spondylosis.
• 2022-08-17, -08-10, -08-03, -07-29 CXR
  • Widening of the left upper mediastinum causing right lateral deviation of the trachea is noted. Please correlate with CT.
  • Enlargement of cardiac silhouette.
  • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
• 2022-07-25 CXR
  • Port-A catheter inserted into SVC via left subclavian vein.
  • Crowding of vascular markings over Rt lower lung zone
  • Displacement of the tracheal axis to right at thoracic inlet and superior mediastinum probably due to lymph node enlargement,
  • enlarged cardiac silhoutte
  • A tracheostomy tube in place, proper position
• 2022-07-22 Patho - esophageal biopsy
  • Esophagus, upper, biopsy — Squamous cell carcinoma, poorly differentiated
  • Section shows several pieces of squamous mucosa with infiltration of nests of poorly differentiated tumor cells.
  • The immunohistochemical stain of p40 is positive.
• 2022-07-22 Miniprobe endoscopic ultrasound
  • Endoscopic findings
    • A fungating ulcerative tumor mass with easily touched bleeding is seen at the upper to middle esophagus 20cm to 35cm below the incisors. Biopsy *8 are done. The scope cannot pass through this stenotic site.
  • EUS findings
    • EUS using miniprobe (Olympus UM-DP-25R) showed whole layer thickening with loss of stratification and invading the surrounding structure. The tumor size is about 15 cm in length. There are three hypoechoic LNs found outside the esophagus.
  • Diagnosis
    • Esophageal cancer, T3N2, s/p Bx
  • Suggestion
    • Pursue biopsy result
• 2022-07-20, -07-18, -07-12 CXR
  • Crowding of vascular markings over both lower lung zones
  • Displacement of the tracheal axis to right at thoracic inlet and superior mediastinum probably due to lymph node enlargement,
  • enlarged cardiac silhoutte
  • A tracheostomy tube in place, proper position
• 2022-07-15 Patho - esophageal biopsy
  • Labeled as “esophagus, 20 cm to 35 cm”, biopsy — squamous cell carcinoma, poorly differentiated.
  • IHC stains: CK5/6 (+), P40 (+), CDX2 (weak +), CD56 (-).
• 2022-07-14 Esophagogastroduodenoscopy, EGD
  • Diagnosis
    • Esophageal cancer, 20-35cm, s/p biopsy
    • Duodenal shallow ulcers, D1 to D2
    • Reflux esophagitis LA grade A
    • Superficial gastritis, s/p CLO test
  • Suggestion
    • Pursue results of pathology and CLO test
    • PPI use
• 2022-07-13 Tc-99m MDP whole body bone scan
  • No strong evidence of bone metastasis.
  • Suspected benign lesions in the skull, maxilla, mandible, T-spine, right clavicle bone, bilateral shoulders, S-I joints, and hips.
• 2022-07-13 MRI - brain
  • no evidence of brain metastasis.
• 2022-07-12 Whole body PET scan
  • A glucose hypermetabolic lesion involving middle portion of the esophagus, compatible with primary esophageal malignancy.
  • Glucose hypermetabolism in some confluent upper left paratracheal lymph nodes with possible invasion to adjacent trachea, two right paratracheal lymph nodes and a lymph node in the upper abdomen just between the stomach and left lobe liver. Metastatic lymph nodes may show this picture.
  • Mild glucose hypermetabolism in the right lower lung field. Inflammation may show this picture.
  • Increased FDG uptake in the right vocal cord. The nature is to be determined (inflammation? physiological FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
  • Increased FDG uptake in bilateral neck muscles and mucles of anterior abdominal wall. Physiological FDG uptake is more likely.

[consultation]

• 2023-01-28 Orthopedics
  • A
    • Pat Bas Info
      • 62y/o male
      • Past history: Squamous cell carcinoma of middle third esophageus, cT4N3M0 stage IVA s/p jejunostomy, left Port-A implantation and tracheostomy on 2022/07/12
      • Allergy: NKDA
      • No current anti-platelet/anti-coagulation medication usage
      • 169cm, 66.5kg
    • Subjective: left proximal forearm tenderness after lifting motorcycle 3 days ago
    • Physical examination:
      • Inspection: left proximal forearm: mild swelling, no ecchymosis, no open wound
      • Palpation: left proximal forearm tenderness, aggravated when motion (supination/pronation)
      • Motion: elbow supination/pronation(+ but tenderness); wrist flexion/extension(+); finger motion(+)
      • Distal sensation: intact
      • Circulation: Capillary refill time <2sec, radial pulse(+)
    • X-ray:
      • Left proximal radius radiolucent density and permeative change, consider pathological fracture
      • No evidence of destructive bone lesion found on KUB.
    • Previous exam
      • 2022/07/13 Tc-99m MDP whole body bone scan
        • No strong evidence of bone metastasis.
        • Suspected benign lesions in the skull, maxilla, mandible, T-spine, right clavicle bone, bilateral shoulders, S-I joints, and hips.
      • 2023/01/28 CXR
        • Nodular lesion at both lungs is found.
    • Plan:
      • Long arm splint and triangular sling immobilization
      • Adequate pain control
      • Please arrange Tc-99m MDP whole body bone scan.
      • Conservative management was recommended first.
      • OPD follow-up and arrange further treatment
• 2022-07-21 Hemato-Oncology
  • Q
    • This 62-y/o male who denied any systemic disease was diagnosed with esophageal cancer this year.
    • Tracheostomy + Prot-A + Jejunotomy were performed on 2022/07/12, and brain MRI, whole body bone scan and PET scan were done.
    • His tumor staging was T4N3M0.
    • We would like to consult your expertise on arrangement of CCRT for the patient, thank you!
  • A
    • Impression:
      • Poorly differentiated Esophageal squamous cell carcinoma, with trachea compression and deviation cT4N3M0, s/p Tracheostomy + Prot-A + Jejunotomy were performed on 2022/07/12
      • Aspiration pneumonia
    • Suggestion:
      • CCRT is indicated in this case (PF4). Please check HbsAg, AntiHbc, Anti HCV. Arrange auditory PTA and 24 urin CCR

[surgical operation]

• 2022-07-12 Feeding jejunostomy + port-A + tracheostomy

[radiotherapy]

• 2022-07-29 ~ 2022-09-20 - 5040cGy/28 fractions of the esophageal tumor, peripheral involved, and regional lymphatic area.

[chemoimmunotherapy]

• 2022-10-13 - cisplatin 80mg/m2 150mg 24hr D1 + fluorouracil 1000mg/m2 1900mg 24hr D1-4
• 2022-09-14 - cisplatin 40mg/m2 75mg 2hr (CCRT)
• 2022-09-07 - cisplatin 30mg/m2 60mg 2hr (CCRT)
• 2022-08-17 - cisplatin 30mg/m2 60mg 2hr (CCRT)
• 2022-08-10 - cisplatin 30mg/m2 50mg 2hr (CCRT)
• 2022-08-05 - cisplatin 30mg/m2 50mg 2hr (CCRT)
• 2022-07-29 - cisplatin 30mg/m2 50mg 2hr (CCRT)

[assessment]

• When pulmonary symptoms limit the patient’s ventilation, oxygenation becomes more important.

• Laboratory 2023-01-28: MCV 68.5fL, MCH 21.5pg, both below LLN since 2nd half 2022, there may be an iron deficiency. It is recommended that the patient’s body iron level be checked in order to determine whether iron supplements need to be added.

221014

[assessment]

• There are no results for HER2 from the pathologies performed on 2022-07-22 and 2022-07-15. In the event that HER2 overexpression is confirmed, trastuzumab should be added to first-line chemotherapy. (NCCN 2022-09-07 version 4.2022)
• The serum magnesium level has been no higher than 1.8mg/dL since 2022-08-05 (with oral MgO currently). Hypomagnesemia due to urinary magnesium wasting occurs in over one-half of cases of cisplatin-induced nephrotoxicity. It can occur without the presence of concomitant AKI. In patients who receive cisplatin for several months, urinary magnesium wasting may persist even after discontinuation of cisplatin therapy. In addition to its direct clinical manifestations, hypomagnesemia may exacerbate cisplatin toxicity. As always, please keep an eye on the related signs.
• Hypokalemia (2022-10-13 3.1mmol/L) is managed with Radi-K (potassium gluconate) currently.
• It is suggested a solution consisting of isotonic saline supplemented with KCl and MgSO4 rather than isotonic saline alone. Specifically, a solution consisting of 1000 mL of isotonic saline plus 20 mEq of KCl and 2 grams of MgSO4, and administer intravenously a minimum of 1000 mL of this solution over two to three hours prior to, and a minimum of 500 mL over the two hours following, the cisplatin administration. This fluid administration should be adequate to establish a urine flow of at least 100 mL/hour for two hours prior to, and two hours after, chemotherapy administration. The rationale for adding potassium and magnesium to the solution is to avoid the development of hypokalemia and hypomagnesemia that may occur with forced diuresis; in addition, magnesium supplementation may help to limit cisplatin nephrotoxicity. The addition of furosemide is generally not required, unless there is evidence of fluid overload. (ref: UpToDate https://www.uptodate.com/contents/cisplatin-nephrotoxicity )

700387653

230127

[tube feeding, drug interactions]

• Scrat (sucralfate) should be administered on an empty stomach. Please shake suspension well before use and do not administer antacids within 30 minutes of administration of sucralfate. In general, it is recommended to separate administration of other oral medications and sucralfate by at least 2 hours. With Panzolec (pantoprazole) 40mg IVD QD (09:00) and Scrat 1g PO Q6H (05:00, 11:00, 17:00, 23:00), it should be less likely that there will be obvious interactions between the two. The adjustment does not need to be made.

• Bromelain, the main active ingredient in Broen-C tablets, is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. The drug is therefore designed to be enteric coated. There is no alternative for this ingredient available in the hospital at present time.

230112

{Management of vasogenic edema in patients with primary and metastatic brain tumors - glucocorticoids} - ref: https://www.uptodate.com/contents/management-of-vasogenic-edema-in-patients-with-primary-and-metastatic-brain-tumors

• 2023-01-11 brain MRI showed increased heterogeneous soft tissue enhacement in the right temporal lobe and right cavernous sinus with right cavernous ICA encasement. suspected radiation necrosis or tumors.

• Systemic glucocorticoids are the mainstay of symptomatic therapy for peritumoral edema. They play a role in stabilizing patients awaiting definitive treatment of the tumor as well as in palliative management of edema related to treatment-refractory tumors.

• Emergency management of increased ICP

  • A significant increase in intracranial pressure (ICP) causing drowsiness and other signs of impending herniation can be a medical emergency, and treatment should be undertaken as expeditiously as possible, typically in an intensive care unit setting. A bolus dose of dexamethasone (eg, 10 mg IV) should be given acutely, followed by 16 mg/day in divided doses. Doses as high as 40 mg/day may be given in the emergency setting for brain tumor-related edema and mass effect. Additional interventions during the first 24 to 72 hours may be required to lower ICP, such as hypertonic saline and mannitol.

• Initiation of glucocorticoids

  • Systemic glucocorticoids should be considered in all patients who have symptomatic peritumoral edema. Depending on the location of the tumor and the extent of edema, symptoms may be generalized (eg, headache, nausea, vomiting) or focal (eg, aphasia, hemiparesis), or both.
  • Dexamethasone is the standard agent for peritumoral edema management because its high potency and relative lack of mineralocorticoid activity reduce the potential for fluid retention [15-17]. In addition, dexamethasone can be given orally or intravenously (IV) with a 1:1 conversion ratio.
  • For patients requiring low to moderate amounts of dexamethasone (eg, 4 to 6 mg daily or less), prednisone is sometimes used as an alternative to dexamethasone in patients with steroid myopathy or in those with a history of adrenal insufficiency, as it allows for a taper in smaller increments.

• Dexamethasone dose and schedule

  • The antiedema effects of dexamethasone are dose dependent, and the starting dose should be individualized based on the extent of edema and the severity of symptoms [16,18,19]. Because most side effects are also dose dependent, the goal is always to use the lowest dose necessary to control symptoms.
    • In patients with moderate to severe symptoms (eg, severe headache, nausea and vomiting, significant focal neurologic deficits), the usual initial dexamethasone regimen consists of a 10 mg loading dose IV, followed by an initial maintenance dose of 8 to 16 mg daily in divided doses orally (or IV for patients not tolerating oral medications).
    • For patients with milder symptoms, a loading dose is usually omitted, and smaller total daily doses (eg, 2 to 4 mg divided once or twice daily) are usually adequate and less toxic.
    • Most patients who are asymptomatic do not require steroids, although clinical judgment is required in patients with large amounts of edema, particularly when antitumor therapy has the potential to worsen edema. Increased caution is also required for posterior fossa tumors and edema, which can be associated with rapid deterioration.
  • Although it has been customary to administer dexamethasone in four divided daily doses, its biologic half-life is sufficiently long (36 to 54 hours) to allow once- or twice-daily dosing, and this approach is preferred for maintenance therapy because it is easier for patients and has not been associated with diminished efficacy. We use once-daily morning dosing when possible and avoid late evening and middle-of-the-night dosing to help reduce insomnia caused by glucocorticoids. To minimize complications, subsequent dosing should be modified to use the lowest possible dose necessary to control peritumoral edema. (See ‘Complications and prophylaxis’ below and ‘Approach to taper’ below.)
  • Absorption of oral dexamethasone is excellent and is complete within 30 minutes of administration. Oral and IV dosing is equivalent. IV dosing may be necessary if oral absorption cannot be assured, or if oral intake is unsafe due to altered mentation or other deficits.

• Response assessment

  • Management of peritumoral edema is largely empiric. Clinical response, rather than radiographic changes, should guide most decisions.
  • Most patients begin to improve symptomatically within hours and achieve a maximum benefit from a given dose of dexamethasone within 24 to 72 hours. In general, headaches tend to respond better and more quickly than focal deficits, in part because edema may not be the only cause of focal deficits. The maximum neuroimaging response lags behind clinical response by days to a week or two.

• Inadequate response to initial dose

  • When patients fail to improve or improve only partially after several days on the initial dose, there are two main possibilities. Either a higher dose is required, or the residual symptoms are caused by factors other than peritumoral edema.
  • A trial-and-error strategy is often used to help distinguish between the two. For patients on submaximal doses, the dexamethasone dose is typically doubled for two to three days as a trial (usual maximum total daily dose, 16 mg). If the patient improves clinically, the higher dose is continued. The less a patient responds to a doubling of the dose, the less likely it is that symptoms are steroid responsive. If there is no response by 72 hours, the dose can generally be returned to the previous dose level without taper. This strategy helps to avoid excessive steroid dosing and toxicity in the absence of clinical benefit.
  • If a dexamethasone dose of 16 mg per day is insufficient, the dose may be increased further, although often with diminishing returns and excess toxicity. Alternative options for refractory edema should be considered in such cases.

• Approach to taper

  • Once patients have responded and stabilized clinically on a given dose of dexamethasone, a gradual taper should be attempted, if possible. This is particularly important for patients on high initial doses of dexamethasone (eg, >8 mg daily), as weight gain and proximal weakness often emerge within weeks at such doses. The likelihood of success and the speed of the taper depend on multiple factors, including the status of the underlying tumor, concurrent therapies, and the duration of steroid therapy. Postoperative steroid tapers in patients who have undergone complete tumor resection can be relatively rapid, for example, whereas efforts to taper steroids in patients with residual or progressive tumors must be approached more cautiously.
  • Dexamethasone has a long duration of action, and therefore a period of at least three to four days should generally follow each dose decrement to establish clinical tolerance of the lower dose. For patients in good clinical condition whose tumor has been stabilized with recent treatment, a taper may entail a reduction in dose of up to 50 percent every four days. A more protracted taper and chronic treatment may be required for patients with active tumors and those who do not tolerate initial attempts to wean steroids. Patients and caregivers should be educated about signs and symptoms that may signal reaccumulation of symptomatic edema as dexamethasone is being tapered (ie, recurrent or worsening headaches, focal deficits).
  • Symptoms not caused by recurrence of brain edema may develop during the course of the steroid taper (steroid withdrawal syndrome). These include mild headache and lethargy that may mimic recurrence of brain edema as well as myalgias and arthralgias (steroid pseudorheumatism). All of the symptoms respond to raising the dose slightly and tapering more slowly.

• Refractory edema

  • Management of chronic, symptomatic edema can be challenging. Many patients develop toxicities related to chronic glucocorticoids, which in some cases eventually outweigh the benefits. Surgical debulking of the associated tumor may be indicated in select cases, even when the goal is not curative, in order to help control the underlying cause of the edema. For certain tumor histologies, bevacizumab may be an option to help control edema. If globally elevated ICP is the main source of refractory headaches or symptomatic plateau waves, ventricular shunting may be an option in some patients.
  • Role of bevacizumab
    • Since vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of peritumoral edema, anti-VEGF monoclonal antibodies such as bevacizumab or inhibitors of VEGF receptors are useful in reducing edema. The steroid-sparing effects of bevacizumab were demonstrated in a randomized phase II study of bevacizumab with or without irinotecan in patients with recurrent glioblastoma, in which 30 to 50 percent of patients had a sustained reduction in glucocorticoid dose and approximately 20 percent achieved a complete taper. Other VEGF inhibitors have shown similar effects.
    • In patients with recurrent/refractory glioblastoma and symptomatic peritumoral edema, the clinical antiedema effects of bevacizumab can often be observed within days of the first dose. This effect tends to be persistent with ongoing therapy and can improve the likelihood of a successful dexamethasone taper.
    • Bevacizumab also finds selective use in the management of edema related to radiation necrosis.

• Symptomatic plateau waves

  • Plateau waves are sustained pressure waves that normally occur within the brain and are caused by activities that transiently raise the ICP (eg, standing, sneezing, coughing). In the presence of a brain tumor, significant further increases in ICP can temporarily cut off cerebral perfusion, leading to loss of consciousness. The treatment of choice for such cases is glucocorticoids and neurosurgical intervention for cerebrospinal fluid (CSF) diversion, when appropriate.

221110

• past history
  • Squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0 (stage III) under CCRT
  • HTN
  • Hyperurecemia
• exam finding
  • 2022-11-01 MRI - nasopharynx
    • The current study was compared to the prior one obtained on 2022/06/14.
    • Known a case of right oropharyngeal cancer S/P CCRT. Marked regression of prior shown soft-palate and tonsillar lesions. But progression of right sphenoid sinus lesion and more invasion of right masticator space.
    • Focal subcortical edema of right temporal lobe tip with abnormal enhancement, may be due to radiation necrosis. But direct invasion by adjacent tumor can not be ruled out. Suggest follow up.
    • Right-sided paranasal sinusitis.
    • Right otitis media and mastoiditis.
  • 2022-10-26 CT - abdomen
    • History: oropharyngeal cancer diagnosed in Mackey asked for further opinion and management
      • 2022-05-31 biopsy over right oropharynx (soft plate) MacKay Memorial Hospital: SCC
    • Findings:
      • There is mild dilatation of IHDs, CHD, and CBD.
        • Please correlate with serum alk-p and bilirubin level.
      • There is mild dilatation of the pancreatic duct and it seems directly drained into minor papilla.
        • Please correlate with MRCP to R/O pancreatic divisum.
      • There are few enhancing nodules on right hepatic lobe at arterial phase images but isodensity in portal venous phase and delayed phase images.
        • Spontaneous arterio-portal shunting are highly suspected.
        • Please correlate with sonography and MRI.
      • There is a newly-developed lobulated poor enhancing soft tissue mass measuring 3.5 cm in left hilum.
        • Metastasis is highly suspected.
      • S/P nasogastric tube insertion
      • Fecal material store in the colon.
    • Impression:
      • There is mild dilatation of IHDs, CHD, and CBD. Please correlate with serum alk-p and bilirubin level.
      • There is mild dilatation of the pancreatic duct and it seems directly drained into minor papilla. Please correlate with MRCP to R/O pancreatic divisum.
      • There are few enhancing nodules on right hepatic lobe at arterial phase images but isodensity in portal venous phase and delayed phase images. Spontaneous arterio-portal shunting are highly suspected. Please correlate with sonography and MRI.
      • There is a newly-developed lobulated poor enhancing soft tissue mass measuring 3.5 cm in left hilum. Metastasis is highly suspected.
  • 2022-09-09 CXR
    • Tortous aorta with calcification is noted.
  • 2022-09-09 ECG
    • Normal sinus rhythm
    • Voltage criteria for left ventricular hypertrophy
    • Abnormal ECG
  • 2022-08-27 CXR
    • S/P NG tube indwelling.
    • S/P Port-A infusion catheter insertion.
    • Ground glass opacity in LLL.
  • 2022-08-24 CXR
    • S/P port-A implantation.
    • S/P nasogastric tube insertion
    • Linear and nodular opacities projecting at left lower lung are noted. please correlate with clinical condition or CT.
  • 2022-08-13 CXR
    • Consolidation in left lower lung, stationary.
  • 2022-08-10 CXR
    • S/P port-A implantation.
    • S/P nasogastric tube insertion
    • Linear and nodular opacities projecting at left lower lung are noted. please correlate with clinical condition or CT.
  • 2022-08-03 Nasopharyngoscopy
    • Findings
      • Left nasal floor Tumor seen, partial obstruction,
      • NP smooth
      • PND+
      • Oropharynx partial occlusion by tumor
      • Bil vocal cord good motility, no paresis
      • Bil parapharyngeal wall tumor involvement
      • No saliva pooling in bil pyriform sinus
      • Vallecula/tongue base patent
      • NG in place
    • Conclusion:
      • orophayrngeal SqCC p16(+) cT4N0M0 Stage II under CCRT
      • OPD f/u
  • 2022-07-26 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Linear and nodular opacities projecting at left lower lung are noted. please correlate with clinical condition or CT.
  • 2022-07-21 CXR
    • Patchy consolidations at LUL-lingula and LLL due to pneumonia with pleural effusion still visualized
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2022-07-20 Bronchoscopy
    • symptom:
      • dyspnea with much sticky sputum
    • clinical diagnosis:
      • SCC of the oropharynx, p16(+), stage cT4bN0M0 (stage III) under CCRT, LLL pneumonia with much sputum
    • bronchoscopic diagnosis
      • Bronchitis, LLL, with pus like sputum over LLL bronchus and emerging from distal airway
  • 2022-07-16 CT - lung
    • LML and LLL consolidations, suspected pneumonia
    • A faint ehancing nodule(0.5cm) in S6 of liver. Suggest sonography correlation.
  • 2022-07-16 ECG
    • Normal sinus rhythm
    • Voltage criteria for left ventricular hypertrophy
    • Abnormal ECG
  • 2022-07-16 CXR
    • Consolidation in left lung
  • 2022-06-15 Tc-99m MDP whole body bone scan
    • 1. A hot spot in the left 1st rib, probably normal variant, post-traumatic change, or other benign nature. Please keep follow-up for further evaluation.
    • 2. Probably benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, S-I joints, and hips.
  • 2022-06-14 MRI - nasopharynx
    • AJCC 8th edition Staging status: T4bN0M0
  • 2022-06-14 Patho - esophageal biopsy
    • A: Esophagus, lower, near EG junction, biopsy — Compatible with Barrett’s esophagus
    • B: Esophagus, upper, biopsy — Compatible with heterotopic gastric mucosa
  • 2022-06-13 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal mucosal lesion, lower esophagus near EG junction, suspected to be secondary mucosal change due to reflux esophagitis or heterotopic gastric mucosa; s/p biopsy (A)
      • Esophageal mucosal lesion, esophageal inlet, probable heterotopic gastric mucosa; s/p biopsy (B)
      • Superficial gastritis
      • Oropharyngeal cancer
    • Suggestion
      • No endoscopic evidence of metachronous esophageal cancer
      • Pursue biopsy result
  • 2022-06-09 Nasopharyngoscopy
    • orophayngeal tumor involved bil. tonsils, soft palate with right soft palate perforation tongue base, hypopharynx, larynx: ok
  • 2022-05-31 Pathology (at Mackey Hospital)
    • Oropharynx, soft palate, right side, biopsy, squamous cell carcinoma.
    • The result of immunohistochemical study with p16 is positive for tumor cells.
    • Dr. DongYing Chen has reviewed the lesion slide and concurs with the diagnosis of carcinoma.
• consultation
  • 2022-08-31 Dermatology
    • Q
      • This 56-year-old man patient is a case of squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0, stage III s/p concurrent chemoradiotherapy. This time, for upper and lower limbs skin itch without redness rash. Now, for evaluate skin itch therapy. Thank you.
    • A
      • The patient had sufferred from SCC under chemoradiotherapy. Erythematous itchy papules with excoriative crust on the four limbs and turnk for days.
        
      • Under the impression of eczema with post-scretch wound and prurigo formation.
      • The following sugeetion:
        • Betason-N onit 3 tube topical bid use on the excoriative wound first
        • Topysm cream 2 tube topical bid use on the reddish itchy papule lesions.
          
        • add Cypromin lotion 10cc QID po for pruritus control.
  • 2022-07-28 Rehabilitation
    • Q
      • This 56 year-old man patient is a care of Squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0, stage III s/p concurrent chemoradiotherapy. This time, for being unable to open mouth. Now, for evaluate mouth rehabilitation. Thank you.
    • A
      • This is a 56 y/o male patient with history of
        • 1. Squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0 (stage III) under CCRT
        • 2.) Hypertension
        • 3.) Hyperurecemia under medication control.
      • He was regular F/U at our oncologist OPD.He was just discharge form our ENT ward on 2022-06-16.
      • PE
        • Consciousness: E4V5M6
        • Cognition:could follow orders
        • Speech: no aphasia
        • Swallowing: NG (+)
        • limited mouth and tongue ROM
        • Functional status: could ambulates with CG
        • BADL: needs max assistance (NG +
          
      • Assessment
        • Squamous cell carcinoma of the orpharynx, p16(+),
      • Plan
        • Lip-mouth movement instruction
  • 2022-06-14 Oral and Maxillofacial Surgery
    • Q
      • This 56 y/o male patient with history of HTN and hyperurecemia under medication control. This time, he went to our hospital due to progressive sore throat for 1 year and dysphagia for 6 months. Poor appetite and weight loss 10 kg in 6 months were also noted. Intermittent headache was also complained. Due to odynophagia and dysphagia progressed, he went to Mackey Hospital for help.
      • Biopsy for right soft palate was done, and the pathology was SCC, P16 (+). He went to our ENT OPD for second opinion and further management. At Dr. Su’s OPD, Nasopharyngoscopy showed orophayngeal tumor involved bil. tonsils, soft palate with right soft palate perforation. Tongue base, hypopharynx, larynx were grossly normal. PE showed no obvious lymphadenopathy. Admission for cancer work-up was suggested, and the patient and family agreed after well explanation. Under the impression of oropharyngeal cancer, P16 (+). the patient was admitted to ENT ward for cancer work-up. We need your help for pre-CCRT dental evaluation and management. Thank you very much!!
    • A
      • This is a 56 y/o male who suffured from SCC of orophayngeal regioninvolved bil. tonsils, soft palate with right soft palate perforation. and is about to received radiotherapy.
      • O:
        • 1. Hopeless tooth 17 and 38 were noted.
        • 2. Chronic gingivitis of full mouth was noted.
        • 3. Poor oral hygiene was noted.
      • P:
        • 1. Take panoramin film for tooth evaluation
        • 2. Suggest extraction of tooth 17 and 38.
        • 3. OHI (oral hygiene instruction)
• radiotherapy
  • 2022-07-13 ~ - 4400cGy/22 fractions of the oropharyngeal to nasopharyngeal tumor, peripheral involved, to bilateral neck.
• chemoimmunotherapy
  • 2022-09-22 - cisplatin 40mg/m2 65mg 2hr (CCRT)
  • 2022-08-24 - cisplatin 40mg/m2 65mg 2hr (CCRT)
  • 2022-08-17 - cisplatin 40mg/m2 65mg 2hr (CCRT)
  • 2022-08-10 - cisplatin 40mg/m2 65mg 2hr (CCRT)
  • 2022-08-03 - cisplatin 40mg/m2 65mg 2hr (CCRT)
  • 2022-07-13 - cisplatin 40mg/m2 65mg 2hr (CCRT)

[assessment]

• The level of SCC was high (2022-11-09 5.1 ng/mL) during the last half year.
• According to 2022-11-01 MRI and 2022-10-26 CT, the disease has regressed in some areas while progressing in others. It appears to be heterogeneous, increasing the possibility of resistance.
• As far as the active prescription is concerned, there is no problem.

220912

[assessment]

• It is possible that this patient will require a transfusion of LPRBC due to HGB 6.7g/dL on 2022-09-12.
• Newly developed oral candidiasis has been promptly managed with Mycostatin oral suspension (nystatin). The erythematous itchy papules that developed at the end of August 2022 are currently being treated with Cypromin (cyproheptadine).
• Blood culture and urine culture were performed on 2022-09-09, but the results have not yet been released. Tapimycin (piperacillin + tazobactam) has been used as an empiric antibiotic since then.
• Tube Feeding
  • Broen-C (bromelain + L-cysteine) is an enteric coated tablet and is not intended for use with a nasogastric tube. As of right now, there is no single ingredient bromelain item in stock, however, Actein (acetylcysteine 200 mg/pk) has also been prescribed and may act in part as cysteine.

220829

[assessment]

• It is not recommended that Broen-C is peel-halfed or ground because it is enteric-coated.
• There was a drop in blood pressure to 98/63 (2022-08-29 16:23), which should be noted.

701320382

230127

{drug interactions}

• Pantoprazole prescribing information states no clopidogrel dose adjustments are required during coadministration with an approved dose of pantoprazole.

700412091

230119

[exam findings]

• 2023-01-18 MRA - brain
  • Indication: The patient said that he started to have blurred vision an hour ago, numbness in his left hand and left face, and he had this once before, a small stroke.
  • IMP: Moyamoya disease. Acute infarct in right occipital lobe.
• 2023-01-18 CT - brain
  • Indication: The patient said that he started to have blurred vision an hour ago, numbness in his left hand and left face, and he had this once before, a small stroke.
  • Findings
    • Small calcifications in pineal gland.
    • A small calcificaiton focus at left VA.
  • IMP: No evidence of intracranial lesion.
• 2022-10-04 MRA - brain
  • Findings:
    • Focal subacute ischemic infarct over right posterior corona radiata (posterior water-shed area).
    • Old ischemic infarcts over both corona radiata (water-shed areas).
    • Engorgement of leptomeningeal vessels.
    • Total occlusion of right MCA and both ACAs. Near-total occlusion of left MCA. Markedly decreased flow of both MCA & ACA branches. Suggest check cerebral angiography.
    • Normal appearance of paranasal sinuses.
    • Normal appearance of both mastoids.
• 2022-10-03 Neurosonology
  • Mild to moderate stenosis in right CCA bifurcation (35.8% stenosis).
  • Minimal atherosclerosis in right proximal ICA and ECA.
  • Smaller caliber with decreased flow in right VA, indicating possible right VA hypoplasia; adequate total VA flow.
  • Normal extracranial carotid, and intracranial cerebral, vertebral, basilar arterial flows.
• 2022-09-11 ECG
  • Normal sinus rhythm
  • Nonspecific T wave abnormality
  • Prolonged QT
• 2022-09-11 CT - brain
  • Findings
    • Low attenuation in right parietal region.
    • A retention cyst (2.1cm) in left maxillary sinus.
    • Degeneration and spondylosis of C-spine.
  • IMP:
    • Low attenuation in right parietal region.
• 2022-08-30 C-spine AP and Lateral
  • Degeneration and spondylosis of C-spine.
• 2017-09-15 KUB
  • Degeneration of bony structures.

701008324

230118

[tube feeding]

• Harnalidge (tamsulosin, designed for extended release) 0.4mg PO QDAC should be replaced by Urief (silodosin) 8mg PO QD for tube feeding.

• Concor (bisoprolol 5mg/tab) package insert recommends swallowing the medication with some liquid and not chewing it. For tube feeding, the simple suspension method (SSM) involves suspending tablets and capsules in warm water for decay and suspension prior to administration, which can be applied to the Concor tablets.

700754253

230116

{High grade B-cell lymphoma with left aspect of mandible, multiple lymph nodes in the abdomen and the regions about the pericardium and pleura of left lower lung field, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1}

• diagnosis
  • 2022-08-31 admission
    • 1. Diffuse large B-cell lymphoma, unspecified site
    • 2. Pericardial effusion (noninflammatory)
    • 3. Essential (primary) hypertension
    • 4. Type 2 diabetes mellitus without complications
• past history
  • diseases
    • Hypertension for more years with medication control
    • Type II diabetes mellitus with OHA control,
    • Hypertensive cardiovascular disease.
  • surgical operation
    • HIVD s/p op on 202201
• family history
  • Mother: HTN, DM
  • No cancer history
• exam finding
  • 2023-01-13 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2022-11-29 CT - abdomen
    • Moderate regression of prior seen lymphoma in paraaortic region as compare with CT study on 2022-07-26.
    • Suspected uterine myomas.
    • Prominent soft tissue densities along bilateral ovarian veins, varices or prominent lymph nodes? Suggest follow up.
  • 2022-11-26 ENT Hearing Test
    • Tymp RE type C, LE type A
    • ART bil absent
    • PTA:
      • Reliability FAIR
      • Average RE 58 dB HL, LE 53 dB HL
      • RE mild to moderately severe SNHL (sensory neural hearing loss)
      • LE normal to moderately seevre SNHL
    • SRT (speech recognition threshold)
      • RE 45 dB HL
      • LE 35 dB HL
    • WDS
      • RE 88 % at MCL
      • LE 92 % at MCL
  • 2022-10-26 ECG
    • Sinus tachycardia
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-08-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (99.3 - 45.8) / 99.3 = 53.88%
    • 1. Normal AV/MV with no MR
    • 2. Concentric LVH, norma lLV wall motion
    • 3. Preserved LV and RV systolic function
    • 4. Mild PR, mild TR, normal IVC size
    • 5. Thickened peri-cardial fat
  • 2022-08-12 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2022-08-12 CXR
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-08-05 Patho - peritoneum biopsy
    • Lymph node, retroperitoneum, CT-guide needle biopsy — High grade B-cell lymphoma
    • Sections show lymphoid tissue with infiltration of medium-size, monoclonal lymphocytes. Marked apoptosis and some small granulomas are seen.
    • The immunohistochemical stains reval CD3(-), CD20(+), CD10(+), BCL6(+), BCL2(-), Cyclin D1(-), cMYC(-), and MUM1(-). The Ki-67 is nearly 100%. The PAS and AFB special stains are negative.
  • 2022-08-04 Whole body PET scan
    • 1. The FDG PET findings are compatible with lymphoma involving multiple lymph nodes in the abdomen (on one side of the diaphragm).
    • 2. Mildly increased FDG uptake in the regions about the pericardium and pleura of left lower lung field. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    • 3. Increased FDG uptake in a focal area in the left aspect of mandible. Dental problem may show this picture. Please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • 4. Increased FDG accumulation in the colon. Physiological FDG accumulation is more likely.
  • 2022-08-03 CXR
    • Cardiomegaly is noted.
    • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
    • Left pleural effusion is found.
    • There is no evidence of destructive bone lesion.
  • 2022-08-01 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • Left pleural effusion is found.
  • 2022-07-28 CXR
    • Cardiomegaly is noted.
    • S/p central line catheter placement with its tip at Superior vena cava.
    • s/p chest tube placement at left hemithorax.
    • Increased pulmonary vasculature is found.
    • Faint aveolar opacity over LEFT LOWER LOBE is found.
  • 2022-07-27 Cell block
    • Positive for malignancy, compatible with malignant B-cell lymphoma
      
    • The smears and cell block show lymphocytes, reactive mesothelial cells and atypical individual lymphoid cells with enlarged nuclei, nucleoli and degenerative quality. Immunocytochemistry shows CK(-), CD20(+), CD3(-), Bcl-2(+, focal) and calretinin(-) for atypical cells.
      
    • According to cytomorphologic findings, it is compatible with B-cell lymphoma. Clinical correlation and confirmatory biopsy is advised for further evaluation.
      
    • The smears and cell block show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2022-07-27 CXR
    • Cardiomegaly is noted.
    • Status post endotracheal tube placement.
    • S/p central line catheter placement with its tip at Superior vena cava.
    • s/p chest tube placement with its tip at left hemithorax.
    • Increased pulmonary vasculature is found.
    • Faint aveolar opacity over right lower lobe and left lower lobe is found.
  • 2022-07-26 CTA - chest
    • Enlarged LNs (up to 3.6cm) at retroperitoneum.
    • Pericardial effusion.
  • 2021-12-23 SONO - kidney
    • CC: left flank pain
    • DX: left hydronephrosis
  • 2021-12-18 CT - abdomen, pelvis
    • Left lower ureter stones (up to 6.3mm) with obstructive uropathy. Grade 4 fatty liver.
  • 2021-11-23 Colonoscopy
    • Diagnosis
      • Colon polyp, transverse colon, s/p forcep polypectomy.
      • Mixed hemorrhoid
    • Suggestion
      • F/U pathology report
    • Complication
      • No immediate complication
• consultation
  • 2022-12-09 Infectous Disease
    • Q
      • Chest film disclosed Faint aveolar opacity over Right lower lobe is found. Patent airway is found.
      • MTB Infection Report showed Indeterminate,pending for PJP and Aspergillus Ag
    • A
      • CxR film showed no pneumonia.
      • IGRA inderterminate report.
      • Aspergillus Ag negative.
      • Recheck IGRA 3-4 months later.
  • 2022-11-16 Colorectal Surgery
    • Q
      • she complained of anal pain and fever also noted, highly suspect anal abscess, we need your expertise for further management        
    • A
      • S
        • The patient was consulted CRS for anal pain for weeks. No anal bleeding
        • She has the diagnosis of High grade B-cell lymphoma with left aspect of mandible, multiple lymph nodes in the abdomen and the regions about the pericardium and pleura of left lower lung field, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1
      • O
        • Abdomen: soft, no tenderness, no distended
        • DRE: no palpable mass, no tenderness, no abscess or fistula, no fissure or ulcer
        • Mixed hemorrhoids(+), mild-moderate without thrombus
      • A: Mixed hemorrhoids
      • P:
        • Alcos-anal oint bid use, Proctosedyl 1# supp HS for 2 weeks
        • Consider sigmoidoscopy if still anal pain or “rectal pain”
        • No surgical indication at present
        • Suggest CRS OPD follow-up
  • 2022-11-01 Infectious Disease
    • Q
      • Lab data showed WBC 240, CRP 3.76. Chest x-ray showed increased denisty in the left lower lung field. Under the impression of neutropenic fever, chemotherapy related she was admitted for further evaluation and treatment.    
      • After admission, empiric antibiotics with Cefepime and targocid was administered but fever with occasionally chills was still noted. the blood culture yielded Corynebacterium spp.
      • We need your expertise for antibiotics evaluation, thanks
    • A
      • This is a case of high grade B-cell lymphoma s/p C/T.
      • WBC: 2960/uL
      • Corynebacterium spp. in blood culture might be contamination.
      • Suggestion:
        • Please collect B/C when fever
        • Check CMV PCR, sputum PjP PCR, sputum culture and sputum TB culture/AFB stain
        • Agree with your current use of imipenem and targocid
        • Please adjust antibiotic according to culture results and clinical conditions.
  • 2022-08-04 Radiological Diagnosis
    • Q
      • A case of B-cell lymphoma of pericardial effusion,CK(-), CD20(+), CD3(-), Bcl-2(+,focal) and calretinin(-).
      • CT of chest to abdomen showed enlarged LNs (up to 3.6cm) at retroperitoneum.
      • we need your expertise for CT guide biopsy,thanks
    • A
      • According to the clinical condition and imaging findings, biopsy is indicated.
  • 2022-08-02 Hemato-Oncology
    • Q
      • This 71 year old female with HTN, dyslipidemia, and DM was within her usual healthy state till 2~3 weeks ago c/o progressive SOB, and DOE.
      • CT showed large amount of bloody pericardial effusion, impending cardiac tamponade. s/p urgent PP window. The effusion appeared bloody pattern, and also intra-op TEE showed there is a ill-defined mass around the RA.
      • CT showed a enlarged LN over retroperitoneal space.
      • cell block showed Malignant b cell lymphoma.
      • Therefore, we need your expertise to guide us for further treatment and workup
    • A
      • The 71 year old female presented with pericardial effusion with impendiac cardiac tamponade post PP window. The effusion cell block revealed B cell lymphoma. Imaging study also revealed enlarged LN over retroperitoneal space and ill-defined mass aroud RA were noted also.
      • Comorbidity: with HTN, dyslipidemia, and DM.
      • Please arrange port-A for her and I can take over this case for further study and treatment.
      • Thank you for your referral.
  • 2022-07-29 Rehabilitation
    • A
      • Assessment
        • Pericardial effusion post PP window on 20220726
          
      • Plan
        • Rehabilitation programs: Bedside PT cardiopulmonary rehabilitation programs + coach training
        • Goal: recondition, improve endurance and muscle strength
        • May arrange PM&R OPD follow-up for further phase 2 cardiac rehabilitation program as needed
  • 2022-07-26 Cardiac Surgery
    • A
      • for opinion regarding treatment options for large amount of pericardial effusion referered from OSH.
      • impending tamponade.
      • Previous Hx: HTN dyslipidemia, DM
      • CXR showed enlarged heart. compared to her CXR in 2021/12 there is significant interval change.
      • CT reviewed, showed large amount of pericardial effusion, heterogenous, suspect old hematoma? cause TBD.
      • also reported there is a enlarged LN at retroperitoneal space
      • S/S wise, she c/o progressive DOE during the past 2 weeks. and after previous trip 2 days ago, significant limitation of exercise was noted. and also reported decreased urine output.
      • LAB: WNL, no anemia,
      • SUGGESTION & PLAN:
        • I think we have reached a point where there is prudence in considering surgical intervention, PP window, given her developing symptoms.
        • PP window will be arranged. specimen will be sent for full workup. (pericardial-pleural window, PP window)
        • TEE (Transesophageal echocardiography, TEE)
        • SICU admission.
      • The patient and family are agreeable with my surgical consultation.
• surgical operation
  • 2022-07-26 PP window via left minithoracotomy
    • pre-op CT and TEE showed large amount of pericardial effusion, also TEE found a heterogenous mass lying over RA, ~5cm in size.
    • 600cc bloody pericardial effusion was drained.
• chemoimmunotherapy
  • 2023-01-05 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
  • 2022-12-12 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
  • 2022-10-17 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
  • 2022-09-22 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
  • 2022-08-31 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
  • 2022-08-10 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 ( vincristine not available then ) + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
• G-CSF
  • Granocyte (lenogastin) CGRAN01
    • 2023-01-12 250ug QD SC D1-4 OPD
    • 2022-12-23 250ug QD SC D1-4 OPD
    • 2022-12-19 250ug QD SC D1-4 OPD
    • 2022-12-15 250ug QD SC D1-3 IPD 2022-12-08
    • 2022-10-20 250ug QD SC D1-3 IPD 2022-10-16
    • 2022-09-25 250ug QD SC D1-3 IPD 2022-09-22
    • 2022-09-09 250ug QD SC D1-3 OPD
    • 2022-08-22 250ug QD SC D1-3 OPD
  • G-CSF (filgrastim) CGCSF01
    • 2023-01-13 300ug QD SC D1-14 IPD
    • 2022-10-26 150ug ST SC IPD
    • 2022-10-26 150ug ST SC OPD
• WBC
  • 2023-01-16 WBC 1.44 *10^3/uL
    
  • 2023-01-15 WBC 0.75 *10^3/uL
    
  • 2023-01-13 WBC 0.23 *10^3/uL
    
  • 2023-01-12 WBC 0.77 *10^3/uL
    
  • 2023-01-05 WBC 3.73 *10^3/uL
    
  • 2022-12-27 WBC 8.58 *10^3/uL
    
  • 2022-12-23 WBC 0.57 *10^3/uL
    
  • 2022-12-19 WBC 5.03 *10^3/uL
    
  • 2022-12-08 WBC 6.85 *10^3/uL
    
  • 2022-11-25 WBC 3.93 *10^3/uL
    
  • 2022-11-13 WBC 6.81 *10^3/uL
    
  • 2022-11-07 WBC 5.83 *10^3/uL
    
  • 2022-11-02 WBC 10.65 *10^3/uL
    
  • 2022-10-31 WBC 2.96 *10^3/uL
    
  • 2022-10-28 WBC 0.99 *10^3/uL
    
  • 2022-10-27 WBC 0.34 *10^3/uL
    
  • 2022-10-26 WBC 0.24 *10^3/uL
    
  • 2022-10-24 WBC 7.69 *10^3/uL
    
  • 2022-10-16 WBC 4.35 *10^3/uL
    
  • 2022-09-29 WBC 4.94 *10^3/uL
    
  • 2022-09-22 WBC 4.27 *10^3/uL
    
  • 2022-09-16 WBC 3.51 *10^3/uL
    
  • 2022-09-09 WBC 2.77 *10^3/uL
    
  • 2022-08-31 WBC 4.90 *10^3/uL
    
  • 2022-08-26 WBC 11.19 *10^3/uL
    
  • 2022-08-22 WBC 1.08 *10^3/uL
    
  • 2022-08-12 WBC 12.86 *10^3/uL
    
  • 2022-08-04 WBC 6.85 *10^3/uL
    
  • 2022-08-01 WBC 6.70 *10^3/uL
    
  • 2022-07-27 WBC 14.02 *10^3/uL
    
  • 2022-07-26 WBC 9.53 *10^3/uL
    
  • 2021-12-23 WBC 5.62 *10^3/uL
    
  • 2021-12-18 WBC 8.24 *10^3/uL
    
  • 2019-05-26 WBC 7.41 *10^3/uL

[assessment]

• In late October 2022 and mid-Jan 2023, grade 4 neutropenia occurred approximately between 1-2 weeks after the patient’s receiving R-CHOP. As soon as neutropenia is identified, filgrastim and/or lenogastin has been appropriatedly administered. The WBC count returned to 1440 cells/uL on 2023-01-16.

• Following a peak of 220mg/dL (2023-01-14 17:00), the patient’s serum glucose level returned to 114mg/dL (2023-01-16 05:17). It is not necessary to modify the patient’s antihyperglycemic agent immediately.

• To treat neutropenic fever in this patient with hematologic malignancy, it is recommended to initialize an antipseudomonal beta-lactam agent, such as cefepime, meropenem, imipenem, or piperacillin-tazobactam. Since 2023-01-13, cefepime 2000mg IVD Q8H has been used.

• Since the culture result has not been released, teicoplanin 600 mg IVD QD and fluconazole 300 mg PO QD have also been added in order to broaden the scope of coverage.

• Based on 2023-01-13, 15, 16 lab data, there is no evidence that the patient’s liver or kidney function has declined. Therefore, no dose adjustment is required for the medication prescribed.

230106

[assessment]

• Cimetidine may increase the serum concentration of metformin. The AUC of metformin increased 40% when combined with a single dose of cimetidine (400 mg) and increased 50% after treatment with cimetidine (400 mg twice daily) for 5 days in healthy volunteers. In an another study of 15 healthy volunteers, cimetidine administration decreased metformin renal tubular clearance by 18.7% to 48.2%, depending on the individual’s organic cation transporter 2 (OCT2) genotype. Participants carrying the OCT2 808G>T polymorphism had lower baseline tubular clearance of metformin and a correspondingly lower magnitude of interaction with cimetidine.

• As the patient’s renal function still works (2023-01-05 Cre 1.08mg/dL, eGFR 53, BUN 14mg/dL), it is less likely to develop lactic acidosis, however, close monitoring might be necessary.

• The historical time series lab data suggest that the roughly cyclic trough WBC level (neutropenia events) was frequently observed around 3 weeks following each R-CHOP treatment. It might be necessary to plan in advance for the possible neutropenia 3 weeks after this hospital stay in order to ensure the G-CSF is accessible to the patient during the Chinese New Year long holidays.

220901

[assessment]

• Diagnosed T2DM. Glucose One Touch data: 228 (2022-08-31 17:05), 203 (2022-09-01 06:09), 256 (2022-09-01 11:12). No HbA1c records found.
• This patient is taking self-carried gliclazide 15mg QD and metformin 500mg TIDCC.
• Suggestion:
  • check HbA1c
  • add Forxiga (dapagliflozin 10 mg) 1# QD (preferred) or Trajenta (linagliptin 5 mg) 1# QD to achieve a fasting glucose level below 200 mg/dL.
  • please monitor for UTIs while the patient taking dapagliflozin.

701351712

230116

• diagnosis - 20230111 discharge note
  • Malignant neoplasm of lower third of esophagus
  • Malignant neoplasm of prostate
  • Squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA status post percutaneous endoscopic gastrostomy and port-A catheter implantation on 2022-09-05
  • Prostatic adenocarcinoma, cT3bN1M1 cstage IVB
  • Chronic viral hepatitis B without delta-agent
• past history - 20230103 admission note
  • Prostate cancer status post hormone therapy since 2022/03/16
  • Smoking (2 packs per day) and Drinking alcohol (over 1 bottled of whistsky) for 40 years, quited 20 years ago
  • Parkinsonism under follow up at our neurology outpatient department
  • Peptic ulcer disease status post medication about 20 years ago
  • Cervical herniated intervertebral disc status post surgery 30 years ago 
• exam findings
  • 2023-01-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 13.4) / 93 = 85.59%
      • M-mode (Teichholz) = 85
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Poor echo window
  • 2023-01-04 CT - chest
    • Indication: Malignant neoplasm of lower third of esophagus Malignant neoplasm of prostate, T3(T_value) N:N3
    • Findings
      • Lungs: extensive, bilateral upper lobes predominant, centrilobular emphysema, in the lungs. minimal fibrotic change at RLL and several small granulomas at RUL.
      • Mediastinum and hila: interval disappearance an intraluminal heterogeneous tumor at distal thoracic esophagus compared with CT on 2022/08/31
        • small LNs in upper paratracheal spaces and A-P window. old calcified LNs in the visceral space and anterior prevascular space, may be sequela of previous TB infection.
      • Vessels: extensive calcified plaques of the LAD, and LCX, and right coronary arteries.
      • Aorta: normal caliber, moderate atherosclerotic change of aortic arch and descending thoracic aorta.
      • Pleura: Rt apical fibrothorax. moderate-sized Lt effusion.
      • Chest wall and visible lower neck: no LAP
      • Visible abdominal contents: s/p percutaneous gastrostomy.
        • regions of atrophic change of Lt kidney. multiple metastatic LAP at E-G junction, along the celiac axis, significant in regression. mild dilated extrahepatic bule duct.
        • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and Rt kidneys.
      • Visualized bones: no destructive lytic or blastic lesion.
    • Impression:
      • D/3 esophageal cancer T3N3, significant in regression compared with CT 2022/08/31
  • 2022-11-30 Patho - esophageal biopsy
    • Labeled as “esophagus”, biopsy — ulcer.
    • IHC stain: CK highlights regular mucosa.
    • Section shows bland squamous mucosa with abundant ulcer debris.
  • 2022-11-30 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal scar, C/W Hx of esophageal cancer, L/3, s/p biopsy
      • Reflux esophagitis LA Classification grade A
      • Hiatal hernia
      • Superficial gastritis
      • PEG in situ
    • Suggestion
      • Pursue the result of pathology report
  • 2022-10-25 Bladder sonography
    • PVR 290 mL
  • 2022-10-11, -10-04 CXR
    • S/P port-A implantation.
    • Emphysematous change of both lung field
    • Borderline cardiomegaly
    • s/p percutaneous endoscopic gastrostomy
  • 2022-09-12, -09-08 CXR
    • areas of hyperlucency and decreased lung vascular markings due to emphysematous change of both lungs upper lung predominance
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
    • Coronary arterial calcification indicating CAD
    • Port-A catheter inserted into SVC via left subclavian vein.
    • small Lt pleural effusion?
  • 2022-09-07 ECG
    • Sinus tachycardia with Premature atrial complexes with Aberrant conduction
  • 2022-09-01 Whole body PET scan
    • Glucose hypermetabolism involving the lower portion of the esophagus, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in a subcarinal lymph node and possible some lymph nodes in the upper abdomen around the EG junction. Metastatic lymph nodes may show this picture.
    • Mild glucose hypermetabolism in bilateral pyriform sinuses. Inflammation is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Increased FDG accumulation in both kidneys, bilateral ureters and colon. Physiological FDG accumulaiton may show this picture.
  • 2022-09-01 Bronchoscopy
    • The nasal mucosa was hypertrophic.
    • The nasal lumen was severely narrowed.
    • The was copious mucoid nasal discharge retained in the nasal cavity.
    • Mucosa of nasopharynx was hypertrophic .
    • Nasopharynx was moderately narrowed.
    • Mucosa of pharynx cobble-stone in shape .
    • Oral and laryngeal mucosal candidiasis, diffuse.
  • 2022-09-01 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (21 - 7) / 21 = 66.67%
      • M-mode (Teichholz) = 65
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
    • Dilated aortic root
    • A tumor size 3.97x3.2 cm external compress LA. It induce LA volume very smal, maybe low preload status.
  • 2022-08-31 Nasopharyngoscopy
    • Smooth oral cavity, oropharynx and nasopharynx
    • Much saliva and sputum cumulation at bil. piriform sinus and esophageal inlet, cannot see mucosal surface well
    • Post. pharyngeal wall protruding with smooth mucosal surface
  • 2022-08-31 Pulmonary Flow Volume Loop
    • Mild restrictive and mild to moderate obstructive pulmonary function impairment
  • 2022-08-31 CT - chest
    • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-08-26 Patho - esophageal biopsy
    • Ulcerative tumor, from 35 cm below the incisors to EC Junction, biopsy — Squamous cell carcinoma
    • The specimen submitted consisted of three small pieces of esophageal tumor tissue measuring up to 0.4 x 0.3 x 0.1 cm in size, fixed in formalin. Grossly, they were gray in color and soft in consistence. All embedded for sections in one cassette.
    • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated of the esophageal tumor tissue characterized by some solid tumor cell nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrate in the stroma with keratin formation. Besides, ulceration, bacteria (bacilli) and fungal spores and hyphae, which morphology compatible with candidiasis are also noted.
    • Immunohistochemical stains of CK(+), P63(+), P16(-), PSA(-) and P53 (+, focal) for tumor.
  • 2022-08-25 Esophagogastroduodenoscopy, EGD
    • Esophageal tumor with luminal narrowing, 35cm below incisor to ECJ, s/p biopsy
    • Whitish esophageal mucosa, 20cm to 35cm below incisor, suspected food coating
    • Deformed antrum and GU scar, antrum
    • Superficial gastritis
    • DU scar, bulb
  • 2022-08-03 Sinoscopy
    • Dysphagia, may be parkinsonism related
  • 2022-05-11 Bladder Sonography
    • PVR 100.09 mL
  • 2022-05-11 Uroflowmetry
    • Q max: low
    • flow pattern: obstructive
  • 2022-05-04 MRA - brain
    • Old cerebral and left cerebellar infarcts. Intracranial artherosclerosis. General brain atrophy.
  • 2022-03-23 Electroencephalography, EEG
    • This EEG study recorded background alpha rhythm (8-9 Hz) and beta activity.
    • No epileptiform discharge.
    • Please correlate with clinical features.
  • 2022-03-11 MRI - prostate
    • Imaging Report Form for Prostate Carcinoma
    • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M1(M_value) STAGE:IVB(Stage_value)
  • 2022-02-22 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the lower C-spine and lower L-spines. Degenerative change may show this picture.
    • Increased activity in the lower portion of bilateral S-I joints. The nature is to be determined (degenerative change? other nature?). Please correlate with other clinical findings for further evaluation.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-02-10 Patho - prostate needle biopsy
    • Prostate, left and right, biopsy — Prostatic adenocarcinoma, Gleason grade 4+4 — 6 out of 6 tissues involved, occupying 50% of tissues
    • Microscopically, section shows Gleason-grade 4+4 adenocarcinoma composed of proliferation of crowded, fused and irregular neoplastic glands and infiltrative growth pattern. The neoplastic acini are lined by a single layer of epithelial cells and absent of basal layer. The epithelial cells are cuboidal and shows pleomorphic nuclei and hyperchromasia.
    • Immunohistochemical stain reveal AMACR(+) and 34BE12(-).
  • 2022-02-08 CXR
    • Post-op at C-spine.
    • No cardiomegaly.
    • Fibrotic infiltrates in right lung apex.
    • Thoracolumbar spondylosis.
  • 2022-02-08 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2022-01-04 Uroflowmetry
    • Q max: low
    • flow pattern: obstructive
  • 2022-01-04 Bladder Sonography
    • PVR 179 mL
  • 2021-12-14 Transrectal Ultrasound of Prostate, TRUS-P
    • Prostate
      • Size of prostate: 4.77(T)cm x 3.94(L)cm x 4.83(AP)cm = 47.2cc
      • Size of adenoma: 4.18(T)cm x 3.19(L)cm x 3.14(AP)cm = 21.8cc
    • Diagnosis: Benign prostatic hyperplasia
  • 2021-12-14 Uroflowmetry
    • Q max: low
    • flow pattern: obstructive
  • 2021-12-08 Bladder Sonography
    • PVR 381 mL
    • TPV 41
    • irregular posterior wall
• consultation
  • 2022-09-07 Gastroenterology
    • Q
      • After admission, cancer work-up was completed. The cancer stage revealed squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA. We has well explaining with patient and his family about further treatment. Further CCRT will be performed. Owing to anti Hbc positive, we need consult you for Entecarvir treatment before chemotherapy. Thanks a lot !
    • A
      • S
        • A case of newly diagnosis with squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA
        • We are consulted of Entecarvir treatment before chemotherapy
        • Plan: schedule chemotherapy at next admission
      • O
        • HBsAg: Nonreactive (8/31)
          
        • Anti-HBc: Reactive (8/31)
          
        • Anti-HCV: Nonreactive (8/31)
          
        • Bilirubin total: 1.43 (8/31)
          
        • S-GOT/AST: 17 (8/30)
          
        • eGFR: 63.28 (8/30)
      • P
        • Baraclude 0.5mg (GFR >50 QD, GFR 30-49 QOD, GFR 15-29 Q3D, GFR<15 or HD QW)
        • HBV carrier (HbsAg(+) or HbsAg(-) but anti-Hbc ab(+))
        • Start the Baraclude treatment 1 week before chemotherapy until 6 months after the end of chemotherapy.
        • Due to patient scheduled chemotherapy at next admission, may arrange GI OPD for prescribe Entecarvir 1 week before starting chemotherapy
          
  • 2022-09-07 Radiatoin Oncology
    • Q
      • After admission, cancer work-up was completed. The cancer stage revealed squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA. We has well explaining with patient and his family about further treatment. Operation of port-A catheter implantation and PEG was done on 2022-09-05. Thus we need consult you for radiotherapy. Thanks a lot !
    • A
      • This 83-year-old male patient has Parkinsonism disease and prostate cancer T3bN1M1a, with pelvic LAPs, status post hormone therapy since 20220316. This time, he suffered from swallowing difficulty for 4 months. Biopsy was done on 2022/08/25 and showed squamous cell carcinoma. The cancer stage revealed squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA.
      • Due to he and his family refused surgery, CCRT is indicated. CT-simulation will be arranged on 20220908. Plan to deliver 45 Gy/ 25 fx to the whole esophagus and adjacent lymphatic drainage area (including bil. SCF). Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. RT will start around 20220912. Thank you very much.
  • 2022-09-05 Hemato-Oncology
    • A
      • Impression
        • Squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA
        • Parkinsonism disease and prostate cancer T3bN1M1a status post hormone therapy since 2022/3/16
      • Suggestion
        • Anti Hbc positive, consult GI doctor for entecarvir before chemotherapy
        • We will discuss with patient and family about further systemic treatment. Please consult RT for further evaluation.
  • 2022-09-01 Thoracic Surgery
    • Q
      • This is a 83-year-old man , newly diagnoised with esophageal cancer, T3N3M0, pending obstruction.
      • Apart from the melignancy, there’s no specific underlying diseases.
      • We’d like to consult to you, with your expertise, we will have a better idea of the futher treatment for the patient.
    • A
      • I have explained possible preoperative CCRT followed by esophagectomy and gastric tube reconstruction.
      • Due to the patient’s old age and emphysema, the patient’s family preferred conservative treatment. As a result, definitive CCRT is suggested.
      • I will arrange EUS to complete esophageal cancer staging. Also, I will perform port-A catheter implantation and PEG for further CCRT and enteral nutrition support.
      • I will take over this case. Thanks for your consultation.
  • 2022-08-31 ENT
    • Q
      • This is a 83 y/o male with past history of prostate cancer s/p ADT, peptic ulcer, Parkisonism, VC HIVD S/P. This time, he was admitted due to dysphagia for 4 month, which was further biopsied and proved to be squamous cell carcinoma. Staging survey is still ongoing and uncertain but will be done in the next few days. We need your expertise to evaluate the presence of head and neck cancer or not. Thank you.
    • A
      • Local finding via scope (PACS):
        • Smooth oral cavity, oropharynx and nasopharynx
        • Much saliva and sputum cumulation at bil. piriform sinus and esophageal inlet, cannot see mucosal surface well
        • Post. pharyngeal wall protruding with smooth mucosal surface –> C-spine HIVD?
      • No obvious abnormal lesion noted via this exam, but cannot see bil. piriform sinus and esophageal inlet mucosal surface well
      • For further confirmation may consider LMS tumor mapping with ETGA, if needed and without contraindication of general anesthesia (ETGA = endotracheal tube intubation general anesthesia)
• SOAP
  • 2022-10-26 Hemato-Oncology
    • due to improved mood and body weight after increasing calorie and fluid, may consider C/T with biweekly HDFL 3 weesk later.
• radiotherapy
  • 2022-09-13 ~ 2022-10-26 completed RT to the esophagus and adjacent lymphatic drainage area (including bil. SCF): 45 Gy/ 25 fx. The esophageal tumor: 48.6 Gy/ 27 fx.
• chemotherapy
  • 2023-01-04 - leucovorin 300mg/m2 450mg 2hr + fluorouracil 300mg/m2 450mg 10min + fluorouracil 2400mg/m2 3600mg 46hr (HDFL for esophageal cancer)
    • dexamethasone 4mg
• medication
  • Leuplin Depot (leuprolide) CLEUP03, CLEUP01
    • 2022-10-25 11.25mg Q3M SC OPD
    • 2022-08-03 11.25mg Q3M SC OPD
    • 2022-05-11 11.25mg Q3M SC OPD
    • 2022-04-13 3.75mg Q4W SC OPD
  • Androcur (cyproterone acetate 50mg/tab)
    • 2022-03-16 ~ 2022-03-23 1# BID OPD
  • Vemlidy (tenofovir alafenamide 25mg/tab)
    • 2023-01-11 ~ 2023-01-18 1# QDCC IPD
    • 2023-01-04 1# ST IPD

[assessment]

• Compared to the image of 2022-08-31, the CT of 2023-01-04 showed significant regress of multiple metastatic LAP along the celiac axis. Considering that esophageal SCC was not treated with chemotherapy by the end of 2022, but prostate cancer has been treated with leuprolide for months, could there be a diminished likelihood that the LAP originates from the esophagus? <- this might not be the right question for the patient has completed radiotherapy during 2022-09-13 ~ 2022-10-26.

• The CT of 2023-01-04 also revealed extensive calcified plaques in the LAD, LCX, and right coronary arteries. Cilostazol may be indicated. 2D transthoracic echocardiography 2023-01-05 revealed an LVEF of 85%, Cilostazol is not contraindicated.

• The patient’s body weight decreased by 2 kg during the past week (2023-01-03 49.6kg, 2023-01-10 47.5kg), Nutritional assistance may be required on a more intensive basis

• Gastrostomy tube feeding is possible for all oral medications listed on the active prescription.

230104

[assessment]

• In accordance with ECOG PS 4, there has been no C/T for R/T. R/T has been completed as of 2022-10-26.
• The patient’s body weight increased from 42.4 kg on 2022-08-30 to 51 kg on 2022-09-13. However, no additional weight gain has occurred since then, even a slight decrease to 49.3 kg on 2023-01-03.
• Left ventricular end-systolic volume index = 7 / 1.45 = 4.8 mL/m2; LVEF 67% (2022-09-01). Cilostazol is not contraindicated.
• Tube feeding is possible for all oral medications listed on the active prescription. The current medication does not pose any problems.

701355603

230116

[assessment]

• 2023-01-15 lab data
  • RBC 3.59 *10^6/uL
    
  • HGB 12.4 g/dL
    
  • MCV 104.2 fL
    
  • MCH 34.5 pg
    
  • MCHC 33.2 g/dL
• MCV, MCH and MCHC

  • Anemia can be classified based on whether the MCV is low, normal, or elevated. A decreased MCV (usually less than 80 fL) indicates a defect in the synthesis of hemoglobin, which may be caused by an iron deficiency. And the presence of an increased MCV (>100 fL) is often attributed to asynchronous maturation of nuclear chromatin, although other factors may also contribute.

  • A low MCH is typically reflected in an enlarged area of central pallor in RBCs on the peripheral blood smear, which defines “hypochromia” on the blood smear. This may be seen in iron deficiency and thalassemia.

  • Very low MCHC values are typical of iron deficiency anemia, and very high MCHC values typically reflect spherocytosis or RBC agglutination.

• The patient’s MCV and MCH were above normal limits, while his MCHC was within normal limits. There might be a lesser likelihood of an iron deficiency. Please confirm whether Foliromin (ferrous sodium citrate) is necessary.

220919

{poorly differentiated squamous cell carcinoma of esophagu, cT3N2M0 stage III; poorly differentiated adenocarcinoma of stomach with liver metastases, cT3N0M1, stage IV}

• exam finding
  • 2022-08-10 CT - chest
    • further decrease in size of several poorly enhanciing hepatic tumors up to 22mm as compared with previous CT on 2022/04/26
    • collapse of thoracic esophagus without obvious wall thickening or intraluminal enhancing nodule or mass based on CT exam.
  • 2022-07-19 ECG
    • Normal sinus rhythm
    • Leftward axis
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-04-26 CT - lung/mediastinum/pleura
    • Findings
      • Lungs:
        • normal appearance of both lower lobes and RML.
        • mild centrilobular emphysema in both upper lobes.
        • Mediastinum and hila: no enlarged LN or mass.
        • a small intraluminal lesion at upper third of thoracic esophagus.
      • Vessels:
        • mild calcified plaques in left main coronary artery.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: trace Lt-sided effusion.
      • Chest wall and neck: unremarkable.
      • Visible abdominal-pelvic contents:
        • decrease in size of several poorly enhanciing hepatic tumors up to 30 mm compared with previous CT exam.
        • no obvious abnormal enhancing wall thickening or ulceration of stomach based on axial CT images
        • several small Rt renal cysts up to 5 mm.
        • normal appearance of gallbladder. unremarkable of the spleen, adrenal glands, and pancreas. no enlarged lymph node.
        • Extensive atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
      • Visualized bones: unremarkable.
    • Impression:
      • decrease in size of several poorly enhanciing hepatic tumors up to 30 mm as compared with previous CT on 2021/12/28
      • a small intraluminal tumor at upper third of thoracic esophagus and no visible sessile like intraluminal lesion at distal thoracic esophagus compared witH CT on 2021/12/28.
  • 2022-03-08 Spirometry and Bronchodilator Test
    • normal baseline without significant reversibility
    • FEV1/FVC = 79%, FVC = 156%, FEV1 = 151%
  • 2022-01-27 Patho - esophageal biopsy
    • Labeled as “35cm from incisor’, biopsy — poorly differentiated malignancy.
    • Section shows pieces of necrotic tissue, pieces of bland squamoius tissue, and neoplastic tissue with diffuse infiltrtion of nests of neoplastic basaloid cells with dysplastic polygonal shape neoplastic cells. The differential diagnoses include, but not limited to, poorly differentiated squamous cell carcinoma, poorly differentiated adenosquamous carcinoma, poorly differentiated adenocarcinoma, and neuroendocrine carcinoma.
    • IHC stains (S2022-1781):
      • CK (diffuse strong +) and CK5/6 (+): compatible with poorly differentiated squamous cell carcinoma.
      • CD56 (-), chromogranin (-), CK7 (-), CK20 (-), CDX-2 (-), Her2/neu: negative =0).
  • 2022-01-27 Patho - stomach biopsy
    • Stomach, labeled as “high body, GC”, biopsy — poorly differentiated malignancy.
    • Section shows pieces of necrotic tissue, pieces of bland gastric glands tissue with diffuse infiltrtion of nests of markedly crushed neoplastic round blue cells. The differential diagnoses include, but not limited to, poorly differentiated squamous cell carcinoma, poorly differentiated adenosquamous carcinoma, poorly differentiated adenocarcinoma, and neuroendocrine carcinoma.
    • IHC stains (S2022-1782):
      • CK (focal +) and CK5/6 (-): poorly differentiated carcinoma, NON-squamous cell.
      • CD56 (-), chromogranin (-): dis-favor neuroendocrine origin;
      • CK7 (-), CK20 (-), CDX-2 (-);
      • LCA (focal +), CD3 and CD20 no monoclonality: dis-favor lymphoma.
      • Her2/neu: negative =0).
  • 2022-01-27 Miniprobe Endoscopic Ultrasound
    • Diagnosis
      • Esophageal cancer, at least cT3N2, 35 to 40cm from incisor, s/p biopsy
      • Gastric cancer, at least cT3, high body, GC, s/p biopsy
    • Suggestion
      • F/U patho
  • 2022-01-24 Patho - liver biopsy needle/wede
    • Liver, CT-guided biopsy — Poorly differentiated carcinoma with extensive tumor necrosis
    • The sections show poorly differentiated carcinoma, composed of a few viable large pleomorphic neoplastic cells in fibrous stroma with extensive tumor necrosis.
    • IHC shows: CK(+), CK7(-), CK20(-), and p40(-). Neither squamous nor glandular differentiation can be identified in the sections examined.
  • 2022-01-24 EKG
    • Left axis deviation
    • Low voltage QRS
  • 2022-01-20 CXR
    • Atherosclerotic change of aortic arch
  • 2022-01-20 KUB
    • Fecal material store in the colon.
    • Spondylosis of the L-spine is noted.
    • Disk space narrowing of L3-4 and L4-5 is suspected.
• consultation
  • 2022-02-21 Radiation Oncology
    • Q
      • This 62 year old male has HBV, squamous cell carcinoma of esophagus suspected liver metastases, cT3N0M1 stage IV and adenocarcinoma of stomach suspected liver metastases, cT2N0M1 stage IV under FOLFOX for treatment since 2022-02. We need your help for RT assessment.
    • A
      • The patient’s history was reviewed and patient was examined.
      • S:
        • For radiotherapy due to esophageal and gastric cancer with liver metastasis.
        • PI: The patient was a case of poorly differentiated squamous cell carcinoma of the esophagus, stage cT3N2M0; and poorly differentiated carcinoma of the stomach, stage cT3N0M1, with liver metastasis. He suffered from body weight loss.
        • Family history: (father: gastric cancer)
        • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
        • Personal Hx: DM(-); HTN(+); HBV(+)
        • Previous RT Hx: (-)
      • O:
        • ECOG: 0
        • PE: neck and bil SCF: neg; bilateral low limbs: no edema; no tenderness and knocking pain of the bone.
        • KUB (2022-01-20): Fecal material store in the colon. Spondylosis of the L-spine is noted. Disk space narrowing of L3-4 and L4-5 is suspected.
        • CXR (2022-01-20): Atherosclerotic change of aortic arch.
        • Pathology (S2022-01455, 2022-01-26): Liver, CT-guided biopsy — Poorly differentiated carcinoma with extensive tumor necrosis
        • Miniprobe endoscopic ultrasound for upper GI (2022-01-27): Esophageal cancer, at least cT3N2, 35 to 40cm from incisor, s/p biopsy; Gastric cancer, at least cT3, high body, GC, s/p biopsy
        • Pathology (S2022-01681, 2022-02-01): CK (diffuse strong +) and CK5/6 (+): compatible with poorly differentiated squamous cell carcinoma. CD56 (-), chromogranin (-), CK7 (-), CK20 (-), CDX-2 (-), Her2/neu: negative =0). DIAGNOSIS: Labeled as “35cm from incisor”, biopsy (B) — poorly differentiated malignancy.
        • Pathology (S2022-01682, 2022-02-01): CK (focal +) and CK5/6 (-): poorly differentiated carcinoma, NON-squamous cell. CD56 (-), chromogranin (-): dis-favor neuroendocrine origin; CK7 (-), CK20 (-), CDX-2 (-); LCA (focal +), CD3 and CD20 no monoclonality: dis-favor lymphoma. Her2/neu: negative =0). DIAGNOSIS: Stomach, labeled as “high body, GC”, biopsy (A) — poorly differentiated malignancy.
      • A:
        • Poorly differentiated squamous cell carcinoma of the esophagus, stage cT3N2M0.
        • Poorly differentiated carcinoma of the stomach, stage cT3N0M1, with liver metastasis.
      • P:
        • Radiotherapy is indicated for this patient with the following indicators: esophageal cancer, stage cT3N2M0.
        • Goal: palliation
        • Treatment target and volume: esophageal tumor, peripheral involved, and regional lymphatic area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the esophageal tumor, peripheral involved, and regional lymphatic, and 5040cGy/28 fractions of the esophageal tumor bed area.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his sister. They understand and would like to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-2-24
  • 2022-01-24 Gastroenterology
    • Q
      • This 62 year old male has history of 1) hypertention for two years under medication control 2) HBV without followed
      • The initial presentations were dizziness and abdominal fullness since Dec 2021. Therefore, he came to Chung Shan Medical University for help. EGD on 2021/12/08 which showed 1) Reflux esophagitis, LA grade A 2) esophageal poyps 1cam at 35cm post lower esophagus suspected maligant polyp s/p tissue biopies. 3) Gastric ulcer, maligancy can not be rule out, GC side of upper body, s/p tissue biopies. EUS was performed on 2021/12/28 and biopsy of esophagus and stomach were sent. Pathology of esophgus proved squamous cell carcinoma and pathology of stomach proved adenocarcinoma. CT was performed on 2021/12/31 revealed 1) proven gastric and esophageal cancer 2) liver metastatic tumors. PET on 2022/01/11 showed cT3N0M1 disease for esophageal carcinoma and cT2N0M1 disease for gastric carcinoma. Owing to personal reason, he came to our ONC OPD for help.
      • Liver biopsy done on 2022/01/24 and pending, we need your expertise for further management.
    • A
      • Finding
        • 62M
        • EGD(2021/12/08):
          • 1. Reflux esophagitis,LA grade A
          • 2. Esophageal poyps 1cm at 35cm post lower esophagus suspected maligant polyp s/p tissue biopies.
          • 3. Gastric ulcer,maligancy can not be rule out, GC side of upper body, s/p tissue biopies
        • EUS(2021/12/28)
          • 1. Esophageal cancer, uT3N0
          • 2. Gastric cancer, EUS staging undefined (at least T2 according to the imaging pictures)
        • CT(2021/12/31)
          • 1. proven gastric and esophageal cancer
          • 2. Multiple liver metastatic tumors.
            • no signs of LC; arterial hypo-enhancement, favored mets
        • PET(2022/01/11)
          • 1. cT3N0M1 disease for esophageal carcinoma
               
          • 2. cT2N0M1 disease for gastric carcinoma
        • According to the previous report,
          • the endoscopy biopsy of the esophageal lesion: SCC, moderate differentiated
          • the endoscopy boipsy of the gastric lesion: poorly-differentiated adenocarcinoma in the specimen on 12/8, poorly-differentiated SCC in the specimen on 12/28
        • GI was consulted for further management
    • Impression:
      • Esophageal cancer, SCC
      • Gastric cancer, poorly-differentiated carcinoma; however, there was discrepancy between the two pathologic reports on 12/08 and 12/28 (SCC or adenocarcinoma)
      • Liver tumors, in favor of metastasis, s/p CT-guided biopsy
      • HBV carrier, without evidence of cirrhosis of liver
    • Suggestion:
      • Await biopsy result to determine the nature of liver tumor
      • Consider repeat EGD with EUS to re-staing and re-biopsy the gastric lesion
      • Check HbeAg, HBV DNA
      • Keep HBV prophylactic treatment
• radiotherapy
  • 2022-03-07 ~ 2022-04-18 - 4500cGy/25 fractions (15 MV photon) of the esophageal tumor, peripheral involved, regional lymphatic, and 5040cGy/28 fractions of the esophageal tumor bed area.
• chemotherapy
  • 2022-02-28 ~ undergoing - FOLFOX6

220608

[assessment]

• The survival outcomes of patients with synchronous primary esophageal squamous and gastric cancers were not worse than those of patients with isolated esophageal cancer or isolated gastric cancer. (Synchronous primary esophageal squamous cell carcinoma and gastric adenocarcinoma. https://www.nature.com/articles/srep13335 )
• It was reported that cases of synchronous esophageal and gastric cancer were successfully treated by multimodal therapy or other methods. references:
  • https://pubmed.ncbi.nlm.nih.gov/27760954/
  • https://pubmed.ncbi.nlm.nih.gov/21737661/
• The patient is able to tolerate the current FOLFOX6 regimen and lab data reported on 2022-06-07 were generally normal.

701458299

230116

• diagnosis - 20230105 discharge note
  • Wild type, adenocarcinoma of Sigmoid with multiple liver metastases, T3N1M1a, stage IVA
  • Chronic viral hepatitis B without delta-agent
• family history
  • Father: coronary artery disease
  • Monther: colon cancer
  • There is no family history of hypertension, mental diseases or asthma.
  • No members of the family with diabetes.
• exam findings
  • 2022-11-04 CXR
    • Atherosclerotic change of aortic arch
  • 2022-10-28 CT - abdomen
    • CC: jaundice, tea-colored urine and poor appetite for 2 weeks
    • histroy of sigmoid colon cancer with liver metastasis S/P operation on 2022/06/17 at MacKay Memorial Hospital
    • Indication: sigmoid cancer with liver metastasis
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There are multiple heterogeneous poor enhancing masses on both hepatic lobes that are c/w metastases. The largest one is measured 12.8 cm in size (the largest dimension).
        • In addition, both lobe portal vein show small size that are c/w passive compression and encasement by the liver metastases.
        • The peripheral IHDs on both lobes show dilatation that is c/w tumor compression.
      • There is ascites, a soft tissue nodule at right upper pelvis omentum, and smudgy appearance of the middle omentum.
        • Carcinomatosis is highly suspected.
        • Please correlate with ascites cytology.
      • There is right UPJ stone 9 mm causing minimal hydronephrosis but no evidence of delayed contrast excretion.
      • S/P right hemicolectomy.
        • S/P LAR with autosuture retention over the rectum.
      • There is mild right side Pleura effusion.
      • There are few enlarged nodes in paratracheal space. Follow up is indicated.
        • In addition, There are few poor enhancing nodules on both lobe thyroid that may be nodular goiter.
        • Please correlate with sonography.
      • Others
        • There is no focal lesion in both lung.
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
          
        • There is no bowel wall thickening, and no bowel obstruction.
          
        • The abdominal aorta and IVC are grossly unremarkable.
          
        • There is no evidence of intrinsic or extrinsic bladder mass.
          
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Multiple liver metastases on both lobes, causing total encasement of both lobe portal vein and dilatation of the peripheral IHDs.
      • Carcinomatosis is highly suspected.
      • Please correlate with ascites cytology.
  • 2022-10-27 SONO - abdomen
    • Diagnosis
      • Suspicious liver tumor with mucin production, both lobe
      • Hepatic cyst, right lobe
      • IHD dilation, left lobe
      • Ascites, mild
    • Suggestion
      • Please arrange other image to correlate clinical context
  • 2022-10-25 KUB
    • A calcified spot at RLQ.
  • 2022-10-25 CXR
    • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage.
• chemoimmunotherapy
  • 2023-01-15 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + palonosetron 250ug
  • 2023-01-03 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + palonosetron 250ug
  • 2022-12-19 - irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + palonosetron 250ug
  • 2022-12-06 - irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + palonosetron 250ug
  • 2022-11-21 - irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + granisetron 3mg
  • 2022-11-07 - irinotecan 180mg/m2 190mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3200mg 46hr (TBI 6.09mg/dL, irinotecan x 0.75, 5-fu x 0.8)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + granisetron 3mg

[assessment]

• As bilirubin total (0.67 mg/dL) and bilirubin direct (0.16 mg/dL) were both within normal ranges, no dose adjustment is required for irinotecan.

700169401

230113

• exam findings
  • 2023-01-02 Patho - breast biopsy (no need margin)
    • Breast, right, core biopsy — invasive lobular carcinoma
    • Microscopically, it shows invasive lobular carcinoma composed of infiltrative neoplastic cells arranged in linear or single-file pattern in a sclerotic background. The tumor cells display uniform, small atypical cells with round nuclei and inconspicuous nucleoli and intracytoplasmic vacuolations.
  • 2022-12-31 CT - chest
    • Indication: Secondary malignant neoplasm of bone
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Diffuse lytic change at spine, long bones, bilateral ribs and pelvic bony structure is found. MM is compatible.
        • Minimal pleural effusion at bilateral basal lungs is found.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • Minimal soft tissue enhancement at right breast, r/o breast cancer.
        • Left breast enhanced nodule. Bilateral breast cancer is favored.
      • Visible abdomen:
        • Hypervascular heptic tumor at S6 of liver measuring 0.8cm in largest dimension is found. Hemangioma is favored.
        • The GB is well distended without soft tissue lesion
        • Soft tissue mass at myometrium measuring 4.1cm in largest dimension. Myoma is favored.
        • Right ovarian cyst measuring 3.05cm in largest dimension.
        • There is no ascites accumulation at abdominal cavity.
        • There is no evidence of destructive bone lesion.
        • Suggest clinical correlation
    • IMp:
      • Diffuse lytic change at bony structures. Bone meta is favored.
      • Suspected right breast cancer and left breast enhanced nodule. Bilateral breast cancer is favored. T2N0M1, Stage IV.
  • 2022-12-30 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, scapulae, sacrum, bilateral multiple pelvic bones, bilateral S-I joints, bilateral humeri, femurs and possible the bone of right forearm.
    • IMPRESSION:
      • The scintigraphic findings suggest multiple bone metastases.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture. Please correlate with other clinical findings.
  • 2022-12-29 Femur RT
    • There is osteolytic lesion in right femoral head, right intertrochanter, and bilateral pubic bone that may be bony metastases. Please correlate with CT.
  • 2022-12-29 CXR
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • Bony metastases are suspected.
  • 2022-12-29 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — metastatic carcinoma.
    • IHC stains: GATA-3 (+); E-cadherin (-): in favor of invasive lobular carcinoma of the breast. ER: (+, 95%, stron gintensity), PR (+, 95%, strong intensity), Her2/neu: Negative (score=0), Ki-67: 10%.
    • Section shows piece(s) of bone marrow with 50% cellularity and marked desmoplasia. There is a predominant round blue neoplastic cell population arranged in file or trabeculae pattewrn.
  • 2022-02-24 Gynecologic ultrasonography
    • ut: 91x28mm
    • Myoma: 36x22mm, 37x31mm, 27x24mm, 19x11mm, 30x23mm,
      
    • EM: 19.5mm
    • ROV: 27x15mm
    • LOV cyst: 19x18mm
    • IMP:
      • suspected Mild Adenomyosis
      • suspected Lt Ovarian cyst
      • Multiple myomas
• medication
  • Zoladex (goserelin 3.6mg/syringe) CZOLA01 (10.8mg/syringe CZOLA02)
    • L02AE03. L02AE Gonadotropin releasing hormone analogues (See also H01CA - Gonadotropin releasing hormones). A combi-pack containing leuprorelin (L02AE02) injection and bicalutamide (L02BB03) tablets indicated for prostate cancer is classified in L02AE51.
    • 2023-02-02 3.6mg SC Q4W
    • 2023-01-05 3.6mg SC Q4W
  • Nolvadex (tamoxifen citreate 10mg/tab) KNOLV01
    • L02BA Anti-estrogens
    • 2023-01-05 ~ 2023-01-20 1# BID
  • Kisqali (ribociclib 200mg/tab)
    • L01EF02. L01EF Cyclin-dependent kinase (CDK) inhibitors. L01E PROTEIN KINASE INHIBITORS This group comprises protein kinase inhibitors used for neoplastic diseases. Substances are classified according to their main target. Substances which are multi-targeted without a clear main target are classified in L01EX. Lipid kinase inhibitors (phosphatidylinositol-3-kinase (Pi3K) inhibitors) are classified in L01EM.
      • The recommended dose of KISQALI is 600 mg (three 200 mg film-coated tablets) taken orally, once daily for 21 consecutive days followed by 7 days off treatment resulting in a complete cycle of 28 days. KISQALI can be taken with or without food.
    • 2023-01-05 ~ 2023-01-25 #3 QD

[assessment]

• The patient was with her husband, who might be the primary caregiver, at the time of my visit approximately 08:45 on 2023-01-13. I gave the patient the Kisqali (ribociclib) empty package along with the insert inside.
• It has been explained to the patient that they should be alert for any signs of adverse reactions of the drug such as interstitial lung disease, pneumonitis, cutaneous adverse reactions, prolonged QT intervals, hepatobiliary toxicity, and neutropenia; and to comply with the doctor’s instructions and cooperate with the regular lab tests.
• A small amount of redness and itching can be seen on the back of the patient’s neck, and there appears to be a small break in the mouth near the lips. Please follow up.
• There might be an increased QT prolongation with concomitant use of tamoxifen and ribociclib. KISQALI is not indicated for concomitant use with tamoxifen.
  • In MONALEESA-7, the observed mean QTcF increase from baseline was > 10 ms higher in the tamoxifen plus placebo subgroup compared with the non-steroidal aromatase inhibitors (NSAIs) plus placebo subgroup. In the placebo arm, an increase of > 60 ms from baseline occurred in 6/90 (7%) of patients receiving tamoxifen, and in no patients receiving an NSAI. An increase of > 60 ms from baseline in the QTcF interval was observed in 14/87 (16%) of patients in the KISQALI and tamoxifen combination and in 18/245 (7%) of patients receiving KISQALI plus an NSAI.
  • Data from a clinical trial in patients with breast cancer indicated that tamoxifen Cmax and AUC increased approximately 2-fold following coadministration of 600 mg ribociclib.
• Following coadministration of ribociclib with anastrozole, letrozole, exemestane, and fulvastrant, clinical trial data indicate that there are no clinically relevant drug interactions between ribociclib and these drugs.
• Palbociclib and abemaciclib are two other kinase inhibitors that are compatible with aromatase inhibitors and both are available in the stock.
• Please monitor ECG and electrolytes very closely if the combination of ribociclib and tamoxifen cannot be avoided.

700126908

230112

[tube feeding]

Current administration routes are IVD and TPN; there is no tube feeding at this time.

700049597

230110

• diagnosis - 2022-12-21 discharge note
  • Rectal cancer with stationary left lung metastases but increase in size of adrenal metastases stage IV
• past history
  • Constipation for many years.
  • Left pleural effusion, left subphrenic and peri-splenic abscess s/p pig-tail drainage on 2008-03-17.
    • COPD, old TB with medications in our hopital regular follow.
  • History of operations: s/p left femoral fracture.
  • Regular medications:
    • Xanthium 200 mg QD
    • Anoro Ellipta INH.
• exam finding
  • 2022-12-01 CT - abdomen
    • History and indication: Rectal cancer with stationary left lung metastases bur increase in size of adrenal metastases stage IV
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum.
      • Tumors (1.7cm, 3.7cm) at bil. adrenal regions.
      • Several nodules (up to 1.3cm) at left lung. Emphysema at bil. lungs.
      • Left renal cyst (0.5cm).
      • Atherosclerosis of aorta, iliac arteries.
      • S/P left femoral operation.
    • IMP: Rectal cancer with lung and adrenal metastases.
  • 2022-09-09 CT - abdomen
    • Findings:
      • Prior CT identified three metastases in LUL and LLL of the lung are noted again, decreasing in size (the maximal one 2.3 cm in prior CT and 1.6 cm at current CT) that are c/w lung metastases S/P C/T with partial response.
        • In addition, focal fibrotic change at RUL and emphysema of both lungs show stationary.
      • Prior CT identified metastases in right and left adrenal gland (4 cm and 2.2 cm) are noted again, stable in size that are c/w adrenal metastases S/P C/T with stable disease.
      • Prior CT identified several enlarged LNs at the mediastinum are noted again, decreasing in size that are c/w mediastinum LNs metastases S/P C/T with partial response.
      • Colostomy at right transverse colon is noted.
      • Left renal cyst (0.5cm).
    • Impression:
      • Lung metastases S/P C/T show partial response.
      • Bilateral adrenal metastases S/P C/T show stable disease.
      • Mediastinum LNs metastases S/P C/T show partial response.
  • 2022-06-29 CT - chest
    • rectal cancer with stationary left lung metastases but increase in size of adrenal metastases compared with CT on 20220224.
  • 2022-03-16 Patho - adrenal gland resection
    • Labeled as “right adrenal tumor”, core needle biopsy — metastatic adenocarcinoma.
    • IHC stains: CK 20 (+), CDX-2 (+), compatible with colonic origin.
    • Specimen submitted in formalin consists of 1 piece(s) of tissue measuring 2.4 x 0.3 x 0.3 cm. All for section(s) in one cassette(s).
  • 2022-03-07 Patho - lung transbronchial biopsy
    • Lung, LUL, CT-guide biopsy — consistent with metastatic colonic adenocarcinoma
    • Specimen submitted in formalin consists of 4 strips of tan, irregular tissue measuring up to 1.0 x 0.1 x 0.1 cm. All for section in one cassette.
    • Sections show acinar and cribriform glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal CDX2(+), TTF-1(-), and Napsin A(-). The results are consistent with metastatic colonic adenocarcinoma.
  • 2022-02-24 CT - abdomen, pelvis
    • Mild regression of recal cancer.
    • Progression of lung and adrenal tumors.
  • 2021-11-15 CT - abdomen, pelvis
    • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T3N2aM1a, stage IVA
  • 2021-11-12 Patho - colorectal polyp
    • Rectum, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (weak +), MSH6 (+), MSH2(+), MLH1 (+).
      
    • Specimen submitted in formalin consists of 5 pieces of tan, irregular tissue measuring 0.2 x 0.2 x 0.1 cm each. All for section in one cassette.
      
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2020-08-13 CT - lung/mediastinum/pleura
    • Imp: Severe COPD.
    • Bilateral apical lung fibrotic change.
  • 2019-06-04 Bronchodilator test
    • Flow-volum curve: Mild airway obstruction with significant response to bronchodilator.
  • 2018-09-18 Bronchodilator test
    • Flow-volum curve: Mild airway obstruction without significant response to bronchodilator.
  • 2017-10-17 Bronchodilator test
    • Flow-volum curve: Suspected small airway obstruction with significant response to bronchodilator.
  • 2017-01-24 Lung volume with function
    • Small airway obstruction with partial response to BD
    • Low IC, no HI, but air-trapping
    • Normal DLCO and normal raw favor smoking related small airway disease
• consultation
  • 2021-11-15 Colorectal Surgery
    • This is a 66-year-old male with a known history of
      • 1. COPD for 10+year under medical control
      • 2. s/p left femoral fracture
    • This time, he experienced constipation for 2 days and dark brownish stool after colonscopy on 2021-11-11, which showed ulcerative mass above 10cm AV s/p multiple boipsy. Besides, lower abdominal pain was accompanied with constipation. So he came to our ER for help. At ER, vital signs were stable. And lab revealed normal liver and kidney function but elevated CRP without leukocytosis and stool OB 4+. CT showed colorectal cancer T3N2aM1a.
    • Lab
      • PE: RLQ tenderness, no rebounding pain, no muscle guarding, no bilateral knocking pain
      • Hb 16 -> 14.6
      • PT 10.7 INR 1.03
      • PLT 198000
    • Colorectal Carcinoma, T3N2aM1a
    • Constipation for 2 days
    • Dark brownish stool after colonscopy on 2021-11-11
    • Assessment
      • Rectal cancer, cT3N2aM1a (Left lung mets)
    • Plan
      • please arrange admission on CRS VS
      • supportive care
      • contact us if still have any CRS problems
• surgical operation
  • 2021-11-17
    • Surgery
      • T-loop colostomy        
    • Finding
      • T-loop colostomy with stent was created at RUQ area   
• radiotherapy
  • 2021-11-29 ~ 2022-01 - deliver 43.2 Gy/ 24 fx to the pelvis, then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx.
• chemoimmunotherapy
  • 2023-01-09 - oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4230mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-12-19 - bevacizumab 5mg/kg 100mg 90min + oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 610mg 2hr + fluorouracil 2800mg/m2 4300mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-28 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 125mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4220mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-09 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 125mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4240mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-10-17 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 125mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4240mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-09-19 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 590mg 2hr + fluorouracil 2800mg/m2 4150mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-09-06 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 590mg 2hr + fluorouracil 2800mg/m2 4180mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-08-23 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4200mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-08-09 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4200mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-07-26 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 70mg/m2 100mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4200mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-07-07 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4250mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
  • 2022-06-17 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4250mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
  • 2022-06-02 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4270mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
  • 2022-05-18 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4290mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
  • 2022-04-28 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 260mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4300mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
  • 2022-04-15 - irinotecan 170mg/m2 260mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4380mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
  • 2022-03-28 - irinotecan 170mg/m2 260mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4400mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
  • 2022-01-05 - fluorouracil 225mg/m2 350mg 24hr (CCRT)
  • 2021-12-20 - fluorouracil 225mg/m2 350mg 24hr D1-5 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2021-12-13 - fluorouracil 225mg/m2 350mg 24hr D1-5 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2021-12-09 - fluorouracil 225mg/m2 350mg 24hr D1-2 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

220519

[assessment]

• The patient was diagnosed with colorectal carcinoma T3N2aM1a stage IVA, had a T-loop colostomy performed in November 2021, received CCRT from December 2021 to January 2022, and then began receiving palliative FOLFIRI in March (plus bevacizumab in April).
• The most recent CT (2022-02-24) revealed a mild regression in colon cancer and a progression of lung and adrenal tumors. In March 2022, biopsies subsequently confirmed that the lung and adrenal tumors were metastatic colonic adenocarcinomas.
• According to lab data reported on 2022-05-18, there were generally normal results. His underlying COPD is followed up in our office of thoracic medicine with refillable prescriptions.

700510940

230110

{not completed}

• exam findings
  • 2022-12-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (52 - 10) / 52 = 80.77%
      • M-mode (Teichholz) = 82
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Degenerative changes of mitral and tricuspid valves and marked posterior mitral annulus calcification with mild MR; trivial TR.
  • 2022-12-20 SONO - abdomen
    • A hepatic cyst 8 mm in S6 is noted.
      
    • A renal stone 0.51 cm in right kidney is suspected.
  • 2022-11-21 ECG
    • Normal sinus rhythm
    • Right atrial enlargement
    • Minimal voltage criteria for LVH, may be normal variant
  • 2022-09-27 Patho - breast mastectomy with regional lymph nodes
    • Diagnosis
      • Breast, right, simple mastectomy (S2022-16451) — Invasive carcinoma. No special type. NST.
      • Resection margin: free.
      • Lymph node, right, sentinel lymph node biopsy with frozen section (F2022-454FSB) — free (0/1)
      • Lymph node, right, Non-sentinel lymph node biopsy with frozen section (F2022-454FSA) — fibroadipose tissue; no lymph node, no malignancy.
      • pT1a pN0 (if cM0); anatomic stage: IA; pathology prognostic stage: IB
    • Gross Description
      • Procedure
        • right, simple mastectomy (S2022-16451): 12 x 8 x 3 cm with intact skin: 8 x 3 cm. Nipple present not retracted. Grossly tumor-like lesion: 1.8 x 1.2 x 0.4 cm, located at > 1 cm from all side margins. (Microscopiccaly, invasive component is 1.5 x 1 mm).
        • Lymph node sampling (if lymph nodes are present in the specimen)
        • sentinel lymph node biopsy with frozen section (F2022-454FSB)
        • Non-sentinel lymph node biopsy with frozen section (F2022-454FSA)
      • Specimen laterality- right
        • Sections are taken and labeled as:
          • Tissue for frozen section: F2022-454 FSA: SLN; FSB.
          • Tissue for formalin fixation: S2022-16451A1: four side margin: A2-4: tumor with deep margin (inked); A5: nipple.
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type:
          • Invasive carcinoma, no special type, NST
        • Size of invasive carcinoma (mm): largest focus: 1.5 x 1 mm
          
        • Histologic grade (Nottingham histologic score): grade II (score 6,7)
        • Extent of tumor (required only if the structures are present and involved)
          • Skin involvement: Absent
          • Chest wall invasion deeper than pectoralis muscle: no chest wall tissue submitted.
      • For Ductal Carcinoma In Situ-
        • Tumor size (mm): largest focus 10 x 2 mm
        • Nuclear grade: 2
        • Architectural pattern: Comedo
        • Tumor necrosis: Present
      • Margins:
        • Negative, Closest margin (4 mm from deep margin)
      • Nodal status: Negative
        • No. examined: 1
        • No. macrometastases (>2 mm): 0
        • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
        • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
      • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received) - no presurgical (neoadjuvant) therapy.
      • Immunohistochemical Study: result of biopsy specimen: S2022-15368: ER (-), PR (-), Her2/neu: negative (0/1+), Ki-67 inedex: < 10%.
  • 2022-09-20 PET
    • Mild glucose hypermetabolism in a focal area in the right breast, compatible with breast malignancy of low FDG uptake.
    • Glucose hypermetabolism in the nasopharynx. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammation may show this picture.
  • 2022-09-13 Patho - breast biopsy (no need margin)
    • Breast, right, core needle biopsy — Invasive carcinoma of no special type
    • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism,and increased N/C ratio.
    • Immunohistochemical study demonstrates ER (-), PR (-), Her2/neu: negative (0/1+), p53( complete -, aberrant-type), p63(-), Ki-67 inedex: < 10%.
• chemoimmunotherapy
  • 2022-12-14 - fluorouracil 500mg/m2 570mg 30min + liposome doxorubicin 30mg/m2 34mg 2hr + cyclophosphamide 500mg/m2 570mg 1hr
    • diphenhydramine 30mg + betamethasone 8mg + famotidine 20mg + granisetron 1mg
  • 2022-11-22 - fluorouracil 500mg/m2 564mg 30min + liposome doxorubicin 30mg/m2 34mg 2hr + cyclophosphamide 500mg/m2 564mg 1hr
    • diphenhydramine 30mg + betamethasone 8mg + famotidine 20mg + granisetron 1mg

[assessment]

• As of 2023-01-10, no neutropenia was detected in the lab result.
  • 2023-01-10 WBC 3.60 *10^3/uL
    
  • 2023-01-04 WBC 1.53 *10^3/uL

[duplicate note]

• Please disregard this duplicate note generated by the system.

230105

[assessment]

• Lab data on 2023-01-04 indicated that WBC was 1.53 K/uL. It was therefore decided to cancel the scheduled admission for FAC regimen treatment.

700736705

230110

• diagnosis - 2023-01-10 discharge note
  • Squamous cell carcinoma of left mandibular gingiva, cT4aN2bM0, stage IVA
  • Infection of the left mandibular gingiva and bone
  • Agranulocytosis secondary to cancer chemotherapy
  • Encounter for antineoplastic chemotherapy
  • Essential (primary) hypertension
• exam findings
  • 2022-11-23 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed one hot spot in the left aspecr of mandible, faint hot spots in both rib cages, and increased activity in the maxilla, some T- and L-spine, bilateral shoulders, elbows, right S-I joint, hips, and knees, in whole body survey.
    • IMPRESSION:
      • One hot spot in the left aspecr of mandible, the natur eis to be determined (advanced cancer or other nature ?), suggesting PET scan for further investigation.
      • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, elbows, right S-I joint, hips, and knees.
  • 2022-11-22 MRI - nasopharynx
    • Indication: Squamous cell carcinoma of left mandibular gingiva, cT2N2bM0, stage IVA. For tumor survery
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • Thin left anterior low gingiva tumor mass, extending to anterior mouth floor, and highly suspect of genioglossus muscle invasion, up to 15 mm measured on the coronal images.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple enlarged left level I-II LNs.
    • IMP:
      • Left low gingiva-mouth floor CA, T4AN2BM0 stage IVA.
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T4A(T_value) N:N2B(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
  • 2022-11-22 SONO - abdomen
    • Tiny gallbladder polyp
  • 2022-11-09 Patho - gingival/oral mucosa biopsy
    • Lingual gingiva (from #31 to #34) , left, incisional biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Rare keratin formation is present. Mucosal ulcer and tumor necrosis can be found also.
  • 2022-11-08, -08-16, -07-26 KUB
    • Lumbar spondylosis.
  • 2022-08-02 SONO - kidney
    • Right renal stone
  • 2022-08-02 SONO - kidney
    • Right hydronephrosis
• chemotherapy
  • 2023-01-06 - docetaxel 36mg/m2 60mg 1hr + cisplatin 36mg/m2 60mg 2hr + [leucovirin 90mg/m2 150mg + fluorouracil 900mg/m2 1500mg] 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-27 - docetaxel 40mg/m2 70mg 1hr + cisplatin 40mg/m2 70mg 2hr + [leucovirin 100mg/m2 170mg + fluorouracil 1000mg/m2 1700mg] 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-13 - docetaxel 40mg/m2 70mg 1hr + cisplatin 40mg/m2 70mg 2hr + [leucovirin 100mg/m2 170mg + fluorouracil 1000mg/m2 1700mg] 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-06 - docetaxel 40mg/m2 70mg 1hr + cisplatin 40mg/m2 70mg 2hr + [leucovirin 100mg/m2 170mg + fluorouracil 1000mg/m2 1700mg] 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
• medication
  • UFT (tegafur 100mg + uracil 224mg) KUFT01
    • 2022-11-29 ~ 2022-12-03 2# BID 20221129 OPD
    • 2022-11-25 ~ 2022-11-29 2# TID 20221121 IPD
  • Zinga (zinc gluconate 78mg/tab) KZING
• zinc supplement related ref:
  • Hoppe C, Kutschan S, Dörfler J, Büntzel J, Büntzel J, Huebner J. Zinc as a complementary treatment for cancer patients: a systematic review. Clin Exp Med. 2021;21(2):297-313. doi:10.1007/s10238-020-00677-6
  • Abt E. Zinc Supplementation May Reduce the Effects of Oral Mucositis for Patients With Cancer Receiving Either Chemotherapy or Radiotherapy. J Evid Based Dent Pract. 2020;20(4):101494. doi:10.1016/j.jebdp.2020.101494
  • Chaitanya NC, Shugufta K, Suvarna C, et al. A Meta-Analysis on the Efficacy of Zinc in Oral Mucositis during Cancer Chemo and/or Radiotherapy-An Evidence-Based Approach. J Nutr Sci Vitaminol (Tokyo). 2019;65(2):184-191. doi:10.3177/jnsv.65.184

[assessment]

• As of 2023-01-10, WBC is 2.87K/uL, neutrophil is 53%, and ANC is greater than 1500 cells/uL.

• However, there is a trend downward in WBC count which should be noted.

  • 2023-01-10 WBC 2.87 *10^3/uL
    
  • 2023-01-06 WBC 7.22 *10^3/uL
    
  • 2023-01-03 WBC 3.43 *10^3/uL
    
  • 2022-12-31 WBC 5.11 *10^3/uL
    
  • 2022-12-27 WBC 5.52 *10^3/uL
    
  • 2022-12-17 WBC 3.83 *10^3/uL
    
  • 2022-12-13 WBC 4.57 *10^3/uL
    
  • 2022-12-10 WBC 8.21 *10^3/uL
    
  • 2022-12-04 WBC 7.02 *10^3/uL
    
  • 2022-11-21 WBC 6.61 *10^3/uL
    
  • 2022-08-02 WBC 5.71 *10^3/uL

700842151

230110

• diagnosis - 20230109 admission note
  • Adenocarcinoma of rectosigmoid junction colon, cT3N2M0, stage: IIIB with with intussusception and partial obstruction status post Laparoscopic low anterior resection(LAR) on 2021/12/02
  • Chronic viral hepatitis B without delta-agent anti-Hbc: positive
• past history
  • C3-6 spondylosis with spinal stenosis s/p laminoplasty on 2006-12-21.
  • Squamous cell carcinoma of upper third esophageal, T3N2M0, stage IIIB since Oct 2014, post Port-A on 2014-10-23, complete CCRT until Feb 2015. Post VATS esophagectomy with RLND, laparoscopic gastric tube reconstruction and feeding jejunostomy on 2015-03-09, ypT3N0M0, Stage IIB.
  • Esophageal stenosis s/p ballon dilation on 2015-05-21 and bilateral pleural effusion, chyothorax post close drainage on 2015-05-21.  
• family history
  • There is no family history of diabetes, hypertension, mental diseases or asthma.
  • No members of the family with cancer.
• exam finding
  • 2022-12-22 MRI - brain
    • Clinical information: Adenocarcinoma of rectosigmoid junction colon, cT3N2M0, stage: IIIB with with intussusception and partial obstruction status post Laparoscopic low anterior resection (LAR) on 2021/12/02
    • Findings:
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
      • One old lacuna infarct over right internal capsule.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • Left mastoiditis.
    • Impression:
      • No evidence of brain metastasis.
  • 2022-12-13 Chest PA + Lat LT
    • Few linear and nodular opacities projecting at bilateral middle lung zone are noted. please correlate with clinical condition and CT.
    • Atherosclerotic change of aortic arch
  • 2022-12-08 Peripheral Vascular Test - Vein, lower limbs
    • Conclusion:
      • Both arm MVO/SVC is normal
      • Left jugular vein is small and patency
      • There is no thrombus was seen in both upper arm
    • Suggestion
      • dupplex of vein could not scan proximal subclavian vein and central vein lesion, if consider central vein lesion, IVDSA or CT with contrast is indication.
  • 2022-12-07 CT - abdomen
    • History:
      • 20211111 CT: Adenocarcinoma of RS junction colon, cT3N2M0, stage: IIIB with intussusception and partial obstruction
      • 20211203 S/P LAR:pT3N2a(if cM0); stage IIIB
      • Past Hx: Eso. ca. s/p op,
    • MD CT (iCT 256 slices) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P LAR with autosuture retention over the rectosigmoid junction.
      • S/P esophagectomy with gastric tube reconstruction via retrosternal space.
      • There are several hepatic cysts in both lobes and the largest one 1.4 cm in size at S5.
      • Prior CT identified several enlarged nodes in paratracheal space, right hilum, and subcarina space are noted again, mild decreasing in size that may be Metastatic nodes S/P C/T with partial response. please correlate with clinical condition.
        • In addition, patchy areas of consolidations and ground-glass opacities in perihilar lungs, with tree-in-bud and centrilobular nodules in peripheral of RUL as well as subsegmental ground-glass opacity in superior segment of LLL, stationary.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • S/P LAR with autosuture retention over the rectosigmoid junction. There is no evidence of tumor recurrence.
      • Prior CT identified several enlarged nodes in paratracheal space, right hilum, and subcarina space are noted again, mild decreasing in size that may be Metastatic nodes S/P C/T with partial response. please correlate with clinical condition.
  • 2022-12-06, -11-13 KUB
    • Spondylosis of the L-spine is noted.
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4, L4-5 and L5-S1.
    • S/P metalic autosuture at the rectum.
  • 2022-12-06, -11-28, -11-25, -11-24 CXR
    • Atherosclerotic change of aortic arch
    • Nodular opacity projecting in the bilateral middle lung are suspected. Please correlate with CT.
  • 2022-10-26, -10-12 CXR
    • Atherosclerotic change of aortic arch
  • 2022-09-08 CT - abdomen
    • S/P colon operation.
    • S/P gastric tube reconstruction.
    • Liver cysts (up to 1.2cm). A hypodense nodule (0.4cm) at left hepatic lobe.
    • Some tiny nodules in bil. lungs (mild regression).
  • 2022-05-04 Patho - lung transbronchial biopsy
    • Lung, left, CT-guide biopsy —- chronic inflammation with interstitial fibrosis
    • Sections show alveolar tissue with active interstitial fibrosis and chronic inflammation. Foamy cell aggregates and alveolar cell hyperplasia is also present. No definite granuloma, or malignancy is found.
    • The immunohistochemical stains reveal CK(+), TTF-1(+), and CDX2(-). Please correlate with the clinical presentation.
  • 2022-05-04 CT Guide biopsy
    • LLL lung nodule, s/p CT-guided biopsy
    • Due to tree-in-bud appearance in CT scans, an infectious process (tuberculosis?) shoulde be ruled out.
    • Suggest clinical correlation
  • 2022-04-29 Whole body PET scan
    • Glucose hypermetabolism in the right middle lung, highly suspected cancer with lung mets, suggesting biopsy for investigation.
      
    • Glucose hypermetabolism in the left upper, left lower, and right upper lungs, the nature is to be determined (inflammation/infecion process, lung mets or others ?), suggesting further investigation and close follow-up.
      
    • Glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, right mediastinal lymph nodes, right cervical lymph nodes and right infraclavicular lymph nodes, the nature is to be determined also (reactive nodes, metastatic lymph nodes or others ?), suggesting further investigation.
      
    • Esophageal and colon cancers with right middle lung metastasis at least, by this F-18 FDG PET scan.
      
  • 2022-04-10 KUB
    • Degeneration of bony structures.
    • Stool retention in bowl.
  • 2022-04-08 CT - abdomen, pelvis
    • S/P LAR with autosuture retention over the rectosigmoid junction. There is no evidence of tumor recurrence.
    • There are several enlarged nodes in the paratracheal space, right hilum, and subcarina space. Metastatic nodes are suspected.
  • 2021-12-03 Patho - colon segmental resection for tumor
    • pathologic diagnosis
      • Large intestine, colon, rectosigmoid junction, laparoscopic LAR — Adenocarcinoma, moderately differentiated
        
      • Resection margins, proximal and distal: free
        
      • Lymph node, mesocolic, dissection— Positive for adenocarcinoma (4/20)
        
      • Pathology stage: pT3N2a(if cM0); AJCC stage IIIB
        
    • microscopic examination
      • Histology: Adenocarcinoma
        
      • Histology Grade: moderately differentiated
      • Depth of invasion: pericolorectal tissue
      • Angiolymphatic invasion: Present.
      • Perineural invasion: Not identified.
      • Discontinuous extramural tumor extension: Not identified
        
      • Circumferential (radial) margin of rectum: Uninvolved
        
      • Lymph node metastasis, mesocolic: Positive (4/ 20)
        
  • 2021-12-01 Sigmoidoscopy
    • advanced colorectal cancer, RS junction (25-28cm from AAV), s/p Tattoo injection
    • mixed hemorrhoid.
  • 2021-11-13 CT - chest
    • s/p esophagectomy with gastric tube reoncstruction.
    • Bilateral lung focal opacity, stationary. Previous inflammation is considered.
    • Intusussception of the sigmoid colon into rectum is found. Compatible with rectal cancer.
  • 2021-11-11 CT - abdomen, pelvis
    • Imaging stage: T3N2M0, stage IIIB
  • 2021-11-11 Patho - colon biopsy
    • RS junction, 25 cm to 28 cm AAV, biopsy — Adenocarcinoma, moderately differentiated
      
    • The sections show a picture of adenocarcinoma, moderately differentiated, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction. Mucosal ulcer is present.
    • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
  • 2021-11-09 Sigmoidoscopy
    • Advanced colorectal cancer, RS junction(25cm to 28cm AAV), s/p biopsy
    • Mixed hemorrhoid.
  • 2021-06-08 CT - chest
    • No recurrent esophageal tumor. post treatment related change and inflammatory process RUL and LLL, stationary.
  • 2020-12-22 CT - chest
    • No recurrent esophageal tumor. post treatment related change and inflammatory process (infectious bronchiolitis) RUL and LLL (new lesion).
  • 2020-05-12 CT - chest
    • No recurrent esophageal tumor; post treatment related change and inflammatory process (infectious bronchiolitis) in lungs, stationary.
    • 2-vessels CAD.
  • 2019-11-03 CT - chest
    • No recurrent esophageal tumor; post treatment related change and inflammatory process (infectious bronchiolitis) in both lungs, slightly in progression.
    • 2-vessels CAD.
  • 2019-06-11 CT - chest
    • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, slightly in regression.
    • 2-vessels CAD.
  • 2018-11-29 CT - chest
    • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, stationary.
  • 2018-06-05 CT - chest
    • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, stationary.
  • 2017-12-13 CT - chest
    • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, in regression.
    • pneumonia in LLL?
  • 2017-06-14 CT - chest
    • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs.
    • pneumonia in LLL?
• consultation
  • 2023-01-10 Radiation Oncology
    • Q
      • for R/O port-A obstruction
      • This 70-year-old man, a patient of colon cancer with lung mets S/P C/T. Owing to left port-A obstruction was noted. We need expertise to evaluate his condition thanks!
    • A
      • According to the clinical history and imaging findings, venography is indicated.
  • 2022-05-04 Radiation Oncology
    • A
      • This 69-year-old patient is a case of bilateral lung nodules, suspected pulmonary metastasis. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
• surgical operation
  • 2021-12-02 Laparoscopic LAR        
    • A large locally advanced tumor at RS-colon with intussusception and partial obstruction. Some turbid (30ml) ascites was found at pelvic floor. Marked edema of the colon wall and dilatation with much soft0liquid stool retention.    
    • The whole procedure was smooth. Blood loss was less than 30ml.    
    • Adhesion of two segment of small bowel with anterior abdomen wall was seen.    
    • Anastomosis was achieved using endo-GIA/black*2 + CDH-33 + TISSEEL. Air test is ok.    
    • A drain in pelvis near anastomosis.    
  • 2018-03-21
    • Diagnosis
      • Paralysis of vocal cords or larynx, unilateral , complete
    • PCS code
      • 66008A
    • Finding
      • Complete paralysis of left vocal cord.
      • Sculptured silicon mass was inserted to left paraglottic space for adduct left vocal cord
• chemoimmunotherapy
  • 2023-01-10 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/m2 4850mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-12-19 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/m2 4850mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-11-07 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-10-12 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-09-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-09-07 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-08-18 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 320mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-07-27 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-07-12 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-06-24 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4300mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-06-09 - irinotecan 170mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4300mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-05-24 - irinotecan 160mg/m2 290mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4300mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
  • 2022-04-22 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4980mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-04-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4980mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-03-23 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-03-08 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-02-21 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-02-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-01-17 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-01-03 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr

[assessment]

• Vital signs are stable without extreme abnormalities in the 2023-01-09 lab results.
• The suspected obstruction of the port-A is referred to Radiation Oncology for venography.
• The patient has less yellowish sputum with his cough.

221220

[assessment]

• The WBC level was elevated at 14K/uL on 2022-12-19, sputum was coughed up recently, and the scheduled chemotherapy was postponed due to a broncopnemonia event in late October 2022. Ciprofloxacin has been prescribed and the sputum culture is currently being conducted.

221207

[assessment]

• The vital signs are stable. Lab data on 2022-12-06 showed no extreme abnormalities. A reduction in body weight of 5kg in the past six months (65.4kg 2022-12-07 <- 70.8kg 2022-06-08) might be caused by a lack of appetite.
• The underlying condition of carrying HBV is appropriately managed with Vemlidy (tenofovir).

220425

[assessment]

• The patient’s stage IIIB R-S colon cancer was treated with FOLFOX since 2022-01-03 following laparoscopic LAR on 2021-12-02.
• On the CT images obtained on 2022-04-08, there were enlarged nodes in paratracheal space, right hilum, and subcarina space, which are suspected to be metastatic.
• Lab results on 2022-04-22 showed liver and kidney functions, serum electrolytes, and blood cell counts were generally normal. However, the CRP level of 3.99 mg/dL and body temperature of 38.9 degrees were observed on 2022-04-23, which is currently being treated with tapimycin (piperacillin, tazobactam) 4.5gm IVD Q6H.

700954740

230110

{Recurrent left breast cancer with bilateral lung, right pleura, liver, bone and lymph node metastases, rcTxN2M1, stage IV}

• lab data
  • CEA
    • 2022-08-02 CEA 24.80 ng/mL
      
    • 2022-07-12 CEA 35.48 ng/mL
      
    • 2022-04-19 CEA 224.79 ng/mL
      
  • CA153
    • 2022-08-02 CA153 643.7 U/mL
      
    • 2022-07-12 CA153 888.4 U/mL
      
    • 2022-06-23 CA153 1277.8 U/mL
      
    • 2022-04-19 CA153 4941.4 U/mL
      
  • CA199
    • 2022-06-23 4351.42 U/mL
      
  • Zinc, Zn
    • 2022-06-06 494 ug/L
      
    • 2021-11-15 432 ug/L
• exam finding
  • 2023-01-09 SONO - chest
    • Bilateral pleural effusion (Left: moderate and Right: loculated minimal), post left pig-tail insertion.
  • 2023-01-08 CXR
    • Mass like lesion over RLL.
    • Bilateral pleural effusion.
    • Segmental atelectasis of both lower lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2023-01-03 SONO - chest
    • Right thorax: small amount pleural effusion.
    • Left thorax: moderate amount, serosanguinous pleural effusion s/p drainage of 550 cc pleural effusion.
  • 2022-12-27 SONO - chest
    • Bilateral thorax: small amount pleural effusion; thoracocentesis was not performed due to high risk of complications.
  • 2022-12-20 CXR
    • Rt greater than Lt bilateral pleural effusions and Rt lateral loculated effusion still visible
    • Osteoblastic metastasis in spine, Rt humeral head, and ribs
  • 2022-12-20, -12-06, -11-12, -10-25 CXR
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
    • Pleura effusion of bilateral costal-phrenic angle
    • S/P Mastectomy, left.
    • Osteosclerotic change at right humeral head is suspected.
  • 2022-12-20 SONO - chest
    • Left thorax: minimal amount pleural effusion
    • Right thorax: small amount pleural effusion s/p drainage of 250 cc, yellowish pleural effusion.
  • 2022-12-15 SONO - chest
    • pleural effusion
    • Chest echography was performed first. The suitable intercostal space was selected and located.
    • Catheter was inserted with negative pressure smoothly.
    • Left side pleural effusion was drawn smoothly.
  • 2022-12-15 SONO - abdomen
    • Diagnosis: Liver metastasis
    • Suggestion: Regular ultrasound follow up
  • 2022-12-06 SONO - chest
    • Special Procedure:
      • Pleural tapping 16 #-needle Right side 210 ml yellowish
      • Pleural tapping 16 #-needle Left side 440 ml straw-color
  • 2022-10-06 KUB
    • Osteoblastic change of L3 vertebral body and bilateral ilium are noted that are c/w bony metastases.
    • Hepatomegaly is suspected.
  • 2022-10-06 SONO - chest
    • Special Procedure:
      • Pleural tapping 16 #-needle Right side 390 ml serosanguineous
      • Pleural tapping 16 #-needle Left side 320 ml bloody
  • 2022-10-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (78.1 - 18.7) / 78.1 = 76.06%
      • M-mode (Teichholz) = 76
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Mild MR, TR and PR
    • No regional wall motion abnormalities
    • Sinus tachycardia during echocardiography
  • 2022-09-28 SONO - chest
    • Special Procedure:
      • Pleural tapping 16 #-needle Right side 350 ml bloody
  • 2022-09-13 SONO - chest
    • Special Procedure:
      • Pleural tapping 16 #-needle Right side 150 ml serosanguineous
      • Pleural tapping 16 #-needle Left side 270 ml bloody
  • 2022-08-23, -08-09, -07-22, -07-12 CXR
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
    • S/P port-A implantation.
    • Pleura effusion of bilateral costal-phrenic angle
    • S/P Mastectomy, left.
    • Borderline cardiomegaly
    • Osteosclerotic change at right humeral head is suspected.
  • 2022-08-11 CT - chest
    • Findings
      • Chest:
        • Bilateral loculated effusion more on right hemithorax is found.
        • S/p port-A placement with its tip at Superior vena cava.
        • S/P mastectomy at left side.
      • Visible abdomen:
        • Patch like low density area is found at both lobes of liver. Liver meta is considered. In comparison with CT dated on 2022-03-08, the lesions regressed.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no ascites accumulation at abdominal cavity.
    • Imp
      • S/P mastectomy at left side
      • Liver meta. In regression.
      • Bilateral pleural effusion, suspected pleural meta.
      • Bone meta, please correlate with bone scan study.
  • 2022-08-05 Bladder Sonography
    • PVR 45.6 mL (postvoided residual)
  • 2022-08-05 Uroflowmetry, UFR
    • flow pattern: obstructive
  • 2022-07-29 Bladder Sonography
    • PVR 8.47 mL (postvoided residual)
  • 2022-06-29 SONO - chest
    • symptom: dyspnea
    • indication: suspected pleural effusion
    • clinical diagnosis: left breast cancer post MRM in 2008, with liver, bone and bilateral malignant pleural effusion
    • procedure: The patient was in sitting upright posture while the chest echography was performed using 3.75-mHz convex probe.
    • findings:
      • There was no pleural effusion and it was free and anaechoic. Limited LLL and left hemidiaphragm movement was found.
      • No active lung lesion of left lung field
        • Left-side of thorax
        • Right-side of thorax
          • There was minimal pleural effusion
          • RLL atelectasis
    • echo diagnosis:
      • 1. Pleural effusion, minimal, right
      • 2. Consolidation, RLL
  • 2022-06-23 CXR
    • S/P port-A implantation.
    • Pleura effusion of right costal-phrenic angle
    • S/P Mastectomy, left.
    • Borderline cardiomegaly
    • Osteosclerotic change at right humeral head is suspected.
  • 2022-05-31 CXR
    • S/P port-A implantation.
    • Pleura effusion of right and left costal-phrenic angle
    • S/P Mastectomy, left.
  • 2022-05-16 Chest PA erect view
    • regression of massive moderate Rt pleural effusion s/p pigtail drain placement
    • resolution of Lt pleural effusion s/p pigtail drain placement
    • port-A catheter inserted into SVC via Right internal jugular vein
    • osteolytic/osteoblastic metastasis in spine,
    • normal heart size
  • 2022-05-13 Chest Ultrasound
    • Echo diagnosis:
      • Right side massive pleural effusion with lung passive collpase, s/p 14Fr. pig-tail catheter insertion smoothly
      • Left side small to moderate amount pleural effusion, s/p 14Fr. pig-tail catheter insertion smoothly.
  • 2022-04-26 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2021/12/07, some of the previous bone lesions are slightly more evident, suggesting multiple bone metastases in slight progression.
  • 2022-04-25 Cell block
    • Adenocarcinoma, in favor of breast origin
      
    • Smears and cell block show clusters and single cells of adenocarcinomatous cells with large hyperchromatic nuclei, pleomorphism and high N/C ratio.
      
    • Immunohistochemical stain reveals Calretinin(-), TTF-1(-) and GATA3(+).
  • 2022-04-25 Chest Ultrasound
    • Echo diagnosis:
      • Bilateral pleural effusion (Left: trivial and Right: moderate), s/p right diagnostic and therapeutic thoracentesis.
  • 2022-04-24 EKG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
  • 2022-04-08 Cell block
    • Positive for malignancy
      
    • 50 cc orange turbid right pleural effusion
      
    • The smears and cell block show many individual or clustering of hyperchromatic atypical epithelial cells, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2022-03-08 Her-2/neu DNA in Situ Hybridization, DISH
    • Result of Her2 in Situ Hybridization
      • HER-2 (by in situ hybridization) — Negative (NOT amplified)
    • Method and Details
      • Number of observers: 1
      • Number of invasive tumor cells counted: 20
      • Average number of HER2 signals per cell: 2.05
      • Average number of CEP17 signals per cell: 1.9
      • HER2/CEP17 ratio: 1.08
      • Heterogeneous signals: Absent
      • Origin slide and block number: S2022-3847
      • Specimen: Formalin-fixed paraffin embedded tissue
      • Adequacy of sample for evaluation: Yes
      • Method of in situ hybridization: CISH (Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay, Roche company)
  • 2022-03-08 Patho - soft tissue/mass/lipoma/debridement
    • Diagnosis
      • Skin, left neck, excision — Consistent with metastatic breast carcinoma — Seborrheic keratosis
    • Microscopic description
      • Section shows one piece of hyperkeratosis, papillomatous skin with keratin cysts and interdigitation of epidermis and papillary dermis. A dermal tumor, measuring 0.5 x 0.4 x 0.3 cm, composed of pleomorphic tumor cells is seen. The immunohistochemical stain reveals GATA3(+). The morphology and immunohistochemical stain are consistent with metastatic breast carcinoma. The tumor is 0.1 cm away from the unspecified closest resection margin.
        
    • Immunohistochemical Study
      • ER (Ab): Positive (95%, strong)
      • PR (Ab): Negative
      • Her-2/neu (Ab): Equivocal (2+)
      • Ki-67: 30%
  • 2022-03-08 CT - liver, spleen, biliary duct, pancreas
    • S/P left breast operation. Progression of liver metastases. Stable condition of bony metastases.
    • Bil. pleural effusion.
  • 2021-12-07 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2020/09/22, more new bone lesions are noted, suggesting multiple bone metastases in progression.
  • 2021-12-06 SONO - breast
    • S/P left mastectomy.
    • Right breast cysts and fibroadenomas.
    • Left chest wall nodule, suggest follow up.
    • BI-RADS2. benign finding
  • 2021-12-06 CT - liver, spleen, biliary duct, pancreas
    • S/P left breast operation. Progression of liver and bony metastases.
  • 2021-05-19 SONO - breast
    • Status post left mastectomy.
    • Tiny right breast fibroadenomas.
    • Suggest follow up.
    • BI-RADS category 2, Benign finding.
  • 2021-05-10 Gynecologic ultrasonography
    • EM 5.0mm
  • 2021-05-04 CT - abdomen, pelvis
    • S/P left mastectomy. Multiple liver metastasis, progression.
    • Multiple bone metastasis.
    • Right axillary lymph node, metastasis?
  • 2021-04-22 SONO - abdomen
    • Bil. liver metastases (up to 2.1cm).
  • 2021-02-24 SONO
    • Metastases on both hepatic lobes are suspected and the largest one 3.35 cm in S7. Please correlate with contrast enhanced dynamic CT.
    • A hepatic cyst 0.7 cm in S3 is noted.
  • 2021-02-24 CT - lung/mediastinum/pleura
    • Findings
      • Lungs: nondependent subpleural fibrotic change in LUL, related to treatment. several nodular opacities in medial basal segment of RLL and a tiny nodule in S6 of the same lobe. nodularity of interlobar fissures in Rt lung.
      • Mediastinum: no enlarged LN or mass.
      • Hila: no enlarged LN or mass.
      • Vessels: aorta: normal appearance, central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: trace pleural effusion.
      • Chest wall: s/p Lt MRM< no LAP
      • Visible abdominal contents:
        • multiple metastatic hepatic tumors up to 3.2 cm (longest axial diamter).
        • normal appearance of gallbladder. gall bladder stones.
        • no abnormal density and size of visible portion of the unremarkable of the liver, spleen, adrenal glands, pancreas, and kidneys. bile ducts: No dilatation.
        • no enlarged lymph node.
      • Extensive Mild atherosclerotic change of the abdominal aorta and bilateral common/external iliac arteries.
      • Visualized bones: lytic and blastic metastatic change in multiple vertebral bodies and left iliac wing..
    • Impression:
      • Lt brest ca s/p MRM with liver, bones, and lung metastases.
  • 2020-11-03 MRI - brain
    • No brain nodule or metastasis.
  • 2020-10-26 Patho - lymphnode biopsy
    • Lymph node, left neck, SONO guided core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 95%, strong intensity), PR( +, 2-5%, intermediate intensity), Her2/neu: negative (score=1+), Ki-67(17%0), p53 (10%, weak intensity).
  • 2020-09-29 Whole body PET scan
    • Glucose hypermetabolism involving the left anterior upper chest wall, in multiple focal areas in bilateral lung fields, pleura and right lobe of the liver, in multiple bones and multiple lymph nodes as mentioned above, compatible with multiple metastatic lesions. Please correlate with other clinical findings for further evaluation.
  • 2020-09-22 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2017/08/01, a new lesion in the the lower T-spine. Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
    • No prominent change is noted in the lesions in the L3-5 spines. Degenerative spine disease may show this picture.
    • A new hot spot in the lateral aspect of left rib cage and increased activity in the right femoral shaft. The nature is to be determined (post-traumatic change? bone metastases? other nature?). Please correlate with other clinical findings and follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and bilateral knees, compatible with benign joint lesions.
  • 2020-09-15 SONO - abdomen
    • Left liver cyst (0.66x0.78cm). Gallbladder polyp (0.18cm).
  • 2020-07-17 Gynecologic ultrasonography
    • EM 5.4mm
  • 2020-03-05 Mammography
    • S/P left mastectomy. A benign calcification in right breast.
    • BI-RADS: Category 2: benign findings.-annual screening.
  • 2020-03-05 SONO - abdomen
    • Left liver cyst (0.64x0.76cm). Gallbladder polyp (0.35cm).
  • 2019-07-06 SONO - abdomen
    • Left liver cyst (0.63x0.68cm). Gallbladder polyp (0.22cm).
  • 2018-07-10 SONO - hepatobiliary
    • Small Gallbladder polyps.
  • 2018-04-17 SONO - hepatobiliary
    • A gallbladder polyp
  • 2017-08-01 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2015/12/15, the faint hot spots in bilateral rib cages are less evident, probably more benign in nature.
    • Mildly increased activity in the L3-5 spines. Degenerative spine disease may show this picture.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and left knee, compatible with benign joint lesion.
• consultation
  • 2022-02-21 Metabolism and Endocrinology
    • Q
      • This 58-year-old post-menopausal woman has left breast cancer (pT1cN0M0,stage:I) s/p MRM on 2008/11/14 at CGMH Linkou branch. The pathology showed invasive ductal carcinoma ,size 1.9 cm, Gr2, LN (0/41); ER(+):60%, PR(+):5%, HER2/neu(+++), FISH(-), pT1cN0M0, stage:IA.
      • She has adjuvant chemotherapy of CEF (Fluorouracil + Epirubicin + Endoxan) 6 course since 2008-12 ~ 2009-05 at CGMH Linkou branch. Then she kept Hermone therapy of Tamoxifen 10 mg/tab 1# po BID. Due to progression high level CEA 6.024 ng/ml (2012/09/10) -> 5.891 ng/ml (2012/12/10) -> 7.484 ng/ml (2013/03/4).
      • After physical examination showed no palpable nodule or mass over bil. breast with axilla regions.
      • Whole body PET scan showed
        • 1. a glucose hypermetabolic lesion in the left axillary region, A metastatic lesion should be considered frist;
        • 2. Mild glucose hypermetabolism in two right upper neck level II lymph nodes, Inflammatory process is more likely on 2013/03/26.
      • Then we arranged FNA for left axillar LN on 2013/04/05. The pathology showed positive for malignant tumor.
      • She underwent removal of left axillary soft tissue and implantation-Port A (Right) on 2013/04/26 (rTxN1M2, stage IIA).
      • Salvage chemotherapy with Taxotere *4~6 course for every three weeks was prescribed since 2013/05/13 ~ 2013/09/06. AI treatment since 2013/09/23.
      • Multiple bone mets by whole body bone scan and mulpital lung, pleural, right liver and LN mets by PET were noted on 2020/09/29.
      • CDK4/6 inhibit with Kisqali + AI since 2020/12/07. Patient hold CDK4/6 inhibit with Kisqali + AI since 2021/05 due to seeking detox therapy on her own. But tumor marker elevated.
      • After explant to patient. PIK3CA mutation (+). Faslodex + piqray was suggest.
      • Under impression of recurrent left breast cancer with multiple bone, lung, pleural, right liver and LN mets, stage IV. She was admitted for piqray 150mg 2tab QD PO.   
      • Due to hyperglycemia, we change metformin 0.5# BID to GalvusMet 1# BID and add on Tresiba 8U HS since 2022-02-11. But nausea and general weakness after GalvusMet. she hold medicine by herself. Now we need your help for medicine suggestion. Thank you so much!!
    • A
      • O:
        • F/S QDAC around 80-110
        • F/S HS around 300-400 (getting higher)
      • P:
        • Taper Tresiba to 6U HS (If F/S HS < 140, take some snack before sleep)
        • Add repaglinide 1# TIDAC, also add Trajenta 1 tab QD
  • 2022-02-12 Metabolism and Endocrinology
    • S:
      • This 58-year-old female, with past history of left breast CA s/p MRM, was admitted due to recurrent left breast cancer. We were consulted for blood sugar control.
    • O:
      • BH: 151 cm, BW: 52.7 Kg
      • Diet: normal diet
      • Medication in OPD: Metformin 0.5# BID
      • Medication during hospitalization: RI 8U ST on the night of 2022-02-10
      • Na: 137, K: 4.3
      • AST/ALT: 41/49
      • BUN/Cr: 19/0.86 (eGFR: 71.78)
      • F/S: 376/419/321
      • HbA1c: 6.1 -> 8.8
      • Urine ACR: unavailable
      • OPH OPD: no record
    • A:
      • Type 2 DM (Alpelisib and megesterol induced)
    • Suggestions:
      • Switch metformin 0.5# BID to GalvusMet 1# BID
      • Add on Tresiba 8U HS (If F/S HS < 140, take some snack before sleep)
      • Megesterol is recommended to drink a small amount regularly
      • Urine ACR can be collected in OPD later
      • Meta OPD F/U
• surgical operation
  • 2022-03-08
    • Surgery
      • left neck tumor excision
    • Finding
      • left neck tumor 1cm
    • Procedure
      • IVGA
      • fusiform incision
      • tumor excision
      • wound closure
  • 2019-01-11
    • Malignant female breast neoplasm, NOS
    • PCS code 62009C
      • Excision of muscle or deep tissue tumoror, deep foreign body
• chemotherapy
  • 2022-09-28 - Halaven (eribulin) 1.4mg/m2 2.22mg 5min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-09-21 - Halaven (eribulin) 1.4mg/m2 2.22mg 5min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-08-31 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
    • dexamethasone 4mg + metoclopramide 10mg
  • 2022-08-11 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
  • 2022-07-21 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
  • 2022-06-29 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
  • 2022-06-07 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
  • 2022-05-16 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
  • 2022-04-29 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
  • 2022-03-14 ~ 2022-05-09 - Afinitor (everolimus 10mg QD). Everolimus is an inhibitor of a kinase called mammalian target of rapamycin (mTOR)
  • 2022-03-14 ~ 2022-05-09 - Aromasin (exemestane 25mg QD)
  • 2021-03-08 ~ 2022-04-11 - Zometa (zoledronic acid, bisphosphonate) 11 cycles.
  • 2021-03-08 ~ 2022-03-07 - Faslodex (fulvestrant) 11 cycles.
  • 2020-12-07 ~ 2021-05-24 - Kisqali (ribociclib 400mg QD). There were 3 CDK4/6 inhibitors - palbociclib, ribociclib, and abemaciclib - that have been approved for HER2 metastatic breast cancers, usually in combination with hormone therapy.
  • 2017-02-20 ~ 2021-04-05 - Femera (letrozole 2.5mg QD)
  • 2013-09-23 - aromatase inhibitor
  • 2013-05-13 ~ 2013-09-06 - Taxotere (docetaxel) 4~6 course for every three weeks
  • ~ 2012? - Tamoxifen 10mg BID
  • 2008-12 ~ 2009-05 - CEF (Fluorouracil + Epirubicin + Endoxan)

[note]

• Systemic Therapy for ER- and/or PR+ Recurrent Unresectable or Stage IV (M1) Disease - HER2-Negative and Postmenopausal or Premenopausal Receiving Ovarian Ablation or Suppression (Breast Cancer - NCCN Evidence Blocks - Version 2.2022 - December 20, 2021, p74)
  • Preferred Regimens
    • First-Line Therapy
      • Aromatase inhibitor + CDK4/6 inhibitor (abemaciclib, palbociclib, or ribociclib) (category 1)
      • Selective ER down-regulator (fulvestrant, category 1) + non-steroidal aromatase inhibitor (anastrozole, letrozole) (category 1)
      • Fulvestrant + CDK4/6 inhibitor (abemaciclib, palbociclib, or ribociclib) (category 1)
    • Second- and Subsequent-Line Therapy
      • Fulvestrant + CDK4/6 inhibitor (abemaciclib, palbociclib, or ribociclib) if CKD4/6 inhibitor not previously used (category 1)
      • For PIK3CA-mutated tumors, see additional targeted therapy options
      • Everolimus + endocrine therapy (exemestane, fulvestrant, tamoxifen)
  • Other Recommended Regimens
    • First- and Subsequent-Line Therapy
      • Selective ER down-regulator
        • Fulvestrant
      • Non-steroidal aromatase inhibitor
        • Anastrozole -Letrozole
      • Selective estrogen receptors modulator -Tamoxifen
      • Steroidal aromatase inactivator -Exemestane
  • Useful in Certain Circumstancesf
    • Subsequent-Line Therapy
      • Megestrol acetate
      • Estradiol
      • Abemaciclib

[assessment]

• The patient refused chemotherapy and began receiving Maruyama vaccine treatment (one shot by the end of 2022), an alternative therapy with few English publications (ref: PubMed, Maruyama vaccine official web site: https://www.nms.ac.jp/sh/vaccine/).
• In most patients with persistent or recurrent symptomatic pleural effusions, repeat therapeutic thoracentesis under ultrasound guidance is generally the first-line option. Multiple sonography-guided pleural effusion tappings have been performed since 2022 with an increase in frequency over time.
• Albumin has been prescribed appropriately to keep fluid from leaking out of blood vessels. For the purpose of removing fluid, furosemide and spironolactone have also been prescribed. Slight hyponatremia (133 mmol/L 2023-01-09) represents a relative excess of water in relation to sodium in this patient.

221013

[assessment]

Despite the use of Radi-K (potassium gluconate, since 2022-10-04) in conjunction with spironolactone (since 2022-10-10), lab data on 2022-10-13 show serum potassium at 2.7mmol/L still below normal (3.5~5.1). It is recommended to shift oral Radi-K from TID to QID or add a potassium supplement injection to prevent low K from becoming symptomatic.

220901

[assessment]

• It is anticipated lower heart rate after taking Concor (bisoprolol). The patient’s heart rate increased to 107 (2022-09-01 08:48) from 86 (2022-08-31 16:38), which should be monitored.
• The current blood pressure is normal (117/73). Concor should be held temperately if hypotension is observed.
• Recent CXRs showed borderline cardiomegaly. It is possible to replace Concor with Coralan (ivabradine 5mg) 1# BID if the diagnosis of heart failure is confirmed (to lower the heart rate).

220722

[assessment]

• The patient’s blood pressure decreased to 101/57 at 13:20 2022-07-22. If the patient’s blood pressure continues to drop and he becomes symptomatic, please DC Concor temporarily.

220630

[assessment]

• The patient has recurrent breast cancer with lung and bone mets characterized by HR(+, ER+, PR-, IHC 2022-03-08) and HER2(-, DISH 2022-03-08) and is receiving docetaxel treatment since early May 2022. Prior to current regimen, mTOR kinase inhibitor everolimus and endocrine therapy exemestane have been employed during mid March to early May of 2022.
• The chest sonography and X-ray performed in June 2022 indicated lung consolidation as well as osteosclerosis of the bones which should be kept on track in order to prevent them from becoming more symptomatic.
• CA153 is decreasing, which is a relatively positive sign (2022-06-23 1277.8 U/mL <- 2022-04-19 4941.4 U/mL).
• Lab data reported on 2022-06-23 indicated that liver and kidney function, CBC, WBC DC, electrolytes were grossly normal. During this hospitalization, both TPR and BP were stable.

220608

[assessment]

• CBC, WBC DC, liver and kidney function, blood electrolytes were gross normal according to lab results on 2022-05-31.
• Low zinc level (494 ug/L, normal 700~1200ug/L, 2022-06-06) is treated with zinc gluconate currently.

700504699

230109

• 2023-01-06 ECG
  • Normal sinus rhythm
  • Left axis deviation
  • Inferior infarct, age undetermined
  • Abnormal ECG
• 2023-01-06 ECG
  • Normal sinus rhythm
  • Right superior axis deviation
  • Pulmonary disease pattern
  • Cannot rule out Inferior infarct, age undetermined
  • Abnormal ECG
• 2022-10-24 CXR
  • Normal sinus rhythm
  • Left axis deviation
  • Incomplete right bundle branch block
• 2022-10-24 CXR
  • Tortuosity of the aorta with atherosclerotic change.
  • Increased lung markings over both lungs.
  • Degenerative joint disease of T-spine with marginal osteophytes.
  • Osteopenic change.
• 2022-07-13 Mini-mental state examination, MMSE
  • Score 10
    • Score Level of impairment

    • = 27 None

    • 21-26 Mild
    • 11-20 Moderate
    • <= 10 Severe
• 2022-07-13 Clinical Dementia Rating, CDR
  • Score 2
    • Composite Rating Symptoms
    • 0 none
    • 0.5 very mild
    • 1 mild
    • 2 moderate
    • 3 severe
• 2022-07-01 CT - brain
  • Brain atrophy and leukoaraiosis.
  • Diffuse osteolytic bone change with some area of cortical destruction. Suggest further workup.
• 2021-11-12 ENT Hearing Test
  • PTA
  • Reliability FAIR
  • Average R’t 89 dB HL; L’t 70 dB HL
  • R’t moderately severe to profound mixed type HL
  • L’t moderate to profound mixed type HL.
  • (masking dilemma)
• 2021-11-12 Auditory brainstem evoked response, ABR
  • ABR show response at 60 dB nHL in both ears.
• 2021-10-15 ENT Hearing Test
  • PTA:
    • Reliability FAIR
    • Average R’t 85 dB HL; L’t 73 dB HL
    • R’t moderately severe to profound mixed type HL
    • L’t moderate to profound mixed type HL.
    • (masking dilemma)
  • Tymp: R’t type C; L’t type A.
  • ART: Bil absent.
• 2021-04-02 ENT Hearing Test
  • PTA:
  • Reliability FAIR
  • Average RE 89 dB HL; LE 60 dB HL
  • RE severe to profound MHL (mixed hearing loss)
  • LE moderate to profound SNHL (sensory neural hearing loss)
• 2021-02-19 ENT Hearing Test
  • Reliabilty Fair
  • PTA
    • R’t : 85 dB HL, severe to profound mixed type HL
    • L’t : 61 dB HL, moderate to severe SNHL
  • Tymp
    • R’t : Type C
    • L’t : Type A
  • ART
    • Bil absent.
• 2021-01-19 Tc-99m MDP whole body bone scan
  • In comparison with the previous study on 2020/03/31, the previous bone lesions in the left humeral head, right pubic bone and bilateral knees are a little less evident.
  • The lesions in the upper portions of bilateral S-I joints and greater trochanter of left femur are new. The nature is to be determined (post-traumatic change? other nature?). Please correlate with other clinical findings for further evaluation.
  • Other bone lesions are either stationary or a little less evident.
• 2021-01-18 Patho - bone marrow biopsy
  • Bone marrow, biopsy — Plasma cell myeloma
    
  • The sections show normocellular marrow (30%). The M/E ratio about 3:1. The myeloid cells show good maturation. The megakaryocytes are unremarkable. Sheets and isolated CD138+ mature and immature plasma cells in interstitium, constitue 50% of marrow cells are noted. The plasma cells also reveal kappa light chain restriction and negative for lambda light chain.
• 2020-03-31 Tc-99m MDP bone scan with SPECT
  • Prominently increased activity in the left humeral head, right pubic bone and bilateral knees. Multiple myeloma involving these bones should be watched out. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Increased activity in the middle and lower C-spines, some middle to lower T-spines, some L-spines and sacrum. Either degenerative change or multiple myeloma may show this picture.
  • Some faint hot spots in bilateral rib cages and increased activity in the sternum. The nature is to be determined (post-traumatic change? other nature?). Please also correlate with other clinical findings for further evaluation.
  • Mildly iuncreased activity in the right shoulder. Arthritis may show this picture.
• 2019-05-30 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (57.8 - 11.6) / 57.8 = 79.93%
    • M-mode (Teichholz) = 79
  • Normal chamber size
  • Adequate LV and RV performance
  • Possibly impaired LV relaxation
  • AV sclerosis with trivial AR ; mild MR, TR and PR
  • No regional wall motion abnormalities
• 2019-05-14 Myocardial perfusion SPECT with persanti
  • Probably mild to moderate myocardial ischemia with possible a small portion of severe ischemia at the apical lateral wall and mild myocardial ischemia at the apical anteroseptal wall.
  • Mild reverse redistribution of radioactivity to the inferolateral wall and posterior wall, either normal variant or myocardial ischemia may show this picture.
• 2017-07-10 Nerve Conduction Velocity, NCV
  • The NCV study showed
    • Prolonged distal motor latency and slowing of motor and sensory nerve conduction velocity in bilateral median nerves.
    • Decreased CMAP and SAP amplitude in left median nerve.
    • Decreased CMAP amplitude in bilateral peroneal nerves.
    • Decreased SAP amplitude in right ulnar and left sural nerves.
    • The F wave and H reflex were normal.
    • The above findings suggest entrapment neuropathy of bilateral median nerves at the wrist(left side was severer) with superimposed bilateral peroneal neuropathy.
    • Advise careful clinical correlation.
• 2019-05-30 2D transthoracic echocardiography
  • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 32) / 120 = 73.33%
    • M-mode (Teichholz) = 73
  • Adequate LV systolic function with normal resting wall motion
  • Dilated LA, septal hypertrophy, LV diastolic dysfunction, Gr 1
  • Trivial MR and trivial TR
  • Preserved RV systolic function
• 2017-01-23 Pulmonary Tc-99m perfusion and ventilation scan
  • The Tc-99m MAA perfusion lung scan was obtained 5-10 minutes after injection of Tc-99m MAA 5 mCi. The scintigraphy revealed several smalll subsegmental or nonsegmental defects in perfusion in the upper lobe and the superior segment of the lower lobe of both the right lung and the left lung.
  • The Tc-99m DTPA aerosol lung ventilation lung scan, which was obtained immediaely after inhalation of the radioagent 30 mCi, revealed that there were deficient ventilation in the upper lobe of the superior segment of the lower lobe of both the right lung and left lung, in an extent much larger than were the defects shown on perfusion scan.
  • The scintigraphy revealed several small subsegmental or non-segmental ventilation-perfusion matched defects in the upper lobe and the superior segment of the lower lobe of both the right and left lung, indicating that the probability of pulmonary embolism was low (reported risk of lower than 20%, by revised PIOPED Criteria for Pulmonary Embolus Diagnosis). Please correlate with clinical findings for further evaluation.
• 2017-01-19 ECG
  • Sinus rhythm with Premature atrial complexes
  • Left axis deviation
  • S1-S2-S3 pattern, consider pulmonary disease, RVH, or normal variant
  • Abnormal ECG
• 2017-01-12 CXR
  • Thoracic aortic arch calcified atheriosclerotic plaque
  • Mild cardiomegaly
  • Osteoporotic compression fracture of multiple vertebral bodies
  • osteolytic change in visible bones.
• consultation
  • 2020-03-28 Orthopedics
    • Q
      • This 82 year-old woman had medical history of 1) Hypertensive heart disease without heart failure 2) Cardiac arrhythmia 3) Hyperlipidemia 4) Osteoarthritis knee 5) multiple myeloma, IgA type, ISS stage 3 under Thado control. she was regular OPD follow up since Jun. 2006.
      • According to her and son, she had right shoulder soreness with pain since few weeks ago. She denied fall down, traumatic recently; there was no local heating nor inflammation situation. She comes to our Oncology OPD for help, the x-ray showed no fracture lesion. We need your expertise for further management, thanks
    • A
      • This 82-year-old woman suffered from right shoulder soreness and pain weeks ago.
      • local findings:
        • no local heat
        • near full ROM of shoulder
        • supraspinatus test: -
      • X-ray:
        • OA change of right shoulder joint, supscious osteolytic lesion in right humerus
      • Suggestion:
        • the pain in right shoulder may caused by Multiple myeloma, further evaluation (MRI, bone scan)
        • OA of the joint also resulted in shoulder pain
        • Please prescribe NSAID (Arcoxia or Celebrex) for symptom relieve.
• medication
  • Ninlaro (ixazomib) KNINL01, KNINL01A
    • 2021-01-29 ~ undergoing 3mg/cap QWAC
  • Revlimid (lenalidomide) KREVL01
    • 2022-02-04 ~ undergoing 25mg QD PO
    • 2021-01-29 ~ 2022-02-01 25mg QOD PO
  • Thado (thalidomide) KTHAD01
    • 2017-01-18 ~ 2020-01-02 50mg HS PO
    • 2017-01-05 ~ 2017-11-16 100mg HS PO
  • Velcade (bortezomib) CVELC01
    • 2017-01-26 1.9mg ST SC
    • 2017-01-05 1.9mg ST SC
  • Licodin (ticlopidine) KLICO01
    • 2019-05-30 ~ undergoing 100mg BID PO
  • Xgeva (denosumab) CXGEV01
    • 2022-01-18 120mg Q1M SC
    • 2021-12-07 120mg Q1M SC
    • 2021-11-09 120mg Q1M SC
    • 2021-10-12 120mg Q1M SC
    • 2021-01-14 120mg Q1M SC
    • 2020-12-10 120mg Q1M SC
    • 2020-11-13 120mg Q1M SC
    • 2020-10-16 120mg Q1M SC
    • 2020-09-08 120mg Q1M SC
    • 2020-08-11 120mg Q1M SC
    • 2020-07-14 120mg Q1M SC

[assessment]

• Neutropenia has be mitigated with filgrastim (G-CSF)

  • 2023-01-09 WBC 2.94 *10^3/uL
    
  • 2023-01-07 WBC 0.96 *10^3/uL
    
  • 2023-01-06 WBC 0.94 *10^3/uL
    
  • 2022-12-23 WBC 4.61 *10^3/uL

• Over the past three months, the IgA levels have been around 500 +- 50 mg/dL, relatively stable, but showing a slowly upward trend.

  • 2023-01-06 IgA515 mg/dL
  • 2022-12-23 IgA527 mg/dL
  • 2022-12-09 IgA473 mg/dL
  • 2022-11-25 IgA534 mg/dL
  • 2022-11-11 IgA460 mg/dL
  • 2022-10-28 IgA451 mg/dL
  • 2022-10-14 IgA410 mg/dL
  • 2022-09-30 IgA390 mg/dL

• Revlimid (lenalidomide) has demonstrated a significantly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as risk of myocardial infarction and stroke in patients with multiple myeloma who were treated with lenalidomide and dexamethasone therapy. Please monitor for and advise patients about the signs and symptoms of thromboembolism as always.

• Ninlaro (ixazomib) has been prescribed as a self-paid item and is not listed on PharmaCloud nor in the active prescriptions. Please make sure that the patient’s ANC be greater than 1000/mm3, platelets be greater than 75,000/mm3, and nonhematologic toxicities be at baseline or less than grade 1 (per prescriber discretion) prior to initiating a new cycle of therapy. It is recommended that patients who are seropositive for Varicella zoster virus (VZV) and herpes simplex virus (HSV) receive an antiviral prophylaxis with acyclovir or valacyclovir prior to receiving a proteasome inhibitor (bortezomib, carfilzomib, ixazomib), as there is an increased risk of reactivation if the proteasome inhibitor is used.

700715492

230109

{colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB}

• diagnosis
  • 1. Malignant neoplasm of ascending colon
  • 2. A-colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB
  • 3. Type 2 diabetes mellitus without complications
  • 4. Gout, unspecified
  • 5. Hyperuricemia without signs of inflammatory arthritis and tophaceous disease
  • 6. Bipolar disorder, in partial remission, most recent episode manic
  • 7. Unspecified dementia without behavioral disturbance
  • 8. Chronic viral hepatitis B without delta-agent
  • 9. Essential (primary) hypertension
• lab data
  • 2022-07-08
    • Anti-HBc Reactive
      
    • Anti-HBc-Value 6.99 S/CO
      
    • Anti-HBs 473.10 mIU/mL
      
    • HBsAg Nonreactive
      
    • HBsAg Value 0.00 IU/mL
      
    • Anti-HCV Nonreactive
      
    • Anti-HCV Value 0.10 S/CO
• exam findings
  • 2023-01-06 Tc-99m MDP whole body bone scan
    • Increased activity in some middle and lower T-spines. Compression fractures and/or degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • A hot spot in the sternum, multiple hot spots in bilateral rib cages and increased activity in the right humeral head. The nature is to be determined (post-traumatic change? other nature?). Please correlate with the clinical history and follow up bone scan for further evaluation.
    • Mildly increased activity in the right wrist, compatible with benign joint lesion.
  • 2023-01-01 KUB plain film and L-spine lateral view
    • Compression fracture of T12.
  • 2023-01-01 CXR
    • Ground glass opacities in bil. lungs.
    • Compression fracture of T12.
  • 2022-12-26 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Hepatic low density lesions are found at right lobe liver up to 4.9cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-09-29, the lesions enlarged.
      • Laminated gallstone is found.
      • Visible chest
        • Nodular lesions at both lower lobes is found. Lung meta is considered. In progression.
        • S/p port-A placement with its tip at Superior vena cava
        • Borderline heart size is found.
    • Imp:
      • Ascending colon cancer, stationary in size and extension.
      • Bilateral lung and right lobe liver meta, in progression.
  • 2022-12-24 Nasal bone
    • Fracture of the nasal bone is found.
    • Regional soft tissue swelling is identified.
  • 2022-12-24 Nasopharyngoscopy
    • Scope: bil nasal cavity blood clot s/p L/T
    • smooth NPx, oropharynx, larynx
    • suspect erosion over ant. nasal cavity due to trauma
  • 2022-12-23 Bladder Sonography
    • PVR 52 mL
  • 2022-09-29 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed: Protocol: 4mm slice thickness, axial scan and coronal reconstruction
      • Mild regression fo A-colon cancer and liver/lung metastases.
      • Right renal angiomyolipoma (1.7cm). Bil. renal cysts (up to 1.0cm).
      • Gallbladder stones (1.5cm, 3.7cm).
    • IMP:
      • Mild regression fo A-colon cancer and liver/lung metastases.
  • 2022-06-29 CXR
    • Multiple nodules at bil. lungs.
  • 2022-06-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 18) / 75 = 76.00%
      • M-mode (Teichholz) = 76
    • Indeterminated LV filling pressure and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis and mild aortic root calcification.
    • Prominent epicardial and pericardial fat.
  • 2022-06-20 CT - abdomen
    • Findings
      • Wall thickening of cecum and proximal A-colon with adjacent fat stranding and reginal LAP. Multiple liver and lung metastases.
      • Right renal angiomyolipoma (1.7cm). Bil. renal cysts (up to 1.0cm).
      • Gallbladder stones (1.5cm, 3.7cm).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2022-06-20 KUB
    • Presence of radiopaque gallbladder stones.
    • Degeneration and spondylosis of L-S spine.
  • 2022-06-17 Patho - colon biopsy
    • Intestine, large, ascending colon, biopsy — adenocarcinoma
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands lined by high-grade dysplastic cells and focal stromal invasion with desmoplasia. The tumor cells display hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic figures.
    • IHC stain — EGFR(+), PMS2(+), MLH-1(+), MSH-2(+), MSH-6(+)
  • 2022-06-16 ECG
    • Left axis deviation
    • Nonspecific T wave abnormality
  • 2022-06-16 Gynecologic ultrasonography
    • Bilateral adnexae: free
    • EM: 3.5mm
  • 2022-06-16 Colonoscopy
    • Diagnosis
      • Highly suspected colon cancer, A-colon, s/p biopsy, s/p tattoo and clipping for localization
      • Mixed hemorrhoids
    • Suggestion
      • OPD F/U
      • F/U pathology report
    • Complication
      • No immediate complication
  • 2022-06-16 Pulmonary bronchodilator test
    • Moderate restrictive ventilatory impairment with significant bronchodilator response suspected poor effort related
    • please correlated with clinical condition
  • 2021-12-23 KUB + L-spine Lat
    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
    • Presence of spondylolisthesis at L4/5, grade I.
  • 2021-09-22 CT - brain
    • IMP: General brain atrophy. Hydrocephalus.
  • 2021-09-07 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Inferior infarct , age undetermined
    • Possible Anterior infarct , age undetermined
    • Abnormal ECG
  • 2018-05-05 SONO - abdomen
    • Diagnosis
      • fatty liver, moderate
      • incomplete exam of liver gallstone
    • Suggestion
      • suboptimal exam of liver because of subcutaneous fat and liver fatty change
      • suggest F/U
  • 2018-02-24 KUB
    • Degenerative change of the thoracic and lumbar spine with spurs formation/scoliosis and narrowed intervertebral disc spaces.
    • Presenc of radiopaque oval or round density in right upper abdomen, c/w gallbladder stone(s).
  • 2018-01-22 KUB
    • Presence of radiopaque gallbladder stones.
  • 2017-02-15 T-spine AP + Lat.
    • s/p VP in the T7 vertebral body with bone cement extravasation.
  • 2017-01-05 T-spine AP + Lat.
    • mild scoliosis of the T-spine.
    • s/p VP in the T7 vertebral body
• consultation
  • 2023-01-06 Psychosomatic Medicine
    • Q
      • This 70-year-old woman patient suffered from Stool OB (LIA) = Positive and Occultblood (LIA) > 999 ng/mL on 2022/05/31. No abdominal pain, tarry stool passage and body weight loss was noted. Colonoscopy on 2022/06/16 showed highly suspected colon cancer, A-colon, s/p biopsy, s/p tattoo and clipping for localization and mixed hemorrhoids. Pathology showed adenocarcinoma, IHC stain - EGFR(+), PMS2(+), MLH-1(+), MSH-2(+), MSH-6(+). Abdominal CT on 2022/06/20 showed A-colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB. Tumor mark on 2022/06/21 with CA-199 showed 15056.5 U/ml, CEA showed 995.6 ng/ml. 2D echo on 2022/06/23 showed 1.Indeterminated LV filling pressure and impaired RV relaxation. 2.Normal LV and RV systolic function. 3.Mild aortic valve sclerosis and mild aortic root calcification. 4.Prominent epicardial and pericardial fat. Port-A catheter insertion on 2022/06/29.
      • Palliative chemotherapy with FOLFIRI (Campto 150mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) on 2022/07/12(C1D1), 2022/07/22(C1D15), 2022/08/05(C2D1), 2022/08/17(C2D15), 2022/08/30(C3D1).2022/9/29(C4D1).2022/10/12(C4D15).2022/10/26(C5D1).2022/11/9(C5D15).2022/11/23(C6D1).2022/12/7(C6D15).2022/12/21(C7D1).
      • Target therapy with Avastin(5mg/kg) was given on 2022/08/30(C1), 2022/09/13(C2), 2022/9/29(C3), 2022/10/12(C4), 2022/10/26(C5), 2022/11/9(C6), 2022/11/23(C7), 2022/12/7(C8), 2022/12/21(C9).
      • Followed up CT was performed on 2022/12/26 revealed Ascending colon cancer, stationary in size and extension. Bilateral lung and right lobe liver meta, in progression.
      • The patient present urinary frequency with interval of 1-2 hour since about one week ago. Urgency urinary incontinence was noted, but no stress urinary incontinence. She also had nocturia every 0.5-1 hour at night with small amount urine. Bilateral flank pain developed for days. Otherwise, she denied cough, rhinorrhea, short of breath, diarrhea, abdominal pain, or chest tightness. Due to mentioned symptoms, she came to our hospital for help.
      • At ER, her vital signs revealed BP:151/83mmHg; HR:100bpm; BT:36.2 degrees Celsius; RR:16/min; GCS:E4V5M6. Lab data revealed leukocytosis, normocytic anemia, elevated CRP and lactic acid. Urine analysis showed pyuria and bacteuria. CXR revealed ground glass opacities in bil. lungs and compression fracture of T12. Under the impression of urinary tract infection, the patient was admitted for further evaluation and management.
      • We had explained the current condition to family and patient still had depressed mood, we need your expertise for further management, thanks 
    • A
      • Acute depressive state
        • suspected adjustment reaction with depressive features
        • suspected bipolar disorder, current episode depressed
      • Symptoms and course:
        • This is a 70 y/o female patient admitted under the impression of urinary tract infection, colon cancer with lung and liver metastasis. We were consulted for fer depressed mood.
        • According to the patient and her family, she recently was informed of the progression of her own disease; therefore, she showed more prominent depressed mood and also transient suicide ideation without plan.
        • She claimed that she would got occasional negative ideation, preoccupied over the condition of her cancer, with hopeless andhelpless feelings; while she also said that she could try to cope with the feelings by sharing them with her family.
        • She denied current suicide ideation or plan.
      • Suggestion:
        • Give depakine 200mg/tab 1# QD + 500mg/tab 1# HS, add zyprexa(5mg) 1# HS
        • Suicide risk assessment: low to moderate, transient idea, family support (+), no organised plan
        • Provide emotional catharsis, and psychoeducation for suicide risk prevention
        • Monitor her mood condition during admission, prevent suicide
        • Arrange PSY OPD f/u
  • 2023-01-04 Hemato-Oncology
    • Q
      • A case of Ascending colon cancer, T4aN2bM1b, stage IVB, with progressing bilateral lung and right lobe liver metastasis s/p palliative chemotherapy, the last biochemotherapy with Avastin plus FOLFIRI was administered on 2022/12/21
      • This time, the patient present urinary frequency with interval of 1-2 hour since about one week ago. Urgency urinary incontinence was noted, but no stress urinary incontinence. She also had nocturia every 0.5-1 hour at night with small amount urine. Bilateral flank pain developed for days. Otherwise, she denied cough, rhinorrhea, short of breath, diarrhea, abdominal pain, or chest tightness. Due to entioned symptoms, she came to our hospital for help.
      • At ER, her vital signs revealed BP:151/83mmHg; HR:100bpm; BT:36.2 degrees Celsius; RR:16/min; GCS:E4V5M6. Lab data revealed leukocytosis, normocytic anemia, elevated CRP and lactic acid. Urine analysis showed pyuria and bacteuria. CXR revealed ground glass opacities in bil. lungs and compression fracture of T12. Under the impression of urinary tract infection, the patient was admitted for further evaluation and management. Owing to patient requested, we need your expertise for further management, thanks
    • A
      • This 69 year old woman is a case of Ascending colon cancer, T4aN2bM1b, stage IVB, with progressing bilateral lung and right lobe liver metastasis s/p palliative chemotherapy. She was admited due to UTI. We may take over if you agree. Thanks for your consultation.
  • 2023-01-03 Family Medicine
    • Q
      • Her family prefered palliative care and decided DNR.
      • We need your expertise to evaluate for palliative caer, sincerely thanks.
    • A
      • 69-year-old female, Ascending colon cancer, T4aN2bM1b, stage IVB, with progressing bilateral lung and right lobe liver metastasis
      • Consciousness clear, ECOG 3
      • We will arrange hospice combine care and follow her condition
      • Indication: Ascending colon cancer
      • Plan: Combined Hospice Care
  • 2022-12-24 ENT
    • A
      • Epistaxis after falling down, mild NO,
        • the patient claimed that she fainted before falling
      • O:
        • Scope: bil nasal cavity blood clot s/p L/T
        • smooth NPx, oropharynx, larynx
        • suspect erosion over ant. nasal cavity due to trauma
      • A:
        • Bil epistaxis, anterior
      • Plan:
        • s/p local treatment
        • Allegra, transamin if no contraindication
        • Education done, if bleeding again, compression ant. nose for at least 20 mins with head downward and mouth open, if still bleeding, back to hosspital soon
        • ENT OPD f/u
• chemoimmunotherapy
  • 2022-12-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-12-07 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-11-23 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-11-09 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-10-26 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-10-12 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-09-29 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-09-13 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-2
  • 2022-08-30 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 230mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-2
  • 2022-08-17 - irinotecan 120mg/m2 200mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-08-05 - irinotecan 90mg/m2 150mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1
  • 2022-07-22 - LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr (standard)
    • dexamethasone 4mg + metoclopramide 10mg
  • 2022-07-12 - LV 300 mg/m2 500mg 2hr + 5-FU 300 mg/m2 500mg 10min + 5-FU 2000 mg/m2 3300mg 46 hr (75% dose)
    • dexamethasone 4mg + metoclopramide 10mg

[assessment]

• The results of the culture have not yet been released.
• UTI is currently managed with empirical Cefepime 2g Q8H (not for ESBL risk; ESBL = extended spectrum beta-Lactamase).
• If VRE or MRSA are suspected (eg, based on prior isolates), vancomycin (for MRSA) or daptomycin or linezolid (for VRE) might be added.

[tube feeding]

• The patient-carried Depakine Tablet (valproic acid 500mg) package insert instructs “not to crush or chew the tablet.”
• To replace Depakine Tablet 500mg HS, it is recommended to use Depakine Solution (sodium valproic 200mg/mL, 40mL/bt, available currently in stock) 2.5mL HS.
• As the liver and kidney function of the patient have not declined (2023-01-05 and 2023-01-09 lab data), there is no need to adjust the dose.

220930

[assessment]

• After adding irinotecan to the regimen in early Aug 2022, the levels of CEA and CA199 have been cut in half since the last month indicated that the treatment was working.
  • 2022-09-16 CEA 1085.5 ng/ml
    
  • 2022-08-19 CEA 1873.6 ng/ml
    
  • 2022-07-26 CEA 1895.2 ng/ml
    
  • 2022-09-16 CA-199 6337.5 U/ml
    
  • 2022-08-19 CA-199 15268.5 U/ml
    
  • 2022-07-26 CA-199 15964.6 U/ml
    
• The patient with type 2 diabetes is currently on Galvus Met (vildagliptin (DPP4i) + metformin (biguanide)) with blood sugar levels over 180 mg/dL as recorded on 2022-09-29 and 2022-09-30.
• The initialization of SGLT2i Canaglu (canagliflozin 100mg) QDAC, Forxiga (10mg) QD, or Jardiance (empagliflozin 25mg) QD might be an option in the event of consecutive 2 or 3 data points over 200 mg/dL.

220831

[assessment]

• 2022-08-19 CEA 1873 ng/mL and CA199 15268 U/mL remained high. 2022-08-30 lab data indicated grossly normal liver and kidney function, serum electrolytes, and CBC.
• The patient has been diagnosed with hypertenstion. The blood pressure records during this hospitalization were 113~138 / 59~75, not excessive for the time being. This is the first time the patient receiving bevacizumab, which is associated with a high incidence of hypertension (24% to 42%), so close monitoring is recommended.

220725

[assessment]

• 2022-06-23 2D transthoracic echocardiography showed: 1. Indeterminated LV filling pressure and impaired RV relaxation; 2. Normal LV and RV systolic function; 3. Mild aortic valve sclerosis and mild aortic root calcification. The initial dose of LV + 5-FU was set at 75% of the standard dose.
• The patient has been prescribed Depakine (valproate) 700mg daily by our psychosomatic medicine OPD for her bipolar disorder since Jan 2017. Well-tolerated.
• The patient has been prescribed Euricon (benzbromarone) 50mg daily by our cardiology OPD for her hyperuricemia since Mar 2017. In accordance with the every helf-year laboratory data, her uric acid levels were all within normal ranges from 2020-11 to 2022-04.
• Blood sugar levels were slightly elevated during this hospitalization, ranging from 110 to 253 mg/dL. In spite of this, there were no two consecutive days with glucose levels over 200 mg/dL, so it might not be necessary to adjust the hypoglycemic medication.

220713

{colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB}

• diagnosis
  • 1. Malignant neoplasm of ascending colon
  • 2. A-colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB
  • 3. Type 2 diabetes mellitus without complications
  • 4. Gout, unspecified
  • 5. Hyperuricemia without signs of inflammatory arthritis and tophaceous disease
  • 6. Bipolar disorder, in partial remission, most recent episode manic
  • 7. Unspecified dementia without behavioral disturbance
  • 8. Chronic viral hepatitis B without delta-agent
  • 9. Essential (primary) hypertension
• lab data
  • HbA1c
    • 2022-04-13 HbA1c 6.9 %
      
    • 2021-10-05 HbA1c 6.9 %
      
    • 2021-05-13 HbA1c 6.5 %
      
    • 2021-02-19 HbA1c 7.2 %
      
    • 2020-11-17 HbA1c 7.7 %
      
    • 2020-05-30 HbA1c 6.6 %
      
    • 2019-12-19 HbA1C 6.9 %
      
    • 2019-01-18 HbA1C 6.7 %
      
    • 2018-10-19 HbA1C 7.1 %
      
    • 2018-05-03 HbA1C 6.7 %
      
    • 2018-02-13 HbA1C 7.4 %
      
  • Glucose AC
    • 2022-06-16 Glucose(AC) 127 mg/dL
      
    • 2022-04-13 Glucose(AC) 160 mg/dL
      
    • 2021-10-05 Glucose(AC) 174 mg/dL
      
    • 2021-09-07 Glucose(serum) 182 mg/dL
      
    • 2021-05-13 Glucose(AC) 147 mg/dL
      
    • 2021-02-19 Glucose(AC) 192 mg/dL
      
    • 2020-11-17 Glucose(AC) 184 mg/dL
      
    • 2020-05-30 Glucose(AC) 152 mg/dL
• exam finding
  • 2022-06-29 CXR
    • Multiple nodules at bil. lungs.
  • 2022-06-23 2D transthoracic echocardiography
    • 1. Indeterminated LV filling pressure and impaired RV relaxation.
    • 2. Normal LV and RV systolic function.
    • 3. Mild aortic valve sclerosis and mild aortic root calcification.
    • 4. Prominent epicardial and pericardial fat.
  • 2022-06-20 KUB
    • Presence of radiopaque gallbladder stones.
    • Degeneration and spondylosis of L-S spine.
  • 2022-06-20 CT - abdomen, pelvis
    • Imaging Report Form for Colorectal Carcinoma
    • Impression (imaging stage): T4aN2bM1b, stage IVB
  • 2022-06-17 Patho - colon biopsy
    • Intestine, large, ascending colon, biopsy — adenocarcinoma
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands lined by hgh-grade dysplastic cells and focal stromal invasion with desmoplasia. The tumor cells display hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic figures.
    • IHC stain: EGFR(+), PMS2(+), MLH-1(+), MSH-2(+), MSH-6(+)
      
  • 2022-06-16 ECG
    • Left axis deviation
    • Nonspecific T wave abnormality
  • 2022-06-16 Gynecologic ultrasonography
    • EM 3.5mm
  • 2022-06-16 Bronchodilator test
    • Moderate restrictive ventilatory impairment with significant bronchodilator response
    • suspected poor effort related
  • 2022-06-16 Colonoscopy
    • Diagnosis
      • Highly suspected colon cancer, A-colon, s/p biopsy, s/p tattoo and clipping for localization
      • Mixed hemorrhoids
    • Suggestion
      • OPD F/U
      • F/U pathology report
    • Complication
      • No immediate complication
  • 2021-12-23 KUB + L-spine Lat
    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
    • Presence of spondylolisthesis at L4/5, grade I.
  • 2021-09-22 CT - brain
    • General brain atrophy. Hydrocephalus.
  • 2021-09-07 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Inferior infarct, age undetermined
    • Possible Anterior infarct, age undetermined
    • Abnormal ECG
  • 2021-09-07 KUB
    • Degenerative change of the spine with marginal spur formation.
  • 2018-05-05 SONO - abdomen
    • diagnosis
      • fatty liver, moderate/ incomplete exam of liver
      • gallstone
    • suggestion
      • suboptimal exam of liver because of subcutaneous fat and liver fatty change, suggest F/U
  • 2018-01-25 SONO - kidney
    • 1. Right renal mass, suspect AML
    • 2. Parenchymal renal disease
  • 2017-02-15 T-spine AP + Lat.
    • s/p VP in the T7 vertebral body with bone cement extravasation.
  • 2017-01-05 T-spine AP + Lat.
    • 1. mild scoliosis of the T-spine.
    • 2. s/p VP in the T7 vertebral body
• chemoimmunotherapy
  • 2022-07-12 - LV 300 mg/m2 in 2 hr + 5-FU 300 mg/m2 in 10 min + 5-FU 2000 mg/m2 in 46 hr (75% dose)

[assessment]

• The patient’s HbA1c were 7 +- 0.4%, serum glucose AC were 160 +- 30 mg/dL in the last three years, slightly above normal, a more intensive intervention might not be necessary if there is no urgency.
• TPR, BP remain stable during this hospitalization.
• In patients with moderate dementia (CDR = 2), Witgen (memantine 10 mg/tab) might be considered as an optional add-on.

700089206

230106

• diagnosis - 20230105 admission note
  • Malignant neoplasm of colon, unspecified
  • Fever, unspecified
  • Malignant neoplasm of sigmoid colon
  • Secondary malignant neoplasm of liver and intrahepatic bile duct
  • Gastrointestinal hemorrhage, unspecified
• family history
  • The patient has very strong family history of colon caner, from the father’s side.
• exam findings
  • 2023-01-05, 2022-12-23 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Possible Inferior infarct, age undetermined
    • Anterolateral infarct, age undetermined
    • Abnormal ECG
  • 2022-12-23 CXR
    • Hypoinflation of both lung is noted.
  • 2022-12-21 CT - brain
    • No evidence of intracranial lesion.
  • 2022-12-21 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
    • normal motor DLs, CMAP amplitudes and NCVs of bil. median, ulnar, peroneal and tibial n.
    • normal sensory DLs, SNAP amplitudes and NCVs of bil. median, ulnar, and sural n.
    • the F-wave latencies of bil. median, ulnar, peroneal and tibial n. were normal.
    • the H-reflex study of bil. tibial n. were normal
  • 2022-12-14 CT - abdomen
    • History: 20220914 CT: sigmoid colon cancer, cT4aN2aM1b (liver and non-regional LNs metastases）
    • Findings: Comparison: prior CT dated 2022/09/14.
      • Prior CT identified segmental asymmetrical wall thickening at the sigmoid colon with irregular contour is noted again, stable in wall thickness except poor enhancement that that is c/w adenocarcinoma of the sigmoid colon S/P C/T with partial response.
      • Prior CT identified metastatic nodes in the adjacent mesocolon are noted again. Most of them show decreasing in size. However, the largest one 4 cm in size shows increasing in size to 5.5 cm that is c/w progressive disease.
      • Prior CT identified multiple metastases on both hepatic lobes are noted again, increasing in size and number that are c/w progressive disease.
      • Prior CT identified several metastatic nodes in the celiac trunk and hepatoduodenal ligament are noted again, mild increasing in size that are c/w progressive disease.
      • There are soft tissue lesions in the liver hilum and ligamentum teres that may be metastatic nodes or lymphedema?
      • The gallbladder shows marked edematous wall thickening that may be hypoalbuminemia.
      • There is ascites in the abdomen and pelvis and suggestive small soft tissue nodules in the omentum and mesentery.
        • Please correlate with ascites cytology to evaluate if there is carcinomatosis?
        • In addition, There is splenomegaly (the greatest anterior-posterior dimention 15 cm).
      • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
      • Others
        • There is no focal abnormality in the biliary system and pancreas.
          
        • The abdominal aorta and IVC are grossly unremarkable.
          
        • There is no evidence of intrinsic or extrinsic bladder mass.
          
    • Impression:
      • Adenocarcinoma of the sigmoid colon with LNs and liver metastases S/P C/T show progressive disease.
  • 2022-09-22 Patho - stomach biospy
    • Stomach, body, AW, biopsy — Fundic gland polyp
  • 2022-09-22 Panendoscopy
    • Reflux esophagitis, lower esophagus, LA classification, grade A
    • Superfical gastritis, antrum
    • Gastric polyp, body, AW, s/p biopsy
  • 2022-09-21 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • There was no variant detected in the KRAS/NRAS gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-09-20 KUB
    • There is vas deferens calcification. Please correlate with serum glucose to R/O DM.
    • Fecal material store in the colon.
  • 2022-09-17 CT - chest
    • Indication: This is a 39-year-old male who was newly diagnosed colon cancer stage IV (with liver metastasis), we would like to arrange him a lung CT, in order to rule out lung metastasis.
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Subpleural nodule at right upper lobe up to 0.2cm in largest dimension is found. Benign process is favored.
        • No evidence of bilateral pleural effusion.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
      • Visible abdomen:
        • Low density lesions at both lobes of liver are found. Liver meta is considered.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • Suggest clinical correlation
    • Imp:
      • Diffuse liver meta.
      • No evidence of pulmonary meta in the study.
  • 2022-09-14 CT - abdomen
    • History:
      • Passing bloody stool since last week asssociated with left upper quadrant pain.
      • 20220912 sigmoidoscopy: An ulcerative mass with annular growth causing luminal stenosis was noted at distal sigmoid colon.
    • Indication:
      • sigmoid colon cancer for staging
    • Findings:
      • There is segmental asymmetrical wall thickening at the sigmoid colon with irregular contour and lumen stenosis, measuring 9 x 3.8 cm in size that is c/w adenocarcinoma of the sigmoid colon (T4a).
        • In addition, There are six enlarged nodes in the adjacent mesocolon and the largest one measuring 4 cm in size (N2a).
      • There are multiple poor-enhancing masses on both hepatic lobes, the largest one measuring 5.6 cm in S7, that are c/w liver metastases.
        • In addition, There are several enlarged nodes in the celiac trunk and hepatoduodenal ligament that may be non-regional lymph nodes metaseses? (M1b)
      • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
      • There is mild ascites in the pelvis. Please correlate with ascites cytology to evaluate if there is carcinomatosis?
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2022-09-13 Patho - colon biopsy
    • Intestine, large, sigmoid colon, biopsy — adenocarcinoma
    • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(-), MSH2(+), MSH6(+)
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • 2022-09-12 Sigmoidoscopy
    • Diagnosis
      • Probable sigmoid colon cancer, s/p biopsy
      • Hemorrhoid
      • Incomplete study of colon
    • Suggestion
      • Total colonoscopy is impossible due to the luminal stenosis caused by the tumor.
      • Pursue pathology result
      • Consider CT scan for further investigation
    • Complication
      • No immediate complication
  • 2020-10-30 SONO - abdomen
    • Diagnosis
      • Fatty liver, moderate
      • GB polyp
      • suspicious, Renal stone, right
      • Renal cyst, left
      • pancreatic body and tail masked by gas.
    • Suggestion
      • encourage exercise and diet adjustment.
      • Visit Urology if symptoms revealed.
  • 2020-10-16 SONO - nephrology
    • Left renal cysts
    • Left renal stone
• consultation
  • 2022-12-20 Neurology
    • Q
      • This is a 40-year-old male underlying colon cancer with multiple liver metastasis, cT4N2aM1b. This time, he came to our emergency room due to fever with chills off and on for three days. He was admitted for infection control and further chemotherapy. During admission, he complaint about dizziness, general weakness, and unstable gait. We need your help for further evaluation. Thank you very much.
    • A
      • dizziness, unsteadiness esp. while standing up and walk for steps, tilting at times, but the symptoms progressed for longer times after each chemotherapy
      • NE: aware, fluent speech, normal cranial nerves, no obvious focal weakness, diffuse hypo-reflexia, bil. thigh and girdle muscle atrophy, no obvious tenderness
      • Impression:
        • suspect cancer related myopathy and neuropathy, also dysautonomia
      • Suggest:
        • brain CT and nerve conduction study (motor and sensory NCV, H-reflex, F-wave) might be arranged
        • I would like to follow up this patient. Thank you for your consultation.
  • 2022-09-15 Hemato-Oncology
    • Q
      • The patient had strong family history of colon cancer from the father’s side.
      • Ealier of the day, CT report shows as follow:
        • There is segmental asymmetrical wall thickening at the sigmoid colon with irregular contour and lumen stenosis, measuring 9 x 3.8 cm in size that is c/w adenocarcinoma of the sigmoid colon (T4a).
          • In addition, There are six enlarged nodes in the adjacent mesocolon and the largest one measuring 4 cm in size (N2a).
        • There are multiple poor-enhancing masses on both hepatic lobes, the largest one measuring 5.6 cm in S7, that are c/w liver metastases.
          • In addition, There are several enlarged nodes in the celiac trunk and hepatoduodenal ligament that may be non-regional lymph nodes metaseses? (M1b)
        • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
        • There is mild ascites in the pelvis. Please correlate with ascites cytology to evaluate if there is carcinomatosis?
        • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value).
      • Consider the patient and his family are eager to engage into further treatment, we’d like to cousult with oncologists, with your expertise, we will have better insight of the future treatment for the patient (Whether the patient should go under what kind of chemotherapy)
      • We know Dr. Wan is very occupied today, please evaluate the patient at your free time, appreciate.
    • A
      • This 39 year old man is a case of sigmoid colon cancer with liver and celiac trunk and hepatoduodenal ligament lymph nodes metastases. Initially presentation is bloody stool. Besides, he has family history of colon cancer from the father’s side. Signoid colonscopy show an ulcerative mass with annular growth causing luminal stenosis was noted at distal sigmoid colon. Further insertion failed due to luminal stenosis. We are consulted for further evaluation.
      • Impression:
        • Favor sigmoid colon cancer with liver and celiac trunk and hepatoduodenal ligament lymph nodes metastases. Wait pathology. CEA pending.
      • Suggestion:
        • Consult CRS for operation or stenting evaluation due to impending luminal stenosis.
        • Systemic chemotherapy is indicated for metastasis colon cancer (for palliative or down stage). Arrange port A insertion, if patient agree further treatment. In addition, may consider clinical trial if avialable. Please check All-RAS + BRAF assays.
        • Check HbsAg, Anti-Hbc, Anti-HCV before chemotherapy. Arrange chest CT (+/-contrast) for complete work up r/o lung meta
        • We wound like to folluw up this case. If there is any problem, please feel free to let us known.
  • 2022-09-13 Colorectal Surgery
    • Q
      • The patient denied any systemic disease before.He presented with passage of blood in stool with dizziness for one week.Hence the patient was brought to our ER for evaluation and management. A series of examinations including blood routine, blood biochemistry, stool routine and image were performed. Sigmoid colon scope showed Probable sigmoid colon cancer, s/p biopsy; Hemorrhoid. Under the tentative diagnosis of Propable colon tumor, S colon, the patient was admitted for further evaluation and treatment. So we need your expert for colon tumor, S colon further Tx. Thanks!
    • A
      • The patient denied any systemic disease before.He presented with passage of blood in stool with dizziness for one week.Hence the patient was brought to our ER for evaluation and management. A series of examinations including blood routine, blood biochemistry,stool routine and image were performed.Sigmoid colon scope showed Probable sigmoid colon cancer, s/p biopsy ;Hemorrhoid.Under the tentative diagnosis of Propable colon tumor,S colon,the patient was admitted for further evaluation and treatment.So we need your expert for colon tumor,S colon..
      • A: Tumor of S-colon with lumen narrowing
      • P:
        • Waiting CT result
        • Surgical intervention with laparoscopic colectomy is indicated
        • We will visit this patient soon
• chemotherapy
  • 2022-12-07 - cetuximab 500mg/m2 1000mg 90min + oxaliplatin 85mg/m2 160mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5100mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg
  • 2022-11-16 - cetuximab 500mg/m2 1000mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5600mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg
  • 2022-11-02 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5600mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-10-19 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5700mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-10-05 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5700mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-09-19 - cetuximab 400mg/m2 800mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 430mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5800mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

[assessment]

• According to the updated lab data (2023-01-06 05:55), the serum potassium level has returned to normal (3.8 mmol/L), and the potassium supplement might be slowed down or held temperarily if there is no continuous leakage suspected.

221215

• exam findings
  • 2022-12-14 CT - abdomen
    • History: 20220914 CT: sigmoid colon cancer, cT4aN2aM1b (liver and non-regional LNs metastases）
    • Findings: Comparison: prior CT dated 2022/09/14.
      • Prior CT identified segmental asymmetrical wall thickening at the sigmoid colon with irregular contour is noted again, stable in wall thickness except poor enhancement that that is c/w adenocarcinoma of the sigmoid colon S/P C/T with partial response.
      • Prior CT identified metastatic nodes in the adjacent mesocolon are noted again. Most of them show decreasing in size. However, the largest one 4 cm in size shows increasing in size to 5.5 cm that is c/w progressive disease.
      • Prior CT identified multiple metastases on both hepatic lobes are noted again, increasing in size and number that are c/w progressive disease.
      • Prior CT identified several metastatic nodes in the celiac trunk and hepatoduodenal ligament are noted again, mild increasing in size that are c/w progressive disease.
      • There are soft tissue lesions in the liver hilum and ligamentum teres that may be metastatic nodes or lymphedema?
      • The gallbladder shows marked edematous wall thickening that may be hypoalbuminemia.
      • There is ascites in the abdomen and pelvis and suggestive small soft tissue nodules in the omentum and mesentery.
        • Please correlate with ascites cytology to evaluate if there is carcinomatosis?
        • In addition, There is splenomegaly (the greatest anterior-posterior dimention 15 cm).
      • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
      • Others
        • There is no focal abnormality in the biliary system and pancreas.
          
        • The abdominal aorta and IVC are grossly unremarkable.
          
        • There is no evidence of intrinsic or extrinsic bladder mass.
          
    • Impression:
      • Adenocarcinoma of the sigmoid colon with LNs and liver metastases S/P C/T show progressive disease.
  • 2022-09-22 Patho - stomach biospy
    • Stomach, body, AW, biopsy — Fundic gland polyp
  • 2022-09-22 Panendoscopy
    • Reflux esophagitis, lower esophagus, LA classification, grade A
    • Superfical gastritis, antrum
    • Gastric polyp, body, AW, s/p biopsy
  • 2022-09-21 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • There was no variant detected in the KRAS/NRAS gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-09-20 KUB
    • There is vas deferens calcification. Please correlate with serum glucose to R/O DM.
    • Fecal material store in the colon.
  • 2022-09-17 CT - chest
    • Indication: This is a 39-year-old male who was newly diagnosed colon cancer stage IV (with liver metastasis), we would like to arrange him a lung CT, in order to rule out lung metastasis.
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Subpleural nodule at right upper lobe up to 0.2cm in largest dimension is found. Benign process is favored.
        • No evidence of bilateral pleural effusion.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
      • Visible abdomen:
        • Low density lesions at both lobes of liver are found. Liver meta is considered.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • Suggest clinical correlation
    • Imp:
      • Diffuse liver meta.
      • No evidence of pulmonary meta in the study.
  • 2022-09-14 CT - abdomen
    • History:
      • Passing bloody stool since last week asssociated with left upper quadrant pain.
      • 20220912 sigmoidoscopy: An ulcerative mass with annular growth causing luminal stenosis was noted at distal sigmoid colon.
    • Indication:
      • sigmoid colon cancer for staging
    • Findings:
      • There is segmental asymmetrical wall thickening at the sigmoid colon with irregular contour and lumen stenosis, measuring 9 x 3.8 cm in size that is c/w adenocarcinoma of the sigmoid colon (T4a).
        • In addition, There are six enlarged nodes in the adjacent mesocolon and the largest one measuring 4 cm in size (N2a).
      • There are multiple poor-enhancing masses on both hepatic lobes, the largest one measuring 5.6 cm in S7, that are c/w liver metastases.
        • In addition, There are several enlarged nodes in the celiac trunk and hepatoduodenal ligament that may be non-regional lymph nodes metaseses? (M1b)
      • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
      • There is mild ascites in the pelvis. Please correlate with ascites cytology to evaluate if there is carcinomatosis?
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2022-09-13 Patho - colon biopsy
    • Intestine, large, sigmoid colon, biopsy — adenocarcinoma
    • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(-), MSH2(+), MSH6(+)
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • 2022-09-12 Sigmoidoscopy
    • Diagnosis
      • Probable sigmoid colon cancer, s/p biopsy
      • Hemorrhoid
      • Incomplete study of colon
    • Suggestion
      • Total colonoscopy is impossible due to the luminal stenosis caused by the tumor.
      • Pursue pathology result
      • Consider CT scan for further investigation
    • Complication
      • No immediate complication
  • 2020-10-30 SONO - abdomen
    • Diagnosis
      • Fatty liver, moderate
      • GB polyp
      • suspicious, Renal stone, right
      • Renal cyst, left
      • pancreatic body and tail masked by gas.
    • Suggestion
      • encourage exercise and diet adjustment.
      • Visit Urology if symptoms revealed.
  • 2020-10-16 SONO - nephrology
    • Left renal cysts
    • Left renal stone
• consultation
  • 2022-09-15 Hemato-Oncology
    • Q
      • The patient had strong family history of colon cancer from the father’s side.
      • Ealier of the day, CT report shows as follow:
        • There is segmental asymmetrical wall thickening at the sigmoid colon with irregular contour and lumen stenosis, measuring 9 x 3.8 cm in size that is c/w adenocarcinoma of the sigmoid colon (T4a).
          • In addition, There are six enlarged nodes in the adjacent mesocolon and the largest one measuring 4 cm in size (N2a).
        • There are multiple poor-enhancing masses on both hepatic lobes, the largest one measuring 5.6 cm in S7, that are c/w liver metastases.
          • In addition, There are several enlarged nodes in the celiac trunk and hepatoduodenal ligament that may be non-regional lymph nodes metaseses? (M1b)
        • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
        • There is mild ascites in the pelvis. Please correlate with ascites cytology to evaluate if there is carcinomatosis?
        • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value).
      • Consider the patient and his family are eager to engage into further treatment, we’d like to cousult with oncologists, with your expertise, we will have better insight of the future treatment for the patient (Whether the patient should go under what kind of chemotherapy)
      • We know Dr. Wan is very occupied today, please evaluate the patient at your free time, appreciate.
    • A
      • This 39 year old man is a case of sigmoid colon cancer with liver and celiac trunk and hepatoduodenal ligament lymph nodes metastases. Initially presentation is bloody stool. Besides, he has family history of colon cancer from the father’s side. Signoid colonscopy show an ulcerative mass with annular growth causing luminal stenosis was noted at distal sigmoid colon. Further insertion failed due to luminal stenosis. We are consulted for further evaluation.
      • Impression:
        • Favor sigmoid colon cancer with liver and celiac trunk and hepatoduodenal ligament lymph nodes metastases. Wait pathology. CEA pending.
      • Suggestion:
        • Consult CRS for operation or stenting evaluation due to impending luminal stenosis.
        • Systemic chemotherapy is indicated for metastasis colon cancer (for palliative or down stage). Arrange port A insertion, if patient agree further treatment. In addition, may consider clinical trial if avialable. Please check All-RAS + BRAF assays.
        • Check HbsAg, Anti-Hbc, Anti-HCV before chemotherapy. Arrange chest CT (+/-contrast) for complete work up r/o lung meta
        • We wound like to folluw up this case. If there is any problem, please feel free to let us known.
  • 2022-09-13 Colorectal Surgery
    • Q
      • The patient denied any systemic disease before.He presented with passage of blood in stool with dizziness for one week.Hence the patient was brought to our ER for evaluation and management. A series of examinations including blood routine, blood biochemistry, stool routine and image were performed. Sigmoid colon scope showed Probable sigmoid colon cancer, s/p biopsy; Hemorrhoid. Under the tentative diagnosis of Propable colon tumor, S colon, the patient was admitted for further evaluation and treatment. So we need your expert for colon tumor, S colon further Tx. Thanks!
    • A
      • The patient denied any systemic disease before.He presented with passage of blood in stool with dizziness for one week.Hence the patient was brought to our ER for evaluation and management. A series of examinations including blood routine, blood biochemistry,stool routine and image were performed.Sigmoid colon scope showed Probable sigmoid colon cancer, s/p biopsy ;Hemorrhoid.Under the tentative diagnosis of Propable colon tumor,S colon,the patient was admitted for further evaluation and treatment.So we need your expert for colon tumor,S colon..
      • A: Tumor of S-colon with lumen narrowing
      • P:
        • Waiting CT result
        • Surgical intervention with laparoscopic colectomy is indicated
        • We will visit this patient soon
• chemotherapy
  • 2022-12-07 - cetuximab 500mg/m2 1000mg 90min + oxaliplatin 85mg/m2 160mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5100mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg
  • 2022-11-16 - cetuximab 500mg/m2 1000mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5600mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg
  • 2022-11-02 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5600mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-10-19 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5700mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-10-05 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5700mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-09-19 - cetuximab 400mg/m2 800mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 430mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5800mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

[assessment]

• 2022-12-13 WBC 15.23 *10^3/uL, CRP 8.15 mg/dL, the infection signs are treated with Brosym (cefoperazone + sulbactam) without an issue.

700962042

230106

• exam finding
  • 2022-11-20 CT - abdomen
    • Clinical history: 53 y/o female patient with ovary cancer with peritonal seeding
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy.
      • Outpouching lesion in ascending colon, suggesting ascending colon diverticulum.
    • Impression:
      • S/P hysterectomy. Suggest follow up.
      • Ascending colon diverticulum.
  • 2022-08-10 CT - abdomen
    • History: ovarain cancer, s/p neoadjuvant bidirectional chemotherapy (IP with Taxotere/Cisplatin x 3 cycles, IV with Taxol/Carboplatin x 4 cycles).
    • Indication: ovary cancer with peritonal seeding S/P HIPEC for FU
    • Impression:
      • S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2022-08-10 CXR
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2022-06-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (163 - 50) / 163 = 69.33%
      • M-mode (Teichholz) = 69
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA
    • Trivial MR, trivial AR, mild to moderate TR
    • Preserved RV systolic function
  • 2022-06-20 CT - chest
    • Comparison was made with previous CT dated on 2021 2022
      • Lungs:
        • Platelike lung atelectasis over Rt middle lobe
        • subtle mosaic pulmonary attenuation in both lungs
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels: mild coronary arterial calcification.
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
    • Impression:
      • suspect small airways disease involving both lungs d/d drug treatment related change.
  • 2022-02-09 CT - abdomen, pelvis
    • S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2021-10-08 Patho - peritoneum biopsy
    • diagnosis
      • Peritoneum, left lower, cytoreductive surgery - Serous carcinoma, seeding
        
      • Appendix, cytoreductive surgery - Serous carcinoma, seeding
      • Peritoneum, right flank, cytoreductive surgery - Serous carcinoma, seeding
        
      • Omenum, cytoreductive surgery - Serous carcinoma, seeding
      • Peritoneum, right upper, cytoreductive surgery - Serous carcinoma, seeding
        
      • Gallbladder, cytoreductive surgery - Serous carcinoma, seeding
    • IHC: WT-1(+), CK7(+), CK20(-), PAX-8(+)
  • 2021-10-08 Patho - uterus neoplastic
    • diagnosis
      • Ovary, bilateral, salpingo-oophorectomy (s/p chemotherapy) - Serous carcinoma, high-grade
        
      • Fallopian tube, bilateral, salpingo-oophorectomy - Serous carcinoma, seeding
        
      • Uterus, serosa, abdominal total hysterectomy - Serous carcinoma, seeding
• consultation
  • 2022-06-25 Chest Medicine
    • Q
      • for dyspnea & pneumonia over both lungs
      • for intermittent fever for one more ago
      • This 52 y/o female, a pt of ovarian CA wt peritoneal seeding Dx in April 2021, s/p pre-Op neoadjuvant IV C/T wt Taxol / Carboplatin concurrently wt IP C/T wt Taxotere / Cisplatin Q3W x 3 (Bidirectional C/T, intraperitoneal-systemic C/T) from May 2021 to July 2021 & #4 IV Taxol / Carboplatin on 20210901 & Bil, salpingo-oophorectomy & cytoreductive surgery & HIPEC on 20211007. She was admitted due to high fever and dyspnea and cough for 2 days. CXR showed pneumonia over both lungs. We need expertise to evaluate her condition thanks!
    • A
      • CxR
        • Lung markings: increased density in the bilateral lower lung fields, in progression
      • CT
        • Platelike lung atelectasis over Rt middle lobe
        • subtle mosaic pulmonary attenuation in both lungs
          • suspect small airways disease involving both lungs d/d drug treatment related change.
        • Imp
          • Bilateral pneumonia, r/o pneumonitis, pathogen?
      • Suggestion
        • Check PJP (done), CMV (done), atypical pathogens (done), TB*3, Cryptococcus, Aspergillus
        • May add IV medason 0.5amp Q12H and taper when condition inproved
        • Keep tapimycin + Targocid, may add Cravit if CxR progression
        • F/U CxR on 20220625 and closely (CXR, BT improved on 20220625)
        • Keep I/O balance, electrolyte balance. correct anemia
        • Arrange 2D for heart function survey
        • Check Alb next time
        • follow up lab and CXR days later
        • If condition still progression with unstable O2 saturation, intubation with ICU admission and bronchoscope with full work-up survey might be needed
  • 2021-10-08 Chest Medicine
    • Q
      • She was admitted and received 3 combined surgery
        • right upper, right flank and left lower peritonectomy, appendectomy, cholecystectomy
        • abdominal total hysterectomy + bilateral salpingooophorectomy
        • bilateral URS-exam and ureteral catheterization on 20211007.
      • Post-op he was transferred to SICU for intensive care.
      • Cruuent problem:
        • right lung pleural effusion
      • We need your epertise for evaluation. Thanks a lot.
    • A
      • Right side pleural effusion abruptly expressed due to
        • elevated hydrastatic pressure
        • Major abdominal operation
      • Suggestion
        • we will arrange chest echo for pig-tail insertion
        • reduce hydrastatif fluid infusion
        • Lasix to keep I/O negative
        • High risk of kidney injury due to multiple nephrotoxic agents use
        • delay extubation till right pleural effusio drained out.
        • Enteral feeding as soon.
        • Thanks and f/u prn.
  • 2021-04-17 Hemato-Oncology
    • Q
      • The 55 y/o female, a pt wt suspected ovarian CA or gastric CA wt peritoneal mets Dx in April 2021.
      • PH:
        • Hypertension under medical control for years.
        • Tachycardia treated with propanolol.
        • HBV.
      • She suffered from left upper abdominal pain since 20210403
      • Her abdominal pain aggravated when she is eating, drinking and lying on the left side. She also had abdomen fullness and nausea for one month, denied of body weight loss. At ER, abdomen echo showed massive ascites, then tapping was done.
      • Abd CT showed ascites and peritoneal soft tissue density, suspected peritoneal carcinomatosis, suspect wall thickening of gastric antrum.
      • Under the impression of spontaneous bacteria peritonitis with hollow organ perforation, she was admitted to GI ward for management on 2021/04/08.
      • GS was consulted for suspected hollow organ perforation, and suggested exploratory laparascopy. She underwent operation of laparoscopic peritoneal tumor excision and PD tube implantation (Ascites amount: 8000ml) on 20210412.
      • CA-125: 496.8, normal CEA, CA-199.
      • Ascites cytology: malignancy. Pathology revealed Metastatic serous carcinoma,
        • IHC the tumor cells shows: CK7(+), CK20(-), CK5/6(-), WT1(+), and PAX8 (+).
      • Bidirectional C/T. We need your expertise for suspect ovarian cancer with peritoneal metastatic evaluation and thanks for your times.
    • A
      • Lab:
        • Peritoneum, laparoscopic peritoneal biopsy (20210413): Met serous carcinoma.
      • Abd CT (20210407):
        • Extraluminal air; DDx: hollow organ performation, previous peritoneocentesis
        • Ascites and peritoneal soft tissue density, r/o peritoneal carcinomatosis
        • Suspect wall thickening of gastric antrum
      • EGD & colonscopy will be done.
      • Medical advice:
        • It is most likely that the pt suffered from ovarian CA wt peritoneal seeding if EGD & colonoscopy shows negative.
        • If the pt accepts aggressive Tx for peritoneal mets, may consider bidirectional systemic IV C/T plus intra-peritoneal (IP) C/T.
      • No standard treatment for peritoneal carcinomatosis (PC) from colon or gastric cer. Peritoneal cavity acts as a sanctuary against systemic C/T probably because of the existence of a blood peritoneal barrier consisting of stromal tissue between mesothelial cells and submesothelial blood capillaries.
        • Only a small amount of systemic drugs are capable of penetrating this barrier and passing into the peritoneal cavity (eg: 5-FU, paclitaxel, docetacel, gemcitabine, doxorubicin).
        • IP chemotherapy offers potential therapeutic advantages over systemic chemotherapy by generating high local concentrations of chemotherapeutic drugs in the peritoneal cavity. This concentration difference enables the exposure of small nodules of PC before cytoreductive surgery ( CRS ) and lowers the systemic toxicity.
      • Bidirectional IV / IP C/T first then do Op. Tx schedule as following:
        • multidisciplinary treatment combining Bidirectional C/T:
          • Neoadjuvant intraperitoneal-systemic C/T protocol (NIPS),
        • Peritonectomy & Gyn Op.
        • Hyperthermic intraperitoneal chemoperfusion (HIPEC)
        • Early postoperative intraperitoneal C/T (EPIC).
      • Aims of NIPS are stage reduction, the eradication of peritoneal free cancer cells, and an increased incidence of complete cytoreduction (CC-0) for PC.
      • Early postoperative intraperitoneal chemotherapy (EPIC) can eradicate residual intraperitoneal cancer cells before fibrin can accumulate around residual cancer cells on the peritoneal surface.
      • The current state-of-the-art treatment for colorectal peritoneal dissemination CRS (cytoreductive surgery) & HIPEC.
      • Pt wt low tumor volume, well/mod. differentiated tumors and complete cytoreduction may potentially benefit from CRS & HIPEC.
      • CRS wt peritonectomy plus HIPEC confers a prolonged survival. Complete cytoreduction is an essential factor for a good outcome.
      • NIPS plus peritonectomy may improve the incidence of complete cytoreduction.
        • ref: J Clin Oncol 2004; 22: 3284-3292 & J Surg Oncol 2009; 100: 311-316 )
      • Peritoneal wash cytological examination was performed before and after NIPS & other intraperitoneal chemotherapy.
      • Systemic IV chemotherpay wt Taxol / Carboplatin concurrently wt IP C/T wt Taxotere / Cisplatin Q3W x 4 (Bidirectional C/T, intraperitoneal-systemic C/T). Then will do abd CT for response evaluation.
• surgical operation
  • 2021-10-07 total hysterectomy + bilateral salpingo-oophorectomy
• chemotherapy
  • 2023-01-06 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg
  • 2022-12-12 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2022-11-21 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-10-31 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg
  • 2022-10-14 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2022-09-19 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-08-09 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg
  • 2022-07-19 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg + diphenhydramine 50mg
  • 2022-06-07 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg + diphenhydramine 50mg
  • 2023-05-16 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg
  • 2022-04-18 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg + diphenhydramine 50mg
  • 2022-03-23 - bevacizumab 7.5mg/kg 600mg 1.5hr
    • dexamethasone 4mg + diphenhydramine 50mg
  • 2022-03-01 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg
  • 2022-02-07 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
  • 2022-01-17 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
  • 2021-12-27 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
  • 2021-12-06 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
  • 2021-11-12 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
  • 2021-10-07 - [cisplatin 75mg/m2 142mg + docetaxel 60mg/m2 114mg + gentamicin 40mg + sodium bicarbonate 4200mg] ST IP 90min (the surgical operation day)
  • 2021-09-02 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 440mg 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
  • 2021-07-06 - paclitaxel 100mg/m2 185mg 3hr + carboplatin AUC 5 540mg 2hr + [docetaxel 40mg/m2 74mg + cisplatin 30mg/m2 55mg + gentamicin 40mg + sodium bicarbonate 2800mg] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
  • 2021-06-02 - paclitaxel 100mg/m2 190mg 3hr + carboplatin AUC 5 600mg 2hr + [docetaxel 40mg/m2 74mg + cisplatin 30mg/m2 56mg + gentamicin 40mg + sodium bicarbonate 2800mg] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
  • 2021-05-04 - paclitaxel 100mg/m2 190mg 3hr + carboplatin AUC 5 435mg 2hr + [docetaxel 40mg/m2 74mg + cisplatin 30mg/m2 56mg + gentamicin 40mg + sodium bicarbonate 2800mg] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg

[assessment]

• As a result of anemia, the patient received blood transfusion of LPRBC and was discharged on 2023-01-06 under stable conditions.

220302

[assessment]

• platin-based regimen has been introduced since May 2021, bevacizumab added since Nov 2021 s/p total hysterectomy + bilateral salpingo-oophorectomy, most recent CT on 2022-02-09 showed no evidence of tumor recurrence. no issue with current medication.

701432080

230106

[OxyNorm tube feeding]

• The package insert of OxyNorm (oxycodone 5mg) instructs “Do not chew or crush them.”
• For NG feedings or gastrostomies, add some water to the tube, open the capsule and pour the contents directly into the tube, then rinse the tube with 15mL of water, then another 10mL of water, several times. In addition to water, milk or liquid nutrition can also be used.

[no sodium version of piperacillin + tazobactam]

• Cefim (cefepime) and Pipe&Tazo (piperacillin + tazobactam) cover overlapping spectrum of micromials. However, the former is a hydrochloride salt, which should not increase the sodium levels in the body, while the latter is sodium-based.
• As this patient is 77 years of age, weighs 50kg, and has a creatinine level of 1.97 mg/dL, the estimated CrCl is 22mL/min, it is recommended that cefepime should not exceed 2g once daily.
• When possible, bacterial culture should still be performed to confirm the pathogen and limit the scope of antibacterial treatment.

701465162

230106

{tube feeding}

It is possible to peel the Concor (bisoprolol 1.25mg) tablet in half or grind it for tube feeding.

221229

• diagnosis
  • Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission
• present illness - 20221228 admission note
  • This is a 61-year-old male with the past history of DM under diet control, hypertension without medication control, monomorphic epitheliotropic intestinal T-cell lymphoma s/p ileocecectomy, small bowel resection, end ileostomy on 2022/11/25. He lived in America and received surgical and medication treatment there, he came back to Taiwan on 2022/12/25. This time, he came to our hematology and oncology outpatient department for further evaluation and treatment. According to the patient, he sufferred from abdominal discomfort for almost four months, especially after meal. Accompanied with poor appetite, nausea, vomiting, and dizziness. Intermittent chest tightness and mild dyspnea without radiation pain nor cold sweating was also mentioned. He lost about 10 kilograms in the recent three months. There was no fever, no chills, no dysuria, no tarry stool. Under the impress
• past history
  • DM under diet control
  • HTN without medication control
  • Monomorphic epitheliotropic intestinal T-cell lymphoma s/p ileocecectomy, small bowel resection, end ileostomy on 2022/11/25
• family history
  • His father has peritoneal cancer.
  • His mother has cervical cancer and hypertension.
  • His sister has lung cancer.
  • His brother has thyroid cancer.
• lab data
  • 2022-12-28 Anti-HBc Reactive
    
  • 2022-12-28 Anti-HBc-Value 6.64 S/CO
    
  • 2022-12-28 Anti-HCV Nonreactive
    
  • 2022-12-28 Anti-HCV Value 0.20 S/CO
    
  • 2022-12-28 HBsAg Nonreactive
    
  • 2022-12-28 HBsAg (Value) 0.45 S/CO

[assessment]

• High bilirubin (total and direct), AST, ALT; slightly high Glucose (AC), HbA1c; slightly low serum Na, K have been seen in lab data on 2022-12-28/29.

• There is no past history of hypercholesterolemia or available laboratory data to support this condition, Tulip (atorvastatin) might not be indicated.

700734842

230105

{Prostate cancer, pT3bN1cM0, s/p RARP on 2015-06-30, s/p adjuvant radiotherapy on 2015-09-25 and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV}

• past history
  • Prostate cancer s/p operation on 2015/06/30
  • BPH s/p TURP
  • Dyslipidemia
  • GERD under PPI control
  • hyperparathyroidism s/p parathyroidectomy
  • meningioma s/p operation,
  • hyroid goiters s/p thyroidectomy    
• lab data
  • PSA
    • 2022-09-20 PSA 6.829 ng/mL
      
    • 2022-08-24 PSA 10.431 ng/mL
      
    • 2022-07-19 PSA 13.088 ng/mL
      
    • 2022-06-21 PSA 16.956 ng/mL
      
    • 2022-05-16 PSA 26.464 ng/mL
      
    • 2022-05-04 PSA 22.462 ng/mL
      
    • 2022-04-26 PSA 27.061 ng/mL
      
    • 2022-03-23 PSA 26.884 ng/mL
      
    • 2022-02-15 PSA 43.235 ng/mL
      
    • 2022-01-19 PSA 37.386 ng/mL
      
    • 2021-12-21 PSA 39.881 ng/mL
      
    • 2021-11-24 PSA 37.837 ng/mL
      
    • 2021-10-29 PSA 28.391 ng/mL
      
    • 2021-08-13 PSA 17.407 ng/mL
      
    • 2021-07-19 PSA 14.190 ng/mL
      
    • 2021-07-06 PSA 12.470 ng/mL
      
    • 2021-04-05 PSA 8.744 ng/mL
      
    • 2021-02-02 PSA 21.330 ng/mL
      
    • 2020-10-30 PSA 27.922 ng/mL
      
    • 2020-04-30 PSA 8.843 ng/mL
      
    • 2019-12-14 PSA 4.507 ng/mL
      
    • 2019-11-12 PSA 3.552 ng/mL
      
    • 2018-12-12 PSA 7.751 ng/mL
      
    • 2018-10-13 PSA 4.267 ng/mL
      
    • 2018-05-03 PSA 4.222 ng/mL
      
  • WBC
    • 2022-09-20 WBC 2.40 *10^3/uL
      
    • 2022-09-13 WBC 7.17 *10^3/uL
      
    • 2022-08-30 WBC 2.51 *10^3/uL
      
    • 2022-08-24 WBC 8.45 *10^3/uL
      
    • 2022-08-09 WBC 6.08 *10^3/uL
      
    • 2022-08-03 WBC 3.27 *10^3/uL
      
    • 2022-07-19 WBC 4.91 *10^3/uL
      
    • 2022-07-12 WBC 1.13 *10^3/uL
      
    • 2022-06-28 WBC 2.52 *10^3/uL
      
    • 2022-06-21 WBC 5.82 *10^3/uL
      
    • 2022-06-07 WBC 2.76 *10^3/uL
      
    • 2022-05-16 WBC 2.93 *10^3/uL
      
    • 2022-05-11 WBC 9.67 *10^3/uL
      
    • 2022-05-04 WBC 0.83 *10^3/uL
      
    • 2022-04-26 WBC 3.77 *10^3/uL
      
    • 2022-04-19 WBC 5.69 *10^3/uL
      
    • 2022-04-06 WBC 4.07 *10^3/uL
      
    • 2022-03-23 WBC 6.88 *10^3/uL
      
    • 2022-03-08 WBC 2.63 *10^3/uL
      
    • 2022-02-23 WBC 1.69 *10^3/uL
      
    • 2022-02-15 WBC 5.48 *10^3/uL
      
    • 2022-02-08 WBC 3.24 *10^3/uL
      
    • 2022-01-25 WBC 5.50 *10^3/uL
      
    • 2022-01-19 WBC 3.33 *10^3/uL
      
    • 2022-01-11 WBC 8.18 *10^3/uL
      
    • 2021-12-29 WBC 3.00 *10^3/uL
      
    • 2021-12-21 WBC 8.44 *10^3/uL
      
    • 2021-12-08 WBC 3.26 *10^3/uL
      
    • 2021-11-24 WBC 1.51 *10^3/uL
      
    • 2021-11-15 WBC 4.03 *10^3/uL
      
    • 2018-12-06 WBC 6.68 *10^3/uL
      
    • 2018-10-28 WBC 7.92 *10^3/uL
      
  • HGB
    • 2022-09-20 HGB 10.3 g/dL
      
    • 2022-09-13 HGB 9.8 g/dL
      
    • 2022-08-30 HGB 10.1 g/dL
      
    • 2022-08-24 HGB 10.8 g/dL
      
    • 2022-08-09 HGB 9.9 g/dL
      
    • 2022-08-03 HGB 9.6 g/dL
      
    • 2022-07-19 HGB 10.2 g/dL
      
    • 2022-07-12 HGB 9.2 g/dL
      
    • 2022-06-28 HGB 10.1 g/dL
      
    • 2022-06-21 HGB 9.2 g/dL
      
    • 2022-06-07 HGB 9.9 g/dL
      
    • 2022-05-16 HGB 10.7 g/dL
      
    • 2022-05-11 HGB 10.0 g/dL
      
    • 2022-05-04 HGB 10.1 g/dL
      
    • 2022-04-26 HGB 11.1 g/dL
      
    • 2022-04-19 HGB 11.1 g/dL
      
    • 2022-04-06 HGB 10.9 g/dL
      
    • 2022-03-23 HGB 10.9 g/dL
      
    • 2022-03-08 HGB 10.5 g/dL
      
    • 2022-02-23 HGB 10.4 g/dL
      
    • 2022-02-15 HGB 10.8 g/dL
      
    • 2022-02-08 HGB 10.2 g/dL
      
    • 2022-01-25 HGB 10.6 g/dL
      
    • 2022-01-19 HGB 10.0 g/dL
      
    • 2022-01-11 HGB 10.4 g/dL
      
    • 2021-12-29 HGB 10.7 g/dL
      
    • 2021-12-21 HGB 11.4 g/dL
      
    • 2021-12-08 HGB 11.1 g/dL
      
    • 2021-11-24 HGB 12.2 g/dL
      
    • 2021-11-15 HGB 12.0 g/dL
• exam findings
  • 2022-12-17 MRI - L-spine
    • Known a case of prostate cancer. Multiple enhancing nodular lesions within visible thoracic-lumbar vertebral bodies. Compatible with metastatic lesions.
    • Retrolisthesis of L2 on L3, grade I.
    • Spondylolisthesis of L4 on L5, grade I.
  • 2022-11-30 SONO - chest
    • Pleural effusion, minimal, bilateral
    • Atelectasis, LLL and RLL
  • 2022-11-28 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/06/30, there is a new lesion of increased activity at the left sternoclavicular junction; probably benign in nature.
    • No prominent change is noted in other bone lesions.
  • 2022-11-28 Peripheral Vascular Test - vein, lower limbs
    • Report:
      • Right side:
        • SVC: 23.8 mmHg ; 27.3 mmHg ;
        • MVO/SVC: 98 % ; 92 % ;
        • Average MVO/SVC: 95 %
      • Left side:
        • SVC: 23.1 mmHg ; 27.2 mmHg ;
        • MVO/SVC: 95 % ; 87 % ;
        • Average MVO/SVC: 91 %
      • Thrombus : None
        • Varicose vein at L’t LSV
    • Conclusion:
      • Significant venous reflux at left saphenofemoral junction with varicose change of left LSV from upper to lower leg level.
      • Slow venous return flow at left poplital vein; a large perforator vein draining from left distal PTV to LSV was detected.
      • No evidence of venous thrombosis at bilateral lower limbs venous systems.
      • Tissue edema at bilateral lower legs.
      • The ratios of MVO and SVC of bilateral legs were within normal limits.
  • 2022-11-26 CT - abdomen
    • Findings
      • S/P prostate operation.
      • Left liver cyst (2.1cm).
      • Bil. pleural effusions.
      • Some LNs (up to 0.8cm, mild regression) at retroperitoneum.
      • Suspected bony metastases at spine.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Gallbladder stone (0.9cm).
      • Patency of portal vein.
      • Minimal ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P prostate operation. Bil. pleural effusions.
      • Some LNs (up to 0.8cm, mild regression) at retroperitoneum.
      • Suspected bony metastases at spine.
      • Gallbladder stone (0.9cm).
  • 2022-07-19 Nasopharyngoscopy
    • clear middle meatus, inferior turbinate hypertrophy, smooth NPX
  • 2022-06-30 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20220311, the previous bone lesions in the upper and middle T-spines, L3 spine and left iliac bone are all a little less evident.
    • No prominent change is noted in other bone lesions.
  • 2022-06-29 CT - abdomen
    • Findings:
      • Prior CT identified some LNs (up to 1.6cm) in para-aortic space and left external iliac chain are noted again, mild decreasing in size that is c/w partial response.
      • There is an ill-defined osteoblastic lesion with central osteolytic change at right lateral aspect of L3 vertebral body that is c/w bony metastasis.
      • There are several hepatic cysts in both lobes and the largest one 2.5 x 1.5 cm in size at S2.
      • A gallstone 1.2 cm is noted.
      • S/P prostatectomy.
    • Impression:
      • 1. Prior CT identified some LNs (up to 1.6cm) in para-aortic space and left external iliac chain are noted again, mild decreasing in size that is c/w metastatic nodes S/P C/T with partial response.
      • 2. There is an ill-defined osteoblastic lesion with central osteolytic change at right lateral aspect of L3 vertebral body that is c/w bony metastasis.
  • 2022-04-19 Water’s view
    • Opacification of right maxillary sinus.
  • 2022-03-11 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20210723, the lesions in the upper and middle T-spines are less evident. However, the lesion in the left iliac bone is a little more evident.
    • The lesions in the right humeral head and L3 spine are new. Bone metastases should be watched out. Please correlate with other clinical findings for further evaluation.
  • 2022-03-10 CT - abdomen, pelvis
    • S/P prostate operation.
    • Some LNs (up to 1.6cm, mild regression) at retroperitoneum.
    • Suspected bony metastases at spine.
    • Gallbladder stone (0.9cm).
  • 2021-11-16 CT
    • S/P prostatectomy.
    • Progression of metastatic paraaortic lymph nodes and bone metastasis.
    • GB stones.
    • Fatty content liver tumor, 2.6cm in S2 liver.
  • 2021-07-23 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20200715, the lesions in the upper and middle T-spines and left iliac bone are new. Bone metastases should be watched out.
    • No prominent change is noted in the previous two faint hot spots in the left frontal region of the skull and posterior aspect of the left 11th rib, possibly more benign in nature.
    • Increased activity in the left aspect of maxilla. The nature is to be determined (dental problem? other nature?).
    • Mildly increased activity in the lower L-spines. Degenerative change is more likely.
    • Suspected benign jount lesions in the right sternoclavicular junction, bilateral shoulders, hips, knees and boh feet.
  • 2021-07-22 MRI
    • S/P prostatectomy.
    • Regression of paraaortic lymph nodes in paraaortic lymph node.
    • Liver cyst.
    • Gallbladder stones.
  • 2021-07-13 CT
    • metastatic Lt supraclavicular fossa and left retroperitoneal paraaortic lymphadenopathy.
  • 2021-03-24 MRI
    • S/P prostatectomy.
    • Suspected metastatic lymph nodes in paraaortic regions. Regression as compare with MRI study on 2020-11-12.
    • Liver cyst.
    • Gallbladder stones.
  • 2021-07-15 Tc-99m MDP whole body bone scan
    • Two faint hot spots in the left frontal region of the skull and post. aspect of the left 11th rib, probably post-traumatic change, suggesting follow-up.
    • Suspected benign lesions in the maxilla, right sternoclavicular junction, bilateral shoulders, and hips.
  • 2019-05-19 MRA - Brain
    • A frontal base meningioma. Left exophthalmus.
  • 2019-01-15 MRI
    • S/P prostatectomy.
    • Suspected metastatic lymph nodes in left common iliac and paraaortic regions.
    • Liver cyst.
  • 2019-01-08 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20180207, the previous lesions in the maxilla, left 11th rib and the left femoral neck are stationary, indicating more benign in nature.
    • Other bone lesions are also stationary. Probably degenerative change in the upper T-spine, bilateral sternoclavicular junctions and bilateral sacroiliac joints, bilateral shoulders, and bilateral hips.
  • 2018-02-07 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20161103, the lesions in the left 11th rib and the left femoral neck had become very faint, indicating benignity in nature.
    • Probably degenerative change in the upper T-spine, sternoclavicular junctions and sacroiliac joints.
    • Increased radiotracer uptake in the maxilla, local inflammatory change such as sinusitis may show such a picture.
  • 2016-04 MRI
    • Prostate cancer with extracapsular extension and seminal vesicle invasion, mainly in left aspect.
    • Metastatic left obturator lymph node. Stage T3N1Mx.
  • 2015-06-30 Patho (HuaLien TzuChi)
    • Prostate gland, radical prostatectomy, adenocarcinoma (Glason score: 5+4=9) (pT3bN1).
    • Urethra, prostatic, radical prostatectomy, squamous metaplasia.
    • Seminal vesicle, right, radical prostatectomy, adenocarcinoma, invasion.
    • Seminal vesicle, left, radical prostatectomy, adenocarcinoma, invasion.
    • Lymph node, right, lymphadenectomy, no lymph node retrived.
    • Lymph node, left, lymphadenectomy, adenocarcinoma, metastatic (1/2).
    • Prostate gland, apex, resection, adenocarcinoma. Urinary bladder, neck, resection, negative for malignancy.
    • Extraprostatic Extension: Present.
    • Seminal Vesicle Invasion (invasion of muscular wall required): Present.
    • Lymph-Vascular Invasion: Present.
    • Perineural Invasion: Present.
• consultation
  • 2022-12-01 Dermatology
    • Q
      • This 66-year-old man patient is a case of Prostate cancer, pT3bN1cM0, s/p RARP on 2015/06/30, s/p adjuvant radiotherapy on 2015/09/25 and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV s/p chemotherapy with Taxotere from 2021/11/17, partal response.
      • He was admitted cellulitis for left lower swelling with redness with antibiotic therapy. This time, for bilateral toe nails onychomycosis. Now, for evaluate bilateral toe nails onychomycosis therapy. Thank you.
    • A
      • The patient had sufferred from prostate cancer s/p chemotherapy. Dry skin patern was noted over lower legs and thickening nail with deformity
        
      • Under the impression of tinea unguium et pedis, xerotic dermatitis on the lower leg.
      • The following suggestion:
        • Exelderm lotion (sulconazole nitrate) 2 tube topical QN use over nail fold and footbase.
          
        • Sinphraderm cream (urea 100mg/gm) 1 tube topical QN use on the dry skin of lower legs.
          
  • 2021-12-30 Mental Health
    • A
      • This is a 65 y/o male patient with prostate cancer, admission for palliative chemotherapy today. He has no psychiatric history.
      • Upon visit, the patient is sitting on his bed, with wife at bedside.
      • The patient is in euthymic, smiley and inviting. Greeting and appropriate speech. He deny depressed mood, deny suicide thought, able to percieve fair night sleep under current medication, fair appetite.
      • No extra medication is needed.
  • 2021-11-15 Hemato-Oncology
    • Q
      • This is a 65 y/o male with underlying hypertension, hypothyroidism and dyslipidemia. He was previous diagnosed prostate cancer, pT3bN1cM0 s/p radical prostatectomy + radiotherapy + hormone therapy with refractory, s/p Zytiga 360# since 2020-02 with poor response, s/p Zoladex and Androcur since 20210109, Pamorelin (Q3M) + Casodex on 20210206. However, follow-up lung CT still showed metastatic lymph nodes in Lt supraclavicular fossa. Bony metastasis of upper, middle T spine and left iliac bone was also noted in bone scan on 20210723. Serial PSA level since 2021 April showed 8.74 -> 12.47 -> 14.19 -> 17.40 -> 28.39. He only complained about back pain in recent few months. There was no decreased appetite or body weight loss. Due to progressed disease, he was admitted for port-A insertion and further systemic chemotherapy.
      • We need your expertise for further systemic chemotherapy regimen suggest after port-A insertion.
    • A
      • A case of castration-resistant prostate cancer is noted.
      • Based on the failure to LHRH + Andreocur and Casodex and further abiraterone, palliative chemotherapy with docetaxel is indicated.
• surgical operation
  • 2015-06-30 at HuaLien TzuChi - radical prostatectomy
    • prostate adhesion to bladder wall, suspicious invasion to bladder neck.
    • tumor invasion in seminal vesicle was also suspected. bilateral neurovascular bundles (NVB) did not preserved.
• radiotherapy
  • 2021-07-28 ~ 2021-08-23: 4560cGy/19 fractions (6 MV photon) to left SCF LAPs.
  • 2020-12-10 ~ 2021-01-14: 5000cGy/25 fractions (15 MV photon) to paraaortic LAPs.
  • 2015-08-05 ~ 2015-09-25: 4500cGy/25 fractions of the pelvic, 5040cGy/28 fractions of the tumor bed and peripheral, and 6480cGy/36 fractions of the reduced tumor bed area.
• G-CSF, granulocyte colony-stimulating factor
  • 2022-09-01 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-08-30
  • 2022-08-17 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-08-10
  • 2022-07-22 Granocyte (lenograstim 250mg) QD SC 3 days IPD
  • 2022-07-12 Granocyte (lenograstim 250mg) QD SC 3 days OPD
  • 2022-06-15 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-06-08
  • 2022-05-25 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-05-19
  • 2022-05-04 Granocyte (lenograstim 250mg) QD SC 3 days OPD
  • 2022-04-06 Granocyte (lenograstim 250mg) QD SC 3 days IPD
  • 2022-03-16 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-03-09
  • 2022-02-23 Granocyte (lenograstim 250mg) QD SC 3 days OPD
  • 2022-01-04 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2021-12-30
  • 2021-12-15 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2021-12-09
  • 2021-11-24 Granocyte (lenograstim 250mg) QD SC 3 days OPD
• chemotherapy
  • 2023-01-04 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-16 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-01 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-10-11 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-09-20 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-08-30 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-08-10 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-07-22 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-06-30 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-06-09 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-05-19 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-04-26 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-04-06 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-03-11 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + aprepitant 125mg D1-3
  • 2022-02-15 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + aprepitant 125mg D1-3
  • 2022-01-25 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + aprepitant 125mg D1
  • 2021-12-30 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + aprepitant 125mg D1
  • 2021-12-10 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + aprepitant 125mg D1-3
  • 2021-11-17 - docetaxel 75mg/m2 120mg 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
• certain medication
  • Xgeva (denosumab) CXGEV01
    • 2023-01-04 120mg ST SC OPD
    • 2022-11-24 120mg ST SC IPD
    • 2022-10-25 120mg Q1M SC OPD
    • 2022-08-31 120mg Q1M SC OPD
    • 2022-08-30 120mg Q1M SC IPD
    • 2022-08-03 120mg Q1M SC OPD
  • Zoladex (goserelin) CZOLA01
    • 2022-10-25 3.6mg Q4W SC OPD
    • 2022-08-30 3.6mg Q4W SC IPD
    • 2022-08-03 3.6mg Q4W SC OPD
    • 2022-06-28 3.6mg Q4W SC OPD
    • 2022-05-31 3.6mg Q4W SC OPD
    • 2022-04-26 3.6mg Q4W SC OPD
    • 2022-03-23 3.6mg Q4W SC OPD
    • 2022-02-08 3.6mg Q4W SC OPD
    • 2021-01-09 3.6mg Q4W SC OPD
  • Andreocur (cyproterone) KANDR
    • 2018-02-03 ~ 2022-04-03 50mg TID OPD
    • 2017-02-11 ~ 2018-01-20 50mg QD OPD
  • bicalutamide KBICA01
    • 2018-05-12 ~ 2020-01-11 50mg QD OPD
  • Casodex (bicalutamide) KCASO01
    • 2021-02-06 ~ 2022-01-07 50mg QD OPD
  • Pamorelin (triptorelin) CPAMO02
    • 2021-10-15 11.25mg Q3M IM OPD
    • 2021-07-28 11.25mg Q3M IM OPD
    • 2021-05-08 11.25mg Q3M IM OPD
    • 2021-02-06 11.25mg Q3M IM OPD
  • Zytiga (abiraterone) KZYTI01 poor response
    • 2020-02-08 1000mg QDAC PO OPD
  • Leuplin Depot (leuprorelin)
    • 2018-12 ~ 2020-08 Q3M

[assessment]

• 2023-01-04 lab data were generally normal, except for a slight decrease in WBC and HGB levels. The vital signs of the patient are stable during this hospitalization.

• All underlying conditions, including HBV, hypothyroidism, and insomnia, are managed with appropriate medication.

220831

[assessment]

• The PSA reading has been trending downward during the last half year (2022-08-14 10 <- 2022-02-15 43). Currently, it appears that the disease is under control and is in a relatively stable state.
• In recent months, G-CSF has been used triweekly on three consecutive days to protect the patient against neutropenic complications caused by a previously administered chemotherapy.

220609

[assessment]

• This patient with an advanced, refractory prostate cancer with paraaortic lymph nodes and bone metastases is being treated with docetaxel palliatively.
• CT (2022-03-10) confirmed that some LNs (up to 1.6cm) had mild regression at the retroperitoneum. PSA floats in the 20s (unit ng/mL) since March 2022. As of now, the disease appears to be still under control.
• Underlying diseases such as HBV, hypothyroidism, hyperlipidemia are currently managed with Baraclude (entecavir), Eltroxin (levothyroxine), Zulitor (pitavastatin), respectively.
• SpO2 has been around 95% these two days, please keep an eye on the reading.
• No issue with active prescription.

220520

[assessment]

• This patient has advanced prostate cancer that is refractory with progression of paraaortic lymph nodes and bone metastases.
• Docetaxel is being administered to the patient palliatively and is generally well tolerated.
• Lab data reported on 2022-05-16 showed grossly normal results, except for a slight pancytopenia and a high PSA (26.464ng/mL).
• Underlying health condition are managed with corresponding self-carried drugs. No issue with active prescription.

220427

[assessment]

• After using hormone therapy from 2017-01 to 2021-10 and proving the disease castration-resistant (2021-11-16 CT showed progression), the patient has begun taking docetaxel since 2021-11-17.
• Bone scans on 2022-03-11 revealed new lesions in the right humeral head and L3 spine, and CTs on 2022-03-10 showed LNs up to 1.6 cm in the retroperitoneum.
• Lab results on 2022-04-26 showed that blood cell counts, liver and kidney function, serum electrolytes were grossly normal, however PSA 27 ng/mL remained high.
• Underlying health condition are managed with corresponding drugs
  • postprocedural hypothyroidism - Eltroxin (levothyroxine)
  • chronic viral hepatitis B without delta-agent - Baraclude (entecavir)
  • hyperlipidemia - Zulitor (pitavastatin)
  • duodenal ulcer - Nexium (esomeprazole)
  • insomnia - Anxiedin (lorazepam)

220407

[assessment]

• Novel hormone therapies include abiraterone, enzalutamide, darolutamide, or apalutamide received for metastatic castration-naïve disease, M0 CRPC, or previous lines of therapy for M1 CRPC.
• After using hormone therapy from 2017-01 to 2021-10 and proving the disease castration-resistant (2021-11-16 CT showed progression), the patient has begun taking docetaxel since 2021-11-17.
• The bone scan on 2022-03-11 revealed new lesions in the right humeral head and L3 spine, however, the PSA level decreased slightly (26.9ng/mL 2022-03-23 <- 43.2ng/mL 2022-02-15).

[suggestion]

• Tumor testing for microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) is recommended in patients with metastatic castration-resistant prostate cancer and may be considered in patients with regional or castration-naïve metastatic prostate cancer.
• Tumor mutational burden (TMB) testing may be considered in patients with metastatic castration-resistant prostate cancer.
• Cabazitaxel 20 mg/m2 plus carboplatin AUC 4 mg/mL per min with growth factor support can be considered for fit patients with aggressive variant prostate cancer (visceral metastases, low PSA and bulky disease, high LDH, high CEA, lytic bone metastases, neuroendocrine prostate cancer histology) or unfavorable genomics (defects in at least 2 of PTEN, TP53, and RB1). source: Cabazitaxel plus carboplatin for the treatment of men with metastatic castration-resistant prostate cancers: a randomised, open-label, phase 1-2 trial https://pubmed.ncbi.nlm.nih.gov/31515154/

220216

[assessment]

• image findings showed the disease progresive and lab data PSA readings keep elevating from 8.7ng/mL (2021-04-05) to 43.2ng/mL (2022-02-15)
• the patient is undergoing hormone therapy triptorelin since 2021-02 (last dose 2021-10) and receiving chemotherapy docetaxel since 2021-11.
• systemic therapies for metastatic castration-resistant prostate cancer such as abiraterone/prednisone, enzalutamide, Ra-223, docetaxel, cabazitaxel, and mitoxantrone have all been shown to reduce skeletal-related events and improve bone pain.

[suggestion]

• triptorelin could be continued with another dose if there is no contraindication. -tumor testing for microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) is recommended in patients with metastatic castration-resistant prostate cancer and may be considered in patients with regional or castration-naïve metastatic prostate cancer. -tumor mutational burden (TMB) testing may be considered in patients with metastatic castration-resistant prostate cancer.

700976532

230104

• past history - 20221229 admisstion note
  • Hypertension
  • Hepatocellular carcinoma (stage unknown) status post partial hepatectomy 8 years ago in RenAi Hospital.
• exam findings
  • 2023-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (145 - 27) / 145 = 81.38%
      • M-mode (Teichholz) = 81
    • Mild biventricular hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation; mildly dilated LA.
    • Dilated LV with normal LV and RV systolic function.
    • Mild aortic valve sclerosis; trivial MR; mild TR.
    • Possible mild to moderate pulmonary hypertension (the estimated systolic PA pressure 53 mmHg).
    • Moderate amount pericardial effusion (100-200 ml) without signs of tamponade
  • 2022-12-31 MRI - L-spine
    • Findings
      • Diffuse bone marrow fat replacing disease was seen, seen as abnormal low signal intensity on T1WI.
      • Multiple nodular bone destructing masses also were noted, up to 23 mm in size at posterior body of L1.
      • A right body mass was found at T2.
      • After IV contrast administration shows well or heterogenous enhancement of the masses or tumors.
      • However, no obvious dural sac or spinal cord compression was found.
    • IMP:
      • Diffuse bone marrow fat replacing disease at bil. pelvic bones, thoraco-lumbar spine, with sloid masses or nodules (myelomas) as described above.
  • 2022-12-29 CT - abdomen
    • Findings
      • Multiple osteolytic lesions in ribs, spine and pelvic bones.
      • Hyperplasia of left adrenal gland.
      • Wall thickening of rectum.
      • Tiny gallbladder stones.
      • Pericardial effusion.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • Right pleural effusion.
    • IMP:
      • Multiple osteolytic lesions in ribs, spine and pelvic bones. DDX: metastases, multiple myeloma.
      • Wall thickening of rectum.
  • 2022-12-29 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Left anterior fascicular block
    • Bifascicular block
    • Abnormal ECG
  • 2022-12-29 Pelvis-THR and Lt. Hip Lat
    • Destruction at left iliac bone, r/o bone metastasis.
  • 2022-12-29 L-spine AP + Lat. (including sacrum)
    • Lumbar spondylosis.
    • Maintained bony alignment.
      
    • Atherosclerosis of abdominal aorta.
  • 2022-10-07 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Right bundle branch block
    • Abnormal ECG
  • 2022-06-27 KUB
    • suspected osteolytic lesions at left iliac and sacral bone
    • No abnormal calcification
    • Unremarkable psoas shadows
    • Suggest clinical correlation and follow up evaluation

[assessment]

• A higher overshoot of bilirubin total than bilirubin direct might hint a sign that the patient’s red blood cells are breaking down at an unusual high rate.

  • 2023-01-04 Bilirubin total 1.57 mg/dL
    
  • 2023-01-02 Bilirubin total 1.18 mg/dL
    
  • 2022-12-30 Bilirubin total 1.06 mg/dL
    
  • 2022-12-29 Bilirubin total 0.54 mg/dL
    
  • 2023-01-04 Bilirubin direct 0.31 mg/dL
    
  • 2022-12-30 Bilirubin direct 0.24 mg/dL

• During the first half hour of 14 o’clock 2023-01-04, there was a brief tachycardia moment with SBP exceeding 200mmHg. The vital signs are relatively stable now.

• According to the Concor (bisoprolol 5mg/tab) package insert, the drug shold be swallowed with some liquid and not to be chewed. We are in the process of consulting the distributor for a response.

• Atenolol can be used as an alternative antihypertensive agent (atenolol 50mg ~ bisoprolol 5mg) available under the brand name Urosin in the stock.

701449858

230104

• diagnosis - 20230103 admission note
  • Enteropathy-type (intestinal) T-cell lymphoma
  • Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
  • Infection following a procedure, initial encounter
  • Non-Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes
  • Pleural effusion, not elsewhere classified
• past history
  • Deny to have history of cancer, hypertension, mental diseases, asthma or diabetes. 
  • Allergy: NKDA
• family history
  • Mother: breast cancer.
• exam findings
  • 2022-12-05 CT - abdomen
    • Indication: Enteropathy-type (intestinal) T-cell lymphoma
    • Abdominal CT with and without enhancement revealed:
      • Abdomen
        • Dilated small intestines at RLQ is found about 6.05cm in largest dimension. Suggest follow up.
        • The urinary bladder is well distended without soft tissue lesion.
        • There is no evidence of destructive bone lesion.
        • Increased intestinal gas is found.
        • The GB is well distended without soft tissue lesion
        • There is no evidence of paraarotic LAPs.
        • Loculated effusion at right anterior abdominal wall is found.
      • Visible chest
        • S/p port-A placement with its tip at Superior vena cava.
        • Small lymph nodes at right sternum, right paracaval and hilar region is found.
    • Imp:
      • Post op. change of the abdomen with loculated effusion at RLQ. Abscess?
      • Mediastinal and sternal lymph nodes, please correlate with PET.
  • 2022-12-02 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy
      • No evidence of T cell prloliferation
      • Hypercellularity (80~90%), in favor of reactive hyperplasia of myeloid linegae
    • Correlation with peripheral blood test, blood smear, flow cytometry and clinical findings is recommended.
    • Microscopically, it shows hypercellularity (80~90%), presence of trilineage marrowe component with increased myeloid lineage. Occasional megakaryocytes are seen. T-cells are highlighted by CD3 and there is no evidence of T cell prloliferation. CD34 and CD117 are negative for blasts.
    • Immunohistochemical stain reveals MPO (diffuse +), CD71(focal+), CD56(-), CD20(focal+), CD138(-), CD10(-) and TdT(-).
  • 2022-11-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (115 - 33) / 115 = 71.30%
      • LVEF (%) = 71
      • M-mode (Teichholz) = 71
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; impaired LV relaxation.
    • Normal RV systolic function.
    • Mild MR; mild TR; mild PR.
  • 2022-11-14 CXR
    • Solitary pulmonary nodule at RLL.
    • Interstitial pattern at bil. lower lungs.
  • 2022-10-24 Whole body PET scan
    • Increased FDG uptake in the abdomen and pelvis, right mediastinal lymph nodes, and right infraclavicular fossa lymph nodes, highly suspected T-cell lymphoma with involvement of lymph node regions on both sides of the diaphragm.
      
    • Glucose hypermetabolic lesions in the right lobe of the liver, highly suspected lymphoma with liver involvement.
      
    • Increased FDG uptake in bilateral pulmonry hilar regions, probably reactive nodes.
    • Increased FDG uptake in bilateral femoral shaft, the nature is to be determined (lymphoma, severe anemia or other nature ?), suggesting biopsy for further investigation.
      
    • T-cell lymphoma, c-stage IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-10-14 Patho - small intestine resection for tumor
    • Diagnosis:
      • Small intestine, resection — Monomorphic epitheliotropic intestinal T-cell lymphoma (type II enteropathy-associated T-cell lymphoma)
      • Peritoneum, peritonectomy — Monomorphic epitheliotropic intestinal T-cell lymphoma, by direct invasion
    • Gross description
      • Specimen submitted in fresh consists of a segment of small intestine, measuring 54 cm in length, with a piece of peritoneum, measuring 7.8 x 6.5 cm. An invasive tumor measuring 15.0 x 9.5 x 8.0 cm is seen in the central portion and measuring 15.0 and 10.0 cm away from the bilateral resection margins. On cutting, the tumor is gray, solid, elastic. Transmural invasion to mesentery and peritoneum, adhesion, and fistula formation are noted. Several enlraged lymph nodes are found and dissected. Representative sections are taken and labeled as: FsA1-2, for frozen examnation. After formalin fixation, additional sections are taken and labeled as: A1-2: bilateral resection margins; A3-4: with peritoneum; A5-8: tumor (A7: fistula); A9-10: lymph nodes.
    • Microscopic description
      • Sections show small intestine with diffuse, transmural invasion of medium-sized lymphoid cells.
      • Lymph node is involved. The tumor has invaded to the peritoneum and very close (< 0.1 cm) to the resection margin of peritoneum. The bilateral resection margins are free of tumor.
      • The immunohistochemical stains reveal CK(-), CD3(+), CD20(-), CD5(-), CD56(+), CD8(+), CD4(-), and Granzyme B(-).
      • NOTE: The tissue is the same as F2022-477.
  • 2022-10-13 Frozen resection
    • Preliminary diagnosis:
      • Small intestine, biopsy — small round blue cell tumor
  • 2022-10-12 Pulmonary Flow Volume Loop
    • mild restrictive impairment
  • 2022-09-05 Patho - lung transbronchial biopsy
    • Lung, RML, CT-guide biopsy — a tiny cluster of atypical cell present (please see microdescription)
    • Sections show alveolar lung tisssue with a tiny cluster of atypical cells.
    • The atypical cells are not found in deeper section. Please correlate with the clinical presentation.
    • The immunohistochemical stains reveal CK(+), TTF-1(-), p40(-), CD56(-), CDX2(-) and CD117(-).
  • 2022-09-02 CT - chest
    • Indication: Suspected of small bowel malignancy
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Subpleural round nodular lesion at right middle lobe up to 0.5cm is found.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Swelling of intestinal wall at RLQ is found. suspected small bowel cancer.
        • Low density change at left liver tip up to 2.8cm is found. Hemangioma is considered.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Imp:
        • Small bowel cancer with right middle lobe meta.
        • Hepatic hemangioma.
  • 2022-09-01 CT - abdomen
    • History and indication: abdominal pain
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of small bowel with adjacent fat stranding, adjacent bowel loop/ right abdominal wall invasion and LNs metastases.
      • Minimal ascites.
      • Left liver hemangioma (3.3cm).
      • Bil. renal cysts (up to 2.1cm).
      • A nodule (1.3cm) at left adrenal gland.
      • A nodule (6mm) at RML.
      • Normal appearance of spleen, pancreas.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • Some calcifications in prostate.
    • IMP:
      • In favor of small bowel cancer with adjacent fat stranding, adjacent bowel loop/ right abdominal wall invasion, LNs and lung metastases.
• consultation
  • 2022-09-01 General and Gastrointestinal Surgery
    • A
      • S
        • periumbilical pain for one week
        • firm but ill-defined mass over central abdominal area
        • poor appetite for several weeks
        • but no significant BW loss
        • no N/V
        • no tarry/bloody stool
      • PE
        • fair looking
        • pale conjunctive
        • smooth respiration
        • RHB
        • abdomen: soft and distended, but firm mass at central abdomen, no peritoneal sign
      • Lab
        • no leukocytosis, no left shift
        • Hb: 10
        • high CRP
      • CT
        • focal bowel wall thickening wtih fat stranding and peritoneal invasion, favor malignancy, less likely inflammation related
      • suggest
        • admit for preop survey
        • BT with PRBC 2u
        • check tumor markers, HBV and HCV
        • arrange lung CT after admission
• surgical operation
  • 2022-10-13
    • Surgery
      • small bowel tumor resection
      • peritonectomy
      • partial T-colon colectomy
    • Finding
      • huge tumor over proximal ileum, about 110cm proximal to the ileocacal valve
      • tumor invasion to the abdomianl wall and T-colon
      • multiple enlarged LNs over mesentary
      • no other palpable seeding tumor
      • no ascites
      • frozen section of small intestine: favor lymphoma, less likely adenocarcinoma
• chemoimmunotherapy
  • 2023-01-03 - methylprednisolone 500mg/m2 900mg D1-4 + etoposide 40mg/m2 70mg 1hr D1-4 + cisplatin 20mg/m2 35mg 18hr D1-4 + cytarabine 1500mg/m2 2700mg 2hr D5 (ESHAP)
    • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + granisetron 2mg D1-5
  • 2022-11-29 - methylprednisolone 500mg/m2 900mg D1-4 + etoposide 40mg/m2 70mg 1hr D1-4 + cisplatin 20mg/m2 35mg 18hr D1-4 + cytarabine 1500mg/m2 2700mg 2hr D5 (ESHAP)
    • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + palonosetron 250ug D1-5
• Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients (2023-01-04 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients)
  • R-ESHAP (Rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) ref: Martín A, Conde E, Arnan M, et al. R-ESHAP as salvage therapy for patients with relapsed or refractory diffuse large B-cell lymphoma: the influence of prior exposure to rituximab on outcome. A GEL/TAMO study. Haematologica 2008; 93:1829.
    • Administration - R-ESHAP includes rituximab (375 mg/m2 on day 1), etoposide (40 mg/m2/day as a one-hour infusion on days 1 to 4), methylprednisolone (250 to 500 mg/day as a 15-minute infusion on days 1 to 5), cisplatin (25 mg/m2/day as a continuous infusion from day 1 to 4), and cytarabine (2 g/m2 as a two-hour infusion on day 5), every three or four weeks.
    • Adverse effects - Hematologic toxicity is universal, with significant rates of neutropenic fever (30 percent) if growth factors are not used. Other adverse effects (eg, nausea, vomiting, diarrhea, nephrotoxicity, electrolyte disturbances) are generally mild.
    • Outcomes - A retrospective study of 163 patients reported that ESHAP for relapsed DLBCL was associated with 75 to 86 percent ORR and 41 to 50 percent CR, while for primary refractory DLBCL, ORR was 33 percent and CR was 8 percent.

700552812

230102

• exam findings
  • 2022-12-30 SONO - abdomen
    • Few small gallstone are noted.
      
  • 2022-12-09 Nasopharyngoscopy
    • Squamous cell carcinoma of right tongue border, pT4aN3bM0, pstage IVb post of operation on 2022/02. recurrence malignancy
    • tumor over right part of mouth floor, submandibular space and overlying skin, buccogingival mucosa, medial pterygoid muscle, soft palate, tongue base and oropharyngeal wall, cT4aN3bM0 under palliative chemotherapy
  • 2022-11-12 Nasopharyngoscopy
    • Scope: smooth NPx
    • NG in serted smoothly
  • 2022-10-31 Patho - soft tissue biopsy / simple excision (non lipoma)
    • Labeled as “midline omentum of the pelvis with suspicious connected with the urinary bladder dome and the uterine fundus”, CT guided biopsy — bland spindle cell lesion.
    • IHC stains: desmin (+), CD34(+), Ki-67 <1%. CK(-), CD117(-), Dog-1(-), S-100(-), GFAP(-).
    • The possibility of bland smooth muscle tumor or glomus tumor cannot be excluded. Further work up, including excisional biopsy, might be considered.
  • 2022-10-26 CT - abdomen
    • History and Indication: biliary hepatitis and GI bleeding,
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is a poor enhancing lesion measuring 3.4 x 2.2 x 8 cm (width x depth x cranial-caudal length) at the midline omentum of the pelvis with suspicious connected with the urinary bladder dome and the uterine fundus. Please correlate with MRI.
      • Few enlarged nodes in ppara-aortic space are suspected.
      • There is mild ascites in the pelvis.
      • The gallbladder shows few small stones and borderline distension but no wall thickening or surrounding fatty stranding. please correlate with clinical condition.
      • There is a tiny renal stone in right lower pole.
      • S/P nasogastric tube insertion
      • Others
        • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
          
        • There is no bowel wall thickening, and no bowel obstruction.
          
        • The abdominal aorta and IVC are grossly unremarkable.
          
        • There is no evidence of intrinsic or extrinsic bladder mass.
          
        • There is no focal lesion over the mesentery.
    • Impression:
      • There is a poor enhancing lesion measuring 3.4 x 2.2 x 8 cm (width x depth x cranial-caudal length) at the midline omentum of the pelvis with suspicious connected with the urinary bladder dome and the uterine fundus. Please correlate with MRI.
        • The differential diagnosis include urachal cyst with infection, urachal tumor, and uterine tumor?
      • Few enlarged nodes in ppara-aortic space are suspected.
      • There is mild ascites in the pelvis.
  • 2022-10-25 SONO - abdomen
    • GB stone, multiple
    • GB sludge
  • 2022-10-24 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Duodenal ulcers with stigma of recent hemorrhage, Forrest classification type IIa or IIc, bulb and 2nd portion s/p
      • hemostasis with APC
      • Gastric ulcer scar, prepyloric antrum, LC site
      • Hypopharynx mass lesion
      • Reflux esophagitis LA grade A
      • Superficial gastritis, s/p CLO tes
      • Gastric erosions, middle body, GC site
    • Suggestion
      • Keep on IV PPI therapy
      • F/U CLO test
  • 2022-10-23 ECG
    • sinus rhythm
    • Left axis deviation
    • Low voltage QRS
  • 2022-10-23 CXR
    • Tortuosity of the aorta with atherosclerotic change.
    • S/P port-A catheter insertion.
    • S/P N-G tube insertion.
  • 2022-10-23 Supine KUB
    • Presence of pneumatosis intestinalis over right-side of the abdomen.
    • S/P N-G tube insertion.
  • 2022-10-09, -09-27 CXR
    • Tortuosity of the aorta with atherosclerotic change.
    • Increased infiltration over LLL. May be active infection.
    • Degenerative joint disease of T-spine with marginal osteophytes.
    • S/P port-A catheter insertion.
  • 2022-09-08 MRI - nasopharynx
    • Post-OP follow up. Pain of right neck and face. Recent fever was noted.
      • Squamous cell carcinoma of right tongue border, pT4aN3bM0, pstage IVb s/p wide excision; neck dissection and free flap reconstruction
      • Complete CCRT
      • Scar contraction of right neck
      • Painful swelling of left neck
      • A fixed palpable mass was noted of right submandibular region with skin involved; Highly suspected tumor recurrence
    • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness＝3 mm, gap＝1 mm), sagittal T1WI (thickness＝4 mm, gap＝1 mm), axial T1WI and T2WI with FS (thickness＝5 mm, gap＝1 mm), and post-contrast coronal T1WI with FS (thickness＝ 3 mm, gap＝1 mm), axial T1WI with FS (thickness＝5 mm, gap＝1mm) and sagittal T1WI with FS(thickness＝ 4 mm, gap＝1 mm) and show:
      • Extensive soft tissue mass with heterogeneous enhancement involving right part of mouth floor, submandibular space and overlying skin, buccogingival mucosa, medial pterygoid muscle, soft palate, tongue base and oropharyngeal wall (with necrotic change). Abnormal intensity also noted in right mandible, masseter muscl, along sternocleidomastoid muscle and surrounding right proximal ECA.
      • S/P flap reconstrution of right part of the oral tongue and lymph node dissection at right neck.
      • No enlarged lymph node.
      • No abnormality at nasopharynx, hypopharynx and larynx.
    • IMP:
      • Right tongue border cancer s/p treatment with advanced recurrence is first considered.
  • 2022-08-19 CT - abdomen
    • History:
      • Persistent cholestatic hepatitis of unexplained cause.
      • Recent echo showed no biliary lesion
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Impression:
      • Few gallstones are noted and the size < 5 mm.
      • A small renal stone 3 mm in right lower pole is noted.
  • 2022-08-15 SONO - nephrology
    • Parenchymal renal disease
    • Incomplete voiding, mild
  • 2022-08-10 SONO - abdomen
    • Parenchymal liver disease
    • GB stones (non-fasting GB)
  • 2022-07-07 Stomach, antrum, biopsy— ulcer with Helicobacter infection
  • 2022-07-06 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Duodenal ulcer, Forrest classification type IIa, bulb s/p hemostasis with APC
      • Reflux esophagitis LA grade A
      • Superficial gastritis
      • Gastric ulcer, Forrest classification type III, antrum
      • Duodenal ulcer, Forrest classification type III, D1 to D2
    • Suggestion
      • High dose PPI *3 day
      • F/U patho
  • 2022-06-08 MRI - nasopharynx
    • Post-OP follow up
      • Squamous cell carcinoma of right tongue border, pT4aN3bM0, pstage IVb s/p wide excision; neck dissection and free flap reconstruction
      • Complete CCRT
    • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness＝3 mm, gap＝1 mm), sagittal T1WI (thickness＝4 mm, gap＝1 mm), axial T1WI and T2WI with FS (thickness＝5 mm, gap＝1 mm), and post-contrast coronal T1WI with FS (thickness＝ 3 mm, gap＝1 mm), axial T1-WI (thickness＝5 mm, gap＝1mm) and sagittal T1WI (thickness＝ 4 mm, gap＝1 mm) and showed:
      • post-OP change at the right tongue with neck dissection and free flap reconstruction.
        
      • heterogeneous enhancing lesions in the right oropharynx, right buccogingival mucosa and right tongue base.
    • IMP:
      • suspected tumor recurrence in the heterogeneous enhancing lesions in the right oropharynx, right buccogingival mucosa and right tongue base.
  • 2022-02-07 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Duodenal ulcer with suspicious SRH, Forrest class IIa, SDA, s/p APC
      • Duodenal ulcers with oozing bleeding, Forrest Ib, second portion, s/p APC
      • Gastric ulcers
      • Reflux esophagitis LA grade A
      • Superficial gastritis, s/p CLO test
      • Incomplete study due to retention of food residue
    • Suggestion
      • High dose PPI use
      • Pursue CLO test result
      • Suggest second-look endoscopy in 2-3 days.
  • 2022-02-07 Sigmoidoscopy
    • Diagnosis
      • Tarry-bloody colon content, suggestive of bleeding proximal to the distal colon
      • Internal hemorrhoids
      • Incomplete study of colon
    • Suggestion
      • This finding is compatible with the clinical diagnosis of UGI bleeding
      • Correlate with other clinical information
      • Repeat colonoscopy after full bowel preparation if clinically indicated
  • 2022-02-07 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • GB stones
      • CHD dilatation, mild; CBD masked
      • Parenchymal renal disease
      • Minimal amount of right pleural effusion with subpleural consolidation of right lower lung
      • suboptimal echo window
    • Suggestion
      • OPD follow-up
  • 2022-02-05 CT - abdomen
    • Gallbladder stones
    • Right renal stone
    • Intravenous contrast leakage in this study
  • 2022-01-25 Pathology - oral cancer (wide excision + lymph node)
    • Diagnosis
      • Tongue, right, frozen section for base margin (F2022-30) followed by wide excision S2022-1491) — Squamous cell carcinoma, well differemtiated
      • Frozen section for base margin (F2022-30) — Free.
      • Lymph node, right neck, dissection — Metastatic carcinoma
        • pT4a pN3b (if cM0) and if p16 is negative; pStage: IVB, at least.
      • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.”, “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, medical department and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
    • Macroscopic examination
      • Surgical Procedure(s): wide excision and radical neck lymph node dissection
      • Specimen Type:
        • Main location: right tongue
        • Other part(s) included: right mandibular gland
        • Lymph node dissection: yes right radical neck dissection
      • Specimen Integrity: intact
      • Specimen Size: Greatest dimensions: Tissue labeled as “01. Main tumor, right”: 7 x 5.5 x 3.5 cm.
        • Additional dimensions (if more than one part): Tissue labeled as “02. right mandibular gland”: 5 x 3.6 x 2.5 cm. And Frozen section tissue (F2022-30) labeled as “base, right”: 1 piee: 0.6 x 0.4 x 0.3 cm.
      • Depth of invasion: 17 mm
      • Tumor Site: right tongue border
        • Laterality: right
      • Tumor Focality: single focus
      • Tumor Size: Greatest dimension: 4.7 cm
        • Additional dimensions (if available): 2.2 x 1.7 cm
      • Mucosal Surface: ulcerated
      • Gross Tumor Extension: muscle
      • Tissue for frozen section: F2022-30: right base margin.
      • Tissue for formalin fixation: S2022-1491A: right main tumor= A1: vertical section of tumor with superior or ventral side margin; A2: vertical section of inferior or mouth floor side margin A3: vertical section of tumor with anterior margin; A4: vertical section of posterior margin; A5: gingiva; A6-9: tumor; A10: sublingual gland; B1: level 1 lymph node; B2-3: level 2 lymph nodes (with the largest one bi-sected, submitted in B2); B4-6: level 3 lymph nodes ( the larger two lymph nodes bi-seted and submitted in B4 and B5); B7: level4 lymph nodes; B8-9: level 5 lymph nodes (with the larger one bi-sected, submitted in B8); B10-11: parotid tail lymph nodes; B12-16: submandibular gland; B17: submandibular gland lymph nodes.
    • Microscopic examination
      • Histologic Type: Squamous cell carcinoma, (classical variant)
      • Histologic Grade: G2: Moderately differentiated
      • Microscopic Tumor Extension: (specify) muscle
      • Margins- Margins uninvolved / involved by invasive carcinoma
        • Distance from closest margin: 7 mm from base margin of the main tissue. This distance does not included the size of the frozen section specimen.
      • Margins uninvolved / involved by moderate and/or severe dysplasia: no dysplasia
        • Distance from closest margin: Not applicable
      • Lymph-Vascular Invasion: present
      • Perineural Invasion: present
      • Neck Lymph Nodes:=B1: level 1 lymph node (0/2); B2-3: level 2 lymph nodes (1/7, 2 mm in size, with extranodal extension); B4-6: level 3 lymph nodes ( 3/12, largest focus 21 mm, with ENE); B7: level4 lymph nodes (0/3); B8-9: level 5 lymph nodes (0/8); B10-11: parotid tail lymph nodes(0/14); B12-16: submandibular gland (0/3); B17: submandibular gland lymph nodes (0/3).
        • Ipsilateral: Number examined: 52; Number involved: 4
        • Contralateral (if available): N/A
      • Size (greatest dimension) of largest metastatic deposit: 2.1 cm
      • Extranodal extension: present
      • IHC stain: p16 (-).
  • 2022-01-21 Tc-00m MDP whole body bone scan
    • Increased activity in the lower C-spine and L3-4 spines. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Some faint hot spots in the anterior aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2022-01-20 MRI - Nasopharynx
    • Indication: SCC of right tongue border
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
    • Findings
      • Right lateral tongue tumor, up to 43 mm in length and 18 mm in depth.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple enlarged right level I-II LNs, some with central necrosis.
    • IMP:
      • Right tongue CA, with neck LAPs. T3N2bMx Stage IVA
        
  • 2022-01-05 Patho - tongue biopsy
    • Labeled as “right tongue border”, incision biopsy — squamous cell carcinoma.
    • IHC stains: p40 (+), p16 (-).
      
  • 2020-11-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (156 - 64) / 156 = 58.97%
      • M-mode (Teichholz) = 59
    • Gr II LV diastolic dysfunction; severely dilated LA and dilated RA.
    • Dilated LV with normal LV and RV systolic function.
    • Prominent posterior mitral annulus calcification with trivial MR; trivial TR; mild aortic valve sclerosis.
    • Prominent aortic root calcification with multiple large protruding atheromas (1.2-1.7 cm of thickness).
    • Dilated proximal ascending aorta (34mm).
• chemotherapy
  • 2022-12-27 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-12-13 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-11-29 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-11-15 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-09-30 - docetaxel 40mg/m2 50mg 2hr + carboplatin AUC 2 150mg 3hr + (leucovorin 100mg/m2 130mg + fluorouracil 1000mg/m2 1300mg) 22hr

    •                 diphenhydramine 30mg + granisetron 1mg

  • 2022-09-29 - cetuximab 400mg/m2 500mg 2hr

    •                 diphenhydramine 30mg

  • 2022-09-13 - decetaxel 40mg/m2 50mg 2hr + carboplatin AUC 2 150mg 3hr + (leucovorin 100mg/m2 130mg + fluorouracil 1000mg/m2 1300mg) 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-04-25 - carboplatin AUC 2 150mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2022-04-15 - carboplatin AUC 2 150mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-04-06 - carboplatin AUC 2 150mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-03-23 - carboplatin AUC 2 150mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-03-15 - carboplatin AUC 2 150mg 3hr

    •                 diphenhydramine 30mg + granisetron 1mg

[assessment]

• 2023-01-01 lab results indicated serum K, Na, Mg and albumin were below normal ranges, and an adequate corresponding supplement may be beneficial.

701446179

230102

{triple negative breast cancer}

• diagnosis
  • Invasive carcinoma of L breast, cT4bN3M1, stage IV, Dx in Aug 2022.
  • Chronic viral hepatitis B without delta-agent
• exam finding
  • 2022-11-18 SONO - breast
    • findings
      • Parenchymal pattem
        • Loosely (inhomogeneously) sonodense
      • Focal sonographic lesion
        • already known left breast cancer with LAP metastasis, receviing chemotherapy now
        • right axillary LAP, distant metastasis of left breast cancer? or double primary breast cancer related?
        • multiple small FAs and cysts over right breast, less likely malignancy
    • diagnosis
      • Highly suspicious of malignancy, with sonographic negative axillary LNs
    • treatment
      • no need to biopsy
    • suggestion and plan
      • Regular OPD follow-up
      • BI-RADS - 6. Known Biopsy - Proven Malignancy
  • 2022-11-09 CT - chest
    • Indication: invasive carcinoma of left breast, ER(-) PR(-) Her-2/neu(-), Ki-67: 90%, T4bN3M1, stage IV
      
    • Findings:
      • Lungs: subpleural ground-glass opacity and reticular opacities at LUL and both lower, may be post treatment change and combined dependent density at lower lobes.
        • no abnormal nodule in the lungs
      • Mediastinum and hila: no enlarged LN
      • Vessels:
        • mild calcified plaques of the LAD and LCX coronary arteries.
        • Thoracic aorta: normal caliber, extensive atherosclerotic change mainly involving the ascending segment, aortic root, and aortic arch.
        • Central pulmonary arteries: dilated trunk (3.3cm in caliber) and right main artery.
        • Heart: normal in size of cardiac chambers.
      • Pleura: no nodule or effusion .
      • Chest wall and visible lower neck: soft-tissue defect with area of skin thickening and disappearance of the hugeleft breaar tumor and significant regression of metastatic lymphadenopathy at axillary region compared with CT on 8/15.
      • Visible abdominal-pelvic contents: several tiny hepatic calcifications.
        • normal appearance of gallbladder. unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node.
        • Mild atherosclerotic change of the abdominal aorta.
      • Visualized bones: sclerotic change at xyphoid process and distal sternal body.
    • Impression:
      • left breast cancer with good response to treatment compared with previous CT exam.
  • 2022-11-08 Whole body PET scan
    • Mild glucose hypermetabolism in a left axillary lymph node and a right axillary lymph node, compatible with metastatic lymph nodes s/p treatment change.
    • Mild glucose hypermetabolism in the left anterior chest wall, compatile with primary breast malignancy s/p treatment change.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-10-14 SONO - abdomen
    • dilated pelvis of left kidney
    • pancreas masked by gas
  • 2022-08-31 ECG
    • Low voltage QRS
    • Possible Inferior infarct , age undetermined
    • Nonspecific ST and T wave abnormality
  • 2022-08-31 CXR
    • Lung markings: increased density in the left middle lung field.
  • 2022-08-24 MRI - brain
    • no evidence of brain metastasis
    • high SI chnage on T2WI in the visible C-cord. Please correlate with C-spine MRI.
  • 2022-08-19 CXR
    • Atherosclerotic change of aortic arch
    • Patchy opacity projecting at left lower chest wall is noted that is c/w left breast cancer after correlate with CT.
  • 2022-08-16 Tc-99m MDP whole body bone scan
    • Decreased activity in the body of the sternum. Bone destruction may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the L3-4 spines. Degenerative change may show this picture.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and left knee, compatible with benign joint lesions.
  • 2022-08-15 CT - chest
    • left huge breast cancer T4bN3M1
  • 2022-08-11 Patho - breast biopsy
    • Breast, left, biopsy — Invasive carcinoma of no special type
    • Section shows skin and breast tissue with irregular neoplastic glands infiltration.
    • IHC:
      • GATA3 (+)
      • ER (Ab) (-)
      • PR (Ab) (-, <1%, moderate)
      • Her-2/neu (Ab): (-, 0)
      • Ki-67 90%
  • 2022-08-09 CXR
    • A mass at left breast.
    • Ground glass opacity in bilateral lower lungs.
• chemoimmunotherapy (docetaxel 75mg/m2 and carboplatin AUC 6, cycled every 21 days x 4-6 cycles, preoperative setting only - NCCN 2022-06-21)
  • 2022-12-22 docetaxel 65mg/m2 100mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 1230 1.27)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
  • 2022-12-01 docetaxel 65mg/m2 100mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 1210 1.88)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
  • 2022-10-24 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 1102 0.80)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
  • 2022-10-03 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
  • 2022-09-12 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 0920 0.70)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
  • 2022-08-23 docetaxel 60mg/m2 90mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 0830 0.68, 0831 0.74)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
• G-CSF
  • 2022-12-30 filgrastim 150ug SC (20221230 OPD)
  • 2022-12-26, -27 lenograstim 250ug SC (20221222 IPD)
  • 2022-12-10 lenograstim 250ug SC (20221210 OPD)
  • 2022-12-05, -06 lenograstim 250ug SC (20221201 IPD)
  • 2022-12-02, -03 lenograstim 250ug SC (20221201 IPD)
  • 2022-11-24 lenograstim 250ug SC (20221124 OPD)
  • 2022-11-02 filgrastim 150ug SC (20221102 OPD)
  • 2022-08-31 filgrastim 150ug SC (20220831 OPD, IPD)

[note]

• PREOPERATIVE/ADJUVANT THERAPY REGIMENS - HER2-Negativeb (Breast Cancer NCCN Guidelines 20220621 Version 4.2022, BINV-L 1 OF 9, p55)
  • Preferred Regimens:
    • Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks
    • Dose-dense AC (doxorubicin/cyclophosphamide) followed by weekly paclitaxel
    • TC (docetaxel and cyclophosphamide)
    • Olaparib, if germline BRCA1/2 mutations
    • High-risk triple-negative breast cancer (TNBC): Preoperative pembrolizumab + carboplatin + paclitaxel, followed by preoperative pembrolizumab + cyclophosphamide + doxorubicin or epirubicin, followed by adjuvant pembrolizumab
    • TNBC and residual disease after preoperative therapy with taxane-, alkylator-, and anthracycline-based chemotherapy: Capecitabine
  • Useful in Certain Circumstances:
    • Dose-dense AC (doxorubicin/cyclophosphamide)
    • AC (doxorubicin/cyclophosphamide) every 3 weeks (category 2B)
    • CMF (cyclophosphamide/methotrexate/fluorouracil)
    • AC followed by weekly paclitaxel
    • Capecitabine (maintenance therapy for TNBC after adjuvant chemotherapy)
  • Other Recommended Regimens:
    • AC followed by docetaxel every 3 weeksc
    • EC (epirubicin/cyclophosphamide)
    • TAC (docetaxel/doxorubicin/cyclophosphamide)
    • Select patients with TNBC:
      • Paclitaxel + carboplating (various schedules)
      • Docetaxel + carboplating (preoperative setting only)

[assessment]

• Several neutropenia events occurred around one week after the chemotherapy was administered.
  • 2022-12-30 WBC 1.27 *10^3/uL
  • 2022-12-10 WBC 1.88 *10^3/uL
  • 2022-11-02 WBC 0.80 *10^3/uL
  • 2022-09-20 WBC 0.70 *10^3/uL
  • 2022-08-31 WBC 0.74 *10^3/uL
  • 2022-08-30 WBC 0.68 *10^3/uL
• There is no problem with treating neutropenia with G-CSF (granulocyte colony stimulating factor).

221223

{triple negative breast cancer}

• diagnosis
  • Invasive carcinoma of L breast, cT4bN3M1, stage IV, Dx in Aug 2022.
  • Chronic viral hepatitis B without delta-agent
• exam finding
  • 2022-12-10 ECG
    • Normal sinus rhythm
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-11-18 SONO - breast
    • findings
      • Parenchymal pattem
        • Loosely (inhomogeneously) sonodense
      • Focal sonographic lesion
        • already known left breast cancer with LAP metastasis, receviing chemotherapy now
        • right axillary LAP, distant metastasis of left breast cancer? or double primary breast cancer related?
        • multiple small FAs and cysts over right breast, less likely malignancy
    • diagnosis
      • Highly suspicious of malignancy, with sonographic negative axillary LNs
    • treatment
      • no need to biopsy
    • suggestion and plan
      • Regular OPD follow-up
      • BI-RADS - 6. Known Biopsy - Proven Malignancy
  • 2022-11-09 CT - chest
    • Indication: invasive carcinoma of left breast, ER(-) PR(-) Her-2/neu(-), Ki-67: 90%, T4bN3M1, stage IV
      
    • Findings:
      • Lungs: subpleural ground-glass opacity and reticular opacities at LUL and both lower, may be post treatment change and combined dependent density at lower lobes.
        • no abnormal nodule in the lungs
      • Mediastinum and hila: no enlarged LN
      • Vessels:
        • mild calcified plaques of the LAD and LCX coronary arteries.
        • Thoracic aorta: normal caliber, extensive atherosclerotic change mainly involving the ascending segment, aortic root, and aortic arch.
        • Central pulmonary arteries: dilated trunk (3.3cm in caliber) and right main artery.
        • Heart: normal in size of cardiac chambers.
      • Pleura: no nodule or effusion .
      • Chest wall and visible lower neck: soft-tissue defect with area of skin thickening and disappearance of the hugeleft breaar tumor and significant regression of metastatic lymphadenopathy at axillary region compared with CT on 8/15.
      • Visible abdominal-pelvic contents: several tiny hepatic calcifications.
        • normal appearance of gallbladder. unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node.
        • Mild atherosclerotic change of the abdominal aorta.
      • Visualized bones: sclerotic change at xyphoid process and distal sternal body.
    • Impression:
      • left breast cancer with good response to treatment compared with previous CT exam.
  • 2022-11-08 Whole body PET scan
    • Mild glucose hypermetabolism in a left axillary lymph node and a right axillary lymph node, compatible with metastatic lymph nodes s/p treatment change.
    • Mild glucose hypermetabolism in the left anterior chest wall, compatile with primary breast malignancy s/p treatment change.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-10-14 SONO - abdomen
    • dilated pelvis of left kidney
    • pancreas masked by gas
  • 2022-08-31 ECG
    • Low voltage QRS
    • Possible Inferior infarct , age undetermined
    • Nonspecific ST and T wave abnormality
  • 2022-08-31 CXR
    • Lung markings: increased density in the left middle lung field.
  • 2022-08-24 MRI - brain
    • no evidence of brain metastasis
    • high SI chnage on T2WI in the visible C-cord. Please correlate with C-spine MRI.
  • 2022-08-19 CXR
    • Atherosclerotic change of aortic arch
    • Patchy opacity projecting at left lower chest wall is noted that is c/w left breast cancer after correlate with CT.
  • 2022-08-16 Tc-99m MDP whole body bone scan
    • Decreased activity in the body of the sternum. Bone destruction may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the L3-4 spines. Degenerative change may show this picture.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and left knee, compatible with benign joint lesions.
  • 2022-08-15 CT - chest
    • left huge breast cancer T4bN3M1
  • 2022-08-11 Patho - breast biopsy
    • Breast, left, biopsy — Invasive carcinoma of no special type
    • Section shows skin and breast tissue with irregular neoplastic glands infiltration.
    • IHC:
      • GATA3 (+)
      • ER (Ab) (-)
      • PR (Ab) (-, <1%, moderate)
      • Her-2/neu (Ab): (-, 0)
      • Ki-67 90%
  • 2022-08-09 CXR
    • A mass at left breast.
    • Ground glass opacity in bilateral lower lungs.
• chemoimmunotherapy (docetaxel 75mg/m2 and carboplatin AUC 6, cycled every 21 days x 4-6 cycles, preoperative setting only - NCCN 2022-06-21)
  • 2022-12-22 - docetaxel 65mg/m2 100mg 1hr + carboplatin AUC 5 600mg 2hr
    • diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg
  • 2022-12-01 - docetaxel 65mg/m2 100mg 1hr + carboplatin AUC 5 600mg 2hr
    • diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg
  • 2022-10-24 - docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr
    • diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg
  • 2022-10-03 - docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr
    • diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg
  • 2022-09-12 - docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr
    • diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg
  • 2022-08-23 - docetaxel 60mg/m2 90mg 1hr + carboplatin AUC 5 600mg 2hr
    • diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg

[note]

• PREOPERATIVE/ADJUVANT THERAPY REGIMENS - HER2-Negativeb (Breast Cancer NCCN Guidelines 20220621 Version 4.2022, BINV-L 1 OF 9, p55)
  • Preferred Regimens:
    • Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks
    • Dose-dense AC (doxorubicin/cyclophosphamide) followed by weekly paclitaxel
    • TC (docetaxel and cyclophosphamide)
    • Olaparib, if germline BRCA1/2 mutations
    • High-risk triple-negative breast cancer (TNBC): Preoperative pembrolizumab + carboplatin + paclitaxel, followed by preoperative pembrolizumab + cyclophosphamide + doxorubicin or epirubicin, followed by adjuvant pembrolizumab
    • TNBC and residual disease after preoperative therapy with taxane-, alkylator-, and anthracycline-based chemotherapy: Capecitabine
  • Useful in Certain Circumstances:
    • Dose-dense AC (doxorubicin/cyclophosphamide)
    • AC (doxorubicin/cyclophosphamide) every 3 weeks (category 2B)
    • CMF (cyclophosphamide/methotrexate/fluorouracil)
    • AC followed by weekly paclitaxel
    • Capecitabine (maintenance therapy for TNBC after adjuvant chemotherapy)
  • Other Recommended Regimens:
    • AC followed by docetaxel every 3 weeksc
    • EC (epirubicin/cyclophosphamide)
    • TAC (docetaxel/doxorubicin/cyclophosphamide)
    • Select patients with TNBC:
      • Paclitaxel + carboplating (various schedules)
      • Docetaxel + carboplating (preoperative setting only)

[assessment]

• The patient’s underlying condition of HBV carrier status is being managed with Baraclude (entecavir). Vital signs are stable and lab data showed no significant abnormalities.

221202

{triple negative breast cancer}

• diagnosis
  • Invasive carcinoma of L breast, cT4bN3M1, stage IV, Dx in Aug 2022.
  • Chronic viral hepatitis B without delta-agent
• exam finding
  • 2022-11-18 SONO - breast
    • findings
      • Parenchymal pattem
        • Loosely (inhomogeneously) sonodense
      • Focal sonographic lesion
        • already known left breast cancer with LAP metastasis, receviing chemotherapy now
        • right axillary LAP, distant metastasis of left breast cancer? or double primary breast cancer related?
        • multiple small FAs and cysts over right breast, less likely malignancy
    • diagnosis
      • Highly suspicious of malignancy, with sonographic negative axillary LNs
    • treatment
      • no need to biopsy
    • suggestion and plan
      • Regular OPD follow-up
      • BI-RADS - 6. Known Biopsy - Proven Malignancy
  • 2022-11-09 CT - chest
    • Indication: invasive carcinoma of left breast, ER(-) PR(-) Her-2/neu(-), Ki-67: 90%, T4bN3M1, stage IV
      
    • Findings:
      • Lungs: subpleural ground-glass opacity and reticular opacities at LUL and both lower, may be post treatment change and combined dependent density at lower lobes.
        • no abnormal nodule in the lungs
      • Mediastinum and hila: no enlarged LN
      • Vessels:
        • mild calcified plaques of the LAD and LCX coronary arteries.
        • Thoracic aorta: normal caliber, extensive atherosclerotic change mainly involving the ascending segment, aortic root, and aortic arch.
        • Central pulmonary arteries: dilated trunk (3.3cm in caliber) and right main artery.
        • Heart: normal in size of cardiac chambers.
      • Pleura: no nodule or effusion .
      • Chest wall and visible lower neck: soft-tissue defect with area of skin thickening and disappearance of the hugeleft breaar tumor and significant regression of metastatic lymphadenopathy at axillary region compared with CT on 8/15.
      • Visible abdominal-pelvic contents: several tiny hepatic calcifications.
        • normal appearance of gallbladder. unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node.
        • Mild atherosclerotic change of the abdominal aorta.
      • Visualized bones: sclerotic change at xyphoid process and distal sternal body.
    • Impression:
      • left breast cancer with good response to treatment compared with previous CT exam.
  • 2022-11-08 Whole body PET scan
    • Mild glucose hypermetabolism in a left axillary lymph node and a right axillary lymph node, compatible with metastatic lymph nodes s/p treatment change.
    • Mild glucose hypermetabolism in the left anterior chest wall, compatile with primary breast malignancy s/p treatment change.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-10-14 SONO - abdomen
    • dilated pelvis of left kidney
    • pancreas masked by gas
  • 2022-08-31 ECG
    • Low voltage QRS
    • Possible Inferior infarct , age undetermined
    • Nonspecific ST and T wave abnormality
  • 2022-08-31 CXR
    • Lung markings: increased density in the left middle lung field.
  • 2022-08-24 MRI - brain
    • no evidence of brain metastasis
    • high SI chnage on T2WI in the visible C-cord. Please correlate with C-spine MRI.
  • 2022-08-19 CXR
    • Atherosclerotic change of aortic arch
    • Patchy opacity projecting at left lower chest wall is noted that is c/w left breast cancer after correlate with CT.
  • 2022-08-16 Tc-99m MDP whole body bone scan
    • Decreased activity in the body of the sternum. Bone destruction may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the L3-4 spines. Degenerative change may show this picture.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and left knee, compatible with benign joint lesions.
  • 2022-08-15 CT - chest
    • left huge breast cancer T4bN3M1
  • 2022-08-11 Patho - breast biopsy
    • Breast, left, biopsy — Invasive carcinoma of no special type
    • Section shows skin and breast tissue with irregular neoplastic glands infiltration.
    • IHC:
      • GATA3 (+)
      • ER (Ab) (-)
      • PR (Ab) (-, <1%, moderate)
      • Her-2/neu (Ab): (-, 0)
      • Ki-67 90%
  • 2022-08-09 CXR
    • A mass at left breast.
    • Ground glass opacity in bilateral lower lungs.
• chemoimmunotherapy (docetaxel 75mg/m2 and carboplatin AUC 6, cycled every 21 days x 4-6 cycles, preoperative setting only - NCCN 2022-06-21)
  • 2022-12-01 docetaxel 65mg/m2 100mg 1hr + carboplatin AUC 5 600mg 2hr
  • 2022-10-24 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr
  • 2022-10-03 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr
  • 2022-09-12 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr
  • 2022-08-23 docetaxel 60mg/m2 90mg 1hr + carboplatin AUC 5 600mg 2hr

[note]

• PREOPERATIVE/ADJUVANT THERAPY REGIMENS - HER2-Negativeb (Breast Cancer NCCN Guidelines 20220621 Version 4.2022, BINV-L 1 OF 9, p55)
  • Preferred Regimens:
    • Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks
    • Dose-dense AC (doxorubicin/cyclophosphamide) followed by weekly paclitaxel
    • TC (docetaxel and cyclophosphamide)
    • Olaparib, if germline BRCA1/2 mutations
    • High-risk triple-negative breast cancer (TNBC): Preoperative pembrolizumab + carboplatin + paclitaxel, followed by preoperative pembrolizumab + cyclophosphamide + doxorubicin or epirubicin, followed by adjuvant pembrolizumab
    • TNBC and residual disease after preoperative therapy with taxane-, alkylator-, and anthracycline-based chemotherapy: Capecitabine
  • Useful in Certain Circumstances:
    • Dose-dense AC (doxorubicin/cyclophosphamide)
    • AC (doxorubicin/cyclophosphamide) every 3 weeks (category 2B)
    • CMF (cyclophosphamide/methotrexate/fluorouracil)
    • AC followed by weekly paclitaxel
    • Capecitabine (maintenance therapy for TNBC after adjuvant chemotherapy)
  • Other Recommended Regimens:
    • AC followed by docetaxel every 3 weeksc
    • EC (epirubicin/cyclophosphamide)
    • TAC (docetaxel/doxorubicin/cyclophosphamide)
    • Select patients with TNBC:
      • Paclitaxel + carboplating (various schedules)
      • Docetaxel + carboplating (preoperative setting only)

[assessment]

• The CT on 2022-11-09 indicated that the left breast cancer responded to the regimen of [docetaxel + carboplatin].

221004

[assessment]

• The use of olaparib may be an option in cases of germline mutations of BRCA1/2.
• The NCCN breast cancer evidence blocks (2022-06-21 version 4.2022): The use of platinum agents in the adjuvant setting is not recommended. If platinum agents are included in an anthracycline based regimen, the optimal sequence of chemotherapy and choice of taxane agent is not established.

701454820

230102

• diagnosis - 2022-11-19 discharge note
  • Pancreatic tail cancer with liver metastasis, stage IV s/p chemotherapy with FOLFIRINOX from 2022/10/21
  • Essential (primary) hypertension
  • Hyperlipidemia, unspecified
• past history
  • Hypertension in 2021/10 with Norvasc 1# po QD and Carvedilol 6.25mg 1# po QD control
  • Hyperlipidemia in 2021/10 with Crestor 10mg 1# po QD control          
• family history
  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.   
• lab data
  • 2022-10-07 Anti-HBc Nonreactive
    
  • 2022-10-07 Anti-HBc-Value 0.15 S/CO
    
  • 2022-10-07 Anti-HBs 163.89 mIU/mL
    
  • 2022-10-07 HBsAg (quantitative) Nonreactive
    
  • 2022-10-07 HBsAg Value (quantitative) 0.00 IU/mL
    
  • 2022-10-07 Anti-HCV Nonreactive
    
  • 2022-10-07 Anti-HCV Value 0.07 S/CO
    
  • 2022-09-26 CA-199 22806 U/mL (Taipei Mackey Hospital)
• exam findings
  • 2022-11-05 ECG
    • Normal sinus rhythm
    • Incomplete right bundle branch block
    • ST elevation, consider early repolarization, pericarditis, or injury
    • Abnormal ECG
  • 2022-10-11 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, well differentiated, compatible with metastatic pancreatic ductal adenocarcinoma
    • The sections show a picture of adenocarcinoma, well differentiated, composed of nests of columnar neoplastic cells with slightly pleomorphic nuclei, abundant cytoplasm, mucin secretion, and form duct-like glandular structures, mainly in portal areas. Vascular invasion is present.
    • IHC shows: CK7(+), CK20(+), and CA19-9(+). The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
  • 2022-09-19 MRI (TaiAn Hospital)
    • Suspected pancreatic tumor (4 cm) with adhesion to spleen hilum, tail and suspected liver metastasis.
• chemoimmunotherapy (FOLFIRINOX)
  • 2022-12-30 - oxaliplatin 85mg/m2 150mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg 4200mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-12-16 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-11-29 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-11-16 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-11-02 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
  • 2022-10-21 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3

221130

[assessment]

• With an initiating of dose-reduced irinotecan and skipped fluorouracil bolus, FOLFIRINOX has been administered to this patient with pancreatic tail cancer with liver metastases since 2022-10-21, and no serious adverse reactions have been reported.
• In recent lab tests, CEA (2022-11-15 20.18ng/mL) and CA199 (2022-11-15 >19090U/mL) levels remained high.
• The underlying conditions of hypertension and hyperlipidemia are managed with patient-carried medication with no extreme abnormal results on examinations.

701012983

221229

• diagnosis
  • Malignant neoplasm of duodenum
• past history]
  • Past medical history:
    • Cardiovascular disease - CAD, DM
    • Hepatitis B or C carrier - denied
    • Current medications – DAPT
  • Past surgical history:
    • no gastrectomy/colectomy/splenectomy   
• family history]
  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.     
• exam findings
  • 2022-11-08 CT - abdomen
    • Clinical history: 56 y/o male patient with duodenal adenocarcinoam pT3bN2 cM0; stage IIIB, s/p Op in May 2022.
    • With and without contrast enhancement CT of abdomen whole:
      • S/P whipple operation.
      • Right renal cyst, 1.2cm.
      • Unremarkable change of the liver, spleen and left kidney.
      • There are multiple enlarged lymph nodes in the paraaortic, aortocaval and peripancreatic regions.
      • Presence of ascites.
    • Impression:
      • S/P whipple operation.
      • Multiple metastatic lymph nodes and ascites, progression.
      • R/O right renal cyst.
  • 2022-11-08 CXR
    • Spondylosis of the T-spine
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2022-11-01 SONO - abdomen
    • Diagnosis
      • Dilated CBD
      • Dilated left intrahepatic duct
      • Splenomegaly, mild
      • Ascites
      • Pancreas masked
    • Suggestion
      • No more fever
      • elevated CEA/CA 19-9
      • highly suspected tumor reucrrent
      • Suggest medical ONC follow up and treat, but patient refuse (due to no money). suggest him seeking help from social worker but also refuse.
  • 2022-06-13 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2022-06-08 CXR
    • Ground glass opacity in RLL.
  • 2022-05-31 Patho - pancreas total/subtotal resection
    • Pathologic diagnosis
      • Duodenum, 2nd and 3rd portion, whpple operation — Periampullary adenocarcinoma, poorly differentiated
      • Pancreas, head, whpple operation — Involved by adenocarcinoma
      • Lymph node, peripancreatic, dissection — Metastatic adenocarcinoma (2/2)
      • Lymph node, group 7,8,9, dissection — Metastatic adenocarcinoma (2/3)
      • Gallbladder, whpple operation — Negative for malignancy
      • Omentum, whpple operation — Negative for malignancy
      • AJCC 8th edition Pathology stage: pT3bN2(if cM0); AJCC stage IIIB
  • 2022-05-24 CT - chest
    • History: Duodenal cancer
    • Impression
      • no abnormality in both lungs. 2nd portion duodenal tumor with pancreatic head involvement and complete obstruction.
      • suspect old subendocardial infarct in LAD territory.
  • 2022-05-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (109 - 33) / 109 = 69.72%
      • M-mode (Teichholz) = 68
    • Adequate LV systolic function with normal resting wall motion
    • Dilated aortic root
    • Septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Trivial MR and trivial TR
    • Preserved RV systolic function
  • 2022-05-18 Pulmonary Flow Volume Loop
    • Mild restrictive lung defect
  • 2022-05-17 MRI - pancreas
    • History and indication: Duodenal stricture
    • Findings
      • Marked motion artifact.
      • Wall thickening of duodenum, 2nd portion, with pancreas invasion. Some LNs at retroperitoneum.
      • Distention of stomach.
      • Tiny renal cysts.
      • Normal appearance of liver, spleen, adrenals.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • No ascites.
      • No abnormal intensity in bilateral basal lungs.
    • IMP:
      • In favor of duodenal tumor with pancreas invasion and obstruction.
  • 2022-05-17 Patho - stomach
    • Labeled as “Some white and plaque-like lesions were noted at lower esophagus”, biopsy (B) — ulcer. PAS stain shows no fungal species.
  • 2022-05-17 Patho - stomach
    • Duodenum, SDA, s/p biopsy (A) — adenocarcinoma.
    • IHC stain: Her2/neu: negative (score =0)
    • Section shows duodenal mucosal tissue with irregular aborted glands and isolated signet ring-like neoplastic cells.
  • 2022-05-16 Upper GI and Small Intestine
    • UGI and small bowel series revealed:
      • The contrast medium passage from oral cavity through esophagus to stomach smoothly without obstruction.
      • Normal contour and mucosal pattern of the esophagus.
      • Distention of stomach.
      • Normal appearance of duodenal bulb.
      • Partial obstruction of duodenum (2nd portion).
      • No abnormal bowel loop displacement.
      • The passage time is about 120 minutes.
  • 2022-05-16 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade D
      • Suspected esophageal candidiasis, lower esophagus, s/p biopsy (B)
      • Superficial gastritis
      • Duodenal obstruction, SDA, r/o peptic stricture according to the recent endoscopic diagnosis of duodenal ulcers in other hospital, s/p biopsy (A)
      • Incomplete study due to residual food retention
    • Suggestion
      • Consult GS for surgical evaluation
      • Arrange upper GI series
  • 2022-05-13 CT - abdomen
    • History: vomit with coffee ground for days accompanied with tarry stool for once since this morning. Abdominal distended
    • Indication: GI bleeding.
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is asymmetrical wall thickening at the duodenal 2nd portion, causing marked distension of the stomach S/P nasogastric tube insertion.
        • Please correlate with gastroscopy to R/O ulcer with deformity or cancer?
      • There is a poor enhancing lesion in the pancreatic uncinate process, measuring 1.5 cm in size.
        • Please correlate with CA199 and MRI.
      • A renal cyst measuring 1.5 cm in right upper pole is noted.
      • There is no focal abnormality in the liver, gallbladder, biliary system, spleen & left kidney.
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • There is asymmetrical wall thickening at the duodenal 2nd portion, causing obstruction.
        • Please correlate with gastroscopy to R/O ulcer with deformity or cancer?
      • There is a poor enhancing lesion in the pancreatic uncinate process, measuring 1.5 cm in size.
        • Please correlate with CA199 and MRI.
  • 2022-05-13 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Suboptimal study due to much residual food retention
      • Reflux esophagitis LA Classification grade C
      • Superficial gastritis
      • Suspicious of duodenal ileus
    • Suggestion
      • Suggest NG tube decompression use
      • Arrange KUB

[assessment]

• The patient has been diagnosed with duodenal cancer for several months. There may be a reason why he does not actively participate in treatment because he is financially underprivileged (according to social service team’s note 2022-12-28). The availability of treatment options may be limited as a result.
• With adequate hydration and flomoxef treatment, the decreased blood pressure has returned to normal (95/55 to 127/70) on 2022-12-29.

700022077

221228

• exam findings
  • 2022-12-03 CT - abdomen
    • Findings:
      • Wall thickening of cecum and proximal A-colon with adjacent mesentery and peritoneal invasions.
      • Multiple enlarged regional lymph nodes, more than 10.
      • Multiple mass lesions with peripheral enhancement in liver.
      • No ascites or extraluminal free air.
      • Enlarged lymph nodes in para-aortic region.
      • No bony destructive lesion on these images.
      • Multiple nodular lesions in both lung fields.
    • Impression
      • suspected Acending colon CA with peritoneal invaion, lymph node metastasis, and liver & lung metastasis

==========

2022-12-28

• A nasogastric tube can be used to administer all of the oral medications listed in the active prescription.
• There may be an enhanced CNS depressant effect when tramadol, chlorzoxazone, and oxazolam are administered together.
• Amlodipine and tramadol’s serum concentrations may be increased by fluconazole, a moderate CYP3A4 inhibitor.
• The ingredients in Acetal, Sketa, and Tramacet all include acetaminophen. The maximum daily dose of acetaminophen is not recommended to exceed 3000mg.
• Please continue to monitor any potential adverse reactions caused by drug interactions.

2022-12-05

• The CT image taken on 2022-12-03 indicated that cancer of the colon or cecum may be present. A work-up is currently being conducted on the patient. As far as the active prescription is concerned, there is no problem.

701173809

221228

• diagnosis
  • Sigmoid cancer with obstruction and invasion to cecum s/p Colostomy then Sigmoid colectomy with lymph nodes dissection and Right hemicolectomy on 2019/03/23, pT4bN2bM0, stage IIIC s/p adjuvant chemotehrapy with FOLFOX for 6 cycles with tumor seeding with posterior lateral aspect
  • Left Kidney clear cell renal carcinoma , pT1aN0M0 s/p partial nephrectomy on 2019/12/31
  • Chronic viral hepatitis B without delta-agent
• past history
  • GERD history 20+ years ago;
  • Lumbar spondylolisthesis, L2-L3 post medical treatment in hospitalized 20+ years ago;
  • Sigmoid colon cancer with obstruction, pT4bN2bM0, stage IIIC s/p T-loop colostomy on 2019/03/23; s/p sigmoid colectomy and right hemicolectomy on 2019/03/27; s/p post Port A catheterimplatation on 2019/04/03. mFOLFOX-6 adjuvant chemotherapy x 6 times then shifted to high dose 5-FU x 6 times on 2019/07/08 to 2019/09/18.
  • Left Kidney clear cell renal carcinoma , pT1aN0M0 s/p partial nephrectomy on 2019/12/31
• exam finding
  • 2022-09-30 CT - abdomen
    • History:
      • 20190323 CT: sigmoid colon cancer with total obstruction.
      • 20190327 surgery: Sigmoid cancer with obstruction and invasion to the cecum s/p Sigmoid colectomy + Right hemicolectomy. Patho: pT4bN2bM0, pstage IIIC
      • 20191231 S/P partial Lt nephrectomy:RCC, clear cell, pT1aN0M0
      • 20220413 CT: a lesion in Lt 11th rib intercostal space, Suspected meta.
      • 20220502 CT-guided biopsy patho favor metastasis c/w colon origin. a lesion in Lt kidney middle pole, suspected recurrent RCC? clinician favor old hematoma.
    • Findings:
      • S/P partial nephrectomy at left kidney upper pole.
        • Prior CT identified a poor enhancing lesion 1.6 x 1.3 cm in left kidney middle pole is noted again, mild decreasing in size to 1.2 x 0.7 cm. Follow up is indicated.
        • Prior CT identified a metastasis measuring 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib intercostal space is not noted again in the current CT that is c/w metastasis S/P surgical resection.
      • Prior CT identified a cyst 7 mm in S4 and a hemangioma 1.3 cm in S7 of the liver are noted again, stationary.
      • S/P right hemicolectomy and S/P LAR with autosuture retention over the sigmoid colon.
    • Impression:
      • S/P partial nephrectomy at left kidney upper pole.
      • There is no evidence of tumor recurrence.
  • 2022-05-27 Patho - peritoneum biopsy
    • Diaphragm, left, excision — Metastatic adenocarcinoma, consistent with colorectal origin
    • Sections show fibroadipose and skeletal muscular tissue with invasive neoplastic glandular cells.
    • The immunohistochemical stain of CDX2 is positive. Lymphovascular invasion is found. The result and morphology are consistent with metastatic adenocarcinoma from colorectal origin. The peripheral resection margins are free of tumor. The tumor is very close (<0.1cm) to the serosal surface.
  • 2022-05-26 CXR
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2022-05-19 Whole body PET scan
    • Glucose hypermetabolism in a focal area in the posterior lateral aspect of left 11th-12th intercostal space, in a focal area in the posterior aspect of left kidney, in a focal area in the middle lower pelvis just in the left anterolateral aspect of rectum and in a focal area in the right anterior lower pelvis. Multiple metastatic lesions should be considered. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • A glucose hypermetabolic lesion in the middle pole of left kidney. Recurrent malignancy should be watched out. Please also correlate with other clinical findings for further evaluation.
  • 2022-05-03 Patho - soft tissue nontumor/mass/lipoma/debridement
    • Labeled as “left 11 rib”, (clinically: sigmoid colon cancer and renal cell cancer), CT guided biopsy — metastatic adenocarcinoma.
    • IHC stains:
      • CD10 (-) and RCC (-): dis-favor RCC,
      • CK20 (+): compatible with colon origin;
      • TTF-1 (-): dis-favor pulmonary origin;
      • PSA (-): dis-favor prostatic origin.
    • Section shows soft tissue with many small nests of criform pattern adenocarcinoma.
  • 2022-04-13 CT - abdomen
    • History:
      • 20190323 CT:sigmoid colon cancer with total obstruction.
      • 20190327 surgery: Sigmoid cancer with obstruction and invasion to the cecum s/p Sigmoid colectomy + Right hemicolectomy
        • Patho: pT4bN2bM0, pstage IIIC
      • 20191231 S/P partial Lt nephrectomy: RCC, clear cell, pT1aN0M0
    • Findings
      • S/P partial nephrectomy at left kidney upper pole.
        • Prior CT identified a poor enhancing lesion 0.9 cm in left kidney middle pole is noted again, mild increasing in size to 1.6 x 1.3 cm.
        • A newly-developed renal cell carcinoma is suspected. Please correlate with contrast enhanced dynamic CT or MRI.
        • In addition, another newly-developed heterogeneous poor enhancing mass measuring 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib rintercostal space is noted that may be tumor seeding.
      • Prior CT identified a cyst 7 mm in S4 and a hemangioma 1.3 cm in S7 of the liver are noted again, stationary.
      • S/P right hemicolectomy and S/P LAR with autosuture retention over the sigmoid colon.
    • Impression
      • RCC 1.6 x 1.3 cm in Lt kidney middle pole is suspected.
      • Tumor seeding 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib rintercostal space is highly suspected. please correlate with clinical condition and biopsy.
  • 2021-12-30 SONO - abdomen
    • Diagnosis
      • Negative finding
      • Pancreas not shown
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2021-07-01 CT - abdomen
    • S/P colon operation.
    • Small liver cyst and hemangioma.
    • Left renal tumors (0.9cm, 2.7cm) without interval change.
  • 2021-04-01 CT - abdomen
    • S/P colon operation.
    • Small liver cyst and hemangioma.
    • Left renal tumors (0.9cm, 2.7cm).
  • 2020-03-20 CT - abdomen
    • dilated small bowel. suspected small bowel ileus.
    • recent renal infarction in the left kidney.
  • 2020-01-02 Surgical pathology Level V
    • PATHOLOGIC DIAGNOSIS:
      • Kidney, left, partial nephrectomy — Clear cell renal cell carcinoma with sarcomatoid feature
        
      • Pathology stage: pT1aNx, stage I at least
    • MICROSCOPIC EXAMINATION
      • Histological type: Clear cell renal cell carcinoma
        
      • Sarcomatoid features: Present (80%)
        
      • Rhabdoid features: Not identified
        
      • Histologic grade: Grade 4
        
      • Tumor necrosis: Present (20%)
        
      • Tumor Extension: Tumor limited to kidney
        
      • Margins: Uninvolved by invasive carcinoma
        
      • Lymphovascular invasion: Not identified
        
      • Regional lymph nodes (pN): No lymph node found
        
      • Distant metastasis (pM): Not applicable
        
      • Nonneoplastic kidney: Chronic pyelonephritis
        
  • 2019-12-02 MRI - liver, spleen
    • A hemangioma (1.3cm) in S7 of liver. A cyst (0.5cm) in S4 of liver.
    • A poor enhancing tumor (2.7cm) in left kidney suspected hypovascular RCC.
  • 2019-09-26 CT - abdomen
    • Colon cancer s/p operation with colostomy. No evidence of tumor recurrence.
    • A poor enhancing tumor (2.7cm) in left kidney (mild increased size).
    • A poor enhancing tumor (1.1cm) in S7 of liver without interval change.
  • 2019-06-25 CT - abdomen
    • No evidence of recurrent tumor in the study.
  • 2019-03-27 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Sigmoid colon, colectomy — Adenocarcinoma, moderately differentiated
      • Ascending colon, R’t hemicoloectomy — Adenocarcinoma, compatible with direct tumor invasion from sigmoid cancer
      • Proximal & distal surgical margins — Free of tumor invasion
      • Lymph nodes, mesocolic, dissection — Positive for tumor metastasis (8/43) with extracapsular extension (2/8)
      • Appendix, terminal ileum — Free of tumor invasion
      • AJCC pathologic stage — pT4bN2bMx, stage IIIC at least
    • MICROSCOPIC EXAMINATION
      • Histology: sigmoid adenocarcinoma directly invades to ascending colon
      • Histology Grade: G2: moderately differentiated
        
      • Depth of invasion: direct invades adjacent colon
      • Angiolymphatic invasion: Present
      • Perineural invasion: NOT identified
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectosigmoid: Involved
      • Lymph node metastasis, mesocolic: Positive for tumor metastasis (8/43)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: Present (2/8)
      • Pathological TNM Stage: pT4bN2bMx, stage IIIC at least
      • Type of polyp in which invasive carcinoma arose: N/A
      • Additional pathologic findings: N/A
      • TNM descriptors: N/A
        
      • Tumor regression grading S/P CCRT: N/A
      • Proximal & distal margins: free from tumor invasion
  • 2019-03-26 Surgical pathology Level IV
    • Colon, sigmoid, 20 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2019-03-23 CT - abdomen
    • Indication: Abdominal dull pain for 2-3 days, mostly over the right, abdominal fullness with no stool passage for 2 days, N∕V(+), no chest pain, no SOB, no flank pain, denied OP history
    • Imaging Report Form for Colorectal Carcinoma
    • Impression:
      • Dilated colon and small intestines with transitional point at sigmoid colon, suspected foreign body related or sigmoid colon cancer.
        
      • T3N1Mx, IIIB
• surgical operation
  • 2022-05-27 Excision of chest wall and repair of diaphragmatic defect.
    • One solid nodular lesion was noted over left CP angle, near diaphram and 11th intercostal muscle, size about 3cm in max. diameter.
    • One J-P drain was inserted beneth the wound.
  • 2020-03-23 Enterolysis with bowel decompression
    • Adhesion band and causing small bowel dilatation
  • 2019-12-31 Partial nephrectomy
  • 2019-10-30 Closure of enterostomy or Colostomy (loop or double-barrel)
  • 2019-03-27 Left hemicolectomy or sigmoid colectomy with anastomosis with lymph node
  • 2019-03-23 Enterostomy for suspected S-colon cancer with obstruction
• drug allergy
  • Eloxatin (oxaliplatin 50 mg/vial) - whole body rash, fever all over
• chemoimmunotherapy
  • 2022-12-27 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
    • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
  • 2022-12-07 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
    • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
  • 2022-11-03 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
    • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
  • 2022-10-17 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
    • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
  • 2022-09-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
    • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
  • 2022-09-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
    • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
  • 2022-08-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 400mg/m2 760mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
    • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
  • 2022-08-02 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 400mg/m2 760mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
    • premed - dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
  • 2022-06-29 - bevacizumab 5mg/kg 400mg 90min + irinotecan 120mg/m2 230mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
    • premed - dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
  • 2022-06-14 - irinotecan 120mg/m2 225mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 200mg/m2 380mg 10min + fluorouracil 2400mg/m2 4570mg 46hr (FOLFIRI, Q2WK)
    • premed - dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + granisetron 2mg
  • 2019-07-08 ~ 2019-09-18 - Adjuvant chemotherapy with mFOLFOX6 for 6 times.

[assessment]

• The CEA and CA199 markers did not show any obvious trend over the past six months.
• Lab data for 2022-12-27 showed a WBC level of 3.82K/uL and a neutrophil percentage of 37%. The possibility of potential infectious events and neutropenia might be kept in mind.
• The most recent CT was dated on 2022-09-30. Possibly, the lesion in the middle pole of the left kidney should be followed up. It may be updated if it is considered to be beneficial to clinical decision-making.
• The active prescription does not pose a problem.

221018

• diagnosis
  • Sigmoid cancer with obstruction and invasion to cecum s/p Colostomy then Sigmoid colectomy with lymph nodes dissection and Right hemicolectomy on 2019/03/23, pT4bN2bM0, stage IIIC s/p adjuvant chemotehrapy with FOLFOX for 6 cycles with tumor seeding with posterior lateral aspect
  • Left Kidney clear cell renal carcinoma , pT1aN0M0 s/p partial nephrectomy on 2019/12/31
  • Chronic viral hepatitis B without delta-agent
• past history
  • GERD history 20+ years ago;
  • Lumbar spondylolisthesis, L2-L3 post medical treatment in hospitalized 20+ years ago;
  • Sigmoid colon cancer with obstruction, pT4bN2bM0, stage IIIC s/p T-loop colostomy on 2019/03/23; s/p sigmoid colectomy and right hemicolectomy on 2019/03/27; s/p post Port A catheterimplatation on 2019/04/03. mFOLFOX-6 adjuvant chemotherapy x 6 times then shifted to high dose 5-FU x 6 times on 2019/07/08 to 2019/09/18.
  • Left Kidney clear cell renal carcinoma , pT1aN0M0 s/p partial nephrectomy on 2019/12/31
• exam finding
  • 2022-09-30 CT - abdomen
    • History:
      • 20190323 CT: sigmoid colon cancer with total obstruction.
      • 20190327 surgery: Sigmoid cancer with obstruction and invasion to the cecum s/p Sigmoid colectomy + Right hemicolectomy. Patho: pT4bN2bM0, pstage IIIC
      • 20191231 S/P partial Lt nephrectomy:RCC, clear cell, pT1aN0M0
      • 20220413 CT: a lesion in Lt 11th rib intercostal space, Suspected meta.
      • 20220502 CT-guided biopsy patho favor metastasis c/w colon origin. a lesion in Lt kidney middle pole, R/O recurrent RCC? clinician favor old hematoma.
    • Findings:
      • S/P partial nephrectomy at left kidney upper pole.
        • Prior CT identified a poor enhancing lesion 1.6 x 1.3 cm in left kidney middle pole is noted again, mild decreasing in size to 1.2 x 0.7 cm. Follow up is indicated.
        • Prior CT identified a metastasis measuring 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib intercostal space is not noted again in the current CT that is c/w metastasis S/P surgical resection.
      • Prior CT identified a cyst 7 mm in S4 and a hemangioma 1.3 cm in S7 of the liver are noted again, stationary.
      • S/P right hemicolectomy and S/P LAR with autosuture retention over the sigmoid colon.
    • Impression:
      • S/P partial nephrectomy at left kidney upper pole.
      • There is no evidence of tumor recurrence.
  • 2022-05-27 Patho - peritoneum biopsy
    • Diaphragm, left, excision — Metastatic adenocarcinoma, consistent with colorectal origin
    • Sections show fibroadipose and skeletal muscular tissue with invasive neoplastic glandular cells.
    • The immunohistochemical stain of CDX2 is positive. Lymphovascular invasion is found. The result and morphology are consistent with metastatic adenocarcinoma from colorectal origin. The peripheral resection margins are free of tumor. The tumor is very close (<0.1cm) to the serosal surface.
  • 2022-05-26 CXR
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2022-05-19 Whole body PET scan
    • Glucose hypermetabolism in a focal area in the posterior lateral aspect of left 11th-12th intercostal space, in a focal area in the posterior aspect of left kidney, in a focal area in the middle lower pelvis just in the left anterolateral aspect of rectum and in a focal area in the right anterior lower pelvis. Multiple metastatic lesions should be considered. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • A glucose hypermetabolic lesion in the middle pole of left kidney. Recurrent malignancy should be watched out. Please also correlate with other clinical findings for further evaluation.
  • 2022-05-03 Patho - soft tissue nontumor/mass/lipoma/debridement
    • Labeled as “left 11 rib”, (clinically: sigmoid colon cancer and renal cell cancer), CT guided biopsy — metastatic adenocarcinoma.
    • IHC stains:
      • CD10 (-) and RCC (-): dis-favor RCC,
      • CK20 (+): compatible with colon origin;
      • TTF-1 (-): dis-favor pulmonary origin;
      • PSA (-): dis-favor prostatic origin.
    • Section shows soft tissue with many small nests of criform pattern adenocarcinoma.
  • 2022-04-13 CT - abdomen
    • History:
      • 20190323 CT:sigmoid colon cancer with total obstruction.
      • 20190327 surgery: Sigmoid cancer with obstruction and invasion to the cecum s/p Sigmoid colectomy + Right hemicolectomy
        • Patho: pT4bN2bM0, pstage IIIC
      • 20191231 S/P partial Lt nephrectomy: RCC, clear cell, pT1aN0M0
    • Findings
      • S/P partial nephrectomy at left kidney upper pole.
        • Prior CT identified a poor enhancing lesion 0.9 cm in left kidney middle pole is noted again, mild increasing in size to 1.6 x 1.3 cm.
        • A newly-developed renal cell carcinoma is suspected. Please correlate with contrast enhanced dynamic CT or MRI.
        • In addition, another newly-developed heterogeneous poor enhancing mass measuring 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib rintercostal space is noted that may be tumor seeding.
      • Prior CT identified a cyst 7 mm in S4 and a hemangioma 1.3 cm in S7 of the liver are noted again, stationary.
      • S/P right hemicolectomy and S/P LAR with autosuture retention over the sigmoid colon.
    • Impression
      • RCC 1.6 x 1.3 cm in Lt kidney middle pole is suspected.
      • Tumor seeding 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib rintercostal space is highly suspected. please correlate with clinical condition and biopsy.
  • 2021-12-30 SONO - abdomen
    • Diagnosis
      • Negative finding
      • Pancreas not shown
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2021-07-01 CT - abdomen
    • S/P colon operation.
    • Small liver cyst and hemangioma.
    • Left renal tumors (0.9cm, 2.7cm) without interval change.
  • 2021-04-01 CT - abdomen
    • S/P colon operation.
    • Small liver cyst and hemangioma.
    • Left renal tumors (0.9cm, 2.7cm).
  • 2020-03-20 CT - abdomen
    • dilated small bowel. suspected small bowel ileus.
    • recent renal infarction in the left kidney.
  • 2020-01-02 Surgical pathology Level V
    • PATHOLOGIC DIAGNOSIS:
      • Kidney, left, partial nephrectomy — Clear cell renal cell carcinoma with sarcomatoid feature
        
      • Pathology stage: pT1aNx, stage I at least
    • MICROSCOPIC EXAMINATION
      • Histological type: Clear cell renal cell carcinoma
        
      • Sarcomatoid features: Present (80%)
        
      • Rhabdoid features: Not identified
        
      • Histologic grade: Grade 4
        
      • Tumor necrosis: Present (20%)
        
      • Tumor Extension: Tumor limited to kidney
        
      • Margins: Uninvolved by invasive carcinoma
        
      • Lymphovascular invasion: Not identified
        
      • Regional lymph nodes (pN): No lymph node found
        
      • Distant metastasis (pM): Not applicable
        
      • Nonneoplastic kidney: Chronic pyelonephritis
        
  • 2019-12-02 MRI - liver, spleen
    • A hemangioma (1.3cm) in S7 of liver. A cyst (0.5cm) in S4 of liver.
    • A poor enhancing tumor (2.7cm) in left kidney suspected hypovascular RCC.
  • 2019-09-26 CT - abdomen
    • Colon cancer s/p operation with colostomy. No evidence of tumor recurrence.
    • A poor enhancing tumor (2.7cm) in left kidney (mild increased size).
    • A poor enhancing tumor (1.1cm) in S7 of liver without interval change.
  • 2019-06-25 CT - abdomen
    • No evidence of recurrent tumor in the study.
  • 2019-03-27 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Sigmoid colon, colectomy — Adenocarcinoma, moderately differentiated
      • Ascending colon, R’t hemicoloectomy — Adenocarcinoma, compatible with direct tumor invasion from sigmoid cancer
      • Proximal & distal surgical margins — Free of tumor invasion
      • Lymph nodes, mesocolic, dissection — Positive for tumor metastasis (8/43) with extracapsular extension (2/8)
      • Appendix, terminal ileum — Free of tumor invasion
      • AJCC pathologic stage — pT4bN2bMx, stage IIIC at least
    • MICROSCOPIC EXAMINATION
      • Histology: sigmoid adenocarcinoma directly invades to ascending colon
      • Histology Grade: G2: moderately differentiated
        
      • Depth of invasion: direct invades adjacent colon
      • Angiolymphatic invasion: Present
      • Perineural invasion: NOT identified
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectosigmoid: Involved
      • Lymph node metastasis, mesocolic: Positive for tumor metastasis (8/43)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: Present (2/8)
      • Pathological TNM Stage: pT4bN2bMx, stage IIIC at least
      • Type of polyp in which invasive carcinoma arose: N/A
      • Additional pathologic findings: N/A
      • TNM descriptors: N/A
        
      • Tumor regression grading S/P CCRT: N/A
      • Proximal & distal margins: free from tumor invasion
  • 2019-03-26 Surgical pathology Level IV
    • Colon, sigmoid, 20 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2019-03-23 CT - abdomen
    • Indication: Abdominal dull pain for 2-3 days, mostly over the right, abdominal fullness with no stool passage for 2 days, N∕V(+), no chest pain, no SOB, no flank pain, denied OP history
    • Imaging Report Form for Colorectal Carcinoma
    • Impression:
      • Dilated colon and small intestines with transitional point at sigmoid colon, suspected foreign body related or sigmoid colon cancer.
        
      • T3N1Mx, IIIB
• surgical operation
  • 2022-05-27 Excision of chest wall and repair of diaphragmatic defect.
    • One solid nodular lesion was noted over left CP angle, near diaphram and 11th intercostal muscle, size about 3cm in max. diameter.
    • One J-P drain was inserted beneth the wound.
  • 2020-03-23 Enterolysis with bowel decompression
    • Adhesion band and causing small bowel dilatation
  • 2019-12-31 Partial nephrectomy
  • 2019-10-30 Closure of enterostomy or Colostomy (loop or double-barrel)
  • 2019-03-27 Left hemicolectomy or sigmoid colectomy with anastomosis with lymph node
  • 2019-03-23 Enterostomy for suspected S-colon cancer with obstruction
• drug allergy
  • Eloxatin (oxaliplatin 50 mg/vial) - whole body rash, fever all over
• chemoimmunotherapy
  • 2022-10-17 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-09-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-09-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-08-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 400mg/m2 760mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-08-02 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 400mg/m2 760mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-06-29 - bevacizumab 5mg/kg 400mg 90min + irinotecan 120mg/m2 230mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-06-14 - irinotecan 120mg/m2 225mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 200mg/m2 380mg 10min + fluorouracil 2400mg/m2 4570mg 46hr (FOLFIRI, Q2WK)
  • 2019-07-08 ~ 2019-09-18 - Adjuvant chemotherapy with mFOLFOX6 for 6 times.

[assessment]

• The patient’s vital signs, laboratory data (2022-10-11), and the disease are in a generally stable state.

220928

• diagnosis
  • Sigmoid cancer with obstruction and invasion to cecum s/p Colostomy then Sigmoid colectomy with lymph nodes dissection and Right hemicolectomy on 2019/03/23, pT4bN2bM0, stage IIIC s/p adjuvant chemotehrapy with FOLFOX for 6 cycles with tumor seeding with posterior lateral aspect
  • Left Kidney clear cell renal carcinoma , pT1aN0M0 s/p partial nephrectomy on 2019/12/31
  • Chronic viral hepatitis B without delta-agent
• past history
  • GERD history 20+ years ago;
  • Lumbar spondylolisthesis, L2-L3 post medical treatment in hospitalized 20+ years ago;
  • Sigmoid colon cancer with obstruction, pT4bN2bM0, stage IIIC s/p T-loop colostomy on 2019/03/23; s/p sigmoid colectomy and right hemicolectomy on 2019/03/27; s/p post Port A catheterimplatation on 2019/04/03. mFOLFOX-6 adjuvant chemotherapy x 6 times then shifted to high dose 5-FU x 6 times on 2019/07/08 to 2019/09/18.
  • Left Kidney clear cell renal carcinoma , pT1aN0M0 s/p partial nephrectomy on 2019/12/31
• exam finding
  • 2022-05-27 Patho - peritoneum biopsy
    • Diaphragm, left, excision — Metastatic adenocarcinoma, consistent with colorectal origin
    • Sections show fibroadipose and skeletal muscular tissue with invasive neoplastic glandular cells.
    • The immunohistochemical stain of CDX2 is positive. Lymphovascular invasion is found. The result and morphology are consistent with metastatic adenocarcinoma from colorectal origin. The peripheral resection margins are free of tumor. The tumor is very close (<0.1cm) to the serosal surface.
  • 2022-05-26 CXR
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2022-05-19 Whole body PET scan
    • Glucose hypermetabolism in a focal area in the posterior lateral aspect of left 11th-12th intercostal space, in a focal area in the posterior aspect of left kidney, in a focal area in the middle lower pelvis just in the left anterolateral aspect of rectum and in a focal area in the right anterior lower pelvis. Multiple metastatic lesions should be considered. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • A glucose hypermetabolic lesion in the middle pole of left kidney. Recurrent malignancy should be watched out. Please also correlate with other clinical findings for further evaluation.
  • 2022-05-03 Patho - soft tissue nontumor/mass/lipoma/debridement
    • Labeled as “left 11 rib”, (clinically: sigmoid colon cancer and renal cell cancer), CT guided biopsy — metastatic adenocarcinoma.
    • IHC stains:
      • CD10 (-) and RCC (-): dis-favor RCC,
      • CK20 (+): compatible with colon origin;
      • TTF-1 (-): dis-favor pulmonary origin;
      • PSA (-): dis-favor prostatic origin.
    • Section shows soft tissue with many small nests of criform pattern adenocarcinoma.
  • 2022-04-13 CT - abdomen
    • History:
      • 20190323 CT:sigmoid colon cancer with total obstruction.
      • 20190327 surgery: Sigmoid cancer with obstruction and invasion to the cecum s/p Sigmoid colectomy + Right hemicolectomy
        • Patho: pT4bN2bM0, pstage IIIC
      • 20191231 S/P partial Lt nephrectomy: RCC, clear cell, pT1aN0M0
    • Findings
      • S/P partial nephrectomy at left kidney upper pole.
        • Prior CT identified a poor enhancing lesion 0.9 cm in left kidney middle pole is noted again, mild increasing in size to 1.6 x 1.3 cm.
        • A newly-developed renal cell carcinoma is suspected. Please correlate with contrast enhanced dynamic CT or MRI.
        • In addition, another newly-developed heterogeneous poor enhancing mass measuring 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib rintercostal space is noted that may be tumor seeding.
      • Prior CT identified a cyst 7 mm in S4 and a hemangioma 1.3 cm in S7 of the liver are noted again, stationary.
      • S/P right hemicolectomy and S/P LAR with autosuture retention over the sigmoid colon.
    • Impression
      • RCC 1.6 x 1.3 cm in Lt kidney middle pole is suspected.
      • Tumor seeding 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib rintercostal space is highly suspected. please correlate with clinical condition and biopsy.
  • 2021-12-30 SONO - abdomen
    • Diagnosis
      • Negative finding
      • Pancreas not shown
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2021-07-01 CT - abdomen
    • S/P colon operation.
    • Small liver cyst and hemangioma.
    • Left renal tumors (0.9cm, 2.7cm) without interval change.
  • 2021-04-01 CT - abdomen
    • S/P colon operation.
    • Small liver cyst and hemangioma.
    • Left renal tumors (0.9cm, 2.7cm).
  • 2020-03-20 CT - abdomen
    • dilated small bowel. suspected small bowel ileus.
    • recent renal infarction in the left kidney.
  • 2020-01-02 Surgical pathology Level V
    • PATHOLOGIC DIAGNOSIS:
      • Kidney, left, partial nephrectomy — Clear cell renal cell carcinoma with sarcomatoid feature
        
      • Pathology stage: pT1aNx, stage I at least
    • MICROSCOPIC EXAMINATION
      • Histological type: Clear cell renal cell carcinoma
        
      • Sarcomatoid features: Present (80%)
        
      • Rhabdoid features: Not identified
        
      • Histologic grade: Grade 4
        
      • Tumor necrosis: Present (20%)
        
      • Tumor Extension: Tumor limited to kidney
        
      • Margins: Uninvolved by invasive carcinoma
        
      • Lymphovascular invasion: Not identified
        
      • Regional lymph nodes (pN): No lymph node found
        
      • Distant metastasis (pM): Not applicable
        
      • Nonneoplastic kidney: Chronic pyelonephritis
        
  • 2019-12-02 MRI - liver, spleen
    • A hemangioma (1.3cm) in S7 of liver. A cyst (0.5cm) in S4 of liver.
    • A poor enhancing tumor (2.7cm) in left kidney suspected hypovascular RCC.
  • 2019-09-26 CT - abdomen
    • Colon cancer s/p operation with colostomy. No evidence of tumor recurrence.
    • A poor enhancing tumor (2.7cm) in left kidney (mild increased size).
    • A poor enhancing tumor (1.1cm) in S7 of liver without interval change.
  • 2019-06-25 CT - abdomen
    • No evidence of recurrent tumor in the study.
  • 2019-03-27 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Sigmoid colon, colectomy — Adenocarcinoma, moderately differentiated
      • Ascending colon, R’t hemicoloectomy — Adenocarcinoma, compatible with direct tumor invasion from sigmoid cancer
      • Proximal & distal surgical margins — Free of tumor invasion
      • Lymph nodes, mesocolic, dissection — Positive for tumor metastasis (8/43) with extracapsular extension (2/8)
      • Appendix, terminal ileum — Free of tumor invasion
      • AJCC pathologic stage — pT4bN2bMx, stage IIIC at least
    • MICROSCOPIC EXAMINATION
      • Histology: sigmoid adenocarcinoma directly invades to ascending colon
      • Histology Grade: G2: moderately differentiated
        
      • Depth of invasion: direct invades adjacent colon
      • Angiolymphatic invasion: Present
      • Perineural invasion: NOT identified
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectosigmoid: Involved
      • Lymph node metastasis, mesocolic: Positive for tumor metastasis (8/43)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: Present (2/8)
      • Pathological TNM Stage: pT4bN2bMx, stage IIIC at least
      • Type of polyp in which invasive carcinoma arose: N/A
      • Additional pathologic findings: N/A
      • TNM descriptors: N/A
        
      • Tumor regression grading S/P CCRT: N/A
      • Proximal & distal margins: free from tumor invasion
  • 2019-03-26 Surgical pathology Level IV
    • Colon, sigmoid, 20 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2019-03-23 CT - abdomen
    • Indication: Abdominal dull pain for 2-3 days, mostly over the right, abdominal fullness with no stool passage for 2 days, N∕V(+), no chest pain, no SOB, no flank pain, denied OP history
    • Imaging Report Form for Colorectal Carcinoma
    • Impression:
      • Dilated colon and small intestines with transitional point at sigmoid colon, suspected foreign body related or sigmoid colon cancer.
        
      • T3N1Mx, IIIB
• surgical operation
  • 2022-05-27 Excision of chest wall and repair of diaphragmatic defect.
    • One solid nodular lesion was noted over left CP angle, near diaphram and 11th intercostal muscle, size about 3cm in max. diameter.
    • One J-P drain was inserted beneth the wound.
  • 2020-03-23 Enterolysis with bowel decompression
    • Adhesion band and causing small bowel dilatation
  • 2019-12-31 Partial nephrectomy
  • 2019-10-30 Closure of enterostomy or Colostomy (loop or double-barrel)
  • 2019-03-27 Left hemicolectomy or sigmoid colectomy with anastomosis with lymph node
  • 2019-03-23 Enterostomy for suspected S-colon cancer with obstruction
• drug allergy
  • Eloxatin (oxaliplatin 50 mg/vial) - whole body rash, fever all over
• chemoimmunotherapy
  • 2022-09-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-09-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-08-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 400mg/m2 760mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-08-02 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 400mg/m2 760mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-06-29 - bevacizumab 5mg/kg 400mg 90min + irinotecan 120mg/m2 230mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-06-14 - irinotecan 120mg/m2 225mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 200mg/m2 380mg 10min + fluorouracil 2400mg/m2 4570mg 46hr (FOLFIRI, Q2WK)
  • 2019-07-08 ~ 2019-09-18 - Adjuvant chemotherapy with mFOLFOX6 for 6 times.

[assessment]

• There is no issue with the active prescription.
• It is recommended that the last abdomen CT image be updated as it is dated 2022-04-13.
• A metastatic adenocarcinoma around the left 11th and 12th ribs (2022-05-03 pathology) might be surgically removed if it is symptomatic and feasible.

220914

[assessment]

• There was a generally normal lab result on 2022-09-12 and a relatively stable TPR and BP reading during this hospital stay. With the current regimen, the patient has tolerated it.
• In this case, the patient has only a muscle power of 4 or less, so some assistive devices might be beneficial.

700132375

221226

{drug identification}

The drug imprinted “CTP A23” on the red-white capsule has not been found in available databases and remains unidentified.

700555339

221226

{ABX use evaluation}

For most adults, the initial recommended antifungal treatment is an echinocandin (caspofungin, micafungin, or anidulafungin) given through the vein. Fluconazole, amphotericin B, and other antifungal medications may also be appropriate in certain situations.

221128

• exam findings
  • 2022-11-25 KUB
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
    • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
  • 2022-11-25 Chest supine view
    • Widening of the right upper mediastinum is noted, which may be due to torturous innomiate vessel or tumor. Please correlate with standing p-a view or CT.
    • Borderline cardiomegaly
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-11-25 Chest plain film
    • Unremarkable change in the visible trachea
    • cardiomegaly; mediastinal widening.
    • Lung markings: unremarkable.
    • Normal bilateral hemidiaphrams
    • Clear bilateral costophrenic angles
    • Unremarkable change in bilateral clavicles
  • 2022-06-05 CT - abdomen (at Shin Kong Hospital)
    • Tumor location: U-M/3 rectum
    • Tumor size: Measurable: around 3.5-cm (largest diameter)
    • Tumor invasion: T4b, transmural, right adnexal to right uteirne border.
    • Regional nodal metastasis: N2, five nodes along IMA.
    • Distant metastasis (In this study): No Other findings: small nodes around IMA orifice level of aorta/IVC.
    • Impression :
      • Locally invasive U-M/3 rectal cancer, T4bN2M0 stage with segmental obstructive colitis.
      • Questionable small nodes around IMA orifice level of aorta/IVC.
      • CBD dilatation with sludge.
      • A-colon diverticulae.
      • Uneven fatty liver with S5 cyst.
      • L3-5 spinal stenosis with left L4-5

[assessment]

• Based on the recent diagnosis and prescription in the PharmaCloud, the patient should have underlying conditions such as CKD stage 3 (N18.3), lumbar region spondylosis with radiculopathy (M4726), cardiovascular promblem (nicorandil, bisoprolol, spironolactone), and diabetes (vildagliptin, gliclazide).
• Nicorandil and bisoprolol have been added to the active prescription as patient-carried items and regular insulin 2 units BID is being used, both the blood pressure and blood sugar levels are within acceptable ranges.
• As of 2022-11-28, the eGFR is 72.1, so there is no need to adjust the dosage.
• The elevated CRP level is decreasing (4.63mg/dL 2022-11-28 <- 13.09ng/dL 2022-11-25), which might suggest a mitigation in the condition.
• The active prescription does not pose an issue.

701045543

221223

• exam findings
  • 2022-11-25 All-RAS + BRAF mutations assay
    • Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • There was no variant detect in the BRAF gene.
  • 2022-11-28 KUB
    • Transitional vertebra of L5-S1, left side.
  • 2022-11-22 Exercise Electrocardiogram Bruce
    • Findings
      • The patient exercised according to the BRUCE for 06:14 min:s, achieving a work level of max METS: 7.3.
      • The resting heart rate of 59 bpm rose to a maximal heart rate of 130 bpm.
      • This value represents 71 % of the maximal, age-predicted heart rate.
      • The resting blood pressure of 110/76 mmHg, rose to a maximum blood pressure of 159/70 mmHg.
      • The exercise test was stopped due to Dyspnea, Frequent PVCs, Fatigue.
    • Conclusion
      • Resting ECG: normal sinus rhythm
      • Arrhythmia: VPC bigeminy during exam
      • Interpretation: No significant ST-T change during exercise and recovery phases.
      • Conclusion Inconclusive, submaximal stress
  • 2022-11-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 35) / 108 = 67.59%
      • M-mode (Teichholz) = 67.9
    • 1.Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
    • Mild MR, PR
  • 2022-11-18 Patho - colorectal polyp
    • Colorectum, rectosigmoid 15 cm above anal verge, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Specimen submitted in formalin consists of 2 pieces of tan, irregular tissue measuring 0.4 x 0.2 x 0.1 cm.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2022-11-17 CT - abdomen
    • History and indication: Abdominal pain
    • Findings
      • Wall thickening of S-colon with uterus invasion and regional LAP.
      • Liver cysts (up to 1.3cm).
      • Suspected left ovary dermoid cyst (3.9cm). Right ovary cyst (6.2cm). Some csytic lesions (up to 1.3cm) in uterus.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2022-11-17 ECG
    • Sinus rhythm with short PR
    • T wave abnormality, consider inferior ischemia
    • Abnormal ECG
  • 2022-11-17 Sigmoidoscopy
    • Findings
      • Rectosigmoid cancer with partial obstruction at 15 cm from AV, biopsy was done
      • Tattooing was performed
    • Diagnosis
      • Rectosigmoid cancer with partial obstruction s/p biopsy and tattooed
    • Suggestion
      • Elective colectomy
    • Complication
      • No immediate complication
• chemotherapy
  • 2022-12-08 - oxaliplatin 70mg/m2 110mg 2hr + leucovorin 400mg/m2 660mg 2hr + fluorouracil 2400mg/m2 3970mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-11-25 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg

[assessment]

• Loperamide is an opioid medication that is used to treat diarrhea. Loperamide works by slowing the movement of the intestines, which helps to reduce the frequency of diarrhea.
• Lactulose is a type of laxative that is used to treat constipation and to help regulate bowel movements. Lactulose works by drawing water into the intestines, which helps to soften stools and make them easier to pass.
• When loperamide and lactulose are coadministered (the current situation), there is no specific expected effect on the body.

700864309

221222

• exam findings
  • 2022-12-09 SONO - urology
    • Right renal stone
    • Right renal cyst
  • 2022-12-09 Bladder Sonography
    • PVR: 22.8ml (PVR = postvoided residual)
  • 2022-12-09 TRUS-P, Transrectal Ultrasound of Prostate
    • Benign prostatic hyperplasia
  • 2022-11-23 Patho - stomach biopsy
    • Labeled as “30cm below the incisors”, Biopsy (B) — benign hyperplastic squamous mucosa.
    • Stomach, antrum. Biopsy (A) — Chronic gastritis, H pylori present
  • 2022-11-23 Whole body PET scan
    • Glucose hypermetabolic lesions in the left soft palate, compatible with the primary malignant neoplasm of soft palate.
      
    • Glucose hypermetabolic lesions in bilateral cervical lymph nodes, highly suspected cancer with regional lymph nodes metastases.
      
    • Glucose hypermetabolic lesions in bilateral pulmonary hilar regions, probably reactive nodes.
      
    • Malignant neoplasm of soft palate, no evidence of distant metastasis, by this F-18-FDG PET/CT scan.
  • 2022-11-22 MRI - nasopharynx
    • Indication: soft palate cancer
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • A left soft palate tumor, extending to right, up to 3 cm.
      • Enlarged bil. neck LNs.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor and LNs.
    • IMP:
      • Left soft palate tumor, T2N2M0 stage II (P16+), IVA (P16-).
    • Imaging Report Form for Oropharynx Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:II (P16+), IVA(P16-)(Stage_value)
        
  • 2022-11-22 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Hiatal hernia.
    • Esophageal ulcer, M/3, s/p biopsy (B)
    • Superficial gastritis, s/p CLO test
    • Gastric shallow ulcers, antrum, s/p biopsy (A)
    • CLO test: Positive
  • 2022-11-22 Pulmonary flow volume loop
    • Mild to moderate obstructive ventilatory impairment
  • 2022-11-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (99 - 24) / 99 = 75.76%
      • M-mode (Teichholz) = 76
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated both atria and RV, grade 1 LV diastolic dysfunction
    • Mild AR, MR, and PR, moderate to severe TR
    • Pulmonary hypertension
  • 2022-11-21 ECG
    • Sinus rhythm with 1st degree A-V block
    • Voltage criteria for left ventricular hypertrophy
    • ST & T wave abnormality, consider anterolateral ischemia
  • 2022-11-21 CXR
    • No cardiomegaly
    • Tortuosity of the aorta with atherosclerotic change.
    • Increased lung markings over both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-11-16 Patho - nasopharyngeal/oropharyngeal biopsy
    • Tumor, soft palate, biopsy — Compatible with squamous cell carcinoma and candidiasis
    • The specimen submitted consisted of three small pieces of tumor tissue measuring up to 0.5 x 0.3 x 0.2 cm in size, fixed in formalin. Grossly, they were gray in color and soft in consistence. All embedded for sections in one cassette.
    • Microscopically, the sections show a picture of ulcer with fungal hyphae and spores, morphology consistent with candidiasis and high grade (severe) dysplasia with pleomorphic and hyperchromatic nuclei and dyskeratosis. However, no convincing stromal tissue included in the limited specimen. According to histopathologic finding and clinical information (Show Chwan Memorail Hospital: pathlology revealed malignancy. Uvula, biopsy — Squamous cell carcinoma, moderately differentiated), it is compatible with squamous cell carcinoma, moderately differentiated. Closely follow up
    • Immunohistochemistry of P16(-)
  • 2022-11-15 Nasopharyngoscopy
    • soft palate cancer
• consultation
  • 2022-11-24 Radiation Oncology
    • Q
      • After admitted, MRI showed : left soft palate tumor, T2N2M0. Abd echo showed some parts of pancreas blocked by bowel gas, especially head and tail. PES showed reflux esophagitis LA Classification grade A. Superficial gastritis, and gastric shallow ulcers. Under the impression of soft palate cancer, cT2N2M0, HPV pending, we suggest him to recevied surgery or CCRT. His daughter need opinion for radiotherpy. We need your help for further evaluation. Thank you very much!!
    • A
      • He has no genuine teeth now. CT-simulation will be arranged on 20221130. Plan to deliver 50 Gy/ 25 fx to the bil. neck lymphatic drainage area and orophayrnx. Then boost the soft palate tumor and LAPs to 70 Gy/ 35 fx. RT will start around 20221202 or 20221205. Thank you very much.
  • 2022-11-24 Cardiology
    • Q
      • This is a 91-year-old man with underlying hypertension and coronary artery disease under medication control for many years. No operation history. He had odynophagia for 3 months. Soft palate cancer was told at Show Chwan Hospital. He admitted to our ENT OPD for cancer work up. After work up, soft palate cancer stage IV was diagnosed.
      • We also arrange 2D echo which revealed Dilated both atria and RV, grade 1 LV diastolic dysfunction, mild AR, MR, and PR, moderate to severe TR, pulmonary hypertension. PFT showed: Mild to moderate obstructive ventilatory impairment.
      • We request your consultation for further evaluation.
    • A
      • S
        • This patient suffered from soft palate cancer and was admitted to our hospital for evaluation about the treatment, including surgical, chemotherapy or radiotherapy. After admission, noted to have mild to modeate pulmonary hypertension while pre-OP heart function survey and CV had been consulted. However, they changed mind about surgical tratment and preferred CCRT at the meantime.
      • O
        • Lung function test: Mild to moderate obstructive ventilatory impairment
        • EChocardiography: M-mode(Teichholz) = 76; TR: moderate to severe; Max pressure gradient = 38 mmHg
          • Preserved LV and RV systolic function with normal wall motion
          • Dilated both atria and RV, grade 1 LV diastolic dysfunction
          • Mild AR, MR, and PR, moderate to severe TR
          • Pulmonary hypertension
      • Diagnosis:
        • mild to moderate pulmonary hypertension
      • Suggestion:
        • This patient currently had no signs of dyspnea, acute heart failure sign or chest pain. Since preserved LV systolic dysfunction noted, there was no acute contra-indication for surgical intervention.
          • If surgical treatment was arranged, may try pre-operative statin to prevent CAD attack, e.g. Short-term Atorvastatin 1/2# ~1# QD (20mg)
        • Since the pulmonary hypertension was only mild to moderate, and patient had no active symptom, conservative management and search for underlying cause are recommended.
          • The most obvious cause of pulmonary hypertension might be lung disease, since patient’s tricuspid valve showed no thickening at the meantime
          • Suspected Group 3: Pulmonary Hypertension Due to Lung Disease
            • may arrange chest CT to evaluate the lung parenchymal (group 3) and with contrast for pulmonary artery (artery intimal narrow, group 1 or thrombus group 4)
• chemoimmunotherapy
  • 2022-12-14 - Erbitux (cetuximab) 250mg/m2 400mg 2hr (CCRT) dose 400 <- 600
    • premed - betamethasone 4mg + diphenhydramine 30mg
  • 2022-12-14 - Erbitux (cetuximab) 400mg/m2 600mg 2hr (CCRT)
    • premed - betamethasone 4mg + diphenhydramine 30mg

[note]

• Cetuximab-Containing Combinations in Locally Advanced and Recurrent or Metastatic Head and Neck Squamous Cell Carcinoma (Front. Oncol., 20 May 2019 https://doi.org/10.3389/fonc.2019.00383)
  • Cetuximab remains to date the only targeted therapy approved for the treatment of head and neck squamous cell carcinoma (HNSCC). The EGFR pathway plays a key role in the tumorigenesis and progression of this disease as well as in the resistance to radiotherapy (RT). While several anti-EGFR agents have been tested in HNSCC, cetuximab, an IgG1 subclass monoclonal antibody against EGFR, is the only drug with proven efficacy for the treatment of both locoregionally-advanced (LA) and recurrent/metastatic (R/M) disease. The addition of cetuximab to radiotherapy is a validated treatment option in LA-HNSCC. However, its use has been limited to patients who are considered unfit for standard of care chemoradiotherapy (CRT) with single agent cisplatin given the lack of direct comparison of these two regimens in randomized phase III trials and the inferiority suggested by metanalysis and phase II studies. The current use of cetuximab in HNSCC is about to change given the recent results from randomized prospective clinical trials in both the LA and R/M setting. Two phase III studies evaluating RT-cetuximab vs. CRT in Human Papillomavirus (HPV)-positive LA oropharyngeal squamous cell carcinoma (De-ESCALaTE and RTOG 1016) showed inferior overall survival and progression-free survival for RT-cetuximab combination, and therefore CRT with cisplatin remains the standard of care in this disease. In the R/M HNSCC, the EXTREME regimen has been the standard of care as first-line treatment for the past 10 years. However, the results from the KEYNOTE-048 study will likely position the anti-PD-1 agent pembrolizumab as the new first line treatment either alone or in combination with chemotherapy in this setting based on PD-L1 status. Interestingly, cetuximab-mediated immunogenicity through antibody dependent cell cytotoxicity (ADCC) has encouraged the evaluation of combined approaches with immune-checkpoint inhibitors in both LA and R/M-HNSCC settings. This article reviews the accumulated evidence on the role of cetuximab in HNSCC in the past decade, offering an overview of its current impact in the treatment of LA and R/M-HNSCC disease and its potential use in the era of immunotherapy.

[assessment]

• During the past month, the patient’s liver and kidney functions have declined.

  • Creatinine
    • 2022-12-21 Creatinine 2.06 mg/dL
      
    • 2022-12-14 Creatinine 1.58 mg/dL
      
    • 2022-11-21 Creatinine 1.29 mg/dL
      
  • BUN
    • 2022-12-21 BUN 67 mg/dL
      
    • 2022-12-14 BUN 51 mg/dL
      
    • 2022-11-21 BUN 34 mg/dL
      
  • S-GPT/ALT
    • 2022-12-21 S-GPT/ALT 89 U/L
      
    • 2022-12-14 S-GPT/ALT 54 U/L
      
    • 2022-11-21 S-GPT/ALT 10 U/L
      
  • S-GOT/AST
    • 2022-12-21 S-GOT/AST 51 U/L
      
    • 2022-12-14 S-GOT/AST 36 U/L
      
    • 2022-11-21 S-GOT/AST 19 U/L

• As the patient’s CrCl level is 17 mL/min according to the Cockcroft-Gault formula, it is recommended that the dosage of clarithromycin and amoxicillin be halved.

• For patients with severely impaired kidney function, neither cisplatin nor carboplatin is recommended. Cetuximab is being administered as part of the patient’s treatment with CCRT.

• In this patient, transthoracic echocardiography (2022-11-22) revealed dilated atria and RV, grade 1 LV diastolic dysfunction, mild AR, MR, and PR, moderate to severe TR, and pulmonary hypertension. Cardiopulmonary arrest or sudden death occurred in patients with squamous cell carcinoma of the head and neck receiving cetuximab with radiation therapy or a cetuximab product with platinum-based therapy and fluorouracil. It is recommended to closely monitor serum electrolytes, including magnesium, potassium, and calcium, during and after cetuximab administration.

701448280

221222

{not completed}

• exam findings
  • 2022-11-23 PD-L1 IHC
    • Tumor cell (TC) staining assessment: TC >= 10% and < 50%
    • Percentage of 28-8 expressing tumor cells (%TC): 30%
  • 2022-11-23 PD-L1 22C3
    • Tumor Proportion Score(TPS) assessment: <1%
      • Tumor Proportion Score(TPS): <1%
    • Combined Positive Score(CPS) assessment: <1
      • Combined Positive Score(CPS): <1
  • 2022-11-23 PD-L1 SP142
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • Tumor cell (TC) staining assessment: TC < 1%
      • Percentage of PD-L1 expressing tumor cells (%TC): < 1 %
      • Tumor-infiltrating immune cell (IC) staining assessment: IC < 1%
      • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): < 1 %
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-11-15 CT - abdomen
    • Regression of prior seen liver dome marginal enhanced tumor as compare with CT study on 2022-09-03.
    • Liver cirrhosis.
    • Paraaortic and mesentery lymph nodes.
    • Left lower lung nodule, suspected lung metastasis.
  • 2022-11-14 Nasopharyngoscopy
    • no obvious tumor mass noticed over hupopharynx
  • 2022-10-04 Patho - stomach biopsy
    • Stomach, upper body, biopsy — Chronic gastritis, H pylori NOT present
  • 2022-10-03 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Hypopharyngeal cancer, post CCRT, with esophageal inlet involvement
      • Esophageal varices, F1CbLi, RCS(-)
      • Superficial gastritis, s/p CLO test and biopsy at LC of upper body
      • Suspected Portal hypertensive gastropathy
      • Shallow duodenal ulcer, bulb
      • R/O Papillitis or periampullary lesion
      • Failure of endoscopy-guided NG insertion
    • Suggestion
      • Suggest surgical gastrostomy
      • Correlate with other clinical data for the endoscopic finding of enlargement of papilla
  • 2022-09-08 CT - abdomen
    • In favor of liver, lung and LNs metastases.
  • 2022-09-02 Whole body PET scan
    • Glucose hypermetabolism involving the right and posterior aspects of the hypopharynx with invasion to the the right thyroid cartilage and proximal portion of the esophagus, compatible with advanced hypopharyngeal malignancy. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in multiple bilateral neck lymph nodes, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in a a focal area in the dome of liver. Either liver metastasis or primary liver malignancy may show this picture.
    • Mild glucose hypermetabolism in the soft palate. The nature is to be determined. Please correlate with other clinical findings for further evaluation.
      
    • Mild to moderate glucose hypermetabolism in the distal portion of the esophagus and mild glucose hypermetabolism in a focal area in the anterior aspect of right lower lung field. The nature is also to be determined (inflammatory process? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2022-09-01 MRI - larynx
    • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage) : T:T4(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-09-01 SONO - abdomen
    • Diagnosis
      • Propable Cirrhosis
      • Suspected regenerative nodules,bil
      • Right pleural effusion ,mild
    • Suggestion
      • OPD f/u
      • Please correlate with other image
      • Follow liver function test and AFP,HBV,HCV
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
      • Because of cirrhosis ,infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
  • 2022-09-01 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Hypopharygeal lesion extended to upper esophagus
      • Esophageal varices, F2CbLm
      • Duodenal ulcer scar, bulb
      • Portal hypertensive gastropathy
    • Suggestion
      • Suspected liver cirrhosis
  • 2022-08-22 Patho - nasopharyngeal/oropharyngeal biopsy
    • DIAGNOSIS
      • Soft palate, right, biopsy— squamous cell carcinoma, moderately differentiated (p16: -)
      • Posterior pharyngeal wall tumor, right, biopsy— high-grade dysplasia (p16: -)
    • Microscopically, section A shows moderately differentiated squamous cell carcinoma consisting of proliferation of atypical squamous cells with focal stromal invasion and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and some mitiotic activity. Section B show a small piece of high-grade dysplastic squamous cells.
    • Immunohistochemical stain reverals p16(-).
  • 2022-08-22 Nasopharyngoscopy
    • Findings
      • smooth nasopharynx, bulging of right lateral pharyngeal wall with obliteration of right pyriform sinus; posterior wall mass with partial necrotic tissue; suspect R vocal cord palsy; poor visualization of glottis.
    • Diagnosis/Conclusion
      • suspect R hypopharyngeal cancer
• consultation
  • 2022-09-05 Hemato-Oncology
    • Q
      • We request your consultation for further management.
    • A
      • Impression:
        • advanced hypopharyngeal malignancy with invasion to the the right thyroid cartilage and proximal portion of the esophagus, cT:T4N3M0, stage IVB, soft palate biopsy SCC
        • Propable Cirrhosis, Suspected regenerative nodules, bil, Right pleural effusion, mild
      • Suggestion:
        • Since a case of iver cirrhosis, the primary tumor of liver is needed to be considered. Triple phase liver CT and AFP would be helpful.
        • CCRT is indicated. Then, consult RT for further evaluation.
        • May arrange my OPD if discharge.
  • 2022-09-02 Oral and Maxillofacial Surgery
    • Q
      • This 50 y/o man is a case of hypopharyngeal cancer. The patient suffered from lumping throat on and off and hoarseness for 2 weeks. Body weight loss was noted too. He had smoking habit 1 pack/day, beer about 3 bottle/day, and betel nuts about 2pack/day.
      • He was admission due to right vocal palsy and soft palate tumor biopsy revealed: soft palate squamous cell carcinoma, moderately differentiated (p16: -); posterior pharyngeal wall high-grade dysplasia (p16: -).
      • After admission, cancer work up was arranged. The neck MRI on 9/1 which revealed the tumor invasion to hypopharynx, thyroid cartilage, cricoid cartilage and extended to esophagus, cT4bN3M0, stage IVB. The abdominal sono revealed suspect liver cirrhosis, and right pleural effusion.
      • We request your consultation for pre-chemotherapy dental evaluaion.
    • A
      • For pre-chemotherapy dental evaluaion.
      • O:
        • Hopeless tooth of 11, 21, 28, 43, 44, 45 were noted.
        • Panoramic film revealed severe periodontitis of full mouth.
        • Severe poor oral hygiene.
      • P:
        • Take panoramic X-ray film to check up.
        • Explain findings and treatment plan to the patient and his brother.
        • Suggest extraction of tooth 11, 21, 28, 43, 44, 45 before chemotherapy and radiotherapy.
      • The risk of osteomyelitis after tooth extraction or implantation after radiotherapy has been informed, the patient said that he did not want to have the tooth extracted, and he had to think again

700365018

221221

{not completed}

• lab data
  • 2022-10-19 HBsAg (NMed) Negative
    
  • 2022-10-19 HBsAg Value (NMed) 0.396
    
  • 2022-10-19 Anti-HBc (NMed) Positive
    
  • 2022-10-19 Anti-HBc Value (NMed) 0.00702
    
  • 2022-10-19 Anti-HCV (NMed) Negative
    
  • 2022-10-19 Anti-HCV Value (NMed) 0.0379
• exam findings
  • 2022-10-26 All-RAS + BRAF mutations assay
    • All-RAS: Detected (KRAS codon 12 GGT>GTT, p.G12V
    • BRAF: There was no variant detected in the BRAF gene.
  • 2022-10-25 Tc-99m MDP whole body bone scan
    • Increased activity in the middle T-spines and some L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-10-24 Whole body PET scan
    • Increased FDG uptake in the rectal region and peripheral lymph nodes, compatible with rectal cancer with regional lymph nodes metastases.
      
    • Glucose hypermetabolic lesions in bilateral retromolar and submandibular lymph nodes, the nature is to be determined (reactive nodes, distant lymph nodes metastases, lymphoma, or others ?), suggesting biopsy for investigation.
      
    • Increased FDG uptake in bilateral palatine tonsils, probably a chronic inflammation/infection process.
      
    • Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, probably reactive nodes.
    • Malignant neoplasm of rectum with regional lymph nodes metastases, cTxN2M0, by this F-18-FDG PET/CT scan.
  • 2022-10-18 CT - abdomen
    • Clinical history: 59 y/o male patient with rectal cancer.
    • With and without contrast enhancement CT of whole abdomen:
      • Thickening wall at the rectum, suspected rectal malignancy.
      • Presence of perirectal lymph nodes.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
      • Fibrotic infiltrates in bilateral lung apex.
      • Suspicious right upper lung nodule, suggest follow up.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE: IIIC__(Stage_value)
  • 2022-09-20 Patho - colon biopsy
    • Large intestine, rectum, 5cm to 10cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • Specimen submitted in formalin consists of several pieces of tan, irregular tissue measuring up to 0.3 x 0.2 x 0.1 cm.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2020-09-20 Colonoscopy
    • Findings
      • The scope reach the cecum under fair colon preparation. Many liquid fece with seeds were noted, which blocked almost half of the colon.
      • One semi-annular rectal tumor was noted from 5cm AAV to 10cm AAV. Biopsy was done.
    • Diagnosis
      • Highly suspected rectal cancer, s/p biopsy
      • Suboptimal study
    • Suggestion
      • F/U pathology report
      • CRS OPD follow up
      • Small lesions may be missed due to suboptimal bowel preparation.
    • Complication
      • No immediate complication
• consultation
  • 2022-10-20 Hemato-Oncology
    • Q
      • After fully explained of the condition, pre-op CCRT first followed by surgical treatment was suggested. We needs your expert experience for evaluation of pre-op CCRT. Thanks a lot !!
    • A
      • I would like to take over this case for neoadjuvant CCRT for his rectal cancer with perirectal lymph nodes, cstage T3N2bM0.
  • 2022-10-19 Radiation Oncology
    • Q
      • This 59 y/o male patient sufferre from loose stool and blood in stool for 1 year. Tumor maker with CEA showed 7.18 ng/mL. Colonscopy was performed on 2022/09/20 and revealed highly suspected rectal cancer, 5~10 cm from anal verge, s/p biopsy. Biopsy pathology showed adenocarcinoma, moderately differentiated. Lab data showed anemia (6.6 g/dL) and blood transfusion was done. Abdominal CT revealed rectal cancer with perirectal lymph nodes, cstage T3N2bM0, stage IIIC.
    • A
      • Pre-op CCRT is indicated. CT-simulation will be arranged on 20221024. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 20221026 or 27.
• chemotherapy
  • 2022-12-20 - oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 620mg 2hr + fluorouracil 400mg/m2 620mg 2hr + fluorouracil 2400mg/m2 3700mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg
  • 2022-12-06
  • 2022-11-21
  • 2022-11-07

[assessment]

• According to the available lab data, the levels of MCV, MCH, and MCHC have been frequently low since July 2022.
• Low MCV, MCH, and MCHC can be caused by anemia which could include iron-deficiency anemia and anemia due to chronic disease.
• Thalassemia can also affect the production of hemoglobin, leading to low MCV, MCH, and MCHC.
• Foliromin (ferrous sodium citrate) has been prescribed since mid-Nov 2022, but the readings of the MCV, MCH, and MCHC have only shown a minimal improvement.
• As far as FOLFOX treatment is concerned, there are no issues.

701446872

221221

[assessment]

• The bowl movement in this patient reached 3 times on 2022-12-20. It is recommended to hold the Through (sennoside) temperately and monitor the changes in the bowl movement these days.

221213

• exam findings
  • 2022-11-29, -11-03, -11-01 Body fluid cytology - ascites
    • negative
  • 2022-10-21 CT - abdomen
    • History: Gastric adenocarcinoma of proximal middle body great curvature, metastasis to adjacent omentum pT4aN1M1 stage IV post total gastrectomy with lymphadenectomy of station 1 to 12A and 14V, Retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA on 2022-09-07.
    • Findings:
      • S/P total gastrectomy.
      • S/P Jackson-Pratt drainage tube insertion from right and left abdominal wall.
      • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • Impression:
      • S/P total gastrectomy.
      • There is no evidence of tumor recurrence.
  • 2022-09-08 Patho - stomach subtotal/total (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Tumor, stomach, total gastrectomy — Poorly cohesive carcinoma
      • Margins, bilateral cutting ends, ditto — Free of tumor invasion
      • Lymph nodes, LN 1, ditto — Free of tumor metastasis (0/7)
      • Lymph nodes, LN 2, ditto — Free of tumor metastasis (0/7)
      • Lymph nodes, LN 3, ditto — Tumor metastasis (1/19) with isolated tumor cells and tumor deposits
      • Lymph nodes, LN 4, ditto — Free of tumor metastasis (0/20)
      • Lymph nodes, LN 5, ditto — Free of tumor metastasis (0/1)
      • Lymph nodes, LN 6, ditto — Free of tumor metastasis (0/4)
      • Lymph nodes, LN 7,8,9,11,12, ditto — Free of tumor metastasis (0/8)
      • Lymph nodes, LN 10, ditto — Free of tumor metastasis (0/5)
      • Lymph nodes, LN 14v, ditto — Fat only
        
      • Omentum, omentectomy — Free of tumor invasion
      • AJCC Pathologic staging — pT4aN1M1, stage IV
    • MACROSCOPIC EXAMINATION
      • Specimen type: Stomach, lymph node and omentum
      • Specimen size: 19.3 x 10.2 x 1.3 cm in size, 189 gm in weight
      • Number of lesions: Solitary
      • Tumor site: middle body, greater curvature
      • Tumor size: 1.2 x 0.8 cm
      • Tumor configuration: ulcerative tumor
      • Omentum: 38 x 16 x 1.2 cm, no significant change
    • MICROSCOPIC EXAMINATION
      • Histologic type: Poorly cohesive carcinoma
      • Histologic grade: Grade 3, poorly differentiated
      • Depth of tumor invasion: serosa layer
      • Lymph nodes: tumor metastasis (1/71) in total number without extracapsular extension
      • Omentum: free of tumor invasion
      • AJCC Pathologic Staging: pT4aN1M1
      • Bilateral resection margins: Free of tumor invasion
      • Additional pathologic findings: ulcer with mild intestinal metaplasia
      • Perineural invasion: Present
      • Lymphovascular space invasion: Present
      • Immunohistochemical stains:
        • CAM5.2(+) for serosal invasion
        • CK(+) for isolate tumor cells within lymph node and tumor deposits in LN3
        • HER2(-, Dako score 0 ) for tumor
  • 2022-08-22 CT - abdomen
    • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T1a(T_value) N:N0(N_value) M:M0(M_value) STAGE:I(Stage_value)
  • 2022-08-16 Patho - stomach biopsy
    • Stomach, antrum to lower body, biopsy— chronic gastritis with intestinal metaplasia. No H.pylori present
      • Microscopically, it shows chronic gastritis with lymphoplasmacytic infiltrate and intestinal metaplasia. No Helicobacter-like bacillus is seen.
    • Stomach, middle body, biopsy— poorly differentiated adenocarcinoma
      • Microscopically, it shows poorly differentiated adenocarcinoma composed of proliferation of atypical tumor cells arranged in solid architecture. The tumor shows pabundant cytoplasm and pushing nuclei with signet ring cell-like picture. No H.pylori is seen.
      • Immunohistochemical stain reveals CK(+) at tumor cells.
  • 2022-08-15 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal phleboectasia, lower and middle esophagus
      • Chronic superficial gastritis, s/p CLO
      • Gastric ulcer, A2-H1, middle body, suspected dysplastic or malignant lesion, s/p biopsy (A)
      • Probable intestinal metaplasia, antrum to lower body, s/p biopsy (B)
      • Gastric xanthoma
      • Bile reflux in stomach
    • Suggestion
      • PPI therapy
      • Pursue CLO test and pathology result
      • EGD follow-up is indicated
• chemoimmunotherapy
  • 2022-12-12 - oxaliplatin 50mg/m2 75mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2500mg/m2 3700mg 46hr + [docetaxel 40mg/m2 60mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-11-29 - oxaliplatin 50mg/m2 75mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2500mg/m2 3760mg 46hr + [docetaxel 40mg/m2 60mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-10-31 - oxaliplatin 50mg/m2 70mg 2hr + leucovorin 400mg/m2 625mg 2hr + fluorouracil 2500mg/m2 3800mg 46hr + [docetaxel 40mg/m2 60mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-10-21 - oxaliplatin 70mg/m2 100mg 2hr + leucovorin 400mg/m2 625mg 2hr + fluorouracil 2500mg/m2 4000mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 1mg
  • 2022-09-14 - mitomycin-c 16mg/m2 25mg 2hr D2 + [fluorouracil 500mg/m2 780mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr D1-5
    • premed - betamethasone 4mg

701464956

221221

{drug identification}

A request has been made for us to identify drugs for 10 items.

In total, 9 items have been identified as follows, with 1 item remaining unidentified.

• Meptin-mini (procaterol 25mcg)
• Nexium (esomeprazole 40mg)
• Tareg (valsartan 80mg)
• Norvasc (amlodipine 5mg)
• Solaxin (chlorzoxazone 200mg)
• Rovo (repaglinide 1mg)
• Aricept (donepezil 10mg)
• Gaslan (dimethicone 40mg)
• Medicon-A (dextromethorphan 20mg)

These drugs will be sent back to ward by the in-hospital porter.

701428029

221220

• diagnosis - 20221130 discharge note
  • Malignant neoplasm of sigmoid colon
  • S-colon adenocarcinoma with reginal and distant lymph nodes and hepatic metastasis, T4N2M1a, stage IV s/p T-colostomy.
  • hepatitis B anti-Hbc :positive
• past history
  • DM with diet control
  • Denied hypertension, CAD, CHF, Cancer
  • OP: Nil   
• family history
  • Denied hypertension, DM, CAD, CHF, Cancer history with famliy
• exam findings
  • 2022-09-22 CT - abdomen
    • History and indication: Malignant neoplasm of sigmoid colon
    • Findings
      • Mild regression of S-colon cancer with liver metastases. S/P colostomy.
      • Renal cysts (up to 2.1cm).
      • Normal appearance of spleen, pancreas, adrenals.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • No abnormal density at bilateral basal lungs.
    • IMP: -Mild regression of S-colon cancer with liver metastases.
  • 2022-06-29 CT - chest
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1b(M_value) STAGE:____(Stage_value)
  • 2022-06-29 Patho - colon biopsy
    • Sigmoid colon, 20 cm AAV, biopsy — Adenocarcinoma
    • The sections show a picture of adenocarcinoma, composed of moderately differentiated columnar to cuboidal neoplastic cells, arranged in glandular and cribriform patterns with subtle desmoplastic stromal reaction.
  • 2022-06-28 Sigmoidoscopy
    • Findings
      • The scope reach the 20cm AAV
      • One tumor with luminal narrowing was noted at S-colon (20cm AAV), s/p biopsy
    • Diagnosis
      • Highly suspect colon cancer with luminal narrowing, S-colon (20cm AAV), s/p biopsy
    • Suggestion
      • F/U pathology report
    • Complication
      • No immediate complication
• consultation
  • 2022-07-07 Hemato-Oncology
    • Q
      • This is a 55y/o man with PMH of DM under diet control. This time he was admitted due to S colon tumor with reginonal lymphadnopathy and several hepatic metastasis. Due to poor intake and prominent obstructive symptoms, after discussing with the patient, he underwent T-loop colostomy and port A insertion. Now that the patient is relatively stable with much improved of the previous symptoms, OP wound and colostomy site with no infection signs, we would like to consult you for further treatment.
    • A
      • Impression:
        • Sigmoid colon cancer with regional and distant LNs and hepatic metastases T4N2M1a s/p T-loop colostomy and port A insertion
        • COVID-19 infection
        • DM
      • Suggestion:
        • We will discuss with patient about further chemotherapy. We may take over this case
        • Pending AntiHbc, HbsAg, Anti-HCV, CEA data
        • Pening colon patholgy for MMR IHC stain (MLH1、MSH2、MSH6、PMS2) and All RAS mutation survey
        • Thanks for your consultation. If there is any problem, please feel free to let us known.
• surgical operation
  • 2022-06-30 T-loop colostomy
• chemotherapy
  • 2022-12-19 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2800mg/m2 5650mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
  • 2022-11-28 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2800mg/m2 5650mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
  • 2022-11-14 bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2800mg/m2 5650mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
  • 2022-10-31 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2800mg/m2 5600mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
  • 2022-10-17 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 370mg 90min + leucovorin 400mg/m2 820mg 2hr + fluorouracil 2800mg/m2 5700mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
  • 2022-09-26 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
  • 2022-09-12 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
  • 2022-08-29 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 340mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5320mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
  • 2022-08-16 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 340mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5320mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
  • 2022-08-03 irinotecan 180mg/m2 330mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5275mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg + atropine 1mg + aprepitant 125mg PO
  • 2022-07-20 irinotecan 180mg/m2 330mg 90min + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg + atropine 1mg + aprepitant 125mg PO
  • 2022-07-05 irinotecan 160mg/m2 290mg 90min + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg + atropine 1mg + aprepitant 125mg PO

701006949

221219

{not completed}

• exam findings
  • 2022-12-12 Chest PA + Lat LT
    • Diffuse osteoblastic change of the T-and L-spine are suspected. Please correlate with bone scan.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2022-10-24 - Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed inhomogenously increased activity in the skull, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, clavicles, sacrum, bilateral multiple pelvic bones, bilateral S-I joints, humeri and femurs.
    • IMPRESSION: Some of the previous bone lesions including the left rib cage, some T- and L-spine, right S-I joint, and left femoral trochanters come to slightly more evident compared with the previus study on 2022-03-31, suggesting metastatic bone disease in progression.
  • 2022-10-13 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • Increased pulmonary vasculature is found.
  • 2022-10-12 CT - abdomen
    • Findings:
      • There is a newly-developed hypodense lesion 1 cm in S4/8 dome of the liver at non-enhanced CT and that may be metastasis? Please correlate with MRI.
      • Presence of gallbladder stone.
      • There are few hyperdense lesions in the distal CBD that are c/w distal CBD stones.
      • Bilateral renal cysts (up to 1.1 cm).
      • Diffuse osteoblastic bony metastases with L2 compression fracture.
      • S/P colostomy at the sigmoid colon.
      • s/p Abdominal-perineal resection.
    • Impression:
      • Metastasis 1 cm in S4/8 of the liver is highly suspected. Please correlate with MRI.
      • Few gallstones and distal CBD stones.
  • 2022-03-31 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed inhomogenously increased activity in the skull, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, clavicles, sacrum, bilateral multiple pelvic bones, bilateral S-I joints, humeri and femurs.
    • IMPRESSION: The scintigraphic findings are compatible with diffuse bone metastases.
  • 2022-03-01 KUB
    • Presence of ileus.
    • Heterogeneous density of bony structures.
    • Compression fracture of L2.
    • A calcified spot at RUQ.
  • 2022-02-24 Patho - colon segmental resection for tumors
    • PATHOLOGIC DIAGNOSIS
      • Lower rectum, laparoscopic abdominal perineal resection —- Metastatic adenocarcinoma, compatible with prostatic acinar adenocarcinoma, Gleason score 4 + 5 = 9, with rectum invasion
        
      • Bilateral resection margins — Free
      • Lymph node, mesocolic, dissection —- Tumor present (2/7) without extracapsular extension (0/2)
      • AJCC 8th edition Pathology stage (prostatic cancer) — pT4N1(cM1b: by CT finding), stage IVB
    • MACROSCOPIC EXAMINATION
      • Operation procedure: laparoscopic abdominal perineal resection
      • Specimen site: lower rectum, 1.5 cm above dentate line
        
      • Specimen size: 16.5 cm in length including a portion of skin measuring 1.2 cm in length
      • Tumor size: annularly ulcerated, 4.5 x 2.5 cm
      • Tumor location: 8.5 cm and 4.0 cm away from the two resection margins, respectively
        
      • Depth of invasion grossly: perirectal fat tissue
        
      • Mucosa elsewhere: congestion, ulcer
      • Another segment of unremarkable colon measuring 6.5 cm in length is reveived
      • Representative sections are taken and labeled as: A1-2: bilateral resection margin; A3: colon, non-tumor; A4-9: tumor; A10-13 and X1-30: lymph node, mesocolic.
    • MICROSCOPIC EXAMINATION
      • Histology: prostatic acinar adenocarcinoma, Gleason score 4 + 5 = 9
      • Depth of invasion: rectal wall to mucosa
      • Angiolymphatic invasion: Present
      • Perineural invasion: Present.
        
      • Lymph node metastasis, mesocolic: tumor present (2/7)
      • Extranodal involvement: Not identified
        
      • Pathologic Stage Classification (prostatic cancer): pT4N1 (cM1b: by CT finding), stage IVB
      • Type of polyp in which invasive carcinoma arose: N/A
        
      • Immunohistochemistry: EGFR(+), CK7(-), CK20(-), PSA(+, focal), CDX-2(+), CD56(-)
  • 2022-01-25 CT - abdomen
    • S/P colostomy. Suggest follow up.
    • Lymph nodes in the mediastinum and right hilar region, suspected lymph node metastasis. Stationary.
    • Gallbladder stone.
    • Intralumal hyperdense lesions in the CBD, suspected CBD stones.
    • Bilateral renal cysts.
    • Ascending colon diverticula.
    • Bone metastasis. L2 compression fracture.
  • 2022-01-25 CXR
    • Ground glass opacity in LLL.
    • Interstitial pattern at right lung.
    • Presence of ileus.
    • Heterogeneous density of bony structures.
  • 2022-01-07 Bronchodilator Test
    • Mild obstructive ventilatory impairment with significant bronchodilator response
  • 2022-01-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 29) / 105 = 72.38%
      • M-mode (Teichholz) = 73
    • Normal LV filling pressure; mild RV hypertrophy with impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis with trivial AR; mild TR.
    • Dilated aortic root and proximal ascending aorta (38mm) with mild calcification.
  • 2021-11-22, -11-03 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2021-10-12 Patho - colon biopsy
    • Colon tumor, 1 cm above dentate line, biopsy — Adenocarcinoma, pooylr differentiated
      
    • Microscopically, the sections show a picture of poorly-differentiated adenocarcinoma characterized by nest or individual tumor cells infiltration.
    • Immunohistochemistry shows CK(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
      
  • 2021-10-12 Colonoscopy
    • Rectal tumor, 1cm above dentate line, with luminal narrowing, s/p biopsy
    • Mixed hemorrhoid
  • 2021-10-07 CT - abdomen
    • History and indication: suspected colon cancer survey
    • Findings
      • Enlargement of prostate.
      • Wall thickening of rectum with adjacent fat stranding.
      • Multiple bony metastases.
      • Some LNs at pelvic cavity and paraaortic region.
      • A calcified spot (1.2cm) at gallbladder fossa.
      • Small renal cysts.
      • Left minimal pleural effusion. Some ground glass opacities at bil. lungs. A nodule at LLL.
      • Gallbladder stone (0.8cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2021-09-29 MRI - L-spine
    • Bony metastasis in T12-S4 vertebral bodies and bilateral iliac wings.
    • Multiple para-aortic metastatic LAPs.
    • Lumbar spondylosis.
  • 2021-09-28 CT - chest
    • no evidence lung infection. moderate centrilobular emphysema in both upper lobes of lungs. no lung tumor.
    • extensive bony lesion, metastasis or hematogical disorder.
    • extensive LAD CAD.
  • 2021-09-23 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta. dilated ascending aorta?
    • mild enlarged cardiac silhoutte
    • Platelike lung atelectasis over Rt midlung zone hazy areas of increased opacity (ground-glass opacitie) over Lt lower lung zone
• chemoimmunotherapy
  • 2022-11-14 - Abraxane (nab-paclitaxel) 75mg/m2 100mg 1hr
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 1mg (palliative, for prostate cancer)
  • 2021-12-06 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
  • 2021-11-29 - fluorouracil 200mg/m2 340mg 24hr (CCRT for colorectal cancer)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
  • 2021-11-22 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
  • 2021-11-08 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
  • 2021-11-01 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg

701070156

221219

• diagnosis - 2022-11-09 discharge note
  • Malignant neoplasm of cervix uteri, unspecified
  • Carcinoma of the uterine cervix, stage T1N1M0, stage IIIB s/p CCRT with recurrence and paraaortic lymph node metastasis with bone invasion
  • hepatitis B of anti-Hbc : positive
  • Hyperkalemia
  • Hyponatremia
• family history
  • Mother died of cervical cancer when 53 y/o.
  • There is no family history of, hypertension, mental diseases or asthma.
  • First older sister diagnosed of diabetes.
• exam findings
  • 2022-11-08, -10-31, -10-28, -09-22 KUB
    • Wedge deformity and total collapse at right lateral aspect of L4 vertebral body and suggestive osteolytic lesion at right lateral aspect of L3 vertebral body are noted that are c/w bony metastase after correlate with CT.
    • scoliosis of L-spine with convex to left side
    • Fecal material store in the colon.
  • 2022-11-07, -10-21, -09-26, -08-30 CXR
    • Enlargement of cardiac silhouette.
  • 2022-10-11 Tc-99m MDP whole body bone scan
    • Increased activity in the lower L-spines. Bone metastases should be watched out.
    • Increased activity in the sacrum and right S-I joint. Either degenerative change or bone metastases may show this picture. Please correlate with other imaging modalities for further evaluation.
    • A faint hot spot in the anterior aspect of right 6th rib. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2022-09-21 CT - abdomen
    • Findings
      • osteolytic lesions in right lateral aspect of L3 and L4 vertebral bodies with right lateral extension and invasion to right psoas muscle, about 122.8mm.
      • Tumor encasement of the right internal and external iliac arteries was noted. Right hydornephrosis and right hydroureter were also noted.
    • IMP:
      • tumors in the right paraspinal region.
      • rihgt hydronephrosis and right hydroureter
  • 2022-09-21 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Abnormal ECG
  • 2022-08-26 ECG
    • Normal sinus rhythm
    • Incomplete right bundle branch block
    • Cannot rule out Inferior infarct, age undetermined
    • ST & T wave abnormality, consider anterior ischemia
    • Abnormal ECG
  • 2022-08-19 CT - abdomen
    • History:
      • 2022/08/18 right hip pain radiated to foot for a peroid of time
      • 2021/11 visited our gyn OPD:
        • Carcinoma of the uterine cervix, stage T1N1M0, stage IIIB
        • Completion of radiotherapy on 2015-04-21. Suspicious paraaortic lymph node metastasis.
      • 2021/11 MRI here showed suspect recurrence
      • She said she has received C/T at Tailand this year, result?
    • Indication: Suspected recurrent tumor in right paraspinal region and L3-4 invasion
    • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is osteolytic lesion in right lateral aspect of L3 and L4 vertebral body with right lateral extension and invaded into right psoas muscle, causing a heterogeneous poor enhancing soft tissue mass lesion (the cranial-caudal diemsnion:12.5 cm) that is c/w bony metastasis.
        • In addition, right external iliac artery shows small size that is c/w encasement by the metastatic mass in right psoas muscle.
      • There is right side hydroureteronephrosis and the etiology is due to passive comprssion of right M/3 ureter by the upper described metastatic mass in right psoas muscle .
      • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Bony metastases in L3 and L4 vertebral body with metastatic mass in right psoas muscle.
  • 2022-08-15 Gynecologic ultrasonography
    • Bilateral adnexae free
    • EM 2.5mm
  • 2021-11-29 MRI - pelvis
    • Clinical history: 56 y/o female patient with carcinoma of the uterine cervix, stage T1N1M0, stage IIIB.
    • Cervical cancer s/p RT.
    • Infiltrative soft tissue tumor, 4.6x9.8cm in right paraspinal region with L3-4 invasion, suspected metastasis.
  • 2021-11-25 Gynecologic ultrasonography
    • Bilateral adnexae free
    • EM 1.6mm
  • 2017-12-25 CT - pelvis
    • Clinical history: 52 y/o female patient with carcinoma of the uterine cervix, stage T1N1M0, stage IIIB, hx of appendectomy/LC for ectopic pregnancy.
    • Findings
      • Lymph node in left paraaortic region, up to 1.25cm, r/o metastatic lymph node. Progression.
    • Impression:
      • Cervical cancer s/p RT, progression of paraaortic lymph node (1.25cm).
  • 2017-07-20 CT - pelvis
    • Clinical history: 52 y/o female patient with carcinoma of the uterine cervix, stage T1N1M0, stage IIIB, hx of appendectomy∕LC for ectopic pregnancy.
    • Findings
      • Lymph node in left paraaortic region, up to 1.03cm, r/o metastatic lymph node.
    • Impression:
      • Cervical cancer s/p RT, regression of pelvic lymph nodes. But presence of paraaortic lymph node, 1.03cm, suggest follow up study.
  • 2017-06-26 Mammography
    • Impression: No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative. - annual screening.
• consultation
  • 2022-08-29 Radiation Oncology
    • Q
      • Patient could not understand our language very well. She said she has received C/T and has MST from Tailand on 2022 ?? This time ,she wa admitted for further management.
    • A
      • S: For radiotherapy due to L3, L4, and right psoas muscle metastases with pain.
        • The patient only received ICRT x 4 fractions at TSGH due to severe left abdomen pain during the 5th ICRT procedure.
        • Chemotherapy: 2015-2-2; 2015-3-2; 2015-4-9
        • PI: This is a case of squamous cell carcinoma of the uterine cervix, initial stage T1N1M0, stage IIIB, s/p CCRT, with L3, L4, and right psoas muscle metastases. The patient suffered from pain of right flank area. She said ever received radiotherapy at Bangkok in 2022.
        • Hx of appendectomy/LC for ectopic pregnancy.
        • Family Hx: mother (died of cervical cancer)
      • O:
        • ECOG: 2
        • PE: neck and bil SCF: neg; bil low limbs: no edema; pain of right flank area.
      • A:
        • Squamous cell carcinoma of the uterine cervix, stage T1N1M0, stage IIIB, s/p CCRT, with L3, L4, and right psoas muscle metastases.
      • P:
        • The patient said she ever received radiotherapy of the right flank area at Bangkok in 2022. We need to understand the details of radiotherapy at Bangkok. She is applying these information. RTC: 2022-08-31.
• chemoimmunotherapy
  • 2022-11-21 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr
  • 2022-10-25 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr
  • 2022-09-29 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr
  • 2022-09-07 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr

[assessment]

• In the lab data collected on 2022-12-18, there were no extreme abnormalities that warranted postponing the chemotherapy schedule.
• It was noted that the blood pressure dropped to 90/50 at dusk on 2022-12-18. Prior to the administration of the chemotherapy, the vital signs should be within a fairly stable range.

701236803

221219

• diagnosis - 20221216 admission note
  • Small cell B-cell lymphoma, lymph nodes of head, face, and neck
  • Pleural effusion, not elsewhere classified
  • Pneumonia, unspecified organism
  • Localized enlarged lymph nodes
  • Essential (primary) hypertension
• exam findings
  • 2022-12-18 CXR
    • approriately positioned endotracheal tube in place
    • Lt internal jugular central venous catheter in place with tip projecting over Rt paratracheal space
    • regression of Lt pleural effusion s/p chest tubes placement
    • Port-A catheter inserted into SVC junction via left subclavian vein.
    • extensive hazy increased opacity in the right mid to lower lung zone with obscuration of silhouttes of the right left heart border
  • 2022-12-16 ECG
    • Sinus tachycardia
    • Low voltage QRS
    • Borderline ECG
  • 2022-12-06 Cell Block Cytology
    • 50 cc brown turbid pleural effusion - Atypia
    • The smears and cell block show small lymphocytes and reactive mesothelial cells.
    • Immunocytochemistry shows CD20(+) > CD3(+) lymphocytes, Bcl-6(+/-, equivocal) and CD10(+, focal) for lymphocytes, follicular lymphoma can not be excluded entirely. Follow up
  • 2022-12-06 SONO - chest
    • Right thorax: minimal amount pleural effusion.
    • Left thorax: moderate amount, serosanguinous pleural effusion s/p insertion of 14 Fr. pig-tail catheter and fixed at 15cm.
  • 2022-12-05 CXR
    • S/P port-A implantation.
    • Hypoinflation of both lung is noted.
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • Enlargement of cardiac silhouette.
    • Left pleura effusion is noted.
    • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
  • 2022-11-22 Patho - peritoneum biopsy
    • Abdomen, CT-guide biopsy— Follicular lymphoma
      
    • Histology type: B-cell neoplasms - Follicular lymphoma
    • Immunohistochemical stain profiles: CD20(+), CD3(-), CD10(+), Bcl-2(+), Bcl-6(+), CD5(+), CD23(-), cyclin D1(-).
  • 2022-11-21 CXR
    • Hypoinflation of both lung is noted.
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • Enlargement of cardiac silhouette.
  • 2022-10-26 Whole body PET scan
    • Glucose hypermetabolic lesions in the left NP region and left axillary lymph nodes come to less evident, and glucose hypermetabolic lesions in bilateral cervical lymph nodes, left iliac bone, right pubic bone and right femur disappear compared with the previous study on 2020-09-17, indicating response to current therapy.
    • However, glucose hypermetabolic lesions in bilateral supraclavicular and left infraclavicular lymph nodes, bilateral mediastinal lymph nodes, abdominal and pelvic lymph nodes, and spleen become markedly more prominent, suggesting lymphoma in progression.
      
    • B-cell lymphoma s/p treatment with residual/recurrent tumor involving lymph node regions on both sides of the diaphragm and spleen, c-stage IIIS (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-10-25 Neurosonology
    • Mild atherosclerosis in Rt ECA.
    • Normal pulsatility index (PI) in detected intracranial artery system.
    • Inadequate total blood flow volume of bilateral Vertebral artery (85 ml/min), indicating Vertebrobasilar insufficiency (VBI).
  • 2022-10-25 Brainstem Auditory Evoked Potentials, BAEP
    • This abnormal BAEP study suggests a peripheral sensori-neural hearing disorder on both sides.
  • 2022-10-01 CT - chest
    • Indication:
      • Small cell B-cell lymphoma, lymph nodes of head, face, and neck
      • Localized enlarged lymph nodes
      • Essential (primary) hypertension
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
        • Lymphadenopathy at bilateral thoracic inlet and superior mediastinum. In comparison with CT dated on 2022-03-19, the lesion enlarged.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Lymphadenopathy at paraaortic and pelvic floor is found.
        • The urinary bladder is well distended without soft tissue lesion.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • IMp:
      • Lymphadenopathy at bilateral thoracic inlet and mediastinum and abdominal paraaortic and pelvic floor, in enlargement.
  • 2022-09-15 Nasopharyngoscopy
    • Findings
      • bi nasal cavity clear; smooth nasopharynx, tongue base and hypopharynx mucosa; normal vocal function; no tumor found at bi pharynx; mucus coating on left nasopharynx, local treatment done
    • Conclusion
      • Head neck lymphoma (nasopharynx and neck) s/p chemotherapy, No evidence of tumor recurrence
  • 2022-06-23, -03-03, -01-06, 2021-10-14, -08-12, -06-10, -05-18 Nasopharyngoscopy
    • Findings
      • bi nasal cavity clear; smooth nasopharynx, tongue base and hypopharynx mucosa; normal vocal function; no tumor found at bi pharynx
    • Conclusion
      • Head neck lymphoma (nasopharynx and neck) s/p chemotherapy, No evidence of tumor recurrence
  • 2022-03-19 CT - chest
    • S/p port-A placement with its tip at Superior vena cava
    • No evidence of recurrent/residual lymphadenopathy in the study.
  • 2021-09-09 CT - chest
    • NO evidence of lymphadenopathy in the current study.
    • Minimal right lower lobe and left lower lobe lung collpase.
  • 2021-04-12 CT - neck
    • a small nodular lesion in the right parotid gland
    • suspicious a nodular lesion in the right thyroid gland.
  • 2020-11-30 CT - neck
    • a nodular lesion in the right parotid gland.
    • regression of the left nasopharyngeal tumor
  • 2020-09-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 17) / 100 = 83%
      • M-mode (Teichholz) = 83
    • Normal LV filling pressure; mild RV hypertrophy with impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis.
    • Mildly dilated proximal ascending aorta (35mm).
  • 2020-09-17 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma involving the left aspect of the nasopharynx, multiple lymph nodes on both sides of the diaphragm and multiple bones as mentioned above. Please correlate with other clinical findings for further evaluation.
  • 2020-09-16 CXR
    • Hypoinflation of both lung is noted.
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • Enlargement of cardiac silhouette.
  • 2020-09-16 Patho - bone marrow biopsy
    • Bone marrow, biopsy — lymphoid aggregation
      
    • Microscopically, it shows 40% of cellularity with 2:2 or M:E ratio, trilineage cellular component, mature megakaryocyts and presence of lymphoid aggregations.
      
    • Immunohistochemical stain reveals CD20(+), Bcl-2(+ at aggregation), CD10(focal+), CD138(1~2%), CD117(-), Bcl-6(-), CD34(-), CYCLIN D1(-), MPO (+), CD71(+).
      
    • NOTE: Clinical correlation is essential.
      
  • 2020-09-04 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharynx, left, biopsy— B cell type lymphoma, low grade
      
    • Microscopically, it shows B cell type lymphoma characterized by proliferation of low-grade B cell type lymphoid cells. The follicular architecture is not significant. Mitoses are not common.
      
    • Immunohistochemical stain reveals CD20(+), CK(-), CD10(+), Bcl-2(+), cyclin D1(-), CD3 (+ at background T cell), MUM1(-), C-myc(-), CD23(-), CD5(+), Ki67 index: < or = 10%.
      
    • NOTE: The result of IHC stain is in favor of follicular lymphoma.
  • 2020-09-03 Nasopharyngoscopy
    • Findings: left nasopharynx mild swelling, biopsy done
    • Diagnosis: left nasopharyngeal lesion
  • 2020-08-28 CT - neck
    • Findings
      • a heterogeneous enhancing lesion, about 22mm in the longest axis, in the left nasopharynx.
      • enlarged lymph nodes in the bilateral posterior cervical spaces, and left supraclavicular fossa.
    • IMP: suspected left NPC with bilateral neck enlarged lymph nodes
  • 2020-05-12 Patho - lymph node region resection
    • Lymph node, level IV, V, excision — reactive follicular hyperplasia
    • Microscopically, sections of regional lymph nodes show reactive follicular hyperplasia characterized by prominent uniformly spaced but enlarged germinal centers.They vary considerably in size and shape,and display dumbbell, hourglass,round or bizarre configurations. The mantle zone and germinal centers are sharply demarcated in a reactive follicle. The germinal centers are prominent and hyperplastic and comprise a mixture of small and large lymphoid cells,centrocytes, and centroblasts.Mitotic activity and tingible body macrophages are noted within the germinal centers. The nodal capsule is intact and extranodal extension is not present.
      
    • Immunohistochemical study revelas Bcl-2: focal negative in germinalcenter, cycline-D1: negative, CD10: neagtive in perigerminal
  • 2020-05-11 Nasopharyngoscopy
    • left neck mass
• consultation
  • 2022-12-17 Thoracic Surgery
    • Q
      • For insertion chest tube.
      • Under sono- and CT-guiding, drainage of left pleural effusion was performed smoothly (8 Fr. pig-tail catheter) and some yellowish fluid was obtained on 20221216.
      • Now obstruction, so we need help insertion chest tube.
    • A
      • I have visited the patient and reviewed the images. Complicated effusion pending empyema was impressed. VATS (Video-assisted Thoracoscopic Surgery) decortication will be indicated. I have explained the current condition with her family. I will arrange operation as soon as possible. Thanks for your consultation!! (Decortication is a type of surgical procedure performed to remove a fibrous tissue that has abnormally formed on the surface of the lung, chest wall or diaphragm.)
  • 2020-09-23 Dermatology
    • Q
      • However vesicles on left waist for one week and pain sensation was noted. we need your expertise for further management, thanks
    • A
      • Skin finding: some erythematous papules and macules and patches with excoriations on face, trunk and 4 limbs
      • Imp: eczema, r/o chichenpox (low probability)
      • Plan:
        • xyzal 1# HS
        • mycomb cream BID topical used for face, trunk and 4 limbs
  • 2020-05-08 ENT
    • Q
      • This 61 year old female is a case of H/T for 6 years regular medication control.
      • She complained left lower neck mass for one month and went to TaoYuan Land Seed Hospital for help. CT showed left neck mass, suspected lymphoma (3.53.5cm fixed to spine r/o neuroma and one lymph node above it around 11cm). Sono guide biopsy done on 2020/04/28 which revealed atypical lymphoid hyperplasia. Owing to personal reason, she came to our hospital for second opinion and was admitted for further management on 2020/05/07.
      • Deaf and mutism
        
      • we need your expertise for biopsy of left lower neck, thanks
    • A
      • We will arrange tumor excision next week

700541887

221216

• diagnosis - 20221215 admission note
  • Malignant neoplasm of transverse colon
  • T-colon CA, pT3N1a cM0, stage IIIB, s/p Op
• past history
  • The patient had no systemic diseases, including CNS,、CV, and infection
  • history of operation:
    • Uterine myoma s/p myomectomy (2014)
    • Left adrenal tumor s/p op (2017),
    • Thyroid benign nodule s/p bil. thyroidectomy (2020), taking thyroid and hypertension drugs
    • Internal hemorrhoid s/p Ligation (2021/12/21, 2022/01/18)
• family history
  • Her elder sister was diagnosed of endometrial cancer
  • No members of the family with diabetes.
• exam finding
  • 2022-09-30 CT - chest
    • Indication: colon cancer S/P op A nodule (4.6mm) at RLL. A ground glass opacity (1.6cm) at RLL.
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • One ground glass nodule at right lower lobe up to 1.69cm in largest dimension is found. A daughter nodule up to 0.63cm is also found. The lesions are more solid as compared with previous CT on 2022-09-08, infectious process is considered.
        • S/p port-A placement with its tip at Superior vena cava.
        • Small lymph nodes are found at left axillary region.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Low density lesion at S2 about 1.71cm in largest dimension is found. Simple cyst is considered.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • The liver, pancreas, both kidneys and adrenals are intact.
    • Imp: One ground glass nodule at right lower lobe up to 1.69cm in largest dimension is found. A daughter nodule up to 0.63cm is also found. the lesions are more solid as compared with previous CT on 2022-09-08, infectious process is considered.
  • 2022-09-08 CT - abdomen
    • History and indication:
      • Adenocarcinoma of esophagogastric junction status post laparotomy partial gastrectomy, thoracostomy partial esophacectomy with gastric tube reconstruction and feeding jejunostomy on 2022/07/18, pT3N2M0 stage IIIB
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P left adrenectomy.
      • Wall thickening of colon at splenic flexure of colon.
      • Wall thickening of EG junction.
      • A nodule (4.6mm) at RLL. A ground glass opacity (1.6cm) at RLL.
      • Liver and renal cysts (up to 1.6cm).
      • A calcified spot (5.7mm) at pancreatic body.
      • Normal appearance of spleen, pancreas.
      • Normal appearance of gallbladder. Bile sludge in CBD.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of the aorta, coronary and iliac arteries.
    • IMP:
      • S/P left adrenectomy.
      • Wall thickening of colon at splenic flexure of colon.
      • Wall thickening of EG junction.
      • A nodule (4.6mm) at RLL. A ground glass opacity (1.6cm) at RLL.
  • 2022-07-19 CXR
    • Atherosclerotic change of aortic arch
  • 2022-07-01 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • Liver cyst, S3
      • Renal cyst, right
      • suspicious, angiomyolipoma of right kidney
    • Suggestion
      • semi-annual ultrasound follow up.
  • 2022-04-15 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, transverse, laparoscopic left segmental colectomy — Adenocarcinoma, moderately differentiated
      • Omentum, partial omentectomy — Negative for malignancy
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- Adenocarcinoma, metastatic (1/14)
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1a(if cM0)
    • Microscopic Description
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
        
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: very close, impending perforation, Distance of tumor from margin: < 0.1 mm
          
      • Lymphovascular Invasion: Present
        
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes:
        • Number of Lymph Nodes Involved/Examined: 1/14; Extranodal involvement: Not identified
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): absent
        • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN): pN1: One to three regional lymph nodes are positive (tumor in lymph nodes measuring >=0.2 mm), or any number of tumor deposits are present and all identifiable lymph nodes are negative
        • Distant Metastasis (pM): if cM0
      • Additional Pathologic Findings (select all that apply): None identified
  • 2022-03-25 CT - abdomen, pelvis
    • Findings:
      • There is asymmetrical wall thickening of the distal transverse colon that is c/w adenocarcinoma.
        • In addition, there are five enlarged nodes in the adjacent mesocolon that may be metastatic nodes.
      • There are two poor enhancing lesion 4 mm in S6 and 6 mm in S4 of the liver that may be cyst. Please correlate with sonography. A hepatic cyst measuring 1.5 cm in S3 is noted.
      • There is no focal lesion in both lung and mediastinum.
      • There are several renal cysts on both kidney and the largest one measuring 1.9 cm in size at right middle pole.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIB (Stage_value)
  • 2022-03-21 Patho - colon biopsy
    • Colon, 40 cm from anal verge, biopsy (B) — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2022-03-21 Colonoscopy
    • Diagnosis
      • Suspect colon cancer, probable distal transverse colon, s/p biopsy, tatto and clipping for localization
      • Colon polyps s/p biopsy removal
      • Internal hemorrhoid
    • Suggestion
      • F/U pathology report
    • Complication
      • No immediate complication
  • 2021-12-27 Gynecologic ultrasonography
    • suspected uterine myoma
• surgical operation
  • 2022-04-14 Laparoscopic left segmental colectomy
    • A 1.5cm depressed tumor lesion is located at distal T-colon
    • After mobilization of splenic and hepatic frexure of colon, segmental resection of T-colon was carried out smoothly. Blood loss was about 30ml.
  • 2022-01-18 Occlusion of Hemorrhoidal Plexus, Open Approach
  • 2021-12-21 Occlusion of Hemorrhoidal Plexus, Open Approach
  • 2020-09-15 Bil. thyroidectomy + neck lymph node resection
    • Hard, ill-defined tumor mass over L’T thyroid gland without extrathyroid extension noted ( frozen section: follicular neoplasm)
    • Several enlarged pre-trachea LNs also noted
  • 2017-11-24 Adrenalectomy
• chemoimmunotherapy
  • 2022-12-15 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5140mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-18 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5160mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-04 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5180mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-10-19 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5150mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-10-19 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5140mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-09-07 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5110mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-08-24 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5090mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-08-09 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5090mg 46hr
  • 2022-07-19 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5060mg 46hr
  • 2022-07-04 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
  • 2022-06-20 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
  • 2022-06-01 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

700946496

221214

{Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2(-), stage IIA s/p MRM on 2022-05-13}

• diagnosis - 2022-11-22 discharge note
  • Malignant neoplasm of unspecified site of left female breast
  • Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2 (-), stage IIA s/p MRM on 2022/05/13 s/p chemotherapy with AC by-T(Adriamycin 60mg/m2, Cyclophosphamide 600mg/m2) on 2022/06/16~2022/08/17 for 4 cycles, (Taxotere 60mg/m2) on 2022/09/07~
  • Essential (primary) hypertension
  • Hyperlipidemia, unspecified
  • Gout, unspecified
• past history
  • Hypertension for >10 years, under medical control in Cathay General Hospital
  • Dyslipidemia for about 3 years under medical control    
• exam finding
  • 2022-12-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 22) / 116 = 81.03%
      • LVEF (%) = 81
      • M-mode (Teichholz) 65
    • Normal LV systolic function with normal wall motion.
    • LV posterior wall thickening, dilated LA; LV diastolic dysfunction Gr 2
    • Normal RV systolic function.
    • Mild to moderate MR; mild TR; aortic valve sclerosis with no AS and AR.
  • 2022-12-05 24Hr Holter ECG
    • Baseline was sinus rhythm
    • Rare isolated VPCs
    • Rare isolated APCs
    • 1 episode of short-run AT, 4 beats
    • No long pause
  • 2022-11-14 Patho - gallbladder (benign lesion)
    • Gallbladder,laparoscopic cholecystectomy — acute cholecystitis
    • The specimen submitted is a gallbladder, in fixed state. The gallbladder measures 6x 3.4x 1.1 cm in size. The serosa is congested and smooth. On opening, the mucosa is eroded. No ulceration is seen. The wall is elastic measuring up to 0.4 cm in thickness. The cystic duct measures 0.3 cm in length and is not remarkable. No gallstone is submitted. Representative sections are taken.
    • Microscopically, it shows chronic cholecystitis with congestion, submucosal fibrosis,and mixed inflammatory infiltrate with Rokitansky-Aschoff sinus formation.
  • 2022-10-28 Patho - stomach biopsy
    • Stomach, PW site of antrum, biopsy — erosion with Helicobacter infection
    • The specimen submitted consists of 3 tissue fragments measuring up to 0.1x 0.1x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic. All for section.
    • Microscopically, it shows erosion with loss of superficial mucosal epithelium. Mild Helicobacter-like bacilli are seen.
  • 2022-10-27 Panendoscopy
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p CLO test
      • Gastric shallow ulcers and erosions, antrum
      • Gastric ulcer scar, PW site of antrum, s/p biopsy
    • Suggestion
      • Pursue CLO test and biopsy result; EGD F/U if clinincally needed
      • oral PPI use
  • 2022-10-24 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      
  • 2022-10-21 CT - abdomen
    • History: Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2 (-), stage IIA s/p MRM on 2022/05/13 s/p chemotherapy with AC by-T (Adriamycin 60mg/m2, Cyclophosphamide 600mg/m2) on 2022/06/16~2022/08/17 for 4 cycles
      • MD CT (Revolution) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P Mastectomy, left.
        • There is a cystic-like lesion in the subcutaneous fat layer of left lower chest wall. please correlate with clinical condition.
      • There is no focal lesion in both lung.
        • There are few enlarged nodes in paratracheal space.
        • Follow up is indicated.
      • Left lobe thyroid shows enlarged in size and a lobulated poor enhancing lesion that may be nodular goiter.
        • Please correlate with sonography.
      • The gallbladder shows mild wall thickening but no evidence of calcified stone or distension.
        • A renal cyst measuring 2.5 cm in right middle pole is noted.
      • There are several ovoid-shaped enlarged lymph nodes in the hepatoduodenal ligament that may be benign reactive nodes.
        • Follow up is indicated.
      • There is no focal abnormality in the liver, biliary system, pancreas, spleen & left kidney.
        
      • There is no ascites.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • S/P Mastectomy, left.
      • There is a cystic-like lesion in the subcutaneous fat layer of left lower chest wall. please correlate with clinical condition.
  • 2022-10-21 SONO - abdomen
    • Diagnosis
      • Fatty liver,mild
      • Suspected fatty infiltration of pancreas
      • Propable GB stone with cholecystopathy
    • Suggestion
      • OPD f/u
      • Please correlate with other image
      • Follow liver function test and AFP
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
  • 2022-08-15 Patho - soft tissue nontumor/mass/lipoma/debridement
    • Skin and soft tissue, left chest wall wound, debridement — acute inflammation.
  • 2022-07-28 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      
  • 2022-07-07 Foot Bilat
    • fracture at the base of the right 5th metatarsal bone
  • 2022-07-06 CXR
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • 2022-06-16 2D transthoracic echocardiography
    • 1. Adequate LV systolic function with normal resting wall motion
    • 2. Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
    • 3. Trivial MR and trivial TR
    • 4. Preserved RV systolic function
    • 5. Minimal pericardiac effusion
  • 2022-05-16 Patho - breast mastectomy with regional lymph nodes
    • Diagnosis
      • Breast, left, modified radical mastectomy (S2022-8352A) —- Invasive carcinoma. Micro-papillary type.
      • Resection margin: free
      • Lymph node, left, sentinel lymph node biopsy with frozen section (F2022-228FS) — metastatic carcinoma (2/2)
      • Lymph node, left, axilla lymph node dissection (S2022-8352B) — Free (0/22)
      • pT2 pN1a (if cM0); anatomic stage: IIB, at least; pathology prognostic stage: IIA, at least.
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive carcinoma, micropapillary type
        • Size of invasive carcinoma (mm): 31 x 26 x 25 mm
        • Histologic grade (Nottingham histologic score): grade III (score 8,9)
        • Extent of tumor (required only if the structures are present and involved)
          • Skin involvement: Absent
          • Chest wall invasion deeper than pectoralis muscle: no tissue submitted
      • For Ductal Carcinoma In Situ: not present
      • Margins:
        • Negative, Closest margin (26 mm from deep margin)
      • Nodal status: Positive = 2/2 SLN and 0/22 left axilary LN
        • No. examined: 24
        • No. macrometastases (>2 mm): 2
        • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
        • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
      • Treatment Effect: Response to presurgical (neoadjuvant) therapy - no neoadjuvant therapy
      • Immunohistochemical Study: result of biopsy specimen: S2022-07648
        • ER(+, strong intensity, >95%), PR(+, strong intensity, 70%), Her2/Neu: (-, score= 0/1+), Ki-67 index: 5%.
  • 2022-05-13 Frozen resection
    • Preliminary diagnosis: SLN left - metstatic carcinoma (2/2)
  • 2022-05-13 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the left axilla.
    • Impression: Probably a sentinel lymph node at the left axillary region.
  • 2022-05-12 Tc-99m MDP whole body bone scan
    • Increased activity in the lower C-spine and lower L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
    • Increased activity in the mandible. Dental problem may show this picture.
    • A hot spot in the left parietal area of the skull and some faint hot spots in the anterior aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and knees, compatible with benign joint lesions.
  • 2022-05-11 2D transthoracic echocardiography
    • Dilated LA
  • 2022-05-11 Lung Flow-Volume Curve
    • mild restrictive impairment
  • 2022-05-11 SONO - abdomen
    • renal cyst, left
  • 2022-05-02 Patho - breast biopsy
    • Diagnosis
      • Breast, left, sono-guide biopsy — invasive carcinoma
    • Microscopically, the breast shows invasive carcinoma characterized by proliferation of tumor cells arranged in single-file or cord-like architecture and infiltrative growth pattern, and stromal fibrosis. The tumor cell shows round to oval nuclei, nuclear hyperchromasia, plemorphism,and dot-like nucleoli.
    • IHC stain — ER(+, strong intensity, >95%), PR(+, strong intensity, 70%), Her2/Neu: (-, 0/1+), Ki-67 index: 5%, E-cadherin(+).
  • 2022-05-02 SONO - breast
    • core needle biopsy
    • Left breast tumors, 2’ region and subareolar region, suspected malignancy, suggest biopsy.
      
    • BI-RADS: Category 4c: highly suspicious abnormality-biopsy should be considered.
  • 2022-03-21 Nerve Conduction Electromyography
    • Findings
      • normal motor DLs, CMAP amplitudes and NCVs of bil. median and ulnar n. Conduction slowing of bil. ulnar n. at elbow.
      • normal sensory DLs, lower SNAP amplitudes and normal NCVs of bil. ulnar n.
      • the F-wave latencies of bil. median and ulnar n. were normal.
    • Conclusion: bil. ulnar n. lesion at elbow
  • 2021-12-06 Neurosonology
    • 1. Minimal atherosclerosis in right CCA bifurcation.
    • 2. Adequate total VA flow volume (88 ml/min).
    • 3. Increased RI in right CCA, bilateral ICA and bilateral VA, indicating distal stenosis.
  • 2021-02-14 CXR
    • Normal heart size.
    • Tortous aorta with calcification is noted.
    • There is no evidence of destructive bone lesion.
    • Scoliotic alignment of the thoracolumbar spine is noted.
    • The lung fields are clear.
    • Clear bilateral costophrenic angle is noticed.
    • Patent airway is found.
    • Suggest clinical correlation
  • 2021-02-14 ECG
    • Normal sinus rhythm
    • Nonspecific ST abnormality
  • 2018-12-10 Flow-volume curve
    • FVC 78%, VC redueced.
  • 2017-09-28 Neck soft tissue
    • mild anterior and posterior spur formation in the lower C-spine
    • moderate decreased disc spaces in the C5/6 and C6/7 discs
  • 2017-01-25 CT - abdomen
    • Findings
      • Diverticulosis of cecum and ascending colon. Perifocal fat stranding of proximal A-colon
      • Bilateral renal cysts.
    • Impression:
      • Acute diverticulitis of A-colon
• consultation
  • 2022-10-28 General and Gastrointestinal Surgery
    • Q
      • This 76-year-old woman patient is a case of Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2 (-), stage IIA s/p MRM on 2022/05/13 s/p chemotherapy with AC by-T(Adriamycin 60mg/m2, Cyclophosphamide 600mg/m2) on 2022/06/16~2022/08/17 for 4 cycles. This time, for right chest pain radiation back pain developed. Abdominal echo on 2022/10/21 showed fatty liver, mild, suspected fatty infiltration of pancreas and propable GB stone with cholecystopathy. Lab deta with TBI showed increased (6.61–>2.71–>1.28–>1.27mg/dL). Now, for evaluate OP of GB stone. Thank you.
    • A
      • S: Due to suspected GB stones with acute cholecystitis, surgical evaluation is consulted.
      • O:
        • vital signs: stable, no fever
        • abdomen: soft, ovoid, decrease bowel sound, mild RUQ & R’t back tenderness, no Murphy’s sign
          
        • lab data: see chart
          
        • CT: GB wall thickness
      • A: Acute acalculous cholecystitis
      • P: NPO, adequate hydration, antibiotics treatment, and closely observation is suggested.
  • 2022-05-11 Rehabilitation
    • This 76 year-old women, she has left breast cancer withleft simple mastectomy + SLNB on 2022/05/13. We were consulted for rehabilitation for preventing complications and post-operation lymphedema.
    • Premorbid functional status
      • Walk ID, ADLs ID.
    • Physical examination
      • Consciousness: clear
      • Cognition: intact
      • MP: RUE/RLE: 5/5, LUE/LLE: 5/5
      • Functional status: ID
      • ADLs: ID
      • Bilateral shoulders PROM:
        • right shoulder pain . Right forward flexion PROM 0-160 with pain. ER 0-60 pain+
        • left shoulder no limitation.
      • Hand and arm circumference (R/L,cm):
        • Elbow joint above 5cm 35/34
        • Elbow joint below 5cm 27/27 rt handed
    • Imp
      • left breast cancer
      • partial mastectomy + SLNB 5/13
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation and home program education
      • Goal: Functional ability ID, maintain ROM, prevent post-OP complications
• surgical operation
  • 2022-08-12 Excision of skin or subcutaneous tumor within 2cm
  • 2022-05-13 Simple mastectomy sentinel lymph node biopsy
    • Surgery
      • Left breast MRM (Modified Radical Mastectomy)
    • Finding
      • left breast tumors x2
      • size: 1cm
      • location: retroalreolar
      • size: 2cm
      • location: 2’/2.5cm
• radiotherapy
  • 2022-05-19 OPD
    • Plan:
      • Adjuvant chemotherapy followed by radiotherapy is indicated for this patient with the following indicators: stage pT2N1a (cM0)
      • Goal: curative
      • Treatment target and volume: left chest wall to SCF
      • Technique: IMRT
      • Preliminary planning dose: 5000cGy/25 fractions of the left chest wall to SCF
• chemoimmunotherapy
  • 2022-12-13 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
    • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-21 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
    • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-09-26 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
    • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-09-06 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
    • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-08-17 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
    • premed - dexamethasone 4mg + aprepitant 125mg D1-D3
  • 2022-07-28 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
    • premed - dexamethasone 4mg + aprepitant 125mg D1-D3
  • 2022-07-06 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
    • premed - dexamethasone 4mg + aprepitant 125mg D1-D3
  • 2022-06-16 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
    • premed - dexamethasone 4mg + aprepitant 125mg D1-D3

[note]

• Breast Cancer NCCN Evidence Blocks, version 2.2022, 2021-12-20
  • BCS (breast-conserving surgery) not possible (p20)
    • Mastectomy and surgical axillary staging + reconstruction (optional)
      • Adjuvant systemic therapy + post-mastectomy adjuvant RT
        • cN+ and ypN0: Strongly consider RT to the chest wall and comprehensive RNI (regional nodal irradiation) with inclusion of any portion of the undissected axilla at risk.
        • Any ypN+: RT is indicated to the chest wall + comprehensive RNI with inclusion of any portion of the undissected axilla at risk.
      • Adjuvant systemic therapy without adjuvant RT for any cN0,ypN0 if axilla was assessed by SLNB or axillary node dissection
  • Preoperative/Adjuvant therapy regimens (p55)
    • HER2-Negative
      • Preferred Regimens:
        • Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks
        • Dose-dense AC (doxorubicin/cyclophosphamide) followed by weekly paclitaxel
        • TC (docetaxel and cyclophosphamide)
        • Olaparib, if germline BRCA1/2 mutations
        • High-risk triple-negative breast cancer (TNBC): Preoperative pembrolizumab + carboplatin + paclitaxel, followed by preoperative pembrolizumab + cyclophosphamide + doxorubicin or epirubicin, followed by adjuvant pembrolizumab
        • TNBC and residual disease after preoperative therapy with taxane-, alkylator-, and anthracycline-based chemotherapy: Capecitabine
      • Useful in Certain Circumstances:
        • Dose-dense AC (doxorubicin/cyclophosphamide)
        • AC (doxorubicin/cyclophosphamide) every 3 weeks (category 2B)
        • CMF (cyclophosphamide/methotrexate/fluorouracil)
        • AC followed by weekly paclitaxel
        • Capecitabine (maintenance therapy for TNBC after adjuvant chemotherapy)
      • Other Recommended Regimens:
        • AC followed by docetaxel every 3 weeks
        • EC (epirubicin/cyclophosphamide)
        • TAC (docetaxel/doxorubicin/cyclophosphamide)
        • Select patients with TNBC: -Paclitaxel + carboplatin (various schedules) -Docetaxel + carboplatin (preoperative setting only)

[assessment]

• The underlying conditions in this patient include: essential (primary) hypertension, hyperlipidemia, gout.
• 2D transthoracic echocardiography (2022-12-06) revealed: LV posterior wall thickening, dilated LA; LV diastolic dysfunction Gr 2; Mild to moderate MR; mild TR; aortic valve sclerosis.
• Available records of blood uric acid levels showed no exceeding the upper limit of normal.
  • 2022-10-22 Uric Acid 3.9 mg/dL
    
  • 2022-07-19 Uric Acid 5.1 mg/dL
    
• Gout patients with established cardiovascular (CV) disease treated with febuxostat had a higher rate of CV death compared to those treated with allopurinol in a CV outcomes study. Consider the risks and benefits of febuxostat when deciding to prescribe or continue patients on febuxostat. Febuxostat is recommended only used in patients who have an inadequate response to a maximally titrated dose of allopurinol, who are intolerant to allopurinol, or for whom treatment with allopurinol is not advisable.
• As an alternative to xanthine oxidase inhibitors, the uric aicd resorption suppressor benzbromarone might be another candidate for treating gout.

220907

[assessment]

• A decline in renal function has been observed. Time series lab log:
  • Date // Creatinine // eGFR
  • 2022-09-06 1.22 45.55 (CrCl ~ 40 mL/min)
  • 2022-08-30 1.19 46.87
  • 2022-08-17 0.91 63.88
  • 2022-08-09 0.77 77.46
• The kidneys excrete little docetaxel (~6%), therefore, the need for docetaxel dosage adjustments for renal dysfunction is unlikely.
• Allegra (fexofenadine 60mg/tab) for GFR 10 to 50 mL/min: Recommended dose every 12 to 24 hours. A possible change is from BID to QD.
• Promeran (metoclopramide 3.84mg/tab) for CrCl >10 to 60 mL/min: Administer ~50% of usual total daily dose. A change from TIDAC to BIDAC might be considered.
• During this hospitalization, the blood pressure was well controlled. The laboratory data related to hyperlipidemia have not been updated since October 2021. A number of tests might be ordered, e.g., TC, LDL-C, Non-HDL-C, ApoB, TG, HDL-C, and ApoA-1.

220818

[assessment]

• There was no evidence of intolerance.
• The TPR and blood pressure were stable during this hospitalization and the lab results for 2022-08-17 were generally normal.
• Underlying cardiovascular conditions are managed with Sevikar (amlodipine + olmesartan), Concor (bisoprolol) and Crestor (rosuvastatin) without issues.

220707

[assessment]

• Since mid-June 2022, the patient has been receiving doxorubicin and cyclophosphamide.
• An optional addition might be tamoxifen or an aromatase inhibitor. (A Comparison of Letrozole and Tamoxifen in Postmenopausal Women with Early Breast Cancer. https://www.nejm.org/doi/pdf/10.1056/NEJMoa052258 )

701362191

221214

• diagnosis
  • 2022-07-18 discharge note
    • Malignant neoplasm of pyloric antrum
    • Gastric cancer s/p lap radical Subtotal gastrectomy with D2 dissection on 2022/03/07, pT4aN1M0, stage IIIA s/p chemotherapy with FOLFOX (from 2022/04/12~2022/06/21 for 6 cycles)
    • Type 2 diabetes mellitus without complications
• exam findings
  • 2022-10-09 Wrist RT
    • Normal bone alignment
    • mild decreased right wrist joint space
  • 2022-08-10 SONO - abdomen
    • Normal sonographic study of the hepatobiliary system.
  • 2022-07-01 CT - abdomen
    • History: epigastric pain
      • UGI scope revealed gastric ca at lower body.
      • 20220223 CT:gastric cancer, cT3N0M0, cSTAGE:IIB
      • 20220308 subtotal gastrectomy PATHO: pT4aN1(if cM0); pstage IIIA
    • Findings:
      • S/P subtotal gastrectomy
      • S/P IUD retention within the endometrial cavity.
    • Impression:
      • S/P subtotal gastrectomy.
      • There is no evidence of tumor recurrence.
        
  • 2022-03-08 Patho - stomach subtotal/total (tumor)
    • Diagnosis:
      • Stomach, middle body, lesser curvature, laparoscpic subtotal gastrectomy — Poorly cohesive carcinoma with signet-ring cell differentiation
      • Cut-ends, proximal and distal, laparoscpic subtotal gastrectomy — Free
      • Lymph node, LN 1, dissection — Negative for malignancy (0/1)
      • Lymph node, LN 3, dissection — Metastatic carcinoma (2/8)
      • Lymph node, LN 4, dissection — Negative for malignancy (0/9)
      • Lymph node, LN 5, dissection — Negative for malignancy (0/3)
      • Lymph node, LN 6, dissection — Negative for malignancy (0/4)
      • Lymph node, LN 7,8,9,11p, 12a, dissection — Negative for malignancy (0/18)
      • Lymph node, LN14V, dissection — Negative for malignancy (0/1)
      • AJCC 8th edition Pathology stage: pT4aN1(if cM0); AJCC stage IIIA
    • Microscopic Description:
      • Histologic Type — Poorly cohesive carcinoma with signet-ring cell differentiation
      • Histologic Grade — Poorly differentiated
      • Tumor Extension — Tumor invades the serosa (visceral peritoneum)
      • Margins
        • Proximal margin: uninvolved by invasive carcinoma
        • Distal margin: uninvolved by invasive carcinoma
        • Radial margin: uninvolved by invasive carcinoma
      • Lymphovascular Invasion: present
        
      • Perineural Invasion: present
        
      • Regional Lymph Nodes — Number of lymph nodes examined: positive (2/44)
        
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply)
          • m (multiple primary tumors) r (recurrent) y (posttreatment)
          • Primary Tumor (pT) — pT4a: Tumor invades the serosa (visceral peritoneum)
          • Regional Lymph Nodes (pN) — pN1: Metastasis in one or two regional lymph nodes
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case) — N/A
        • IHC stain— CK(+), CK20(focal+), CK7(+), CDX-2(+)
  • 2022-03-04 Patho - stomach biopsy
    • Tumor, gastric angle, biopsy — Poorly cohesive carcinoma with signet-ring cell differentiation
    • Microscopically, the sections show a picture of poorly cohesive carcinoma with signet-ring cell differentiation characterized by linear or individual tumor cells infiltrating in stroma.
    • Immunohistochemistry of CK(+) and Her2 (-, Dako score 0) for tumor cell.
    • Besides, colony of Helicobacter Pylori is not present in the submitted specimen.
  • 2022-02-23 CT - abdomen, gastric filling with water
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:IIB(Stage_value)
• surgical operation
  • 2022-03-07 laparoscpe subtotal gastrectomy with LN D2 dissection
    • Finding
      • 3cm ulcerative mass at middle body lesser curvature with serosa involve
      • regional LN enlarge at station 3
      • peritoneal seeding (-)
      • ascite (-)
      • cT4aN1M0
• chemoimmunotherapy
  • 2022-12-13 - oxaliplatin 85mg/m2 165mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
  • 2022-11-24 - oxaliplatin 85mg/m2 165mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
  • 2022-11-09 - oxaliplatin 75mg/m2 145mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
  • 2022-10-17 - oxaliplatin 65mg/m2 120mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr # Allergy with whole body skin redness rash with itch after chemotherapy with Oxalip
    • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
  • 2022-09-13 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
    • premed - dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-D3
  • 2022-08-24 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
    • premed - dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-D3
  • 2022-07-18 - leucovorin 20mg/m2 40mg 10min D1 + fluorouracil 400mg/m2 600mg 10min D1 (CCRT)
    • premed - dexamethasone 4mg + metoclopramide 10mg D1
  • 2022-07-12 - leucovorin 20mg/m2 40mg 10min D1-4 + fluorouracil 400mg/m2 600mg 10min D1-D4 (CCRT)
    • premed - dexamethasone 4mg + metoclopramide 10mg D1-D4
  • 2022-06-21 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
    • premed - dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-D3
  • 2022-06-07 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
  • 2022-05-24 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
  • 2022-05-10 - oxaliplatin 85mg/m2 170mg 24hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
  • 2022-04-26 - oxaliplatin 85mg/m2 170mg 24hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
  • 2022-04-12 - oxaliplatin 85mg/m2 170mg 24hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 5000mg 46hr

[assessment]

• It has not been observed that there is an allergy resulting in a skin rash or itching after the addition of diphenhydramine and famodidine as the premedication since Oct 2022.
• During this hospital stay, the FS blood sugar levels were around 200 mg/dL. The available blood sugar records indicate that the patient’s blood sugar levels almost always exceed the upper limit of normal for the past months. If no imaging is scheduled that requires iodinated contrast, metformin 500mg BID is recommended since her kidneys do not exhibit any insufficiency.

221125

[assessment]

• Perhaps due to a lack of authorization from the patient, the recent 3-month prescription list is not available from PharmaCloud at present.
• According to the admission note, the patient regularly takes both Amepiride (glimepiride) and meformin to control her type 2 DM.
• For the renal hyperfiltration (2022-11-23 eGFR 133) was still noted and her preprandial blood sugar level is still high (173mg/dL 2022-11-25 07:02) under current single antidiabetic agent Amepiride (glimepiride), it is recommended that metformin be added to her active prescription as a patient-carried item if no imaging scheduled.

221110

[assessment]

• A preprandial blood sugar level of 198mg/dL was recorded on 2022-11-10 morning.
• The renal hyperfiltration (2022-11-03 eGFR 125) driven by increased glomerular filtration pressure and by glucose diuresis can affect renal O2 consumption that unleashes detrimental sympathetic activation. The sodium-glucose co-transporters inhibitors (SGLTi) can rebalance the reabsorption of Na+ coupled with glucose and can restore renal O2 demand, diminishing neuroendocrine activation. (ref: The Benefit of Sodium-Glucose Co-Transporter Inhibition in Heart Failure: The Role of the Kidney. Int J Mol Sci. 2022;23(19):11987. Published 2022 Oct 9. doi:10.3390/ijms231911987)
• There is only one antidiabetic agent Amepiride (glimepiride) in the active prescription. The SGLT2i drugs empagliflozin, dapagliflozin, and canagliflozin are available in stock and could be considered if UTI is unlikely.

221018

[assessment]

• This patient has been prescribed Amepiride (glimepiride) for months, which may cause body weight gain, however, her body weight has decreased by more than 15kg during the past seven months (85kg 2022-10-17 <- 101kg 2022-03-06). Is it an intentional diet cuased weight loss or an unintentional weight loss? Did insulin resistance result in body breakdown or poor dietary intake?
• Pre-breakfast blood sugar level reached 215 mg/dL on 2022-10-18 under metformin and glimepiride. If fasting levels persist over 200 mg/dL for two consecutive days, acarbose, vidagliptin, or dapagliflozin might be added to the current medication list.

700105612

221212

• exam findings
  • 2022-12-09 CT - brain
    • Indication: confusion
    • Findings
      • brain atrophy with prominent sulci, fissures and dilated ventricles.
      • confluent hypodensity at bilateral periventricular white matter, indicating leukoaraiosis.
      • no acute intracranial hemorrhage.
      • no definite skull lesion.
      • chronic left maxillary sinusitis.
    • Impression:
      • Brain atrophy and leukoaraiosis.
      • Chronic left maxillary sinusitis.
  • 2022-12-09 CXR
    • Cardiomegaly is noted.
    • Osteopenia of the bony structure is noted.
    • Senile fibrotic change is noted at lung fields.
  • 2022-11-04 Water’s view
    • Opacification of left maxillary sinus.
  • 2022-11-04 Nasopharyngoscopy
    • sticky post nasal drip
  • 2022-10-26 CXR
    • S/P coronary artery stent implantation.
    • Enlargement of cardiac silhouette.
  • 2022-02-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (82.2 - 29.0) / 82.2 = 64.72%
      • M-mode (Teichholz) = 64.7
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Trivial mitral and tricuspid regurgitation
    • Impaired LV relaxation
    • Mildly thick IVS and LVPW
  • 2022-02-09 CXR
    • Patchy opacity projecting in the right lower mediastinum shows stationary.
    • S/P coronary artery stent implantation.
  • 2022-02-09 ECG
    • Sinus rhythm with Premature supraventricular complexes and with occasional Premature ventricular complexes
  • 2022-09-23 CXR
    • Patchy opacity projecting in the right lower mediastinum is suspected. Follow up is indicated.
    • S/P coronary artery stent implantation.
  • 2021-09-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (87.7 - 36.2) / 87.7 = 58.72%
      • M-mode (Teichholz) = 58.7
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with trivial AR, mild MR, TR and PR
    • No regional wall motion abnormalities
  • 2021-08-26 Patho - gingival/oral mucosa biopsy
    • Bone, left maxilla, excisional biopsy — Dead bone with acute and chronic inflammation
      
    • Section shows squamous mucosa and dead bone with granulation tissue, fibrosis, and acute and chronic inflammation.
    • The immunohistochemical stain of CD138 shows no aggregation of plasma cells in bone.
      
  • 2020-12-07 CXR
    • Patchy opacity projecting in the right lower mediastinum is suspected. Follow up is indicated. Otherwise, Please correlate with CT.
    • S/P coronary artery stent implantation.
  • 2020-12-07 ECG
    • Sinus rhythm with Premature atrial complexes
    • Increased R/S ratio in V1, consider early transition or posterior infarct
  • 2020-11-03 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Myeloma.
    • IHC stains: CD138 : 10-15%, lambda light chain > kappa light chain. IgA: 10-15%, IgG: <5%.
    • Section shows piece(s) of bone marrow with 40-50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There are a few plasmacytoid cells present.
  • 2020-08-14 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Negative for malignacy (CD138+ plasma cell: < 5%)
      
    • Microscopically, it shows 3 % of cellularity, 1:1 of M:E ratio, presece of trilinegae cellular component and ocassional megakaryocytes.
      
    • Immunohistochemical stain reveals CD138(< 5%), CD71(+), CD20(-), CD117(-), Kappa(-), MPO(focal+), CD117(-).
      
    • NOTE: Clincal correlation is essential.
      
  • 2020-06-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 30) / 116 = 74.14%
      • M-mode (Teichholz) = 74
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis; degenerative changes of mitral valve with trivial MR.
    • Dilated proximal ascending aorta (35mm); mild aortic root calcification.
  • 2020-04-10 Patho - bone marrow biopsy
    • Bone marrow, iliac, history of myeloma (S2018-2795), biopsy — Compaible with replased of myeloma.
    • IHC stains: CD138: 10-15% of the nucleated cells, lambda > kappa, approximately 3:1.
      
    • Section shows one piece of bone marrow with 30 % cellularity and M:E ratio of approximately 3:1. There is aprroxomately 10-15% of the plasmcytoid cells demonstrated by IHC stain of CD138. lambda > kappa, approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number.
  • 2020-03-20 Patho - breast biopsy
    • Breast, right, sono-guided biopsy — Gynecomastia
      
  • 2020-03-20 SONO - breast
    • Subareolar duct development, both side, gynecomastia should be considered. Suggest clinical correlation.
  • 2019-03-01 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 36) / 105 = 65.71%
      • M-mode (Teichholz) = 65
    • Septal and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild AV sclerosis; mild MR; mild PR.
  • 2018-10-25 transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (102 - 30.3) / 102 = 70.29%
      • M-mode (Teichholz) = 70.3
    • Normal chamber size
    • Adequate LV and RV performance
    • Possibly impaired LV relaxation
    • AV sclerosis with trivial AR ; mild MR, TR and PR
    • No regional wall motion abnormalities
  • 2018-09-07 Surgical pathology Level IV
    • Bone marrow, iliac, biopsy — see description.
    • Section shows one piece of bone marrow with 50 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number.
    • IHC stain shows approximately 10 % of CD138 (+) plasmacytoid cells with slightly more kappa than lambda light chain stain, suggestive of few residual neoplastic cells. Additional CD34 (+) <1%, CK (-).
  • 2018-04-03 MRI - T-spine
    • Indication: A case of myeloma, T, L spine survey, for chest pain
    • Findings:
      • Moderate degree of old compression fracture of T3 vertebral body.
      • Abnormal enhanced lesions in T3, T4, T5, T7, T8 T12, and L1 vertebrae (as hypointense on T1WI).
      • Mild degree of compression fracture of T9 vertebral body (hypointense on T1WI, hyperintense on STIR images), with abnormal enhancement.
      • Marginal spurs of multiple vertebral bodies.
      • Mild thickening of ligamentum flavum at T10-T11 level..
      • The visualizedl spinal cord shows normal size and signal intensity. There is no extrinsic compression of the cord.
    • Impression:
      • multiple myeloma with T4 and T9 compression fracture and small enhancing
      • lesions in multiple vertebrae.
  • 2018-03-19 transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 28) / 111 = 74.77%
      • M-mode (Teichholz) = 74
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, LV diastolic dysfunction, Gr 1
    • Mild MR, mild TR
    • Preserved RV systolic function
  • 2018-03-19 ECG
    • Sinus rhythm with Premature atrial complexes
  • 2018-02-20 Surgical pathology Level IV
    • Bone marrow, biopsy — Plasma cell myeloma
    • The sections show slightly hypercellular marrow (50%). Sheets of mature plasma cells with numerous Russell bodies in interstitium, account for 50% nucleated cells in CD138 immunostain. These plasma cells also reveal kappa light chain restriction and negative for lambda light chain.
  • 2017-04-17 CT - heart CTA
    • History:
      • 20110128
        • Admitted due to exertional dyspnea and palpitation, cardiac catheterlization was perforemd smoothly and reveaeld CAD, LAD. middle, right hand cath wound clear, still irregular heart rate and DOE, keep medication therapy.
          
        • History of abnormal LFT told in Cathay General Hospital even with lipitor for 10 mg ∕QD
      • 200812
        • Referred from chief Lin, hx of Palpitation, and short run of Af; palpitation when emotional upset. Palpitation and chest pain for 17 years.
        • Holter ECG in Cathay General Hospital showed occasional APC and VPCs with 4minutes of short run Af with no symptoms even with lipitor for 10 mg ∕QD
    • Nonenhanced ECG-gated CT for calcium scoring and enhanced spiral CT of heart and coronary arteries were obtained using 256-slice multidetector row CT scanner (iCT philips) showed:
      • Calcification of the coronary arteries (total calcium score=643, LMA=7.33, LAD=514.48, LCX=77.31, RCA=43.87)
      • Left main coronary artery: Patent
      • Left anterior descending coronary artery: calcified plaques in S6, S7, and S8, with severe stenosis in S7 and S8.
      • Visible diagonal branches: Patent
      • Left circumflex coronary artery: Patent
      • Visible obtuse marginal branches: Patent
      • Right coronary artery: Patent
      • Posterolateral and posterior descending branches: Patent
      • Pericardium : Unremarkable
      • Cardiac structure and morphology: Normal cardiac chamber size
      • Lungs: Unremarkable
      • Mediastinum and hilars: No mass lesion
      • Visible abdominal contents: Unremarkable
    • Impression
      • Total calcium score = 643, indicating extensive atherosclerotic plaque burden.
      • Atherosclerosis major coronary arteries with significant stenosis in LAD, S7 and S8.
      • No lung nodule.
  • 2017-04-12 24hrs Holtor’s scan
    • Sinus rhythm
    • Occasional isolated apcs
    • Rare apc couplets
    • A few isolated vpcs
    • No long pause
    • No significant tachyarrhythmia
  • 2017-03-06 MRI - L-spine
    • Mild cervical spondylosis.
    • Disc bulge with mild stenotic lateral recesses, L3-L4,L4-L5.
    • Multilevel degenerative disc disease.
• consultation
  • 2022-12-12 Family Medicine
    • Q
      • The 76 y/o man has IgA Multiple myeloma, 20180223 proved with bone marrow study. VTD from 20180301, S/P autoPBSCT on 20190306, complicated with HSV-1 genital ulcer infection (20190401). S/P Lenalidomide + dexa. Daraturumab + Velcade + dexa. Kyrolip + dexa. IgA level in progress. Last time, he received chemotherapy as Kyrolip on 2022/11/11. He has poor intake for 3 weeks, just 1 meal a day and lay down all day. He denied take medicine as oral steroid and oral chemotherapy. This time, he has multiple bone pain for 2 weeks and in progress, and yellow snivel around 1 month (his wife not sure), so he was brought to our ED for help. At ED, the lab data showed anemia, mild elevated CRP level and hypokalemia. Due to confusion consciousness, brain CT was arranged at ER and showed 1. Brain atrophy and leukoaraiosis, 2. Chronic left maxillary sinusitis. Under the impression of IgA MM without control and severe bone pain, and malnutrition, so he was admitted on 2022/12/09.
      • Due to disease progression, the patient’s family ask for palliative care. We need your help for further evaluation. Thank you very much.
  • 2022-12-12 Neurology
    • Q
      • Due to confusion consciousness, brain CT was arranged at ER and showed: 1. Brain atrophy and leukoaraiosis, 2. Chronic left maxillary sinusitis. We need your help for further evaluation and treatment suggestion. Thank you very much.
• surgical operation
  • 20190306 autoPBSCT
• chemoimmunotherapy
  • 2022-11-11 - Kyprolis (carfilzomib) 70mg/m2 100mg 1hr
    • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
  • 2022-09-21 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
    • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
  • 2022-09-07 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
    • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
  • 2022-08-17 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
    • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
  • 2022-08-03 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
    • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
  • 2022-07-20 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
    • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
  • 2022-07-06 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
    • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
  • 2022-06-15 - Kyprolis (carfilzomib) 70mg/m2 115mg 1hr
  • 2022-05-25 - Kyprolis (carfilzomib) 70mg/m2 115mg 1hr
  • 2022-05-04 - Kyprolis (carfilzomib) 70mg/m2 116mg 1hr
  • 2022-04-20 - Kyprolis (carfilzomib) 70mg/m2 116mg 1hr
  • 2022-04-06 - Kyprolis (carfilzomib) 70mg/m2 116mg 1hr
  • 2022-03-23 - Kyprolis (carfilzomib) 70mg/m2 118mg 1hr
  • 2022-03-09 - Kyprolis (carfilzomib) 70mg/m2 118mg 1hr
  • 2022-03-02 - Kyprolis (carfilzomib) 50mg/m2 85mg 1hr
    • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
  • 2022-03-02 - Kyprolis (carfilzomib) 20mg/m2 34mg 1hr
    • premed - diphenhydramine 50mg + dexamethasone 20mg + acetaminophen 1000mg
  • 2021-12-29 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • premed - diphenhydramine 50mg + dexamethasone 20mg + acetaminophen 1000mg
  • 2021-12-01 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-11-03 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-10-06 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-09-01 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-08-04 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-07-07 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-06-15 - Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-05-18 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-04-27 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-04-06 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-03-16 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-02-23 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
  • 2021-02-02 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
  • 2021-01-29 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
  • 2021-01-26 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
  • 2021-01-22 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
  • 2021-01-19 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
  • 2021-01-11 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
  • 2021-01-04 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
  • 2020-12-31 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
  • 2020-12-28 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
  • 2020-12-21 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
  • 2020-12-14 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 7hr
  • 2020-12-11 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
  • 2020-12-07 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 7hr
  • 2018-03-19 ~ 2018-11-28 - Velcade (bortezomib) 2.25mg SC (weekly, biweekly, triweekly)
  • 2020-11-13 ~ 2021-07-21 - Xgeva (denosumab) 120mg Q1M SC
  • 2018-04-06 ~ 2019-01-03 - Zobonic (zoledronic acid) 4mg IV (roughly monthly)
  • 2021-08-04 ~ 2022-11-25 - Endoxan (cyclophosphamide) 50mg BID PO
  • 2020-05-15 ~ 2020-10-29 - Revlimid (lenalidomide) 25mg QD PO
  • 2018-03-19 ~ 2020-01-31 - Thado (thalidomide) 50mg HS PO

[assessment]

• FS blood sugar levels from 2022-12-10 to 2022-12-11 were approximately 300 to 400 mg/dL. If the reading on 2022-12-12 still exceeds 200 mg/dL (regular insulin 8 unit has been prescribed since 2022-12-11), then addition of basal insulin might be considered.

700071716

221209

{NSCLC, not completed}

• diagnosis - 2022-12-09 discharge note
  • Right upper lobe lung cancer, adenocarcinoma, T2bN1M1b with bone metastasis, ECOG 1
  • Encounter for antineoplastic chemotherapy
  • Encounter for antineoplastic immunotherapy
  • Chronic viral hepatitis B without delta-agent
  • Hypertension
  • paronychia with granulation over toenail
  • Suspect folliculitis with secondary irriation eczema
  • mebomian gland dyusfunction
  • Dry eye
  • Reflux esophagitis LA Classification grade A
• lab data
  • 2021-10-13 ROS1 FISH not detected
    
  • 2021-10-08 ROS1 IHC Negative
    
  • 2021-10-06 EGFR G719X not detected
    
  • 2021-10-06 EGFR Exon19 del not detected
    
  • 2021-10-06 EGFR S768I not detected
    
  • 2021-10-06 EGFR T790M not detected
    
  • 2021-10-06 EGFR Exon20 ins not detected
    
  • 2021-10-06 EGFR L858R detected
    
  • 2021-10-06 EGFR L861Q not detected
    
  • 2021-10-05 ALK IHC Negative
    
  • 2021-10-05 PD-L1 (22C3) TPS>=1% and <50%
    
  • 2021-09-22 Anti-HCV Nonreactive
    
  • 2021-09-22 Anti-HCV Value 0.05 S/CO
    
  • 2021-09-22 HBsAg Nonreactive
    
  • 2021-09-22 HBsAg (Value) 0.35 S/CO
    
  • 2021-09-22 Anti-HBs 7.64 mIU/mL
• exam findings
  • 2021-09-22 Patho - lung transbronchial biopsy
    • Lung, right, CT-guide biopsy—adenocarcinoma, moderately differentiated
      
    • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
• consultation
  • 2022-12-06 Dermatology
    • A
      • The patient had sufferred from pronychia with granulation formaiton. several itchy papules over expose area with mild vesicles was noted.
        
      • Under the impression of paronychia with granulation over toenail. suspected folliculitis with secondary irriation eczema.
        
      • The following sugeetion:
        • Do cryotherapy at Derma OPD and further wound care with tetracycline onit 1 tube topical bid use.
        • consider Doxycycline 1# bid and allgrea 1# bid po use for 7 days.
        • Ulex cream 1 tube topical bid over itchy papules of the trunk.
  • 2022-12-06 Ophthalmology
    • A
      • S: bilateral eye strain and pain for 2 days
      • O
        • bcva od 0.15(1.0/-2.5) os 0.1(1.0x-2.25)
        • pt 18/18 mmHg
        • pupil: 3mm+/+, 3mm+/+, no rapd
        • MGD
        • conj: np ou
        • K: cl ou
        • ac deep and clear ou
        • lens ns+
        • c/d: 0.5-6 neurorim ok
      • A
        • mebomian gland dyusfunction ou
        • dry eye ou
      • P
        • tear nature 1gtt qid ou
        • if s/s worsen, come back earlier
• chemoimmunotherapy
  • 2022-12-06 - Opdivo (nivolumab) 100mg 1hr
  • 2022-12-05 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-11-14 - Opdivo (nivolumab) 100mg 1hr
  • 2022-11-10 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-10-09 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-09-27 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-09-06 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-08-16 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-07-26 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-07-05 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-06-14 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-05-24 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-05-03 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-04-12 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-03-22 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-03-01 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-02-08 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-01-11 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-12-21 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2022-11-30 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2021-11-09 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2021-10-19 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
    • premed - diphenhydramine 30mg
  • 2021-10-07 ~ undergoing - Giotrif (afatinib 30mg) 1# QDAC
  • 2022-09-05 - Xgeva (denosumab) 120mg SC
  • 2022-08-13 - Xgeva (denosumab) 120mg SC
  • 2022-07-15 - Xgeva (denosumab) 120mg SC
  • 2022-06-13 - Xgeva (denosumab) 120mg SC
  • 2022-05-02 - Xgeva (denosumab) 120mg SC
  • 2022-04-08 - Xgeva (denosumab) 120mg SC
  • 2022-03-11 - Xgeva (denosumab) 120mg SC
  • 2022-02-07 - Xgeva (denosumab) 120mg SC
  • 2022-01-07 - Xgeva (denosumab) 120mg SC
  • 2021-12-10 - Xgeva (denosumab) 120mg SC

700191291

221209

• lab data
  • 2022-04-21 ROS1 IHC
    • The immunostaining of the section slide labeled S2022-03626, using ROS1(SP384) antibody along with a Ventana autostainer system, revealed 1+ cytoplasmic staining, in over 50%, of tumor cells.
  • 2022-03-28 PD-L1 (22C3)
    • Tumor Proportion Score (TPS) assessment: TPS >= 50%
    • Tumor Proportion Score (TPS): 50%
  • 2022-03-21 ROS1 FISH
    • Rearrangement of ROS1 gene is NOT detected.
    • Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
  • 2022-03-18 EGFR gene mutation
    • The EGFR mutation testing was for detection of exons 18 (G719X), 19 (Deletions), 20 (T790M, S7681, Insertions), 21 (L858R, L861Q) mutations of EGFR gene.
    • A point mutation was detected at exon 21 (L858R) of EGFR gene in this specimen.
  • 2022-03-17 ALK IHC
    • The immunostaining of the section slide labeled S2022-03626, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining of tumor cells.
  • 2022-03-03 Anti-HCV Nonreactive
    
  • 2022-03-03 Anti-HCV Value 0.04 S/CO
    
  • 2022-03-03 HBsAg Nonreactive
    
  • 2022-03-03 HBsAg (Value) 0.39 S/CO
    
  • 2022-03-02 Mycoplasma IgM Negative Index
    
  • 2022-03-02 Mycoplasma IgM Value 0.1 Index
• exam findings
  • 2022-12-07 Tc-99m MDP whole body bone scan
    • Findings:
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs in whole body bone survey.
    • Impression:
      • All of above-mentioned bone lesions are old and most of them show stationary or less evident compared with the previous study on 2022-07-13, indicating partial response to current therapy.
        
      • There is still lung cancer with multiple bone metastases in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs.
  • 2022-12-06 MRI - brain
    • As compared with prior MRI (2022/07/12), markedly regression of the multiple nodules over bil. cerebellar and cerebral, no obvious edema was found.
    • Mild periventricular small vessel disease. NO acute ischemic infarct.
    • Paranasal sinusitis.
  • 2022-12-06 CT - chest
    • Indication: lung cancer restaging
    • Findings: Comparison was made with previous CT dated on 2022/07/12
      • Lungs:
        • normal appearance of RML, RLL, and left lung.
        • residual spiculated RUL tumor with corona radiata (26mm in longest dimension), in comparison with the previous study, the lesion is slightly decreasing in size.
        • Mediastinum and hila: no enlarged LN.
      • Vessels:
        • Aorta: normal caliber of thoracic aorta.
        • Central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
      • Pleura: minimal residual bilateral effusions.
      • Visible abdominal contents:
        • no abnormal density and size of visible portion of the liver, spleen, both adrenal glands, and pancreas
        • no enlarged lymph node.
      • Visualized bones: destructive lytic or blastic change in visualized bones with pathological compression fracture of many vertebral bodies, stationary.
    • Impression:
      • RUL cancer with slightly decrease in size of primary tumor and stationary of bony metastasis as compared with CT on 2022/07/12
  • 2022-12-05, -09-04, -08-08 CXR
    • osteolytic/blastic metastases in multiple bones of thoracic cage
    • a nodular opacity (ill-defined) over RUL, consistent a primary lung cancer, stationary
    • marginal spurs of multiple vertebral bodies due to spondylosis
    • Lt subpulmonary effusion?
  • 2022-07-13 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs in whole body bone survey.
    • IMPRESSION:
      • Most of above-mentioned bone lesions are old and show stationary or less evident compared with the previous study on 2022-03-09, indicating partial response to current therapy.
        
      • Highly suspected cancer with multiple bone metastases in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs.
  • 2022-07-12 MRI - brain
    • Findings: comparison 2022/03/08 MRI
      • Markedly regression of the multiple bil. cerebellar and cerebral nodules, no obvious edema was found
        
      • After IV contrast administration shows no obvious focal nodule.
        
      • Normal cisterns and sulcal systems.
      • Normal bilateral ventricular size and shapes.
      • Normal appearance of bilateral cochlear and vestibular nerves complexes.
      • MRA shows patency of the major vessels of the Willis circle, bilateral ICAs and vertebrobasilar trunk.
    • Imp:
      • Markedly regression of the multiple bil. cerebellar and cerebral nodules
  • 2022-07-12 CT - chest
    • Findings: Comparison was made with previous CT dated on 20220303
      • Lungs:
        • normal appearance of RML, RLL, and left lung.
        • residual spiculated RUL tumor (26mm in longest dimension), in comparison with the previous study, the lesion is significantly dencreasing in size.
        • Mediastinum and hila: complete resolution of extensive lymphadenopathy in the visceral space and anterior prevascular space and Rtt hilum as compared with previous CT
      • Vessels:
        • Aorta: normal caliber of thoracic aorta.
        • Central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
      • Pleura: minimal residual bilateral effusions.
      • Visible abdominal contents:
        • Rt Lt bilateral renal cysts stone up to cm (longest axial diameter)
        • a hepatic cyst multiple hepatic cysts up to cm (longest axial diameter).
        • normal appearance of gallbladder. gall bladder stones up to cm.
        • no abnormal density and size of visible portion of the unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. bile ducts: No dilatation.
        • no enlarged lymph node.
      • Visualized bones: destructive lytic or blastic in visualized bones with pathological compression fracture of many vertebral bodies, in regression.
    • Impression:
      • RUL cancer with significant decreased size of primary tumor and resolution of mediastinal-hilar LAPs, and regression bony metastasis compared with CT on 20220303
  • 2022-07-11, -06-04, -04-07, -03-28 CXR
    • osteolytic/blastic metastases in multiple bones of thoracic cage
    • a mass opacity (ill-defined) over RUL-anterior segment along the minor fissure,consistent with a primary lung cancer,stationary
    • marginal spurs of multiple vertebral bodies due to spondylosis
    • Rt and Lt subpulmonary effusion?
  • 2022-05-04 Mammography
    • BI-RADS category 1, Negative.
  • 2022-03-30 Whole body PET scan
    • Glucose hypermetabolism in the right upper lung and right mediastinal lymph nodes, compatible with the primary lung cancer with regional lymph nodes involvement.
      
    • Glucose hypermetabolism in the skeleton including sternum, multiple C-, T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs, highly suspected lung cancer with multiple bone metastases.
      
    • Right upper lung cancer with regional lymph nodes and multiple bone metastases, cTxN2M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-03-09 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs in whole body bone survey.
    • IMPRESSION: Highly suspected cancer with multiple bone metastases in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs.
  • 2022-03-08 MRI - brain
    • Findings
      • Multiple bil. cerebellar and cerebral nodules, up to 14 mm in left parietal lobes.
      • After IV contrast administration shows well or heterogenous enhancement of the nodules.
        
      • Normal cisterns and sulcal systems.
      • Normal bilateral ventricular size and shapes.
      • Normal appearance of bilateral cochlear and vestibular nerves complexes.
      • MRA shows patency of the major vessels of the Willis circle, bilateral ICAs and vertebrobasilar trunk.
    • Imp: Multiple bil. cerebellar and cerebral metastases.
  • 2022-03-04 Patho - lung transbronchial biopsy
    • Lung, RUL, CT-duide biopsy—adenocarcinoma, poorly differentiated
    • Specimen submitted in formalin consists of 3 strips of tan, irregular tissue measuring up to 0.6 x 0.1 x 0.1 cm. All for section in one cassette.
    • Sections show solid nests, acinar and cribriform glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), GATA3(-), p40(focal +), and CD56(-). The results are supportive for the diagnosis.
  • 2022-03-04 CXR
    • no pneumothorax or pleural effusion s/p transthoracic needle biopsy of RUL mass
    • osteolytic metastases in multiple bones of thoracic cage
    • bilateral pleural effusions
    • marginal spurs of multiple vertebral bodies due to spondylosis.
  • 2022-03-03 CT - chest
    • Indication: RUL mass
    • Findings
      • Chest:
        • Spiculated mass at right upper lobe up to 4.35cm in largest dimension is found. Lung cancer is considered.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Lymphadenopathy at bilateral mediastinum and bilateral axillary region.
        • Minimal atelectatic change at right middle lobe is found.
        • Bilateral pleural effusion is found.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Visible brain
        • Several enhanced nodules at brain parenchyma is found. Brain meta is considered.
        • There is no evidence of destructive bone lesion.
        • No evidence of ICH, SAH or SDH.
    • Imp:
      • Right upper lobe lung cancer with mediastinal lymphadenopathy, bone meta and brain meta.
  • 2022-03-01 CXR
    • a mass opacity (ill-defined) over RUL-anterior segmnmt along the minor fissur, stationary
    • small Rt pleural effusion
    • lytic change at Rt 3rd rib, left inferior scapular body and axillary border and may be left 5th rib too due to metastases
    • old fracture of Rt 4th and Lt 4th ribs
    • hazy area of increased opacity Lt lower lung zone
    • Normal heart size
  • 2022-03-01 SONO - chest
    • Right side minimal pleural effusion; thoracocentesis was not performed due to high risk of complications.
    • Left thorax: no pleural effusion.
  • 2022-03-01 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 46) / 120 = 61.67%
      • M-mode (Teichholz) = 61
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA, grade 1 LV diastolic dysfunction
    • Mild AR, MR
  • 2022-02-26 CXR
    • a mass opacity (ill-defined) over RUL-anterior segmnmt along the minor fissur, high possibly of a malignant lesion suggest do CT study
    • small Rt pleural effusion
    • lytic change at Rt 3rd rib, left inferior scapular body and axillary border and may be left 5th rib too due to metastases
    • old fracture of Rt 4th and Lt 4th ribs
    • hazy area of increased opacity Lt lower lung zone
    • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, T-spine.
    • Normal heart size
  • 2022-02-18 CXR
    • An opacity in right middle lung zone; DDx: loculated pleural effusion, mass
    • Bilateral pleural effusion
    • Normal heart size and configuration
    • Left ribs old fracture
• chemoimmunotherapy
  • 2022-12-05 - ramucirumab 10mg/kg 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-10-03 - ramucirumab 10mg/kg 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-09-05 - ramucirumab 10mg/kg 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-08-08 - ramucirumab 10mg/kg 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-07-11 - ramucirumab 10mg/kg 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-04-19 - ramucirumab 10mg/kg 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-03-29 - ramucirumab 10mg/kg 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-05-04 ~ undergoing - Giotrif (afatinib 30mg/tab) 1# QDAC

[note]

• this patient EGFR L858R mutation detected, ROS1 (IHC 1+, FISH undetected)

• NCCN v5.2022

  • EGFR L858R
    • Preferred
      • Osimertinib (category 1)
    • Other Recommended
      • Erlotinib (category 1)
      • or Afatinib (category 1)
      • or Gefitinib (category 1)
      • or Dacomitinib (category 1)
      • or Erlotinib + ramucirumab
      • or Erlotinib + bevacizumab,
  • ROS1
    • Preferred
      • Entrectinib
      • or Crizotinib
    • or Other Recommended
      • Ceritinib

701350013

221209

• lab data

  • 2021-12-23 ALK IHC specimen S2021-17986
    
  • 2021-12-23 ALK IHC Negative
    
  • 2021-12-22 EGFR specimen S2021-17986
    
  • 2021-12-22 EGFR G719X not detected
    
  • 2021-12-22 EGFR Exon19 del not detected
    
  • 2021-12-22 EGFR S768I not detected
    
  • 2021-12-22 EGFR T790M not detected
    
  • 2021-12-22 EGFR Exon20 ins not detected
    
  • 2021-12-22 EGFR L858R detected
    
  • 2021-12-22 EGFR L861Q not detected
    
  • 2021-12-21 PD-L1(22C3) specimen S2021-17986
    
  • 2021-12-21 PD-L1(22C3) TPS < 1%
    
  • 2021-12-15 Anti-HCV Nonreactive
    
  • 2021-12-15 Anti-HCV Value 0.08 S/CO
    
  • 2021-12-15 HBsAg Nonreactive
    
  • 2021-12-15 HBsAg (Value) 0.33 S/CO
    
  • 2021-12-15 Anti-HBs 23.01 mIU/mL

• exam findings

  • 2022-12-05, -11-09, -10-17, -09-21, -08-29, -08-03, -07-04,… CXR
    • an ill-defined nodular opacity with reticular opacities over Lt lower lung zone stationary
    • reticular opacities over Rt lower lung zone
    • mixed osteolytic and osteoblastic metastasis in spine
  • 2022-09-29 CT - chest
    • Indication: Left lower lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis, ECOG 1
    • Findings
      • Chest:
        • Irregular mass like lesion attaching interlobar fissure at left lower lobe is found about 2.39cm in largest dimension. In comparison with CT dated on 2022-06-16, the lesion is stationary.
        • Calcified coronary arteries is found.
        • There is no evidence of mediastinal LAP
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • IMp: left lower lobe lung cancer with interlobar fissure attachment and bone meta. The primary tumor is stationary in size.
  • 2022-09-28 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone.
    • IMPRESSION: In comparison with the previous study on 2022/06/17, all of above-mentioned bone lesions are stationary, indicating multiple bone metastases in stable condition.
  • 2022-09-27 MRI - brain
    • Findings
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • Sella and pituitary are normal. The parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • There are no abnormalities in the calvarium.
        
      • No abnormal enhancement after contrast administration.
    • Imp: No brain nodule or metastasis. Mild cortical brain atrophy.
  • 2022-06-17 Tc-99m MDP bone scan
    • In comparison with the previous study on 2022/02/11, all the previous bone lesions are less evident, suggesting multiple bone metastases with some resolution.
  • 2022-06-16 CT - chest
    • Findings
      • Chest:
        • Fibrotic mass at left lower lobe up to 2.47cm is found. In comparison with CT dated on 2022-02-10, the lesion regressed.
        • S/p port-A placement with its tip at Superior vena cava.
        • Calcified coronary arteries is found.
        • Fibrotic change at left lingula lobe, left lower lobe and right middle lobe and right lower lobe is found.
        • Calcified coronary arteries is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • The GB is well distended without soft tissue lesion
    • IMp: Left lower lobe lung cancer with bone meta. The left lower lobe primary tumor regressed.
  • 2022-02-11 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone.
    • IMPRESSION: The scintigraphic findings suggest multiple bone metastases.
  • 2022-02-10 CT - chest
    • Lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis
    • Findings
      • Chest:
        • Spiculated mass at left lower lobe up to 2.95cm in largest dimension is found. In comparison with previous CT performed at other hospital on 2021-11-24, the lesion regressed.
        • Minimal left pleural effusion is found.
        • Calcified coronary arteries is found.
        • Linear atelectatic change at bilateral basal lungs is found.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Visible brain
        • No evidence of space occupying lesion in the brain parenchyma is found.
        • No evidence of ICH, SAH or SDH.
    • IMp:
      • left lower lobe lung cancer with primary tumor regression.
      • Bone meta. Suggest correlate with bone scan for comparison.
  • 2021-12-08 Whole body PET scan
    • Glucose hypermetablic lesion in the left lower lung, compatible with the primary lung cancer.
      
    • Glucose hypermetablic lesions in the left lower ribs, some T-spine, L1-3 spines with adjacent left-sided soft tissue, left S-I joint, and left iliac bone, highly suspected lung cancer with distant metastases. Please correlate with other clinical findings for further evaluation.
    • Left lower lung cancer with multiple bone metastases, cTxNxM1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2021-12-07 Patho - lung transbronchial biopsy
    • Lung, LLL, CT-guide biopsy — adenocarcinoma, poorly differentiated
      
    • Sections show large pleomorphic tumor cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal CK(+), TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
  • 2021-12-06 MRI - brain
    • No evidence of intracranial lesion.

• consultation

  • 2022-06-09 Metabolism and Endocrinology
    • Q
      • This is a 52-year-old man with past history of Left lower lobe Lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis, ECOG 1, diagnosed on 2021-12; T3: LLL mass with parietal pleura invades, N0: no definite mediastinal LAPs, M1c: multiple bone metasatsis,
        • EGFR mutation: L858R (+), exon 19 (-), ALK(-), PD-L1: <1%; with chemotherapy and radiotherapy.
        • The lung cancer treatment regimen as below:
          • 1st chemotherapy with TKI Giotrif since 2021-12-29.
          • Angiogenesis inhibitor with Cyramza C1 since 2021-12-16.
          • Immunetherapy with nivo C1 on 2022-01-11 and Ipi C1 on 2022-03-28.
          • Radiotherapy 2400cGy/8 fractions to T7-8, T12-L3 and paraspinal mass, 2021-12-09 ~ 2021-12-22.
      • This time, he was admitted for TKI induced severe diarrhea, due to severe diarrhea, we hold chemotherapy and TKI with Giotrif.
      • Laboratory data showed TSH: 7.841 uIU/mL. So we sicerely need your help for evaluation. Thanks a lot!!!
    • A
      • S
        • This 52-year-old male, with past history of left lower lobe Lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis, ECOG 1, diagnosed on 2021-12, was admitted for chemotherapy and immunotherapy. We were consulted for abnormal TFT.
      • O
        • BW: 57-58 kg
        • HR: 100-114
        • Possible related medication: Nivolumab
        • AST/ALT: 19/16
        • BUN/Cr: 20/0.67
        • Na: 128, K: 2.9
        • TSH/FT4: 7.841/1.01
        • ATPO, ATG, TSH receptor Ab: unavailable
        • ACTH/Cortisol: 16.9/21.26
        • Thyroid echo: nil
      • A:
        • Suspected immunotherapy related subclinical hypothyroidism
      • Suggestions:
        • Check anti-TPO Ab, Anti-thyroglobulin Ab
        • Recheck TSH/FT4 2 weeks later
        • No need of thyroxine supplement at this moment.
        • Arrange thyroid sonography
        • Endocrine OPD F/U. Contact us if needed. I’d like to follow up this patient.
  • 2022-04-19 Dermatology
    • Q
      • This is a 52-year-old man who denied any systemic disease history. He was admitted for scheduled chemotherapy and PortA insertion for LLL cancer with spine metastasis. According to his history, he was in his usual status of health until 2021/10, when he started to note left tronchanteric area tenderness, accompanied with left lateral thigh and bilateral sole numbness. Therefore, he went to local clinic for analgesic injection. However, on 2021/11/22 when he was working, another painful episode occurred and usual analgesic injection would not relieve the pain. Also, marked dyspnea on exertion was noted on the same day, when he had difficulty climbing stairs. The patient also mentioned body weight loss for 16kg (72 -> 56kg) in one month. Therefore, he first went to the NS OPD in Cardinal Tien Hospital for help.
      • After spine MRI and chest CT image were obtained, he went to our OPD for help. At OPD, interpretation of the image revealed LLL spiculated tumor with pleural effusion and spine tumors (T9, T12, L1, and L2), suspected LLL cancer with pleura and bone metastases. Under the impression of LLL cancer with spine metastasis, he was admitted for CT-guided lung biopsy and further cancer staging work-up. He had started EGFR TKIs with afatinib since 2021.12.29. And is admitted scheduled chemotherapy and port A insertion.
      • For skin rash of abdominal. We sinecrely need your professional evaluation, thank you!!
    • A
      • This patient suffered from generalized erythematous papules on whole trunk and scalp and 4 limbs for days.
      • Imp: Subacute dermatitis
      • Suggestion:
        • Zaditen (ketotifen) 1/ Bid
        • Xyzal (levocetirizine) 1 / Hs
        • Zalain Gel (sertaconazole) * 1 BT/Qd
        • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) * 6 tubes/bid
  • 2022-03-25 Radiation Oncology
    • Q
      • consult for radiotherapy
      • This is a 52-year-old man who denied any systemic disease history. He was admitted for scheduled chemotherapy for LLL cancer with spine metastasis. According to his history, he was in his usual status of health until 2021/10, when he started to note left tronchanteric area tenderness, accompanied with left lateral thigh and bilateral sole numbness. Therefore, he went to local clinic for analgesic injection. However, on 2021/11/22 when he was working, another painful episode occurred and usual analgesic injection would not relieve the pain. Also, marked dyspnea on exertion was noted on the same day, when he had difficulty climbing stairs. The patient also mentioned body weight loss for 16kg (72-＞56kg) in one month. Therefore, he first went to the NS OPD in Cardinal Tien Hospital for help. After spine MRI and chest CT image were obtained, he went to our OPD for help.
      • At OPD, interpretation of the image revealed LLL spiculated tumor with pleural effusion and spine tumors (T9, T12, L1, and L2), suspected LLL cancer with pleura and bone metastases. Under the impression of LLL cancer with spine metastasis.
        
      • He had started EGFR TKIs with afatinib since 2021.12.29. And this time is admitted for C5 Ramu 600mg, C4 Nivo 200mg free (20X10), Ipi 50mg charge, NGS liquid biopsy.
      • Bone scan reveals increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone. Some bone pain over SI and iliac joint.
      • We need your ptofessional expertise for help, thank you very much.
    • A
      • Subjective:
        • This is a 52-year-old man who denied any systemic disease history. He was in his usual status of health until 2021/10, when he started to note tenderness over left tronchanteric area, accompanied with left lateral thigh and bilateral sole numbness. Therefore, he went to local clinic for analgesic injection. However, on 2021/11/22 when he was working, another painful episode occurred and usual analgesic injection would not relieve the pain. Also, marked dyspnea on exertion was noted on the same day, when he had difficulty climbing stairs. The patient also mentioned body weight loss for 16kg (72->56kg) in one month.
        • Therefore, he first went to the NS OPD in Cardinal Tien Hospital for help. After spine MRI and chest CT image were obtained, he went to our OPD for help. At OPD, interpretation of the image revealed LLL spiculated tumor with pleural effusion and spine tumors (T9, T12, L1, and L2), suspected LLL cancer with pleura and bone metastases. Under the impression of LLL cancer with spine metastasis.
          
        • He had started EGFR TKIs with afatinib since 2021/12/29. And this time is admitted for C5 Ramu 600mg, C4 Nivo 200mg free (20X10), Ipi 50mg charge, NGS liquid biopsy.
        • Some bone pain over SI and iliac joint has been noted for weeks.
          • Previous RT: s/p RT to T7-8, T12, L1-3 spines, 3000cGy/10 fx, 2021/12/09-22.
          • Other disease: denied.
          • Family history: denied.
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2022/3/25: No SCF LAPs.
        • Pathology, CT-guided biopsy, 2021/12/07 10am: adenocarcinoma, poorly differentiated.
        • Images:
          • Chest CT, 2022/2/10: Spiculated mass at left lower lobe up to 2.95cm in largest dimension is found. (Se202 IM64). In comparison with previous CT performed at other hospital on 2021-11-24, the lesion regressed. Minimal left pleural effusion is found. Linear atelectatic change at bilateral basal lungs is found. Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • Bone scan, 2022/2/11: increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone. IMP: The scintigraphic findings suggest multiple bone metastases.
      • Diagnosis:
        • Lung cancer, LLL, PD adenocarcinoma, cT1cN0M1c, with minimal left pleural effusion, bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord s/p RT on 2021/12/22, under EGFR TKIs with afatinib since 2021/12/29. And this time is admitted for C5 Ramu 600mg, C4 Nivo 200mg free (20X10), Ipi 50mg charge; ECOG: 1.
      • Suggest: Radiotherapy.
        • Goal: Palliative.
        • RT Plan:
          • Target & Volume: left S-I joint and left iliac bone.
          • Technique: IMRT by linear accelerator.
          • Dose & Fractionation: 3000cGy/10 fractions.
      • Plan:
        • RT to bone metastasis is suggested for pain control. CT simulation is arranged on March 28, 10:30am. Possible treatment toxicity (radiation dermatitis) is told. To prevent heavy weight bearing and falling accidence was told.
  • 2022-01-17 Dermatology
    • Q
      • He had started EGFR TKIs with afatinib since 2021.12.29. And is admitted for C2 Ramu 600mg, Nivo 200mg injection treatment.
      • This time, skin rash over head and chest, we need your help, thank you a lot!
    • A
      • Skin finding: multiple erythematous papules with pustules on face, scalp and chest
      • Imp: acniform eruption due to EGFR TKI
      • Plan:
        • doxycycline 1# BID
        • clindamycin gel BID for scalp, face and chest
  • 2022-01-11 Dermatology
    • Q
      • He had started EGFR TKIs with afatinib since 2021.12.29. And is admitted for C2 Ramu 600mg, Nivo 200mg injection treatment.
      • However, TKI related side effect was noted. paronychia and some eash over face was noted. We need your help to evalaute his problems and give further suggestion. Thanks for your kindly help.
    • A
      • Skin finding: erythematous macules and patches on T area of face
      • Imp: seborrheic dermatitis
      • Plan:
        • rinderon-V cream (betamethasone) BID topical used
  • 2021-12-10 Thoracic Medicine
    • Q
      • This is a 52-year-old male patient without underlying disease. This time he has experienced low back pain with radiation to left leg since one month ago. Cancer staging work-up revealed poorly differentiated adenocarcinoma, LLL of lung, with metastases to left lower ribs, some T-spines, L1 to L3 spines with adjacent left-sided soft tissue, left S-I joint, and left iliac bone, cT2aN0M1c, sage IVB.
      • We sincerely need your expertise for lung cancer treatment. Thank you very much!
    • A
      • Impression:
        • LLL lung cancer with lung to lung, bone metastasis, T4N0M1ic, stage IVB
      • Suggesion:
        • Check EGFR, ALK, PDL1 mutation
        • Bone radiotherapy
  • 2021-12-09 Painology
    • Q
      • This is a 52-year-old male patient without underlying disease. This time he has experienced low back pain with radiation to left leg since one month ago. Image studies were done at Cardinal Tien Hospital, and LLL lung cancer with T and L spine metastases is strongly suspected. He was admitted for cancer survey. After admission, we consulted Radiation Oncology for spine tumor radiotherapy. This time, we sincerely need your expertise for bone pain control. Thank you very much!
      • Regular medications:
        • Muaction 100 mg/SR tab (Tramadol)  1 tab     PO      TID     
        • Acetal 500 mg/tab (Acetaminophen)  1 tab     PO      TID     
        • Aelocon 50mg & 5mg/tab (Thiamine Disulfide & Riboflavin; B1 & B2)  1 tab     PO      BID     
        • Votan-SR 100mg/tab  1 TAB     PO      TID  
      • Morphine 5mg IV prnq6h use
    • A
      • S:
        • left lateral pelvis pain with radiation to inguinal area for weeks
      • O:
        • NRS (Numerical Rating Scale for pain measurement): 3-8 (after taking tramadol can remain 4-5 hours down to 3, it can be up to 8 if not well-timing; morphine IV 5mg can remain up to over night > 6 hours)
        • Touch pain, tenderness, allodynia. No rash, local heat or nodule
        • Tenderness at lateral and post waist and paraspinal area (Left L1-3 level) and left iliac
      • A:
        • Left lower lung cancer with multiple bone metastases, cTxNxM1c, stage IV
        • Susp L1-3 spine, susp left psoas or QL muscle? metastasis with intercostal nerve, ilioinguinal, genitofemoral nerve entrapement.
        • Diagnostic USG intervention: Left lumbar plexus block (T12-L1): reactive
        • US: a hypoechoic lesion over QL/Psoas muscle: soft tissue metastasis?
      • P:
        • According to latest NCCN guideline, you may shift tramadol to low dose oral morphine/oxycontin (for pain NRS > 4, low dose high potent opioids +- adjuvant medication and interventional treatment). Morphine 15mg PO Q6H-Q8H (or Oxycontin 10mg Q12H) was suggested first.
        • Due to multiple metastasis at bone/ soft tissue and his fear to intervention, I suggested that medication adjustment and RT would be better for him now.
      • Please record the pain scale and the PRN dose
  • 2021-12-06 Radiation Oncology
    • A
      • Objective:
        • General Condition-ECOG: 1. On wheel chair use due to bone pain.
        • PE, 2021/12/06: No SCF LAPs.
        • Pathology, CT-guided biopsy, 2021/12/07 10am: pending.
        • Images:
          • L spine MRI, 2021/11/23: bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord.
          • Chest CT, 2021/11/24: 23-mm tumor over LLL, small mediastinal LNs, minimal left pleural effusion, bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord. Imp: cT1cN0M1c.
          • Brain MRI, 2021/12/06: No brain metastasis.
      • Diagnosis: Lung cancer, LLL, R/O adenocarcinoma, cT1cN0M1c, with minimal left pleural effusion, bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord; ECOG: 1.
      • Suggest: Radiotherapy.
      • Goal: Palliative.
      • RT Plan:
        • Target & Volume: bone metastasis over T8, T12, L1, L2.
        • Technique: IMRT by linear accelerator.
        • Dose & Fractionation: 3000cGy/10 fractions.
      • Plan:
        • RT to bone metastasis is suggested for pain control. CT simulation is arranged on Dec 07 11am. Possible treatment toxicity (radiation dermatitis and esophagitis) is told. To prevent heavy weight bearing and falling accidence was told. Diet education is given.

• radiotherapy

• chemoimmunotherapy

  • 2022-12-07 - Yervoy (ipilimumab) 50mg 30min
  • 2022-12-06 - Opdivo (nivolumab) 100mg 1 hr
  • 2022-12-05 - Cyramza (ramucirumab) 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-11-12 - Yervoy (ipilimumab) 50mg 30min
  • 2022-11-11 - Opdivo (nivolumab) 100mg 1hr
  • 2022-11-10 - Cyramza (ramucirumab) 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-10-20 - Yervoy (ipilimumab) 50mg 30min
  • 2022-10-19 - Opdivo (nivolumab) 200mg 1hr
  • 2022-10-18 - Cyramza (ramucirumab) 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-09-23 - Yervoy (ipilimumab) 50mg 30min
  • 2022-09-22 - Opdivo (nivolumab) 100mg 1hr
  • 2022-09-21 - Cyramza (ramucirumab) 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-09-01 - Yervoy (ipilimumab) 50mg 30min
  • 2022-08-31 - Opdivo (nivolumab) 100mg 1hr
  • 2022-08-30 - Cyramza (ramucirumab) 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-08-05 - Yervoy (ipilimumab) 50mg 30min
  • 2022-08-05 - Opdivo (nivolumab) 200mg 1hr
  • 2022-08-04 - Cyramza (ramucirumab) 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-07-06 - Yervoy (ipilimumab) 50mg 30min
  • 2022-07-05 - Opdivo (nivolumab) 200mg 1hr
  • 2022-07-04 - Cyramza (ramucirumab) 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-06-13 - Cyramza (ramucirumab) 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-05-18 - Yervoy (ipilimumab) 50mg 30min
  • 2022-05-17 - Opdivo (nivolumab) 200mg 1hr
  • 2022-05-16 - Cyramza (ramucirumab) 500mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-04-20 - Yervoy (ipilimumab) 50mg 30min
  • 2022-04-19 - Opdivo (nivolumab) 200mg 1hr
  • 2022-04-18 - Cyramza (ramucirumab) 600mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-03-28 - Yervoy (ipilimumab) 50mg 30min
  • 2022-03-25 - Opdivo (nivolumab) 200mg 1hr
  • 2022-03-24 - Cyramza (ramucirumab) 600mg 1.5hr
    • premed - dexamethasone 8mg + diphenhydramine 30mg
  • 2022-03-02 - Opdivo (nivolumab) 200mg 1hr
  • 2022-03-01 - Cyramza (ramucirumab) 600mg 2hr
  • 2022-02-08 - Opdivo (nivolumab) 200mg 1hr
  • 2022-02-07 - Cyramza (ramucirumab) 600mg 2hr
  • 2022-01-11 - Opdivo (nivolumab) 200mg 1hr
  • 2022-01-10 - Cyramza (ramucirumab) 600mg 2hr
  • 2021-12-16 - Cyramza (ramucirumab) 600mg 2hr
  • 2022-08-03, 2022-08-14 ~ 2022-11-01 undergoing - Vizimpro (dacomitinib) 15mg/tab 1# QD
  • 2021-12-29 ~ 2022-07-27 - Giotrif (afatinib) 30mg/tab 1# QDAC
  • 2021-12-05, 2022-02-28, 2022-04-17, 2022-05-15 - Xgeva (denosumab) 120mg SC

221019

[assessment]

• The disease is characterized by L858R(+), exon19del(-), ALK(-), and PD-L1<1%. This patient has been treated with oral afatinib(2021-12 ~ 2022-07)/dacomitinib(2022-08 ~ undergoing) and IV ramu(2021-12 ~)/nivo(2022-01 ~)/ipi(2022-03 ~). It appears that the current regimen is still effective to keep the disease stable (2022-02 and 2022-06 CT: regression; 2022-09 CT: stationary).

• The serum potassium level in 2022-10-17 was 2.9 mmol/L, and it might be beneficial to add potassium supplements.

• The main concern for the patient and his caregiver might be pain management. For patients who require four or more doses of short-acting opioids consistently each day, addition of a long-acting opioid should be considered based on the total daily dose. A controlled-release oxycondone regimen has been prescribed to the patient since 2022-10-18.

• In the event that the patient’s goals are not met (uncontrolled pain persists), then administer an opioid dose equivalent to 10%~20% of the total opioid taken in the previous 24 hours and reassess effectiveness and adverse effects (at 15 minutes if administered IV or at 60 minutes if administered PO).

  • pain unchanged or increased => increase dose by 50%~100%
  • pain decreased but inadequately controlled => repeat same dose
  • pain improved and adequately controlled => continue at current effective dose as needed over initial 24h

700806859

221208

{gastric cancer, T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414}

• diagnosis - 2022-12-07 admission note
  • gastric CA. T1a pN3a (6/32) cM0,  pStage: IIB, s/p Op
  • chronic peptic ulcer, site unspecified, without hemorrhage or perforation
  • myasthenia gravis without (acute) exacerbation
• past history - 2022-12-07 admission note
  • Myasthenia Gravis s/p thymic OP with regular using steroid control for 20 years
  • Right breast cancer s/p
  • hypothyroidism with medication control
• current medications - 2022-12-07 admission note
  • Thyroxin 0.1mg/tab 1 TAB QW123456PO
  • Thyroxin 0.1mg/tab 2 TAB QW7
  • prednisolone 15mg QD
  • pyridostigmine 1 tab BID
• exam findings
  • 2022-11-23 CT - abdomen
    • History: gastric CA. T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414
    • Findings:
      • S/P subtotal gastrectomy.
      • Moderate fatty liver, grade 4-5.
      • There is fat sparing area in S1 and S2/3.
      • S/P hysterectomy
    • Impression:
      • S/P subtotal gastrectomy.
      • There is no evidence of tumor recurrence.
  • 2022-10-03 SONO - abdomen
    • suboptimal examination of liver
    • fatty liver, severe
    • fatty infiltration of pancreas
  • 2022-09-20 CXR
    • right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2022-09-20, -06-24 KUB
    • Disc space narrowing with marginal osteophyte formation of L2-3.
    • Fecal material store in the colon.
  • 2022-04-14 Patho - stomach subtotal/total (tumor)
    • Diagnosis
      • Stomach, lesser curvature midbody, laparoscope subtotal gastrectomy with LN D2 dissection — adenocarcinoma, moderately differentiated. invading muscularis mucosa, confirmed with IHC stain of cytokeratin.
      • Lymph node, LN 1,3-9, 11p ,12a, 14v, LN D2 dissection — metastatic carcinoma
      • pT1a pN3a (if cM0); pStage: IIB, at least.
    • Gross Description:
      • Procedure: laparoscope subtotal gastrectomy with LN D2 dissection
      • Tumor Site: lesser curvature midbody
      • Tumor Size: 1.8 x 1.5 cm
      • Gross configuration: Type IIc: Flat, slightly depressed
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
        • Lauren classification of adenocarcinoma: Intestinal type
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades the muscularis mucosae
      • Margins
        • Proximal margin: uninvolved by invasive carcinoma. > 4 cm away
        • Distal margin: uninvolved by invasive carcinoma. > 4 cm away.
        • Radial margin: uninvolved by invasive carcinoma.
      • Lymphovascular Invasion: not identified.
      • Perineural Invasion: not identified.
      • Regional Lymph Nodes
        • Number of lymph nodes involved/examined: 8/32.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition): IIB, at least.
        • TNM Descriptors (required only if applicable): N/A.
          • Primary Tumor (pT): pT1a: Tumor invades the lamina propria or muscularis mucosa
          • Regional Lymph Nodes (pN): pN3a: Metastasis in seven to 15 regional lymph nodes
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case) (if cM0);
      • Additional Pathologic Findings- None identified
      • Ancillary Studies – IHC stains: (result of biopsy specimen S2022-06142): Her2/neu: negative (score=0)
  • 2022-04-12 Patho - stomach biopsy
    • Stomach, LC side of low body, biopsy — Adenocarcinoma.
    • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
  • 2022-04-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (96 - 28) / 96 = 70.83%
      • LVEF (%) = 71
      • M-mode (Teichholz) = 71
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Trivial MR; trivial TR; trivial PR.
  • 2022-03-29 CT - abdomen
    • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:Tx(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • Impression: Clinical gastric cancer, cstage T1N0M0. Suggest clinical correlation.
  • 2022-03-16 Patho - stomach biopsy
    • Stomach, low body, biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of adenocarcinoma of the gastric tissue characterized by tumor cells arranged in tubular, fused glandular or cribriform pattern with enlarged and hyperchromatic nuclei infiltrating in ulcerative stroma.
    • Immunohistochemistry of CK(+) and Her2/neu (-, Dako score 1+) for tumor cells.
    • Besides, mild intestinal metaplasia and colony of Helicobacter pylori are also present.
• consultation
  • 2022-10-19 Ophthalmology
    • Q
      • for left eye reddish & dry
      • This 55-year-old female, a pt of gastric CA. T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414 S/P C/T with FOLFOX. She was admitted for C/T.
      • She complained of left eye reddish & dry for days. We need expertise to evaluate her condition thanks!
    • A
      • Itchy and soreness ou for 3 days, redness os for days, no worsen BV
      • Gastric cancer T1a pN3a cM0, pStage: IIB, s/p op, under chemotherapy (Oxaliplatin, high-dose 5-fluorouracil)
        • HBV infection under entacavir
        • OPHx: op(-), nka
        • BCVA: OD 0.05(0.5X-2.50/-1.25X55) OS 0.05(0.5X-2.00/-1.50X95)
        • PT: 11/11mmHg
        • Pupil: 3mm, light reflex + ou, no RAPD
        • Conj: np od, temporal SCH os
        • K: clear ou
        • a/c: deep/clear ou
        • lens: co+ od, co++, psc + os
        • c/d 0.3 ou
        • fundus macula ok, retinal vessels ok ou
      • A:
        • Subconjunctival hemorrhage os
        • Cataract ou
      • P:
        • Kary 1gtt BID ou + Eyehelp 1gtt QID ou
        • oph opd f/u
  • 2022-04-15 Rheumatology
    • Q
      • This 55yo female has underlying diseases of:
        • breast cancer
        • myasthenia gravis, prednisolone 15mg QD (0413 hold) and pyridostigmine
        • hypothyroidism
      • This time, she was admitted for gastrectomy on 20220414.
      • We would like to consult your expertise for post-operative medication (IV form) adjustment due to NPO for many days.
    • A
      • History review was perdormed. Patient was admitted for gastrectomy. She has medical Hx of MG & took prednisolone 15mg QD. For post-operation NPO, I was consulted for adjusting IV form steroid dosage.
      • Suggestion:
        • Treatment as current your expert’s maangement.
        • Please add Decan 4mg IV QD for 3-7 days. Then shift to regular oral prednisolone dosage.
• surgical operation
  • 2022-04-14 laparoscope subtotal gastrectomy with LN D2 dissection
    • subtotal gastrectomy with LN 1,3-9, 11p ,12a, 14v dissection
    • anticolic isoperistalsis B-II anastomosis
• radiotherapy
  • 2022-05-18 ~ 2022-06-24 - 4500cGy/25 fractions (6 MV photon) to stomach and regional lymphatics
• chemoimmunotherapy
  • 2022-12-07 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4780mg 46hr (adjuvant)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-11-04 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4750mg 46hr (adjuvant)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-10-19 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr (adjuvant)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-09-21 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4780mg 46hr (adjuvant)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-08-25 - oxaliplatin 80mg/m2 130mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4720mg 46hr (adjuvant)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-08-12 - oxaliplatin 70mg/m2 118mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4720mg 46hr (adjuvant)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-07-20 - oxaliplatin 60mg/m2 100mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4790mg 46hr (adjuvant)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
  • 2022-06-20 - fluorouracil 225mg/m2 380mg 24hr D1-5 (adjuvant CCRT)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
  • 2022-06-13 - fluorouracil 225mg/m2 380mg 24hr D1-5 (adjuvant CCRT)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
  • 2022-06-10 - fluorouracil 225mg/m2 380mg 24hr D1 (adjuvant CCRT)
    • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg

[assessment]

• The serum ALT level trended upward.

  • 2022-12-07 S-GPT/ALT 61 U/L
  • 2022-11-22 S-GPT/ALT 66 U/L
  • 2022-11-14 S-GPT/ALT 66 U/L
  • 2022-10-19 S-GPT/ALT 52 U/L
  • 2022-09-20 S-GPT/ALT 58 U/L
  • 2022-08-25 S-GPT/ALT 25 U/L
  • 2022-08-16 S-GPT/ALT 36 U/L
  • 2022-08-11 S-GPT/ALT 22 U/L
  • 2022-07-26 S-GPT/ALT 14 U/L
  • 2022-07-19 S-GPT/ALT 26 U/L
  • 2022-06-20 S-GPT/ALT 14 U/L
  • 2022-06-13 S-GPT/ALT 18 U/L
  • 2022-06-10 S-GPT/ALT 26 U/L
  • 2022-06-01 S-GPT/ALT 25 U/L

• The use of oxaliplatin has been associated with an increase in ALT levels (incidence of 36% with monotherapy)

• There is no need to adjust the dosage of the components in the current regimen of FOLFOX.

• The addition of pyridostigmine as a self-carried item is recommended for the patient with myasthenia gravis since this medication has no known heavy interactions with the active prescription.

700261909

221206

• exam findings
  • 2022-12-05 CXR
    • Distention of stomach.
    • Ground glass opacity in bilateral lower lungs.
  • 2022-11-24 Patho - bone marrow biopsy
    • Bone marrow, iliac crest, biopsy — See description
    • The sections show normocellular marrow (20%). The CD71+ erythroid precursors are markedly decreased (10%). The myeloid cells show left shift in MPO stain. The CD61+ megakaryocytes are slightly increased, and few micromegakaryocytes are present. No increased CD34+ blasts. Scattered CD117+ immature cells (<3%) are present. Myelodysplastic syndrome can be considered in differential diagnosis. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2022-09-01 Patho - bone marrow biopsy
    • Bone marrow, right pelvic, biopsy — Suggested myelodysplastic syndrome
      
    • Sections show 10-70 % cellularity. The M/E ratio is about 4/1–5/1. Dysgranulopoiesis is seen. Anisocytosis and poikilocytosis are present. Atypical micromegakaryocytes are found about 4-7/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells.
    • IHC stains: CD117: 2%; CD34: <1%; CD71: 10-30%; Hemoglobin A: 10-20%; CD138: 5%. The morphology is suggesting myelodysplastic syndrome. Please correlate with the bone marrow smear, peripheral blood smear and lab data for final diagnosis.
  • 2022-08-16 Panendoscopy
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, antrum
  • 2022-07-28 SONO - abdomen
    • Liver cirrhosis with splenomegaly.
    • Left liver cyst (0.87x0.59cm).
    • S/P cholecystectomy.
  • 2022-07-12 CXR
    • Tortous aorta with calcification is noted.
    • Elevation of left hemidiaphragm is found.
  • 2022-07-06 ECG
    • Sinus rhythm with Premature atrial complexes
    • Nonspecific ST and T wave abnormality
    • Left atrial enlargement
  • 2021-03-16, 2020-09-18 SONO - nephrology
    • Parenchymal renal disease
  • 2019-11-22 CXR
    • Tortous aorta with calcification is noted.
    • Elevation of left hemidiaphragm is found.
    • Blunted left CP angle is found.
  • 2019-10-24 Flow-Volume Curve and Bronchodilator Test
    • Severe lung restriction
  • 2019-10-24, -10-22 CXR
    • Elevation of Lt hemidiaphragm may be due to LLL volume loss and fibrosis or bronchiectasis
    • bronchiectasis at Rt lung base
  • 2019-10-18 CXR
    • Elevated left hemidiaphragm.
    • Increased infiltration at RLL
• chemoimmunotherapy
  • 2022-12-05 - Vidaza (azacitidine) 75mg/m2 100mg SC D1-D2

[assessment]

• In the past, serum iron, total iron-binding capacity, ferritin, vitamin B12, and folate have been measured. Since the patient’s renal function appears to be in good condition, it is unlikely that the anemia is caused by low EPO levels.
• No increase in blasts has been observed. WBC sometimes falls below normal range, RBC and HGB often fall below normal ranges. The results of the pathology indicated that MDS may be present. (with single lineage or multilineage dysplasia?) No cytogenetic del (11q, 5q, 12p, 20q,…) data available currently.
• The patient is receiving azacitadine for the first time. Please monitor for any signs of intolerance.
• The recommended dosing of azacitadine for patients with MDS: Initial cycle: 75 mg/m2/day for 7 days of a 28-day treatment cycle. Subsequent cycles: 75 mg/m2/day for 7 days every 4 weeks; dose may be increased to 100 mg/m2/day if no benefit is observed after 2 cycles and no toxicity other than nausea and vomiting have occurred. Patients should be treated for a minimum of 4 to 6 cycles; treatment may be continued as long as patient continues to benefit.

700307071

221206

{Left ovarian cancer (clear cell carcinoma) post Debulking surgery on 2022/06/08, pT2aN0M0, FIGO stage IIA}

• family history
  • Father: esophageal cancer
  • Mother: lung adenocarcinoma
• exam finding
  • 2022-11-15 CT - abdomen
    • S/P hysterectomy and oophorectomy.
    • Ground glass opacity, 0.6cm in RUL. Nature?
  • 2022-10-06 SONO - joint soft tissue
    • right shoulder supraspinatus tendinitis
    • limitation of passive movement in the glenohumeral joint, compatible with right shoulder adhesive capsulitis.
  • 2022-10-05 T-L spine AP + Lat
    • mild anterior spur formation at the middle and lower L-spine.
  • 2022-09-28 CXR
    • Atherosclerotic change of aortic arch
    • Scoliosis of the T-spine with convex to right side.
  • 2022-07-29 CXR
    • Scoliotic alignment of the thoracolumbar spine is noted.
  • 2022-06-09 Patho - ovary (tumor)
    • pathologic diagnosis
      • 1. Ovary, left, BSO — Mixed clear cell carcinoma and endometroid carcinoma
      • 2. Lymph nodes, pelvic and para-aortic, bilateral, BPLND — Negative for malignancy (0/28)
      • 3. Soft tissue, labeled “tumor seeding on colon”, excision — Inflammation and fibrosis, no malignancy
      • 4. AJCC 8 th edition, Pathology stage: pT2aN0; stageIIA; FIGO stage IIA if cM0
    • macroscopic examination
      • 1. Procedure: ATH + BSO + omentectomy + BPLND + para-aortic LN dissection + tumor seeding on colon excision
      • 2. Specimen Size: 16.5 x 11.8 x 7.0 cm (Lt ovary), 2.5 x 1.0 x 0.6 cm (Rt ovary), 8.2 x 0.5 cm (Lt tube), 4.2 x 0.5 cm (Rt tube), 6.0 x 3.8 x 2.2 cm (uterus), 0.6 x 0.4 x 0.3 cm (colon tumor), 24 x 8.5 x 0.5 cm (omentum)
      • 3. Specimen Integrity
        • 3.1. Right ovary: Capsule intact
        • 3.2. Left ovary: Capsule ruptured
        • 3.3. Right fallopian tube: Serosa intact
        • 3.4. Left fallopian tube: Serosa intact
      • 4. Tumor Site: Left ovary
      • 5. Ovarian Surface Involvement: Present
      • 6. Fallopian tube Surface Involvement: Absent
      • 8. Tumor Size: Tri-cystic and aolid tumor, 16 x 11.8 x 7.0 cm
      • 9. Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic
      • 10. Representative parts are taken for section and labeled as: F2022-00264FSA1, FSA2, FSA3= left ovary tumor, A1= left tube, A2-A10= left ovary tumor. S2022-09335 A= left iliac LNs, B= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E= left para-aortic, F= right para-aortic LNs, G1= cervix, G2-G3= uterine corpus, G4= right ovary and fallopian tube, G5= left parametrium, G6= right parametrium, H= omentum, I= tumor seeding on colon.
    • microscopic examination
      • 1. Histologic Type: Mixed clear cell carcinoma and endometroid carcinoma
      • 2. Histologic grade: High grade
      • 3. Implants: Not identified
      • 4. Other Tissue/Organ Involvement: Tumor invades uterine wall
      • 5. Peritoneal Fluid: Not submitted
      • 6. Regional Lymph Nodes: All lymph nodes are negative for tumor cells (0/28)
        • number of lymph node examined: 3 (left iliac), 7 (left obturator), 4 (right iliac), 6 (right obturator), 3 (left para-aortic) and 5 (right para-aortic)
        • number with metastases >10 mm: 0
        • number with metastases 10mm or less: 0
        • number with isolated tumor cells (<=0.2mm): 0
      • 7. Pathologic Stage
        • 7.1. Primary Tumor: pT2a (tumor extension on the uterus)
        • 7.2. Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
        • 7.3. Distant Metastasis: Not applicable
      • 8. FIGO Stage: Stage IIA if cM0
      • 9. Lymphovascular invasion: Absent
      • 10. Perineural invasion: Absent
      • 11. Additional Pathologic Findings:
        • 11.1. Cervix: Chronic cervicitis with Nabothian cysts
        • 11.2. Endometrium: Atrophy
        • 11.3. Myometrium: Leiomyoma
        • 11.4. Ovary, right: Cortical inclusion cysts
        • 11.5. Fallopian tube, right: Para-tubal cyst
        • 11.6. Fallopian tube, left: Unremarkable
        • 11.7. Omentum: No remarkable change
        • 11.8. Specimen labeled “tumor seeding on colon”: Chronic and acute inflammatory cells infiltrate, fibrin exudate, and fibrosis
      • 12. IHC: Napsin A (rare + for clear cell carcinoma component), PR(+ in endometroid carcinoma), WT1(-), p53(wide type)
  • 2022-06-08 Frozen section
    • Ovary, frozen section — Malignant, favor clear cell carcinoma
  • 2022-06-08 Patho - colon biopsy
    • Colon, ileocecal valve, s/p cold snare polypectomy — Hyperplastic polyp with chronic inflammation.
  • 2022-06-06 Patho - stomach biopsy
    • Labeled as “30cm below the incisor, s/p biopsy(B)”, biopsy — benign squamous mucosa with abundant granular cytoplas, in favor of glycogenosis.
    • Stomach, LC site of antrum, s/p biopsy (A) — Chronic gastritis, H pylori NOT present
  • 2022-06-06 CT - abdomen, pelvis
    • Huge soft tissue mass at pelvis with solid and cystic component is found up to 16.5cm in largest dimension. Ovarian cancer is considered.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:Nx(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-05-30 Gynecologic ultrasonography
    • huge ovarian mass 183mm x 105mm
  • 2022-05-30 SONO - abdomen
    • suspected liver parenchymal disease, mild
    • lower abdomen tumor: cause to be determined
  • 2020-04-29 Patho - stomach biopsy
    • Stomach, low body, biopsy — fundic gland polyp. No H.pylori present
  • 2017-07-26 Mammography
    • Impression: Dense breast.
      • 1. Asymmetry in axillary tail region of left breast, stationary.
      • 2. Benign calcifications in bilateral breasts.
    • BI-RADS: Category 2: benign findings. - annual screening.
• surgical operation
  • 2022-06-08 Debulking surgery (ATH + BSO + BPLND + paraaortic LN disection + infracolic omentectomy), Bilateral ureteral catheterization
• chemoimmunotherapy
  • 2022-12-05 - paclitaxel 175mg/m2 260mg 3hr + carboplatin AUC 5 500mg 2hr
  • 2022-11-14 - paclitaxel 175mg/m2 270mg 3hr + carboplatin AUC 5 500mg 2hr
  • 2022-10-24 - paclitaxel 175mg/m2 250mg 3hr + carboplatin AUC 5 500mg 2hr (Owing to Leukopenia (ANC: 368) was noted on 20221011 and next will given Lenograstim x 3 post C/T, 2022-10-26 ~ 2022-10-28)
  • 2022-09-27 - paclitaxel 175mg/m2 250mg 3hr + carboplatin AUC 5 500mg 2hr
  • 2022-09-06 - paclitaxel 175mg/m2 246mg 3hr + carboplatin AUC 5 500mg 2hr
  • 2022-08-15 - paclitaxel 175mg/m2 246mg 3hr + carboplatin AUC 5 500mg 2hr
  • 2022-07-15 - paclitaxel 175mg/m2 246mg 3hr + carboplatin AUC 5 530mg 2hr

220928

[assessment]

• If there is a suspicion of megaloblastic anemia (RBC 2.75 *10^6/uL, HGB 9.4 g/dL, MCV 104 fL, 2022-09-27), a vitamin B12 (cobalamin) and/or a vitamin B9 (folate) supplement might be beneficial to the patient.

701024299

221205

• 2022-12-03 CXR

  • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
  • Bilateral pleural effusion.

• 2022-11-21, -11-17 CXR

  • Borderline cardiomegaly
    
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?

• 2022-11-18 SONO - chest

  • right side minimal amount of pleural effusion
  • left side small amount of pleural effusion, 290cc serosangious fluid was aspirated for analysis.

• 2022-11-13 ECG

  • Sinus tachycardia

• 2022-10-20 CT - abdomen

  • History and indication: ovary cancer with peritonal seeding right breast cancer with bone mets
  • Findings
    • Right breast cancers. Bil. pleural effusions. Enlarged LNs at left neck, mediastinum, bil. axillary regions, mesentery and retroperitoneum.
    • S/P hysterectomy. Some tumors in peritoneal cavity.
    • Tiny liver cysts. A metastases at left hepatic lobe. Progression of metastases at spleen and LUQ.
    • Swelling of right chest wall and abdominal wall.
  • IMP:
    • Right breast cancers. Bil. pleural effusions. Enlarged LNs at left neck, mediastinum, bil. axillary regions, mesentery and retroperitoneum.
    • S/P hysterectomy. Some tumors in peritoneal cavity.
    • A metastases at left hepatic lobe. Progression of metastases at spleen and LUQ.

• 2022-10-14 CXR

  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Borderline cardiomegaly
    
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?

• 2022-07-29 Whole body PET scan

  • In comparison with the previous study on 2021/12/09, the lesions in the right breast, two right supraclvicular lymph nodes, multiple right axillary lymph nodes and multiple bilateral parasternal lymph nodes are new. Primary breast malignancy with multiple lymph node metastases may show this picture. However, please correlate with the pathologic findings for further evaluation.
  • A new glucose hypermetabolic lesion in the the region about the skin of right upper back, compatible with a metastatic lesion.
  • The glucose hypermetabolic lesions in the left supraclavicular fossa, mediastinum, spleen, abdominal and pelvic cavities seem either new, more evident or larger in size, suggesting multiple metastases in progression. However, other lesions such as the lesions in the left pulmonary hilar region, pleura of right lung and left lobe of the liver are either a little less evident or disappeared.

• 2022-07-28 CT - chest

  • History
    • 45 y/o female, a pt of ovarian CA wt peritoneal seeding, rpT3bN0 (If cM0); pStage: IIIB , FIGO stage: IIIB, s/p pre-Op NIPS wt Taxotere / Carbopaltin IV and Taxotere / Cisplatin IP Q3W x 4 finihsed in Oct 2020 s/p debulking Op on 11/30 20 by Dr Wu, s/p post-Op salvage C/T wt Taxotere/PF + IP C/T wt Taxotere / Cisplatin x 4 finished in Feb 2021 & s/p post-Op salvage Avastin 7.5mg/kg IV Q3W x 1yr since 3/9 21.
  • Findings
    • Chest:
      • Soft tissue mass/noduless at lateral breast up to 2.57cm and inner breast about 3.5cm in largest dimension. breast cancer is considered.
      • Lymphadenopathy at right axillary region, mediasitnum and paraaortic region. Lymphadenopathy from breast cancer or residual ovarian cancer is favored.
      • Very tiny nodule at right upper lobe is found.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • Tiny low density nodules at S6 of liver about 0.34cm and 0.2cm in largest dimension. In comparison with CT dated on 2022-06-01, the lesions are stationary.
      • Low density change at splenic hilum is found. In progression.
      • The pancreas, both kidneys, adrenals are intact.
      • Suggest clinical correlation
  • Imp:
    • Right breast cancer with lymphadenopathy at right axillary, mediastinal and abdominal hepatic hilar and paraaortic region.
    • SPlenic hilar tumor, in progression.
    • Liver meta. Stable.

• 2022-06-06 Patho - lymphnode biopsy

  • Labeled as “left supraclavicular fossa/ lymph node”, past history of ovarian and breast cancers, excision biopsy — metastatic carcinoma.
  • Section shows pieces of soft tissue with metastatic carcinoma
  • IHC stains: PAX-8 (+) and GATA-3 (-): pattern is in favor of ovarian origin rather than breast origin.
  • Residual lymph node-like tissue is present.

• 2022-06-06 CT - abdomen

  • History and Indication:
    • 2020/08/05: Echo: susp pelvic mass with ascites.
    • OP: ATH + RSO 3 yr ago
    • 2020/08/05 CT: Cystic adenocarcinoma of ovary & carcinomatosis
    • 2020/11/30 PATHO: serous carcinoma, high grade, involved bilateral ovary, Fallopian tube and Peritoneum,rpT3bN0(If cM0); pStage:IIIB , FIGO stage: IIIB,
    • 20220309 CT: Metastases in the liver, spleen, and multiple LNs.
  • Findings:
    • S/P hysterectomy
    • Prior CT identified a metastasis 1.7 x 1.1 cm in S3 of the liver is not noted in the current CT that is c/w liver metastasis S/P C/T with complete response .
      • Prior CT identified two lobulated metastases 3 cm and 2.5 cm in between the gastrosplenic ligament, spleen, and pancreatic tail are noted again, decreasing in size to 2 cm and 1 cm that are c/w metastases S/P C/T with partial response .
      • Prior CT identiifed multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space and para-cava space are noted again, stable in size that is c/w metastatic nodes S/P C/T with stable disease .
      • Prior CT identified A enlarged node with central low density measuring 2 x 1.2 cm in left side neck is noted again, stationary.
    • Prior CT identified a cyst 4 mm in S5/8 of the liver is noted again, stationary.
      
    • Mild ascites in the cul-de-sac is noted.
    • Others
      • There is no focal abnormality in the gallbladder, biliary system, & both kidney.
        
      • There is no bowel wall thickening and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion in the omentum.
  • Impression:
    • Metastasis in the liver shows complete response.
    • Metastases in the spleen shows partial response.
    • Metastatic nodes show stable disease

• 2022-05-31 2D transthoracic echocardiography

  • LVEF = (LVEDV - LVESV) / LVEDV = (62 - 18) / 62 = 70.97%
    • M-mode (Teichholz) = 71
  • Preserved LV and RV systolic function with normal wall motion
  • Normal chamber size
  • Trivial MR

• 2022-05-23 Patho - lymphnode biopsy

  • Lymph node, right axillary, score biopsy — positive for invasive carcinoma
  • Microscopically, it shows presence of invasive carcinoma nestes with necrosis and stromal fibrosis in a lymphoid background.
  • IHC stain — CK(+)

• 2022-05-23 Patho - breast biopsy (no need margin)

  • Breast, right, core biopsy — invasive carcinoma of no special type
  • Microscopically, the breast shows invasive carcinoma characterized by proliferation of tumor cells with infiltrative growth pattern, ductal differentiation and stromal fibrosis with necrosis. The tumor cell shows hyperchromatic nuclei, plemorphism and high N/C ratio.

• 2022-05-17 SONO - breast

  • Bil. fibroadenomas and cysts
  • BI-RADS: 2. benign finding

• 2022-03-09 CT - abdomen

  • Findings:
    • S/P hysterectomy
    • There is a newly-developed poor enhancing mass 1.7 x 1.1 cm in S3 of the liver that is c/w liver metastasis.
      • There are two lobulated poor enhancing mass 3 cm and 2.5 cm in between the gastrosplenic ligament, spleen, and pancreatic tail that are c/w metastases.
      • In addition, There are newly-developed multiple enlarged nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space and para-cava space that are c/w metastatic nodes.
      • A enlarged node with central low density measuring 2 x 1.2 cm in left side neck that is c/w metastatic node.
    • Prior CT identified a cyst 4 mm in S5/8 of the liver is noted again, stationary.
      
  • Impression:
    • Metastases in the liver, spleen, and multiple lymph nodes.

• 2021-12-09 Whole body PET scan

  • Multiple glucose hypermetabolic lesions in the left supracalvicular fossa, mediastinum, left pulmonary hilar region, pleura of right lung, spleen, left lobe of the liver, abdominal and pelvic cavities, compatible with multiple metastatic lesions. Please correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in the fat tissues in bilateral necks, bilateral supraclavicular fossae and bilateral paraspinal regions. Physiological FDG uptake is more likely.

• 2021-11-26 CT - abdomen

  • Findings
    • S/P hysterectomy
    • The long segmental terminal ileum shows mild dilatation with feces-like material (Srs:302 Img:63-69) that may be partial obstruction?
      • The differential diagnosis include normal variation. please correlate with clinical condition.
      • In addition, there is a suspicious soft tissue nodule in the cul-de-sac that may be tumor seeding. The differential diagnosis include normal variation? Follow up is indicated.
    • There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst.
  • Impression:
    • S/P hysterectomy
    • Partial obstruction of the terminal ileum and a tumor seeding in the cul-de-sac is suspected.
      • The differential diagnosis include normal variation.
      • please correlate with clinical condition.

• 2021-11-18 SONO - abdomen

  • Hepatic lesion, right lobe, suspected cyst.

• 2021-08-27 CT - abdomen

  • Findings
    • S/P hysterectomy -There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst.
      
  • Impression:
    • S/P hysterectomy. There is no evidence of tumor recurrence.

• 2021-07-08 Gynecologic ultrasonography

  • ATH + BSO
  • minimal fluid

• 2021-06-10 CT - abdomen

  • Findings
    • S/P hysterectomy. Minimal ascites in pelvic cavity.
    • Tiny liver cysts.
    • Some low attenuations in both kidneys.
  • IMP:
    • S/P hysterectomy. Minimal ascites in pelvic cavity. No evidence of tumor recurrence.

• 2021-05-27 SONO - abdomen

  • pancreatic cystic lesion, body

• 2021-03-10 CT - abdomen

  • Findings:
    • S/P hysterectomy
    • There is mild ascites in the pelvis.
    • There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst.
      
  • Impression:
    • S/P hysterectomy. There is no evidence of tumor recurrence.

• 2020-12-01 Patho - soft tissue tumor, extensive resection

  • PATHOLOGIC DIAGNOSIS
    • Ovary and fallopian tube? right, labeled “right pelvic peritonum”, peritonectomy — Involved by serous carcinoma
      
    • Round ligament of liver, peritonectomy — Involved by serous carcinoma
      
    • Appendix, appendectomy — Involved by serous carcinoma
      
    • Ovary and fallopian tube? left, labeled “left pelvic peritonum”, peritonectomy — Involved by serous carcinoma
      
    • Right diaphragm peritoneum, peritonectomy — Involved by serous carcinoma
      
    • PD tube with its tract, peritonectomy — Free of carcinoma
      
    • Ometum, omentectomy — Involved by serous carcinoma
      
    • AJCC 8 th edition, Pathology stage: ypT3bNx; stage IIIB; FIGO stage IIIB if cM0
      
  • MACROSCOPIC EXAMINATION
    • Procedure: Debulking surgery + peritonectomy + appendectomy
      
    • Specimen Size
      • Right pelvic peritonum (including right adnexa): three pieces, up to 3.2 x 2.8 x 2.5 cm
        
      • Round ligament of liver: 5.0 x 2.5 x 2.2 cm
        
      • Appendix: 4.0 x 1.0 x 1.0 cm
        
      • Left pelvic peritoneum (including left adnexa): three pieces, up to 3.4 x 2.9 x 2.8 cm
        
      • Right diaphragm peritoneum: multiple pieces up to 12.5 x 8.0 x 4.5 cm
        
      • PD tube with its tract: 8.0 x 0.9 cm with tract 5.0 x 1.2 cm
        
      • Omenum: 22.0 x 11.0 x 1.5 cm
    • Specimen Integrity: Fragmented
      
    • Tumor Site: Both adnexa
      
    • Ovarian Surface Involvement: Present
      
    • Fallopian tube Surface Involvement: Present
      
    • Representative parts are taken for section and labeled as: A1-A3= right pelvic peritonum (including right ovary and fallopian tube), B1-B3= round ligament of liver, C1-C2= appendix, D1-D3= left pelvic peritoneum (including left ovary and fallopian tube), E1-E3= right diaphragm peritoneum, F= PD tube with its tract, G1-G3= omentum
      
  • MICROSCOPIC EXAMINATION
    • Histologic Type: Serous carcinoma
      
    • Histologic grade: High grade
      
    • Ovary and fallopian tube? right, labeled “right pelvic peritonum”: Involved by serous carcinoma
      
    • Round ligament of liver: Involved by serous carcinoma
      
    • Appendix: Involved by serous carcinoma
      
    • Ovary and fallopian tube?left, labeled “left pelvic peritonum”: Involved by serous carcinoma
      
    • Right diaphragm peritoneum: Involved by serous carcinoma
      
    • PD tube with its tract: Chronic inflammation, fibrosis and free of carcinoma
      
    • Ometum: Involved by serous carcinoma
      
    • Pathologic Stage
      • Primary Tumor: ypT3b (macroscopic peritoneal metastasis beyond the pelvis 2 cm or less in greatest dimension)
        
      • Regional Lymph Nodes: Not submitted
        
      • Distant Metastasis: Not applicable
        
    • FIGO Stage: Stage IIIB if CM0
      
    • Additional Pathologic Findings: Psammoma bodies

• 2020-11-30 Patho - ovary (tumor)

  • PATHOLOGIC DIAGNOSIS
    • Ovary, right, debulking surgery (s/p neoadjuvant treatment) — serous carcinoma, high-grade
      
    • Ovary, left, debulking operation — serous carcinoma, high-grade
      
    • Fallopian tube, right, debulking operation — involved by serous carcinoma
      
    • Fallopian tube, left, debulking operation — involved by serous carcinoma
      
    • Lymph node, right iliac, dissection — negative for malignancy ( 0 / 3 )
      
    • Lymph node right obturator, dissection — negative for malignancy ( 0 / 1 )
      
    • Lymph node, left iliac, dissection — negative for malignancy ( 0 / 4 )
      
    • Lymph node, left obturator, dissection — negative for malignancy ( 0 / 1 )
      
    • Pelvic mass, debulking surgery — involved by serous carcinoma
      
    • Omentum, debulking surgery — involved by serous carcinoma
      
    • pTNM: rpT3bN0 (If cM0); FIGO stage: IIIB; pStage:IIIB
      
  • MACROSCOPIC EXAMINATION
    • Operation Procedure: debulking surgery
      
    • Specimen type: bilateral ovaries, fallopian tubes, regional LNs, omentum
      
    • Specimen size:
      • right ovary: 4.2x 3.5x 2.2 cm;
        
      • left ovary: 5x 4x 2.5 cm;
        
      • right tube: 4.5 cm in length;
        
      • left tube: 4.5 cm in length;
        
      • uterus: not received
        
    • Tumor site: right and left ovaries
      
    • Tumor size: up to 1.3 cm in size
      
    • Tumor appearance: solid and papillary
      
    • Specimen integrity: Ovarian capsule ruptured (right)
      
    • Lymph node: (tissue size) up to 1 cm
      
  • MICROSCOPIC EXAMINATION
    • Histologic type: serous carcinoma
      
    • Histologic grade: high grade
      
    • Contralateral ovary involvement: present
      
    • Tumor side ovarian surface involvement: present
      
    • Contralateral ovary surface involvement: present
      
    • Right tube involvement: present
      
    • Left tube involvement: present
      
    • In situ adenocarcinoma in right and/or left fallopian tube: absent
      
    • Right adnexa soft tissue involvement: absent
      
    • Left adnexa soft tissue involvement: absent
      
    • Pelvic soft tissue involvement: present (labeled pelvic mass)
      
    • Uterine serosa involvement: non-applicable
      
    • Omentum involvement: present
      
    • Uterine Cervix involvement: N/A
      
    • Endometrium involvement: N/A
      
    • Myometrium involvement: N/A
      
    • Appendix involvement: N/A
      
    • Lymph nodes metastasis:
      • Group as specified No. Positive / No. Total
        
      • Right iliac ( 0 / 3)
        
      • Right obturator ( 0 / 1 )
        
      • Left iliac ( 0 / 4 )
        
      • Left obturator ( 0 / 1 )
        
    • Other organs or specimens involvement: none
      
    • Immunohistochemical stain shows WT-1(+), CK7(+), CK20(-)

• 2020-11-18 Whole body PET scan

  • Glucose hypermetabolism in the left pelvis, compatible with the CT findings of much regression of ovary cancer and peritoneal carcinomatosis with residual tumor at the left ovary.
    
  • Glucose hypermetabolism in bilateral palatine tonsils, probably chronic inflammation/infection process.
    
  • Glucose hypermetabolism in bilateral pulmonary hilar regions, probably physiological uptake of FDG or reactive nodes.
    
  • Increased FDG accumulation in the colon and urinary bladder, physiological FDG accumulation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.

• 2020-11-18 Gynecologic ultrasonography

  • ATH
  • Suspected Lt ovarian mass: 48x42mm

• 2020-11-16 CT - abdomen

  • History and indication: ovary cancer with peritonal seeding
  • Findings
    • Much regression of ovary cancer and peritoneal carcinomatosis (residual tumor at left ovary).
    • Thyroid nodules (3-5mm).
    • Tiny liver cysts.
    • Some low attenuations in both kidneys.
    • S/P Port-A infusion catheter insertion.
  • IMP:
    • Much regression of ovary cancer and peritoneal carcinomatosis (residual tumor at left ovary).

• 2020-10-28, -09-16, -09-15, -08-26, -08-25, -08-13 Body fluid cytology - ascites

  • Malignancy

• 2020-08-13 Patho - peritoneum biopsy

  • Labeled as “ovary cancer with diffuse peritoneal seeding”, biopsy — adenocarcinoma
    
  • Section shows adenocarcinoma.

• 2020-08-07 Patho - ovary biopsy/wedge resection

  • Labeled as “s/p 3 yr rt partial ovrain tumor excision, intraabd peritoenal tumor with ascite”, biopsy — adenocarcinoma, serous type, high grade.
  • Section shows piece of tissue with short papillae of neoplastic cells containing hyperchromatic nuclei and abundant eosinophilic cytoplasm.
  • IHC stains: PAX-8 (+), WT-1 (+), CK20 (-), a pattern of ovarian origin.
  • IHC stains: ER (+, 1-5%, moderate intensity); PR (+, 1-5%, moderate intensity).

• 2020-08-06 Gynecologic ultrasonography

  • ATH + RSO
  • Imp:
    • Ascites
    • Suspected Lt ovarian mass (RI: 0.13) 144x106mm, malignancy cannot be ruled out.

• 2020-08-05 CT - abdomen

  • Findings:
    • There is a large multilocular mixed cystic and solid masses in the pelvis that may be cystic adenocarcinoma of the ovary. please correlate with clinical history.
    • There is massive ascites and soft tissue nodules in the omentum and right perihepatic space (Srs:3, Img:25) that is compatible with carcinomatoais.
    • There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst. The differential diagnosis include metastasis. Please correlate with sonography.
  • Impression:
    • Cystic adenocarcinoma of the ovary with carcinomatosis is highly suspected. please correlate with clinical condition.
    • A hepatic cyst 4 mm in S5/8 is suspected. The differential diagnosis include metastasis. Please correlate with sonography.

• 2020-08-05 SONO - abdomen

  • Diagnosis
    • Suspected pelvic mass lesion
    • Ascites with peritoneal nodule; D/D: peritonitis, carcinomatosis
  • Suggestion
    • CT scan
    • GYN survey

• 2020-05-16 Mammography

  • Impression: Dense breast. Probably benign calcifications in bilateral breasts.
  • BI-RADS: Category 2: benign findings.-annual screening.

• consultation

• chemoimmunotherapy

  • 2022-06-07 doxorubicin 50mg/m2 70mg 10min + cyclophosmamide 500mg/m2 700mg 1hr
  • 2021-11-16 bevacizumab 17.5mg/kg 375mg 1.5hr
  • 2021-10-26

700356362

221202

{Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1}

• diagnosis
  • malignant neoplasm of appendix
  • secondary malignant neoplasm of retroperitoneum and peritoneum
  • hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
  • anemia, unspecified
• exam finding
  • 2022-11-17, -09-29 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • Nodular and linear opacities projecting in right middle lung, right lower lung, and left lower lung are noted. Please correlate with CT.
  • 2022-09-09 ECG
    • Sinus bradycardia with Premature atrial complexes
  • 2022-09-08 24hr portable ECG
    • Sinus rhythm
    • Occasional isolated apcs
    • Rare apc couplets
    • Rare episodes short run atrial tachycardia (longest: 11 beats)
    • Rare isolated vpcs
    • No long pause
    • No significant tachyarrhythmia
    • Frequent sinus bradycardia even at day-time, please correlate with clinical and drug history to r/o chronotropic incompetence
  • 2022-09-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (146 - 31) / 146 = 78.77%
      • M-mode (Teichholz) = 78
    • Mild septal hypertrophy with indeterminated LV filling pressure; moderately dilated LA.
    • Dilated LV with normal LV and RV systolic function.
    • Prominent aortic valve sclerosis with mild AR; mild MR; mild TR; mild PR.
    • Dilated aortic root with mild calcification.
    • Sinus bradycardia.
  • 2022-09-06 ECG
    • atrial fibrillation with slow ventricular response
  • 2022-07-08 Flow volume loop and volume time curve
    • mild restrictive ventilatory impairment
  • 2022-07-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (147 - 56) / 147 = 61.90%
    • Dilated LA, LV, Ao
    • Adequate LV, RV systolic function with normal wall motion
    • Thick IVS, Impaired LV relaxation
    • Mild MR,TR,AR
  • 2022-06-30 Electroencephalogram, EEG
    • normal awake EEG with alpha rhythm 9-10Hz.
  • 2022-06-07 CT - chest
    • Findings
      • Lungs:
        • lobular areas of consolidation and centrilobular nodular and branching opacities as well as septal thickening at LLL, RML and RLL, in progression.
        • centrilobular nodular and branching opacities at posterior RUL.
        • subsegmental consolidation with centrilobular nodular and branching opacities at LLL.
      • Mediastinum and hila: a 5 mm nodule in thymic bed.
      • Several mildly enlarged LNs in visceral space.
      • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
      • pulmonary arteries: normal caliber and well opacification.
      • Heart: normal in size of cardiac chambers.
      • Pleura: small bilateral effusions.
      • Visible abdominal-pelvic contents: s/p peritoneal drains in place.
        • extensive and large soft-tissue mass at anterior peritoneal cavity, displacing and compressing liver surface, with Rt perihepatic loculated ascites, and moderate free ascites.
        • several small Rt renal cysts.
        • unremarkable of the spleen, adrenal glands, the pancreas.
    • Impression:
      • lung infection in progression. hyperplastic reactive mediastinal LNs.
      • peritoneal carcinomatosis.
  • 2022-06-06 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • Nodular and linear opacities projecting in right middle lung, right lower lung, and left lower lung are noted. Please correlate with CT.
  • 2022-05-09 Chest XR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • Nodular opacities projecting in right middle lung, right lower lung, and left lower lung are noted. Please correlate with CT.
  • 2022-04-12 CT - CTA, chest
    • Findings
      • Lungs:
        • lobular areas of consolidation and centrilobular nodular and branching opacities at RML and RLL. centrilobular nodular and branching opacities at posterior RUL.
        • subsegmental consolidation with centrilobular nodular and branching opacities at LLL.
        • ground glass nodule solid nodule at RUL RML RLL LUL LLL (up to 2. Mediastinum and hila: a 5 mm nodule in thymic bed.
      • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
      • pulmonary arteries: normal caliber and well opacification.
      • Heart: normal in size of cardiac chambers.
      • Pleura: small Lt-sided effusion.
      • Visible abdominal-pelvic contents:
        • extensive and large soft-tissue mass at anterior peritoneal cavity, displacing and compressing liver surface, with Rt perihepatic loculated ascites.
        • several small Rt renal cysts.
        • unremarkable of the spleen, adrenal glands, the pancreas.
    • Impression:
      • no pulmonary embolism.
      • lung infection or aspiration pneumonia.
      • peritoneal carcinomatosis.
  • 2022-04-02 Chest PA/AP view
    • Supine chest image shows:
      • elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
      • reticular opacities over Lt lower lung zone
      • marginal spurs of multiple vertebral bodies
  • 2022-03-28 Body fluid cytology - ascites
    • Atypia
    • Smears show mucinous material, neutrophils and reactive mesothelial cells.
  • 2022-01-17 Tc-99m MDP whole body bone scan
    • Faint hot spots in the left 11th costovertebral junction and both rib cages, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3-6 months for further evaluation.
    • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral shoulders, hips, and ankles.
  • 2022-01-17 MRA - brain
    • Mild general brain atrophy. Left mastoiditis. Bilateral chronic paranasal sinusitis.
  • 2022-01-13 CT - CTA, chest
    • Post op. change of the abodominal cavity.
    • Locualted effusion at RLQ of the abdomen. Nature?
    • No evidence of pulmonary embolism nor aortic dissection is found.
    • Some small patches at both lungs. suspected infection.
  • 2022-01-13 CT - brain
    • Mild ventriculomegaly. Intracraniaal artherosclerosis.
  • 2022-01-13 KUB
    • The psoas shadow is clear.
    • Degenerative change of the bony structure with marginal osteophyte formation is identified.
    • Increased intestinal gas is found.
    • Osteopenia of the bony structure is noted.
  • 2021-12-31 Patho - soft tissue tumor, extensive resection
    • pathologic diagnosis
      • Peritoneum, RUQ and right flank, peritonectomy - Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1
      • Round ligament of liver, excision - Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1
      • Greater omentum, omentectomy - Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1
    • microscopic examination
      • The sections show a picture of pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1, composed of abundant mucin with scant cohesive strips of low-grade mucinous epithelium.
  • 2021-12-27 Patho - pleural/pericardial biopsy
    • Lung, left, CT-guide biopsy - interstitial fibrosis and chronic inflammation - atypical pneumocyte present
      
    • Sections show alveolar lung tissue with interstitial fibrosis, chronic inflammatory cell infiltration and atypical pneumocyte proliferating along the alveolar wall.
    • No granuloma or malignancy is found.
    • IHC: CK7(+), CK20(-), TTF-1(+), Napsin A(+), and CDX2(-).
  • 2021-12-14 CT - lung/mediastinum/pleura
    • lung infection or aspiration pneumonia.
    • peritoneal carcinomatosis. RUQ free air due to infection or prior abdominal intervention.
  • 2021-12-06 Patho - peritoneum biopsy
    • diagnosis
      • Omentum, biopsy - metastatic mucinous adenocarcinoma, origin?
      • Peritoneum, biopsy - metastatic mucinous adenocarcinoma, origin?
    • IHC: CK7(-), CK20(+), CDX2(+), and PAX8(-). The results are in favor of GI tract (including appendix) tumor.
  • 2021-12-03 Colonoscopy
    • mixed hemorrhoid
    • no tumor was found in colonic lumen
• consultation
  • 2022-09-08 Cardiology
    • Q
      • For bradycardia was noted last night, associated symptoms with syncope, chest tightness, we need your further evaluation and management.
      • The patient is an 72-year-old man with a history of Benign prostatic hyperplasia with Hamalidge OCAS control, Appendix cancer with peritoneal metastatic mucinous adenocarcinoma, cT4aN1aM1, stage IVA status post laparoscopic examination and biopsy on 2021/12/06, immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), with IP chemotherapy (Docetaxel + cisplatin 60ml each with N/S 500ml and Gentamycin + Jusomin equally split to port-a at abdomen and oral chemotherapy with TS1 25mg/cap 3cap QD for one weeks and add IV chemotherapy.
    • A
      • S
        • This is a 72 years old man who was admitted for chemotherapy for appendiceal cancer.
        • We were consulted for near syncope survey. She is currently in abdominal pain for intraperitoneal assess route catheter infection.
      • O
        • Vital sign : stable
        • 2022/07/08 echography showing
          • EF: 66%
          • Dilated LA, LV, Ao
          • Adequate LV, RV systolic function with normal wall motion
          • Thick IVS, Impaired LV relaxation
          • Mild MR, TR, AR
        • EKG: sinus bradycardia with poor isoelectric line.
      • Impression
        • Near syncope rule out vaso-vagal. syncope or sick sinus syndrome
        • PD assess site infection under tapimycin
        • Sinus bradycardia.
      • Suggestion
        • Adequate pain control and fluid support
        • to check BP and HR at supine, sitting and standing position with 5 mins of interval to exclude postural hypotension
        • to check thyroid function and to arrange 24 H holter monitor due to marked sinus bradycardia episode.
        • Consider to consult neurology for neurogenic cause.
  • 2022-01-14 Neurology
    • Q
      • For seizure evaluation
      • This 72 y/o male has history of BPH. He just discharge on 20220108 due to mucinous adenocarcinoma of appendix with peritoneal metastatic, cT4aN1aM1, stage IVA, status post omentectomy and peritonectomy and PD tube inserted and intraperitoneal port implantation + HIPEC on 20211230.
      • According to his statement, he suffered from chest tightness, dyspnea since yesterday. He went to our ER for help on 20220113. His EKG data showed NSR, cardiac enzyme within normal range, D-dimer: 3730ng/ml. Unfortunately, he had seizure(hanging eyes) for 5 seconds at ER, Ativan and Keppra stat were given. Brain CT without constrast was done and showed mild ventriculomegaly, intracranial atherosclerosis. Chest CTA was done it revealed (1) no evidence of pulmonary embolism nor aortic dissection, (2) left pleural effusion and minimal right pleural effusion, (3) locualted effusion at RLQ of the abdomen. Nature?, (4) Some small patches at both lungs. suspected infection. Now, his con’s clear, stable of vital sign, pupil size 3.0 (OU) light reflux, four limbs muscle power 5point. We need your expertise for seizure evaluation and management. Thanks for your times.
    • A
      • Due to seizure at ER, we are consulted. Patient told he had no history of seizure and he didn’t remember during seizure attack. He also denied tongue biting, urinary/bowel incontinence, todd’s paralysis, diplopia, swallowing problem, slurred speech, limbs numbness or limbs weakness.
      • NE
        • Consciouness: E4V5M6
        • Visual field: no hemianopia
        • EOM: free
        • Pupil: 3.0/3.0 mm, Light reflex: +/+
        • Face: no central facial palsy
        • No dysarthria
        • no tongue deviation
        • Muscle power: 5/5
        • Babinski: down/down
        • Sensory: no hypoesthesia
        • FNF & HKS: no dysmetria
        • D dimer : 3700, Na 124, CRP 4.9
      • Assessment
        • Generalized tonic clonic seizure, 1st episode, suspected metastasis related or electrolyte imbalance
        • mucinous adenocarcinoma of appendix, stage IV A
      • Suggestion
        • Arrange EEG and MRA brain with/without contrast to r/o metastasis
        • Vit B6 1# bid po and Keppra 500mg bid po for seizure
        • We have given seizure educations to caution on driving scooter/car
  • 2022-01-06 Hemato-Oncology
    • Q
      • For further bidirectional chemotherapy evaluation
      • This 71 years old male has history of benign prostatic hyperplasia under medication treatment. According to his statement, he suffered from abdomen fullness for half year and body weight loss 4 kgs within 6 months, ever has tarry stool at 3 months ago. Then the symptom of RLQ pain worse since 2021-09, so he went to the Shin Kong Hospital for help.
      • On 2021-11-25 abdomen CT showed (1) Ruptured appendix mucinous cancer with peritoneal carcinomatosis, omental caking and hepatic surface implantation, (2) Focal peribronchial inflammation. And he was admitted to our Oncology ward for survey on 2021-11-29. During last admitted, he underwent laparoscopic examination with peritoneal tumor biopsy was done on 2021-12-06.
      • The pathology revealed metastatic mucinous adenocarcinoma. On 2021-12-14 following chest and abdomen CT was performed which showed (1) lung infection or aspiration pneumonia, (2) peritoneal carcinomatosis. Abdomen echo was done and showed no GB stone. Heart echo revealed LVEF: 80%, aortic valve sclerosis with mild AR; mild to moderate MR; mild TR; moderate PR. We check tumor marker showed CEA: 10.93ng/ml, CA-199: 283.12U/ml.
      • Under stable condition condition and fair oral intake, he was discharge on 20211215. After discharge, he was followed at GS OPD. He denied of poor appetite, no nausea or vomit, no tarry stool, no bloody stool, no abdomen fullness, no abdomen pain. Physical examination showed andomen ovoid and soft, no tenderness, no palpable mass. After fully explain, right hemicolectomy and cytoreductive surgery and HIPEC was suggested. This time, he was admitted to our ward for lung lesion biopsy and surgical intervention. However, during operation his PCI: 29/39 was noted, thus underwent omentectomy, peritonectomy, CAPD and IP port implantation and HIPEC with oxaliplatin 300mg/m2 was done on 20211230. Now, he try to semi-liquid diet was smoothly, normal bowel function and stable condtion. We need your expertise for further bidirectional chemotherapy evaluation. Thanks for your times.
    • A
      • This 71 years old man is a case of Appendix cancer with peritoneal metastatic mucinous adenocarcinoma, cT4aN1aM1, stage IVA status post laparoscopic examination and biopsy on 2021/12/06, immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), and PAX8(-), ECOG:0 s/p omentectomy, peritonectomy, CAPD and IP port implantation and HIPEC with oxaliplatin 300mg/m2 was done on 20211230. For bidirectional chemotherapy, we are consulted.
      • The impact of adjuvant chemotherapy following CRS/HIPEC in appendiceal mucinous neoplasms has not been well established due to rareness of this disease and lack of randomized trials. In the advanced-disease setting, available retrospective data suggest beneficial effect from systemic chemotherapy in moderate- to high‐grade appendiceal mucinous tumors.
      • Systemic therapy with FOLFOX/bevacizumab +/- IP chemotherpay as ajuvant chemotherapy may consider in this case
      • We will disucss with patient, thanks for your consultation
  • 2021-12-09 General and Gastroenterological Surgery
    • Q
      • for metastatic mucinous adenocarcinoma surgery, prepare the IP chemotherapy and on port-a evaluation
      • This time, he is admitted for colonfibroscopy examination and biopsy and staging, follow-up colonoscopy: no tumor was found in colonic lumen on 20211203, and he received the laparoscopy for tumor biopsy showed metastatic mucinous adenocarcinoma, origin? The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), and PAX8(-). The results are in favor of GI tract (including appendix) tumor. So we need your help for metastatic mucinous adenocarcinoma (for peritoneum biopsy) surgery, prepare the IP chemotherapy and on port-a evaluation, thanks a lot!!
    • A
      • impression
        • psudomyxoma with peritoni, favor appendical mucinous adenocarcinoma related
      • suggest
        • radical right hemicolectomy with cytoreductive surgery and HIPEC is indicated
        • please arrange 2D echo and PFT first
        • please transfer to our survice next Monday
        • PPN support
• surgical operation
  • 2021-12-30
    • omentectomy
    • RUQ and right flank peritonectomy
    • CAPD (continuous ambulatory peritoneal dialysis)
    • IP port implantation
  • 2021-12-06 Laparoscopic exploration and biopsy
    • Post-Op Dx: suspect pseudomyxoma peritoni        
    • Finding
      • Multiple white nodular lesions within omentum and peritoneal surface were noted. pieces were excised of them for biopsy.
      • Gelly like ascites about 100 ml and ascites cytology was done.
• chemotherapy
  • 2022-12-01 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
  • 2022-11-18 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
  • 2022-11-04 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
  • 2022-10-17 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
  • 2022-09-30 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
  • 2022-08-15 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr (The patient complaints poor intake due to the oral chemotherapy, so shift to TS1 25mg/cap 3cap QD for one week)
  • 2022-06-06 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
  • 2022-05-10 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
  • 2022-04-15 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
  • 2022-03-25 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 80mg + NaHCO3 70mg/mL 80mL] in N/S 500mL IP 1.5hr x2 = 3hr ?
  • 2022-03-04 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 80mg + NaHCO3 70mg/mL 80mL] in N/S 500mL IP 1.5hr x2 = 3hr ?
  • 2022-02-09 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 80mg + NaHCO3 70mg/mL 80mL] in N/S 500mL IP 1.5hr x2 = 3hr ?
    • Neoadjuvant Intraperitoneal Chemotherapy in Patients with Pseudomyxoma Peritonei - A Novel Treatment Approach
      • Cancers 2020, 12(8), 2212; https://doi.org/10.3390/cancers12082212

[assessment]

• The vital signs are stable, and laboratory results indicate a grossly normal condition, except for hypomagnesemia (2022-12-01 1.6 mg/dL) which is being treated with magnesium sulfate injection.

220906

[assessment]

• If neoadjuvant or adjuvant systemic chemotherapy is needed, a combination of fluoropyrimidine and an alkylating agent is recommended. 5-FU (TS-1) and oxaliplatin were included in the regimen used in the last hospitalization (2022-08-15). (ref: Lin, YL. et al. Consensuses and controversies on pseudomyxoma peritonei: a review of the published consensus statements and guidelines. Orphanet J Rare Dis 16, 85 (2021). https://doi.org/10.1186/s13023-021-01723-6 ).
• Due to the patient’s poor intake caused by TS-1, the regimen has been changed to 7 consecutive days of administration. If this is also followed by a week of rest, thereby making the cycle 14 days, then the dose of oxaliplatin might need to be adjusted to accommodate this modification in cycle length.

220607

[assessment]

• This case represents a patient with pseudomyxoma peritonei (PMP), who underwent omentectomy, RUQ, and right flank peritonectomy in 2021-12-30 along with hyperthermic intraperitoneal chemotherapy (HIPEC).
• The patient has been receiving intraperitoneal treatment with [docetaxel + cisplatin + gentamicin] since 2022-02-09 in conjunction with oral TS-1, a regimen that has been outlined at doi:10.3390/cancers12082212.
• Since records began in Nov 2021, certain items of lab results have been consistently outside normal ranges. These include low HGB (2022-06-07 8.7g/dL), low RBC (2022-06-07 2.61 106/uL), and high D-dimer (2022-06-06 6969.93 ng/mL FEU).
• Anemia is rarely mentioned in PMP case reports, so it is possible that anemia could be caused by another condition which might be worth further investigation.
• TPR and BP are generally normal and stable since this hospital stay from 2022-06-06.

220606

{drug identification}

Total 1 drug for identification.

The identified item is Vemlidy film-coated tablet containing tenofovir alafenamide 25mg which is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults with compensated liver disease.

The drug will be sent back to ward by the in-hospital porter.

220406

[assessment]

• This is a patient with pseudomyxoma peritonei (PMP), s/p omentectomy, RUQ and right flank peritonectomy (2021-12-30) and hyperthermic intraperitoneal chemotherapy (HIPEC).
• From 2022-02-09, he has been receiving intraperitoneal [docetaxel plus cisplatin + gentamicin] in combination with oral TS-1, a regimen which was published at doi:10.3390/cancers12082212.
• Hypoosmolarity and hypoelectrolytemia are treated with appropriate electrolyte solutions.
• A low WBC reading of 910/uL was recorded on 2022-04-05. G-CSF might be an option.

700561561

221202

{pancreatic cancer, endometrial cancer}

• diagnosis
  • Pancreatic cancer with peritoneum metastasis s/p Laparoscopic exploration on 2022/02/25
  • Endometrial cancer, pT1bN0M0, Stage IB status post laparoscopic vaginal total hysterectomy on 2018/04/17
• lab data
  • CEA
    • 2022-07-26 CEA 5.21 ng/mL
      
    • 2022-05-02 CEA 3.10 ng/mL
      
    • 2022-01-24 CEA 1.96 ng/mL
      
    • 2021-10-25 CEA 1.84 ng/mL
      
  • CA125
    • 2022-07-26 CA125 788.2 U/mL
      
    • 2022-05-02 CA125 460.8 U/mL
      
    • 2022-01-24 CA125 15.1 U/mL
      
    • 2021-10-25 CA125 5.8 U/mL
      
    • 2021-07-26 CA125 5.5 U/mL
      
    • 2021-04-26 CA125 3.5 U/mL
      
  • CA199
    • 2022-07-26 CA199 12024.11 U/mL
      
    • 2022-05-23 CA199 >19680.00 U/mL
      
    • 2020-04-13 CA199 23.72 U/mL
• exam finding
  • 2022-11-28 CT - abdomen
    • Indication: Pancreatic cancer with peritoneal carcinomatosis
    • Findings
      • Abdomen and pelvis
        • Low density change at pancreatic tail about 4.74cm in largest dimension is found. pancreatic cancer is considered. In comparison with CT dated on 2022-09-05, the lesion is stationary.
        • Massive ascites is found. Cancerous peritontitis is considered first
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Low density lesion at S4 of liver about 2.5cm in largest dimension is found. Liver meta is considered. In progression.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • The spleen, pancreas, both kidneys and adrenals are intact.
      • Visible chest
        • Cardiomegaly is noted.
        • No pleural effusion is found.
        • Clear bilateral basal lungs.
      • Suggest clinical correlation
    • Imp:
      • Pancreatic tail cancer with cancerous peritonitis and massive ascites. Stable.
      • Liver meta. In progression.
      • Bone meta. Please correlate with bone scan study.
  • 2022-11-16 CXR
    • Fracture of left clavicle, M/3.
    • Pleura effusion of right and left costal-phrenic angle
    • Atherosclerotic change of aortic arch
  • 2022-09-05 CT - abdomen
    • Indication: Pancreatic cancer with peritoneal seedings
    • Findings
      • Abdomen and pelvis
        • s/p ATH and BSO.
        • Low density lesion at pancreatic tail about 4.6cm is found. In comparison with CT dated on 2022-05-09, the lesion is stationary.
        • Massive ascites is found. Cancerous peritonitis is considered.
        • The GB is well distended without soft tissue lesion
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Low density lesion at S4 of liver about 0.7cm in largest dimension is found. suspected liver meta or others. Stationary.
        • There is no evidence of paraarotic LAPs.
      • Visible chest
        • Normal heart size.
        • The lung fields are clear.
        • No pleural effusion is found.
      • Suggest clinical correlation
    • Imp:
      • Massive ascites, suspected cancerous peritonitis
      • Pancreatic tail tumor, 4.6cm, stable. Pancreatic cancer is favored.
      • Bone meta. New.
      • Liver low density lesion. S4, meta?
  • 2022-06-14 SONO - abdomen
    • Gallbladder sludge
    • Asictes
  • 2022-06-10 CXR
    • S/P port-A implantation.
    • Fracture of left clavicle, M/3.
    • Pleura effusion of right and left costal-phrenic angle
    • Atherosclerotic change of aortic arch
  • 2022-06-09 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 18 dB HL; LE 24 dB HL
    • bil normal to moderate SNHL (sensorineural hearing loss)
  • 2022-05-25 Patho - peritoneum biopsy
    • Peritoneum, biopsy — Metastatic adenocarcinoma, origin? (please see microdescription)
    • Section shows fibroadipose tissue with metastatic adenocarcinoma.
    • The immunohistochemical stians reveal CK7(+), CD20(-), CDX2(focal weak +), GATA3(+), PAX8(-), and Calretinin(-).
    • The results are more favor pancreatic tumor than endometrial tumor.
  • 2022-05-25 Patho - omentum biopsy
    • Greater omentum, biopsy — Negative for malignancy
  • 2022-05-24 ECG
    • Sinus tachycardia
    • Low voltage QRS
  • 2022-05-24 SONO - abdomen
    • massive ascites
    • diffuse wall-thickening of small bowel, suspected carcinomatosis
  • 2022-05-13 Clavicle LT
    • Left M/3 clavicle fracture
  • 2022-05-09 CT - abdomen, pelvis
    • s/p ATH and BSO.
    • Massive ascites and bilateral pleural effusion is found.
    • Pancreatic body lesion about 5.53cm in largest dimension is found. Either meta or primary tumor should be D.D.
  • 2022-05-09 Gynecologic ultrasonography
    • p/s ATH + BSO
    • Ascites (+)
  • 2022-05-04 Gynecologic ultrasonography
    • Bil adnexa: s/p BSO
    • EM cancer post staging, ascites (+)
    • suspected tumor recurrence
  • 2022-05-04 KUB
    • Presence of ileus.
  • 2022-05-04 CXR
    • Fracture of left clavicle.
    • Left pleural effusion.
    • Presence of ileus.
  • 2022-04-01 Clavicle LT
    • Left M/3 clavicle fracture with displacement
  • 2022-01-26 CT - abdomen, pelvis
    • S/P hysterectomy. There is no evidence of tumor recurrence.
    • A lesion in S4 liver shows stationary.
    • The gallbladder shows few small stones and posterior displacement by the S4 liver lesion.
  • 2021-11-01 Gynecologic ultrasonography
    • p/s ATH + BSO
    • no obvious uterine or ovarian lesion
  • 2021-07-26 CT - abdomen, pelvis
    • S/P hysterectomy.
    • No evidence of tumor recurrence.
  • 2021-05-03 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • Hepatic high echoic lesions, nature? fibrosis lesions?
      • GB stones
      • Fatty pancreas
    • Suggestion
      • Please correlate with clinical information and other image studies, and follow sonography in 3-6 mon.
      • Please check tumor, hepatitis markers and LFTs q3-6 mon
  • 2021-05-03 Gynecologic ultrasonography
    • p/s ATH + BSO
    • no obvious uterine or ovarian lesion
  • 2020-10-07 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • Hepatic low echoic lesions, nature?
      • GB stones
      • Fatty pancreas
    • Suggestion
      • Please correlate with clinical information and other image studies, and follow sonography in 3-6 mon.
      • Please check tumor, hepatitis markers and LFTs q3-6 mon
  • 2020-07-27 CT - abdomen, pelvis
    • S/P hysterectomy.
    • No evidence of tumor recurrence.
  • 2020-04-13 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • GB stones?
    • Suggestion
      • Please follow sonography in 3-6 mon.
  • 2020-04-13 Gynecologic ultrasonography
    • p/s ATH + BSO
    • no obvious uterine or ovarian lesion
  • 2020-01-03 CT - abdomen
    • S/P hysterectomy. There is no evidence of tumor recurrence.
    • A lesion in S4 liver is suspected. Follow up MRI 3 months later may be indicated.
    • The gallbladder shows few small stones and posterior displacement by the S4 liver lesion.
  • 2019-09-26 Transvaginal Ultrasonography
    • No obvious uterine or ovarian lesion
  • 2019-06-03 CT - abdomen
    • S/P hysterectomy. There is no evidence of tumor recurrence.
    • A lesion in S4 liver is suspected.
    • The gallbladder shows few small stones and posterior displacement by the S4 liver lesion.
  • 2019-02-25 Transvaginal Ultrasonography
    • No obvious uterine or ovarian lesion
  • 2018-11-27 CT - abdomen
    • s/p ATH and BSO.
    • No focal lesion in the pelvis
  • 2018-05-11 CT - abdomen
    • S/P hysterectomy.
    • Relative dirty mesentery fat plane, post-op change?
    • Loculated fluid density in right obturator region, suspected lymphocele or seroma, suggest follow up study.
  • 2018-05-11 Transvaginal Ultrasonography
    • No obvious uterine or ovarian lesion
  • 2018-04-18 Patho - laparoscopic vaginal total hysterectomy (LAVH), Level VI
    • Uterus, endometrium, laparoscopic vaginal total hysterectomy (LAVH) — Endometrioid adenocarcinoma, grade 1
    • Uterus, myometrium, laparoscopic vaginal total hysterectomy (LAVH) — Endometrioid adenocarcinoma, invading >1/2 of the thickness of the myometrium.
    • Uterus, cervix, laparoscopic vaginal total hysterectomy (LAVH) — Free.
    • Ovaries and fallopian tubes, bilateral, laparosocpic salpingo-oophorectomy (BSO) — Free
    • Lymph node, bilateral pelvic, dissection (BPLND) — Free (0/25)
    • Omentum, omentectomy — Free (with one lymph node free of malignancy 0/1)
    • AJCC 8th edition Pathology stage: pT1bN0 (if cM0); pStage: IB.
    • S2018-05404: ER (+, 90%), PR (+, 90%)
  • 2018-04-14 MRI - pelvis
    • Imaging Report Form for Endometrial Carcinoma
    • Impression:
      • Endometrial malignancy, cstage T1bN0Mx.
      • Right obturator lymph node, suggest follow up.
  • 2018-04-03 Surgical pathology Level IV
    • Uterus, endometrium, D&C — Adenocarcinoa with squamous metaplasia.
    • IHC: ER (+, 90%), PR (+, 90%), p40 (-), p16 (+, 70%), vimentin (+, 80%).
  • 2018-04-02 Gynecologic ultrasonography
    • Suspected endometrial hyperplasia
• consultation
  • 2022-05-04 Obstetrics and Gynecology
    • Q
      • poor appetite after traffic accident in Feburary
      • diarrhea, nausea for 2 weeks
      • periumbilical fullness for 2 weeks
      • EGD at LMD last week: GERD
      • abdominal sono at LMD on 5/2: ascites
      • PH: Malignant neoplasm of endometrium S/P hysterectomy, R/T
      • Allergy: NKA
    • A
      • findings
        • a case of endometrial cancer post staging surgery (ATH + BSO + BPLND + omentectomy) + radiotherapy in 2018.
        • post op course was smooth without recurrence, checked by CT scan, sonar and tumor marker until 2022/2
        • c/o abdominal distension, poor appetite for 2 weeks (c/o: complaint of)
        • no fever nor pain
        • CA125: 15 -> 460 elevated
        • GYN sonar: ascites > 1000 c.c
        • PV – vaginal stump no mass palpated, seemed free
        • no bleeding
      • Imp
        • ascites,
        • suspected cancer recurrence
      • Suggestion:
        • consider to arrange abdominal tapping (+ send ascites cytology) if indicated
        • symptom treatment with gascon, etc
        • please arrange abdominal CT scan
        • scheduled 20220509 W1 GYN OPD for further Tx
• surgical operation
  • 2022-05-25
    • Operation
      • Laparoscopic exploration
    • Finding
      • Massive turbid ascites, > 4000cc
      • Multiple peritoneal seedings, compatible with carcinomatosis
      • Culture: ascites*1
  • 2018-04-17
    • Diagnosis
      • endometrial cancer (adenocarcinoma)
    • PCS
      • 80424B
    • Finding
      • Uterus: enlarged, 12x10x7cm
      • endometrium – thickened, soft necrotic tissues at fundus; EM cancer cells likely
      • myometrium – seemed invaded by cancer
      • cervix eroded
      • bil adnexa: normal-looking, seemed free of cancer invasion
      • omentum, appendix, bowels: seemed free of cancer invasion
      • CDS: no fluid (send ascites washing cytology) but severe pelvic bowel adhesion (due to previous vertival laparotomy?) was noted between ant peritoneum, left pelvis and bowels; between uterus and ant bladder s/p LSC adhesiolysis
      • A 7mm JP drain was placed in CDS
  • 2018-04-02
    • Diagnosis
      • Suspected endometrial hyperplasia or cancer – EM 2.43cm
    • PCS
      • 80423B
    • Finding
      • Under IVGA, Hysteroscopic endometrial curettage were done.
      • Thickened endometrium noted with a lot of soft necrotic tissues, suspected endometrial hyperplasia or cancer
• chemoimmunotherapy
  • 2022-11-09 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
  • 2022-10-26 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
  • 2022-10-19 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
  • 2022-10-05 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
  • 2022-09-28 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
  • 2022-09-14 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 90min
  • 2022-09-07 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 90min
  • 2022-08-24 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
  • 2022-08-17 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
  • 2022-08-04 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
  • 2022-07-28 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
  • 2022-07-14 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
  • 2022-07-08 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
  • 2022-06-21 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
  • 2022-06-14 - gemcitabine 800mg/m2 1250mg 30min + cisplatin 20mg/m2 30mg 24hr

[assessment]

• It should be noted that both serum creatinine and BUN increased 50% in the last two weeks (Cre 1.76 mg/dL 2022-11-30 <- 1.18 mg/dL 2022-11-16; BUN 33 mg/dL 2022-11-30 <- 20 mg/dL 2022-11-16), as well as bilirubin total exceeded 6 x ULN (6.95 mg/dL 2022-11-30).

• 2022-11-30 eGFR 31.2

  • gemcitabine for patients with altered kidney function:
    • CrCl >= 30 mL/minute: IV: No dosage adjustment necessary (Cetina 2004; Delaloge 2004; Li 2007; Lichtman 2007; Venook 2000).
    • CrCl <30 mL/minute: IV: No dosage adjustment necessary. However, risk of hematologic toxicity may be increased in these patients, which may require gemcitabine dose modification (Cetina 2004; Li 2007; Lichtman 2007; Mir 2005; Tanji 2013; Venook 2000).
  • nab-paclitaxel for patients with altered kidney function:
    • CrCl <30 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling (insufficient data).

• 2022-11-30 bilirubin total 6.95 mg/dL, ALT 442 U/L, AST 342 U/L

  • gemcitabine for patients with hepatic Impairment - there are no dosage adjustments provided in the manufacturer’s labeling. The following adjustments have been reported:
    • Transaminases elevated (with normal bilirubin): No dosage adjustment necessary (Venook 2000).
    • Serum bilirubin > 1.6 mg/dL: Use initial dose of 800 mg/m2; may escalate if tolerated (Ecklund 2005; Floyd 2006; Venook 2000).
    • Dosage adjustment for hepatotoxicity during treatment: Discontinue if severe hepatotoxicity occurs during gemcitabine treatment.
  • nab-paclitaxel for patients with hepatic Impairment
    • Not recommended in case of AST > 10x ULN or bilirubin > 5x ULN

• It is suggested to ensure that the patient’s kidney and liver function are in good condition prior to the chemotherapy.

220729

[assessment]

• Tumor markers
  • CEA
    • 2022-07-26 5.21 ng/mL
      
    • 2022-05-02 3.10 ng/mL
      
    • 2022-01-24 1.96 ng/mL
      
    • 2021-10-25 1.84 ng/mL
      
  • CA125
    • 2022-07-26 788.2 U/mL
      
    • 2022-05-02 460.8 U/mL
      
    • 2022-01-24 15.1 U/mL
      
    • 2021-10-25 5.8 U/mL
      
    • 2021-07-26 5.5 U/mL
      
    • 2021-04-26 3.5 U/mL
      
  • CA199
    • 2022-07-26 12024.11 U/mL
      
    • 2022-05-23 >19680.00 U/mL
      
    • 2020-04-13 23.72 U/mL
      
• In recent months, tumor markers have trended upward. The current regimen has been used to treat patients since mid-June 2022 (still less than 2 months).
• FOLFIRINOX vs Gemtabine plus Nab-Paclitaxel, there is disagreement among studies regarding the choice between the two. references:
  • Klein-Brill A, Amar-Farkash S, Lawrence G, Collisson EA, Aran D. Comparison of FOLFIRINOX vs Gemcitabine Plus Nab-Paclitaxel as First-Line Chemotherapy for Metastatic Pancreatic Ductal Adenocarcinoma. JAMA Netw Open. 2022;5(6):e2216199. doi:10.1001/jamanetworkopen.2022.16199
  • Riedl JM, Posch F, Horvath L, et al. Gemcitabine/nab-Paclitaxel versus FOLFIRINOX for palliative first-line treatment of advanced pancreatic cancer: A propensity score analysis. Eur J Cancer. 2021;151:3-13. doi:10.1016/j.ejca.2021.03.040
  • Chun JW, Lee SH, Kim JS, et al. Comparison between FOLFIRINOX and gemcitabine plus nab-paclitaxel including sequential treatment for metastatic pancreatic cancer: a propensity score matching approach. BMC Cancer. 2021;21(1):537. Published 2021 May 11. doi:10.1186/s12885-021-08277-7
  • Tahara J, Shimizu K, Otsuka N, Akao J, Takayama Y, Tokushige K. Gemcitabine plus nab-paclitaxel vs. FOLFIRINOX for patients with advanced pancreatic cancer. Cancer Chemother Pharmacol. 2018;82(2):245-250. doi:10.1007/s00280-018-3611-y

220706

[assessment]

• No mutation test results were found for BRCA1/2 or PALB2. A change in the regimen from gemcitabine + cisplatin to gemcitabine + nab-paclitael has been made in late June 2022. Whereas FOLFINOX or modified FOLFINOX (not used in this case) should be limited to patients with an ECOG of 0 or 1.
• There has been a low potassium level of 1.9 mmol/L on 2022-07-05. A KCl injection, oral potassium gluconate, and a spironolactone dose have been prescribed.

700570266

221202

• diagnosis
  • 2022-08-15 discharge
    • Malignant neoplasm of cervix uteri, unspecified
    • cervical cancer (adenocarcinoma), stage IVa post CCRT, suspected cancer recurrence (C53.9)
    • urinary tract infection, urine culture: mixed growth 7000
    • constipation
• past history
  • Septoplasty, 20 years ago
  • Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion, start radiotherapy and chemotherpy since 2021/04
  • Large gallstone 2021/03
  • Left side moderate hydronephrosis and hydroureter 2021/03
  • C/S surgery (Cesarean Section), by patient personal choose  
• family history
  • Mother: Colon cancer
  • Father: HCC
  • Sister: Breast cancer   
• exam finding
  • 2022-11-10 CT - abdomen
    • S/P hysterectomy. No evidence of tumor recurrence.
    • S/P bilateral double J catheters insertion.
  • 2022-10-12 CXr
    • S/P Port-A infusion catheter insertion.
    • S/P bilateral double J catheters insertion.
    • Solitary pulmonary nodule at RLL.
    • Normal appearance of trachea and bil. main bronchus.
  • 2022-10-04 SONO - breast
    • Diagnosis
      • Benign neoplasm of breast, infavor of benign fibrocystic disease (FCD), Uncertain breast tumor, in favor of benign fibroadenoma (FA)
    • Treatment
      • biopsy is not necessary
    • Suggestion and Plan
      • Regular OPD follow-up, Follow up breast sonography in next OPD visit
      • BI-RADS 3 - Probably Benign Finding (<2% malignant) Initial Short-Interval Follow-Up Suggested
  • 2022-08-11 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • PTA
      • R’t : 30 dB HL, normal to mild SNHL
      • L’t : 33 dB HL, normal to severe SNHL.
  • 2022-07-13 Patho - uterus with or without SO non-neoplastic/prolapse
    • Cervix uteri cancer checklist:
    • pathologic diagnosis
      • Tumor, uterine cervix, laparoscopic total hysterectomy — Adenocarcinoma
      • Endometrium, uterus, ditto — Free of tumor
      • Myometrium, uterus, ditto — Tumor invasion, leiomyoma
      • Lymph nodes, dissection — Not received
      • AJCC pathological stage (post CCRT) — ypT2a1, if cN0 and cM0, stage IIA1 / FIGO stage IIA1
        
    • microscopic examination
      • Tumor location:
        • Cervix
          
        • Vagina involvement: N/A
        • Corpus involvement: involved and one leiomyoma measured 3 cm
      • Tumor size: 2.5 x 2.0 cm
      • Tumor type: Adenocarcinoma
      • Histologic grade: moderately differentiated
      • Depth of invasion: about 0.6 cm, ＞1/2 cervical wall
      • Parametrial involvement: N/A
      • Parametrial cut end: N/A
      • Vaginal cut end: N/A
      • Lymphovascular invasion: NOT identified
      • Perineural invasion: Present
      • Lymph nodes: NOT received
    • IHC
      • P16(-), CEA(+), ER(-), PR(-), vimentin(-), P53(focal +, wild type), compatible with endocervical origin
  • 2022-05-31 Patho - cervix biopsy, endocervix curretage/biopsy
    • Uterus, cervix, biopsy (S2022-8981) — adenocarcinoma, well differentiated.
      • IHC stains: p16 (-), vimentin (-), p53 (diffuse +), Napsin-A (-), PAX-8 (+).
    • Uterus, endocervix, ECC (S2022-8982) — adenocarcinoma, well differentiated.
      • IHC stains: p16 (-), vimentin (-), p53 (diffuse +), Napsin-A (-), PAX-8 (equivocal).
  • 2022-05-18 MRI - pelvis
    • Findings
      • Soft tissue tumor(2.5cm) in cerivcal region, suspected cervical malignancy.
      • Relative thickening posterior wall of urinary bladder.
      • Soft tissue tumor, 3cm in posterior wall of uterine body, suspected uterine myoma.
      • Presence of gallbladder stones.
        
    • Impression
      • 1. Cervical tumor, suspected malignancy.
      • 2. Suspected uterine myoma.
      • 3. Relative thickening posterior wall of urinary bladder.
      • 4. GB stones.
  • 2022-02-24 Gynecologic ultrasonography
    • suspect degeneration myoma
    • adenomyosis
  • 2022-02-18 CT - abdomen
    • Findings
      • There is mild enhancing lesion 1.5 cm in left side uterine cervix area. Please correlate with physical examination or hysteroscope.
      • There is no enlarged node in left common iliac chain.
      • Soft tissue tumor 2.6 cm in posterior aspect of uterine body myometrium is noted that may be myoma.
      • S/P double J catheter insertion, bilateral.
      • Left renal cyst, 1.2cm.
    • Impression
      • Mild enhancing lesion 1.5 cm in left side uterine cervix araa. Please correlate with physical examination or hysteroscope.
  • 2021-12-06 Gynecologic ultrasonography
    • EM: 7.5mm with fluid
    • Uterine myoma
  • 2021-11-24 MRI - pelvis
    • Cervical cancer s/p RT.
    • Relative thickening posterior wall of urinary bladder with adhesion with anterior uterine cervix. Residual tumor? Suggest cystoscopy follow up.
    • Suspected uterine myoma.
    • GB stones.
  • 2021-08-17 CT - abdomen, pelvis
    • Cervical cancer with lymph node in left common iliac region s/p, regression as compare with old CT study.
    • S/P double J catheter insertion, bilateral.
    • Suspected uterine myoma.
    • Left renal cyst.
  • 2021-05-02 Gynecologic ultrasonography
    • Uterine myoma
    • Clinical: cervical cancer VIIA under CCRT with massive vaginal bleeding
  • 2021-04-19 Pure Tone Audiometry, PTA
    • PTA: Reliability FAIR
    • Average RE 31 dB HL // LE 31 dB HL
    • RE normal to mild SNHL
    • LE normal to moderately severe SNHL
  • 2021-03-31 Pathology (Cardinal Tien Hospital)
    • Uterus, exocervix, biopsy — Adenocarcinoma.
  • 2021-03-30 Patho - endocervix curretage/biopsy
    • Uterus, endocervix, ECC — severe glandular dysplasia
      
    • Immunohistochemical stain reveals CK(-), VIMENTIN (-), p16(-) and CEA(+).
      
  • 2021-03-30 Patho - cervix biopsy
    • Cervix, biopsy— adenocarcinoma
      
    • Immunohistochemical stain reveals CK(+), p16(-), CEA(+), vimentin(-). CK20(-), GATA3(-)
  • 2021-03-23 CT (Cardinal Tien Hospital)
    • Findings
      • A 7 x 3.5cm mass in the uterine cavity and extension to the cervix and, to the posterior urinary bladder wall.
      • A 3.5cm cyst at the left adnexa. No definite iliac or paraaortic lymphadenopathy.
      • No abdominal fluid collection.
    • Imp:
      • Uterine tumor involving endometrial cavity and cervix with posterior, urinary bladder wall extension, suspect endometrial ca or cervical ca.
      • Small hepatic cysts in the right lobe, Left ovarian cyst, stage cT4N1M0.
  • 2021-03-22 IntraVenous Pyelography, IVP (Cardinal Tien Hospital)
    • suspect left bladder tumor with left side obstructive uropathy.
  • 2021-03-20 SONO - abdomen (Cardinal Tien Hospital)
    • 1. Moderate fatty liver and fat infiltration the pancreas
    • 2. Large gallstone
    • 3. Left side moderate hydronephrosis and hydroureter
• consultation
  • 2021-05-02 Obstetrics and Gynecology
    • Q
      • S: Abnormal viginal bleeding since yesterday
        • No TOCC
        • She just discharged from OBGYN ward 2 days ago due to 2nd course C/T of cervical cancer.
    • A
      • S
        • P1NSD1, 25 years ago. Adenocarcinoma of the uterine cervix, FIGO stage IVA under CCRT.
        • Denied TOCC
        • She just discharged from hematology ward 2 days ago due to 2nd course C/T of cervical cancer.
          • Family history: (mother: colon cancer, elder sister: breast cancer)
          • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
          • Personal Hx: DM(-); HTN(-)
      • O
        • Endocervical adenocarcinoma; S/P radiotherapy due to cervical cancer.
        • PI: The patietn suffered from urinary frequence and post menopausal bleeding (uncertain duration).
          • GU cystoscopy – suspected meta adenocarcinoma in Cardinal Tien hospital. cervical biopsy as done in Cardinal Tien hospital, cervical cancer.
        • Previous RT Hx: (-)
        • Lab data: Hb=8.9 g/dL; CRP=1.7
        • Vaginal bleeding was noted in our ER.
        • Echo:
          • Uterus: 11.9x8.36 cm, EM: 1.3 cm with blood clot.
          • Uterine myoma 2.4x3.0 cm
      • A: Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion.
      • P: CCRT is indicated for this patient with the following indicators: FIGO stage IVA.
        • Plan:
          • Blood transfusion for anemia
          • Transamin and Ergometrine for hemostasis
          • OPD follow up
  • 2021-04-20 Obstetrics and Gynecology
    • Q
      • For vaginal bleeding
      • This 58 y/o woman was Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion.
      • She was admitted for per-chemotherapy examination and CCRT with weekly CDDP on 2021/04/15.
      • Vaginal bleeding was noted last night, we need your help for further mamagement, thanks a lot.
    • A
      • Blood clot was noted in vagina. No active bleeding right now.
      • Bosmin gauze was inserted for compression.
      • Conservative treatment, CCRT and Transamin IV were suggested.
• radiotherapy
  • 2021-04-20 ~ 2021-06-17
    • 4500cGy/25 fractions (15MV photon) of the pelvic
    • 5400cGy/30 fractions (15MV photon) of the cervical tumor
    • 7020cGy/39 fractions (15MV photon) of the cervical tumor bed.
• chemoimmunotherapy
  • 2022-12-01 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr
  • 2022-11-10 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr
  • 2022-10-21 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr
  • 2022-09-01 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr
  • 2022-08-12 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr
  • 2021-06-10 - cisplatin 40mg/m2 65mg 24hr (CCRT)
  • 2021-05-28 - cisplatin 40mg/m2 65mg 24hr (CCRT)
  • 2021-05-21 - cisplatin 40mg/m2 65mg 24hr (CCRT)
  • 2021-05-13 - cisplatin 40mg/m2 65mg 24hr (CCRT)
  • 2021-05-07 - cisplatin 40mg/m2 65mg 24hr (CCRT)
  • 2021-04-28 - cisplatin 40mg/m2 65mg 24hr (CCRT)
  • 2021-04-20 - cisplatin 40mg/m2 65mg 24hr (CCRT)

[assessment]

• There is no LVEF test result available in HIS5 currently. Since bevacizumab has been determined to be an agent that may either cause reversible direct myocardial toxicity or exacerbate underlying myocardial dysfunction (magnitude: moderate/major) (AHA [Page 2016]), It is recommended that a 2D cardiac sonography be ordered.
• Other than a slightly elevated SBP, the vital signs are stable. Readings from the lab on 2022-12-01 were generally normal.

221111

[assessment]

• Exforge (amlodipine 5mg + valsartan 160mg) QD has been prescribed by our cardiologist on 2022-10-01 for 28 days as a treatment for the patient’s primary hypertension.
• Since the patient’s blood pressure remains elevated during this hospitalization, Exforge might be considered for reinstatement to replace current Diovan (valsartan).

221024

[assessment]

In the last 3 weeks, the serum creatinine level has increased (1.24 2022-10-19 <- 1.18 2022-10-04 <- 0.80 2022-09-26). Please monitor the renal function if it continues to decline.

220921

[assessment]

• The patient’s SBP appeared to be between 146 and 197 when she arrived on the ward. The use of Sevikar (amlodipine + olmesartan) 1# QD or Exforge (amlodipine + valsartan) 1# QD might be considered to replace current Norvasc if hypertension (SBP > 150mmHg) for consecutive days is observed.

701450418

221201

• exam findings
  • 2022-10-04 Pelvis and Bilat. Hip. Lat.
    • Narrowed joint or discal space with bony sclerosis but without acute fracture, bone destruction or dislocation.
  • 2022-10-03 CXR
    • Left pleural effusion. A LLL tumor mass.
    • No cardiomegaly by cardiac/thoracic ratio.
    • Post operative appearance in or at the area of TL spine.
    • Presence of numerous small miliary-like lesions in bilateral lung fields, metastases should be rule out.
  • 2022-09-28 T-L spine AP + Lat.
    • Presence of spondylolisthesis at L4/5, grade I.
    • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s) L2.
    • S/P posterior longitudinal transpedicular spine screws and rods fixation.
  • 2022-09-27 EGFR mutation
    • A deleteion was detected at exon 19 of EGFR gene in this specimen.
    • The EGFR mutation testing was based on real-time PCR technique for detection of exons 18 (G719X), 19 (Deletions), 20 (T790M, S7681I, Insertions), 21 (L858R, L861Q) mutations of EGFR gene. The limit of detection (LoD) of this test was 10% mutant gene of whole EGFR gene.
  • 2022-09-29 PD-L1 (22C3)
    • Tumor Proportion Score (TPS) assessment: TPS < 1%
  • 2022-09-29 PD-L1 28-8 IHC
    • Tumor cell (TC) staining assessment: TC < 1%
    • Percent of PD-L1 expression in tumor cells (TC): < 1%
  • 2022-08-11 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana) - S2022-16383
      • Tumor type: adenocarcinoma
      • Tumor location: lung
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>=50 viable tumor cells): Yes,
    • Result:
      • Tumor cell (TC) staining assessment: TC category: TC < 1%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-09-26 Patho - lung transbronchial biopsy
    • Lung, left, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show neoplastic acinar glandular cells infiltrating in a fibrotic stroma.
  • 2022-09-21 Whole body PET scan
    • Glucose-hypermetabolic lesions in the left upper and lower lungs with pleura involvement, highly suspected lung cancer with lung to lung mets and malignant pleural effusion.
      
    • Glucose hypermetabolic lesions in bilateral mediastinal and right pulmonary hilar lymph nodes, highly suspected lung cancer with regional lymph nodes metastases.
      
    • Increased uptake of FDG in the right adrenal gland, L2 spine, and left frontal skull, highly suspected lung cancer with multiple distant metastases.
      
    • Left lung cancer with lung to lung, bilateral mediastinal and right pulmonary hilar lymph nodes, right adrenal gland, L2 spine, and left frontal skull metastases, cT4N3M1c, stage IVB (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-09-20 MRI - brain
    • No obvious brain or intracranial nodule or metastasis 2. r/o Focal left frontal skull metastasis.
• consultation
  • 2022-11-30 Rehabilitation
    • A
      • Assessment
        • Left lower lobe lung cancer with bilateral lung to lung meta, mediastinal lymphadenopathy, lumbar spine pathological fracture, right adrenal meta and probably liver meta
        • Multiple bone metastases with L2 pathological fracture
      • Plan
        • Rehabilitation programs: Bedside PT, OT rehabilitation programs; apply ant. AFO for left drop foot
        • Goal: improve ADL, muscle power and endurance
  • 2022-11-09 Rehabilitation
    • Assessment
      • Malignant neoplasm of lower lobe, left bronchus or lung
      • Secondary malignant neoplasm of bone
      • Left lung adenocarcinoma with pathology fracture of L2 status post L2-L3 laminectomy, fixation and postero-lateral spinal fusion on 2022/09/12 s/p TKI with Afatinib from 2022/10/25
      • Chronic viral hepatitis B without delta-agent
    • Plan
      • Rehabilitation programs: Bedside PT and OT rehabilitation programs
      • Goal: improved ADL and muscle power, ambulate with device under supervision
  • 2022-11-10 Dermatology
    • Q
      • This 48-year-old woman patient is a csae of Left lung adenocarcinoma with pathology fracture of L2 status post L2-L3 laminectomy, fixation and postero-lateral spinal fusion on 2022/09/12 s/p TKI with Afatinib from 2022/10/25. This time, for whole body skin red rash after TKI. Now, for evaluate whole body red rash therapy. Thank you.
    • A
      • The patient had sufferred from exfoliative reddish plaques with scales over face and mutiple pustular lesions over chest/back.
        
      • Under the impression of seborrheic dermatitis (immunocompressed state?) and follculitis on the trunk.
      • The following sugeetion:
        • Oral doxycycline and broen-C 1# bid po for 5 days.
        • For face, Free gel 1 tube topical bid use over large area first and consider Rinderon-V cream 2 tube topical bid over reddish itchy area.
        • For trunk, Clindamycin gel 1 tube topical bid use on the pustular lesions.
          
  • 2022-09-23 Oral and Maxillofacial Surgery
    • Q
      • This 48 years old female patient was diagnosed of lung cancer with bone metastatic. She had underwent L2, L3 laminectomy and fixation and posterior-lateral fusion cause by L2 pathological fracture with spinal stenosis. We had keep lung cancer treatment, and prepare use denosumab. We need your professional evaluation and recommendation for dental evaluation. Thank you very much for your time!
    • A
      • O:
        • Full mouth chronic periodontitis
        • Fair oral hygiene.
        • No visible caries was notd.
      • P:
        • Explain the finding to the patient.
        • Home care instrcution.
        • OPD follow up
          
  • 2022-09-21 Hemato-Oncology
    • A
      • Impression:
        • LEFT LOWER LOBE lung cancer with bilateral lung to lung meta. Mediastinal lymphadenopathy, lumbar spine pathological fracture, right adrenal meta and probably liver meta, cT4N3M1c, StageIVB
      • Suggestion:
        • family meeting has been arranged on 20220922 18:00
        • Arrange Chest CT guide biopsy for EGFR gene mutation test, PD-L1
        • May check Anti Hbc, HbsAg, Anti-HCV
        • Consult oral surgery for denal evaluation (prepare use denosumab which has been associated with osteonecrosis of the jaws)
        • We woukd like to follow up this case, thanks for your consultation. If there is any problem, please feel free to let us know.
  • 2022-09-14 Rehabilitation
    • A
      • Assessment
        • suspected left L1-L3 radiculopathy due to multiple bone metastases with L2 pathological fracture
      • Plan
        • Keep pain control medication
        • suggest waist support when sitting up
        • futher L-spine image could be follow up if pain exaggerates
• chemoimmunotherapy
  • 2022-10-25 ~ 2022-11-08 Giotrif (afatinib 30mg) 1# QDAC

[note]

• Giotrif (afatinib 30mg) nasogastric tube feeding - Alternative Methods of Administration (package insert 20210526)
  • If dosing of whole tablets is not possible, GIOTRIF tablets can be dispersed in approximately 100 mL of noncarbonated drinking water. No other liquids should be used. The tablet should be dropped into the water without crushing it, and stirred occasionally until the tablet is broken up into very small particles (approximately 15 minutes). The dispersion should be consumed immediately. The glass should be rinsed with approximately 100 mL of water which should also be consumed. The dispersion can also be administered through a gastric tube.

[assessment]

• In accordance with NCCN recommendations for NSCLC (guideline version 5.2022), osimertinib is preferred for patients with EGFR exon 19 deletion, along with erlotinib, afatinib, and dacomitinib.
• Giotrif (afatinib) was prescribed to the patient during 2022-10-25 and 2022-11-08.
• As of 2022-11-30, there were no extrem results in the lab test, and the patient’s vital signs remained stable.
• There is no issue with the active prescription.

700341408

221130

{This 80-year-old man patient is a case of Diffuse large B-cell lymphoma, Non-GCB type, at the right maxillary gingiva and tuberosity, Ki-67 index >95%, Lugano stage II, IPI score: 1, Low risk group, PS:0}

• past history
  • Hyperlipidemia
  • Arrythmia
  • Coronary artery disease, with middle left anterior descending artery myocardial bridge
• operation history:
  • s/p appendectomy
  • pituitary macroadenoma s/p transsphenoisia reemoval of pituitary adenoma on 20131105.
  • tumor excision over mesenchymal origin tumor over left buttock on 20210304 showed benign fibrotic cystic wall tissue  
• family history
  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.
• exam findings
  • 2022-11-29 ECG
    • Sinus tachycardia
    • Nonspecific ST abnormality
  • 2022-11-24, -11-14, -10-27, -08-17 CXR
    • Atherosclerotic change of aortic arch
  • 2022-11-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (58 - 16) / 58 = 72.41%
      • M-mode (Teichholz) = 72
    • Mild septal hypertrophy with Gr I LV diastolic dysfunction.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis with mild AR; prominent posterior mitral annulus calcification with mild MR; moderate TR; mild PR.
  • 2022-11-03 SONO - abdomen
    • Hepatic calcification, right lobe
    • Renal cysts, both
    • Renal lesion, LK, favor angiomyolipoma
  • 2022-11-02 MRI - nasopharynx
    • Indication: He was just proved lymphoma in his mouth. He was referred by a local dentist because of an oral tumor. According to his statement, he notes this mass aroud one month ago. He has history of pitutary problem, hypertension for years.
    • Findings
      • metallic artifacts in the oral cavity
      • mild mucosal thickening in the bilateral maxilalry sinuses.
      • mucasal thickening in the upper esophagus. Please correlate with other image modality.
      • a multi-lobulated heterogeneous enhancing tumor, about 33mm, in the head of the right medial pterygoid muscle, inferior aspect of the maxillary sinus and right upper buccogingival mucosa.
        
      • no neck LAP.
    • IMP:
      • a multi-lobulated heterogeneous enhancing tumor, about 33mm, in the head of the right medial pterygoid muscle, inferior aspect of the maxillary sinus and right upper buccogingival mucosa.
      • mucosal thickening in the upper esophagus.
  • 2022-09-29 Sonography - thyroid gland
    • Normal size of the thyroid gland.
    • A heterogenic nodule (0.47x0.78cm) in left thyroid gland.
  • 2022-09-20 Myocardial perfusion SPECT with persantin
    • Probably mild myocardial ischemia at the lateral wall.
  • 2022-09-19 ECG
    • Sinus bradycardia
    • T wave abnormality, consider anterolateral ischemia
  • 2022-09-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (49.8 - 11.9) / 49.8 = 76.10%
      • M-mode (Teichholz) = 76.1
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mild to moderate MR and TR, mild AR and PR
    • Mildly thick IVS and LVPW
  • 2022-09-03 ECG
    • Atrial flutter with variable A-V block
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-09-03 ECG
    • Possible atrial flutter with 2:1 AV conduction
    • ST & T wave abnormality, consider anterolateral ischemia
    • Abnormal ECG
  • 2022-08-18 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (67.5 - 15.3) / 67.5 = 77.33%
      • M-mode (Teichholz) = 77.3
    • Adequate LV,RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild MR, TR
  • 2022-08-16 Whole body PET scan
    • Glucose hypermetabolism in a focal area involving the right maxillary sinus, right nasal cavity, soft palate and right oropharynx, in the left maxillary sinus and in two left submandibular lymph nodes, compatible with lymphoma.
    • Glucose hypermetabolism in a focal area in the pituitary fossa, compatible with a macroadenoma. However, please correlate with other clinical finidngs for further evaluation and to rule out other possibilities.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
  • 2022-08-02 Patho - gingival/oral mucosa biopsy
    • Pathologic diagnosis
      • Oral cavity, right maxillary gingiva, incisional biopsy — Diffuse large B-cell lymphoma, Non-GCB
        
    • Macroscopic description
      • Operation procedure: incisional biopsy
      • Topology: Oral cavity, right maxillary gingiva
      • Specimen size and number: 2 pieces, up to 1.2x 0.8x 0.4 cm
    • Microscopic examination
      • Histology type: B-cell neoplasms - Diffuse large B-cell lymphoma (any subtype)
      • Immunohistochemical stain profiles: C-myc(+, >40%), CD3(-), CD20(+), CD10(-), CD56(-), Cyclin D1(-), Bcl-6(+),Bcl-2(+),MUM-1(+), CK(-), Ki-67 index: > 95%.
  • 2022-05-26 SONO - abdomen
    • Diagnosis
      • Hepatic cysts, bilateral lobes
      • Fatty infiltration of pancreas
      • Pancreatic cystic lesion, neck-body
    • Suggestion
      • Hepatic lesion may be masked by fatty liver background
  • 2022-05-18 MRI - sella
    • Indication: for follow up brain tumor. patient had diplopia pituitary macroadenoma, s/p resection 7 yrs ago. residual tumor enlarging in size recently. S: for SRS arrangement. check prolactin level, consider surgical intervention. PATIENT REQUEST FOR STEREOTACTIC RADIOSURGERY. for follow up image study.
    • Findings
      • The high SI on T1WI in the posterior lobe of the pituitary gland was preserved.
      • a pituitary gland tumor, about 15mm x 16mm x 17mm, in the pituitary fossa and suprasellar cistern. The pituitary stalk was elevated. The lesion revealed low SI on T1WI and heterogeneous high SI on T2WI. Tumor invasion to the left cavernous sinus was noted. Tumor encasement of the left caverous ICA was noted.
      • unremarkable change in the bony middle cranial fossa
      • some white matter gliosis in the bilateral frontal and parietal lobes.
    • IMP: pituitary gland macroadenoma with invasion to the left cavernous sinus and tumor encasement of the left cavernous ICA.
  • 2022-04-14 Sonography - thyroid gland
    • Normal size of the thyroid gland.
    • Some hypoechoic nodules (0.26x0.36cm, 0.41x0.69cm) in left thyroid gland.
• consultation
  • 2022-09-03 Cardiology
    • A
      • O
        • ECG: suspected atrial flutter or atrial tachycardia (less than 24 hours)
        • CxR: RLL infiltration; L’t pleural effusion
        • SBP 140 mmHG;
        • PH of thyroxine supplement;
      • Suggestion
        • Amiodarone infusion for possibly atrial flutter; concor 0.5# st and qd if SBP > 110 mmHg.
        • F/U Tn-I level; if further elevation, may admit to ICU for close monitoring.
        • Check thyroid function.
        • Infection survey and empiric antibiotic for suspected pneumonia.
        • Arrange 2D echo after admission.
  • 2021-01-14 Cardiology
    • Q
      • Hx of myocadial bridge
    • A
      • I was consulted for elevated troponin I of a 79-year-old man who visited to ED acute onset of chest pain relieved by SL NTG this morning.
      • S
        • No cold sweating and radiation pain.
        • Episodes of chest pain for 4 times in recent months.
        • Hx of myocardial bridge in 2017.
      • O
        • 2021/01/14 07:12 hs-Troponin I = 16.5 pg/mL;
        • 2021/01/14 09:45 hs-Troponin I = 71.8 pg/mL;
        • No chest pain on visit
        • No signicant murmur, no pitting edema
        • EKG: TWI from V1-6 on admission to ED, then resolution of TWI at V1-2, persistent TWI at V4-6
        • Beside cardiace echo: normal wall motion.
      • Impression:
        • Elevated troponin I due to myocardial bridge is more likely
        • Angina pectoris due to myocardial bridge
      • Suggestion:
        • Regular medication for myocardial bridge with angina pectoris is suggested. Please prescribe Diltiazem (30) 0.5# BID and Coxine 0.5# BID PO (may hold Diltiazem if SBP <90mmHg or dizziness)
        • Option for cardiac catheterization was explained to the patient and his wife; if they want to recieve cardiac cathetertization, please call me (before noon).
        • The patient was informed to observe the symptoms and also informed about the warning sign.
        • CV OPD follow up if they choose to discharge
• chemoimmunotherapy (R-mCHOP)
  • 2022-11-17 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5
  • 2022-10-17 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5
  • 2022-09-21 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5
  • 2022-08-26 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5

[assessment]

• WBC 410/uL 2022-11-30 <- 580/uL 2022-11-29. For (febrile) neutropenia, filgrastim and cefepime have been used. The results of the blood culture are pending.
• The heart rate is volatile (63 ~ 122 beat/minute), 2022-11-29 ECG showed sinus tachycardia and nonspecific ST abnormality. Please continue to monitor the hemodynamic parameters.

701125676

221130

{Esophageal cancer, cT2N2Mo stage III, Port-A insertion at left cephalic vein on 20220922, jejunostomy tube insertion at abdomen on 20220922}

• lab data
  • 2022-09-16 HBsAg High Reactive
    
  • 2022-09-16 HBsAg Value 551.57 IU/mL
    
  • 2022-09-16 Anti-HBc Reactive
    
  • 2022-09-16 Anti-HBc-Value 8.41 S/CO
    
  • 2022-09-16 Anti-HCV Nonreactive
    
  • 2022-09-16 Anti-HCV Value 0.07 S/CO
• exam finding
  • 2022-11-02 Tc-99m MDP whole body bone scan with SPECT
    • Increased activity in the left iliac crest and bilateral acetabula, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, sacrum, bilateral shoulders, and S-I joints.
  • 2022-11-01, -10-03, -09-27, -09-21 Abdomen - standing (diaphragm)
    • S/P compression plate and screws fixation at right ilium and right acetabulum.
  • 2022-09-16 CT - chest
    • Indication: Malignant neoplasm of esophagus, unspecified.
      • He was referred on account of due to difficult of swallowing and chest dyscomfort for about one week. PES and biopsy showed esophageal cancer (at New Taipei City Hospital)
    • Findings
      • Chest:
        • Dilated upper and middle third esophagus with narrowing at lower third extending to EG junction is found.
        • Enlarged lymph nodes are found at gastric cardiac region. (n＝5)
        • Paraseptal Emphysematous change over both apical lungs is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Lower third esophageal cancer with regional lymphadenopathy
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): cT2N2M0, Stage III
  • 2022-09-15 CXR (New Taipei City Hospital SanChong Branch)
    • No cardiomegaly.
    • Prominent bronchovasculature over bilateral lung fields.
    • No blunting of bilateral costo-phrenic angles.
  • 2022-09-13 Pathology (New Taipei City Hospital SanChong Branch)
    • Diagnosis
      • S22-4658 Esophago-cardia junction, endoscopic biopsies, Adenocarcinoma, moderate to poorly differentiation.
    • MACROSCOPIC:
      • Quantity: one tissue fragments, 0.5 x 0.2 x 0.2 cm in size. All for section.
    • MICROSCOPIC:
      • Histological diagnosis: Adenocarcinoma.
      • High grade dysplasia (including severe dysplasia and carcinoma in situ): present.
      • Invasive carcinoma: present.
      • Lymphovascular invasion: absent.
      • Histologic grade: G2, moderately to poorly differentiated with focal individually cells infiltration throughout muscularis mucosa.
      • Comment: No Helicobactor bacillus found on Giemsa stain.
      • Immunohistochemical stains: the tumor cells showed cytoplasmic stains for CK7 and nuclear stain for STAB2.
  • 2022-09-17 UGI panendoscopy (New Taipei City Hospital SanChong Branch)
    • swelling and irregular mucosa which was easily contact bleeding was found at EC junction post biopsy was taken.
  • 2018-05-05 SONO - abdomen (Nephrology)
    • Left parapelvic renal cyst.
    • Suspected left small renal stone.
• consultation
  • 2022-11-01 Dermatology
    • Q
      • for skin rash at the face.
      • This time, he is admitted for C2 CCRT with PF on 2022/11/01, and the skin rash at the face noted, so we need your help, thanks a lot!!
    • A
      • The patient had sufferred from bilateral facial reddish flush/papules with fine scales on the nasalfold and cheek area.
        
      • Under the impression of seborrheic dermatitis.
      • The following sugeetion:
        • Free gel 1 tube topical bid use for facial erythema region
        • If severe itchy sensation, consider futisone cream 1 tube topical bid PRN use on these itchy area.
  • 2022-09-22 Radiatoin Oncology
    • A
      • S:
        • For preoperative CCRT due to low third esophageal carcinoma.
        • PI: The patient suffered from dysphagia and chest discomfort since 2022-8. He went to New Taipei City Hospital SanChong Branch for help. The Panendoscopy and biopsy showed esophageal cancer. Under the personal reason, he was referred to our Hematology Oncology. Followed-up chest CT (Sep 16,22) showed Lower third esophageal cancer with regional lymphadenopathy cT2N2M0, stage III.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (quit); Smoking (+); Betel nut (quit).
        • Personal Hx: DM(-); HTN(-)
        • Allergy(-)
        • Previous RT Hx: (-)
      • O:
        • ECOG: 0
        • PE: neck and bil SCF: neg.
        • UGI panendoscopy (2022-09-07, New Taipei City Hospital SanChong Branch): swelling and irregular mucosa which was easily contact bleeding was found at EC junction post biopsy was taken.
        • Pathology (2022-09-13, New Taipei City Hospital SanChong Branch): S22-4658 Esophago-cardia junction, endoscopic biopsies, Adenocarcinoma, moderate to poorly differentiation. MACROSCOPIC: Quantity: one tissue fragments, 0.5 x 0.2 x 0.2 cm in size. All for section. MICROSCOPIC: Histological diagnosis: Adenocarcinoma. High grade dysplasia (including severe dysplasia and carcinoma in situ): present. Invasive carcinoma: present. Lymphovascular invasion: absent. Histologic grade: G2, moderately to poorly differentiated with focal individually cells infiltration throughout muscularis mucosa. Comment: No Helicobactor bacillus found on Giemsa stain. Immunohistochemical stains: the tumor cells showed cytoplasmic stains for CK7 and nuclear stain for STAB2.
        • CXR (2022-09-15, New Taipei City Hospital SanChong Branch): No cardiomegaly. Prominent bronchovasculature over bilateral lung fields. No blunting of bilateral costo-phrenic angles.
        • CT scan of lung (2022-09-16): Lower third esophageal cancer with regional lymphadenopathy, AJCC stage cT2N2M0 (stage III).
      • A:
        • Adenocarcinoma, moderate to poorly differentiation of the low third esophagus to EG junction, AJCC stage cT2N2M0 (stage III).
      • P: Radiotherapy is indicated for this patient with the following indicators: AJCC stage cT2N2M0 (stage III)
        • Goal: curative
        • Treatment target and volume: esophageal tumor, periphjeral involved, to regional involved nodal area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the esophageal tumor, periphjeral involved, to regional involved nodal area, and 5040cGy/28 fractions of the esophageal tumor and involved nodal lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2022-9-26.
• radiotherapy
  • 2022-10-03 ~ 2022-11-17 - 4500cGy/25 fractions (15MV photon) of the esophageal tumor, periphjeral involved, to regional involved nodal, and 5040cGy/28 fractions of the reduced area.
• chemoimmunotherapy
  • 2022-11-29 - cisplatin 75mg/m2 120mg 4hr D1 + fluorouracil 1000mg/m2 1600mg 24hr D1-D4 (PF, CCRT)
  • 2022-11-03 - cisplatin 75mg/m2 120mg 4hr D1 + fluorouracil 1000mg/m2 1650mg 24hr D1-D4 (PF, CCRT)
  • 2022-10-03 - cisplatin 75mg/m2 120mg 4hr D1 + fluorouracil 1000mg/m2 1700mg 24hr D1-D4 (PF, CCRT)

[assessment]

• In one month, there has been a substantial loss of weight, almost ten kilograms (52.3kg 2022-11-29 <- 61.1kg 2022-10.27).
• A low serum creatinine level (0.68mg/dL 2022-11-29) was noted. Creatinine generation could be reduced in the setting of low skeletal muscle mass.
• It is recommended that intake be increased.
• In terms of the active prescription, there is no problem.

700021863

221128

{Protocol: Capsule suspension preparation and NG tube dispensing procedures for Xtandi (enzalutamide, 160mg dose)}

The following in-situ oral dosing syringe suspension preparation and NG tube dispensing procedures were identified as being facile and which essentially eliminate human exposure to capsule components:

Utensils: Tweezers, medical grade scissors, 2-3mL oral dosing syringe, 20mL oral dosing syringe, NG tube, and one 2-3 oz (60-90 mL) glass or plastic dosing container (e.g., beaker or med cup).

Materials: Ethanol, 95%, Deionized water, 4x40mg enzalutamide capsules

• Prepare 40-50mL of 90% v/v ethanol:water. Transfer 30mL to a container. Cover if not used immediately. Use as reservoir for subsequent steps.
• Swipe-clean the dosing container, tweezers and scissors with alcohol wipes.
• Using tweezers and scissors carefully cut a small vent, ~2mm long, through a soft gel capsule wall-just enough to vent internal pressure. Note: cut vent over dosing cup since some material may flow out of the vent hole. Place vented capsule in dosing cup. Repeat for remaining 3 capsules.
• Using tweezers and scissors, slowly cut each capsule in half laterally. Allow capsule contents (enzalutamide in Labrasol) to empty into dosing cup (fill material flows out easily). Repeat for all capsules. Note: all 8 capsule shell pieces and fill contents will be in in the dosing cup.
• Hold each capsule shell piece with tweezers and rinse the inside and outside into the dosing cup using 90% ethanol. Use 1-2mL per capsule half (2-3mL syringe). Discard rinsed capsule shells.
• Withdraw 10mL of ethanol solution and rinse the tweezers and scissors into the dosing cup.
• Withdraw and dispense solution back into dosing cup at least 5 times to ensure a homogeneous mixture.
• Withdraw the solution into the dosing syringe.
• Slowly dispense through the NG tube.
• Withdraw the remaining ~10mL of 90% ethanol, rinse dosing cup, withdraw into dosing syringe, cap and shake, and dose through the NG tube. Flush tube with 6mL of water.

Please prepare two vials of 99.5% alcohol (drug code ‘CALCO01’), add one ml of purified water, take eight ml of the solution to dissolve one split capsule of 40 mg Xtandi, and tube feed this solution containing enzalutamide with prandial.

701321501

221125

{Mesenchymal chondrosarcoma, high grade}

• exam finding
  • 2022-11-17, -10-20, -09-22, -08-22, -07-21 Sinoscopy
    • Right maxillary sinus sarcoma s/p op on 2022-03-30, no evidence of tumor
  • 2022-11-01 MRI - nasopharynx
    • Clinical information: Right maxillary sinus sarcoma s/p Right total Maxillectomy on 2022-03-30, patho: high grade mesenchymal chondrosarcoma, pT4aN0M0, Grade 3
    • Findings:
      • The current study was compared to the prior one obtained on 2022/08/09.
      • Known a case of right maxillary sinus sarcoma S/P operation and flap reconstruction. Progression of abnormal enhancing lesion over right face, near the reconstructive area. Suggest tissue proof to rule out recurrence.
      • Paranasal sinusitis.
      • The right parotid gland enhance as before. It is consistent with post-radiation inflammation.
      • S/P resection of right submandibular gland.
  • 2022-08-09 MRI - nasopharynx
    • Post total right maxillectomy, no obvious residual tumor or mass. No neck LAP.
  • 2022-07-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 25) / 87 = 71.26%
      • M-mode (Teichholz) = 70
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR, and trivial TR
    • Preserved RV systolic function
  • 2022-06-09, 2022-05-26, 2022-05-12, 2022-04-28 Sinoscopy
    • Right maxillary sinus sarcoma s/p op on 2022-03-30
  • 2022-05-26 Hearing Test
    • Tymp:
      • R’t type B; L’t type As.
    • ART:
      • R’t and L’t contra absent.
    • PTA
      • Reliability FAIR
      • Average RE 60 dB HL; LE 23 dB HL.
      • R’t moderate to profound MHL.
      • L’t normal to moderate HL.
      • (masking dilemma)
  • 2022-04-21 Nasopharyngoscopy
    • Right maxillary sinus sarcoma s/p op on 2022-03-30
  • 2022-03-31 Patho - oral cancer (wide excision + lymph node)
    • Pathologic diagnosis
      • Maxillary sinus, right, total maxillectomy — Mesenchymal chondrosarcoma, high grade
      • Lymph nodes, right neck, selective neck dissection — Negative for malignancy (0/31)
      • Submandibular gland, right, neck dissection — No remakable change
      • Pathology stage: pT1N0; Stage IIA if cM0
    • Macroscopic examination
      • Surgical Procedure(s): Total maxillectomy + right selective neck dissection
      • Specimen Type:
        • Main location: Maxillary sinus
        • Lymph node dissection: Yes, including right neck level I, level II, and level III
      • Specimen Integrity: intact
      • Specimen Size: 6.2 x 5.5 x 5.4 cm
      • Tumor Site: Maxillary sinus; Laterality: Right
      • Tumor Focality: Single focus
      • Tumor Size: 6.0 x 4.5 x 4.0 cm, 0.5 cm from posterior margin
      • Mucosal Surface : Ulcerated
      • Gross Tumor Extension: Tumor invades submucosa
      • Representative parts are taken for section and labeled: A1-A2 = level I LN + submandibular gland, B = level II LNs, C = level III LNs, D = pterygoid plate, E = zygoma with soft tissue, F1 = tumor + posterior margin, A2 = tumor + lateral margin, F3 = tumor + upper margin, F4-F10 = tumor, G = posterior nasal margin, H = temporalis margin.
      • F2022-00138FSA1 = post. nasal margin, post. orbital floor and post. oral floor margin; FSA2 = lat. margin, masseter margin, and tempolais margin; FSA3 = orbital lat. margin and lat pterygoid margin; FSA4 = med. pterygoid margin and tissue near zygoma; FSE = posterior nasal margin (re-excision).
    • Microscopic examination
      • Histologic Type: Mesenchymal chondrosarcoma
      • Histologic Grade: G3 (poorly differentiated, high grade)
      • Mitotic Rate: 6/10 high power fields
      • Necrosis: Present (10%)
      • Microscopic Tumor Extension: To submucosa
      • Margins: Margins free, Distance from closest margin: 0.5 cm (posterior margin)
      • Lymph-Vascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Neck Lymph Nodes, Right: Negative (0/31)
        • Number of LN examined: 11 (level I), 9 (level II), and 11 (level III)
        • Number of LN metastasis: 0
      • Submandibular gland, right: Unremarkable and free of tumor
      • Pterygoid plate, right: Involved by tumor
      • Zygoma with soft tissue, right: Free of tumor
      • Post nasal margin, right: Free of tumor
      • Temporalis margin, right: Free of tumor
      • Post nasal margin and temporalis margin, received frozen section: Involved by tumor
      • Surgical margins received for frozen section, including post. orbital floor, post oral floor margin, lat margin, masseter margin, tempolais margin, orbital lat margin, lat pterygoid margin, med pterygoid margin, tissue near zygoma, and posterior nasal margin (re-excision): Free of tumor
  • 2022-03-30 Frozen section
    • Post. nasal margin #1, right, frozen section — Involved by tumor
    • Temporalis margin, right, frozen section — Favor inflammation but tumor involvement can not be excluded
    • Tissue near zygoma, right, frozen section — Favor inflammation
    • Post. orbital floor, post. oral floor margin, lat. margin, masseter margin, orbital lat. margin, lat. pterygoid margin, med. pterygoid margin; right, frozen section — Free of tumor
    • Posterior nasal margin #2, right, frozen section — Free of tumor
  • 2022-03-25 Nasopharyngoscopy
    • Right maxillary sinus sarcoma
  • 2022-03-22 SONO - abdomen
    • GB polyp
    • Pleural effusion, right
  • 2022-03-21 Whole body PET scan
    • Glucose hypermetabolism in the right maxillary sinus and adjacent facial soft tissue, compatible with the primary maxillary sarcoma. .
      
    • Glucose hypermetabolism in the left nasal cavity with left maxilla bone involvement, the nature is to be determined (another nasal cavity tumor or other nature ?), suggesting biopsy for further investigation.
      
    • Right maxillary sinus sarcoma, cTxN0M0; suspected left nasal cavity tumor, by this F-18 FDG PET scan.
  • 2022-03-18 CT - lung/mediastinum/pleura
    • Bilateral pleural effusion and lung partial collapse
    • suspected acute pancreatitis.
  • 2022-03-17 MRI - nasopharynx
    • Huge lobulated mass lesion (6.4cmx4.6cm) over right maxillary sinus with destruction of sinus walls, heterogeneous enhancement and cetral necrosis of this tumor. Highly suspect malignancy such as SCC or sarcomatous tumor.
    • Marked swollen change of right face and masticator space with subcutaneous fatty strandings.
  • 2022-03-15 Patho - gingival/oral mucosa biopsy
    • Oral cavity, right upper gingiva, biopsy — sarcoma
    • IHC: CK(-), Vimentin(+), SMA(focal +), CD34(-), CD56(-), and S-100(-). The Ki-67 is about 15%. The results are in favor of sarcoma. Please correlate with the clinical presentation and image study.
  • 2022-03-15 2D transthoracic echocardiography
    • Normal AV/MV with trivial MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, trivial TR, normal IVC size
  • 2022-03-14 CT - brain
    • IMP: Right maxillary sinus lesion as described.
    • DDX: malignancy, osteomyelitis, sinusitis.
  • 2022-03-14 ECG
    • Sinus tachycardia
    • Right superior axis deviation
• consultation
  • 2022-04-12 Radiation Oncology
    • A: Mesenchymal chondrosarcoma, high grade, of the right maxillary sinus, stage pT1N0(cM0); Stage IIA, s/p operation (Rt. total Maxillectomy; Rt. selective neck dissection, level I~III; Tracheostomy; Tooth extraction of #46; free right anterolateral thigh flap resurfacing to the defect of right cheek, palate, and nasal cavity; reconstruction of right orbital bony frame with titanic microplates and screws).
    • P: Radiotherapy is indicated for this patient with the following indicators: margin involve and close (depend on HN tumor board conclusion).
      • Goal: curative
      • Treatment target and volume: right maxillary tumor bed area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 6000 ~ 6600cGy/30 ~33 fractions
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his mother. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-04-25.
    • HN tumor board (2022-04-15). RTC: at 2pm, 2022-04-15.
  • 2022-03-23 Oral and Maxillofacial Surgery
    • This is a 43 year-old male patient suffering from osteosarcoma of right maxilla and is scheduled for surgical intervention including right hemi-maxillectomy next week.
    • This time, we were consulted for pre-OP and pre-RT dental evaluation
    • O:
      • Radiographic findings:
        • Progressive destruction of right maxilla with root resorption of tooth 14 was noted.
        • Residual roots of tooth 46 was noted.
      • Full mouth poor oral hygiene with periodontitis
    • P:
      • Took panoramic film to evaluate full mouth condition
      • Explained the findings and treatment plan to the patient and his family
      • Suggest extraction of residual roots 46 during surgery.
      • Oral hygiene instruction.
  • 2022-03-16 Gastroenterology
    • S
      • According to the patient, no HBV history
    • O
      • AST: x, ALT: 18, Bil T: 0.78, ALP: x, r-GT: x, Cr: 0.79
      • HBsAg(-), Anti-HBc(+), Anti-HCV(-)
      • Abdominal echo: nil
    • Impression
      • Occult or resolved HBV infection
    • Suggestion
      • No NHI indication for HBV medication now; if patient needed chemotherapy or immunotherapy, please tell us
      • GI OPD follow up
  • 2022-03-15 Hemato-Oncology
    • A
      • Impression:
        • Right maxillary sinus lesion. DDX: malignancy, osteomyelitis, sinusitis.
      • Suggestion:
        • Please check EB V EA/NA IgA, SCC, LDH
        • Pending pathology and culture result
        • Treat sepsis as your expertise
        • We wound like to follow up this case, thanks for your consultation. If there is any problem, please feel free to let us known.
  • 2022-03-15 ENT
    • Granular tumor with pus discharge at right upper gingiva and hard palate was noted.
    • Malignant tumor of right maxillary sinus with oral cavity involvement was highly suspected.
    • Biopsy was done smoothly.
    • Please pursue the pathologic result.
  • 2022-03-14 Oral and Maxillofacial Surgery
    • S: My right face swelling and my upper right gingiva ozzing
    • O:
      • Right face swelling was noted
      • 15 16 17 missing with a mass over upper right gingiva, about 5x7 cm, ulcerative surface was noted
    • A:
      • Impression: SCC or osteosarcoma
    • P:
      • Physical exam and explain the finding to the patient
      • Please prescribe curam for infection control
      • Admission in MICU for infection control and arrange OPD follow up
• surgical operation
  • 2022-06-20
    • Right grommet insertion
  • 2022-03-30
    • free right anterolateral thigh flap resurfacing to the defect of right cheek, palate, and nasal cavity
    • reconstruction of right orbital bony frame with titanic microplates and screws
  • 2022-03-30
    • Rt. total Maxillectomy
    • Rt. selective neck dissection, level I~III
    • Tracheostomy
    • Tooth extraction of #46
• radiotherapy
  • 2022-04-29 ~ 2022-06-16
    • 4000cGy/20 fractions of the right maxillary tumor bed area,
    • 5000cGy/25 fractions of the reduced right maxillary tumor bed area, and
    • 6600cGy/33 fractions of the right maxillary tumor bed.
• chemoimmunotherapy
  • 2022-11-24 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
  • 2022-10-28 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
  • 2022-10-03 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
  • 2022-09-01 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
  • 2022-08-05 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
  • 2022-07-07 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
  • 2022-05-03 ~ 2022-06-14 - cisplatin 40mg/m2 65mg 2hr (weekly x7, CCRT)

[assessment]

• Despite the absence of tumor evidence by sinoscopy (2022-11-17), the nasopharynx MRI (2011-11-01) suggested a tissue proof to rule out recurrence for the abnormally enhancing lesions near the reconstruction area.
• In addition to slight tachycardia (108 pulses per minute) and decreased SpO2 (94%), otherwise vital signs were unremarkable.
• Except for slightly low serum potassium (3.3 mmol/L) and low HGB (11.3 g/dL), all lab results were generally normal on 2022-11-24.
• The active prescription is working as intended.

221004

[assessment]

• The available data now argues for adjuvant chemotherapy in mesenchymal chondrosarcoma, with little reliable data on craniofacial lesions in particular. The optimal drug combination to be employed has not been well-defined. (ref: Systemic treatment for primary malignant sarcomas arising in craniofacial bones. Front Oncol. 2022;12:966073. doi:10.3389/fonc.2022.966073)
• In mesenchymal chondrosarcoma, treatment with Ewing sarcoma-like chemotherapy regimens may be considered, although data supporting its use is even more limited given its rarity. (ref: Systemic Therapy for Chondrosarcoma. Curr Treat Options Oncol. 2022;23(2):199-209. doi:10.1007/s11864-022-00951-7)
• It was reported that ifosfamide-doxorubicin may be more beneficial in younger patients with >5 cm, high-grade, soft-tissue-sarcoma of the trunk or extremity in synovial-cell, dedifferentiated-liposarcoma, myxofibrosarcoma, round-cell-liposarcoma, undifferentiated-pleomorphic-sarcoma, and undifferentiated-sarcoma-not-otherwise-specified. (ref: The role of Ifosfamide-doxorubicin chemotherapy in histology-specific, high grade, locally advanced soft tissue sarcoma, a 14-year experience. Radiother Oncol. 2021;165:174-178. doi:10.1016/j.radonc.2021.10.019)
• It was possible to treat soft tissue sarcoma using a regimen using a daily dose of mesna equivalent to that of ifosfamide. (ref: Crossover randomized comparison of intravenous versus intravenous/oral mesna in soft tissue sarcoma treated with high-dose ifosfamide. Clin Cancer Res. 2003;9(16 Pt 1):5829-5834.)
• TPR, blood pressure, and SpO2 during the hospital stay, as well as lab data on 2022-09-29 were grossly stable or normal.

700361559

221123

• diagnosis - 2022-11-05 discharge note
  • Malignant neoplasm of biliary tract, unspecified
  • Malignant neoplasm of biliary tract, unspecified, sarcomatoid carcinoma with biliary differentiation, CK(+), CK7(+), CK20(-), p63(-) and Hepatocyte(-) with LN metastases and tumor seeding ( carcinomatosis), stage IV
  • Adeocarcinoma of the gallbladder with liver metastasis, lymph nodes metastases, and tumor seeding (carcinomatosis),cT4 N2 M1, Stage:IVB
  • Urinary tract infection, site not specified
  • Hypoalbuminemia
• history - 2022-11-05 discharge note
  • HTN with medicine control for 20+ years
  • CAD with medicine control for 20+ years
  • BPH
  • Unclear liver disease, tumor or inflammation, since Aug 2021, initial admission at ShuangHo Hospital that UTI also told.
  • Liver abscess drainage was performed at ward on 2022/05/22
  • COVID-19 infection on 2022/05/28
• exam findings
  • 2022-11-20, … CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Prominence of bilateral hilar shadows are noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and follow-up.
  • 2022-11-11 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2022-11-11 KUB
    • Degenerative joint disease of lumbar spine with marginal osteophytes.
    • Surgical clips retention over epigastric region.
    • Ileus with gas-filled distended bowel loops of the abdomen.
      
  • 2022-10-31 Abdomen
    • Spondylosis of the L-spine is noted.
    • Ascites is highly suspected.
  • 2022-10-18 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Sarcomatoid carcinoma with biliary differentiation
    • The specimen submitted consists of three strips of yellow gray soft tissue, labeled liver, measuring up to 0.6 x 0.1 x 0.1 cm. All for section.
    • The sections show a picture of sheets of poorly differentiated, polygonal and spindle-shaped neoplasic cells, arranged in short fascicles. Neither glandular nor squamous differentiation can be found.
    • IHC shows: CK(+), CK7(+), CK20(-), p63(-) and Hepatocyte(-). The finding is consistent with sarcimatoid carcinoma with biliary differentiation. Suggest clinic correlation.
  • 2022-10-17 Tc-99m MDP whole body bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, some T- and L-spine, sacrum, bilateral sternoclavicular junctions, shoulders, elbows, S-I joints, hips, and knees.
  • 2022-07-22 CT - abdomen
    • History: liver abscess
      • 20220517 CT：Multicystic lesion in Rt lobe liver 10cm suspected abscess
      • A tumor 1.7cm in S6 with rim enhancement, suspected cholangiocarcinoma 20220519 S/P drainage was performed.
    • Indication: S5 tumor in progress.
    • Findings:
      • There is a heterogeneous lobulated soft tissue mass in the medial subhepatic space, directly attached the gallbladder, measuring 4.8 cm in size at the largest dimension.
        • Gallbladder cancer is highly suspected.
      • There is an ill-defined hypodense mass lesion measuring 3 cm in S5 of the liver. During dynamic study, this mass shows poor contrast enhancement in arterial phase and portal venous phase images, and mild centropedal enhancement in delayed phase images
        • Metastasis is highly suspected.
        • The differential diagnosis include Cholangiocarcinoma.
      • There are several enlarged nodes in the hepatoduodenal ligament that are c/w metastatic nodes.
        • In addition, There are lobulated soft tissue lesions in the periportal area of the liver hilum and ligamentum teres. Metastatic nodes are highly suspected.
      • There are several soft tissue nodules in RUQ omentum that are c/w tumor seeding.
        • In addition, There are few enhancing soft tissue lesions in bilateral lower pelvis that may be tumor seeding?
      • Prior CT identified multicystic lesions in right hepatic lobe is noted again, marked decreasing in size that is c/w liver abscess S/P catheter drainage and antibiotics treatment with near complete response.
      • Non-visualization of the spleen is noted. please correlate with clinical condition.
      • Several gallstones are noted.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, & both kidney.
          
        • There is no bowel wall thickening, and no bowel obstruction.
          
        • The abdominal aorta and IVC are grossly unremarkable.
          
        • There is no evidence of intrinsic or extrinsic bladder mass.
          
    • Impression:
      • Adeocarcinoma of the gallbladder with liver metastasis, lymph nodes metastases, and tumor seeding (carcinomatosis) is highly suspected.
        • According to American Joint Committee on Cancer(AJCC) staging system, 8th edition for gallbladder cancer: T4 N2 M1, Stage:IVB
      • A poor enhancing mass 3 cm in S5 liver is noted.
      • Metastasis is highly suspected.
      • The differential diagnosis include Cholangiocarcinoma.
• chemoimmunotherapy
  • 2022-11-02 - irinotecan liposome 70mg/m2 125mg 1.5hr + leucovorin 400mg/m2 700mg 1hr + fluorouracil 2400mg/m2 4000mg 46hr

[assessment]

• Fatal neutropenic sepsis occurred in 0.8% of patients receiving irinotecan (liposomal). Severe or life-threatening neutropenic fever or sepsis occurred in 3% and severe or life-threatening neutropenia occurred in 20% of patients receiving irinotecan (liposomal) in combination with fluorouracil and leucovorin.
• When irinotecan is suspected of causing acute gastroenteritis, UGT1A1 genotyping might be utilized to confirm the homozygous state (homozygous UGT1A1*28).
• Atropine 0.5mg SC is recommended as a premedication prior to the use of irinotecan in the next chemotherapy if there is no contraindication.

700384079

221122

• exam findings
  • 2022-11-16, -09-28, -08-29, -08-25 CXR
    • Atherosclerotic change of aortic arch
  • 2022-11-16 CT - abdomen
    • History: UGI bleeding
      • 20220808 gastroscopy: One 25mm ulcer with elevated margin was noted at AW side of bulb/SDA. Patho: duodenal adenocarcinoma
      • 20220817 CT: duodenal adenocarcinoma or metastatic node with superior mesenteric vein invasion? cT4N2M0, cstage: IIIB
    • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, arterial phase, and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings: Comparison: prior CT dated 2022/08/17.
      • Prior CT identified lobulated wall thickening in duodenal bulb measuring 1.5 cm in wall thickness is noted again, increasing in size to 2.1 cm. The stomach shows marked distension that may be gastric outlet obstruction?
        • Please correlate with gastroscopy.
        • In addition, There is a poor enhancing mass measuring 2.5 cm in the medial aspect of the duodenal 2nd portion with direct invasion the superior mesenteric vein is noted again, decreasing in size to 1.8 cm that may be metastatic node S/P C/T with partial response .
        • The differential diagnosis include adenocarcinoma with exophytic growth?
        • Prior CT identified two enlarged nodes in the hepatoduodenal ligament are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response.
      • There are several gallstones.
      • There are few metalic coils implantation at the gastroduodenal artery that are c/w TAE for prior GI bleeding.
      • Abdominal aorta shows atherosclerosis and mild intramural thrombus formation.
      • There is no focal abnormality in the liver, biliary system, pancreas, spleen & both kidney.
        
      • There is no ascites.
        
      • There is no bowel obstruction.
        
      • The IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
      • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Adenocarcinoma of the duodenal bulb shows mild increasing in size. However, metastatic nodes show decreasing in size.
  • 2022-08-23 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • There was no variant detected in the KRAS/NRAS gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-08-23 CT - chest
    • Pancreatic cancer with suspect duodenal bulb and SMV invasion
    • MDCT (256-detector rows, GE Revolution, was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Findings
      • Lungs: minimal centrilobular nodules at posterobasal segment of RLL.normal appearance of RUL, RML, and left lung.
      • Mediastinum and hila: no enlarged LN or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels:
        • moderate calcified plaques of the LAD coronary artery.
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta/aortic root.
        • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents: Pancreatic head cancer with suspect duodenal bulb and SMV invasion
        • multiple small gall bladder stones
      • Visualized bones: multiple marginal spurs of vertebrae..
    • Impression:
      • minimal bronchiolitis in RLL-S10. moderate LAD CAD.
  • 2022-08-17 CT - abdomen
    • History: UGI bleeding
      • 20220808 gastroscopy: One 25mm ulcer with elevated margin was noted at AW side of bulb/SDA. Patho: duodenal adenocarcinoma
    • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, arterial phase, and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is lobulated wall thickening in duodenal bulb measuring 1.5 cm in wall thickness.
        • Adenocarcinoma of the duodenal bulb is highly suspected.
        • In addition, There is a poor enhancing mass measuring 2.5 cm in the medial aspect of the duodenal 2nd portion with direct invasion the superior mesenteric vein that may be metastatic node.
        • The differential diagnosis include adenocarcinoma with exophytic growth?
        • There are two enlarged nodes in the hepatoduodenal ligament that may be metastatic nodes.
      • There are several gallstones.
      • There are few metalic coils implantation at the gastroduodenal artery that are c/w TAE for prior GI bleeding.
      • Abdominal aorta shows atherosclerosis and mild intramural thrombus formation.
      • There is no focal abnormality in the liver, biliary system, pancreas, spleen & both kidney.
        • There is no ascites.
          
        • There is no bowel obstruction.
          
        • The IVC are grossly unremarkable.
          
        • There is no evidence of intrinsic or extrinsic bladder mass.
          
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Adenocarcinoma of the duodenal bulb is highly suspected.
  • 2022-08-10 Embolization (TAE: trans arterial embolisation) - abdomen
    • TAE of duodenal hemorrhage via right common femoral artery puncture using Seldinger technique revealed:
      • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
      • Under local anesthesia, a 4 Fr arterial sheath was inserted into right common femoral artery smoothly.
      • Active bleeding of gastroduodenal artery.
      • We used microcatheter for superselective catheterization due to easy spasm, tortuous, small size of bleeding artery.
      • TAE was performed using four microcoils (2-4-42mm x3 and 2-6-85mm x1) plus some gelfoam pieces.
      • No procedure-related complication during the whole procedure. Remain the arterial sheath (4 Fr) at right inguinal region. Thanks for your further care.
    • IMP: Active bleeding of gastroduodenal artery s/p TAE.
  • 2022-08-09 Patho - duodenum biopsy (malignancy)
    • Duodenum, AW side of bulb/SDA, biopsy — moderately differentiated adenocarcinoma
    • Microscopically, it shows moderately differentiated adenocarcinoma composed of proliferation of irregular neoplastic glands with stromal invasion. The tumor shows nuclear hyperchromasia, pleomorphsim, prominent nucleoli and increased N/C ratio.
    • Immunohistochemical stain — CK(+), CDX-2(+)
  • 2022-08-08 Panendoscopy
    • Diagnosis
      • Severe duodenal ulcer, Forrest classification type Ib, suspected tumor, s/p hemostasis with APC and biopsy
      • Incomplete of stomach
    • Suggestion
      • NPO and PPI pump for 3 days.
      • Due to anticipated prolonged NPO time, suggest TPN supply
        • Calories: 25kcal per ideal body weight
        • Protein: 1.5gm per ideal body weight
      • Consult interventional radiologist and surgical department if further bleeding.
      • Weaning ventilator ASAP
  • 2022-08-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (74.7 - 17.0) / 74.7 = 77.24%
      • M-mode (Teichholz) = 77
    • Conclusion:
      • Normal chamber size
      • Septal hypertrophy
      • Adequate LV and RV systolic function
      • Mild MR and PR
      • No regional wall motion abnormalities
  • 2022-08-01 Panendoscopy
    • Diagnosis
      • Superfical gastritis, antrum
      • Duodenal ulcer, junction of 1st and 2nd portion, LC side, Forrest classification IIb
    • Suggestion
      • NPO and give high dose PPI
  • 2022-07-29 ECG
    • Sinus tachycardia
    • Right bundle branch block
    • Abnormal ECG
  • 2022-04-19 SONO - abdomen
    • Fatty liver, mild to moderate
    • GB stone, multiple
  • 2021-01-27 ECG
    • Sinus tachycardia
    • Right bundle branch block
  • 2019-11-04 CPA, carotid phonoangiograph
    • Sonographic diagnosis:
      • Moderate atheromatous lesions in bil BIF and right proximal ICA.
      • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows; stenotic flow in left MCA, more severe over proximal segment; resistant flow in right CCA and left ECA, suspect distal stenosis, suggest clinical correlation and further evaluation.
        
      • Poor temporal windows for left PCA and right ACA.
      • Normal left ophthalmic arterial flows; reverse flow in right OA.
      • Suggest MRA (neck + intracranial arteries) for further study if no contraindication.
  • 2018-03-26 SONO - hepatobiliary
    • Fatty liver.
    • GB stone.
  • 2018-02-18 ECG
    • Sinus tachycardia
    • Right bundle branch block
  • 2017-07-04 Barium Enema (double contrast)
    • Double contrast study of LGI series revealed:
      • The contrast medium passage from anus to terminal ileum smoothly without obstruction.
      • Redundancy of T-colon.
      • Much stool retention in colon.
      • Normal contour and mucosal pattern of the colon.
      • Normal haustration and peristalsis of the colon.
• consultation
  • 2022-08-24 Hemato-Oncology
    • Q
      • For neoadjuvant chemotherapy of pancreatic cancer suspected duodenal invasion suspected SMV invasion
      • THis is a 56 y/o male with history of DM, hypertension under medication control
      • He was admitted since 20220730 due to gastric ulcer with bleeding complicated with hypovolemic shock s/p ETT intubation (extubated), EGD hemostasis and active bleeding of gastroduodenal artery s/p TAE on 20220810. There was an incidental finding of duodenal neoplasm, pathology revealed adenocarcinoma. CT revealed adenocarcinoma of the duodenal bulb, suspect SMV invasion.
      • Further tumor biomarker study revealed CA-199 = 1089; while other biomarkers were within normal range, pancreatic cancer suspected duodenal bulb invasion was suspected.
      • Due to above, surgical intervention was not recommended in the first place, suggested by GS Dr. Wu.
      • We sincerely need your expertise for chemotherapy evaluation and management.
    • A
      • O
        • Abdominal CT show:
          • There is lobulated wall thickening in duodenal bulb measuring 1.5 cm in wall thickness.
          • Adenocarcinoma of the duodenal bulb is highly suspected.
          • In addition, There is a poor enhancing mass measuring 2.5 cm in the medial aspect of the duodenal 2nd portion with direct invasion the superior mesenteric vein that may be metastatic node. The differential diagnosis include adenocarcinoma with exophytic growth?
          • There are two enlarged nodes in the hepatoduodenal ligament that may be metastatic nodes.
        • Pathology: Duodenum, AW side of bulb/SDA, biopsy — moderately differentiated adenocarcinoma.
          • Immunohistochemical stain — CK(+), CDX-2(+)
      • Impression:
        • Duodenum adenocarcinoma with SMV invastion, T4N2Mx, stage IIIB at least
      • Suggestion:
        • Arrange chest CT, EUS for complete staging
        • For Locally unresectable duodenum cancer, systemic chemotherapy is indicated (goal for down stage)
        • Arrange port A insertion if patient agree further chemotherapy and check HbsAg, Anti Hbc, Anti HCV
        • Thanks for your consultation. If there is any problem, please feel free to let us known.
  • 2022-08-18 General and Gastrointestinal Surgery
    • Q
      • For duodenal adenocarcinoma
      • This is a 56 y/o male with history of DM, hypertension under medication control
      • He was admitted since 07/30 due to gastric ulcer with bleeding complicated with hypovolemic shock s/p ETT intubation (extubated), EGD hemostasis and active bleeding of gastroduodenal artery s/p TAE on 08/10. There was an incidental finding of duodenal neoplasm, pathology revealed adenocarcinoma. CT revealed adenocarcinoma of the duodenal bulb, suspect SMV invasion.
      • We sincerely need your expertise for surgical intervention evaluation and management.
    • A
      • A case suspect of duodenal or pancreatic tumor
      • further op will arrange on 8/24
      • we will take over for this case on 8/22
      • Due to pancreatic neck ca with SMV invasion and tumor seeding is impression
      • Suggest further neoadjuvant chemotherapy first for tumor down stage
  • 2022-08-11 Diagnostic Radiology
    • Q
      • For TAE (trans arterial embolisation)
      • The 57-year-old male patient, he has history of: 1. Type 2 diabetes mellitus for years. 2. Hypertension for years. He was under regular medical treatment in our GI and Family Medicine Department OPD in the recent years. He is a bus driver who fainted once in the toilet during his lunch break yesterday. This time, he complained of black stool for about a week. And also has dizziness again and cold sweat after going to the toilet last night.
      • At ER, his consciousness was clear. KUB showed: Increase bowel gas and presence of ileus.The serum examination showed : glucose: 336 mg/dL; BUN: 62 mg/dL; Creatinine: 1.83 mg/dL; WBC: 11.10 *10^3/uL; HGB: 8.8 g/dL. Under the impression of upper gastrointestinal bleeding, IV Panzolec pump were given and he was admitted for further evaluation and management. After admitted to ward, the EGD performed on 08/01 showed gastric ulcer Forrest class IIb. His tarry stool passage mildly subsided since then(no loosen nor sticky unshaped stool, hemoglobin level around 8.0-8.7) s/p PPI high dose pump and then Q12H since 08/05.
      • However, on 08/06, he was noted dizziness, bloody stool passage, the discharge was postponed. Following Hb today revealed 6.4, EGD was arranged this afternoon. Hematemesis with consciousness disturbance developed when undergo anesthesia surveillance, with cold and wet skin, tachycardia, pale appearance, suspect hypovolemic shock. ETT intubation was performed to secure airway(Dormicum x1, Esmeron x1), foley catheter and CVC were also inserted in the same time. Fluid resuscitated with N/S 500 cc and LPRBC 2U ST, vesopressor with levophed 2 amps in 500 N/S run 20 cc/hr, PPI pump with 5 amps in 500 N/S run 20 cc/hr. His family was informed and fully understood current situation. After emergent management, the patient’s condition was temporarily under control and was transferred to MICU for further evaluation and management on 2022-08-08.
        
      • After transferred to MICU, on ventilator full support and blood transfusion with LPRBC 4u, FFP 4u and cyro 10u stat. On vasopressor with levophed titration(8/8-) and N/S 500ml challenge for unstable hemodynamic condition. Arranged pandoscope immediately which report showed Severe duodenal ulcer, Forrest classification type Ib, suspected tumor, s/p hemostasis with APC and biopsy. Jusomin 5amp iv stat for metabolic acidosis. Extubation on 8/9 and then on nasal cannula support. However, fresh bloody around 200ml via NG tube was noted now, so we contact GI who suggested If active bleeding, arrange TAE. Therefore, we need your help for TAE examination. Thanks!!
    • A
      • According to the clinical condition and imaging findings, TAE is indicated.
• chemoimmunotherapy
  • 2022-11-08 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 160mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2000mg/m2 4000mg 48hr
  • 2022-10-25 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 160mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2000mg/m2 4000mg 48hr
  • 2022-09-28 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr
  • 2022-09-13 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr
  • 2022-08-29 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr

[note]

• GOLF regimen ref:
• Simplified/Same Day(s)-GOLF as First-line Treatment of Metastatic Carcinoma of Unknown Primary (CUP), Suggestive of Pancreatobiliary Tumors. JOP. 2019;20(5):121-124;
• Biweekly triple combination chemotherapy with gemcitabine, oxaliplatin, levofolinic acid and 5-fluorouracil (GOLF) is a safe and active treatment for patients with inoperable pancreatic cancer. J Chemother. 2008;20(1):119-125. doi:10.1179/joc.2008.20.1.119;
• A novel biweekly multidrug regimen of gemcitabine, oxaliplatin, 5-fluorouracil (5-FU), and folinic acid (FA) in pretreated patients with advanced colorectal carcinoma. Br J Cancer. 2004;90(9):1710-1714. doi:10.1038/sj.bjc.6601783

[assessment]

• The GOLF regimen was introduced as a neoadjuvant treatment since late August 2022 with the aim of downstaging the tumor. The CT (2022-11-16) revealed that the adenocarcinoma of the duodenal bulb showed a mild increase in size and that the metastatic nodes displayed a decrease in size. There appears to be a greater likelihood that this will improve the feasibility of the surgery.

• The decreased CA199 marker also served as a side evidence that the regimen is still effective.

  • 2022-11-21 CA199 346.54 U/mL
    
  • 2022-10-11 CA199 740.79 U/mL
    
  • 2022-09-13 CA199 1286.58 U/mL

• Data available indicate stable vital signs, and there is no problem with the active prescription.

700568782

221122

• diagnosis - 2022-11-10 discharge note
  • Right breast invasive carcinoma with liver and bone metastasis, cT4N1M1, stage IV. ECOG:0
  • Viral hepatitis B without hepatic coma
  • Upper Gastrointestinal Bleeding, vomit OB: 3+
  • Reflux esophagitis, lower esophagus, LA classification, grade B
  • Gastric ulcer
  • Superfical gastritis
• exam findings
  • 2022-11-21 CXR
    • Ground glass opacity in RLL.
  • 2022-11-10 Patho - stomach biopsy
    • Stomach, AW of antrum, biopsy — Non-atrophic chronic gastritis, Helicobacter Pylori: NOT present
  • 2022-11-10 Panendoscopy
    • Reflux esophagitis, lower esophagus, LA classification, grade B
    • Superfical gastritis, antrum
    • Gastric ulcer, antrum, AW, s/p biopsy
  • 2022-11-08 CT - abdomen
    • Clinical history: 54 y/o female patient with breast cancer with liver mets, elevated TBI and liver dysfunction.
    • Findings
      • Diffuse liver tumors in both lobes of the liver, suggesting liver metastasis. Progression as compare with CT study on 20220505.
      • Presence of gallbladder stones.
      • Unremarkable change of the spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • Presence of ascites.
      • Bilateral pleural effusion with right lower lung collapse.
      • Diffuese osteoblastic and osteolytic lesions in the bones, could be due to bone metastasis.
    • Impression:
      • Liver metastasis and ascites with progression.
      • Diffuse bone metastasis.
      • Bilateral pleural effusion with right lung collapse.
      • GB stones.
  • 2022-11-07 ECG
    • Normal sinus rhythm
    • ST & T wave abnormality, consider anterior ischemia
    • Prolonged QT
    • Abnormal ECG
  • 2022-11-05 KUB
    • Diffuse bony metastases of the lower T-spine, L-spine, sacrum, and bilateral ilium.
  • 2022-11-05 CXR
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Osteoblastic bony metastases in the lower T-spine and L-spine are noted after correlate with prior CT.
  • 2022-10-28 Whole body PET scan
    • Findings
      • There was increased FDG uptake in the some mediastinal lymph nodes and in multiple focal areas in the liver.
      • There was increased FDG uptake in multipe bones including the skull, mandible, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, bilateral clavicle, bilateral scapulae, sacrum, bilateral pelvic bones, bilateral humeri and femurs.
    • Impression
      • Glucose hypermetabolism in multiple focal areas in the liver and in multipe bones as mentioned above, suggesting multiple liver and bone metastases.
      • Glucose hypermetabolism in some mediastinal lymph nodes. Metastatic lymph nodes should be considered.
  • 2022-10-28 ENT Hearing Test
    • Tymp:
      • Bil type A.
    • ART:
      • R’t contra absent.
      • L’t WNL.
    • E-tube function test:
      • Bil poor.
    • PTA
      • Reliability FAIR
      • Average RE 18 dB HL; LE 19 dB HL.
      • Bil WNL.
  • 2022-10-27 Sonography of hepatobiliary system
    • Findings
      • Bil. liver tumors (up to 6.39cm).
      • Moderate amount ascites.
      • Gallbladder stones (0.65cm, 1.10cm).
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
      • Normal appearance of pancreatic head. The other portions of pancreas masked by gastric/bowel gas.
        
      • Normal appearance of spleen.
      • No evidence of pleural effusion.
      • Normal appearance of kidneys.
    • IMP:
      • Bil. liver tumors (up to 6.39cm). Moderate amount ascites. Gallbladder stones (0.65cm, 1.10cm).
  • 2022-10-27 CXR
    • Consolidation at RLL.
  • 2022-05-09 Tc-99m MDP whole body bone scan
    • Highly suspected multiple bone metastases in multiple T- and L-spine, sternum, bilateral multiple ribs, sacrum, bilateral S-I joints, left ischium, bilateral humeri, and femurs.
    • Increased tracer uptake in the skull and hips, the nature is to be determined, suggesting follow-up with bone scan in 3 months for investigation.
  • 2022-05-05 CT - abdomen
    • Findings
      • S/P right breast operation.
      • Bil. liver metastases (up to 6.5cm). AP shunt at right hepatic lobe. Bil. liver cysts (up to 2.6cm).
      • Multiple bony metastases.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Tiny gallbladder stones (2-3mm).
      • Patency of portal vein.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • No abnormal density at bilateral basal lungs.
    • IMP:
      • S/P right breast operation.
      • Multiple liver and bony metastases.
  • 2022-03-18 SONO - abdomen
    • Metastasis 9 cm in S4 liver is highly suspected.
      • Please correlate with contrast enhanced dynamic CT.
      • Several hepatic cysts on both lobes.
    • Two polyp-like lesion 1.29 cm and 0.86 cm in the gallbladder are suspected.
      
  • 2022-01-18 Patho - breast biopsy (no need margin)
    • PATHOLOGIC DIAGNOSIS
      • Breast, right, partial mastectomy — Invasive carcinoma of no special type, s/p CDK 4/6 inh + AI treatment
      • Resection margin: involved
      • Lymph node, right left axilla/ sentinel, lymphadenecomy — Not received
      • AJCC 8 th edition, Pathology stage: Anatomic stage: ypStage IV, ypT2Nx (if cM1)
    • MACROSCOPIC EXAMINATION
      • Breast: Size: 4.5 x 3.1 x 3.0 cm
      • Skin: Size: 4.1 x 1.3 cm.
      • Nipple: Not Included
        
      • Tumor: Size: 2.8 x 2.0 x 1.7 cm.
      • Resection Margin: involved
      • Lymph node: Not received
      • Representative sections are taken and labeled as: A1-6.
    • MICROSCOPIC EXAMINATION
      • FOR INVASIVE CARCINOMA
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma: 2.8 x 2.0 x 1.7 cm.
        • Histologic grade (Nottingham histologic score): grade II (score 7)
          • Tubule formation: score 3
          • Nuclear pleomorphism: score 3
          • Mitotic count: score 1
        • Extent of tumor (required only if the structures are present and involved)
        • Skin involvement: Absent; The immunohistochemical stain of CK7 is negative.
          
        • Chest wall invasion deeper than pectoralis muscle: not received
      • FOR DUCTAL CARCINOMA IN SITU
        • Tumor size (cm): several foci, measuring up to 0.5 x 0.25 cm, intermix with invasive carcinoma.
        • Nuclear grade: 3
        • Architectural pattern: Non-comedo (solid and cribriform)
        • Tumor necrosis: Present
      • Margins: Involved ( unspecified margin)
      • Nodal status: Not received
        • number of lymph node examined: Not received
        • number with macrometastases (>2mm): Not received
        • number with micrometastases (>0.2~2mm and/or >200 cells): Not received
        • number with isolated tumor cells (<=0.2mm and <=200 cells): Not received
      • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
        • In the Breast: Probable or definite response to presurgical therapy in the invasive carcinoma
        • In the Lymph nodes: No lymph nodes removed
      • Lymphovascular invasion: present
      • Perineural invasion: present
    • IMMUNOHISTOCHEMICAL STUDY
      • ER (Ab): Positive (strong, 80 %)
      • PR (Ab): DCIS: Positive (strong, 10%); IDC: Negative
      • HER-2/Neu (Ab): DCIS: Positive (3+); IDC: Equivocal (2+)
        • The HER2/NEU In-Situ Hybridization Test from Taipei Institute of Pathology is NEGATIVE.
        • There is NO amplification of HER2 detected.
      • Ki-67: < 5%
  • 2022-01-17 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Nonspecific ST abnormality
  • 2021-12-31 SONO - abdomen
    • Diagnosis
      • Fatty liver,mild
      • Suspected liver cyst,left
      • Liver tumors,bil.Propable metastases
      • Suspected GB polyp
    • Suggestion
      • OPD f/u
      • Please correlate with other image
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
• consultation
  • 2022-11-09 Family Medicine
    • Q
      • This time, she has nasuea and vomit and poor intake, so she was admission for supprtiva care ( IVF & Bfluid ) on 11/5 22. Howevee, the patient’s condition, liver function worse, and request the combine hospice care, so we need your help, thanks a lot!!
    • A
      • 54-year-old female, right breast cancer with liver and bone metastasis
      • Consciousness clear, ECOG 2
      • We will arrange hospice combine care and follow her condition

[assessment]

• There was an increase in serum bilirubin (both direct and total), AST, ALT, and ammonia as a result of poor liver function.
• Presently, Baraclude (entecavir), Baogan (silymarin) and Lactul Syrup (lactulose) are used to treat liver insufficiency symptoms.
• Hospice combined care has been arranged.
• Her edema in the lower extremities might be mitigated by the use of albumin (2.8 g/dL 2022-11-05).

700361615

221121

{drug identification}

requesting drug identification for 4 items.

the 3 items are identified as following while the other 1 item remains unknown.

• Broen (l-cysteine 20mg, bromelain 20000unit)
• Acetal (acetaminophen 500mg)
• Sodicon (dextromethorphan 15mg)

The drug will be sent back to ward by the in-hospital porter.

700952001

221121

• diagnosis 20221001 discharge
  • Infiltrating duct carcinoma of left breast, pT2N0M0 post MRM (20131017), ER:positive (90%), PR:40%, Her2/neu:equivocal(2+, FISH negative), P53(-), Ki-67 index 30%, bone metastases
  • Essential (primary) hypertension
• exam findings
  • 2022-11-18 KUB
    • Fecal material store in the colon.
    • Spondylosis of the L-spine is noted.
    • S/P total hip arthroplasty, left hip and the screw penetration into the pelvis.
  • 2022-11-18 CXR
    • Spondylosis of the T-spine
    • Few nodular opacity projecting in the left upper and middle lung are suspected. Please correlate with CT.
    • S/P partial Mastectomy, left.
  • 2022-10-25 L-spine AP + Lat (including sacrum)
    • Straightening alignment of lumbar spine. Degenerative change of the spine with marginal spur formation. Status post left total hip replacement.
    • Multiple geographic areas of sclerotic bone change in visible bones with pedicle involvement, compatible with bone metastases.
  • 2022-10-25 Pelvis + Lt. Hip Lat
    • Status post left total hip replacement. Mild osteoarthritis change of right hip joint with joint space narrowing (more at superior aspect), subchondral sclerosis and marginal spur formation.
  • 2022-10-25 CXR
    • Ill-defined faint patch at LUL.
    • Degenerative change of the spine with marginal spur formation.
  • 2022-10-25 CT - brain
    • Brain atrophy.
  • 2022-10-25 ECG
    • Sinus tachycardia
    • Left axis deviation
  • 2022-09-17 MRI - brain
    • Bony metastases at skull, clivus and C2 vertebral body.
    • Suspected metastases at pituitary stalk and gland.
  • 2022-09-16 CT - chest
    • Left breast cancer s/p MRM with bilateral lung meta, liver meta and mediastinal lymphadenopathy, in progression.
    • Bone meta. Please correlate with bone scan study.
  • 2022-06-17 CT - chest
    • S/P mastectomy at left side.
    • Bilateral lung meta and mediastinal lymphadenopathy
    • Liver meta
    • Bone meta.
  • 2022-04-28 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20210702, more new bone lesions are noted, suggesting multiple bone metastases in progression.
  • 2022-02-05 CT - abdomen
    • S/P mastectomy at left side
    • Suspected bone meta at L1
    • S/p Total hip replacement over left side is found. The nails of the S/p Total hip extends to pelvic cavity.
  • 2021-07-02 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20200210, the lesions in the left 10th costovertebral junction, L1 spine and sarum are new. Bone metastases should be considered frist.
    • The lesion in the L5 spine is a little more evident. Either degenerative spine disease in a little more severe status or bone metastasis may show this picture. Please correlate with other clinical findings for further evaluation.
    • Suspected benign lesions in the maxilla, L2 spine, right sternoclavicular junction, bilateral shoulders, S-I joints and knees.
  • 2021-05-14 SONO - abdomen
    • Fatty liver, mild to moderate
    • Suspected fatty infiltration of pancreas
  • 2020-02-10 Tc-99m MDP whole body bone scan
    • A hot spot at the left femoral head and neck, the nature is to be determined, suggesting further investigation and follow-up with bone scan in 3 months.
    • Suspected benign lesions in the maxilla, L2-5 spines, right sternoclavicular junction, bilateral shoulders, S-I joints, and knees.
  • 2020-02-07 Pelvis & Lt. Hip Lat
    • Osteoporotic change at the left femoral head is noted.
    • Chip fracture or Marginal osteophyte formation at the lateral aspect of left acetabulum is noted. please correlate with clinical condition or CT.
  • 2018-03-09 Bone densitometry - spine
    • AP L-spines, BMD of L1-4 0.763 gms/cm2, about 2.1 SD below the peak bone mass (76%) and 0.1 SD above the mean of age-matched women (102%).
    • IMP: Osteopenia.
  • 2018-03-09 Bone densitometry - hip
    • Left hip, BMD is 0.530 gms/cm2, about 2.6 SD below the peak bone mass (66%) and 0.7 SD below the mean of age-matched people (90%).
    • IMP: Osteoporosis
• consultation
  • 2022-09-20 Radiation Oncology
    • Q
      • This 72-year-old woman had past history of 1) infilltrating duct carcinoma of left breast, pT2N0M0, grade II ER: positive (90%), PR:40%, Her2/neu:equivocal (2+)–FISH NEGATIVE , P53(-), Ki- 67 index: 30%. post MRM (2013/10/17).
      • She received the chemotherapy with AC followed by hormone therapy on 2013 then was regularly followed up at ONC OPD. Bone scan on 2022/04/22 showed in comparison with the previous study on 2021/7/2, more new bone lesions are noted, suggesting multiple bone metastases in progression.Then she started the CDk4/6 inhibitor with Kisqali and Femara from July 2022 to August 2022. Hold due to leukopenia and general weakness.
    • A
      • A: Infiltrating ductal carcinoma, grade II, of the left breast, ER: positive (90%), PR:40%, Her2/neu:equivocal (2+, FISH: negative), stage pT2N0(cM0), s/p MRM and chemotherapy, with multiple including liver and bone metastases.
      • P: Radiotherapy is indicated for this patient with the following indicators: Bony metastases at skull, clivus, C2 vertebral body, pituitary stalk and gland.
        • Goal: palliation
        • Treatment target and volume: whole brain including bony metastases at skull, clivus, C2 vertebral body, pituitary stalk and gland.
        • Technique: 2D
        • Preliminary planning dose: 3000cGy/15 fractions of the whole brain including bony metastases at skull, clivus, C2 vertebral body, pituitary stalk and gland.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family (husband and son). They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2022-09-28.
  • 2022-09-08 Oral and Maxillofacial Surgery
    • Q
      • 20220819 Xgeva
      • However, gingiva swelling was noted today, we need your expertise for further management, thanks
    • A
      • For gingiva swelling
      • O:
        • Poor oral hygiene with lots of calculus was noted of full mouth.
        • Tenderness and swelling of right chin was noted.
        • Abscess with sinus tract of right anterior mandible. Pus discharged was noted. Residual root of 42 s/p RCF with gingiva inflammation was noted
        • Breast cancer under Xgeva treatment
      • A:
        • Periapical abscess with sinus tract of tooth 42
      • P:
        • Explained the finding to patient and her family.
        • Periodontal emergency of right mandible.
        • Suggest systemic antibiotics treatment.
        • OPD follow up
• chemoimmunotherapy
  • 2022-10-07 ~ undergoing - Aromasin (exemestane)
  • 2022-10-07 ~ undergoing - Afinitor (everolimus)
  • 2022-03-25 ~ undergoing - Arimidex (anastrozole)
  • 2021-09-10 ~ 2022-03-29 - Kisqali (ribociclib)
  • 2021-07-16 ~ undergoing - Xgeva (denosumab)
  • 2017-01-06 ~ 2022-03-XX - Femara (letrozole)

[assessment]

• The results of the uric acid lab showed an upward trend and indicated an increased risk of renal damage. It may be possible to consider Feburic (febuxostat 80mg) 0.5# QD without the need of adjusting the dose based on the current level of liver function.
  • 2022-11-18 Uric Acid 8.6 mg/dL
    
  • 2022-10-31 Uric Acid 6.7 mg/dL
    
  • 2022-09-30 Uric Acid 6.1 mg/dL

221026

[assessment]

• Cell plasticity constitutes the ability of cancer cells to rapidly reprogramme their gene expression repertoire, to change their behaviour and identities, and to adapt to microenvironmental cues. These features also directly contribute to tumour heterogeneity and are critical for malignant tumour progression. (ref: Breast cancer as an example of tumour heterogeneity and tumour cell plasticity during malignant progression. Br J Cancer 125, 164–175 (2021). https://doi.org/10.1038/s41416-021-01328-7). It is likely that the available gene assay results “ER:positive (90%), PR:40%, Her2/neu:equivocal(2+, FISH negative), P53(-), Ki-67 index 30%” were obtained long ago (MRM in 2013). A new gene expression assay might be beneficial.
• The use of Aromasin (exemestane) and Afinitor (everolimus) has been started since Oct 2022 after a CT image (Sep 2022) indicated that the disease was in progress.
• It does not appear that there is a problem with the active prescription.

700569043

221118

{drug identification}

It was requested that four drugs be identified.

The items identified are as follows:

• Lipanthyl Supra (fenofibrate 160mg)
• Trajenta (linagliptin 5mg)
• Crestor (rosuvastatin 10mg)
• Bentomin (metformin 500mg)

These drugs will be sent back to ward by an in-hospital porter.

701196725

221118

• diagnosis - 2022-11-04 discharge note
  • Colon adenocarcinoma with obstruction s/p right hemicolectomy on 2021/12/01, pT4aN2bcM0(7/15), G2, LVI(+), PNI(+), CRM(-), stage IVA with liver metastasis s/p chemotherapy with Avastin(5mg/kg)(self pay)/FOLFIRI(Campto 120mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) from 2022/03/18~2022/05/26 for 4 cycles, patient refuse therapy with bilateral lungs, pleura, liver, peritoneal and retroperitoneal metastases s/p palliative chemotherapy with FOLFIRI from 2022/09/12
  • Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation
  • Type 2 diabetes mellitus without complications
  • Chronic viral hepatitis B without delta-agent
  • Essential (primary) hypertension
  • Unspecified hemorrhoids
• exam finding
  • 2022-11-02 CT - abdomen
    • History:
      • 20211120 CT:Dilatation of small bowel and collapse of colon, r/o obstruction at ileocecal valve. Suspect wall thickening of terminal ileum and Small bowel feces sign in distal ileum +.
      • 20211124 colonoscopy: One ulcerative tumor with about 1/2 circumferential involvement at ICV and extending to A-colon.
      • 20211201 S/P right hemicolectomy:pT4aN2b, if cM0, stage IIIC
        
      • 20220712 CT：Peritoneal carcinomatosis, lung and liver metastases.
    • Findings:
      • Prior CT identified multiple hypodense masses on both hepatic lobes are noted again, increasing in size and number that are c/w liver metastases with progressive disease.
      • Prior CT identified few metastases on both lung are noted again, mild increasing in size that is c/w progressive disease.
      • There is massive ascites and soft tissue nodules in the omentum and mesentery that is c/w carcinomatosis. Please correlate with ascites cytology.
      • S/P right hemicolectomy
      • Few small gallstones are noted.
      • There is no hyper-or hypodense lesion in the biliary system, pancreas, spleen & both kidney.
      • There is no lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
    • IMP:
      • Peritoneal carcinomatosis, lung and liver metastases show progressive disease.
  • 2022-09-27 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • Detected (KRAS codon 12 GGT>GAT, p.G12D)
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600: p.V600M, p.V600L, p.V600E, p.V600A, p.V600G, p.V600K, p.V600R
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-09-06 SONO - abdomen
    • Chronic liver parenchymal disease
    • c/w liver and lymph node metastasis
    • Ascites
    • Minimal pleural effusion
  • 2022-09-05 Patho - stomach biopsy
    • Esophagus, 25 cm to EC junction, biopsy — Ulcer, with no viable tissues
    • Microscopically, it shows necrotic debris, granulation tissue,and abundant lymphocytic and leukocytic infiltrate. No viable tissue is seen.
    • Immunohisotchemical stain reveals CK(-), CD20(-), CD3(-), LAC(focal+),and CMV(-).
  • 2022-09-05 Patho - stomach biopsy
    • Stomach, angle, biopsy — ulcer with Helicobacter infection
    • Microscopically, it shows ulcer with ulcerative debris, focal intestinal metaplasia and leukocytic infiltrate.
      
    • Mild Helicobacter-like bacilli are seen.
  • 2022-09-02 CXR
    • Tortous aorta with calcification is noted.
    • Increased pulmonary vasculature is found.
  • 2022-09-02 KUB
    • Degenerative change of the bony structure with marginal osteophyte formation is identified.
    • Stool impaction at the abdominal cavity is noted.
  • 2022-09-02 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis with ulceration, LA-D
      • Superficial gastritis, s/p CLO test
      • Gastric ulcer, angle, s/p biopsy*4
      • CLO test (+)
    • Suggestion
      • PPI pump and algitab
      • Pursue pathology
      • GI OPD for HP eradication after discharge
  • 2022-07-12 CT - abdomen
    • Findings
      • S/P colon operation.
      • A nodule (5.4mm) at LLL.
      • Some soft tissues in peritoneal cavity with ascites.
      • Multiple liver tumors.
      • Some calcifications in peritoneal cavity.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Tiny gallbladder stones.
      • Intact bony structures.
      • No enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
    • IMP:
      • S/P colon operation. Peritoneal carcinomatosis, lung and liver metastases.
  • 2022-05-27 SONO - abdomen
    • Diagnosis
      • Liver cirrhosis with borderline splenomegaly
      • Hepatic hypoechoic lesions, multiple, both lobe, suspected metastases
      • Gallbladder polyp
      • Cholecystopathy
      • Small amount ascites
    • Suggestion
      • Please correlate with other image study
  • 2022-03-01 CT - abodmen, pelvis
    • Clinical history: 71 y/o male patient with cecal cancer s/p OP and C/T.
    • Findings
      • S/P right colectomy with regional dirty mesentery fat plane, post-op change? Suggest follow up.
        
      • There are several low density tumors (up to 1.4cm) in both lobes of the liver, suspected liver metastasis.
      • Presence of gallbladder stone.
    • Impression:
      • S/P right hemicolectomy with regional dirty mesentery fat plane, post-op change? Suggest follow up.
        
      • Liver tumors, suspect liver metastasis.
  • 2021-12-02 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • 1. Tumor, ascending colon, right hemicolectomy — Adenocarcinoma
           
      • 2. Resection margins, bilateral, ditto — Free from tumor
           
      • 3. Lymph node, mesocolic, dissection — Tumor metastasis (7/15) with extracapsular extension (3/7)
           
      • 4. Appendix, right hemicolectomy — Tumor emboli present, but no direct invasion
           
      • 5. AJCC pathologic stage — pT4aN2b, if cM0, stage IIIC
           
    • MICROSCOPIC EXAMINATION
      • 1. Histology: adenocarcinoma
      • 2. Histology Grade: G2-3: moderately to poorly differentiated
           
      • 3. Depth of invasion: visceral peritoneum and some tiny nodules at ileal wall
           
      • 4. Angiolymphatic invasion: Present
           
      • 5. Perineural invasion: Present
           
      • 6. Discontinuous extramural tumor extension: NOT identified
           
      • 7. Circumferential (radial) margin of rectosigmoid: NOT involved
           
      • 8. Lymph node metastasis, mesocolic: tumor metastasis (7/15)
           
      • 9. Lymph node metastasis, IMA / SMA: N/A
           
      • 10. Extranodal involvement: Present (3/7)
            
      • 11. Pathological TNM Stage: pT4aN2b
            
      • 12. Type of polyp in which invasive carcinoma arose: N/A
            
      • 13. Additional pathologic findings: focal tumor necrosis
            
      • 14. TNM descriptors: N/A
            
      • 15. Tumor regression grading S/P CCRT: N/A
  • 2021-11-26 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (162 - 47) / 162 = 70.99%
      • Dilated LA, LV
      • Adequate LV, RV systolic function with normal wall motion
      • Thick IVS, Impaired LV relaxation
      • Mild MR,TR,AR
  • 2021-11-25 Patho - colorectal polyp
    • Colon, ileocecal valve, biopsy — Adenocarcinoma, moderately differentiated
      
    • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
      
  • 2021-11-24 Colonoscopy
    • Diagnosis
      • Suspect advanced colon cancer, ICV, s/p biopsy(A), terminal ileum maybe involved.
      • Colon polyp, proximal T-colon, s/p cold polypectomy(B) and clip
      • Colon polyp, T-colon, s/p hot polypectomy(C) and clip
      • ICV stenosis.
    • Suggestion
      • F/U pathology report
    • Complication
      • No immediate complication
  • 2021-11-23 Small bowel series
    • Small bowel dilatation, suspected partial obstruction at distal small bowel. Suggest clinical correlation
  • 2021-11-20 CT - abdomen
    • Imaging Report Form for Colorectal Carcinoma
    • Impression ( Imaging stage ): T:T4(T_value) N:N2(N_value) M:M0(M_value)
  • 2021-11-20 KUB
    • Dilatation of small bowel and collapse of colon, suspected obstruction
  • 2021-11-20 ECG
    • Sinus tachycardia
    • Right bundle branch block
  • 2021-11-11 Abdomen - standing (diaphragm)
    • Stool retention in the colon
  • 2021-11-05 Small Intestinal Series
    • Normal haustration of the jejunum and ileum.
    • The peristasis of the small intestine is intact.
    • No evidence of stenotic or obstructive lesion in the study.
    • The transit time is 4 hours
  • 2021-11-04 Abdomen - standing (diaphragm)
    • Presence of ileus.
  • 2021-11-02 CT - abdomen
    • Dilated intestines and colon, suspected enterocolitis
  • 2021-11-02 KUB
    • Dilated bowel gas, suspect ileus. Degenerative change of the spine with marginal spur formation. Calcified nodules in the pelvic cavity, could be urinary bladder stone.
  • 2021-11-02 ECG (emergency)
    • Sinus tachycardia
    • Right bundle branch block
    • Minimal voltage criteria for LVH, may be normal variant
    • T wave abnormality, consider inferolateral ischemia
  • 2019-09-24 ECG
    • Right bundle branch block
    • Nonspecific T wave abnormality
• consultation
  • 2021-11-25 Colon and Rectal Surgery
    • Q
      • This is a 70-year-old male patient with the underlying diseases DM, HCVD under medicine control. This time, he is presented with LUQ abdominal pain and fullness, nausea sensation, no stool passage, and intermittent fever for 2 days .
      • He had ileus on 20211103, and AAD on 20211105 under small serious normal. Under the impression of ileus again, he came to our ward to do further management and examination.
      • On 20211120 abdominal CT, Small bowel dilatation, suspected obstruction, Suspect wall thickening of terminal ileum with regional lymphadenopathy.
      • On 20211124 colonscope found suspect advanced colon cancer, ICV, s/p biopsy, terminal ileum maybe involved.
      • We had arranged him to do 2D heart echo and PFT.
    • A
      • A: Tumor of cecum with partial obstruction
      • P: The operaion of right hemicolectomy is indicated
  • 2021-11-22 General and Gastroenterological Surgery
    • Q
      • This is his second-time intestinal ileus, so we would like to consult your expertise for him. Does he need the surgery survey?
    • A
      • A: ileus, suspected colonic lesion ot terminal ileum lesion with mechanical obstruction
      • P: Please arrange colonoscopy to rule out colonic lesion ot terminal ileum lesion. If no colonic lesion ot terminal ileum lesion, but symptoms persisted, laparoscopy exam may be considered.
• chemoimmunotherapy
  • 2022-11-17 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-11-02 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-10-17 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-09-27 - irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-09-12 - irinotecan 120mg/m2 200mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-08-16 ~ 2022-08-30 - UFT (tegafur 100mg, uracil 224mg)/cap 2# BID PO
  • 2022-06-14 ~ 2022-08-09 - Xeloda (capecitabine 500mg/tab) 1# TID PO
  • 2022-05-26 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-04-25 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-03-18 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-02-23 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)
  • 2022-02-09 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)
  • 2022-01-19 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)
  • 2022-01-05 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)

[assessment]

• CT imaging on 2022-11-02 revealed peritoneal carcinomatosis and lung and liver metastases and a progressive disease was present.
• In the past two months, more than 10 kg of weight have been lost (63 kg 2022-11-17 <- 74 kg 2022-09-22). The use of appetite stimulants (e.g. megestrol) may be beneficial.
• Based on the updated elevated bilirubin levels, there are no issues associated with the irinotecan dose.

221018

[assessment]

• The patient with mCRC has received FOLFOX/FOLFIRI plus bevacizumab since early 2022.
• Regorafenib might be an option as a subsequent treatment if the patient’s disease becomes resistant, and would be covered by the national health insurance program without prior use of cetuximab or panitumumab due to the detected KRAS mutation (2022-09-27 All-RAS + BRAF mutations assay). Regorafenib does not require dosage adjustment in patients with mild or moderate hepatic impairment (total bilirubin 1.79mg/dL 2022-10-11 < 3 times ULN), closely monitor for adverse effects. The drug can be administered orally 160 mg once daily for the first 21 days of each 28-day cycle; continue until disease progression or unacceptable toxicity.
• Lonsurf (trifluridine/tipiracil) is also covered by NHI, however the drug is not recommended for this patient due to his total bilirubin > 1.5 times ULN.

220928

[assessment]

• The serum glucose level remains within acceptable limits with the use of patient-carried Uformin (metformin), Amepiride (glimepiride), and Januvia (sitagliptin).
• Human albumin is used to treat hypoalbuminemia (3.2g/dL 2022-09-22) associated with liver cirrhosis (ABD Sono 2022-09-06).
• The total bilirubin level was 1.51mg/dL (above 1.5 x ULN, 2022-09-22); the treated dose of irinotecan was 150mg/m2 (2022-09-27), not exceeding the recommended limit of 200mg/m2.

701446396

221118

• diagnosis
  • Right ovarian cancer (Clear cell adenocarcinoma) pT1a pN0 ; AJCC/FIGO pStage: IA, at least. post debulking surgery on 2022/08/26
  • Unspecified viral hepatitis B without hepatic coma.
• exam findings
  • 2022-11-09 SONO - breast
    • Diagnosis: Bil. fibroadenomas
    • Suggestion: regular OPD follow up
    • BI-RADS: 2. benign finding
  • 2022-11-02 Mammography
    • Impression: Dense breast. Probably benign calcifications in bilateral breasts. Suggest clinical correlation and follow up.
    • BI-RADS: Category 2: benign findings.-annual screening.
  • 2022-08-29 Patho - soft tissue tumor, extensive resection
    • Ovarian Fallopian tube Peritoneum Cancer Checklist (Based on AJCC 8th ed. and FIGO 2014)
    • PATHOLOGIC DIAGNOSIS
      • Ovary, right, oophorectomy with frozen section (F2022-400) — Clear cell adenocarcinoma, high grade.
        • IHC stains: Napsin-A (+), P53: (wild type), PAX-8 (+), CK20 (-), ER (-, 0%)
      • Ovary, left , salpingectomy (S2022-14311) — Free.
      • Fallopian tube, right, salpingectomy — Free
      • Fallopian tube, left, salpingectomy — free
      • Uterus, corpus, total hysterectomy — myoma; No malignancy.
      • Uterus, cervix, total hysterectomy — free
      • Omentume, omentectomy — free
      • Lymph node, dissection — free
      • pT1a pN0 (if cM0); AJCC/FIGO pStage: IA, at least.
        • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated. Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, medical department and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
    • MICROSCOPIC EXAMINATION:
      • Histologic type: clear cell adenocarcinoma
        
      • Histologic grade: ghigh grade
      • Contralateral ovary involvement: absent
      • Tumor side ovarian surface involvement: absent
      • Contralateral ovary surface involvement: absent
      • Right tube involvement: absent
        
      • Left tube involvement: absent
      • In situ adenocarcinoma in right and/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: absent
      • Left adnexa soft tissue involvement: absent
      • Pelvic soft tissue involvement: absent
      • Uterine serosa involvement: absent
      • Omentum involvement: absent
      • Uterine Cervix involvement: absent
      • Endometrium involvement: absent
      • Myometrium involvement: absent
      • Appendix involvement: not received
      • Largest Extrapelvic Peritoneal Focus - none
      • Peritoneal/Ascitic Fluid-Negative for malignancy (normal/benign)
      • Regional Lymph Nodes: - free
      • Other organs or specimens involvement: none.
  • 2022-08-26 Frozen section
    • Preliminary diagnosis: right ovary: malignant
  • 2022-08-26 Patho - stomach biopsy
    • Gastric polyp, cardia, biopsy — Compatible with fundic gland polyp
  • 2022-08-24 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2022-08-15 CT - abdomen
    • Findings
      • Cystic tumor, 13.8cm in the pelvic cavity, with soft tissue component, suspected right ovarian malignancy.
      • Liver cyst, 0.77cm in S2.
      • Soft tissue tumor, 2.7cm in the uterine fundus region, suspected uterine myoma.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ia (Stage_value)
  • 2022-08-15 Gynecologic ultrasonography
    • Suspected pelvis mass: 109X75mm with papillary: 25x19mm
    • Suspected pelvis mass or uterine myoma: 98x77, RI: 0.47
    • Adenomyosis
• consultation
  • 2022-10-28 Chinese Medicine
    • Q
      • The 59 y/o woman has right ovarian cancer (Clear cell adenocarcinoma) pT1a pN0 ; AJCC/FIGO pStage: IA, at least. post debulking surgery on 2022/08/26. She was admitted for chemotherapy. She asks for your help for assessment.
• surgical operation
  • 2022-08-26 debulking surgery (total abdominal hysterectomy + bil salpingo-oophorectomy + BPLND + partial omentectomy) + enterolysis
    • uterus and bil adnexa
      • Uterus: 12x8x5 cm
      • corpus – adenomyosis-like with some uterine myomas
      • cervix – seemed free of cancer invasion
      • right adnexa –
      • ROV 15x14cm tumor with large solid and cystic contents, containing chocolate fluid 600 c.c
      • Frozen section of ROV–malignancy
      • right tube – np
      • left adnexa: normal-looking
      • bowels, omentum, liver– seemed free of cancer invasion
      • Bilateral pelvic iliac and obturator LNs was removed
      • left iliac LNs
      • left obturator LNs
      • right iliac LNs
      • right obturator LNs
      • CDS: no ascites (washing cytology was sent) but pelvic adhesion was noted between right adnexa, pelvis, peritoneum and bowels s/p enterolysis A 7mm JP drain was placed in CDS
• chemoimmunotherapy
  • 2022-11-17 paclitaxel 175mg/m2 268mg 3hr + carboplatin AUC 5 600mg 2hr
  • 2022-10-27 paclitaxel 175mg/m2 268mg 3hr + carboplatin AUC 5 600mg 2hr
  • 2022-10-06 paclitaxel 160mg/m2 240mg 3hr + carboplatin AUC 5 600mg 2hr (paclitaxel first time 160, next 175)

[assessment]

• The lab results (2022-11-17) were grossly normal and should be considered satisfactory for the scheduled chemotherapy.
• The currently used [paclitaxel + cisplatin] regimen is preferable since carboplatin produces equivalent response rates and survival outcomes to cisplatin and is associated with less toxicity, while paclitaxel is less myelosuppressive than docetaxel. There is, however, a higher risk of neuropathy, myalgias, and weakness associated with paclitaxel in comparison with docetaxel, which should be monitored regularly.
• The underlying condition of viral hepatitis B is appropriately managed with Vemlidy (tenofvir alafenamide).

701262855

221117

{drug identification}

requesting drug identification for 6 items.

the 5 items are identified as following while the other 1 item remains unknown.

Indershin (indomethacin 25mg) Anrokin (chlorzoxazone 200mg) Leflo (levofloxacin 500mg) Ketofen (ketoprofen 50mg) Decan (dexamethasone 0.75mg)

The drugs were packaged as one dose in an opaque bag, which was opened irreversibly. The checked drugs will not be returned to the ward due to the possibility of contamination.

700399143

221116

• exam findings
  • 2022-11-03, -10-30, -10-27 CXR
    • Massive right side Pleura effusion causing mediastinum shift to left side.
    • There are patchy opacity on right lung and nodular opacity projecting in left lung. Please correlate with CT.
  • 2022-10-27 CT - chest
    • Indication: Malignant neoplasm of right main bronchusLung cancer, clinical trail
    • Findings
      • Huge soft tissue mass at right lung up to 16.cm with massive right pleural effusion is found. In enlargement.
      • Left lung nodules are found up to 1.7cm in largest dimension is found. In comparison with CT dated on 2022-09-12, the lesion enlarged markedly.
      • Marked paraseptal Emphysematous change over both lungs more on upper lobes is found.
      • Right axillary lymphadenopathy is found.
    • Imp:
      • Huge right lung cancer with lung to lung meta, right axillary lymphadenopathy, in progression.
  • 2022-10-06 ROS1 FISH
    • Result
      • Number of invasive tumor cells counted: 50
      • Number of cells (%) classified as negative: 49 (98%)
      • Number of cells (%) classified as positive: 1 (2%)
    • Interpretation
      • Rearrangement of ROS1 gene is NOT detected. Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
  • 2022-10-06 ALK IHC
    • ALK immunostaining result: Negative
    • The immunostaining of the section slide labeled S2022-15576, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining in tumor cells.
  • 2022-10-04 MRI - brain
    • No intracranial metastatic lesion.
  • 2022-09-27 Tc-99m MDP whole body bone scan with SPECT
    • Mildly increased activity in some L-spines and sacrum. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2022-09-22 PD-L1 (22C3)
    • PD-L1 immunostaining result
    • Tumor Proportion Score (TPS) assessment: >= 50%
    • Tumor Proportion Score (TPS): 85%
  • 2022-09-22 EGFR mutation
    • Result: No mutation was detected at exons 18 (G719X), 19 (Deletions), 20 (T790M, S768I, Insertions), 21 (L858R, L861Q) of EGFR gene in this specimen.
  • 2022-09-15 Patho - bronchus biopsy
    • Lung, RLL, CT-guide biopsy — poorly differentiated non-small cell carcinoma, origin?
    • Sections show large pleomorphic tumor cells infiltrating in a fibrotic stroma with marked tumor necrosis.
    • The immunohistochemical stains reveal CK7(+), CK20(-), CK5/6(-), GATA3(+), CDX2(focal weak +), TTF-1(-), Napsin A(-), CD56(-), and p40(-). Please correlate with the clinical presentation and image study to exclude other tumor origin.
  • 2022-09-12 CT - chest
    • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1a(M_value) STAGE:____(Stage_value)
  • 2022-09-12 CXR
    • Huge mass lesion over right lung. Suggest check CT scan.
  • 2022-08-01 T-spine AP + Lat.
    • Large patchy consolidation over RUL.
• chemoimmunotherapy
  • 2022-11-03 - pembrolizumab 100mg 1hr
  • 2022-10-31 - carboplatin AUC 2 300mg 2hr D1 + paclitaxel 80mg/m2 120mg 1hr D2

[assessment, not posted]

• There were no mutations or arrangements detected for EGFR, ALK, or ROS1. There is a tumor proportion score of 85% greater than 50% for PD-L1. In this case, the [carboplatin + paclitaxel + pembrolizumab] regimen is appropriate.

700016065

221115

• diagnosis - 20221114 admission note
  • Malignant neoplasm of esophagus, unspecified
  • Chronic viral hepatitis B without delta-agent
  • Chronic hepatitis, unspecified
  • Unspecified cirrhosis of liver
• past history - 20221114 admission note
  • HBV and alcohol related to liver cirrhosis, Episode hepatic encephalopathy times on 2009
  • Hemorroid bleeding on 2009.05
  • Reflux esophagitis, gastric ulcer, duodenal ulcer and esophageal varices history for years
  • CAD under medication treatment for months
• exam findings
  • 2022-11-08 SONO - abdomen
    • Cirrhosis of liver
    • Splenomegaly, mild
    • Poor echo window due to inter-position of colon between liver and abdominal wall
    • Collateral vessels, splenic hilum
  • 2022-09-22 Miniprobe Endoscopic Ultrasound
    • Esophageal cancer, middle and lower esophagus, T3 (suspicioius N1) Mx
  • 2022-09-21 Tc-99m MDP whole body bone scan with SPECT
    • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, some C-, T- and L-spine, bilateral sternoclaviculr junctions, shoulders, S-I joints, hips, and left knee.
  • 2022-09-06 Patho - esophageal biopsy
    • Esophagus, 30 cm below incisor, biopsy — modertaely differentiated squampus cell carcinoma
    • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests of squamous tumor cells in infiltrative growth pattern. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
  • 2022-09-05 Panendoscopy
    • Esophageal cancer, middle esophagus, s/p biopsy
    • Advance esophageal lesion, middle and lower esophagus
    • Reflux esophagitis, lower esophagus, LA classification, grade B
    • Superfical gastritis, antrum
  • 2022-03-07 CT - abdomen
    • Indication
      • Alcoholic + HBV related, Liver cirrhous with hepatic encephalopathy
      • 2021/12/20: echo and lab stable, follow up 3 months later by lab and CT
    • Findings
      • Severe splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
      • Significant splenic varices formation with splenorenal shunt is also noted.
    • Imp
      • Liver cirrhosis with varices formation and splenorenal shunt
      • No evidence of hepatic tumor in the study.
  • 2021-06-29 SONO - abdomen
    • Cirrhosis of liver
    • Splenomegaly, mild
    • Colleteral vessels, LUQ of abdomen
  • 2021-04-05 CT - abdomen
    • Liver cirrhosis with portal hypertension, left splenorenal shunt and splenomegaly.
    • Much stool retention in colon.
  • 2020-05-06 CT - abdomen
    • Liver cirrhosis with splenomegaly and varices formation.
    • No evidence of hepatic tumor in the study.
  • 2019-11-19 SONO - abdomen
    • Cirrhosis of liver
    • Part of right lobe masked by gas
    • Splenomegaly, mild
  • 2019-08-27 SONO - abdomen
    • Cirrhosis of liver
    • Splenomegaly, mild
    • Spleno-renal shunt
  • 2019-05-31 CT - abdomen
    • Liver cirrhosis and portal hypertension.
    • Splenomegaly.
  • 2019-03-19 SONO - abdomen
    • Cirrhosis of liver
    • Splenomegaly, mild
  • 2018-07-05 CT - abdomen
    • Liver cirrhosis with portal hypertension and splenomegaly.
  • 2017-08-02 CT - abdomen
    • Liver cirrhosis with portal hypertension and splenomegaly.
  • 2017-02-17 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (118 - 31) / 118 = 73.73%
      • M-mode (Teichholz) = 73
    • Septal hypertrophy with Gr I LV diastolic dysfunction; dilated LA.
    • Normal LV and RV systolic function.
    • Mild MR; mild TR.
    • VPC bigeminy.

[assessment]

• Metoclopramide is recommended to be given at a dose of 5 mg four times daily (maximum dose: 20 mg) for patients with moderate or severe hepatic impairment (Child-Pugh class B or C). The medication is currently prescribed in both oral and IV forms, with a dose of 3.84mg PO TIDAC and 10mg IVD PRNQ6H.
• As far as morphine for patients with hepatic impairment is concerned, the manufacturer’s labeling does not provide any dosage adjustments. Pharmacokinetics remain unchanged in mild liver disease; substantial extrahepatic metabolism may occur. There may be a need to adjust the dosage in patients with cirrhosis due to increases in half-life and AUC.
• A dose adjustment is not required for any other drug in the active prescription.

700054842

221115

• exam findings
  • 2022-11-09 CT - abdomen
    • Indication: liver mass
    • CC:
      • Nausea and diarrhea for 2 weeks. Dizziness.
      • Abdominal fullness and passage of black stools for 2 weeks.
      • Tea-colored urine was noted. Tense leg edema for 10 days.
    • Past history:
      • An oral caner patient and received operations and RT since 2013/2/15. He has sleeping problem and abnormal taste in his mouth after operation and RT. He quit betel nut chewing and smoking in his past years. He had been received induction chemotherapy, operations and adjuvant RT due to oral cancer at his left lower gum since 2011/11.
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
    • Findings:
      • There is hepatomegaly (the greatest cranial-caudal dimension measuring 21.2 cm) and infiltrative hypodense masses on both hepatic lobes.
        • Metastases on both hepatic lobes are highly suspected.
        • The tumor margin is hard to define in non-enhanced CT. Please correlate with contrast enhanced dynamic CT or non-enhanced MRI.
        • In addition, There is minimal dilatation of right lobe inferior segment IHDs that may be tumor compression.
        • Please correlate with serum alk-p and bilirubin level.
          
      • There is a soft tissue lesion in left para-aortic space, 2.2 cm in size that may be metastatic node (Srs:201 Img:26) .
      • There is ascites.
      • There is lack of subcutaneous fat that may be cachexia status and hypoalbuminemia.
      • A renal cyst measuring 1.9 cm in right middle pole is noted.
      • There is no hyper-or hypodense lesion in the gallbladder, , pancreas, spleen & left kidney.
        
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • IMP:
      • Metastases on both hepatic lobes are highly suspected.
      • Metastatic node in left para-aortic space 2.2 cm.
      • Ascites
  • 2022-11-04 SONO - abdomen
    • Diagnosis
      • Liver tumor, right lobe, suspicious HCC with main and right portal vein encasement.
      • Liver hemangioma, S2
      • Renal cyst, right
      • Ascites, mild
    • Suggestion
      • arrange liver dynamic CT and correlate with tumor markers.
  • 2022-08-16 KUB and lateral L-spine
    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
  • 2019-05-28 MRI - nasopharynx
    • Post OP at left oral cavity and mandible, stationary.
  • 2018-08-03 MRI - nasopharynx
    • Prominent soft tissu in the right lower gingiva. Nature?
  • 2017-11-24 MRI - L-spine
    • mild retrolisthesis at L2-3.
    • herniated discs in the L2/3 and L3/4 discs
    • annulus tears in the L4/5 and L5/S1 discs
  • 2017-11-23 MRI - nasopharynx
    • Post flap reconstruction surgery at left anterior lower buccal-gingival region, mandible and submental region with sof-tissue tissue defect, and retention of surgical clips. As compared with previous study on 2017/04/11, there was no interval change. No focal mass or nodule.
    • Post LNs dissection with clips retention with metallic artifact and/or soft tissue or muscle defect, left.
  • 2017-04-11 MRI - nasopharynx
    • Post flap reconstruction surgery at left anterior lower buccal-gingival mandible regions with left neck LNs dissection. No evidence of tumor recurrence.

700312743

221115

{gastric signet-ring cell carcinoma}

• exam findings
  • 2022-11-13 CXR
    • Consolidations in both lung fields
    • Normal heart size and configuration
    • Suspect left pleural effusion
  • 2022-11-09 SONO - chest
    • Finding
      • Left-side of thorax
        • Irregularly thickened pleurae was noted along with moderate free and anaechoic effusion LLL consolidaiton and atelectasis
      • Right-side of thorax
        • no pleural effusion
        • No active lung lesion
    • Echo diagnosis:
      • Pleural effusion, moderate, left
      • atelectasis, LLL
      • Pleural nodules, left
  • 2022-11-08 Pelvis & Lt. Hip Lat
    • Avascular necrosis of right femoral head is highly suspected. please correlate with clinical condition and MRI.
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
  • 2022-11-08, -10-31 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2022-11-04 CT - chest
    • Bil. pleural effusion with adjacent lung collapse.
    • No evidence of pulmonary embolism.
  • 2022-10-28 Panendoscopy
    • Diagnosis
      • Esophageal mucosal oozing, s/p hemostasis with APC
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, remnant stomach
      • c/w s/p antrectomy with B-II anastomosis
    • Suggestion
      • High dose PPI * 3 days
  • 2020-10-26 CT - abdomen
    • History:
      • 20200729 BW loss 6 Kgs in recent 6 months, postprandial epigastric discomfort and poor appetie for 3 months
      • 20200729 Gastroscopy: Borrmann type II gastric cancer in the antrum. CT staging: cT4aN2M0, cSTAGE:III
      • 20200810 S/P subtotal gastrectomy: Tumor present at greater omentum. Surgeon suggests tumor seeding and c/w distant metastasis. pT4aN3aM1, pstage IV
    • Indication: LUQ pain persist in recent months
    • Findings:
      • There is left side Pleura effusion with suggstive thickening at the parietal pleura that may be pleura tumor seeding. Please correlate with pleura biopsy and pleura effusion cytology.
        • In addition, There are multiple enlarged nodes in paratracheal space, subaortic space, bilateral hilum and subcarina space that are c/w metastatic nodes.
      • S/P subtotal gastrectomy
      • Prior CT identified Mild soft tissue density lesion in the celiac trunk surrounding area is noted again, stationary that may be normal variation.
        • The differential diagnosis include metastatic nodes. Follow up is indicated.
      • There are several hepatic cysts in both lobes and the largest one 1.3 cm in size at S7.
        
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
      • There is no evidence of lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • Impression:
      • There is left side Pleura effusion with suggstive thickening at the parietal pleura that may be pleura tumor seeding. Please correlate with pleura biopsy and pleura effusion cytology.
      • Metastatic nodes in the mediastinum are noted.
  • 2022-10-12 Patho - pleural/pericardial biopsy
    • Pleura, left, biopsy — metastatic signet-ring cell carcinoma, consistent with gastric origin
    • Section shows skeletal muscle fibers and fibroadipose tissue with metastatic signet-ring cell carcinoma.
    • The immunojostochemical stains reveal CK(+), CDX2(+), Calretinin(-), and TTF-1(-). The results are consistent with gastric origin.
    • The immunohistohcmeical of Her-2/neu (Ab) is done and shows Negative (0).
  • 2022-10-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 27) / 89 = 69.66%
      • LVEF (%) = 70
      • M-mode (Teichholz) = 70
    • Normal LV systolic function with normal wall motion.
    • Impaired LV relaxation.
    • Normal RV systolic function.
    • Mild MR; moderate TR; mild PR; aortic valve sclerosis.
    • Possible mild pulmonary hypertension, estimated PASP: 36 mmHg.
    • Flat IVC and tachycardia; consider hypovolemia.
    • Left pleural effusion.
  • 2022-09-24 CT - abdomen
    • Indication
      • [ICD10CM] Malignant neoplasm of pyloric antrum
      • [ICD10CM] Malignant neoplasm of stomach, unspecified
    • Findings
      • s/p partial gastrectomy.
      • The GB is well distended without soft tissue lesion
      • Minimal soft tissue mass around the celiac trunk is found. In comparison with CT dated on 2022-07-18, the lesion is stationary.
      • The urinary bladder is well distended without soft tissue lesion.
      • There is no evidence of destructive bone lesion.
      • Non-specific bowel gas at abdominal cavity is found.
      • Dilated CBD is found. Stationary.
      • Massive left pleural effusion is found.
      • Normal heart size.
      • The lung fields are clear.
    • Imp:
      • s/p partial gastrectomy.
      • Minimal soft tissue mass around the celiac trunk is found. In comparison with CT dated on 2022-07-18, the lesion is stationary.
  • 2022-07-18 CT - abdomen
    • s/p subtotal gastrectomy.
    • Soft tissue mass surrounding the celiac trunk is found. In comparison with CT dated on 2022-04-20, the soft tissue is stationary in size and extention.
    • Increased intestinal gas is found. The intestines are wall dilated. Post op. change is favored.
  • 2022-04-28 MRI - T-spine
    • The thoracic spine shows normal alignment and vertebral contour.
    • The thoracic disk spaces show no disk bulging, extrusion or protrusion.
    • The thoracic spinal cord shows normal size and signal intensity without evidence of compressive edema, ischemia or myelomalacia. There is no extrinsic compresson of the cord.
    • The neural foramina of the thoracic spine are patent. No impingement is seen.
  • 2022-04-27 Whole body PET scan
    • Glucose hypermetabolism in the LUQ of abdomen, compatible with S/P subtotal gastrectomy.
      
    • Glucose hypermetabolism in the soft tissue in the left supra-renal region and in the pre-vertebral space of T12 spine, the nature is to be determined (reactive nodes, metastatic lymph nodes or others ?), suggesting further investigation.
      
    • Glucose hypermetabolism in the right submandibular lymph nodes, the nature is to be determined also (reactive nodes or others ?), suggesting further investigation.
      
    • No prominent abnormal focal FDG uptake is noted elsewhere.
  • 2022-04-25 SONO - abdomen
    • Findings
      • Anechoic nodules, 1.19x0.65cm and 1.29x0.96cm in left lobe, 1.2x0.68cm and 1.07x0.85cm in right lobe, suspected liver cysts.
      • Normal appearance of gallbladder without stone.
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
    • Impression
      • Liver cysts.
  • 2022-04-20 CT - abdomen
    • S/P subtotal gastrectomy.
    • Prior CT identified Mild soft tissue density lesion in the celiac trunk surrounding area is noted again, stationary that may be normal variation.
    • The differential diagnosis include metastatic nodes.
  • 2022-03-31 MRI - L-spine
    • Thoracicolumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, es T10-11-12 (with left OYL) and L4-5 (with Gr I spondylolisthesis).
  • 2022-01-27 CT - abdomen
    • S/P gastric operation. No evidence of tumor recurrence.
  • 2022-01-26 Tc-99m MDP whole body bone scan
    • Faint hot spots in the left fronto-parietal region of skull and right hip joint, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3-6 months for investigation.
    • Suspected benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, and knees.
  • 2021-11-08 SONO - abdomen
    • Findings
      • Anechoic nodules, 1.22x0.7cm, 1.29x1.16cm and 1.14x0.98cm in left lobe, 0.96x0.51cm and 1.47x0.85cm in right lobe, could be due to liver cysts.
      • Normal appearance of gallbladder without stone.
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
    • Impression:
      • Liver cysts.
  • 2021-08-16 CT - abdomen
    • S/P gastric operation. No evidence of tumor recurrence.
    • Liver cysts (up to 1.1cm).
  • 2021-03-09 CT - abdomen
    • s/p subtotal gastrectomy.
    • No evidence of recurrent/residual tumor in the study.
  • 2020-08-11 Patho - stomach subtotal/total (tumor)
    • Addendum:
      • Tumor present at greater omentum. Surgeon suggests tumor seeding and compatible with distant metastasis in clinico-pathologic conference.
      • AJCC pathologic staging is revised to pT4aN3aM1, stage IV
    • PATHOLOGIC DIAGNOSIS
      • Stomach, subtotal gastrectomy — Signet-ring cell carcinoma
        
      • Margins, bilateral cutting ends, ditto — Free of tumor
        invasion
        
      • MCA, ditto — Free of tumor metastasis (0/1)
        
      • Greater omentum, omentectomy — Tumor present
        
      • Lymph node, LN 1, dissection — Negative for tumor metastasis (0/1)
        
      • Lymph node, LN 3, ditto — Tumor metastasis (4/8) without extracapsular extension (0/4)
        
      • Lymph node, LN 4, ditto — Tumor metastasis (3/6) with extracapsular extension (2/3)
        
      • Lymph node, LN 5, ditto — Negative for tumor metastasis (0/4)
        
      • Lymph node, LN 6, ditto — Tumor metastasis (4/5) with extracapsular extension (1/4)
        
      • Lymph node, LN 7, 8, 9,12, ditto — Negative for tumor metastasis (0/3)
        
      • Lymph node, LN 11p, ditto — Negative for tumor metastasis (0/1)
        
      • Lymph node, LN 14, ditto — Tumor metastasis (3/3) with extracapsular extension (2/3)
        
      • AJCC Pathologic staging — pT4aN3a (if cM0), stage IIIB
        
    • MICROSCOPIC EXAMINATION
      • Histologic type: Signet-ring cell carcinoma
        
      • Histologic grade: Grade 3
        
      • Depth of tumor invasion: visceral peritoneum
        
      • Lymph nodes: tumor metastasis (14/31) with extracapsular extension (5/14) in total number
        
      • Omentum: Tumor present
        
      • AJCC Pathologic Staging: pT4aN3a
        
      • Bilateral Margins: Free of tumor invasion
        
      • Additional pathologic findings: intestinal metaplasia, focal mucin production
        
      • Immunohistochemical stains: CK(+), Her2(-, Dako score 0) for tumor cells
        
      • Perineural invasion: present
        
      • Lymphovascular space invasion: present
        
  • 2020-08-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 35) / 112 = 68.75%
      • M-mode (Teichholz) = 69
    • Dilated LA, Ao
    • Adequate LV,RV systolic function with normal wall motion
    • Thick IVS, Impaired LV relaxation
    • Mild TR, AR
  • 2020-07-29 Patho - stomach biopsy
    • Stomach, biopsy — Adenocarcinoma
      
    • Section shows fragments of gastric tissue infiltrated by isolated neoplastic cells.
  • 2020-07-29 CT - abdomen
    • History and Indication:
      • BW loss 6 Kgs in recent 6 months, postprandial epigastric discomfort and poor appetie for 3 months
      • 2020/07/29 Gastroscopy: Borrmann type II gastric cancer in the antrum. CT staging
    • FINDINGS:
      • There is lobulated wall thickening in the gastric antrum and low body and the maximal wall thickness measuring about 2.2 cm that is compatible with adenocarcionoma.
      • There are at least 4 enlarged nodes in the dorsal aspect mesentery of the perigastric antrum area (Srs:302, Img:38,43) that may be metastatic nodes in station 4 and 6.
      • Ascites in the pelvis is noted, nature?
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2(N_value) M:M0(M_value) STAGE:III (Stage_value)
  • 2020-07-29 Panendoscopy
    • big gastric ulcers. A2, highly suspected gastric cancer Bormman type II; antrum
• consultation
  • 2022-10-17 ENT
    • Q
      • for hoarse throat days
      • This 67-year-old man, a patinet of gastric cancer with Gastric adeno CA of antrum, cT4aN2N0 stage III, pT4aN3aM1, stage IV, s/p Op & HIPEC on 20200810 & post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T finishing in Oct 2020 & post-CCRT adjuvant C/T wt Oxaliplatin / HDFL IV Q2W x 11 finishing in May 2021. He was admitted due to dyspnea S/P pig-tail drainage inserted. He complained of hoarse throat for days. WE need expertise to evaluate his condition thanks!
    • A
      • Scope: smooth nasopharynx, oropharynx, hypopharynx. Fair vocal cord movement.
      • Impression: favor functional dysphonia.
      • Plan: May give Broen-C 2# TID.
      • ENT OPD follow-up after discharge.
  • 2022-08-12 Nephrology
    • Q
      • for hyponatremia,thanks
      • This 65-year-old male, a pt of gastric adeno CA of antrum, cT4aN2N0 stage III, pT4aN3aM1, stage IV, s/p Op & HIPEC on 20200810, suffered from initial presentation of marked weight loss of 6kg from Feb 2020.
      • Surgical pathology with stomach, subtotal gastrectomy (20200810) proved signet-ring cell carcinoma.
      • Subtotal gastrectomy, BII anticolic anastomosis, D2 dissection, with T-colectomy and HIPEC with oxaliplatin 360mg/m2 (650mg) 42C for 60 min, on 20200810.
      • He was referred to our hemato-oncologic clinic on 20200901 for post-Op adjuvant CCRT & C/T.
      • We explain to pt & his wife about the indication & risk / benefit of post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-CCRT adjuvant C/T wt Oxaliplatin / HDFL IV Q2W x 12.
      • HBsAg, anti-HCV (20200901): negative.
      • #1 R/T to gastric tumor bed on 9/14 20
      • #1 post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T on 9/16~9/18 20, #2 on 9/28 20, #3 on 10/12 20.
      • #1 post-Op adjuvant CCRT with Oxaliplatin / HDFL IV Q2W x 12 on 11/17 20, #2 on 12/14 20, #3 on 12/28 20, #4 on 1/11 21, #5 on 1/25 21, #6 on 2/22 21, #7 on 3/15 21, #8 on 3/29 21, #9 on 4/12 21, #10 on 4/27 21, #11 on 5/11 21
      • The whole abdominal CT (3/9 21) showed s/p subtotal gastrectomy. No evidence of recurrent/residual tumor in the study.
      • Painless gastroscopy (4/1 21): Erosive reflux esophagitis LA Classification grade A
      • S/p subtotal gastrectomy with B-II anastomsis, superficial gastritis, remnant stomach.
      • Followed CXR & abd sono (11/8 21): negative but liver cysts.
      • Followed Abd CT (8/16 21) (1/27 22) revealeds/p gastric Op. No evidence of tumor recurrence.Liver cysts (up to 1.1cm).
      • Followed Abd CT (4/20 22)revealed s/p subtotal gastrectomy.Prior CT identified Mild soft tissue lesion in the celiac trunk noted again, stationary that may be normal variation. D/D include mets nodes.
      • PET scan (4/27 22) showed negative.
      • Followed Abd CT (7/18 22) revealed s/p subtotal gastrectomy.Soft tissue mass at the celiac trunk, compared wt CT on 4/20 22, the soft tissue is stationary in size and extention. c/o L lower chest wall pain. Dr Wu did bone scan.
      • Bone scan (1/26 22) showed negative. (2/8 22).
      • He complained of back pain & left lower abdominal discomfort, Dr Wu consult Dr Chang for CCRT on 7/26 22. Palliative R/T to recurrnet LAPs for 3500cGy/14 fractions is suggested for pain control. Suggest concurrent chemotherapy.The radiotherapy started on 8/5 22
      • This time ,he was admitted for #1 CCRT wt 5-FU 24 hr QD x 5 per wk x 3 on 8/9 22
      • However, hyponatremia was noted during CCRT.3% NACL 15ml/hr was administered. Followed the thyroid function and pending. We need your epertise for further management,thanks
    • A
      • This 65 years old male patient had underlying history of gastric adeno CA of antrum, cT4aN2N0 stage III, pT4aN3aM1, stage IV, s/p subtotal gastrectomy BII anticolic anastomosis, D2 dissection, with T-colectomy and HIPEC on 20200810 , post-Op adjuvant CCRT. Consult for hyponatremia.
      • Lab data:
        • WBC: 2.76, Hb: 11.9,Plt: 182
        • Na: 132-> 128-> 126-> 125(8/9)-> 115(8/12)
        • K: 4.3, Ca: 2.42, Albumin: 4.6, Ca: 2.14, Mg: 1.7
        • BUN: 16, Cre: 0.75
        • Uric acid: 1.6, T bil: 1.03, D bil: 0.21, GOT :31
        • E4V5M6, BW 67.15kg
      • Assessment :
        • Severe acute hyponatremia
      • Suggetsion:
        • Supplementation with 3% NS run 20ml per hr for one day
        • Follow up serum Na Q4hr and not more than 8-10mmol/L per day
        • Check plasma osmolality, urine osmolarity and urine Na, FeNa, Fe uric acid (serum uric acid, urine uric acid, serum Cr, urine Cr) , TSH, Free T4, ACTH, cortisol
        • We will follow up this case.
      • Follow up (20220813)
        • Lab
          • Na: 117
          • Urine uric aicd : 21.7
          • Urine osmolarity: 377
          • Plasma osmolality : 236
          • Uric acid: 1.6
        • Assessment: suspect SIADH
        • Suggestion:
          • Keep 3% NS 20ml per hr for 2 days
          • Fluid restriction
          • Follow up Na Q4h or Q6h
          • Lasix 1 amp IV st
• surgical operation
  • 2020-08-10
    • Surgery
      • Subtotal gastrectomy with D2 LNdissection
      • mesocolon resection
      • HIPEC with Oxaliplatinum 360mg/M2 650 mg T 42 C for 60 mins
      • B-II anticolic anastomosis
    • Finding
      • huge gastric ulcerative mass at greater cuvature with direct invasion to moesocolon
      • small nodular seeding at greater omentum
      • ascite(-)
• chemoimmunotherapy
  • 2022-10-25 - irinotecan 160mg/m2 270mg 1.5hr + leucovorin 400mg/m2 670mg 1.5hr + fluorouracil 2800mg/m2 4700mg 46hr
  • 2022-08-22 - fluorouracil 200mg/m2 350mg 24hr D1-D3 (CCRT)
  • 2022-08-15 - fluorouracil 200mg/m2 350mg 24hr D1-D5 (CCRT)
  • 2022-08-09 - fluorouracil 200mg/m2 350mg 24hr D1-D4 (CCRT)
  • 2021-05-11 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr
  • 2021-04-27 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr
  • 2021-04-12 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
  • 2021-03-29 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
  • 2021-03-15 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
  • 2021-02-22 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
  • 2021-01-25 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
  • 2021-01-11 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
  • 2020-12-28 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
  • 2020-12-14 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
  • 2020-11-17 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
  • 2020-10-12 - fluorouracil 200mg/m2 350mg 24hr D1-D5 (CCRT)
  • 2020-10-01 - fluorouracil 200mg/m2 350mg 24hr D1 (CCRT)
  • 2020-09-28 - fluorouracil 200mg/m2 350mg 24hr D1-D3 (CCRT)
  • 2020-09-15 - fluorouracil 200mg/m2 350mg 24hr D1-D4 (CCRT)
  • 2020-08-10 - [cisplatin 360mg/m2 650mg + gentamicin 40mg + sodium bicarbonate 7% 60mL] IP 1hr for HIPEC at OR

[assessment]

• As the patient reported bilateral lower limb edema after taking Lyrica (pregabalin), so the pregabalin has been held for the moment. As part of discharge preparations, gabapentin could be prescribed as a substitute for pregabalin for the patient’s neuropathic pain with less than half the risk of edema. (ref: UpToDate)

700900195

221114

• exam findings
  • 2022-11-08 CT - brain
    • No ICH. Brain atrophy. Old left anterior basal ganglia lacunar infarcts.
  • 2022-08-22 MRI - c-spine
    • Cervical spondylosis, retrolordotic change, subluxation, mild spinal canal stenoses.
  • 2022-01-07 CT - c-spine
    • Cervical spinal kyphosis.
    • Degenerative spinal and disc disease.
    • Severe right C4-5, C5-6 neuroforaminal narrowing.
  • 2021-05-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (54 - 13) / 54 = 75.93%
      • M-mode (Teichholz) = 76
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild AR, TR
  • 2021-05-11 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.

[assessment]

• Following the last cholesterol total measurement in April 2021 (275 mg/dL), there has been no further follow-up. It might be beneficial to collect the reading again to determine whether a statin agent is required (Zulitor (pitavastatin 4mg) 1# QN has been used in the past).

701447350

221114

• exam findings
  • 2022-10-31 Pelvis & Bilat. Hip Lat
    • There is an osteolytic or osteopenic lesion in the lesser trochanter of right femur. Please correlate with CT to R/O bony metastasis.
  • 2022-10-05 Tc-99m MDP whole body bone scan
    • A hot area in the right iliac bone and increased activity in the sternum, malignancy with bone metastases should be considered, suggesting further investigation.
      
    • Increased activity in the sacrum, left humerus, and left hip, the nature is to be determined (bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for evaluation.
    • Suspected benign lesions in some C-, T- and L-spine, bilateral shoulders, and right femoral trochanter.
  • 2022-10-04 Patho - liver biopsy
    • Liver, CT-guided biopsy — Adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma
    • The sections show adenocarcinoma, poorly differentiated, composed of nests of large pleomorphic neoplastic cells, arranged in solid pattern with desmoplastic stromal reaction. Subtle glandular formation is present.
    • IHC, tumor cells reveal: CK7(+), CK20(-), Hepa-1(-) and Arginase-1(-).
  • 2022-09-14 CT - abdomen
    • Hepatocholangiocarcinoma is highly suspected. The differential diagnosis include cholangiocarcinoma and metastases? Biopsy is indicated.
    • Multiple metastatic nodes in hepatoduodenal ligament, para-aortic space and para-cava space.
    • Bony metastases.
• consultation
  • 2022-11-02 Radiation Oncology
    • A
      • A: Intrahepatic cholangiocarcinoma with multiple metastases.
      • P: Radiotherapy is indicated for this patient with the following indicators: bone metastases.
        • Goal: palliation
        • Treatment target and volume: metastatic right ilium, sacrum, and right lesser trochanter lesions
        • Technique: IMRT
        • Preliminary planning dose: 3000cGy/12 fractions of the metastatic right ilium, sacrum, and right lesser trochanter lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2022-11-07.
  • 2022-10-28 Rheumatology
    • Q
      • This 64-year-old man, a patient of being diagnosed to have HBV-related HCC several years ago (3-4 yrs) post TAE at SYKCC & bililary ca was diagnosed later and received further chemotherapy (cisplatin and gemza x 7 times) and bone met S/P R/T x 6 times was noted later. He was admitted for C/T. He complained of whole body skin rash & icthing did not improve for days. The ANA:1:80, IgE: 425. We need expertise to evaluate his condition thanks!
    • A
      • History review was performed. Patient was admitted due to HBV-related HCC & for C/T. I was consulted for generalized itching sensation.
      • RIA condition:
        • Allergic rhinitis Hx(+)
        • multiple small papules over four limbs
        • WBC/Hgb/PLT:4550/8.1/49K; Eosinophils:1.1%
        • IgE:425
        • ANA:1:80(s)
      • Suggestion:
        • Treatment as current your expert’s management.
        • Please check cryoglobulin, Panel 5 specific allergen test.
        • Keep allegra 1#BID & add chlorpheniramine 1# prn HS.
  • 2022-10-03 Dermatology
    • Q
      • for skin rash & icthing over whole body
      • This 64-year-old man, Being diagnosed to have HBV-related HCC several years ago (3-4 yrs) post TAE at SYKCC . Bililary ca was diagnosed later and received further chemotherapy (cisplatin and gemza )and bone met was noted later. The abdominal CT (9/14 22) showed Hepatocholangiocarcinoma is highly suspected. The differential diagnosis include cholangiocarcinoma and metastases? Biopsy is indicated.Multiple metastatic nodes in hepatoduodenal ligament, para-aortic space and para-cava space,Bony metastases. He complained of skin rash & icthing over whole body for days. We need expertise to evaluate his condition thanks!
    • A
      • This patient suffered from erythematous papules on limbs for 2 wks. and dyskeratoticnails for yrs.
      • Imp:
        • Subacute dermatitis
        • Tinea unguim
      • Suggestion:
        • Please check CBC. ANA. TSH. IgE
        • Dexamethason * 1 /Qd
        • Topsym cream * 4 tubes/bid
        • Excelderm soln * 2 Bt/Bid
• chemoimmunotherapy
  • 2022-10-31 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5300mg 46hr

700132355

221110

[assessment]

• The trough value of vancomycin was reported on 2022-11-10 at 25.4 mcg/mL.

• A blood draw time of “2022-11-10 00:00” has been recorded, this should be due to an invalid entry, please confirm that the concentration is actually a “trough”.

• Redraw the value if it is not truly a “trough”.

• In the event that the value is a real “trough”, then it is recommended to hold vancomycin and perform a renal function test.

700161803

221103

• exam findings
  • 2022-11-02 CT - abdomen
    • Findings:
      • There are multiple enlarged lymph nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, mesentery, para-aortic space, para-cava space, and bilateral common iliac chain.
        • Metastatic nodes are highly suspected.
        • The differential diagnosis include lymphoma.
        • In addition, thrombosis in right superficial femoral vein is noted.
      • There is diffuse wall thickening at the low body and antrum of the stomach. Please correlate with gastroscopy.
      • Prior CT identified a poor enhancing Soft tissue tumor, 4cm in the uterus, is noted again, stationary. Myoma is suspected.
        • In addition, There is a homogeneous soft tissue mass measuring 2.8 x 1.8 cm in left adnexa, near the uterine fundus, that also may be myoma.
      • Bilateral renal cysts, up to 2.6cm.
      • There are massive bilateral Pleura effusion.
    • Impression:
      • Multiple Metastatic nodes are highly suspected.
        • The differential diagnosis include lymphoma.
        • In addition, thrombosis in Rt superficial femoral vein is noted.
  • 2021-05-15 CT - abdomen
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:I(Stage_value)
  • 2021-05-11 Patho - stomach biopsy
    • Stomach, GC-PW of middle body, biopsy — Adenocarcinoma, moderately differentiated
      
    • The sections show a picture of tubular adenocarcinoma, moderately differentiated, composed of gastric mucosal tissue with columnar to cuboidal neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic reaction.

[assessment]

• Low molecular weight heparin (LMWH) is probably superior to unfractionated heparin (UFH) in reducing mortality in the initial treatment of venous thromboembolism (VTE) in people with cancer (2022-11-02 CT: thrombosis in right superficial femoral vein). Also, there are additional advantages of LMWH related to subcutaneous administration and outpatient management. (ref: Anticoagulation for the initial treatment of venous thromboembolism in people with cancer. Cochrane Database of Systematic Reviews 2021, Issue 12. Art. No.: CD006649. DOI: 10.1002/14651858.CD006649.pub8). For most patients with active malignancy and acute VTE who have a reasonable life expectancy and adequate renal function (CrCl >=30 mL/minute), LMWH is the preferred agent for initial anticoagulation, rather than other agents.

701035130

221103

• diagnosis - 2022-11-02 adminssion note
  • Unspecified abdominal pain
  • Malignant neoplasm of unspecified part of left bronchus or lung
  • Malignant neoplasm of esophagus, unspecified
  • Chronic viral hepatitis C
  • Malignant neoplasm of upper lobe, left bronchus or lung
  • Malignant neoplasm of middle third of esophagus
  • Alcohol dependence, uncomplicated
  • Secondary malignant neoplasm of bone
  • Calculus of bile duct with cholangitis, unspecified, with obstruction
• exam findings
  • 2022-10-06 Tc-99m MDP whole body bone scan with SPECT
    • The scintigraphic findings suggest multiple bone metastases.
    • Increased activity around right hip prosthesis. The nature is to be determined (infection or inflammation? other nature?). Please correlate with other clinical findings.
    • Mildly increased activity in the right knee. Arthritis may show this picture. Please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2022-10-05 Patho - pleural/pericardial biopsy
    • Lung, left upper lobe, CT-guide biopsy — small cell carcinoma
    • Sections show large nests of small hyperchromatic tumor cells with scanty cytoplasm and marked crushing artifact.
    • The immunohistochemical stains reveal CK7(+), CK20(-), TTF-1(-), Napsin A(-), Synaptophysin(-), Chromogranin A(-), CK5/6(-), p40(-), GATA3(focal +), SALL4(-), OCT4(-), and beta-hCG(-). The morphology is the same as S2022-16555.
  • 2022-09-30 MRI - pancreas
    • History: 20220924 CC: abdomen pain
      • 20220924 CT: A mass (2.6x5.4cm) at LUL and left pulmonary hilum. Some LNs at mediastinum, hepatic hilum, and retroperitoneum. Some hypodense lesions (up to 4.7cm) in both hepatic lobes.
        • Suspected lung cancer at LUL with LNs and liver metastases
      • 20220927 CA199: 19090 U/mL (< 35), CEA and AFP: normal.
      • 20220928 liver biopsy: neuroendocrine carcinoma
  • 2022-09-28 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Poorly differentiated carcinoma,compatible with neuroendocrine carcinoma
    • The sections show nests of medium to large-sized, poorly differentiated neoplastic cells with marked apoptosis, in fibrous stroma. Neither squamous nor glandular differentiation can be identified.
    • IHC shows: CK(+), p40(-), TTF1(-), CD56 (+), and Synaptophysin(-). The findings favor neuroendocrine carcinoma.
  • 2022-09-28 Patho - stomach biopsy (middle esophagus)
    • Labeled as “middle esophagus”, biopsy (B) — squamous cell carcinoma.
    • IHC stains: CK5/6 (+), p63 (+).
  • 2022-09-26 SONO - abdomen
    • Diagnosis
      • Liver tumors, favor metastatic tumors
      • liver parenchymal disease
      • mild GB wall thickening
    • Suggestion
      • correlate with other image study such as contrast-enhanced CT scan or MRI
  • 2022-09-24 CT - chest
    • Suspected lung cancer at LUL with LNs and liver metastases. Suggest tissue study.
• consultation
  • 2022-11-02 Family Medicine
    • Q
      • This is a 51-year-old man with past history of
        • Squamous cell carcinoma involved middle esopahgus
        • Nueroendocrine carcinoma of liver, poor differentiated, multiple metastatic lymph nodes
        • Small cell carcinoma of lung
        • Tc99m: multiple bone metastasis
          
        • Left hip AVN, alcoholism related, s/p left THR in 2013 at WanFang Hospital.
        • Left distal tibial fracture and lateral malleolar fracture by trauma, s/p ORIF with plate fixation in 2017/07
        • Left THR acetabular component loosening, s/p left hip revision THR in 2017/12
        • Right hip s/p bipolar hemiarthoplasty s/p infection, s/p ROI and antibiotic cement beads insertion in 2020/04
        • Hepatitis C under Maviret treatment since 20221021.
      • According to family, the patient developed chest tightness, abdominal pain, and severe right knee pain for several days. Productive cough with difficult swallowing were also noted. So he visited our ER for help. He managed to talk oriently and was able to eat by himself then.
        • Vital sign at ER revealed BP:117/76 mmHg; HR:102 bpm; BT:35.6 celsius degree; RR:18 /min ; GCS:E4V5M6. Laboratory data revealed leukocytosis, elevated CRP and direct/total bilirubin. Icteric appearance was noted. Cefataxime was prescribed at ER. However, he became lethargy and confused this morning. Though his eyes opened spontaneously, he could not answer questions properly or obey order. Productive cough was also noted. Under the impression of (1) squamous cell carcinoma involved middle esopahgus (2) Nueroendocrine carcinoma of liver (3) Small cell carcinoma of lungs (4) altered mental status (5) pneumonia, the patient was admitted for further evaluation and management. Due to difficult swallowing and altermental status, NG tube was inserted today.
      • Considering the irreversible end stage cancers and his family decided not to accept advanced treatment, we need your expertise for this patient’s hospice care. Thank you very much!!
    • A
      • After discussion, I decided to arrange hospice combine care for this patient. Thanks for your consultation.
      • Current condition: 51 y/o Esophageal cancer, bone mets
      • Indication for hospice combine care: Advanced esophageal cancer
  • 2022-10-03 Hemato-Oncology
    • Q
      • This is a 51-year-old man, who was admitted for GI bleeding. PES was done and his vital signs is stable now. Further investigation revealed 1. Esophageal Ca, r/o lung cancer and liver neuroendocrine carcnioma were noted.
      • We would like to request your expertise upon further management of the condition.
    • A
      • This 51-year-old man was consulted and evaluated for liver tumor and esophageal cancer.
        
      • History and medical records reviewed and patient interviewed at bedside.
      • Recommendation:
        • lung biopsy to R/O small cell carcinoma of lung
        • chemotherpay with cisplatin based regimen is suggested after the lung tumor pathology is elucidated.
        • check bone scan
        • suggest to consult the radiation oncologist for possible of CCRT
      • I will follow up this patient, Thank you for the referral.
  • 2022-09-27 Thoracic Medicine
    • Q
      • This is a 51-year-old patient, he came to our ward since GI bleeding.
      • On 20220924, chest x ray shows: Mass like lesion at left upper lobe is found.
      • on 20220924, CT shows: A mass (2.6x5.4cm) at LUL abutting mediastinum and left pulmonary hilum.
      • Meanwhile, abdominal sonography shows multiple liver tumors, metastatic suspected.
      • We would like to consult to Dr. we wonder if there’s any advices, or would you recommand surgical intervention for the patient?
      • Please insight us. Thanks for your time and reply.
    • A
      • This 51-year-old man without chronic disease was admitted due to GI bleeding and CXR showed incidental finding of lung tumor.
        • Chest CT revealed multiple liver hypodense tumor with LUL mass near hilum with multiple LD at retroperitonium, and mediastinum. Therefore, we were consulted for further evaalution and management.
      • Lab:
        • CA19-9: 19090, AFP, CEA: normal
        • Anti-HCV: (+)
        • smoking, alcohol, and betel nut history: (+)
        • Panendoscopy revealed esophageal lesion post biopsy, GU post biopsy, and DU scar.
      • Impression:
        • Lung tumor with multiple liver tumor and LN with esophageal lesion, primary origin?
        • Gastric ulcer, with esophageal lesion s/p biopsy
      • Suggestion:
        • Pending biopsy report
        • Could ask the interventional radiologist for CT guided biopsy (liver tumor first due to lower risk) if negative findings of esophageal lesion.
          • If interventional radiologist refuse, we could arrange bronchoscopy to see whether we could approach the mass lesion.
        • could also check other tumor marker - SCC for evaluation.
        • Treat Gi bleeding as your expertise.
        • We will closely follow up the patient.
      • Thanks for your consultation
  • 2022-09-26 Rehabiliation
    • A
      • Right knee:
        • No erythermatous change, no swelling, no heating, no tenderness over his right knee
        • Lockman test: negative; McMurray test: Positive
        • Pain when flexion and extension ROM, relief after resting
      • Right knee sonogram: mild effusion in suprapatellar
      • Assessment
        • Right knee internal derangement
      • Plan
        • Arranged right knee sonogram (done, pending report)
        • Knee IA with low dose steriod injection
        • Please arrange right knee X-ray, and MRI
        • Please arrange rehab OPD after discharge for follow up if his right knee is still pain

[assessment]

• Tube feeding is possible for all oral medications in the active prescription.
• It is recommended that the patient-carried medication Maviret (glecaprevir 100mg + pibrentasvir 40mg) be taken with food (cum cibos) and the frequency should be amended to QDCC.

701458197

221031

{drug identification}

requesting drug identification for 1 item.

the item is identified as Serenal (oxazolam 10mg/cap).

the drug will be sent back to ward by an in-hospital porter.

701272100

221028

• diagnosis 2022-06-24 discharge
  • Pancreas adenocarcinoma, pT2N2(cM0); Stage III status post pylorus-preserving pancreaticoduodenectomy with lymph node dissection on 2021/03/29 s/p concurrent chemoradiotherapy
  • Chronic viral hepatitis B without delta-agent
• exam finding
  • 2022-09-09 CT - abdomen
    • FINDINGS:
      • Prior CT identified several metastatic nodes in para-aortic space and left common iliac chain are noted again, decreasing in size that may be metastatic nodes S/P C/T with partial response .
      • S/P Whipple operation and S/P cholecystectomy.
        • Mild dilatation of the IHDs on both lobes are noted.
        • Please correlate with serum alk-p and bilirubin level.
      • There is a poor enhancing lesion 1.1 cm in S6 liver that is c/w cyst.
        
      • There is a enlarged node measuring 1.8 x 1.1 cm in the para-tracheal space that may be metastatic node.
    • IMP:
      • Metastatic nodes in para-aortic space and left common iliac chain S/P C/T show partial response. Follow up is indicated.
      • Metastatic node in paratracheal space measuring 1.8 x 1.1 cm is highly suspected.
  • 2022-07-15 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the lower C- and lower L-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
  • 2022-06-21 SONO - neurology
    • Minimal atherosclerosis in bilateral CCA bifurcations.
    • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows.
  • 2022-06-16 MRI - brain
    • No abnormal enhancing lesion within brain parenchyma.
    • Mild periventricular small vessel disease. NO acute ischemic infarct.
  • 2022-05-25 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2022-05-25 CT - abdomen, pelvis
    • Findings:
      • There are several newly-developed nodes in para-aortic space and left common iliac chain that may be metastatic nodes.
      • S/P Whipple operation and S/P cholecystectomy.
      • Mild pneumobilia on both lobes IHDs are noted.
      • There is a poor enhancing lesion 1.1 cm in S6 liver that is c/w cyst.
        
    • Imp:
      • There are several newly-developed nodes in para-aortic space and left common iliac chain that may be metastatic nodes.
  • 2022-03-28 Patho - soft tissue biopsy/simple excision (non lipoma)
    • Skin and soft tissue, abdominal wall #1, excision — Fat necrosis
    • Soft tissue, abdominal wall #2, excision — Fat necrosis
  • 2022-03-01 Patho - soft tissue debridment
    • Labeled as “abdominal wall tumor around the scar region”, clinical history of pancreatic ductal carcinoma, needle biopsy — fibrosis.
    • IHC stains: CD68 highlights many histiocytes. CK (-): no carcinoma.
  • 2022-02-25 CT - abdomen, pelvis
    • S/P Whipple operation and S/P cholecystectomy. There is no evidence of tumor recurrence.
    • Mild pneumobilia on both lobes IHDs are noted.
  • 2021-10-14 CT - abdomen, pelvis
    • Pancreatic cancer s/p operation. No evidence of tumor recurrence.
  • 2021-07-27 MRI - MR Cholangiography, MRCP
    • Pancreatic cancer s/p operation. No evidence of tumor recurrence.
  • 2021-07-07 CT - abdomen, pelvis
    • Findings
      • S/P Whipple operation and S/P cholecystectomy.
      • There is mild fatty stranding and suspicious mild fluid collection at the anastomosis area of the pancreaticojejunostomy that may be post-operative change. The differential diagnosis include partial leakage? please correlate with clinical condition.
      • There is a round, encapsulated lesion in the subcutaneous fat layer of the midline incisional wound with a central area of predominantly fat attenuation, a finding indicative of encapsulated fat necrosis.
      • Mild ascites in the pelvis is suspected.
      • Fatty liver, grade 4, is noted.
    • IMP:
      • Post-operative change at the anastomosis area of the pancreaticojejunostomy is suspected. The differential diagnosis include partial leakage? please correlate with clinical condition.
      • Encapsulated Fat necrosis in the subcutaneous fat layer of the incisional wound is suspected.
  • 2021-03-30 Patho - gallbladder (benign lesion)
    • Gallbladder, cholecystectomy — Chronic cholecystitis
      
    • The sections show a picture of chronic cholecystitis, composed of congestion, mild chronic inflammatory cells infiltration, mild mural fibrosis, and scattered Rokitansky-Aschoff sinuses.
  • 2021-03-30 Patho - liver partial resection
    • pathologic diagnosis
      • Lymph nodes, LN 7, 8, 9, 11p, 12, dissection — Metastatic adenocarcinoma (1/18)
        
      • Lymph node, J1, dissection — Metastatic adenocarcinoma (1/1)
        
      • Lymph node, SMV, dissection — Metastatic adenocarcinoma (1/1)
        
  • 2021-03-30 Patho - pancreas total/subtotal resection
    • pathologic diagnosis
      • Pancreas, Whipple operation — Ductal adenocarcinoma, moderately differentiated
        
      • Lymph nodes, regional, Whipple operation — Metastatic carcinoma (8/44)
        
      • Pathologic Staging: pT2N2; Stage III if cM0
        
    • macroscopic examination
      • Specimen Type: Whipple operation
        
      • Venous (Large Vessel) Invasion: Absent
        
    • microscopic examination Representative parts are taken for section and labeled as: A1=
      • Histologic Type: Ductal adenocarcinoma
        
      • Histologic Grade: Moderately differentiated (G2)
        
      • Tumor Extension: Tumor invades peripancreatic soft tissue
        
      • Lymphvascular Invasion: Present
  • 2021-03-12 Patho - pancreas biopsy
    • Labeled as “pancreatic tumor”, EUS guided FNA/B of Pancreas — adenocarcinoma.
    • IHC stain: CK highlights small irregular infiltrative neoplastic ducts.
      
    • Section shows cores of markedly necrotic tissue with atypical mucinous gnads.
  • 2021-03-12 Cell block
    • cytologic diagnosis
      • Atypia
    • gross description
      • 32 cc, light orange, turbid
        
    • microscopic description
      • Smears an cell block show scant atypical hyperchromatic epithelial cells. The speicmen may not be representative for low cellularity.
        
  • 2021-03-12 Endoscopic Ultrasonography, EUS
    • Diagnosis
      • Suspected Pancreatic head cancer s/p CH-EUS & EUS/FNB
      • Pancreatic cystic lesions, pancreatic body, suspected IPMN
      • Peri-pancreatic lymphadenopathy
      • Shallow duodenal ulcer, bulb
    • Suggestion
      • F/u pathology
      • PPI use for ulcer
  • 2021-03-11 Abdominal Ultrasonography
    • Diagnosis
      • Pancreatic tumor, uncinate process
      • Pancreatic cystic lesions, body
      • Main pancreatic duct dilatation
      • Liver cysts, three, S3 and S6
      • Suspected renal stone, left kidney
    • Suggestion
      • correlated wtih other images and tumor markers
• consultation
  • 2022-06-15 ENT
    • Q
      • For dizziness when turn the neck for 1 week.
      • This 64-year-old female has past history of gastric ulcer. According for her statement, she noted for pancreatic tumor for 3 years with regular follow up at other hospital. However, health examination revealed pancreatic lesion by abdomen MRI which showed a 2.2cm sized progressive rim enhancing lesion is noted at uncinate process of the pancreas, with high signal intensity on T2WI, diffusion restriction, nature to be determined. suspect of pancreatic cancer, solid pseudopapillary tumor. She came to our OPD for further management. EUS was also performed and showed 1) R/o Pancreatic head cancer s/p biopsy. 2) Pancreatic cystic lesions, pancreatic body, r/o IPMN. 3) Peri-pancreatic lymphadenopathy. 4) Shallow duodenal ulcer, bulb. Tumor marker of CEA: 2.05ng/ml, CA-199: 469.32U/ml on 2021/03/16. She referred to our GS OPD for further treatment.
      • Now, she is admitted for Abraxane and Gemcitabine on 2022-06-14, she complaints dizziness when turn the neck for 1 week, so we need tour help, thanks a lot!!
    • A
      • PE: Bil. Dix-Hallpike test negative, no spontaneous nor motional nystagmus
      • According to her statement, favoring resolved BPPV, unspecific ear
      • However, still have to r/o tumor metastasis
      • May prescribe Diphenidol for her remaining dizziness
  • 2021-08-20 Infectious Disease
    • Q
      • This 63-year-old is a case of Pancreas adenocarcinoma, pT2N2(cM0); Stage III status post pylorus-preserving pancreaticoduodenectomy with LN dissection s/p CCRT. This time, for abdominal wound casr with pus in 2021/07 with antibiotic Metrozole 1# po QID and Amoxicillin 2# po Q8H theraoy. But, Pus/C showed normal. Now, for evaluate antibiotic therapy. Thank you.
    • A
      • A 63-year-old woman of pancreas adenocarcinoma. Wound/pus culture revealed no growth. The common infecting bacteria of deep wound infection including Streptococci, Staphylococci, and gram negative-negative enteric bacteria possible. MRSA has been reported to account for up to 21% of nosocomial skin infections. Vancomycin typically is the drug of choice for methicillin-resistant coagulase-negative and coagulase-positive staphylococcal infections. It is also useful against penicillin-resistant streptococcal infections. Anti-microbiologic coverage as with parenteral Vancocin 500 mg or + - (plus Fortum 1.0 gm) q12h is recommended.
  • 2021-04-10 Hemato-Oncology
    • Q
      • For further chemotherapy
      • This 64 y/o female a case of pancreatic head cancer s/p PPPD + LND on 20220329. The final pathology revealed ductal adenocarcinoma, moderately differentiated, lymph nodes metastatic (8/44), Staging: pT2N2M0; Stage III. Now, her condition improve and appetite fair. We need your expertise for further chemotherapy. Thanks for your times.
    • A
      • A case MD pancreatic ductal adenocarinoma, post PPPD and LND, pT2N2(8/44)M0, Stage III, was noted.
      • My suggestion would be:
        • The adjuvnat treatment is mandatory. May consider CCRT followed by C/T
        • Please check HBV (HBs Ag, Anti-HBs Ab, Anti-HBc Ab) and HCV (Anti-HCV) status during this admission, or I will check in my OPD
        • If possible, please check CA199/CEA, or I will check in my OPD
        • If MBD, please arrange my OPD
        • Please arrange Port-A if possible.
      • Thanks for your consultation. Any problem, please let me know.
  • 2021-04-09 Radiation Oncology
    • Q
      • For further radiotherapy
      • This 64 y/o female a case of pancreatic head cancer s/p PPPD + LND on 20220329. The final pathology revealed ductal adenocarcinoma, moderately differentiated, lymph nodes metastatic (8/44), Staging: pT2N2M0; Stage III. We need your expertise for further radiotherapy. Thanks for your times.
        
    • A
      • The patient’s history was reviewed and patient was examined.
      • S:
        • For postoperative radiotherapy due to pancreatic cancer.
        • PI: Ductal adenocarcinoma, moderately differentiated of the pancreas, pathologic Staging: pT2N2(cM0); Stage III, s/p PPPD with LN 5, 6,7,8,9,11p,12, 14a & v dissection on 2021-03-29.
          
        • Family history: (father: prostate cancer, elder brother: esophageal cancer)
        • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
        • Personal Hx: DM(-); HTN(-)
        • Other disease: (-)
        • Previous RT Hx: (-)
      • O:
        • ECOG: 1
        • PE: neck and bil SCF: neg; abdomen: surgical scar and status during drainage.
        • CXR (2021-03-09): Essential negative findings
        • Abd sono (2021-03-11): pancreatic tumor, uncinated process; pancreatic cystic lesions, body; main pancreatic duct dilatation; liver cysts, three, S3 and S6; suspected renal stone, left kidney.
        • CA199 (2021-03-16): 469.32
        • Operation (2021-03-29): PPPD with LN 5, 6,7,8,9,11p,12, 14a & v dissection.
        • Pathology (S2021-04713, 2021-04-01): 1. Lymph nodes, LN 7, 8, 9, 11p, 12, dissection — Metastatic adenocarcinoma (1/18). 2. Lymph node, J1, dissection — Metastatic adenocarcinoma (1/1). 3. Lymph node, SMV, dissection — Metastatic adenocarcinoma (1/1).
        • Pathology (S2021-04715, 2021-04-01): 1. Pancreas, Whipple operation — Ductal adenocarcinoma, moderately differentiated. 2. Lymph nodes, regional, Whipple operation — Metastatic carcinoma (8/44). 3. Pathologic Staging: pT2N2; Stage III if cM0. Uncinate margin: Uninvolved by invasive carcinoma, 1 mm from closest margin.
          
      • A:
        • Ductal adenocarcinoma, moderately differentiated of the pancreas, pathologic Staging: pT2N2(cM0); Stage III, s/p PPPD with LN 5, 6,7,8,9,11p,12, 14a & v dissection.
      • P:
        • Radiotherapy is indicated for this patient with the following indicators: Staging: pT2N2(cM0); Stage III, and close margin.
        • Goal: curative
        • Treatment target and volume: pancreatic tumor bed, peripheral, to regional lymphatic area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractiobns
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her brother’s son. They understand and agree to receive radiotherapy. The treatment planning of radiotherapy will be started at 11AM, 2021-04-22.
• surgical operation
  • 2021-03-29
    • Surgery
      • PPPD with LN 5, 6, 7, 8, 9, 11p, 12, 14a & v dissection
    • Finding
      • 2 x 2.0cm tumor at uncinate process with SMV partial invasion
      • multiple LN palpable at proximal SMA to J1
      • P-duct 3mm with soft pancreas
      • C-duct 1.0cm
  • 2021-03-28
    • Surgery
      • Excision of subcut tumor 4 x 2 cm
      • and 1.5 x 1.0 cm at midline abdominal wound
    • Finding
      • two subcut hard mass at upper mdiline laparotomy wound
      • 4 cm and 1.5 cm
• radiotherapy
  • 2021-04-29 ~ 2021-06-02) - 4500cGy/25 fractions (15MV photon) of the pancreatic tumor bed, peripheral, to regional lymphatic area.
• chemoimmunotherapy
  • 2022-10-19 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
  • 2022-10-05 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
  • 2022-09-28 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
  • 2022-09-14 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
  • 2022-09-07 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
  • 2022-08-24 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
  • 2022-08-17 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
  • 2022-08-03 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
  • 2022-07-20 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
  • 2022-07-13 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
  • 2022-06-29 - gemcitabine 1000mg/m2 1400mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
  • 2022-06-23 - gemcitabine 1000mg/m2 1400mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
  • 2022-02-09 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
  • 2022-01-18 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
  • 2022-01-03 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
  • 2021-12-16 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
  • 2021-12-01 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
  • 2021-11-16 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
  • 2021-11-03 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
  • 2021-10-15 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
  • 2021-09-30 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
  • 2021-09-09 - gemcitabine 1000mg/m2 1600mg 30min + oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 600mg 48hr + fluorouracil 2800mg/m2 4300mg 48hr
  • 2021-08-24 - gemcitabine 800mg/m2 1100mg 30min + oxaliplatin 65mg/m2 100mg 2hr + leucovorin 200mg/m2 280mg 48hr + fluorouracil 2000mg/m2 2800mg 48hr
  • 2021-07-19 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 65mg/m2 100mg 2hr + leucovorin 240mg/m2 350mg 48hr + fluorouracil 2400mg/m2 3500mg 48hr
  • 2021-06-02 - gemcitabine 400mg/m2 600mg 30min (CCRT)
  • 2021-05-27 - gemcitabine 400mg/m2 600mg 30min (CCRT)
  • 2021-05-17 - gemcitabine 400mg/m2 600mg 30min (CCRT)
  • 2021-05-07 - gemcitabine 400mg/m2 600mg 30min (CCRT)
  • 2021-04-29 - gemcitabine 400mg/m2 700mg 30min (CCRT)

[note]

• NCCN Pancreatic Adenocarcinoma 20210225 evidence blocks p35~36
  • neoadjuvant therapy
    • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
    • Gemcitabine + albumin-bound paclitaxel +- subsequent chemoradiation
    • Only for known BRCA1/2 or PALB2 mutations
      • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
      • Gemcitabine + cisplatin (>= 2-6 cycles) +- subsequent chemoradiation
  • adjuvant therapy
    • preferred regimens
      • Modified FOLFIRINOX (category 1)
      • Gemcitabine + capecitabine (category 1)
    • other recommended regimens
      • Gemcitabine (category 1)
      • 5-FU + leucovorin (category 1)
      • Continuous infusion 5-FU
      • Capecitabine (category 2B)
      • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation
      • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation followed by subsequent chemotherapy  - Gemcitabine followed by chemoradiation followed by gemcitabine -Bolus 5-FU + leucovorin followed by chemoradiation followed by bolus 5-FU + leucovorin -Continuous infusion 5-FU followed by chemoradiation followed by continuous infusion 5-FU

[assessment]

• According to 2022-09-09 CT (compared to 2022-05-25 CT), the disease has had a partial response to the current regimen started 2022-06-23.
• Oxacillin (currently used) or cefalotin remain the drugs of choice for treating uncomplicated cellulitis (of left lower limb) in regions where community-acquired methicillin-resistant S. aureus is infrequent.
• The active prescription does not pose any problems.

220615

[assessment]

• 2022-05-25 CT showed several newly-developed nodes in para-aortic space and left common iliac chain that may be metastatic nodes.
• CA199 levels time series showed the biomarker has roughly tripled in the last six months.
  • 2022-06-13 88.35 U/mL
  • 2022-05-25 78.08 U/mL
  • 2022-04-29 83.18 U/mL
  • 2022-02-23 31.33 U/mL
  • 2022-01-26 28.59 U/mL
  • 2022-01-18 29.57 U/mL

701457957

221027

{colon cancer}

• exam findings
  • 2022-10-22 CXR
    • Tortuosity of the aorta with atherosclerotic change.
    • Increased infiltration over RLL. May be active infection.

[assessment]

• Fasting blood sugar level is highly volatile (103 ~ 419 mg/dL). Acute infections lead to difficulty in controlling blood sugar levels and infectious diseases are more frequent and/or serious in patients with diabetes mellitus. The patient has been prescribed biosynthetic human insulin.
• Despite improvements in renal function compared to 2022-10-24, creatinine and BUN levels remain high (creatinine 2.33 mg/dL and BUN 55 mg/dL on 2022-10-27).
• When there is no evidence of active bleeding, the pantoprazole injection might be switched to an oral PPI.

700014137

221026

{Extranodal NK/T-cell lymphoma, nasal type, Lugano stage II, PS: 0}

• initial presentation
  • 2022-04
    • nasal stuffness and abscess discharge.
    • fever and weight loss about 4kg in 2 months and night sweats were also noted.
• lab data
  • 2022-08-08 CMV viral load assay 39 IU/mL
    
  • Anti-HBc
    • 2022-06-09 Reactive 7.68 S/CO
      
  • EBV DNA PCR
    • 2022-06-08 2724 copies/mL
      
  • HBsAg
    • 2022-06-01 Negative 0.517
      
  • Anti-HCV
    • 2022-06-01 Negative 0.0409
• exam finding
  • 2022-10-06 Sinoscopy
    • bil profuse otorrhea, L mucopus
  • 2022-09-19 Sinoscopy
    • nasal ca s/p CCRT
  • 2022-09-05 Nasopharyngoscopy
    • nasal cancer s/p CCRT
    • gr4 mucositis + mucopus
  • 2022-08-22 Sinoscopy
    • bil nasal synehiae (basal) + L IT synechiae lyzed after intranasal injection + L nasal packing + post nasal septal R/T mucositis, gr 3
    • post R/T mucositis, ENT local treatment done
  • 2022-08-22 Pure Tone Audiometry, PTA
    • Tymp:
      • Bil grommet
    • PTA
      • Reliability FAIR
      • Average RE 50 dB HL; LE 56 dB HL.
      • bil mild to severe mixed type HL.
      • tinnitus(+)
  • 2022-08-19 C-spine AP + Lat.
    • Degeneration and spondylosis of C-spine.
  • 2022-08-15 Nasopharyngoscopy
    • nasal ca under CCRT
  • 2022-08-02 Nasopharyngoscopy
    • crust and bloody discharge at bil nasal internal nasal valve and bil nasal septum, covered with Surgicel, smooth OPx, HPx
  • 2022-07-31 ECG
    • Sinus tachycardia
    • Left axis deviation
    • Abnormal ECG
  • 2022-07-28 Pure Tone Audiometry, PTA
    • Tymp:
      • R’t type C; L’t type B.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 61 dB HL; LE 54 dB HL.
      • R’t mild to profound MHL.
      • L’t moderate to severe mixed type HL.
  • 2022-07-21 Sinoscopy
    • much mucopus
    • no visible tumor
  • 2022-07-14 Nasopharyngoscopy
    • sinonasal lymphoma undergong CCRT
  • 2022-06-16 Sinoscopy
    • remove packing + R packing with Surgicel
    • 2022/6/13 fiber = R nasal cancer, bleeing spontaneous (cancer+) again after removal of nasal packing; thus, bil Merocel packing again
    • intermittent L epistaxis noted for 2 months, went to ShuangHo Hospital and Biopsy, NK/T-cell lymphoma, nasal type was diagnosed
    • went to our hospital for CCRT
    • Left epistaxis during admission, ENT was consulted, s/p L merocel packing
  • 2022-06-16 SONO - abdomen
    • Diagnosis
      • Fatty liver, moderate
      • Pancreas not shown
      • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
      • Because of poor echo window, infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months.
  • 2022-06-15 Nerve Conduction Velocity (NCV), Electromyography (EMG)
    • Findings
      • The ENoG study showed a facial CMAP amplitude ratio as 73% (right/left) and prolonged distal latency in bilateral facial nerves.
      • The results of blink reflex study were within normal limits.
    • Conclusion
      • The above findings may suggest bilateral peripheral facial nerve lesion, more severe in the right side, with demyelinating pattern. Advise clinical correlation.
  • 2022-06-13 Nasopharyngoscopy
    • smooth NPx, OPx, HPx
  • 2022-06-01 CT - lung/mediastinum/pleura
    • no abnormality in the chest and upper abdomen.
  • 2022-05-30 MRI - larynx
    • Findings
      • Extensive soft tissue tumor with T1-hypointensity, T2-hyperintensity and vivid enhancement involving nasopharynx, soft palate, bilateral nasal cavities, bilateral ethmoid and sphenoid sinsues, right maxillary sinus wall, clivus and adjacent sphenoid bones.
      • No enlarged lymph node.
      • No abnormality at hypopharynx and larynx.
      • Diffuse mottled T2-hyperintensity filling in bilateral mastoid air cells, indicating amstoiditis.
      • No abnormality at parotid, submandibular and sublingual glands.
    • IMP:
      • Nasal-nasopharyngeal tumor with aforementioned involvement. D/D: lymphoma, NPC.
  • 2022-05-30 2D transthoracic echocardiography
    • Normal AV/MV with no AR/MR
    • Mild concentric LVH, normal LV wall motion
    • Preserved LV and RV systolic function
    • No PR, trivial TR, normal IVC size
  • 2022-05-30 EKG
    • Left axis deviation
  • 2022-05-28 CXR
    • Chest PA and Lat. LT view: Widening of the right upper mediastinum is suspected. Please correlate with CT.
  • 2022-05-17 PET scan (at ShuangHo Hospital)
    • c/w lymphoma involving a NP, nasal cavity, ethmoid sinus, soft palate.
  • 2022-05-03 Surgical pathology - nasal tumor biopsy (at ShuangHo Hospital)
    • extranodal NK/T-cell lymphoma, nasal type.
  • 2018-02-21 Blink Reflex Studies
    • The ENoG study showed facial CMAP amplitude ratio as 74 % (right/left). The blinking reflex study showed relatively prolonged ipsilateral R1 and R2 latency when right side stimulation and relatively prolonged contralateral R2 latency when left side stimulation. These findings may suggest right facial nerve lesion.
• radiotherapy
  • 2022-06-22 ~ 2022-08-08 - 2000cGy/10 fractions of the nasal - nasopharyngeal, peripheral involved to bilateral neck nodal, and 5000cGy/25 fractions of the reduced nasal - nasopharyngeal, peripheral involved area.
• chemoimmunotherapy
  • 2022-09-20 - carboplatin AUC 4 200mg/m2 300mg 2hr D1 + etoposide 67mg/m2 110mg 1hr D1-3 + ifosfamide 1000mg/m2 1700mg 4hr D1-3
  • 2022-08-29 - carboplatin AUC 2 150mg/m2 260mg 2hr D1 + etoposide 67mg/m2 110mg 1hr D1-3 + ifosfamide 900mg/m2 1500mg 4hr D1-3 (full dose: carboplatin 200mg/m2, etoposide 67mg/m2, ifosfamide 1000mg/m2)
  • 2022-07-21 - carboplatin AUC 2 150mg/m2 270mg 2hr D1 + etoposide 67mg/m2 120mg 2hr D1-3 + ifosfamide 900mg/m2 1600mg 4hr D1-3
    
  • 2022-06-08 - carboplatin AUC 2 150mg/m2 270mg 2hr D1 + etoposide 67mg/m2 120mg 2hr D1-3 + ifosfamide 900mg/m2 1600mg 4hr D1-3
• G-CSF
  • 2022-09-06 Granocyte (lenograstim) 250mg QD SC OPD 2022-09-06
  • 2022-08-03 Granocyte (lenograstim) 250mg QD SC IPD 2022-07-31

==========

2022-10-26

• Swelling around the eyes might be caused by inflammation resulting from a variety of conditions, including infection, injury, and allergies. If this is the case, some eye drops containing steroid/antihistamine and/or antimicrobial might be beneficial.

2022-08-30

• Pure-tone audiometry 2022-08-22 RE 50 dB HL LE 56 dB HL <- 2022-07-28 RE 61 dB HL LE 54 dB HL. There is no evidence of rapid deterioration in hearing.
• Tamsulosin has been prescribed. Please make sure that any possible obstruction to the urinary tract has been eliminated or corrected before beginning treatment with ifosfamide.

2022-07-22

• 2022-06-15 electromyography suggested bilateral peripheral facial nerve lesion, more severe in the right side, with demyelinating pattern.
• The neurology related adverse reaction incidences of the drugs in current regimen:
  • carboplatin - Nervous system: Neurotoxicity (5%), peripheral neuropathy (4% to 6%)
  • etoposide - Peripheral neuropathy (1% to 2%)
  • ifosfamide - Central nervous system: Brain disease (<=15%), central nervous system toxicity (<=15%)
• Please monitor for newly developed neuropathy as usual.

2022-06-09

• There is no re-biopsy performed at our facility, in addition to our imaging studies and pathology results from ShuangHo Hospital.
• An EBV positive result (lab 2022-06-08 EBV DNA PCR 2724 copies/mL) is consistent with NK/T-cell, nasal type. EBV-associated T- and NK-cell lymphoproliferative disorders (LPD), including chronic active EBV infection (CAEBV), can progress to aggressive NK-cell leukemia (ANKL).
• For extranodal NK/T-cell lymphomas, suggested treatment regimens can be (ref https://www.cancertherapyadvisor.com/wp-content/uploads/sites/12/2018/12/nhl-extranodalnk_0318_9414.pdf )
  • combination chemotherapy regimen (asparaginase-based)
    • Modified SMILE (steroid [dexamethasone], methotrexate, ifosfamide, pegaspargase, and etoposide) x 4-6 cycles for advanced stage
    • P-GEMOX (gemcitabine, pegaspargase, and oxaliplatin)
    • DDGP (dexamethasone, cisplatin, gemcitabine, pegaspargase)
  • combined modality therapy
    • concurrent chemoradiation therapy: RT and 3 courses of DeVIC (dexamethasone, etoposide, ifosfamide, and carboplatin) <= currently applied.
    • sequential chemoradiation: For stage I, II, modified SMILE x 2-4 cycles followed by RT
    • sandwich chemoradiation: P-GEMOX x 2 cycles followed by RT followed by P-GEMOX x 2-4 cycles
• CCRT using DeVIC is currently being applied during this hospital stay.
• Lab results 2022-06-08 indicated liver and kidney function, CBC, WBC DC, electrolytes were grossly normal. TPR, PB is relatively stable.
• There is a self-carried drug - amoxicillin 500mg PO Q8H - listed in active prescription for the apical infection of tooth 26 and its complicated extraction.

701049370

221025

• diagnosis 20221003 discharge
  • B cell lymphoma, high grade, stage IV
  • Splenomegaly, not elsewhere classified
• exam findings
  • 2022-09-30 CXR
    • Fibrosis of left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • 2022-09-19 Whole body PET scan
    • Glucose hypermetabolism lesions in bilateral cervical, bilateral axillary, celiac chain, bilateral para-aortic space, and pre-vertebral lymph nodes of lower T-spine, and spleen, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    • Glucose hypermetabolism lesions in T9-11 spines, highly suspected lymphoma with involvement of bones and/or bone marrow.
      
    • Increased FDG uptake in bilateral pulmonary hilar and bilateral mediastinal lymph nodes, probably reactive nodes (priority) or lymphoma with involvement of lymph node regions, suggesting further investigation.
    • B cell lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-09-20 CXR
    • Interstitial pattern at LUL.
  • 2022-09-15 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Atypical lymphoid aggregates, favor reactive
    • The sections show normocellular marrow (30%). The myeloid series show good maturation. The megakaryocytes are normal in number and morphology. Scattered interstitial, mixed small and large lymphoid cell aggregates are present.
    • IHC, a mixture of CD3+ T and CD20+ B lymphocytes haphazardly arranged with slightly B cell predominant are noted. The B cells also show: BCL6(focal +), CD10(-), and CD23(-). The findings favor reactive lymphoid aggregates. Suggest bone marrow smear evaluation and clinic correlation.
  • 2022-09-01 Patho - fibrolipoma
    • Labeled as “right neck”, excisional biopsy — B cell lymphoma, high grade.
    • Section shows lymph nodes with architecture obscured by large blasts like neoplastic lymphoid cells (more than 15/HPFs) and scattered centrocytes like cells.
    • IHC stains: CK (-), CD3 (focal+), CD20 (diffuse +), CD10 (+), bcl-2 (+), bcl-6 (+), MUM-1 (focal +, 10%), Ki-67: 60%, cyclin-D1: (equivocal), c-myc (-). Vague lymphoid follicles are highlighted by IHC stains. The pattern is suggestive of follicular lymphoma, grade 3A.
  • 2022-09-01 CT - abdomen
    • Thickening of right posterior pleura and prevertebral tissue at T10-12.
    • Portal hypertension and splenomegaly.
    • Some LNs (up to 2.0cm) at retroperitoneum.
  • 2022-03-24 CT - abdomen
    • Thickening of right posterior pleura and prevertebral tissue at T10-12.
    • Increased soft tissue at left pubic cavity.
    • Portal hypertension and splenomegaly.
  • 2021-12-21 Patho - soft tissue nontumor/mass/lipoma/degridement
    • Soft tissue mass, left pelvic cavity, CT-guide biopsy — Suggestive of benign, reactive change
      
    • Microscopically, the sections show a picture of almost small to medium-sized lymphocytes infiltration with monocytoid feature.
      
    • Immunohistochemistry shows CK(-), CD3, CD5 and CD43 (+, diffuse), CD20(+, diffuse), CD10(+) for follicle, Bcl-2(-) for follicle, CD23(-) and Cyclin-D1(-). According to all histopathologic findings, it is suggestive of reavtive hyperplasia and less likely lymphoma. However, repeat biopsy or excision is advised for further evaluation, if malignancy is still suspected clinically.
  • 2021-12-13 CT - abdomen
    • Thickening of right posterior pleura and prevertebral tissue at T9-12.
    • Increased soft tissue at left pubic cavity.
    • Portal hypertension and splenomegaly.
  • 2021-12-07 SONO - abdomen
    • Splenmegaly, marked
• chemoimmunotherapy
  • 2022-10-24 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1200mg 30min + doxorubicin 50mg/m2 50mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD D1-5
  • 2022-09-30 - rituximab 375mg/m2 600mg 8hr + prednisolone 60mg/m2 5mg/tab 8# 40mg BID D1-5

[assessment]

• There is evidence of splenomegaly, portal hypertension, and high bilirubin levels (direct and total), but the cause is not yet known.
• Interstitial pattern and/or fibrosis at LUL has been observed. Rituximab has been associated with pulmonary disease and/or pulmonary toxicity. It might be necessary to monitor the lung status on a regular basis.
• As far as the current prescription is concerned, there is no problem.

700141460

221024

• chemoimmunotherapy
  • 2022-09-14 - irinotecan 150mg/m2 230mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3600mg 46hr

[assessment]

• Coxine (isosorbide-5-mononitrate) has been prescribed for the patient’s high hs-Troponin I (241.8 pg/mL 2022-10-22) and CKMB (9.7 ng/mL 2022-10-22).
• The most recent record of blood pressure was 100/52 (2022-10-24 08:41). The perfusion of vital organs, including the coronary arteries, might be compromised by low blood pressure. Saline 0.9% 500mL IVD PRNQD has been prescribed.
• There is an impairment of renal function in the patient. Hemodialysis will be arranged by a nephrologist.
• Currently, the serum potassium level is within the normal range (3.5 mmol/L 2022-10-22)
• The blood calcium concentration of this patient is frequently below normal. The addition of some phosphate binders may be beneficial. Phosphate binders are categorized as calcium-containing and noncalcium-containing. Calcium-containing binders include calcium carbonate and calcium acetate. Major noncalcium-containing binders include sevelamer and lanthanum. Other agents include ferric citrate and sucroferric oxyhydroxide.

700511404

221024

• past history (2022-10-22 adminnote)
  • DM
  • Hypertension
  • Left breast cancer s/p OP
  • GERD
  • Constipation
  • Hyperthyroidism
  • Breast cancer s/p C/T (bil leg numbness)
  • Multiple myeloma IgA kappa + lambda biclonce /p Ixazomib since 2022/7-2022/8 and lenalidomide 1# QOD and dexamethasone since 2022/7 to now.
• exam findings
  • 2022-12-02 CT - brain
    • A skull defect at left temporal region. Some lucent lesions in skull.
    • Brain atrophy and lacunar infarct.
  • 2022-11-03 Myocardial perfusion SPECT with persantin
    • Probably mild myocardial ischemia at the apex.
    • Mild reverse redistribution of radioactivity to the anteroapical wall and posterior wall, either normal variant or myocardial ischemia may show this picture.
  • 2022-11-03 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (124 - 49) / 124 = 60.48%
      • M-mode (Teichholz) = 60
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR, mild AR, mild TR
    • Mild pulmonary hypertension
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
    • Sinus rhythm at the exam
  • 2022-10-25 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — myeloma.
    • IHC stains: CD138: 60%; Kappa and Lambda light chains show a predominant lambda sub-population. CD34: <1 %; MPO: 30-40% (of the nucleated cells).
    • Section shows piece(s) of bone marrow with 40 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes and increase in the number of plasmacytoid cells. Megakaryocytes are adequate in number.
  • 2022-10-24 Abdomen
    • Spondylosis of the L-spine is noted.
    • Compression fracture of T12, L2, L4, and L5 are suspected.
  • 2022-10-22 CXR
    • Cardiomegaly and tortuosity of the thoracic aorta.
    • Widening of the mediastinum.
    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-03-08 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Multiple myeloma
    • Microscopically, the bone marrow shows multiple myeloma characterized by hypercellularity (90%), 2:3 of M:E ratio and a proliferation of plasma cells (11~20%).
    • Immunohistocehmical stain reveals CD20(+, 15%), CD138(>10%), Kappa(-), Lambda(+), MPO(+), CD34(-), CD117(-) and CD71(+).
  • 2021-12-09 Gynecologic ultrasonography
    • Bilateral adnexae: free
    • EM: 8.3mm.
  • 2021-03-05 Patho - bone marrow biopsy
    • Bone marrow, biopsy — <2% of CD138+ cells
      
    • Microscopically, it shows 30% of cellularity, 1:1 of M:E ratio, occasional normal megakaryocytes and <2% of CD138+ cells.
      
    • Immunohistochemical stain reveals CD138(<2%), CD71(+), MPO(+), CD117(-), CD34(-), CD20 (2~3%).
      
  • 2021-01-25 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 58 dB HL
      • L’t : 50 dB HL
      • Bil mild to moderately severe SNHL
    • Tymp
      • R’t : Type As
      • L’t : Type C
    • ART
      • Bil absent.
  • 2020-10-20 ENT Hearing Test
    • Tymp bil type As
    • ART bil contra and RE ipsi absent, LE ipsi reduced thretholds
    • E- tube function bil poor
    • PTA:
      • Reliability FAIR
      • Average RE 60 dB HL, LE 50 dB HL
        • RE mild to severe SNHL
        • LE mild to moderately severe SNHL
    • RE tinnirus
  • 2020-10-20 OVEMP
    • oVEMP (ocular vestibular-evoked myogenic potential)
      • Bil show no response
    • cVEMP (cervical VEMP)
      • Bil show no response
  • 2020-10-20 Electronystagmography, ENG
    • no abnormal nystagmus
  • 2020-09-28 C-spine Lat. flex. and ext.
    • Osteoporosis. Spondylosis, esp C5-6-7.
  • 2020-08-28 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with plasma cell myeloma with partial remission
      
    • The sections show normocellular marrow (20%). M/E ratio = 3:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology.
    • IHC, scattered CD138+ plasma cells in interstitium, account for <5% of marrow cells with lambda light chain restriction and negative for kappa light chain. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2020-04-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 44.1) / 112 = 60.63%
      • M-mode (Teichholz) = 60.6
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mild aortic, mitral and tricuspid regurgitation
    • Dilated LA, thick IVS and LVPW
    • Impaired LV relaxation
  • 2020-04-09 Long bones series
    • Few osteopenic defects at bilateral radius, bilateral humerus, bilateral femur, bilateral fibular and bilateral scapular are suspected.
  • 2020-04-07 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Myeloma.
    • IHC stains: CD138 (+, 85-90% of the nucleated cells), kappa (+, 80-90%), lambda (<5%), MPO (<5%), CD117 (<1%)
      
    • Section shows one piece of bone marrow with 40-50% cellularity and a predominant plasmacytoid cells.
  • 2020-04-06 Patho - bone exostosis
    • Soft tissue and bone, L5 body and right upper sacrum, CT-guided biopsy — Plasma cell neoplasm, compatible with plasma cell myeloma
      
    • The sections show plasma cell neoplasm, composed of diffuse sheets of neoplastic round cells with abundant basophilic cytoplasm and eccentric nuclei. Occasional intranuclear inclusions (Dutcher body) can be found.
    • IHC, the neoplastioc cells reveal: CD138(+), cytokeration(-), lambda light chain(+), and kappa light chain(-). Suggest clinic correlation.
  • 2020-04-01 SONO - nephrology
    • right adrenal tumor, nature to be determined
  • 2020-03-31 MRI - L-spine
    • Small L4/5 central HIVD.
    • L2 compression fracture.
    • Mass or nodule in anterior L5 body and right upper sacrum, suspected multiple myeloma, metastases
  • 2019-06-05 Color Transcranial Sonographic, CPA (carotid phonoangiograph)
    • Mild atheromatous lesions in bilateral ICAs and carotid bifurcations.
    • Normal extracranial carotid, vertebral arterial flows.
    • Poor bilateral temporal windows for transcranial insonation.
    • Normal other intracranial and bilateral ophthalmic arterial flows.
• consultation
  • 2020-04-10 Rehabiliation
    • Q
      • Being unable to sit up in bed
    • A
      • Assessment
        • Multiple myeloma
        • Anemia
        • Hypercalcemia, improved
        • Hypertension
        • Diabetic mellitus (2020/3/13 HbA1c 6.6%)
      • Plans
        • Please treat the myeloma and related back pain as your expertise
        • Keep back brace use except when lying down
        • Rehabilitation programs: Bedside PT rehabilitation programs
          • Goal: better sitting/standing balance, ambulate with device under support
  • 2020-04-10 Radiation Oncology
    • A
      • A: Multiple myeloma with L spine and sacrum involvement.
      • P: Radiotherapy is indicated for this patient with the following indicators: Multiple myeloma with low back pain.
        • Goal: palliation.
        • Treatment target and volume: L2~L5 and sacrum.
        • Technique: IMRT
        • Preliminary planning dose: 2800cGy/14 fractions.
  • 2020-03-31 Hemato-Oncology
    • Q
      • For MRI showed Mass or nodule in anterior L5 body and right upper sacrum, suspected multiple myeloma, metastases
        
      • This 73-year-old female with a past history of 1) DM 2) Hypertension 3) Left breast cancer s/p OP 4) Constipation, she had dizziness for half years, under regular Neuro OPD follow up. She was admitted due to severe low back pain, L-MRI showed Mass or nodule in anterior L5 body and right upper sacrum, suspected multiple myeloma, metastases. We need your help for further management, thanks a lot.
    • A
      • This is a case of hypercalcemia. Mass over anterior L5 vertebral body was noted. MRI sifggested D/D of myeloma and metastasis.
      • Suggest check immunoglobulin profile (IgG, A, M, kappa/lambda light chain), tumor marker screening (CEA, CA199, CA153, CA125). We’ll follow up this case, if there is abnormal immunoglobulin profile, we’ll make diagnostic BM biopsy; otherwise, do tumor survey according tumor markers and do tumor mass mass biopsy is suggested.
  • 2020-03-31 Orthopedics
    • Q
      • for severe low back pain
    • A
      • consult for low back pain radiation to bilateral buttock and lower leg, weakness and paresthesia,unable to bear weight
      • Xray showed bil SI joint OAand decreased disc space and foramen of L5-S1 level
        • suggest pain control (Arcoxia 1# QD or even Dynastat Q12H x 3 days if severe pain + Mefno 1# QD + Neurontin 1# QD)
        • suggest L-spine MRI for further evaluation
        • contact me afteer MRI was done
  • 2020-03-24 Orthopedics
    • Q
      • Due to right lower back pain was noted for days, she also mentioned she was her CVA husband main care giver, we would like to need your visit to rule out orthologic disease. Thank you very much!
    • A
      • S: low back pain, radiation to bil buttock and thigh
      • O: tenderness. knocking pain+, muscle spasm, SLRT-X: L5-S1 narrow, bil SI arthritis
      • A: lumbar spondylosis, L5-S1 narrow, degeneration
      • P: Arcoxia 1# QD, Traumacet 1# bid, Neurontin 1# HS, use waist support
• chemoimmunotherapy
  • 2022-04-21 ~ 2022-09-01 - Ninlaro (ixazomib) 3mg QWAC
  • 2022-04-14 ~ 2022-11-25 - Revlimid (lenalidomide) 25mg QOD
  • 2022-01-27 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2022-01-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2022-01-13 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2022-01-06 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-12-09 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-12-02 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-11-25 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-11-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-11-11 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-11-04 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-10-28 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-10-21 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-10-15 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-10-08 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-09-30 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-09-23 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-09-17 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-09-09 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-08-27 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-08-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-05-07 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-04-30 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-04-23 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-04-16 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-03-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-03-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-03-12 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-03-05 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-02-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-02-19 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-01-15 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2021-01-08 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-11-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-11-13 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-11-06 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-10-30 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-10-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-10-16 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-10-02 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-09-25 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-09-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-09-11 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-07-10 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-07-03 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-06-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-06-19 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-05-27 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-05-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-04-28 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-04-21 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-04-14 - Velcade (bortezomib) 1.3mg/m2 2mg SC
  • 2020-05-13 ~ 2022-04-14 - Thado (thalidomide) 100mg QN
  • 2020-07-03 ~ on and off - Xgeva (denosumab) 120mg Q1M SC

[assessment]

• As the patient’s serum calcium levels have dropped into the normal range, it may be appropriate to hold or discontinue Miacalcic (calcitonin) if no other considerations exist.
  • 2022-12-05 Ca (Calcium) 2.39 mmol/L
    
  • 2022-12-04 Ca (Calcium) 2.74 mmol/L
    
  • 2022-12-03 Ca (Calcium) 3.25 mmol/L
    
  • 2022-12-02 Ca (Calcium) 3.25 mmol/L
• For it has been observed that multiple data points of blood sugar levels exceeding 200 mg/dL since this hospitalization under current metformin treatment, the initialization of basal insulin is recommended.

701120825

221024

• exam finding
  • 2022-10-21 ECG
    • Sinus tachycardia
    • Right atrial enlargement
    • Rightward axis
    • Possible Anterior infarct, age undetermined
    • Abnormal ECG
  • 2022-10-21 Nasopharyngoscopy
    • Tumor involving soft palate, bilateral palatine tonsil, tongue base, epiglottis, supraglottic region and nasopharyngeal roof. Bilateral vocal fold immobility with airway narrowing.
  • 2017-10-05 Whole body PET scan
    • Glucose hypermetabolism in a focal area in the left lower neck about level IV. A metastatic lymph node may show this picture.
    • Asymmetric FDG uptake in bilateral tonsils with a little more FDG uptake in the right tonsil. The nature is to be determined (inflammatory process? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions, bilateral shoulders and right hip. Inflammatory process may show this picture.
  • 2017-07-17 MRI - larynx
    • A nodule or LN with central necrosis in left lower neck, level IV.
  • 2017-02-22 CT - neck, hypopharynx
    • several small lymph nodes in the right parotid space
  • 2016-04-23 CT
    • Post LNs dissection with soft tissue or muscle defect, right.
    • Small left neck LNs.
    • No obvious nasopharynx, oropharynx, hypopharynx or larynx mass..
    • No obvious abnormal enhancement after contrast medium administration.
  • 2015-04-23 pathology
    • Tonsil, right, biopsy — Negative for malignancy.
    • Lymph node, neck level I, right, neck dissection — Negative for malignancy (0/2).
    • Salivary gland, submandibular, right, neck dissection — Negative for malignancy.
    • Lymph node, neck level II, right, lymphadenectomy with frozen section — Presence of metastatic carcinoma, in favor of non-keratinizing sqaumous cell carcinoma, with extranodal extension(1/1).
    • Lymph node, neck level II, III and IV, right, neck dissection — Negative for malignancy( 0/10).
    • Tissue labelled as “internal jugular vein”, right, neck dissection — Negative for malignancy.
    • Soft tissue, sternocleidomastoid muscle, right, neck dissection — Negative for malignancy.
• consultation
  • 2022-10-22 Family Medicine
    • Q
      • The 64 y/o woman has head and neck non-keratinizing sqaumous cell carcinoma, with extranodal extension, regular at Mackey Hospital for supportive care. Deu to dyspnea, so she sent to our ED. Family favor hospice. We need your help. Thanks!
    • A
      • Dyspnea.
      • NOW with UFT 1# BID
      • Our share care would follow up.
  • 2022-10-21 ENT
    • Q
      • The 64 y/o woman has head and neck non-keratinizing sqaumous cell carcinoma, with extranodal extension, regular at Mackey for supportive care. Due to suspect air obstruction, we need your help for management.
    • A
      • Oral cavity: trismus with <1 FB.
      • Neck: stiffness, previous OP wound over right neck, an about 3cm tumor over rigt post-auricular region.
      • Scope: Tumor involving soft palate, bilateral palatine tonsil, tongue base, epiglottis, supraglottic region and nasopharyngeal roof. Bilateral vocal fold immobility with airway narrowing.
      • Impression: Head and neck malignancy with diffuse involvement.
      • Plan: Since the patient has signed DNR consent, palliative therapy is suggested for the patient.
• surgical operation
  • 2015-04-23
    • Surgery
      • Radical neck dissection, right
      • Tumor mapping with right tonsil biopsy
    • Finding
      • Hypertrophy of lower pole of right tonsil, s/p biopsy.
      • 4x4cm capsulized tumor at right neck level II, severe adhesion to surrounding muscle and vessel, ruptured intra-operatively and some serous flowed out, which was sent for culture. The tumor was sent for frozen section. Frozen section = suspected squamous cell carcinoma
      • Lymphoareolar tissue at right level I, II, III, III as well as internal jugular vein, SCM were dissected out and removed. Spinal accessory nerve was preserved.

[assessment]

• 2022-10-21 serum creatinine 0.39 mg/dL, eGFR 175, serum glucose 127 mg/dL. Glomerular hyperfiltration promoted by hyperglycemia? Muscle loss?
• Celebrex (celecoxib) should be limited as short as necessary to prevent possible renal injury.

701370027

221024

[assessment]

• eGFR was around 15 ~ 20 over the past half year (2022-04 ~ 2022-10), and the medication dosage has been adjusted accordingly.
• There is no restriction on the use of nasogastric tubes in the administration of oral medications included in the active prescription.

700629294

221022

• exam finding
  • 2022-10-22 CT - chest
    • No evidence of recurrent/residual tumor in the study
  • 2022-10-06 Gynecologic ultrasonography
    • Bilateral adnexae: free
    • EM: 4.7mm.
  • 2022-07-22 Patho - breast simple/partial mastectomy
    • DIAGNOSIS:
      • A. Breast, right partial mastectomy with frozen section (F2022-337SA) — atypical ductal hyperplasia (ADH) with microcalcifciation.
        • IHC stains: CK5/6 (+, focal rim staining) p63 (rim staining).
      • B. Lymph node, sentinel, right, sentinel LN, s/p neoadjuvant chemotherapy (F2022-337FSC) — negative for malignancy. Two focus of fibrosis probably involuted lymph node after chemotherapy.
      • C. Breast, right, total mastectomy total mastectomy (S2022-11852) — scleroscing adenosis, fibrocystic disease, and adenosis.
    • MICROSCOPIC DESCRIPTION:
      • A. Sections F2022-337FSA1-2 show breast tissue with atypica ductal hyperplasia with microaclcification.
        • IHC stains: CK5/6 (+, focal rim staining) p63 (rim staining). Foci of scleroscing adenosis, fibrocystic disease, and adenosis are present.
      • B. Sections F2022-337FSC1-2 show fibroadipose tissue with moderate fibrosis.
      • C. Sections S2022-11852 show breast tissue with scleroscing adenosis, fibrocystic disease, and adenosis are present.
  • 2022-07-22 Patho - breast simple/partial mastectomy
    • Diagnosis
      • Breast, left, s/p neoadjuvant chemotherapy followed by total mastectomy (S2022-11851) — no residual malignancy
      • Resection margin: free:
      • Lymph node, left, sentinel lymph node biopsy with frozen section (F2022-337FSB) — free
      • yp T0 ypN0(sn) (if cM0)
    • Gross Description
      • Procedure - mtotal mastectomy with senteinel lymph nodes.
      • Lymph node sampling - sentinel lymph node(s)
      • Specimen laterality - Left
        • Sections are taken and labeled as:
          • Tissue for frozen sections: F2022-337FSB: left sentinel lymph nodes.
          • Tissue for formalifixation: S2022-11851A1-12: left breast.
    • Microscopic Description
      • For Invasive Carcinoma: no residual malignancy.
      • For Ductal Carcinoma In Situ: no DCIS
      • Margins: no residual malignancy
      • Nodal status: Negative (if lymph nodes are present in the specimen)
        • No. examined: 2
        • No. macrometastases (>2 mm): 0
        • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
        • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
      • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
        • In the Breast
          • No residual invasive carcinoma is present in the breast after presurgical therapy
        • In the Lymph nodes
          • No lymph node metastases and no prominent fibrous scarring in the nodes
      • Immunohistochemical Study: result of biopsy specimen: S2021-19572
        • IHC stains (using blockS2021-19572): ER(+ , 100%, strongintensity), PR(-), Her2/neu: positive(score=3+), Ki-67(70 %), p53(50%).
  • 2022-07-21 Frozen section
    • Preliminary diagnosis:
      • FSA1-2: right breast: irrregular duct. The possibility of malignancy cannot be excluded. Will need IHC stain to determine the nature of these ducts.
      • FSB: left sentinel LN s/p neoadjuvant therapy: free (0/2).
    • ADDENDUM:
      • FSC1-2: right sentinel LN, s/p neoadjuvant chemotherapy: negative for malignancy. Two focus of fibrosis probably involuted lymph node after chemotherapy.
  • 2022-07-21 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential dynamic and static images over the chest revealed at least one focal area of increased accumulation of radioactivity at the left axilla.
    • IMPRESSION: Probably at least one sentinel lymph node at the left axillary region.
  • 2022-07-07 Mammography
    • Impression:
      • Regression of left breast tumor (LIQ) and axillary lymph node.
      • Focal asymmetry in UOQ of right breast (posterior portion), stationary.
    • BIRADS 6
  • 2022-07-07 SONO - breast
    • Diagnosis
      • Bil. fibroadenomas as described
      • Left breast cancer
    • BI-RADS:
      • 6 - known biopsy-proven malignancy
  • 2022-06-11 CT - lung/mediastinum/pleura
    • IMP: No evidence of lung metastases based on this CT study.
  • 2022-01-25 2D transthoracic echocardiography
    • LVEF(%) = 72
  • 2022-01-14 CT - abdomen, pelvis
    • Left breast cancer with left axillary lymph node metastasis is highly suspected. please correlate with clinical condition.
    • The gallbladder shows mild irregular wall thickening and few stones that may be chronic inflammation. The differential diagnosis include gallbladder cancer.
  • 2021-12-28 Patho - breast biopsy
    • Breast, left, 5/2, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains (using blockS2021-19572): ER (+, 100%, strongintensity), PR(-), Her2/neu: positive (score=3+), Ki-67(70 %), p53 (50%).
  • 2021-12-28 Patho - lymphnode biopsy
    • Lymph node, left, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains (using blockS2021-19571): ER (+, 100%, strongintensity), PR(+, 30%, strong intensity), Her2/neu: positive (score=3+), Ki-67(90 %), p53 (60%).
      
  • 2021-12-28 SONO - breast
    • Bilateral breast irregular tumors, suspected malignancy, suggest biopsy.
    • Enlarged left axillary lymph node, suspected lymph node metastasis.
    • Suggest biopsy.
      
    • BI-RADS: Category 4c: highly suspicious abnormality-biopsy should be considered.
  • 2021-12-18 Mammography
    • BI-RADS category 0, Need additional imaging evaluation.
    • Suggest ultrasound correlation for developing left breast nodules and enlarged left axillary lymph node.
  • 2019-05-03 Mammography
    • Impression: No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative.-annual screening.
• consultation
  • 2022-03-31 ENT
    • Q
      • for right ear pain and headache
      • This 58 year-old woman panient suffered from left breast mass in 2021/11. Breast SONO on 2021/12/28 showed bilateral breast irregular tumors, suspected malignancy, suggest biopsy, enlarged left axillary lymph node, suspected lymph node metastasis and suggest biopsy. Left lymph node core biopsy showed invasive carcinoma, no special type, NST. IHC stains (using block S2021-19571): ER (+ , 100%, strongintensity), PR(+, 30%, strong intensity), Her2/neu: positive(score=3+), Ki-67(90 %), p53 (60%). Left 5/2 breast core biopsy showed Invasive carcinoma, no special type, NST. IHC stains (using block S2021-19572): ER (+ , 100%, strongintensity), PR(-), Her2/neu: positive(score=3+), Ki-67(70 %), p53 (50%).
      • This time, she was admitted to ward for chemotherapy with AC(C4) on 2022/03/31, then she complaints right ear pain and headache for 3-4 days, so we need your help for survey evulation, thanks a lot.
    • A
      • Eating on side(+, L) R otalgia with bil temple pain for 3 days.
      • PE:
        • Ear drum: bil intact
        • EAC: clean
        • TMJ: right TMJ tenderness when compression
      • Imp: TMJ syndrome
      • Plan: Pain control
• surigcal operation
  • 2022-07-21
    • Surgery
      • bilateral simple mastectomy and SLNB
    • Finding
      • left breast cancer, HER-2 type, s/p neoadjuvant chemotherapy and target therapy, tumor regression, SLNB: negative of malignancy
      • right breast tumor, excision for frozen pathology: irrregular duct. The possibility of malignancy cannot be excluded. Will need IHC stain to determine the nature of these ducts –> do simple mastectomy and SLN sampling
  • 2018-07-05 PCS code 87003C
    • Benign neoplasm of skin of eyelid, including canthus
    • lid tumor, os
• chemoimmunotherapy
  • 2022-10-18 - Herceptin (trastuzumab) 600mg SC
  • 2022-09-27 - Herceptin (trastuzumab) 600mg SC
  • 2022-09-06 - Herceptin (trastuzumab) 600mg SC
  • 2022-08-16 - Herceptin (trastuzumab) 600mg SC
  • 2022-06-29 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
  • 2022-06-10 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
  • 2022-05-16 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
  • 2022-04-22 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
  • 2022-04-01 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
  • 2022-03-11 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
  • 2022-02-15 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
  • 2022-01-25 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr

[assessment]

• Trastuzumab administration (2022-04-22 ~ undergoing) might result in subclinical and clinical cardiac failure. The incidence and severity might be higher for patients received anthracycline-containing chemotherapy regimens (doxorubicin 2022-01 ~ 2022-04). An update of 2D transthoracic echocardiography is recommended (the most recent was performed on 2022-01-25 prior to the introduction of doxorubicin).

220517

[assessment]

• The patient was diagnosed with breast cancer (ER+, PR (-, + lymph nodes) Her2/neu 3+) and has been treated with doxorubicin/cyclophosphamide followed by docetaxel/trastuzumab.
• The last CT performed on 2022-01-14 showed a thickening of the gallbladder wall. Since gallbladder mets from breast cancer are rare, it might be sufficient to follow the gallbladder on an annual basis.
• Lab data on 2022-05-10 showed that liver and kidney function, electrolytes and CBC were generally normal.
• TPR readings remain stable during this hospital stay, no issues with active prescription.

700269001

221021

• lab data
  • UGT1A1 6/7
  • Bilirubin total
    • 2022-07-14 Bilirubin total 0.70 mg/dL
      
    • 2022-06-16 Bilirubin total 1.30 mg/dL
      
    • 2022-04-21 Bilirubin total 0.60 mg/dL
      
    • 2022-04-07 Bilirubin total 0.98 mg/dL
      
    • 2022-03-31 Bilirubin total 0.98 mg/dL
      
    • 2022-03-22 Bilirubin total 1.18 mg/dL
      
    • 2022-03-09 Bilirubin total 2.15 mg/dL
      
    • 2022-02-24 Bilirubin total 1.44 mg/dL
      
    • 2022-02-09 Bilirubin total 1.22 mg/dL
      
    • 2022-01-26 Bilirubin total 1.27 mg/dL
      
    • 2021-12-30 Bilirubin total 0.98 mg/dL
      
    • 2021-12-25 Bilirubin total 0.78 mg/dL
• exam finding
  • 2022-08-29 CT - abdomen, pelvis
    • Rectal cancer s/p operation. Minimal ascites in pelvic cavity.
  • 2022-07-15 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 18 dB HL, LE 21 dB HL
    • bil normal to moderate SNHL
  • 2022-07-08 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average R’t 13 dB HL, L’t 31 dB HL
    • R’t normal to mild SNHL.
    • L’t normal to moderately severe SNHL.
    • Tymp: Bil type A.
    • ART: R’t WNL.
    • L’t 500 Hz reduced thresholds.
  • 2022-07-01 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • R’t: 19 dB HL, WNL except 8k Hz
    • L’t: 45 dB HL, mild to moderately severe SNHL.
  • 2022-06-23 Hearing Test
    • Reliabilty Fair
    • PTA - Pure Tone Audiometry
      • R’t: 18 dB HL, normal to moderate SNHL
      • L’t: 46 dB HL, normal to moderately severe SNHL
    • Tymp - Tympanogram
      • Bil Type A
    • ART - Acoustic reflex threshold
      • R’t: Ipsi absent
      • L’t: Ipsi 500-1k Hz reduced, contra absent.
  • 2022-05-23 Patho - colon segmental resection for tumor
    • pathologic diagnosis
      • 1. Tumor, lower rectum, Robotic Abdominal Perineal Resection — Residual intramucosal adenocarcinoma
      • 2. Resection margins, ditto — Free of tumor
      • 3. Lymph nodes, mesocolic, dissection — Free of tumor metastasis (0/8)
      • 4. AJCC pathologic stage — ypTisN0, stage 0, if cM0
    • macroscopic examination
      • Tumor appearance: elevated mucosa
      • Depth of invasion grossly: lamina propria
    • microscopic examination
      • 1. Histology: residual intramucosal adenocarcinoma
      • 2. Histology Grade: G1, well differentiated
           
      • 3. Depth of invasion: lamina propria
      • 4. Angiolymphatic invasion: not identified
      • 5. Perineural invasion: not identified
      • 6. Discontinuous extramural tumor extension: absent
      • 7. Circumferential (radial) margin of rectosigmoid: Not involved
      • 8. Lymph node metastasis, mesocolic: free of tumor metastasis (0/8)
      • 9. Lymph node metastasis, IMA / SMA: N/A
      • 10. Extranodal involvement: N/A
      • 11. Pathological TNM Stage: ypTisN0
      • 12. Type of polyp in which invasive carcinoma arose: N/A
      • 13. TNM descriptors: y
            
      • 14. Tumor regression grading S/P CCRT: grade 2 (rare residual cancer)
  • 2022-05-23 SONO - abdomen
    • Liver calcification nodules (incomplete exam of liver)
  • 2022-05-19 ECG
    • Normal sinus rhythm
    • RSR or QR pattern in V1 suggests right ventricular conduction delay
    • Borderline ECG
  • 2022-04-07 CT - abdomen, pelvis
    • History and indication:
      • Rectal cancer s/p CCRT suspected low rectal cancer at anterior; 1.5*1.5 cm with ulceration and bleeding at 3 cm from AV
    • IMP:
      • Mild regression of rectal cancer.
  • 2022-04-07 Colonoscopy
    • Findings
      • The scope reach the S-colon.
      • Rectal cancer s/p CCRT with tumor regression at anterior wall, 4cm from AV
    • Diagnosis
      • Rectal cancer s/p CCRT with tumor regression
  • 2022-03-24 Cardiac Catheterization
    • Type of arrhythmia
      • WPW
    • Ablation Diagnosis
      • Intermittent Wolff-Parkinson-White syndrome (iWPW), s/p successful cryoablation of para-Hisian accessory pathway through non-coronary cusp (NCC) approach
  • 2022-03-14 SONO - abdomen
    • suspected liver parenchymal disease, mild fatty liver
    • liver calcification nodules
  • 2022-02-17 ECG
    • Sinus rhythm with frequent Premature ventricular complexes in a pattern of bigeminy
    • Fusion complexes
  • 2022-01-28 Cardiopulmonary Exercise Testing
    • summary:
      • maximal exercise
      • normal exercise capacity ( VO2 99%, WR 118%)
      • normal stroke volume response during exercise
      • normal ventilatory function ( FVC 127%, FEV1 118%)
      • normal respiratory muscle strength (MIP 75%, MEP 89%)
    • suggestions:
      • treat underlying condition
      • survey and treat cardiac function, refer to CV for EKG with ST-T changes
      • arrange pulmonary rehab with exercise training
  • 2022-01-12 CXR
    • A calcified spot at RUQ.
  • 2021-12-28 Patho - colon biopsy
    • Colon, dentate line to 8 cm AAV at anterior wall, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2021-12-28 Colonoscopy
    • Diagnosis
      • Highly suspected rectal cancer, 1/4 circumference, from dentate line to 8 cm AAV at anterior wall, s/p biopsy
    • Suggestion
      • F/U pathology report
    • Complication
      • No immediate complication
  • 2021-12-27 CT - abdomen, pelvis
    • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T3N0M0, stage IIA
• consultation
  • 2022-01-18 Psychosomatic Medicine
    • Q
      • This 57-year-old woman patient is a case of low rectal cancer arising from dentate line with broad-based villous tumor up to 8 cm from AV cT3N0M0; stage II. She was admitted for concurrent chemoradiotherapy. For evaluate anxiety with insomnia therapy. Thank you.
    • A
      • Psychiatric impression:
        • depression and anxiety
        • suspected adjustment reaction with anxiety and depression
      • Psychiatric history:
        • This 57-year-old woman patient is a case of low rectal cancer cT3N0M0; stage II was diagnosed in December 2021. This time she was admitted for concurrent chemoradiotherapy. We were consulted due to anxiety and insomnia were noted.
        • According to the patient, she suffered from low mood, anxiety and worry about the cancer treatement (enteroproctia, artificial anus). surgical treatment, fearfulness, anticipatory anxiety, negative thought, free floating anxiety, poor appetite and poor sleeplasting (1-2 hour), suicide ideation before.
        • MSE: coherent and relevent speech, fair spontaneous speech, anxiety and low mood, negative thinking, worrisome, denied panic like attack.
      • Suggestion:
        • emotional support and empthy
        • may give Mirtapine (mirtazapine) 0.5# HS and alprazolam 0.5# prn if anxiety
        • arrange psychiatric OPD (patient request W1 evening OPD)
• radiotherapy
  • 2022-01-10 ~ 2022-02-23 - Concurrent radiotherapy 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectal tumor bed area.
• chemoimmunotherapy
  • 2022-10-20 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
  • 2022-09-30 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
  • 2022-09-07 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
  • 2022-08-26 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
  • 2022-08-12 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
  • 2022-07-29 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
  • 2022-07-15 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
  • 2022-07-01 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr (oral mucostatis with ulcer with pain for 2 weeks, upper and lower limbs numbness in 2022-06)   
  • 2022-04-11 - oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 400mg/m2 600mg 10min + 2400mg/m2 3600mg 46hr
  • 2022-03-09 - oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 400mg/m2 600mg 10min + 2400mg/m2 3600mg 46hr
  • 2022-02-14 - Leucovorin 20mg/m2 10min D1~2 + 5-FU 400mg/m2 10min D1~2; CCRT
  • 2022-02-09 - Leucovorin 20mg/m2 10min D1~3 + 5-FU 400mg/m2 10min D1~3; CCRT
  • 2022-01-17 - Leucovorin 20mg/m2 10min D1~3 + 5-FU 400mg/m2 10min D1~3; CCRT
  • 2022-01-13 - Leucovorin 20mg/m2 10min D1~2 + 5-FU 400mg/m2 10min D1~2; CCRT

[note]

• All You Need to Know About UGT1A1 Genetic Testing for Patients Treated With Irinotecan: A Practitioner-Friendly Guide ( https://ascopubs.org/doi/full/10.1200/OP.21.00624 )
  • Irinotecan is an anticancer agent widely used for the treatment of solid tumors, including colorectal and pancreatic cancers. Severe neutropenia and diarrhea are common dose-limiting toxicities of irinotecan-based therapy, and UGT1A1 polymorphisms are one of the major risk factors of these toxicities.
  • In 2005, the US Food and Drug Administration revised the drug label to indicate that patients with UGT1A128 homozygous genotype should receive a decreased dose of irinotecan. However, UGT1A128 testing is not routinely used in the clinic, and specific reasons include lack of access to concise information on this wide issue as well as mixed recommendations by regulatory and professional entities.
  • To assist oncologists in assessing whether and when to use UGT1A1 genetic testing in patients receiving irinotecan-based therapies, this article provided (1) essential knowledge of UGT1A1 polymorphisms; (2) an update on the impact of UGT1A1 polymorphisms on efficacy and toxicity of contemporary irinotecan-based regimens; (3) dosing adjustments based upon the UGT1A1 genotypes, and (4) recommendations from currently available guidelines from the US and international scientific consortia and major oncology societies.

[assessment]

• FOLFOX regimen has been modified by lowering oxaliplatin dose (65mg/m2 <- 85mg/m2) and skipping fluorouracil bolus since July 2022 due to mucositis and limb numbness observed in June 2022.
• Oral mucositis is appropriately treated with Nincort Oral Gel (triamcinolone) currently.
• Duloxetine is recommended for the mitigation of chemotherapy-induced peripheral neuropathy (ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. Journal of Clinical Oncology 2020 38:28, 3325-3348)
• Duloxetine for chemotherapy-induced peripheral neuropathy (off-label use): Oral initial: 30 mg once daily for 1 week, then 60 mg once daily. (ref: UpToDate)

700514824

221021

[assessment]

• Since the patient began her hospital stay, her blood sugar levels have exceeded 200 mg/dL in all data points ( with a record high 401 mg/dL) under current basal/bolus insulin therapy.
• In this case, it is recommended to gradually increase the basal insulin by 2 or 3 units and monitor the changes in blood sugar levels to determine whether further adjustments are necessary.

700999894

221021

• diagnosis
  • 2022-10-18 discharge note
    • Right lower lobe lung cancer, adenocarcinoma, T2bN0M0, stage IIA, status post operation, with recurrent rT4N2M1a, stage IVA with lung to lung metastasis, ECOG 1, EGFRmutation: L858R (-), exon 19 (-), ALK(-), ROS1(-)
    • Essential (primary) hypertension
    • Type 2 diabetes mellitus without complications
    • Insomnia, unspecified
    • Malignant neoplasm of lower lobe, right bronchus or lung
    • Chronic obstructive pulmonary disease
    • Chronic rhinitis
• History
  • hypertension under regular control for 2-3years (at LMD)
  • RLL lung cancer,adenocarcinoma, pStage IIA, pT2bN0(cMx)s/p VATS RLL lobectomy + RLND on 20170904, diagnosed on 20170908 ECOG:1; EGFR mutation wild type; Alk negative; PDL1 <1%.
    • post operation adjuvent chemotherapy:
      • immunotherapy Keytruda 20171006 ~ 20190603
      • chemotherapy with C1D1D8 Navelbine (20171007 and 20171031);
      • Gemzar total 6 cycle (20171030 ~ 20180501);
      • CDDP total 4 cycle (201761103, 20171127, 20180302, 20180503);
      • Vinorelbine total 6 cycle (20180528, 20180621, 20180726, 20180821, 20180914, 20181012)
    • For lung cancer re-staging, the chest CT was performed, wich multiple nodular lesions of varying sizes in both lungs shown, favor recurrent lung tumor with lung to lung metastasis.
      • Brain MRI and whole body bone scane also done without brain or bone metastasis.
    • For tissue prove, thet thoracoscopic wedge or Partial resection of the Lung on 20190315 and the pathogen disclosed Adenocarcinoma.
      • Therefore, the progression lung cancer pT2bN0 staage IIA -> rT2bN0M1a Stage IV was diagnosed.
    • For progression lung cancer, we was re-challenge the chemotherapy to immunotherapy C1 with Tecentriq (Atezolizumab), chemotherapy C1 Alimta, C1 Avastin and C1 CDDP since 201904.
    • The chest film showed ill-defined nodular/masses lesions of varying sizes in both lungs, recurrent lung cancer with lung to lung metastases, in progression on 20220907.
  • The lung cancer treatment regimen as below:
    • 1st chemotherapy with C1 Alimta, C1 Avastin and C1 CDDP since 201904
    • 2nd chemotherapy with C1 Docetaxel since 20220913.
    • immunotherapy C1 with Tecentriq since 201904, and changed to double immunetherapy with C1 Nivo total 200mg (free) IVF on 20210304 and Ipilmumab total 50mg (charge) IVF on 20210305.
• chemoimmunotherapy
  • 2022-10-14 - Yervoy (ipilimumab) 50mg 30min
  • 2022-10-14 - Opdivo (nivolumab) 200mg 1hr
  • 2022-10-13 - Nolboxol (docetaxel) 25mg/m2 40mg 1hr
  • 2022-09-15 - Yervoy (ipilimumab) 50mg 30min
  • 2022-09-14 - Opdivo (nivolumab) 200mg 1hr
  • 2022-09-13 - Nolboxol (docetaxel) 25mg/m2 40mg 1hr
  • 2022-06-30 - Yervoy (ipilimumab) 50mg 30min
  • 2022-06-29 - Opdivo (nivolumab) 200mg 1hr
  • 2022-06-28 - Alimta (pemetrexed) 500mg/m2 900mg 10min
  • 2022-06-27 - Cyramza (ramucirumab) 500mg 1.5hr
  • 2022-06-08 - Yervoy (ipilimumab) 50mg 30min
  • 2022-06-07 - Alimta (pemetrexed) 500mg/m2 900mg 10min
  • 2022-06-06 - Cyramza (ramucirumab) 500mg 1.5hr
  • 2022-04-29 - Yervoy (ipilimumab) 50mg 30min
  • 2022-04-28 - Opdivo (nivolumab) 200mg 1hr
  • 2022-04-27 - Alimta (pemetrexed) 500mg/m2 900mg 10min
  • 2022-03-24 - Yervoy (ipilimumab) 50mg 30min
  • 2022-03-23 - Opdivo (nivolumab) 200mg 1hr
  • 2022-03-22 - Alimta (pemetrexed) 500mg/m2 900mg 10min
  • 2022-03-21 - Cyramza (ramucirumab) 10mg/mg 600mg 90min
  • 2022-02-24 - Yervoy (ipilimumab) 50mg 30min
  • 2022-02-23 - Opdivo (nivolumab) 200mg 1hr
  • 2022-02-22 - Alimta (pemetrexed) 500mg/m2 900mg 10min
  • 2022-02-21 - Cyramza (ramucirumab) 10mg/mg 600mg 90min
  • 2022-01-21 - Yervoy (ipilimumab) 50mg 30min
  • 2022-01-20 - Opdivo (nivolumab) 200mg 1hr
  • 2022-01-19 - Alimta (pemetrexed) 500mg/m2 900mg 10min
  • 2022-01-19 - Cyramza (ramucirumab) 10mg/mg 600mg 90min

701356390

221021

{breast cancer with brain mets}

• cheif complaint (2022-09-16 adminnote)
  • Gait disturbance within recent half month, headedness, headache, poor memory, left hand tremor also noted.
• present illness (2022-09-16 adminnote)
  • The skin-sparing mastectomy with immediate breast reconstruction was done on 2007-11-26.
    • The pathological report showed the diagnosis of Invasive Lobular Carcinoma. The stage was pT2N0M0, Stage IIA, with ER (4+), PR (4+), Her-2 IHC (1+).
  • The adjuvant treatement was LHRH agonist (Zoladex) from 2007-12-27 to 2012-12-13.
  • The anti-estrogen, tamoxifen, was added from 2012-06-28 to 2013-01-10.
  • On 2018-03-21, she sustained a mass over left supraclavicular area.
  • On 2018-03-26, the whle body bone scan showed the possibility of bone mets over left anterior 1st and 2nd ribs.
  • The denosumab (XGEVA) was given from 2018-03-29 to now.
  • The palbociclib plus letrozole was given 2018-04-26 to 2018-11-06.
  • On 2018-06-27, the Chest CT scan revealed necrotized mass over the left uper anterior mediastinum with direction invasion to left antirior 1st and 2nd ribs, which might explain the findings of increasing tracer uptake in the whole body bone scan on 2018-06-27 and later on 2018-08-21.
    • It indicated the recurrence of invasive lobular carcinoma over mediastinum, The treatment was at SD, based on the findings of CT on 2018-10-16.
  • On 2018-10-26, the PET-CT demonstraged: 1. a huge hypermetabolic mass wiht central necrosis, abunting anterior chest wall and possible invsding sternum in the anterior mediastinum; 2. several hypermetaboic nodes in the left supraclavicular, left para-sternal and left lower pleura, indicating nodal metastases or pleural seeding.
  • The sono-guided biopsy on 2018-11-02 disclosed metastaic poorly differentiated carcinoma, with ER (30%), PR (-), Her-2 (<10%), Ki-67 (<3%)
  • On 2018-12-25, the thyroid sonography revealed bilateral multinodular gioter, without evident malignancy by aspiration cytology. The weekly eribulin for 2 weeks every 3 weeks was given from 2018-11-07 to 2019-10-09.
  • The letrozole from hospital and palbociclib from outside hospital were resumed from 2019-12-04 to now.
  • On 2019-03-14, the follow-up PET-CT showed marked regression of prepericardial and left intercostal LAPs, mild regression of the anterior mediastinal mass.
  • To maximize the anti-cancer effect, the radiotherapy to the anterior mediastinal mass was given with 45 Gy/18Fx was given from 2019-04-02 to 2019-04-25.
  • On 2019-09-18, the follow-up PET-CT showed partial regression of the anterior mediastinal mass and invisibility of those aforementioned LAPs.
  • On 2020-04-01, the follow-up CT showed the metastases of mass and LAP in PR.
  • On 2021-04-26, the follow-up PET-CT showed the metastases of mass and LAP in PR.
  • She suffered from lower limbs weakness, and visited our ER on 2022-01-10. Brain CT on 2022/01/10 showed c/w brain metastasis and midline shift, 8mm. Brain MRI on 2022-01-10 showed intra-axial lesions, R/O brain metastasis.
  • Brain CT on 2022-01-12 showed multiple brain metasatses with mass effect. S/P markers for stereostatic surgery. Stereotactic biopsy and aspiration for right PO cystic lesion and left frontal deep tumor on 2022-01-13
    • CSF pathology suspicious for adenocarcinoma,
    • Brain pathology showed metastatic carcinoma, breast origin ,
      • Immunohistochemistry shows CK(+), GATA-3(+), ER(-), PR(-) and HER2(2+, equivocal) for tumor cells, compatible with metastatic breast carcinoma.
  • Abdominal CT on 2022-02-11 showed 1. S/P Mastectomy, left. There is soft tissue swelling at the left upper anterior mediastinum, nature? please correlate with clinical condition. 2. Detailed findings, please see description.
  • Whole body bone scan on 2022-02-14 showed two hot spots in bilateral fronto-parietal region of the skull, respectively, and increased activity in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?).
  • Plan to deliver 30 Gy/ 10 fractions to the whole brain from 2022/01/24~2022/01/28 for 15 Gy/ 5 fractions.
  • Xgeva 1pc SC on 2022/01/27, 2022/02/24, 2022/03/24, 2022/04/19.
  • Received palliative chemotherapy with Q3W Adriamycin(60mg/m2)/Cyclophosphamide(600mg/m2) on 2022/02/24(C1), 2022/03/16(C2), 2022/04/07(C3), 2022/04/27(C4), 2022/05/17(C5), 202206/07(6).
  • Chemotherapy with QW Docetaxel(35mg/m2) on 2022/06/30(C1), 2022/07/14(C2), 2022/07/28(C3), 2022/08/11(C4),2022/09/01(C5).
  • Brain MRI on 2022/08/10 showed 1.unremarkable change in the intraventricular and extraventricular CSF spaces; 2.solid and rim-enhnaincg lesions in the left frontal lobe, 22mm; left cindulate gyrus,14.8mm; right cerebellar hemisphere, 5.7mm. right parieto-occipito-temporal lobe, 42.3mm. The small one in the left parietal lobe on the previous study on 20220510 was missing. The solid nodule in the left frontal lobe was increased in size; 3. unremarkable change in the skull base.
  • She suffered from gait disturbance within recent half month, headedness, headache, poor memory, left hand tremor also noted. She came to NS OPD for help on 2022/09/09.
  • Brain CT was done showed: 1.mild dilated intraventricular and extraventricular CSF spaces, 2.two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe, 3.unremarkable change in the skull base.
  • Now, she was admitted to ward for radiotherapy evaluate and change chemotherapy regimen for disease progression.
• past history
  • Breast cancer s/p about 15 year ago, s/p OP and radiotherapy with bone and lymph node metastases s/p chemotherapy with brain metastasis s/p radiotherapy
  • Left lymph node s/p biospy, about 2 year ago. under Hormones and Targeted Therapy. Re-follow CT show Left lymph node and clavicle metastasis.
  • Hypertension for 10 years with Novrasc 1# po QD and Bisoprolol 1.25mg 1# po QD
  • Diabetes for 10 years with Glimet(glimepiride 2mg+metformin 500mg) 1# po QD.
• exam finding
  • 2022-10-20 CT - abdomen
    • Partial consolidation at LLL suspected pneumonia.
    • Colon diverticula. Fat stranding abutting S-colon suspected diverticulitis.
    • Left ovary cyst (5.2cm).
  • 2022-10-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (99.8 - 21.7) / 99.8 = 58.82%
      • M-mode (Teichholz) = 78.3
    • Adequate LV,RV systolic function with normal wall motion
    • Mild PR
    • Impaired LV relaxation
  • 2022-09-09 CT - brain
    • mild dilated intraventricular and extraventricular CSF spaces
    • two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe.
    • unremarkable change in the skull base
  • 2022-08-19 CT - chest
    • Left breast cancer with chest wall meta s/p left mastectomy, C/T and R/T. The chest wall meta is stationary .
  • 2022-08-10 MRI - brain
    • multiple brain metastasis with some stationary; one missing ; the solid one, increase in size.
  • 2022-08-01 Tc-99m MDP whole body bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the skull, both rib cages, sternum, lower L-spine, sacrum, bilateral shoulders, S-I joints, hips and knees.
  • 2022-05-24 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/02/25, the previous two hot spots in the skull are a little less evident. However, no prominent change is noted in the lesions in the sternum.
    • Suspected benign lesions in lower L-spines, sacrum, bilateral shoulders, S-I joints, hips and knees.
  • 2022-05-19 CT - chest
    • Left anterior chest wall soft tissue lesion. Stationary.
    • S/P mastectomy at left side.
    • Radiation pneumoniitis at left upper lobe
  • 2022-05-10 MRI - brain
    • At least 7 intra-axial lesions, mixed solid and cystic components, in bilateral cerebral hemispheres and right cerebellar hemisphere. 5.6mm of the largest one in right posterior temporal lobe. Enhancement of the solid part after contrast administration.
    • compatible with breast cancer with brain metastases.
  • 2022-02-25 Ventricular ejaction fraction and wall motion study
    • The RVEF and LVEF were 63% and 65% respectively.
    • Normal wall motion of the LV.
  • 2022-02-24 transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (121 - 51.2) / 121 = 57.69%
    • Adequate LV,RV systolic function with normal wall motion
    • Thick IVS, Impaired LV relaxation
    • Mild PR,TR
  • 2022-02-14 Tc-99m MDP whole body bone scan
    • Two hot spots in bilateral fronto-parietal region of the skull, respectively, and increased activity in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in lower L-spine, sacrum, bilateral shoulders, S-I joints, and hips.
  • 2022-02-11 CT - whole abdomen, pelvis
    • S/P Mastectomy, left.
    • There is soft tissue swelling at the left upper anterior mediastinum, nature?
  • 2022-01-13 Patho - brain biopsy
    • Brain tumor, r’t frontal area, frozen section and biopsy - Metastatic carcinoma, breast origin
    • IHC: CK(+), GATA-3(+), ER(-), PR(-) and HER2(2+, equivocal) for tumor cells, compatible with metastatic breast carcinoma.
      • There is NO amplification of HER2 detected by FISH assay in Taipei Institute of Pathology
  • 2022-01-13 Frozen section
    • Tumor, brain, frozen section - Malignancy, poorly-differentiated.
  • 2022-01-12 CT - Brain for navigator
    • Multiple brain metasatses with mass effect. S/P markers for stereostatic surgery.
  • 2022-01-10 MRI - Brain for navigator
    • Intra-axial lesions, suspected brain metastasis
  • 2022-01-10 CT - Brain
    • c/w brain metastasis
    • Midline shift, 8mm
  • 2021-04-26 PET
    • metastases of mass and LAP in PR.
  • 2020-04-01 CT
    • metastases of mass and LAP in PR.
  • 2019-09-18 PET
    • partial regression of the anterior mediastinal mass and invisibility of those aforementioned LAPs.
  • 2019-03-14 PET
    • marked regression of prepericardial and left intercostal LAPs, mild regression of the anterior mediastinal mass.
  • 2018-12-25 Sonography - thyroid
    • bilateral multinodular gioter, without evident malignancy by aspiration cytology.
  • 2018-11-02 Patho - sono-guided biopsy
    • metastaic poorly differentiated carcinoma
    • ER (30%), PR (-), Her-2 (<10%), Ki-67 (<3%)
  • 2018-10-26 PET
    • a huge hypermetabolic mass wiht central necrosis, abunting anterior chest wall and possible invading sternum in the anterior mediastinum
    • several hypermetaboic nodes in the left supraclavicular, left para-sternal and left lower pleura, indicating nodal metastases or pleural seeding.
  • 2018-10-16 CT
    • SD - stable disease
  • 2018-08-21, -06-27 Whole body bone scan
    • increasing tracer uptake
    • it indicated the recurrence of invasive lobular carcinoma over mediastinum
  • 2018-06-27 CT - chest
    • necrotized mass over the left uper anterior mediastinum with direction invasion to left antirior 1st and 2nd ribs
  • 2018-03-26 Whole body bone scan
    • possibility of bone mets over left anterior 1st and 2nd ribs.
  • 2018-03-21 Presentation
    • she sustained a mass over left supraclavicular area.
  • 2007-11-26 Patho - skin-sparing mastectomy
    • Invasive Lobular Carcinoma. The stage was pT2N0M0, Stage IIA,
    • IHC: ER (4+), PR (4+), Her-2 (1+).
• surgical operation
  • 2022-01-13 Stereotactic biopsy and aspiration for right PO cystic lesion and left frontal deep tumor; breast cancer history (+);
    • finding
      • OP 1:
        • Two pieces white-grayish soft tumor was harvest at left forntal deep brain.
        • Frozen section: Tumor, brain, frozen section - Malignancy, poorly-differentiated.
      • OP 2:
        • Xanthochromic then light reddish fluid about 40cc was apirated at right PO area.
        • sent for cytology/culture and CSF profile.
  • 2007-11-26 skin-sparing mastectomy with immediate breast reconstruction
• radiotherapy
  • 2022-02-07 medrec plan to deliver 30 Gy/ 10 fx to the whole brain.
  • 2022-01-24 ~ 2022-01-28 - the whole brain 15 Gy/ 5 fractions?
  • 2019-04-02 ~ 2019-04-25 - 45 Gy/18Fx to the anterior mediastinal mass
• chemotherapy
  • 2022-10-21 ~ 2022-10-24 - Granocyte (lenograstim) 250mg QD SC
  • 2022-10-20 - G-CSF (filgrastim) 150mg ST SC
  • 2022-10-07 - Lipo-Dox (liposome doxorubicin) 50mg/m2 80mg 2hr
  • 2022-09-01 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
  • 2022-08-11 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
  • 2022-07-28 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
  • 2022-07-14 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
  • 2022-06-30 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
  • 2022-06-07 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
  • 2022-05-17 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
  • 2022-04-27 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
  • 2022-04-13 ~ 2022-04-15 - Granocyte (lenograstim) 250mg QD SC
  • 2022-04-07 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
  • 2022-03-21 ~ 2022-03-23 - Granocyte (lenograstim) 250mg QD SC
  • 2022-03-16 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
  • 2022-02-24 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
  • 2019-12-04 ~ undergoing ? palbociclib + letrozole
  • 2018-11-07 ~ 2019-10-09 - weekly eribulin for 2 weeks every 3 weeks
  • 2018-04-26 ~ 2018-11-06 - palbociclib + letrozole
  • 2018-03-29 ~ on-and-off - Xgeva (denosumab)
    • 2022-01-27, 2022-02-24, 2022-03-24, 2022-04-19, 2022-05-17, 2022-06-16, 2022-07-28, 2022-08-13, 2022-09-16
  • 2012-06-28 ~ 2013-01-10 - anti-estrogen tamoxifen
  • 2007-12-27 ~ 2012-12-13 - LHRH (luteinising hormone releasing hormone) agonist Zoladex (goserelin)

[assessment]

• Grade 4 neutropenia (2022-10-21 WBC 20 cells/uL) is observed. The patient has been received lenograstim and filgrastim.
• As the disease itself and its metastases evolve, their characteristics are changing
  • 2007-11-26 patho - mastectomy: ER(4+), PR(4+), Her2(1+).
  • 2018-11-02 patho - sono-guided biopsy: ER(30%), PR(-), Her2(<10%), Ki-67(<3%)
  • 2022-01-13 patho - brain biopsy: CK(+), GATA-3(+), ER(-), PR(-) and HER2(2+, equivocal)
• A brain MRI on 2022-08-10 revealed that a solid mass had increased in size. Researchers have demonstrated that trastuzumab deruxtecan had a high intracranial response rate in patients with active brain metastases associated with HER2-positive breast cancer (ref: Trastuzumab deruxtecan in HER2-positive breast cancer with brain metastases: a single-arm, phase 2 trial. Nat Med 28, 1840–1847 (2022). https://doi.org/10.1038/s41591-022-01935-8). Upon confirmation that Her2 is positive, trastuzumab deruxtecan may be considered as a treatment option.
• The blood sugar level records showed a monotonic increase (331 <- 265 <- 208 mg/dL). In addition to current used Galvus Met (metformin and vildagliptin), acarbose, glimepiride or basal insulin is recommended. The SGLT2i would not be preferred for her since she recently experienced a UTI event.

221013

[assessment]

• During this hospital stay, all data points of serum glucose before meal were above 220mg/dL and a 368mg/dL peak record was observed.
• Metformin/vildagliptin is currently being taken by the patient. There is a recommendation to add alpha-glucosidase inhibitors, e.g., acarbose, SGLT-2 inhibitors, such as canagliflozin, dapagliflozin (use SGLT2i if no more UTI concern), or a basal insulin therapy.

220919

[assessment]

• This patient had received doxorubicin/cyclophosphamide (6, 2022-02-24 ~ 2022-06-07) and docetaxel (5, 2022-06-30 ~ 2022-09-01)

• Brain MRI (2022-08-10) showed one solid mets increased in size and brain CT (2022-09-09) showed mild dilated intraventricular and extraventricular CSF spaces and two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe.

• Pathology (2022-01-13) comfirmed breast cancer brain mets triple negative. Neither trastuzumab and its biosimilars/ADC(antibody drug conjugates) nor CDK4/6 inhibitors (e.g., ribociclib, palbociclib) might likely to show effective.

• National Health Insurance covers PARP (poly ADP-ribose polymerase) inhibitors like olaparib and talazoparib for metastatic triple negative breast cancer with BRCA1/2 mutations since 2022-08-01.

• For patients with triple-negative brain metastases from breast cancer (BCBM), two chemotherapy regimens seem to show specific CNS activity:

  • the anti-vascular endothelial growth factor agent bevacizumab plus paclitaxel in a small Phase 2 study (70% ORR but only 6 patients with triple negative MBC) and the microtubule inhibitor eribulin in case reports.
  • A Phase 2 trial presented at ASCO 2013 highlighted a combination of bevacizumab plus carboplatin in the treatment of BCBM. In this study, 38 patients were treated with bevacizumab plus carboplatin, and trastuzumab was added if the tumour was HER2+. The composite brain ORR was 63% and the global ORR was 45%.
  • For these HER2– patients, therefore, standard chemotherapy comprising capecitabine, eribulin or carboplatin plus bevacizumab can be used for progressive BM after local treatment.
  • ref: Bailleux, C., Eberst, L. & Bachelot, T. Treatment strategies for breast cancer brain metastases. Br J Cancer 124, 142–155 (2021). https://doi.org/10.1038/s41416-020-01175-y

220408

[assessment]

• The patient has TNBC with brain mets and is being treated with doxorubicin and cyclophosphamide as from late February 2022.
• In lab results reported on 2022-04-06, liver and kidney functions were normal, and no obvious abnormalities were noted in the CBC or WBC levels.
• If the current regimen fails to produce satisfactory outcome, capecitabine might be a subsequential alternative.
• Olaparib or talazoparib might be an optional add-on if the BRCA1/2 mutation germline sequencing result is positive.
• Phase III KEYNOTE-355 trial demonstrated the benefits of pembrolizumab added to chemotherapy in locally advanced or metastatic triple-negative breast cancer.
  • Pembrolizumab Improves Outcomes in Early-Stage and Locally Advanced or Metastatic Triple-Negative Breast Cancer.
  • https://pubmed.ncbi.nlm.nih.gov/35348777/

220317

[assessment]

• The patient has TNBC with brain mets and is being treated with doxorubicin and cyclophosphamide as from late February 2022.
• In the event that the results do not meet expectations, capecitabine might be an alternative.
  • reference:
    • https://pubmed.ncbi.nlm.nih.gov/17611719/
    • https://pubmed.ncbi.nlm.nih.gov/16005228/
    • https://pubmed.ncbi.nlm.nih.gov/14650117/
    • https://pubmed.ncbi.nlm.nih.gov/16777702/
    • https://pubmed.ncbi.nlm.nih.gov/16909414/

701450829

221021

• exam findings
  • 2022-10-20 CT - abdomen
    • Cecal cancer with colostomy, peritoneal seeding, LNs, liver and lung metastases. Compression fracture of T12.
  • 2022-10-20 KUB
    • Lumbar spondylosis.
    • T12 compression fracture.
  • 2022-10-20 CXR
    • Increase bilateral lung markings.
    • Mild cardiomegaly.
    • Thoracic spondylosis and scoliosis.
    • T12 compression fracture.
  • 2022-10-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (109 - 32.2) / 109 = 70.46%
      • M-mode (Teichholz) = 70.5
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Calcified mitral annulus with mild MR, mild TR and PR
    • AV sclerosis with mild AR , trivial AS
    • Possibly mild pulmonary HTN
    • No regional wall motion abnormalities
  • 2022-10-04 ECG
    • Sinus rhythm with Fusion complexes
    • T wave abnormality, consider inferior ischemia
  • 2022-10-04 CXR
    • Multiple nodules at bil. lungs.
  • 2022-09-26 Patho - colon biopsy
    • Colon, hepatic flexure, biopsy — Adenocarcinoma, moderately differentiated
    • The sections show a picture of adenocarcinoma, moderately differentiated, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction.
    • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
  • 2022-09-23 Colonoscopy
    • One tumor mass (4-5 cm in size) was noted in thehepatic flexure withlumen narrowing (80 cm from anal verge).
  • 2022-09-16 CT - abdomen
    • History: Mild epigastric discomfort and fullness, acid reflux, weight loss due to decrease intake, microcytic anemia was noted at OPD post transfusion
      • 20220915 sono: A 71.8x57.8 mm hypoechoic heterogeneous mass lesion at the RT lobe liver. Suspected HCC
      • 20220916 CA125: 97.2 U/mL (<35), CA199: 1896 U/mL (<35), AFP: normal.
    • Findings:
      • There is circumferrential asymmetrical wall thickening at the cecum, proximal ascending colon, ileocecal valve, and terminal ileum with irregular contour, measuring 4.7 x 6.8 cm in size.
        • Cecal cancer (T4a) is highly suspected. Please correlate with colonoscopy.
        • In addition, there are several enlarged nodes in the adjacent mescolon (T2a).
      • There are heterogeneous poor enhancing masses in S5 and S6 of the liver and the largest one measuring 8 cm in size. It is c/w liver metastasis.
        • In addition, there are two soft tissue nodules in LLL and LUL of the lung that are c/w lung metastases.
        • There are two small soft tissue nodule in the omentum of RMQ and lower pelvis that may be tumor seeding (M1C).
      • There is mild ascites in the cul-de-sac.
      • A renal cyst measuring 2.9 cm in left upper pole is noted.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a (T_value) N:N2a (N_value) M:M1c (M_value) STAGE:IVC(Stage_value)
  • 2022-09-15 Sonography - abdomen
    • hepatic tumor favor HCC
    • susp. parenchymal liver disease.
• consultation
  • 2022-10-21 Family Medicine
    • Q
      • The 85 y/o woman has ascending colon cancer with liver, peritoneal seeding, LNs, liver and lung metastases, stage IVc (cT4aN2aM1c) status post laparoscopy with loop-ileostomy on 20221006. Family need information for hospice care. Thanks! 64749陳宣妃
    • A
      • DNR(-) The patient is unaware of the situation?
      • Our share care would follow up.

700997286

221020

{ovarian cancer s/p debulking surgery}

• discharge diagnosis
  • 2022-07-22
    • 1: Ovarian cancer s/p Debulking surgery (bilateral salpingo-oophorectomy + omentectomy + peritoneal tumor excision + bilateral inguinal mass excision) on 2021/11/09, pT3cN0M1b, Stage IVB s/p chemotherapy with Taxaol/Carboplatin(from 2021/12/15~2022/03/16 for 9 cycles), PD
    • 2: Major depressive disorder, single episode, severe with psychotic features
    • 3: Delusional disorders
    • 4: Hypomagnesemia
• drug allergy
  • Ibuprofen Injection 100mg/ml,4ml/amp: angioedema
  • Voren 12.5mg/supp (diclofenac sodium): angioedema
• exam finding
  • 2022-08-04 CT - abdomen, pelvis
    • S/P hysterectomy.
    • Progression of peritoneal/abdominal wall seeding, retroperitoneal and pelvic recurrence.
    • Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region.
  • 2022-06-10 Patho - lymph node region resection
    • Lymph node, left inguinal, excision — metastatic ovarian high-grade serous adenocarcinoma (2/2)
    • Section shows pieces of lymph nodes with metastatic papillary tumor cells.
    • The immunohistochemical stains reveal PAX8(+), WT-1(+), and p53 (aberrant expression).
    • The results are in favor of metastatic ovarian high-grade serous adenocarcinoma.
  • 2022-06-02 ECG
    • Minimal voltage criteria for LVH, may be normal variant
    • Borderline ECG
  • 2022-04-25 ECG
    • Sinus rhythm with Premature atrial complexes
    • Incomplete right bundle branch block
    • T wave abnormality, consider anterior ischemia
    • Prolonged QT
  • 2022-04-25 CT - abdomen, pelvis
    • Findings
      • S/P hysterectomy. Some soft tissue masses in retroperitoneum and pelvic cavity.
      • Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region.
      • Some fluid at operative wound site.
      • Left renal stone (2mm).
    • Impression
      • S/P hysterectomy. Recurrent tumors in retroperitoneum and pelvic cavity. Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region. Some fluid at operative wound site.
  • 2022-04-14 2D transthoracic echocardiography
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild MR,TR,PR
    • Mild Pulmonary HTN
  • 2022-03-23 CT - abdomen, pelvis
    • 1. Recurrent serous adenocacinoma in left inguinal area.
    • 2. Metastatic nodes in para-aortic space, aortocaval space, Lt common iliac chain, and Lt external iliac chain.
    • 3. There are lobulated cystic lesions in the pelvis and smuddgy appearance of the omentum that may be residual tumor seeding (carcinomatosis)?
  • 2021-12-13 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • R’t : 15 dB HL
    • L’t : 10 dB HL
    • Bil WNL.
  • 2021-11-09 Patho - soft tissue tumor, extensive resection
    • Pathologic diagnosis
      • Ovary, right, salpingo-oophorectomy —- serous adenocarcinoma, high grade.
        
      • Ovary, left, salpingo-oophorectomy —- serous adenocarcinoma, high grade.
      • Fallopian tube, right, salpingo-oophorectomy —- serous adenocarcinoma, high grade. By seeding.
        
      • Fallopian tube, left, salpingo-oophorectomy —- serous adenocarcinoma, high grade. By seeding.
        
      • Uterus — absent – post hysterectomy
        
      • Omentume, omentectomy —- serous adenocarcinoma, high grade.
        
      • Douglous pouch mass, tumor excision — serous adenocarcinoma, high grade.
        
      • Para-rectal mass, tumor excision — serous adenocarcinoma, high grade.
      • Omentum mass x 2, tumor excision — serous adenocarcinoma, high grade.
      • Right inguinal mass, tumor excision — serous adenocarcinoma, high grade.
        
      • Left inguinal mass, tumor excision — serous adenocarcinoma, high grade.
        
      • An addendum report of the consensus pathological stage will be followed after tumor board meeting.
        
      • The consensus pathology tumor staging of gynecology tumor board meeting on Nov. 18, 2021: pT3c pNx pM1b, FIGO stage: IVB.
        
    • Microscopic examination
      • 1. Histologic type: serous adenocarcinoma
           
      • 2. Histologic grade: high grade
      • 3. Contralateral ovary involvement: present
           
      • 4. Tumor side ovarian surface involvement: present
           
      • 5. Contralateral ovary surface involvement: present
           
      • 6. Right tube involvement: present (on serosa)
      • 7. Left tube involvement: present (on serous and in parenchyma)
           
      • 8. In situ adenocarcinoma in right and/or left fallopian tube: absent
      • 9. Right adnexa soft tissue involvement: present
           
      • 10. Left adnexa soft tissue involvement: present
            
      • 11. Pelvic soft tissue involvement: present: 3). central pelvic mass; 4). Douglous pouch mass; 5). para-rectal mass x 2)
      • 12. Uterine serosa involvement: non-applicable (previous hysterectomy; no uterus received)
            
      • 13. Omentum involvement: present.
            
      • 14. Uterine Cervix involvement: not received
            
      • 15. Endometrium involvement: not received
            
      • 16. Myometrium involvement: not received
            
      • 17. Appendix involvement: not received
            
      • 18. Largest Extrapelvic Peritoneal Focus - Macroscopic (2 cm or less)
            
      • 19. Peritoneal/Ascitic Fluid-Not submitted.
            
      • 20. Regional Lymph Nodes: No lymph nodes submitted
            
      • 21. Other organs or specimens involvement: present. 7). right inguinal mass; 8). left inguinal mass.
            
  • 2021-09-22 Patho - ovary (tumor)
    • Pelvic mass, CT-guide biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of adenocarcinoma characterized by pleomorphic and hyperchromatic tumor cells arranged in papillary or soild pattern.
    • Immunohistochemistry shows CK7(+), CK20(-), PAX-8(+, focal), WT-1(+) and calretinin(-) for tumor cells, serous carcinoma originating from adnexa maybe first considered. Please check GYN condition and clinical correlation is advised.
  • 2021-06-17 CT - abdomen, pelvis
    • S/P hysterectomy. Some soft tissue masses (up to 6.2cm) in peritoneal cavity (esp. pelvic cavity) suspected peritoneal seeding. Suspected liver metastases.
  • 2021-05-13 Gynecologic ultrasonography
    • pelvis mass 57x50mm, RI:0.22, ATH
    • suspect pelvis mass
• consultation
  • 2022-05-06 Plastic and Reconstructive surgery
    • Q
      • The 61 y/o woman has ovary cancer with recurrent tumors in retroperitoneum and pelvic cavity. Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region. Some fluid at operative wound site. We confirm GYN, who suggested debridement, so we need your help. Thanks!
    • A
      • I will check on her next Monday. Thanks.
  • 2022-05-05 Infectious Disease
    • Q
      • The 61 y/o woman has ovarian cancer with peritoneal sign and fistula with fungating. Due to spiked fever noted, so we hold Tapimycin and shift to Meropenam and Targocid for infection control. We need your agree. Thanks!
    • A
      • keep present antibiotic Rx, and adjust to culture data later
      • monitor CRP
• chemoimmunotherapy
  • 2022-10-19 - topotecan 1.2mg/m2 1.5mg 90min D1-D5
  • 2022-09-13 - topotecan 1.2mg/m2 1.5mg 90min D1-D5
  • 2022-08-18 - topotecan 1.2mg/m2 1.5mg 90min D1-D5
    • topotecan dosing
      • package insert: Ovarian cancer and SCLC:
        • Initial Dose: The recommended dose of topotecan is 1.5 mg/m2 body surface area/day administered by intravenous infusion over 30 minutes daily for 5 consecutive days with a 3 week interval between the start of each course.
        • Subsequent Dose: Preconditions: Neutrophil >= 10^9/L, PLT >= 100*10^9/L, HGB >= 9 g/dL
      • UpToDate: Ovarian cancer, metastatic: IV: 1.5 mg/m2/day for 5 consecutive days every 21 days, continue until disease progression or unacceptable toxicity (ten Bokkel Huinink 2004) or (off-label dosing) 1.25 mg/m2/day for 5 days every 21 days until disease progression or unacceptable toxicity or a maximum of 12 months (Sehouli 2011) or (weekly administration; off-label dosing) 4 mg/m2 on days 1, 8, and 15 every 28 days until disease progression or unacceptable toxicity or a maximum of 12 months (Sehouli 2011).
  • 2022-07-21 - liposome doxorubicin 40mg/m2 50mg 1hr + carboplatin AUC 5 600mg 2hr
  • 2022-06-22 - liposome doxorubicin 40mg/m2 50mg 1hr + carboplatin AUC 5 600mg 2hr
  • 2022-04-14 - liposome doxorubicin 40mg/m2 50mg 1hr + carboplatin AUC 5 600mg 2hr
  • 2022-03-16 - paclitaxel 80mg/m2 100mg 1hr + carboplatin AUC 2 220mg 2hr
  • 2022-03-09 - paclitaxel 80mg/m2 100mg 1hr + carboplatin AUC 2 190mg 2hr
  • 2022-02-23 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 190mg 2hr
  • 2022-02-16 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 190mg 2hr
  • 2022-01-19 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
  • 2022-01-12 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
  • 2022-01-05 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
  • 2021-12-22 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
  • 2021-12-15 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
• lab data
  • WBC
    • 2022-10-19 WBC 7.13 *10^3/uL
    • 2022-09-08 WBC 4.19 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-09-20,21,22
    • 2022-08-19 WBC 7.81 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-08-25,26,27
      
    • 2022-08-16 WBC 5.49 *10^3/uL
      
    • 2022-08-09 WBC 1.92 *10^3/uL
    • 2022-08-02 WBC 2.73 *10^3/uL
      
    • 2022-07-21 WBC 4.34 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-07-27,28,29
    • 2022-07-14 WBC 3.21 *10^3/uL
      
    • 2022-07-07 WBC 1.18 *10^3/uL
      
    • 2022-06-22 WBC 9.33 *10^3/uL
      
    • 2022-06-20 WBC 9.86 *10^3/uL
      
    • 2022-06-02 WBC 10.30 *10^3/uL
      
    • 2022-05-09 WBC 3.54 *10^3/uL
      
    • 2022-05-02 WBC 7.09 *10^3/uL
      
    • 2022-04-29 WBC 1.11 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-04-29,30,2022-05-01,02
    • 2022-04-25 WBC 2.31 *10^3/uL
      
    • 2022-03-30 WBC 4.38 *10^3/uL
      
    • 2022-03-16 WBC 4.55 *10^3/uL
      
    • 2022-03-09 WBC 8.12 *10^3/uL
      
    • 2022-02-23 WBC 3.27 *10^3/uL
      
    • 2022-02-16 WBC 3.12 *10^3/uL
      
    • 2022-02-09 WBC 2.45 *10^3/uL
      
    • 2022-01-19 WBC 2.91 *10^3/uL
      
    • 2022-01-12 WBC 3.56 *10^3/uL
      
    • 2022-01-05 WBC 4.00 *10^3/uL
      
    • 2021-12-22 WBC 5.48 *10^3/uL
      
    • 2021-11-29 WBC 10.34 *10^3/uL
      
    • 2021-11-10 WBC 10.67 *10^3/uL
      
    • 2021-11-07 WBC 8.92 *10^3/uL
      
    • 2021-10-04 WBC 6.82 *10^3/uL
      
    • 2021-09-13 WBC 5.54 *10^3/uL
      
    • 2021-08-05 WBC 6.03 *10^3/uL
      
    • 2021-04-28 WBC 5.37 *10^3/uL

[assessment]

• Grade 2 neutropenia (ANC <1.5 *10^3/uL) has not been observed since mid-August 2022 as a result of the administration of G-CSF in late August and September 2022.
• The use of electrolyte supplements is appropriate in the treatment of hypokalemia (3.1 mmol/L 2022-10-19) and hypomagnesemia (1.6 mg/dL 2022-10-19).

2022-08

• WBC and regiemn:
  • 2022-08-09 WBC 1.92 *10^3/uL <– 2022-07-21 liposome doxorubicin + carboplatin
  • 2022-07-07 WBC 1.18 *10^3/uL <– 2022-06-22 liposome doxorubicin + carboplatin
  • 2022-04-29 WBC 1.11 *10^3/uL <– 2022-04-14 liposome doxorubicin + carboplatin
• During the 2 to 3 weeks after receiving [liposome doxorubicin 40 mg/m2 + carboplatin AUC 5], severe neutropenia was observed, whereas during the prior nine cycles of [paclitaxel 80 mg/m2 + carboplatin AUC 2], there was no such severe neutropenia observed.

700335277

221018

{DLBCL, diffuse large B-cell lymphoma}

• past history
  • Systemic disease: CAD (coronary artery disease), 2VD s/p POBA (plain old balloon angioplasty) + DES (drug eluting stent) at prox to mild LAD (left anterior descending artery) and POBA to distal LCX (left circumflex artery) on 20210906, paroxysmal atrial fibrillation and atrial flutter, hypertension, benign prostatic hyperplasia  
• exam finding
  • 2022-10-02 ECG
    • Atrial fibrillation
    • Minimal voltage criteria for LVH, may be normal variant
    • Abnormal ECG
  • 2022-09-21 MRI - larynx
    • An enhancing lesion (9 mm) at C2 vertebral body. Stationary as compared with MRI on 20220316. Suggest regular follow-up.
  • 2022-09-04 ECG
    • Sinus rhythm with 1st degree A-V block
    • Moderate voltage criteria for LVH, may be normal variant
    • Borderline ECG
  • 2022-08-22 CXR
    • Borderline cardiomegaly
  • 2022-08-08 ECG
    • Atrial flutter with variable A-V block
    • Abnormal ECG
  • 2022-08-03 ECG
    • Atrial fibrillation
    • Nonspecific ST abnormality
  • 2022-08-01, 2022-07-29, 2022-07-26 CXR
    • Borderline cardiomegaly
  • 2022-07-26 2D transthoracic echocardiography
    • LVEF(%) = 65
    • Conclusion:
      • 1. Normal LV systolic function with normal wall motion.
      • 2. Concentric LVH, severely dilated LA; LV diastolic dysfunction Gr 2.
      • 3. Normal RV systolic function.
      • 4. Aortic valve sclerosis with no AS, moderate AR; moderate MR; mild to moderate TR; mild PR.
      • 5. Possible mild pulmonary hypertension, estimated PASP: 37 mmHg.
      • 6. Mildly dilated ascending aorta.
  • 2022-07-25 ECG
    • Sinus rhythm with 1st degree A-V block
    • Early repolarization
  • 2022-07-24 ECG
    • Atrial fibrillation with a competing junctional pacemaker
  • 2022-07-24 CXR
    • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage. Suggest clinical correlation.
  • 2022-06-23 CXR
    • S/P port-A implantation. Otherwise, there is no significant abnormality of the chest.
  • 2022-05-17 CXR
    • Elevation of both hemidiaphragms
    • Skin fold over Rt hemithorax
    • Crowding of vascular markings and/or reticular opacities over lung fields
  • 2022-03-22 EKG
    • Normal sinus rhythm
    • Voltage criteria for left ventricular hypertrophy
    • Abnormal ECG
  • 2022-03-16 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Hypercellularity (50%)
    • Microscopically, the bone marrow shows hypercellularity with hemopoietic components accounting for about 50% of the marrow space, M/E ration of 1~2: 1 and presence of trilineage component. Megakaryocytes are occasionally seen.
    • Immunohistochemical stain reveals MPO(+), CD34(-),CD117(-), CD138(<5%), CD20 (focal+, <3%), Bcl-2(-), Bcl-6(-), CD71(+).
  • 2022-03-14 ECG
    • Sinus rhythm with 1st degree A-V block
    • Minimal voltage criteria for LVH, may be normal variant
  • 2022-03-14 2D transthoracic echocardiography
    • 1. Normal AV with moderate AR
    • 2. Normal MV with mild MR
    • 3. LV septal hypertrophy
    • 4. Preserved LV and RV systolic function
    • 5. Mild PR, mild TR, normal IVC size
    • 6. Dilated LA
  • 2022-02-24 Whole body PET scan
    • There was increased FDG uptake involving the left tonsil and some left upper neck lymph nodes.
    • The FDG PET findings are compatible with lymphoma involving the left tonsil and some left upper neck lymph nodes.
  • 2022-02-22 ECG
    • Sinus rhythm with 1st degree A-V block
    • Minimal voltage criteria for LVH, may be normal variant
  • 2022-02-16 Tc-99m MDP whole body bone scan
    • Several hot or faint hot spots in the left lower temporal region of the skull, right rib cage, right S-I joint, L/3, and right acetabulum, respectively, the nature is to be determined (post-traumatic change or othr nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
    • Suspected benign lesions in some middle to lower C-spine, L4 spine, L-S junction, bilateral shoulders, elbows, left knee, and left foot.
  • 2022-02-14 Patho - tonsil and/or ademoid
    • Tonsil tumor, left, biopsy — Diffuse large B-cell lymphoma
      
    • Histology type: diffuse large B-cell lymphoma shows large atypical lymphoid cells with nucleoli and focal tumor necrosis
    • Immunohistochemistry: CK(-), P16(-), P63(+, scatter), CD3(-), CD20(+, diffuse), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), C-MYC(+, 20-30%) tumor.
  • 2022-02-11 CT - neck
    • Imaging Report Form for Oropharynx Carcinoma
    • Impression (Imaging stage): T2N0M0, stage II
  • 2022-02-11 Neck Soft Tissue
    • Film(s) of neck soft tissue shows:
      • Degeneration and spondylosis of C-spine.
      • A calcified spot at left neck.
  • 2022-02-11 ECG
    • Sinus rhythm with 1st degree A-V block
    • Otherwise normal ECG
  • 2022-02-11 Nasopharyngoscopy
    • smooth NPx, moderate obstruction at velum level, smooth OPx, HPx, airway mild compromised
  • 2021-09-07 ECG
    • Sinus rhythm with 1st degree A-V block
    • Otherwise normal ECG
  • 2021-09-06 ECG
    • Sinus bradycardia with 1st degree A-V block
  • 2021-09-06 Cardiac Catheter
    • Intervention Summary
      • LAD P-M, Pre-DS = 70%
        • MLD/RVD=/3.5 mm mm → /3.5 mm, Post Balloon DS = 50%%.
          • Guiding catheter: Boston 6F CLS3.5.
          • Guide Wire: Terumo Runthrough Floopy.
          • Guide Wire2: Asahi SION BLUE.
          • Balloon: B Braun NSE alpha balloon. 3.5 X 13mm mm. Pressure: 12 atmospheres. 43 secs.
          • Balloon2: Abbott NC Trek. 3.5 X 20mm mm. Pressure: 9 atmospheres. 30 secs.
          • Balloon3: Medtronic NC Euphora. 4.0 X 12mm mm. Pressure: 22 atmospheres. 15 secs.
          • Stent: B Braun Coroflex ISAR DES. 3.5 X 28mm mm. Pressure: 14 atmospheres. 14 secs.
          • Stent-MLD/RVD=/3.5 mm Stent DS = 0% residual stenosis.
      • LCX-D, Pre-DS = 80%
        • MLD/RVD=/2.5mm mm → /2.5 mm, Post Balloon DS = 30%%.
          • Guiding catheter: Boston 6F CLS3.5.
          • Guide Wire: Terumo Runthrough Floopy.
          • Guide Wire2: Asahi SION BLUE.
    • In conclusion: CAD DVDs/p PCI with DES for proximal to mid LAD and POBA for distal LCX, successful
    • Recommendation: PCI for LAD and LCX
  • 2021-09-03 2D transthoracic echocardiography
    • 1. Preserved LV and RV systolic function with normal wall motion
    • 2. Dilated LA, grade 2 LV diastolic dysfunction
    • 3. Mild AR, MR, TR
  • 2021-09-01 ECG
    • Sinus rhythm with 1st degree A-V block
  • 2021-08-27 19:52 ECG
    • Atrial fibrillation
    • Abnormal ECG
  • 2021-08-27 17:26 ECG
    • Atrial flutter with variable A-V block
    • Abnormal ECG
  • 2021-08-01 ECG
    • Atrial fibrillation
    • Abnormal ECG
  • 2021-05-31 ECG
    • Sinus bradycardia with 1st degree A-V block with Premature supraventricular complexes
  • 2021-04-14 Vestibular Evoked Myogenic Potential, VEMP
    • oVEMP Interaural Amplitude Asymmetry ratio 22.78 %,WNL
    • cVEMP Interaural Amplitude Asymmetry ratio 8.98 %, WNL
  • 2021-04-06 C-spine AP + Lat.
    • Radiograph of the cervical spine (AP and lateral):
      • Osteoporosis.
      • Spondylosis, esp C4-5-6-7.
  • 2020-07-28 Myocardial perfusion SPECT with persantin
    • Probably mild to moderate myocardial ischemia with possible a portion of severe ischemia at the inferolateral wall and posterior wall and mild myocardial ischemia at the apical lateral wall.
  • 2020-07-17 CXR
    • Spondylosis of the T-spine
    • Atherosclerotic change of aortic arch
  • 2020-07-17 ECG
    • Sinus rhythm with 1st degree A-V block
    • Minimal voltage criteria for LVH, may be normal variant
    • Borderline ECG
  • 2019-12-20 KUB
    • The psoas shadow is clear.
    • Degenerative change of the bony structure with marginal osteophyte formation is identified.
    • Increased intestinal gas is found.
    • Phlebolith at pelvic cavity is also found.
    • Suggest clinical correlation
  • 2019-12-10 Surgical pathology Level III
    • Clinical diagnosis: Other cellulitis & absess, leg, except foot
    • Pathologic diagnosis
      • Benign
      • Skin and soft tissue, right lateral calf, regional fasciectomy — necrotizing inflammation
  • 2019-12-10 Surgical pathology Level III
    • Clinical diagnosis: Benign neoplasm of connective and other soft tissue, unspecified
    • Pathologic diagnosis
      • Benign
      • Tumor, chest, excision — Neurofibroma
  • 2017-11-14 Knee Bilat. standing
    • Moderate osteoarthritis of both knees with varus configuration
    • Ahlback calcification: grade 3, 3
• consultation
  • 2022-06-29 Cardiology
    • Q
      • for hypertension poor control
      • This 78-year-old male, a pt of DLBCL, Lungano stage II, Dx in Feb 2022, suffered from initial presentation of enlarged neck near thyroid in Jan 2022. He was admitted due to port-A infection for anti treatment. Owing to hypertension poor control (SBP:200-206)/DBP(90) was noted during admission. We need expertise to evaluate his condition thanks!
    • A
      • S:
        • He also suffered Zoaster with neuropathic pain in T4-6 dermatome region from back to chest with large surface area, now in healing stage, but neuropathic pain remains but can tolerate. He also has port A removal site pain. He felt headache when in hypertension. He also has mild right ankle joint pain but not inflammed on inspection.
        • Denied of chest and abdominal pain. shortness of breath.
      • O
        • BP: near control till 20220627 then elevated upto 200/90 in 2022/06/27-28.
        • HR: average 70
        • Bed side BP during visit: 155/78-169/81
        • Current medication
          • po candesartan 1# qn
          • po atenolol 1# qd
          • po lasix 1# qd
        • Lab
          • Renal and electrolyte : normal
      • Impression
        • Elevated blood pressure in prior HCVD patient suspected neuropathic and post op pain related.
        • Port A infection with psuedomonas infection
      • Suggestion
        • please add po norvasc 1# qd for BP and hold If SBP < 140mmHg (observe ankle swelling which could be worsen due to norvasc side effect)
        • educate patient if home BP is relatively lower than 140mmHg. and also, if recurrent zoaster infection, then visit dermatologist for UV radiation that fasten healing and reduce neuropthic pain.
        • Adequate pain control.
  • 2022-05-10 Dermatology
    • Q
      • For herpes zoter
      • This 78-year-old man, a patient of DLBCL (triple-hit lymphoma) at L tonsil, Lungano stage II, IPI: 1, non-GCB subtype, Dx in Feb 2022, suffered from initial presentation of enlarged neck near thyroid in Jan 2022 S/P C/T. He was admitted for C/T. He complained of pain & herpes zoter over right chest, armpit, back for 3 days. We need expertise to evaluate his condition thanks!
    • A
      • This patient suffered from grouped vesicels on R’t trunk for 3 days.
      • Imp: Herpes zoster
      • Suggestion:
        • 1. Famvior 1 / Tid
        • 2. Lyrica * 1 /Bid
        • 3. ZnO* 1 tube/bid
  • 2022-02-11 ENT
    • Q
      • Sore throat > blood pressure or heartbeat is different from the patient’s usual value, however hemodynamics is stable, tonsils are suppuration, and there is no improvement after visiting local clinics.
        • throat pain noted for days
        • no fever
        • odynophagia(+)
        • no vomiting
      • PH: HTN; Af ; CAD
      • NKA
      • s/p 2nd Moderna last Dec.
    • A
      • S
        • Odynophagia, VAS 4-5 for a week.
        • Fever(-) Dypsnea(-)
      • O
        • PE:
          • Oral: swelling of left tonsil with exudate, swelling of left soft palate s/p aspiration(no pus)
          • Scope: smooth NPx, moderate obstruction at velum level, smooth OPx, HPx, airway mild compromised
      • Imp: Suspect left peritonsillar abscess
      • Plan:
        • 1. Neck CT with/without contrast (last meal: 20220211 11:40)
        • 2. OA to ENT, IV Curam + Genta
        • 3. Monitor airway
• chemoimmunotherapy
  • R-DA-EPOCH, Dose-adjusted EPOCH-R ([etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin] + rituximab). Titration up: etoposide, doxorubicin, cyclophosphamide
  • 2022-10-18 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 17mg 24hr D1-4 + vincristine 0.4mg/m2 0.7mg 24hr D1-4 + cyclophosphamide 750mg/m2 1285mg 30min D5 + prednisolone 60mg/m2 tmg/tab 20# QD D1-5
  • 2022-09-19 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 17mg 24hr D1-4 + vincristine 0.4mg/m2 0.7mg 24hr D1-4 + cyclophosphamide 750mg/m2 1285mg 30min D5 + prednisolone 60mg/m2 tmg/tab 20# QD D1-5
  • 2022-08-22 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 17mg 24hr D1-4 + vincristine 0.4mg/m2 0.7mg 24hr D1-4 + cyclophosphamide 750mg/m2 1300mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5
  • 2022-07-26 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 9mg/m2 15mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5 (vincristine not available then)
  • 2022-05-03 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 9mg/m2 15mg 24hr D1-4 + vincristine 0.4mg/m2 0.6mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5
  • 2022-04-12 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 9mg/m2 15mg 24hr D1-4 + vincristine 0.4mg/m2 0.6mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5
  • 2022-03-17 - rituximab 375mg/m2 640mg 8hr + etoposide 40mg/m2 68mg 24hr D1-4 + doxorubicin 6mg/m2 10mg 24hr D1-4 + vincristine 0.4mg/m2 0.6mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5

220919

[drug identification]

One drug for identification.

• It is identified as Doudart (dustasteride 0.5mg + tamsulosin 0.4mg).
• In men, it is used to treat the signs of an enlarged prostate.

The drug will be sent back to ward by the in-hospital porter.

220823

[assessment]

• During this hospitalization, the blood pressure was around (180+-30)/(85+-10) with prescribed Norvasc (amlodipine 5mg) 1# QD, Blopress (candesartan 8mg) 1# QN and self-carried Urosin (atenolol 100mg) QD. If HTN still becomes symptomatic, thiazide diuretics such as Tricozide (trichlormethiazide 2mg/tab) 1# QD or Natrilix (indapamide 1.5mg/tab) 1# QD might be also considered.
• Renal denervation is another BP-lowering strategy in hypertensive patients with high CV risk, such as resistant or masked uncontrolled hypertension, established ASCVD, intolerant or nonadherent to antihypertensive drugs, or features indicative of neurogenic hypertension after careful clinical and imaging evaluation (COR IIa, LOE B).

220725

[assessment]

• There is a history of cardiovascular disease in the patient, 2022-03-14 2D transthoracic echocardiography showed: Mild PR, mild TR, Dilated LA, grade 2 LV diastolic dysfunction.
• There were elevated levels of hs-Troponin I and NT-proBNP in the lab data that might indicate cardiovascular conditions.
  • hs-Troponin I
    • 2022-07-24 58.3 pg/mL
      
    • 2022-07-24 59.4 pg/mL
      
    • 2022-02-11 36.3 pg/mL
      
  • NT-proBNP
    • 2022-07-24 847 pg/mL
      
    • 2020-12-31 194 pg/mL
      
• Doxorubicin was initialized at 6mg/m2 (2022-03-17) and titrated up to 9mg/m2 (2022-04-12), this is a relatively conservative and robust way of administration, last dose was administered on 2022-05-03.
• Control of blood pressure was better than last hospitalization for there was no event of a SBP exceeding 200 mmHg and/or a DBP exceeding 100 mmHg.

220315

{drug identification}

Two drugs need identification.

the 2 identified items has been shown as following:

• Duodart (tamsolosin 0.4mg, dutasteride 0.5mg)
• Urosin (atenolol 100mg)

these drugs will be sent back to ward by an in-hospital porter.

700805995

221018

{Endometrioid carcinoma, grade 2, of the uterine endometrium, AJCC Pathologic stage — pT3aN1aM1, stage IVB / FIGO stage IVB, s/p Laparoscopic gynecologic oncology staging surgery.}

• exam finding
  • 2022-10-18 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 12) / 93 = 87.10%
      • LVEF (%) = 87
      • M-mode (Teichholz) = 87
    • Normal LV systolic function with normal wall motion.
    • LV diastolic dysfunction Gr 2.
    • Normal RV systolic function.
    • Mild MR; mild TR; aortic valve sclerosis
  • 2022-09-16 CXR
    • Scoliotic alignment of the thoracolumbar spine is noted.
  • 2022-09-16 Peripheral Vascular Test - AV fistula
    • adequate size of RUV
  • 2022-08-23 Patho - uterus with or without SO
    • PATHOLOGIC DIAGNOSIS
      • Endometrium, uterus, LSC staging surgery — Endometrioid carcinoma, grade 2
      • Myometrium, uterus, ditto — Tumor invasion, more than half thickness
      • Uterus, cervix, ditto — Free of tumor, 5.2 cm away from tumor
      • Ovary, right, ditto — Tumor invasion
      • Fallopian tube, right, ditto — Free of tumor
      • Ovary, left, ditto — Free of tumor
      • Fallopian tube, left, ditto — Free of tumor
      • Lymph node, left iliac, dissection — Free of tumor metastasis (0/9)
      • Lymph node, left oburator, ditto — Tumor metastasis (1/6) with extracapsular extension (1/1)
      • Lymph node, right iliac, ditto — Free of tumor metastasis (0/9)
      • Lymph node, right oburator, ditto — Free of tumor metastasis (0/14)
        
      • Omentum, omentectomy — Tumor invasion
      • AJCC Pathologic stage — pT3aN1aM1, stage IVB / FIGO stage IVB
    • MICROSCOPIC EXAMINATION
      • Histology type: Endometrioid carcinoma
      • Histology grade: Grade 2
      • Depth of invasion: more than half thickness of myometrium
      • Lymphovascular invasion: Present
      • The cervical stroma involvement: Absent
      • Resection margins of the cervix: Free, 5.2 cm away from tumor
      • Additional pathologic findings: focal tumor necrosis and focal squamous differentiation
      • Lymph nodes: tumor metastasis (1/38) with extracapsular extension (1/1) in total number
      • Uterine cervix: Free of tumor, chronic cervicitis
      • L’t ovary: corpus albicans and free
      • R’t ovary: tumor invasion
      • Bilateral fallopian tubes: Free of tumor
      • Omentum: tumor invasion characterized by scant tumor measured less than 0.1 cm with stromal inflammation. Immunohistochemistry of CK(+) for tumor
  • 2022-08-22 Body fluid cytology - ascites
    • diagnosis
      • Malignancy
    • macroscopic examination
      • 40 cc grey-orange cloudy ascites
        
    • microscopic examination
      • The smears show lymphocytes, reactive mesothelial cells and some hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2022-08-18 MRI - pelvis
    • Imaging Report Form for Endometrial Carcinoma
    • Imaging stage : T:T1b(T_value) N:N1a(N_value) M:M0(M_value) STAGE: IIIc(Stage_value)
    • Imperssion: Uterine tumor with lymph nodes, suspected endometrial malignancy with lymph nodes metastasis, cstage T1bN1aM0, IIIc.
  • 2022-08-08 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, D＆C — endometrioid adenocarcinoma, grade 1.
    • IHC stains: ER (+, 100% strong intensity), PR (+, 90%, strong intensity), vimentin (+), P53 (wild type), Napsin-A (-), CK20 (-).
• surgical operation
  • 2022-08-08
    • Surgery
      • D&C, theraputic and diagnostic, vaginal bleeding 
      • Pathology: pending
    • Finding
      • Uterus: Anteversion, 7 cm.
      • Some endometrial tissue were curetted out.
      • Estimated blood loss: 10 mL
      • Blood transfusion: nil
      • Complication: nil.  
• radiotherapy
  • 2022-09-28 ~ undergoing? 1980cGy/11 fractions of the pelvic area.
• chemoimmunotherapy
  • 2022-10-17 - doxorubicin 50mg/m2 77mg 30min + cisplatin 50mg/m2 77mg 2hr (Q3W)
  • 2022-09-21 - paclitaxel 160mg/m2 250mg 3hr + carboplatin AUC 5 490mg 2hr (Q3W, paclitaxel first 160mg/m2, full 175mg/m2)
    • After admission, she took pre-medication as Dorison 20mg at 20220920 2300 and 20220921 0500. She received Taxel (Initial 160mg/m2) and Carboplatin AUC 5 on 20220921.
    • When the Taxel drip around 11 ml, she has dyspnea and mild SOB. We stopped chemotherapy and IVF hydration.
    • Under the stable condition, she can be discharged on 20220922. OPD follow up is arranged.

700175387

221014

[assessment]

• Tube feeding is possible with all oral medications included in the active prescription.

• The CNS depressant estazolam might enhance the CNS depressant effect of tramadol, so please monitor any adverse effects as always.

221003

• exam finding
  • 2022-09-30 KUB
    • Stool impaction at the abdominal cavity is noted.
    • Phlebolith at pelvic cavity is also found.
  • 2022-09-19 CXR
    • Blunted bilateral CP angle is found.
  • 2022-09-16 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma involving the huge confluent soft tissue masses in the retroperitoneal space, stomach, multiple focal areas in the abdominal and pelvic cavities and some focal areas in the mediastinum. Please correlate with other clinical findings for further evaluation.
  • 2022-09-09 CT - abdomen
    • Findings:
      • There is huge confluent soft tissue masses in retroperitoneal space with total encasement of celiac trunk, superior mesenteric artery, abdominal aorta, and bilateral renal artery. The largest cranial-caudal dimension of this mass measuring 19 cm in size.
        • In addition, There are multiple enlarged nodes in the omentum, mesentery, gastrohepatic ligament, para-aortic space, bilateral common iliac chain.
        • Malignant lymphoma is highly suspected.
      • There is mild ascites in the pelvis.
      • There are minimal pleura effusion in bilateral posterior basal CP angle.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
      • There is no evidence of intrinsic or extrinsic bladder mass.
        
    • Impression:
      • Malignant lymphoma is highly suspected.
        • CT-guided biopsy is indicated.
  • 2022-09-08 Patho - stomach biopsy
    • Stomach, AW of low body, biopsy — Diffuse large B cell lymphoma, non- GCB
      
    • Histology type: B-cell neoplasms — Diffuse large B-cell lymphoma (any subtype)
    • Immunohistochemical stain profiles: Ki-67 index: 90%, CK(-), CD20(+), CD3(-, immunoreactive at background T cells), CD10(focal +), MUM-1(+), Bcl-2(+), CD23(-), CD5(focal+), C-myc (-, < 30%), cyclin D1(-).
  • 2022-09-08 Esophagogastroduodenoscopy, EGD
    • Highly suspected gastric cancer, Borrmann type III, AW of low body, s/p biopsy
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • Pseudodiverticula and deformed bulb
  • 2022-09-08 SONO - abdomen
    • Finding: A huge retroperitoneal lesion measured at least 13 cm was noted.
    • Diagnosis: Retroperitoneal tumor, huge
  • 2022-09-02 ECG
    • Sinus tachycardia
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2021-10-12, 2020-11-02 SONO - neurology
    • Mild atheromatous lesions in R subclavian artery.
    • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • Poor temporal windows for transcranial insonation.
  • 2019-12-02 Carotid phonoangiograph, CPA
    • Sonographic diagnosis:
      • Mild atheromatous lesions in R distal CCA.
      • Normal extracranial carotid, vertebral, and L intracranial basal cerebral arterial flows.
      • Poor R temporal windows for transcranial insonation.

[assessment]

• In the case of this patient, who has recently been diagnosed with DLBCL, RCHOP might be an option for treatment.
• Under prescribed medications, blood pressure and blood sugar levels were in acceptable ranges.
• Serum electrolyte imbalances (lab data 2022-10-03) are treated with corresponding supplements currently.
• Hypoalbuminemia (2.6 g/dL 2022-10-03), could it be due to albumin loss in the urine in the nephrotic syndrome? due to decreased hepatic albumin synthesis?
• There is no issue with the active prescription.

also contributes to edema formation

700866748

221014

• diagnosis
  • Adenocarcinoma, moderately differentiated, of the esophagus, EG junction, stage IV, pT3N1(pM1), s/p thoracoscopic esophagectomy, radiotherapy, UFUR, and TS-1, with left mediastinal lymph nodes metastases and suspicious right lung metastases, s/p radiotherapy and status during chemotherapy with brain metastases, s/p radiotherapy.
  • EG junction adenocarcinoma s/p adjuvant CCRT (4860 cGy and UFUR) followed by adjuvant C/T with TS-1, with recurrent adenocarcinoma over middle and lower third trachea, s/p palliative C/T of docetaxel with or without 5-FU /Folinic Acid, s/p R/T with 5760 cGy, in progression, s/p CAL056, with progression of lung metastasis s/p palliative C/T with FOLFOX with brain metastasis s/p whole brain R/T and palliative C/T with FOLFIRI from 2022/08/10
  • Chronic obstructive pulmonary disease, unspecified
  • Gout, unspecified
  • Insomnia, unspecified
• past history
  • 1. Gout from 2002 to now
  • 2. Limping gait from 2006 to now
  • 3. Benign prostatic hyperplasia from 2010 to now
  • 4. Herniated Intervertebral Disc from 2010-06-10 to now
  • 5. Bilateral renal cysts from 2010-06-10 to now
  • 6. Mitral regurgitation Gr 1 from 2010-06-12 to now
  • 7. Tricuspid regurgitation Gr 1 from 2010-06-12 to now
  • 8. Degenerative change of the thoraco-lumbar spine with narrowed intervertebral disc spaces and spurs formation from 2012-04-13 to now
  • 9. Superimposed bilateral lumbosacral radiculopathy from 2013-08-26 to now
  • 10. Spondylosis from 2013-09-03 to now
  • 11. Onychomycosis from 2017 to now
  • 12. Obstruction sleep apnea from 2017-01-31 to now
  • 13. Fatty liver from 2017-01-13 to now
  • 14. Insomnia Gr 1 from 2017-02-07 to now
  • 15. Productive cough Gr 1 from 2017-06 to now
  • 16. Chronic obstructive pulmonary disease from 2017-07-14 to now
  • 17. Chronic allergic rhinitis Gr 1 from 2017-07-14 to 2020-10-21, Gr 2 from 2020-10-22 to now
  • 18. Gastroesophageal reflux disease Gr 2 from 2018-01-04 to now
  • 19. Hyperlipidemia Gr 1 from 2018-04-24 to now
  • 20. Hiatal hernia from 2018-10-16 to 2022-02-06
  • 21. Superficial gastritis from 2019-12-30 to 2022-02-06
  • 22. Marginal spurs of multiple vertebral bodies from 2020-07-28 to now
  • 23. Esophageal shallow ulcers (above ECJ) from 2020-08-05 to now
  • 24. Hemoptysis, intermittently from 2021-08 to 2021-09-28
  • 25. Anemia Gr 1 from 2020-08-25 to now
  • 26. Atherosclerotic change of aortic arch from 2020-10-16 to now
  • 27. Bilateral carpal tunnel syndrome from 2020-11-17 to now
  • 28. Retrolordotic curve change of the spine 2020-11-23 to now
  • 29. Gallbladder stones from 2021-04-13 to now
  • 30. Reflux laryngitis from 2021-05-13 to now
  • 31. Mild posterior pericardial effusion from 2021-08-04 to now
  • 32. Bilateral pleura effusion from 2021-08-04 to now
  • 33. Platelet count decreased Gr 1 from 2021-12-14 to now
  • 34. Blood-stinged sputum, intermittently from 2022-01-28 to now      
• exam finding
  • 2022-09-15 Patho - bronchus biopsy
    • Lung, LB8 endobronchial tumor, bronchoscopic biopsy — adenocarcinoma, consistent with metastatic tumor
    • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma with focal tumor necrosis.
    • The immunohistochemical stains reveal CK7(+), CK20(-), CDX2(focal +), TTF-1(-), and Napsin A(-). The results are consistent with metastatic adenocarcinoma from esophagogastric junction (cardiac cancer of stomach).
  • 2022-09-15 Bronchoscopy
    • The nasal mucosa was hypertrophic.
    • The nasal lumen was severely narrowed.
    • The was copious mucoid nasal discharge retained in the nasal cavity.
    • Mucosa of nasopharynx was hypertrophic .
    • Nasopharynx was severely narrowed.
    • Mucosa of pharynx cobble-stone in shape .
    • Movement of the both. vocal cord(s) was normal .
    • Bilateral arytenoid proceww was normal .
    • Trachea whole segment: patent and the mucosa was normal .
    • Main carina: sharp and movable on deep breathing.
    • Bilateral endobronchial trees:
      • Trachea: no tumor recur
      • RML/RLL carina submucosal lesion, without airway mucosal invasion
      • RLL orifice two submucosal lesions, without airway mucosal invasion
      • LB 8 endobronchial tumor with total occlusion
    • Under fluoroscent bronchoscopy:
      • Trachea: no tumor recur
      • RML/RLL carina submucosal lesion, without airway mucosal invasion
      • RLL orifice two submucosal lesions, without airway mucosal invasion
      • LB8 endobronchial tumor with total occlusion, s/p biopsy
    • After RB8 tumor biopsy by 15C biopsy forceps and snare-loop, tumor bleeding was noted, electrocautery with 25W/25W to 35W/35W with heat-probe was done for bleeding control.
  • 2022-08-11 MRI - brain
    • Known a case of EG junction adenocarcinoma s/p CCRT. One enhancing nodular lesion (3.7cm) over right cerebellar lobe, favor a metastatic lesion.
    • Prominent peritumoral edema.
    • The intracranial vessels are normally signal-void.
    • The paranasal sinuses and mastoid air cells are aerated.
    • The globes, optic nerve and extraoccular muscles are sketchyily intact in the non-FatSat images.
  • 2022-07-08 CT - abdomen, pelvis
    • Findings
      • Prior CT identified several metastases in both lung are noted again. Most of then show stable in size. However, two metastases in RLL and LLL of the lung show increasing in size.
      • Pleura reaction in bilateral posterior basal CP angle.
      • Few calcified gallstones are noted.
      • There are several renal cysts on both kidney and the largest one measuring 3.6 cm in size at left middle pole.
        • In addition, both kidney show mild irregular contour that may be old inflammatory process or normal variation.
      • s/p distal esophagectomy, cardiectomy and esophagogastrostomy.
        • There is no evidence of tumor recurrence.
      • There is no focal abnormality in the liver, biliary system, pancreas, and spleen.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression
      • Prior CT identified several metastases in both lung are noted again. Most of then show stable in size. However, two metastases in RLL and LLL of the lung show increasing in size.
  • 2022-06-16 Bronchial Washing
    • Positive for malignancy
  • 2022-06-15 CXR
    • Bilateral pleural effusions
    • Atherosclerotic change of aortic arch
    • Coarse reticular opacities or Platelike lung atelectasis over Lt Rt lower lung zones
    • Marginal spurs of multiple vertebral bodies.
  • 2022-04-08 CT - abdomen, pelvis
    • Lung metastases show mild increasing in size.
  • 2022-02-07 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis, LA-A (minimal)
      • Postoperative status of partial esophagectomy and gastric tube reconstruction.
      • Much food residue retention in esophagus and stomach
      • Incomplete study
    • Suggestion
      • OPD follow-up
  • 2022-01-28 CT - abdomen, pelvis
    • Lung metastases show mild increasing in size.
  • 2022-01-06 Bronchoscopy
    • The nasal mucosa was hypertrophic.
    • The nasal lumen was severely narrowed.
    • The was copious mucoid nasal discharge retained in the nasal cavity.
    • Mucosa of nasopharynx was hypertrophic .
    • Nasopharynx was severely narrowed.
    • Mucosa of pharynx cobble-stone in shape .
    • Movement of the both. vocal cord(s) was / werenormal .
    • Bilateral arytenoid proceww was normal .
    • Trachea whole segment: patent and the mucosa was normal.
    • Main carina: sharp and movable on deep breathing.
    • Bilateral endobronchial trees:
      • RML bronchus swelling and hyperremic, easy touch bleeding.
      • No visible endobronchial lesion
  • 2021-11-22 CT - lung
    • bilateral lung and mediastinal metastases, slightly in progression as compared with previous CT study on 20210804
  • 2021-08-04 CT - lung
    • consistent with bilateral lung and mediastinal metastases, in progression as compared with previous CT study on 20210719
  • 2021-07-19 CT - abdomen
    • S/P gastric operation.
    • Small nodules at right lung suspected metastases.
  • 2021-04-13 CT - abdomen
    • 1. Gastric cancer s/p partial gastrectomy. Suggest follow up.
    • 2. Bilateral renal cysts.
    • 3. GB stones.
    • 4. Old fractures at bilateral ribs.
    • 5. Bilateral basal lung atelectasis.
  • 2021-02-24 ECG
    • Sinus tachycardia
    • Possible Inferior infarct, age undetermined
  • 2020-11-06 CT -lung
    • Gastric cancer s/p partial gastrectomy.
    • Right lower lobe and left lower lobe intrafissural nodule. Decreased in size.
    • Right upper lobe tiny nodule. Stable.
  • 2020-09-03 Patho - trancheal biopsy
    • Lung, side ?, bronchoscopic biopsy — adenocarcinoma, poorly differentiated, consistent with recurrence
  • 2020-08-07 Tc-99m MDP whole body bone scan with SPECT
    • 1. Prominently increased activity in the L3-5 spines and L5-sacrum junction. Severe degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • 2. Mildly increased activity in the lower C-spine, middle and lower T-spines. Degenerative change is more likely.
    • 3. Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • 4. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, wrists and knees, compatible with benign joint lesions.
  • 2020-08-05 Patho - trancheal biopsy
    • Lung, ? side, bronchoscopic biopsy — adenocarcinoma, moderately differentiated, in favor of recurrence
    • Sections show bronchail mucosa with neoplastic glandular cells infiltrating in submucosa.
    • The immunohistochemical stains reveal CK7(+), CK20(-), CDX2(focal +), TTF-1(-), and Napsin A(-). The results are in favor of recurrent tumor.
    • The HER2/NEU In-Situ Hybridization Test report from Taipei Institute of Pathology is NEGATIVE. There is NO amplication of HER2 detected.
      
  • 2020-08-04 Esophagography
    • s/p distal esophagectomy with esophagogastrostomy
    • High grade gastroesophageal reflex
  • 2020-07-28 CT - lung
    • recurrent gastric cancer as metastatic left mediastinal LAP and suspect two metastatic Rt lung nodules.
  • 2019-08-01 Impedance Audiometry
    • Reliabilty Fair
    • PTA
      • R’t : 41 dB HL
      • L’t : 41 dB HL
      • Bil normal to severe SNHL
    • Tymp
      • Bil Type B
    • ART
      • Bil absent.
  • 2019-04-01 CT - abdomen
    • s/p distal esophagectomy and cardiectomy with esophagogastrostomy.
    • There is no evidence of tumor recurrence.
• surgical operation
  • 2016-12-12
    • VATS with subtotal esophagectomy, cardiectomy and jejunostomy
• radiotherapy
  • 2020-08-14 ~ 2020-09-28 - 5760 cGY/32Fx
  • 2017-05-18 ~ 2017-06-27 - CCRT with 4860 cGy/27 fractions
• chemoimmunotherapy
  • 2022-10-06 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 4800mg 48hr
  • 2022-09-21 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 4970mg 48hr
  • 2022-09-07 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
  • 2022-08-24 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
  • 2022-08-10 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
  • 2022-07-20 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
  • 2022-07-06 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
  • 2022-06-01 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
  • 2022-05-18 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
  • 2022-05-04 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
  • 2022-04-20 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
  • 2022-03-14 - investigational CAL056
  • 2022-02-15 - investigational CAL056
  • 2022-01-12 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5000mg 48hr
  • 2021-12-29 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
  • 2021-12-15 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2000mg/m2 4300mg 48hr
  • 2021-11-17 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2000mg/m2 4300mg 48hr
  • 2021-11-03 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
  • 2021-10-20 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
  • 2021-10-06 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
  • 2021-09-22 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
  • 2021-09-08 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5000mg 48hr
  • 2021-08-25 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2400mg/m2 5000mg 48hr
  • 2021-08-11 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
  • 2021-07-28 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
  • 2021-07-14 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
  • 2021-06-30 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
  • 2021-06-16 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
  • 2021-06-02 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
  • 2021-05-19 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
  • 2021-05-05 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
  • 2021-04-21 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
  • 2021-04-07 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
  • 2021-03-24 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
  • 2021-03-09 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
  • 2021-02-17 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
  • 2021-02-03 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
  • 2021-01-21 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
  • 2020-12-25 - docetaxel 25mg/m2 54mg 1hr
  • 2020-11-27 - docetaxel 25mg/m2 54mg 1hr
  • 2020-11-20 - docetaxel 25mg/m2 54mg 1hr
  • 2020-11-05 - docetaxel 25mg/m2 54mg 1hr
  • 2020-10-30 - docetaxel 25mg/m2 54mg 1hr
  • 2020-10-16 - docetaxel 25mg/m2 54mg 1hr
  • 2020-10-08 - docetaxel 25mg/m2 54mg 1hr
  • 2020-10-02 - docetaxel 25mg/m2 54mg 1hr
  • 2020-09-17 - docetaxel 25mg/m2 54mg 1hr
  • 2020-09-10 - docetaxel 25mg/m2 54mg 1hr
  • 2020-08-25 - docetaxel 25mg/m2 54mg 1hr
  • 2020-08-19 - docetaxel 25mg/m2 54mg 1hr
  • 2017-08-22 ~ 2018-05-07 - TS-1 (25 mg bid of Tegafur/Gimeracil/Oteracil, 25 mg/7.25 mg/24.5 mg)
  • 2017-05-18 ~ 2017-06-27 - UFUR (2 capsules bid of Tegafur/Uracil, 100 mg/224 mg), CCRT

[assessment]

• There is an underlying condition of COPD in this patient. The CXR taken on 2022-10-13 showed ground glass opacities in both lungs. His symptoms of SOB lasted for a week and he has been treated with tapimycin (piperacillin + tazobactam) since 2022-10-13.

221007

[assessment]

• In the last two months, weight loss has exceeded 10 kilograms (86.3kg 2022-10-06 <- 99.1kg 2022-08-03) (due to reduced intake or other factor?)
• The underlying conditions of COPD, gout, and insomnia are managed with appropriate medication and remain stable.

220811

[assessment]

• As indicated by CT findings of mildly growing lung metastases, the lab tumor markers CEA and CA199 have slowly trended up since March 2022.
  • CEA
    • 2022-07-19 5.77 ng/mL
      
    • 2022-06-14 4.91 ng/mL
      
    • 2022-05-17 4.13 ng/mL
      
    • 2022-04-12 3.44 ng/mL
      
    • 2022-03-14 2.81 ng/mL
      
  • CA199
    • 2022-07-19 38.82 U/mL
      
    • 2022-06-14 29.36 U/mL
      
    • 2022-05-17 23.62 U/mL
      
    • 2022-04-12 12.43 U/mL
      
    • 2022-03-14 9.06 U/mL
      
• Curam 1000mg/tab (amoxicillin 875mg + clavulanic acid 125mg) 1# PO BID has been prescribed since 2022-06-21. Either amoxicillin-clavulanate or a respiratory fluoroquinolone (ie, levofloxacin or moxifloxacin) are recommended for exacerbations of COPD patients who have risk factors for poor outcomes (but no increased risk for Pseudomonas infection). Elderly patients might be at increased risk of developing amoxicillin-clavulanate-induced jaundice. Prolonged treatment might increase the risk of hepatotoxicity.
• There is a history of gout, mitral regurgitation, and tricuspid regurgitation in the patient. A recent large RCT showed that in patients with gout and major cardiovascular coexisting conditions, febuxostat was noninferior to allopurinol with respect to rates of adverse cardiovascular events. Allcause mortality and cardiovascular mortality were higher with febuxostat than with allopurinol. ( https://www.nejm.org/doi/full/10.1056/NEJMoa1710895 ). Febuxostat is currently prescribed as equivalent daily dose of 20 mg (80 mg 0.5# QOD), which should reduce the risk of cardiovascular events.

700928671

221014

• lab data

  • 2021-12-14 Anti-HBs 7.30 mIU/mL
    
  • 2021-12-13 HBsAg Nonreactive
    
  • 2021-12-13 HBsAg (Value) 0.45 S/CO
    
  • 2021-12-13 HBeAg Nonreactive
    
  • 2021-12-13 HBeAg(Value) 0.326 S/CO
    
  • 2021-12-13 Anti-HBe Reactive S/CO
    
  • 2021-12-13 Anti-HBe Ratio 0.66 S/CO
    
  • 2021-12-13 Anti-HBc Reactive
    
  • 2021-12-13 Anti-HBc-Value 5.36 S/CO
    
  • 2021-12-13 Anti-HBc IgM Nonreactive
    
  • 2021-12-13 Anti-HBc IgM Value 0.12 S/CO

• exam findings

  • 2022-10-12 CXR
    • Port-A catheter inserted into cavo-atrial junction via right subclavian vein.
    • small Rt hemithorax, elevation of hemidiaphgram and superior convexity of major fissure due to post operative change of RUL lobectomy
    • Subcutaneous emphysema in Rt chest wall neck in regression as compared with the previous image
    • no right pneumothorax
  • 2022-09-26 Patho - lung total/lobe/segmental
    • PATHOLOGIC DIAGNOSIS:
      • Lung, right, upper lobe, lobectomy —- pleomorphic carcinoma with squamous cell carcinoma
      • Lymph node, lobar, lymphadenectomy —- pleomorphic carcinoma, metastatic (3/4)
      • Lymph node, right, group No.2+4, lymphadenectomy —- pleomorphic carcinoma, metastatic (6/11)
      • Lymph node, right, group No.7, lymphadenectomy —- Negative for malignancy (0/1)
      • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
      • Lymph node, right, group No.10, lymphadenectomy —- Negative for malignancy (0/2)
      • Lymph node, right, group No.11, lymphadenectomy —- Negative for malignancy (0/2)
      • Lymph node, right, group No.12, lymphadenectomy —- pleomorphic carcinoma, metastatic (3/3)
      • AJCC 8th edition pTNM Pathology stage: pStage IVA, pT4N2(if cM1a(by CT finding)) or pStage IIIB, pT4N2(if cM0)
    • MACROSCOPIC EXAMINATION:
      • Specimen:
        • Lung, size: 12 x 7 x 4.5 cm with a piece of parietal pleura, measruing 3.3 x 3.0 cm
        • Lymph nodes, 6 bottles, group 2+4, 7, 9, 10, 11, 12; maximal size: 2.8 x 1.9 cm
      • Tumor Site: Periphery
      • Tumor Size: Multiple (Number: several), Maximal one: 8.2 x 5.5 x 5.0 cm
      • Gross tumor patterns: poorly defined, Pleural retraction with invasion to parietal pleura
      • Tissue for sections:
        • A1: bronchial and vascular resection margins; A2: parenchymal resection margin; A3: lymph node, lobar; A4: lung with satellite tumor nodules; A5: bronchus; A6-7: tumor with parietal pleura; A8-10: tumor; B1-4: lymph node, group 2+4; C: lymph node, group 7; D: lymph node, group 9; E: lymph node, group 10; F: lymph node, group 11; G: lymph node, group 12.
    • Microscopic Description
      • Tumor Focality: Separate tumor nodules of same histopathologic type (intrapulmonary metastases) in same lobe
      • Histologic Type (select all that apply): Pleomorphic carcinoma with squamous cell carcinoma; The immunohistochemical stains reveal CK7(-), CK20(-), CK5/6(+), p40(+), TTF-1(-), Napsin A(-), CD56(-).
      • Histologic Grade: G3: Poorly differentiated
      • Spread Through Air Spaces (STAS): Present
      • Visceral Pleura Invasion: Present (PL2) with invasion to parietal pleura
      • Lymphovascular Invasion (select all that apply): Present, Lymphatic
      • Direct Invasion of Adjacent Structures (select all that apply): Adjacent structures present and involved, Parietal pleura
      • Margins (select all that apply):All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 0.05 cm
        • Specify closest margin: Parietal pleura
        • Bronchial resection margin: 2.5 cm
      • Treatment Effect: No known presurgical therapy
      • Regional Lymph Nodes: lobar: 3/4; group 2+4: 6/11; group 7: 0/1; group 9: 0/1; group 10: 0/2; group 11: 0/2; group 12: 3/3.
        
      • Extranodal Extension: Present
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pT4: Tumor >7 cm in greatest dimension;
          
        • Regional Lymph Nodes (pN): pN2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM1a (by CT finding)
      • Additional Pathologic Findings (select all that apply): None identified
  • 2022-09-20 Whole body PET scan
    • Glucose hypermetabolism in a large focal area in the upper lobe of right lung, compatible with primary lung malignancy.
    • Glucose hypermetabolism in a smal focal area in the upper lobe of right lung, compatible with a metastatic lesion.
    • Glucose hypermetabolism in the right pulmonary hilar region and in some right lower paratracheal lymph nodes. Metastatic lymph nodes may show this picture.
    • Glucose hypermetabolism in the right adrenal gland and in multiple bones as mentioned above. Adrenal metastasis and multiple bone metastases may show this picture.
    • Mild glucose hypermetabolism in the lower portion of the esophagus and in a right supraclavicular lymph node. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • 2022-09-14 CT - lung/mediastinum/pleura
    • Imaging Report Form for Lung Carcinoma
    • T4N2M1a AJCC8.0
  • 2022-09-01 MRI - nasopharynx
    • C/W oral cancer s/p operation without evidence of recurrence. Right upper lung mass (67 mm), suspected infection or metastasis.
  • 2022-03-03 Patho - oral cancer (wide excision + lymph node)
    • Left buccal mucosa, partial lips and extraoral facial skin near lip conner, s/p induction chemotherapy wide excision (S2022-3441H) with frozen section (F2022-85) — Residual verrucous carcinoma.
      
    • Lymph node, left neck, dissection — Free
    • ypT2 ypN0 (if cM0); ypStage: II, at least.
  • 2022-03-01 MRI - nasopharynx
    • Markely regressed left buccal, oral commissure, upper lip tumors. Regressed left level I LAP.
    • Tumor, left buccal mucosa, incisoinal biopsy — Compatible with squamous cell carcinoma and ulcer
    • Microscopically, the sections show a picture of ulcer with dense inflammation and atypical squamous epithelium with hyperkeratosis, occasional mitoses and few isolated nests or buds in dense inflammatory stroma. According to clinical (7 cm big mass), MRI (T4a) and histopathologic findings, it is compatible with squamous cell carcinoma, microinvasive. However, more advanced invasion can not excluded due to limited specimen.
    • Immunohistochemistry shows CK5/6(+), CK(+, weakly), P16(-), P53(+, focal) and P63(+) for tumor.
  • 2021-12-10 Tc-99m MDP whole body bone scan
    • Increased activity in the middle C-spine, L3 and L5 spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2021-12-10 SONO - abdomen
    • Diagnosis
      • Fatty liver, mild
      • Left renal cyst
    • Suggestion
      • Please correlate with other image study and clinical condition
      • Regular f/u
  • 2021-12-09 MRI - nasopharynx
    • Imaging Report Form for Oral Cavity Carcinoma
    • Impression (Imaging stage): T:4a(T_value) N:1(N_value) M:0(M_value) STAGE:IVA(Stage_value)
  • 2021-11-30 Patho - gingival/oral mucosa biopsy
    • Oral cavity, left buccal mucosa to lip commissure, incisional biopsy — Verrucous carcinoma
      
    • Microscopically, it shows verrucous carcinoma composed of club-shaped papillae and blunt intrastromal invagination of well-differentiated squamous neoplasm with inflammatory infiltrate at the submucosa. The tumor invades the stroma with a pushing.
    • IHC stain — p16(-)

• consultation

  • 2022-03-18 Radiation Oncology
    • A
      • A: Squamous cell carcinoma and verrucous carcinoma of the left lip commissure to left buccal area, stage cT4aN1M0 (IVA), s/p induction chemotherapy and operation (Modified radical neck dissection of left side. Wide excision of the malignant tumor at the left buccal mucosa, partial lips and extraoral facial skin near lip conner. Complicated tooth extraction of 7 teeth. Alvealoplasty of left and right maxilla. Left ALT free flap reconstruction. ALT donor site closure using fasciocutaneous rotational flap), stage ypT2N0(cM0).
      • P: According to HN tumor board (2022-03-18) conclusion: postoperative CCRT is indicated for this patient with the following indicators: skin sparing conservative surgery with cosmetic and function preservation of his left lip commissure area.
        • Goal: curative
        • Treatment target and volume: left lip commissure, buccal tumor bed to bilateral neck area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the left lip commissure, buccal tumor bed to bilateral neck, and 6600cGy/33 fractions of the left lip commissure and buccal tumor bed.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-03-24.

• SOP

  • 2022-10-11 Radiation Oncology
    • A:
      • Squamous cell carcinoma and verrucous carcinoma of the left lip commissure to left buccal area, stage cT4aN1M0 (IVA), s/p induction chemotherapy and operation (Modified radical neck dissection of left side. Wide excision of the malignant tumor at the left buccal mucosa, partial lips and extraoral facial skin near lip conner. Complicated tooth extraction of 7 teeth. Alvealoplasty of left and right maxilla. Left ALT free flap reconstruction. ALT donor site closure using fasciocutaneous rotational flap), stage ypT2N0(cM0), s/p CCRT.
      • Pleomorphic carcinoma with squamous cell carcinoma of the lung, RUL, stage AJCC 8th edition pTNM. Pathology stage: pStage IVA, pT4N2(cM1b), s/p VATS, RUL lobectomy + RLND.
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: very close surgical margin
      • Goal: palliation
      • Treatment target and volume: primary lung tumor bed and regional lymphatic area.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5400cGy/30 fractions of the primary lung tumor bed and regional lymphatic area.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his sons. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-10-19.

• radiotherapy

• chemoimmunotherapy

  • 2022-05-16 - cisplatin 40mg/m2 70mg 2hr
  • 2022-05-04 - cisplatin 40mg/m2 70mg 2hr
  • 2022-04-21 - cisplatin 40mg/m2 70mg 2hr
  • 2022-04-13 - cisplatin 40mg/m2 70mg 2hr
  • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
  • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
  • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
  • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 170mg in fluorouracil 900mg/m2 1700mg 22hr (neoadjuvant)
  • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
  • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)

[assessment]

• Pleomorphic carcinoma is a poorly differentiated non-small cell carcinoma that contains at least 10% spindle and/or giant cells or a carcinoma consisting only of spindle and giant cells.
• There are no related molecular testing results available in HIS5 that might be considered, including: EGFR mutations, ALK, KRAS, ROS1, BRAF, NTRK1/2/3, METex14 skipping, RET, ERBB2 (HER2), PD-L1.
• Hypercalcaemia (2022-10-14 3.86 mg/dL) and hyperuricemia (2022-10-14 8.7 mg/dL) are treated with allopurinol and zoledronic acid, respectively.

701394404

221014

{Gastric adenocarcinoma of antrum with gastric outlet obstruction cT3N3bM1, stage IV, ECOG 1 status post laparoscoppic gastrojejunostomy and Port-A implantation on 2022-06-16}

• last discharge diagnosis
  • 1: Gastric adenocarcinoma of antrum with gastric outlet obstruction cT3N3bM1, stage IV, ECOG 1 status post laparoscoppic gastrojejunostomy and Port-A implantation on 2022-06-16
  • 2: Postive of anti-HBc
  • 3: Anemia
  • 4: Hypertension
  • 5: Hyperlipidemia
  • 6: Hypoalbuminemia
• lab data
  • albumin
    • 2022-07-08 2.9 g/dL
    • 2022-06-21 2.8 g/dL
• exam finding
  • 2022-10-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (34 - 14) / 34 = 58.82%
      • M-mode (Teichholz) = 58
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy
    • Trivial MR, trivial AR and mild TR and trivial PR
    • Mild to moderate pulmonary hypertension
    • Preserved RV systolic function
    • Tachycardia with E/A fusion at the exam.
  • 2022-10-12 KUB
    • marginal spurs of multiple vertebral bodies due to spondylosis.
    • Atherosclerosis of abdominal aorta and bilateral common and external iliac arteries.
    • Abdominal ascites
    • interrupted lower body of gastric air column and scanty colonic air
    • Normal shape and size of kidneys and spleen.
    • Normal appearance of psoas shadows
  • 2022-10-12 CXR
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • Fullness and increased density of Rt infrhilum hila may be due to lymphadenopathy
    • Normal heart size
    • Costophrenic angles are preserved
  • 2022-10-12 ECG
    • Sinus tachycardia
    • Low voltage QRS
    • Borderline ECG
  • 2022-09-16 CT - abdomen
    • Findings:
      • There are several newly-developed poor enhancing masses on both hepatic lobes that are c/w liver metastases.
        • The largest one measuring 4.3 cm in S3.
      • There is mild ascites and soft tissue nodules in the omentum that may be carcinomatosis.
      • Prior CT identified gastric wall thickening is noted again, mild increasing in wall thickness.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space are noted again, mild increasing in size.
      • There is no focal lesion in both lung.
        • There are several enlarged nodes in paratracheal space.
      • Few gallstones are noted and the largest one 1.6 cm.
      • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • Multiple liver metastases.
      • Carcinomatosis is highly suspected.
  • 2022-06-16 Body fluid cytology - ascites
    • 20 cc dark-brown turbid ascites — Atypia
    • The smears show lymphocytes, reactive mesothelial cells and few atypical cells show enlarged and hypochromatic nuclei with degenerative quality. Follow up.
  • 2022-06-15 Upper GI series
    • The contrast medium passage from oral cavity through esophagus to stomach smoothly without obstruction.
    • Normal contour and mucosal pattern of the esophagus. S/P NG tube indwelling.
    • Distention of stomach suspected outlet obstruction.
  • 2022-06-13 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Adenocarcinoma.
    • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
  • 2022-06-11 CT - abdomen, pelvis
    • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T3N3M1, stage IVB
  • 2022-06-11 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Highly suspected gastric cancer, Borrmann classification type III, with suspected gastric outlet obstruction, s/p biopsy.
      • Reflux esophagitis LA Classification grade D
      • Incomplete study due to much coffee ground content and food retention in stomach and gastric outlet obstruction
    • Suggestion
      • PPI Q12H IV
  • 2022-06-10 ECG
    • Sinus tachycardia
    • Nonspecific ST abnormality
    • Abnormal ECG
• consultation
  • 2022-06-13 General and Gastrointestinal Surgery
    • Q
      • This is a 67-year-old male with hx of HTN.
      • This time, he suffered from vomiting with black vomitus, dizziness, and tarry stool for 2 days. Body weight loss ~15kg in 1-2 month was noted. He was brought to our ER for help. At ER, the vital signs were generally normal with tachycardia (HR 129bpm) with BP 117/58mmHg. Lab study found Hb: 5.0g/dL, with stool OB: 2+, emergent blood transfuion with LPRBC 4U was given, and anemia improved (Hb: 5.0 -> 8.4 g/dL with f/u Hb: 6.9 -> 7.6). Abdome CT showed gastric cancer with gastric outlet obstruction cstage: T3 N3b M1 (lack of detailed description of metastasis).
      • Under the impression of Suspect gastric cancer, so he was admitted for urther evaluation and management.
      • We need your expertise for further evaluation for the patient’s condition of gastric cancer, and outlet obstruction, and future feeding method.
    • A
      • S: A 67-year-old male with hx of HTN. This time, he suffered from vomiting with black vomitus, dizziness, and tarry stool for 2 days. Body weight loss ~15kg in 1-2 month was noted. He was brought to our ER for help. At ER, the vital signs were generally normal with tachycardia (HR 129bpm) with BP 117/58mmHg. Lab study found Hb: 5.0g/dL, with stool OB: 2+, emergent blood transfuion with LPRBC 4U was given, and anemia improved (Hb: 5.0–＞8.4 g/dL with f/u Hb: 6.9-＞7.6). Abdome CT showed gastric cancer with gastric outlet obstruction cstage: T3 N3b M1(lack of detailed description of metastasis). Surgical evaluation is consulted.
      • O: vital signs: stable, no fever
        • abdomen: soft, ovoid, decrease bowel sound, mild epigastric pain, no Murphy’s sign
          
        • lab data: see chart
      • A: gastric cancer with gastric outlet obstruction cstage: T3 N3b M1, stage IV
      • P: Suggest neoadjuvant chemotherapy for down staging first.
        • If gastric outlet obstruction related poor oral intake and malnutrition is noted, laparoscopic gastrojejunostomy may be considered.
  • 2022-06-16 Hemato-Oncology
    • Q
      • This is a 67 year-old male who has the history of hypertension with medication control. This time, he suffered from vomiting with black vomitus, dizziness, and Tarry stool for 2 days. Body weight loss ~15kg in 1-2 month, so he was brought to our ER for help. Under the impression of gastric cancer, he was transfer to GS for surgery of gastrojejunostomy on 2022/06/16. We need your help for neoadjuvant chemotherapy. Thank you so much!!
    • Q
      • Impression:
        • Suspect gastric cancer with gastric outlet obstruction cstage: T3 N3b M1, stage IV
      • Suggestion
        • 1. Pending pathology, if confirm gastric cancer, we will discuss with patient about neoadjuvant chemotherapy for down staging.
        • 2. Check anti Hbc, HbsAg, Anti HCV
      • s/p gastrojejunostomy on 2022/06/16.
      • Medical advice:
        • It will be possible to be cured only in the patient whose gastric cancer is amenable to total surgical resection (R0 resection). The local advanced gastric CA wt gastric outlet obstruction of this pt is deemed not operably subjected to total surgical resection.
        • Pre-Op neoadjuvant C/T is indicated.
          • Pre-Op neoadjuvant C/T regimen may be: Oxaliplatin / HDFL or 5-FU / LV / Oxaliplatin / Docetaxel ( FLOT ) IV Q2W x 3~4 cycles beofore / after Op.
        • If gastric tumor bleeding persists, may consider R/T to gastric tumor to cease bleeding.
• surgical operation
  • 2022-06-16
    • Surgery
      • 1. Laparoscopic gastrojejunostomy
      • 2. Port-A insertion, L’t after L’t cephalic vein exploration        
      • Post-OP Dx: gastric antrum Ca, cT3N3M1, stage IV, ECOG 1    
    • Finding
      • 1. We explore and identify the L’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.        
      • 2. Hypertorphy and distension of stomach.
      • 3. No visible peritoneal wall tumor and enlarged lymph node was noted. We collect ascites for cytology.
      • 4. Gastric juice 2750 ml was decompressed.
• chemoimmunotherapy
  • 2022-07-08 ~ undergoing - FOLFOX

[assessment]

• 2022-10-13 2D transthoracic echocardiography showed adequate LV systolic function with normal resting wall motion and preserved RV systolic function.
• It is possible that the rising levels of hs-Troponin I (366.4 <- 226.8 <- 134.4) are related to sepsis. The infection is currently being managed with tapimycin (piperacillin + tazobactam).

220711

[assessment]

• This patient is taking two antiplatelet agents: aspirin, cilostazol (antiplatelet agent; phosphodiesterase-3 enzyme inhibitor; vasodilator); four antihypertensives: amlodipine (antianginal agent; antihypertensive; calcium channel blocker), indapamide (thiazide diurectic), spironolactone (antihypertensive; potassium sparing diurectic; mineralocorticoid (aldosterone) receptor antagonists), ramipril (angiotensin-converting enzyme (ACE) inhibitor; antihypertensive).
• It was reported that salicylates and/or thiazides could enhance the nephrotoxic effect of angiotensin-converting enzyme inhibitors, and potassium-sparing diuretics may enhance the hyperkalemic effect of angiotensin-converting enzyme inhibitors. According to lab data on 2022-07-08, renal function and serum potassium were normal.
• Since the afternoon of 2022-07-09, blood pressure readings have returned to normal, and no tachycardia has been observed since 2022-07-10. TPR and BP are stable currently.
• Crestor (rosuvastatin calcium 10mg) QD might be an option if hyperlipidemia is still a medical problem.

700410422

221012

• exam findings
  • 2022-09-13 CXR
    • distorted and small left hilum, small left hemithorax with decreased vascular markings, and Lt shift of heart due to LLL lobectomy
    • Lt pleural effusion/thickening with loculation, stationary
  • 2022-07-21 MRI - brain
    • Known a case of lung. No metastatic lesion of brain parenchyma.
  • 2022-07-19 CT - chest
    • post op change in left hemithorax. decreased volume of left pleural effusion compared with CT on 20220309.
    • mild emphysema in left upper lung and RUL.
    • no mediastinal or hilar enlarged lymph nodes.
    • no new lung nodule or mass.
  • 2022-04-11 Whole body PET scan
    • Glucose hypermetabolism in the left lower and right upper lungs, cancer s/p treatment with chronic inflammation may show this picture. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
      
    • Increased FDG uptake in the left aspect of the maxilla, probably dental and/or gum problems.
      
    • Increased FDG uptake/accumulation in the colon and bilateral ureters, physiological FDG uptake/accumulation is more likely.
    • No prominent abnormal focal FDG uptake is noted elsewhere.
  • 2022-03-09 CT - chest
    • post op change in left hemithorax. increase in volume of moderate left pleural effusion compared with CT on 20211208
    • mild emphysema in left upper lung and RUL.
    • no mediastinal or hilar enlarged lymph nodes.
    • no new lung nodule or mass.
  • 2021-12-10 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20210728, no prominent change is noted.
    • Suspected benign lesions in the maxilla, mandible, some L-spines, bilateral shoulders, S-I joints, hips, and knees.
  • 2021-12-09 MRI - brain
    • No evident brain metastasis.
  • 2022-03-09 CT - chest
    • post op change in left hemithorax. stationary of moderate left pleural effusion compared with CT on 20210916
    • mild emphysema in left upper lung and RUL.
    • no mediastinal or hilar enlarged lymph nodes.
    • no new lung nodule or mass.
  • 2021-09-16 CT - chest
    • Left pleural effusion.
    • s/p left lower lobe lobectomy.
  • 2021-07-28 Tc-99m MDP whole body bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the maxilla, mandible, L-spine, bilateral shoulders, S-I joints, hips, and knees.
  • 2021-06-23 CT - chest
    • post op change in left hemithorax. slighlty increase in volume of left pleural effusion compared with CT on 20210304.
    • mild emphysema in left upper lung and RUL.
    • suspect mild small airways disease in RLL.
    • no new lung nodule or mass.
  • 2021-03-04 CT - chest
    • Ground glass pacthes at left lung with left pleural effusion. Recent pneumonia is favored.
  • 2021-03-03 MRI - brain
    • no evidence of metastatic brain tumors
  • 2020-11-12 Whole body PET scan
    • Mild glucose hypermetabolism in the left lower lung field. Post-operative inflammation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
      
    • Increased FDG uptake in the region about the left aspect of maxilla. The nature is to be determined (some kind of dental and/or gum problem? other nature?). Please also correlate with other clinical findings for further evaluation.
      
    • Increased FDG uptake/accumulation in bilateral vocal cords and both kidneys. Physiological FDG uptake/accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2020-11-11 MRI - brain
    • focal SI change in the splenium of the corpus callosum. Nature?
  • 2020-11-10 CT - chest
    • post op change in left hemithorax. increase in volume of left
    • pleural effusion compared with CT on 20200818.
    • mild emphysema in left upper lung and RUL.
    • suspect mild small airways disease in RLL.
    • no new lung nodule or mass.
  • 2020-08-18 CT - chest
    • post op change in left hemithorax.
    • mild emphysema in left upper lung and RUL.
    • no new lung nodule or mass.
  • 2020-06-03 Patho - lung total/lobe/segmental
    • PATHOLOGIC DIAGNOSIS:
      • Lung, left, lower lobe, lobectomy —- Adenocarcinoma, moderately differentiated, s/p CCRT and Immuotherapy
        
      • Lymph node, lobar, lymphadenectomy —- Negative for malignancy (0/1)
        
      • Soft tissue, group No.7 lymph node, lymphadenectomy —- Negative for malignancy (0/0)
        
      • Lymph node, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
        
      • Lymph node, group No.10, lymphadenectomy —- Negative for malignancy (0/1)
        
      • Lymph node, group No.12, lymphadenectomy —- Negative for malignancy (0/1)
        
      • AJCC 8th edition pTNM Pathology stage: ypStage IB, ypT2aN0(if cM0)
        
    • MACROSCOPIC EXAMINATION:
      • Specimen:
        • Lung, size: 13.5 x 7.4 x 2.7 cm; 89.9 gm
          
        • Lymph nodes, 4 bottles, group 7, 9, 10, and 12; maximal size: 0.8 x 0.3 x 0.3 cm
          
      • Tumor Site: Periphery
        
      • Tumor Size: Solitary: 2.1 x 2.0 x 1.8 cm
        
      • Gross tumor patterns: poorly defined, Pleural retraction
        
    • Microscopic Description
      • Tumor Focality: Single tumor
        
      • Histologic Type (select all that apply): Invasive adenocarcinoma, acinar predominant (60 %);
        • The immunohistochemical stains reveal CK(+) and TTF-1(+).
          
        • Other subtypes present (specify subtype(s), may also include percentages): lepidic: 40%
          
      • Histologic Grade: G2: Moderately differentiated
        
      • Spread Through Air Spaces (STAS): Not identified
        
      • Visceral Pleura Invasion: Present (PL2)
        
      • Lymphovascular Invasion (select all that apply): Present, Lymphatic
        
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
        
      • Treatment Effect: Greater than 10% residual viable tumor
        
      • Regional Lymph Nodes: lobar: 0/1; group 7: 0/0; group 9: 0/1; group 10: 0/1; group 12: 0/1
        
      • Extranodal Extension: Not identified
        
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) : y (posttreatment)
          • Primary Tumor (pT): pT2a: Invades visceral pleura (PL2);
            
          • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
            
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
            
      • Additional Pathologic Findings (select all that apply): None identified
  • 2018-05-23 Surgical pathology Level IV
    • Clinical diagnosis
      • Chronic airway obstruction (COPD), NEC;
    • Pathological diagnosis
      • Soft tissue, neck, needle biopsy — adenocarcinoma, moderately differentiated, metastatic, consistent with lung origin
    • Specimen submitted in formalin consists of 2 strips of tan, irregular tissue measuring up to 1.6 x 0.1 x 0.1 cm. All for section in one cassette.
    • Sections show solid tumor nests, with focal glandular pattern, infiltrating in a fibrotic stroma. No lymphoid tissue is seen.
      • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for metastatic lung adenocarcinoma.
  • 2018-05-18 Surgical pathology Level IV
    • Indication: Localized swelling, mass and lump, neck; Fracture of frontal skull and SAH; Unspecified open wound of scalp, initial encounter; Hypovolemic shock; Unspecified open wound, right foot, initial encounter; Screening for malignant neoplasms of oral cavity; Enlargement of lymph nodes; Swelling, mass,or lump in head and neck;
    • Pathological Diagnosis: Lymph node, left lower neck, sono-guide biopsy — Metastatic adenocarcinoma, pulmonary origin
    • The specimen submitted consisted of 1 strip of lymph node tissue measuring 1.2 cm in length, fixed in formalin. Grossly, it was grey in color and soft in consistence. All embedded for sections in one cassette.
    • Microscopically, the section shows a picture of metastatic adenocarcinoma of the lymph node tissue characterized by nest or tubular-arranged tumor cells infiltrated in parenchyma.
    • Immunohistochemical stains of CK(+), TTF-1(+); P40(-), Napsin-A(+) and CD56(-) for tumor cells.
      • According to clinical information and above histopathologic findings, it is consistent with metastatic adenocarcinoma of pulmonary origin. Clinical correlation is advised.
  • 2018-05-18 Neck sonography
    • Findings: Multiple LNs in bilateral neck, with size up to 1.37 cm in length at right and 3.3 cm at left.
    • Imp: Multiple bilateral neck LNs.
• SOP
  • 2018-07-18
    • 20180718 Apply Crizotinib for ALK inhibitor 1st line, maybe wait to August admission for C/T with Alimta, Kytruda first, CCRT
    • A case of Lung cancer, adenocarcinoma, T2aN3M0, stage IIIB, with left supraclavicular LAPs metastasis, ECOG 1, T2a: LLL mass N3: bilateral mediastinal and left supraclavicular LAPs M0: no definite brain, lung to lung metasatsis
    • EGFR mutation: L858R (-), exon 19 (-), PD-L1: 5%, ALK(+)
    • cough with sputum, chest tightness, dyspnea, rhinorrhea(-), nasal congestion(-), post nasal dripping(-), acid regurgitation, DOE(+), body weight loss(+), poor appetite(+) Past history: Family history of malignancy(-) Smoking(+), 1ppd for 20 yrs, Allergic history:(-) Traveling history:(-) PFT: Mild restriction without Significant response to Bronchodilator
    • C1 Keytruda (2mg/kg) 100mg IVF on 20180620, C1 Alimta (500mg/m2) 800mg on 20180621, admission for 20180712 for Alimta, may add Keytruda or Crizotinib
• radiotherapy
  • 2018-07-02 ~ 2018-07-30 - 5000cGy/20 fractions (14 MV photon) to LLL tumor, mediastinal & SCF LAPs.
• chemoimmunotherapy
  • 2022-09-14 - Cyramza (ramucirumab) 500mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2022-08-17 - Cyramza (ramucirumab) 500mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2022-07-20 - Cyramza (ramucirumab) 500mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2022-05-05 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2022-04-06 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2022-03-08 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2022-02-17 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2022-01-04 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2021-12-07 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2021-11-15 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2021-10-12 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2021-09-15 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2021-08-18 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2021-07-27 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2021-06-23 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2021-04-26 - Cyramza (ramucirumab) 200mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2021-03-29 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
  • 2021-03-02 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2021-02-02 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2021-01-11 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-12-09 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-11-10 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-10-13 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-09-15 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-08-18 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-07-21 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-06-22 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-05-25 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-04-27 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-03-31 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-03-05 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2020-02-12 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
  • 2019-09-06 ~ ?? - Cyramza (ramucirumab) 400mg
  • 2018-06-21 - Alimta (pemetrexed) 500mg/m2 800mg
  • 2018-06-20 ~ 2019-08-15 - Keytruda (pembrolizumab) 100mg (C1-13)
  • 2021-11-15 ~ 2022-07-25 - Alunbrig (brigatinib) 90mg/tap 1# QD
  • 2020-09-14 ~ 2021-10-13 - Zykadia (ceritinib) 150mg/cap 1# QD
  • 2019-08-28 ~ undergoing - Alecensa (alectinib) 150mg/cap 4# BIDCC
  • 2018-08-29 ~ 2019-07-25 - Xalkori (crizotinib) 250mg/cap 1# BID
    • alectinib, brigatinib, ceritinib, crizotinib are for ALK rearrangement

701116474

221012

[exam findings]

• 2023-05-31 ECG
  • Sinus bradycardia with 1st degree A-V block
• 2023-05-31 CXR
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • Enlargement of cardiac silhouette.
  • Linear opacity projecting at right lower lung show stationary.
• 2023-04-07 CT - abdomen
  • History: 65 y/o male with Mantle cell lymphoma with bone marrow involvement, Lugano stage IV, MIPI: 6.4 points.
  • Indication: FU mantle cell lymphoma over both side of diaphragm
  • Findings: Comparison prior CT dated 2023/01/17.
    • Prior CT identified several enlarged nodes in bilateral inguinal area noted again, stationary.
    • Prior CT identified infiltrative soft tissue lesions (confluent enlarged nodes) in the retroperitoneum around the aortocaval region, encasement of SMA/SMV and celiac trunk are noted again, stationary that is c/w Mantle cell lymphoma S/P C/T with stable disease.
    • There is minimal pleura reaction in Rt CP angle.
    • There are several renal cysts on left kidney and the largest one measuring 2.3 cm in size at left upper pole.
  • Impression:
    • Mantle cell lymphoma S/P C/T show stable disease.
• 2023-01-17 CT - abdomen
  • History and indication: pain over Rt inguinal region with tenderness for 2 days.
  • With and without-contrast CT of abdomen-pelvis revealed:
    • Enlarged LNs (up to 3.1cm) at bil. inguinal regions, RLQ, mesentery and paraaortic region.
    • Left renal cyst (2.4cm).
    • Atherosclerosis of aorta, iliac, coronary arteries.
  • IMP:
    • Enlarged LNs (up to 3.1cm) at bil. inguinal regions, RLQ, mesentery and paraaortic region (stable condition).
• 2022-10-18 Patho - lymphnode biopsy
  • Soft tissue, lymph node? inguinal region, right, excision — Granulation tissue
• 2022-10-15 CT - abdomen
  • With and without contrast enhancement CT of abdomen–whole:
    • Infiltrative soft tissue in the retroperitoneum around the aortocaval region and encasement of SMA/SMV and celiac trunk. Stationary as compare with CT study on 2022-08-19.
    • Left renal cysts, up to 2.8cm.
    • Focal atelectasis in right lung and pleural thickening, stationary.
    • There are lymph nodes in the mediastinum and right hilar region.
    • Coronary artery calcifications.
    • Enlarged right inguinal lymph nodes. Cystic lesion(3.1cm) in right inguinal region with subcutaneous infiltrates and skin thickening. R/O abscess and cellulitis. DDx: lymph node necrosis.
  • Impression:
    • Clinical lymphoma s/p treatment.
    • Enlarged right inguinal lymph nodes. Cystic lesion in right inguinal region with focal fatty infiltrates and skin thickening, r/o absces and cellulitis. DDx: lymph node necrosis.
    • Focal atelectasis in ight lung and pleural thickening, stationary.
    • Coronary artery calcifications.
• 2022-10-11 CXR
  • Blunted right costophrenic angle.
  • Ground glass opacity in RLL.
• 2022-08-19 CT - abdomen
  • History: 65 y/o male with Mantle cell lymphoma with bone marrow involvement, Lugano stage IV, MIPI: 6.4 points.
  • Indication: FU mantle cell lymphom over both side of diaphragm
  • Findings
    • Prior CT identified infiltrative soft tissue lesions (confluent enlarged nodes) in the retroperitoneum around the aortocaval region, encasement of SMA/SMV and celiac trunk are noted again, decreasing in size that is c/w Mantle cell lymphoma S/P C/T with partial response.
    • Prior CT identified enlarged lymph nodes in the paratracheal space are noted againm, mild decreasing in size that is c/w mantle cell lymphoma with mediastinum LNs involvement S/P C/T with partial response.
    • There is minimal pleura effusion or reaction in Rt CP angle.
    • There are several renal cysts on left kidney and the largest one measuring 2.3 cm in size at left upper pole.
  • Impression:
    • Mantle cell lymphoma over both side diaphragm S/P C/T show partial response.
  • 2022-05-17 CT - abdomen
    • Clinical history: 65 y/o male patient with Mantle cell lymphoma with bone marrow involvement, Lugano stage IV, MIPI: 6.4 points.
    • Findings
      • Infiltrative soft tissue in the retroperitoneum around the aortocaval region and encasement of SMA/SMV and celiac trunk. Relative regression as compare with CT study on 2022-03-08.
      • Mild right pleural effusion. Focal atelectasis in right lung.
      • There are lymph nodes in the mediastinum and right hilar region.
      • Coronary artery calcifications.
    • Impression:
      • Clinical lymphoma, with mild regression, suggest follow up.
      • Mild right pleural effusion. Focal atelectasis in right lung.
      • Coronary artery calcifications.
  • 2022-04-26 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
    • Enlargement of cardiac silhouette.
    • Linear opacity projecting at right lower lung show stationary.
  • 2022-04-08 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Mantle cell lymphoma
    • Sections show 20-30 % cellularity. The M/E ratio is about 3/1 - 4/1. Megakaryocytes are found about 0-2/HPF. No increase of blasts is noted. Several foci of aggregation of lympohid cells are seen.
    • The immunohistochemical stains reveal CD20(+), CD3(-), Cyclin D1(+). The results are consistent with Mantle cell lymphoma.
  • 2022-03-08 CT - chest
    • Findings
      • Lungs: subsegmental opacities with extensive septal thickening and peribronchovascular bundle thickening in Rt lung, RML and RLL predominance, in regression as compared with previous CT study on 1/3. a centrilobular nodule at lingula.
      • Mediastinum: extensive lymphadenopathy in visceral and Rt anterior prevascular spaces, in regression.
        • Rt pericardial thickening.
      • Hila: enlarged LN, Rt, in regression.
      • Vessels: extensive coronary arterial calcification
        • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: small Rt pleural effusion with extensive thick parietal thickening.
      • Chest wall and visible lower neck: residual small and slightly enlarged LNs at Rt axilla and supraclavicular fossae, stationary.
      • Visible abdominal-pelvic contents: moderate splenomegaly.
        • regression of extensive confluent lympapathy in the para-aortic region and msentery root, involving the pancreas, and discrete lymphadopathies in both inguinal regions compared with CT on 20220103
        • a well-defined cystic lesion of water in density (27x34 mm) at Rt inguinal region.
        • a small left renal cyst and wall thickening of.
        • the gallbladder. no focal lesion in the liver and adrenal glands
        • Visualized bones: marginal spurs of vertebrae.
    • Impression:
      • Mantle cell lymphoma in both sides of diaphgram, with regression of lung involvement and slightly regression of extensive lymphadenopathy as compared with CT on 20220103
  • 2022-03-07 Patho - bone marrow biopsy
    • Bone marrow, iliac bone, biopsy — B-cell lymphoma involvement
    • Microscopically, the sections show pictures of extensively crush artifact of bone marrow tissue. The cellularity maybe increased.
    • Immunohistochemistry shows CD3(+, focal), CD20(+), CD5(+), CD34(-) and cyclin-D1(-), compatible with B-cell lymphoma involvement, and mantle cell lymphoma maybe first considered according to past history. Clinical correlation is advised.
  • 2022-01-03 CT - chest
    • Mantle cell lymphoma in both sides of diaphgram, with progression of lung involvement and slightly regression of extensive lymphadenopathy as compared with CT on 20211002
  • 2021-11-03 SONO - chest
    • Pleural effusion, minimal, bilateral, organizing
    • Pleural thickening, bilateral
  • 2021-10-18 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (131 - 39) / 131 = 70.23%
      • M-mode (Teichholz) = 70
    • Mild septal hypertrophy with Gr I LV diastolic dysfunction.
    • Mildly dilated LV with normal LV and RV systolic function.
    • Aortic valve sclerosis with mild AR.
    • Mild aoratic root calcification; dilated proximal ascending aorta (38mm).
  • 2021-10-13 Patho - bone marrow biopsy
    • Bone marrow, iliac, clinically: mantle cell lymphoma, biopsy — Lymphoma involvement.
    • IHC stains: Cyclin-D1 (weak +).
      
    • Section shows piece(s) of bone marrow with 70% cellularity and with a predominant small to intermediate size atypical lymphoid cells.
  • 2021-10-12 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm as mentioned above (at least stage III).
    • Mildly and diffusely increased FDG uptake in the bone marow of the skeleton. The nature is to be determined (lymphoma involving the bone marrow? bone marrow hyperplasia?). Please correlate with other clinical findings for further evaluation.
    • Mildly increased FDG uptake in the right lower lung field and pleura of right lower lung. Inflammation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2021-10-05 Patho - lymph node region resection
    • Lymph node, right inguinal, excision biopsy —- Mantle cell lymphoma
      
    • Soft tissue, neck, excision — Consistent with mantle cell lymphoma
      
    • Histology type: B-cell neoplasms, Mantle cell lymphoma Mantle cell lymphoma — classic,
      
    • Immunohistochemical stain profiles: CD3(-), CD20(+), CD5(+), CD10(-), BCL2(+), BCL6(-), Cyclin D1(+), Ki-67 is about 10-20%.
  • 2021-10-02 CT - chest
    • Probably lymphoma with mediasitinal, paraaortic, iliac and inguinal lymphadenopathy
    • Pneumonia at right middle lobe and right lower lobe with bilateral pleural effusion.
    • Hepatosplenomegaly.

[chemoimmunotherapy]

• 2023-05-30 - etoposide 500mg/m2 1000mg NS 50mL 2hr D1-4

  • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-4

• 2022-06-02 - undergoing - Imbruvica (ibrutinib) 140mg/cap 4# QD

• 2022-04-11 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3

• 2022-03-11 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP)

• 2022-02-08 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3

• 2022-01-04 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5

• 2021-12-08 - cytarabine 2000mg/m2 3900mg 3hr Q12H D3

• 2021-12-07 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3

• 2021-11-16 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5

• 2021-10-19 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 30mg BID PO D1-5

==========

2022-10-12

• This mantle cell lymphoma patient had been treated with R-CVP/R-CHOP/R-DHAP (until April 2022) and started receiving Bruton’s tyrosine kinase inhibitor ibrutinib in early June 2022 and achieved a partial response (2022-08-19 CT). As part of this hospitalization, images will be updated.

• The combination of ibrutinib and venetoclax (this is not covered by National Health Insurance at present) has been shown to promote responses in patients with relapsed or refractory mentle cell lymphoma.

  • ref:
    • Combining BTK inhibitors with BCL2 inhibitors for treating chronic lymphocytic leukemia and mantle cell lymphoma. Biomark Res. 2022;10(1):17. Published 2022 Apr 4. doi:10.1186/s40364-022-00357-5
    • Dose-finding study of ibrutinib and venetoclax in relapsed or refractory mantle cell lymphoma. Blood Adv. 2022;6(5):1490-1498. doi:10.1182/bloodadvances.2021005357
    • Concurrent ibrutinib plus venetoclax in relapsed/refractory mantle cell lymphoma: the safety run-in of the phase 3 SYMPATICO study. J Hematol Oncol. 2021;14(1):179. Published 2021 Oct 30. doi:10.1186/s13045-021-01188-x

701306067

221011

• lab data
  • 2022-09-12 Anti-HBs >1000.00 mIU/mL
    
  • 2021-10-04 ROS1 IHC specimen number S2021-11626
    
  • 2021-10-04 ROS1 IHC 1+
    
  • 2021-09-23 EGFR specimen number S2021-11626
    
  • 2021-09-23 EGFR G719X not detected
    
  • 2021-09-23 EGFR Exon19 del detected
    
  • 2021-09-23 EGFR S768I not detected
    
  • 2021-09-23 EGFR T790M not detected
    
  • 2021-09-23 EGFR Exon20 ins not detected
    
  • 2021-09-23 EGFR L858R not detected
    
  • 2021-09-23 EGFR L861Q not detected
    
  • 2021-09-23 PD-L1(22C3) specimen number S2021-11626
    
  • 2021-09-23 PD-L1(22C3) TPS >= 50%
    
  • 2021-09-23 ALK IHC specimen number S2021-11626
    
  • 2021-09-23 ALK IHC Negative
• exam finding
  • 2022-09-14 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2021/09/14, the old lesions at the T10 and L1 spines are more evident; the right rib cage and left S-I joint show stationary, and a new lesion at the sacrum is noted, indicating metastatic bone disease in progression.
      
    • Suspected benign lesions at bilateral shoulders and hips.
  • 2022-09-12 CXR
    • A poorly defined nodule over Rt lower lobe due to tumor
    • Nodular opacitiy projecting over Lt lower lung zone due to nipple shadow
    • pathological compression fracture of T9 vertebral body
  • 2022-09-01 MRI - brain
    • Findings: Multiple intra-axial enhancing lesions (all smaller than 10 mm) along cortical gyrus or corticomedullary junction of bilateral frontal and temporal lobes, indicating metastases. Increased in number as compared with MRI on 20220502.
    • IMP: Multiple brain metastases. Progressive change as compared with MRI on 20200502.
  • 2022-08-02 CT - lung/mediastinum/pleura
    • stationary in size of primary RLL cancer with two small nodules in the same lobe stationary as compared with CT on 2022/02/16
    • no locoregional recurrent breast tumor.
  • 2022-07-21 CXR
    • Patch density at bil. lungs.
  • 2022-07-21 SONO - abdomen
    • Findings: A hyperechoic nodule (1.40x2.08cm) at S7 of liver. Bil. liver cysts (up to 2.0cm).
    • IMP: A hemangioma (1.40x2.08cm) at S7 of liver. Bil. liver cysts (up to 2.0cm).
  • 2022-05-02 MRI - brain
    • Bifrontal and left temporal metastases.
    • Newly developing right frontal nodules. One lesion of left frontal lobe, seems enlarged.
  • 2022-03-31 SONO - abdomen
    • Left liver cyst (2.48x2.70cm).
    • A hyperechoic nodule (1.53x1.57cm) in S6 of liver suspected hemangioma.
  • 2022-02-16 CT - chest
    • decreased size of primary RLL cancer with two small nodules in the same lobe and mediastinal LAP resolved compared with CT on 2021/9/18.
    • questionable left frontal brain nodule based on noncontrast CT images.
  • 2021-12-15 SONO - abdomen
    • Liver cyst, S4 and S6
    • Liver tumor, suspicious hemangioma, S6
    • Accessory spleen
    • pancreatic tail masked by gas.
  • 2021-11-17 T-, L-spine AP + Lat
    • mild scoliosis of the L-spine.
    • Unremarkable change in the width of the bony spinal canal
      
    • mild anterior spur formation at the L-spine.
    • decreased disc spaces in the T-spine discs and the middle L-spine discs..
  • 2021-09-18 MRI - brain
    • Left fronto-temporal metastases
    • Suspected Bil. cerebellar metastases.
  • 2021-09-14 Tc-99m MDP whole body bone scan with SPECT
    • In comparison with the previous study on 2021/07/26, the lesions in the T10 spine, L1 spine and left S-I joint are more evident. Bone metastases should be watched out.
    • Some new faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? bone metastases?). Please follow up bone scan for further evaluation.
  • 2021-09-10 CT - chest
    • Indication
      • Right breast cancer proved by CNB on 20210707
      • 20210628
        • Breast lump, right
        • self examination
        • palpable at right/ left breast: yes
    • Findings
      • Chest:
        • Spiculated mass at right lower lobe up to 3.5cm in largest dimension is found. Lung cancer is suspected.
        • Some lymph nodes are found at paratracheal region.
        • No evidence of bilateral pleural effusion.
        • S/P mastectomy at right side.
      • Visible abdomen:
        • Hepatic simple cysts at both lobes of liver up to 2.3cm at S1 and 1.5cm at S7/8.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp: left lower lobe lung cancer with medistinal lymph nodes, T2aN2M0
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2021-09-01 Patho - lung wedge biopsy
    • Lung, right, CT-guide biopsy — adenocarcinoma, moderately to poorly differentiated, in favor of lung primary tumor
      
    • Sections show solid nests and neoplastic glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(focal +), Napsin A(focal +), GATA3(focal weak +), Mammaglobin (-), ER(-), PR(-), and HER2(2+, equivocal). The Ki-67 is about 50%. The results are in favor of primary lung adenocarcinoma.
      
  • 2021-08-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (80.42 - 13.74) / 80.42 = 82.91%
    • LVEF = 65 (%)
      • M-mode (Teichholz) = 70.97
    • Normal AV/MV with no AR/MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, mild TR, normal IVC size
  • 2021-08-23 Peripheral Vascular Test - vein, lower limbs
    • Clinical diagnosis: edema
    • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
      • Lower limbs R_CFV R_SFV R_PV R_PTV R_SV L_CFV L_SFV L_PV L_PTV L_SV
      • Spontaneous signal A N N N N N N A N N
      • Respiratory changes A N N N N N N A N N
      • Cough response A N N N N N N A N N
      • Compression study A N N N N N N A N N
    • Report:
      • Right side:
        • SVC: 16.3 mmHg ; 17.6 mmHg ;
        • MVO/SVC: 99 % ; 97 % ;
        • Average MVO/SVC: 98.00 %
      • Left side:
        • SVC: 17.0 mmHg ; 17.0 mmHg ;
        • MVO/SVC: 100 % ; 100 % ;
        • Average MVO/SVC: 100.00 %
      • Thrombus : None
      • Varicose vein : None
    • Conclusion:
      • A perforator vein connecting the right PTV and LSV at middle lower leg level, but no engorgement of LSV was noted. Increased venous return flow velocity at right CFV. Tissue edema at right lower leg.
      • Mild venous reflux at left popliteal vein; mild veonus reflux at left popliteal vein; a perforator vein connecting the left PTV and LSV at middle lower leg level, but no engorgement of LSV was noted. Tissue edema at left lower leg.
      • No evidence of venous thrombosis at bilateral lower limbs venous systems.
      • The ratios of MVO and SVC of bilateral legs were within normal limits.
  • 2021-07-28 Whole body PET scan
    • Glucose hypermetabolism in the right lower lung, probably another primary (priority) or secondary lung malignancy, suggesting biopsy for further investigation.
      
    • Glucose hypermetabolism in the right SCF lymph nodes, bilateral mediastinal lymph nodes, and right pulmonary hilar lymph nodes, probably lung cancer with regional lymph nodes metastases, suggesting biopsy for further investigation also.
      
    • Glucose hypermetabolism in the right rib cage, T10 and L1 spines, and left iliac bone, probably lung cancer with multiple bone metastases.
      
    • Increased FDG uptake at the initial end of A-colon, the nature is to be determined (physiological uptake of FDG, polyp, or other nature ?), suggesting colon fibroscopy for investigation.
    • Increased FDG uptake at the left shoulder, probably post-traumatic change.
    • Right breast cancer s/p treatment, no evidence of residual tumor; right lower lung cancer (if proved), cTxN3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2021-07-27 Patho - breast simple/partial mastectomy
    • pathologic diagnosis
      • Breast, right, simple mastectomy — Invasive carcinoma of no special type
        
      • Resection margin, breast, right, simple mastectomy — Free
        
      • Lymph node, sentinel, right axilla, SNLB — Negative for malignancy (0/1)
        
      • AJCC 8 th edition, Pathology stage: pT2N0; Anatomic stage IIA; Prognostic stage IIA if cM0
    • microscopic examination
      • Histologic type: Invasive carcinoma of no special type
        
      • Size of invasive carcinoma: 3.5 x 3.0 x 3.0 cm
        
      • Histologic grade (Nottingham histologic score): Grade 3 (score = 8)
        
      • Skin involvement: Absent
      • Ductal carcinoma in situ (DCIS): Present; Extensive DCIS: Negative
        
      • Margins: Negative, Closest margin ( 2 mm from base margin)
        
      • Nodal status: Negative (sentinel 0/1)
        • number of lymph node examined: 1 (sentinel)
          
        • number with macrometastases (>2mm): 0 (sentinel)
          
        • number with micrometastases (>0.2~2mm and/or >200 cells): 0
          
        • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
          
      • Treatment Effect: No presurgical neoadjuvant therapy received
        
      • Lymphovascular invasion: Presnt
        
      • Perineural invasion: Absent
        
      • Representative parts are taken for section and labeled: A1 = nipple, A2-A4 = tumor + base margin, A5-A7 = tumor + skin, A8 = non-tumor. F2021-000286 FSA= sentinel lymph node, FSB= skin.
        
    • IMMUNOHISTOCHEMICAL STUDY (S2021-08728)
      • ER (Ab): Positive (strong, >90%)
        
      • PR (Ab): Negative
        
      • HER-2/Neu (Ab): Equivocal (score= 2+)
        
      • Ki-67: 10%
        
      • p53: Positive
        
    • IN-SITU HYBRIDIZATION (S2021-08728)
      • HER2/NEU In-Situ Hybridization: Neagtive.
      • There is NO amplification of HER2 detected
  • 2021-07-27 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
    • IMPRESSION: Probably a sentinel lymph node at the right axillary region.
  • 2021-07-26 CT - abdomen
    • A tumor (2.5cm) at RLL.
    • Retroversion of uterus.
    • Liver cysts (up to 2.3cm).
  • 2021-07-26 Tc-99m MDP whole body bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the maxilla, a middle C- spine,T10 and L3-4 spines, sacrum, bilateral shoulders, S-I joints, and hips.
  • 2021-07-26 SONO - abdomen
    • Hepatic tumor, S7
    • Hepatic cysts
    • Parenchymal liver disease
    • Parenchymal renal disease
  • 2021-07-23 Mammography
    • S/P right mastectomy.
    • No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative.
  • 2021-07-02 Patho - breast biopsy (no margin)
    • Breast, right, sono guide biopsy— invasive carcinoma of no special type
    • Microscopically, the breast shows invasive carcinoma characterized by proliferation of tumor cells with infiltrative growth pattern, ductal differentiation and stromal fibrosis. The tumor cell shows hyperchromatic nuclei, plemorphism and high N/C ratio.
      
    • IHC stain— ER:positive (strong, > 90%), PR: negative, Her2/neu: equivocal (2+), Ki-67 index: 10%, P53: positive
      
    • HER2/NEU In-Situ Hybridization — Neagtive: There is NO amplification of HER2 detected.
      
  • 2021-07-02 SONO - breast
    • Right breast tumor, suspected malignancy.
    • Complex cystic tumor in right breast, 10’region.
    • Right axillary lymph node, suspected metastasis.
• consultation
  • 2022-09-30 Dermatology
    • Q
      • Consult for pressure sore with necrosis and of buttock
      • This 70-year-old woman had history of
        • Right breast cancer s/p simple mastectomy and SLNB on 20210727, T2N3M1, Stage IV
        • Lung cancer, adenocarcinoma, cT2aN2M1c, stage IVB, with bone, brain metastasis, ECOG 1, under Iressa since 20210915.
      • Falling accidence for 2 times in 2022/07 (also Zoledronic acid). Nausea with diarrhea for more weeks, suspect Iressa side effect.
      • Brain MRI on 2022-09-01 showed multiple brain metastases. Progressive change as compared with MRI on 20200502.
      • Thus she was admitted to our chest ward for further exam with treatment.
      • After admission, pressure sore with necrosis and of buttock was noted, aerobic culture of pus grown Staphylococcus.
      • Wet dressing with diluted betaiodine (1:1) gauze BID not improve due to nearly bed riddeen and poor nutrition.
    • A
      • This patient suffered from one ulceration on L’t buttock for days.
      • Imp: Bedsore
      • Suggestion:
        • Doxyclin 1 /Bid
        • Fuciden * 2 tube/bid
        • ZnO * 1 tube/bid
  • 2022-09-15 Infectious Disease
    • Q
      • Consultation for Zyvox
    • A
      • Patient’s sacral pressure sore wound culture showed MSSA infection.
        • There is penicillin anaphylactic shock history that use of penicillin should be avoided.
        • From the MSSA antibiogram, Baktar, Avelox, and Cipro all susceptible.
        • Use of Zyvox should be not necessary.
      • Suggestion:
        • DC Zyvox.
        • Add oral Avelox or Cipro for coverage of bedsore MSSA infection.
  • 2022-09-12 Plastic and Reconstructive Surgery
    • Q
      • Consult for open wound of buttock
      • This 70-year-old woman had history of
        • Right breast cancer s/p simple mastectomy and SLNB on 2021-07-27, T2N3M1, Stage IV
        • Lung cancer, adenocarcinoma, cT2aN2M1c, stage IVB, with bone, brain metastasis, ECOG 1, under Iressa since 2021-09-15.
      • Falling accidence for 2 times in 2022/07 (also Zoledronic acid). Nausea with diarrhea for more weeks, suspect Iressa side effect.
      • Brain MRI on 2022-09-01 showed multiple brain metastases. Progressive change as compared with MRI on 20200502. Thus she was admitted to our chest ward for further exam with treatment.  
      • After admission, pressure sore with pus of buttock was noted, aerobic and anarobic culture of pus was collect.
      • We need your professional expertise for help, thank you very much.
    • A
      • This is a case of pressure sore with necrosis and cellulitis of the sacrum.
      • Suggestion
        • The conservative treatment
          • antibiotic use;
          • wet dressing with diluted betaiodine (1:1) gauze bid;
          • avoiding the supine position;
          • nutrition supportion
        • and observation are suggested.
  • 2022-09-12 Radiation Oncology
    • Q
      • Consult for brain radiotherapy
      • This 70-year-woman had history of
        • Right breast cancer s/p simple mastectomy and SLNB on 2021-07-27, T2N3M1, Stage IV
        • Lung cancer, adenocarcinoma, cT2aN2M1c, stage IVB, with bone, brain metastasis, ECOG 1, under Iressa since 2021-09-15.
      • Falling accidence for 2 times in 2022/07 (also Zoledronic acid). Nausea with diarrhea for more weeks, suspect Iressa side effect. Brain MRI on 2022-09-01 showed multiple brain metastases. Progressive change as compared with MRI on 20200502.
      • Thus she was admitted to our chest ward for further exam with treatment.  
      • Due to multiple brain metastasis, we need your professional expertise for radiotherapy, thank you very much.
    • A
      • Subjective:
        • History: This 70-year-woman had history of
          • Right breast cancer s/p simple mastectomy and SLNB on 2021/07/27, cT2N3M1, Stage IV;
          • Lung cancer, adenocarcinoma, cT2aN2M1c, stage IVB, with bone, brain metastasis, ECOG 1, under Iressa since 2021/09/15.
        • Falling accidence was noted for 2 times in 2022/07 (also Zoledronic acid). Nausea with diarrhea was noted for more weeks, suspect Iressa side effect. Brain MRI on 2022-09-01 showed multiple brain metastases, with progressive change as compared with MRI on 20200502. Poor intake and dehydration due to nausea has been noted for weeks.
          
        • Previous RT: denied.
        • Other disease: as above.
        • Family history: denied.
          • Habit: Alcohol, denied; smoking: denied; betel nuts: denied.
          • Single. Caregiver: her friend. Job: nil. Mild economic stress.
          • Language: Taiwanese. Mandarin.
          • Religion: Buddism.
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2022/09/12: No palpable neck LNs.
        • Pathology, 2021/09/01: Lung, right, CT-guide biopsy — adenocarcinoma, MD to PD, in favor of lung primary tumor. TTF-1(focal +), Napsin A(focal +), GATA3(focal weak +), Mammaglobin (-), ER(-), PR(-), and HER2(2+, equivocal). The Ki-67 is about 50%.
        • Images:
          • Brain MRI, 2022/05/02: Bifrontal and left temporal metastases. Newly developing right frontal nodules. One lesion of left frontal lobe, seems enlarged.
          • Brain MRI, 2022/09/01: Multiple intra-axial enhancing lesions (all smaller than 10 mm) along cortical gyrus or corticomedullary junction of bilateral frontal and temporal lobes, indicating metastases. Increased in number as compared with MRI on 20220502. IMP: Multiple brain metastases. Progressive change as compared with MRI on 20200502.
          • Chest CT, 2022/08/02: stationary in size of primary RLL cancer with two small nodules in the same lobe stationary as compared with CT on 2022/02/16; no locoregional recurrent breast tumor.
      • Diagnosis: Lung cancer, adenocarcinoma, cT2aN2M1c, stage IVB, with bone, brain metastasis, ECOG 1, under Iressa since 2021/9/15 with progressive brain metastasis; ECOG 2; poor intake & dehydration.
      • Goal of radiotherapy: Palliative.
      • RT Plan:
        • Target & Volume: Brain metastasis (n=15) with sparring of hippocampus.
        • Technique: VMAT.
        • Dose & Fractionation: 3960cGy/12 fractions.
        • Plan: Brain RT for 3960cGy/12 fractions is suggested for symptom control. First fraction was prescribed smoothly on Sep 12, 15:00. Possible radiation side effects are told to the patient and her friend. Please prescribe adequate dose of dexamethasone and Famotidine to prevent IICP during brain RT. IV fluids may be prescribed due to poor intake & dehydration.
• surgical operation
  • 2021-07-27 Simple mastectomy + SLNB    
    • right breast tumor 3cm, 1-2 oclock/1cm from nipple
    • axillary sentinel lymph node: 0/1
• chemoimmunotherapy
  • 2022-01-12, 2022-02-09 - zoltedronic acid 4mg IVD (for bone mets)
  • 2021-09-23 ~ undergoing - Iressa (gefitinib 250mg/tab) 1# QD
  • 2021-09-22 ~ 2022-05-25 - Kisqali (ribociclib 200mg/tab) 2# QD
  • 2021-08-11 ~ undergoing - Femara (letrozole 2.5mg/tab) 1# QD

[assessment]

• The patient has been diagnosed with ER(+) PR(+) HER2(-) breast cancer and has been treated with letrozole, an aromatase inhibitor, in combination with the CKD4/6 inhibitor, ribociclib (2021-09-22 ~ 2022-05-25).

• She was also diagnosed with EGFR Exon19 deletion, PD-L1 TPS >= 50% lung adenocarcinoma, and is currently undergoing the TKI gefitinib (2021-09-23 ~ undergoing).

• The use of atezolizumab might be an option for her subsequent treatment, as her lung cancer is also characterized by PD-L1 TPS >= 50%. (2021-09-23 S2021-11626)

• Her bone mets were treated with zoltedronic acid (2022-01-12, 2022-02-09) and two falling accidents were noted in July 2022. In the event that zoltedronic acid is not well tolerated by the patient, Xgeva (denosumab 120mg SC) or romosozumab (currently not available at this hospital) might be an alternative.

700199371

221007

• exam finding
  • 2022-08-13 Gynecologic ultrasonography
    • ATH + BSO
    • Suspected Lt adnexal cyst (26mmx22mm)
    • Suspected Rt mass? (39mmx30mm), RI:0.65
  • 2022-07-22 CT - abdomen
    • Local recurrent tumor 3.7 cm in left pelvis is suspected. please correlate with clinical condition.
    • Metastatic node 3.1 cm in pre-cava space.
      • In addition, several metastatic nodes in para-aortic space and para-cava space, bilateral common iliac chain, and bilateral inguinal area are highly suspected.
        
  • 2022-05-07 Gynecologic ultrasonography
    • ATH + BSO
    • Suspected Lt adnexal cyst (29mmx28mm)
    • Suspected Rt mass? (37mmx30mm)
  • 2022-04-27 CT - abdomen
    • Prior CT identified a soft tissue mass measuring 2.7 cm in left pelvis is noted again, mild increasing in size to 2.9 cm. Follow up is indicated.
  • 2022-01-27 CT - abdomen
    • S/P hysterectomy. A soft tissue tumor (2.7cm) at left pelvic cavity. A cystic lesion (2.2x6.3cm) at left pelvic cavity.
    • Grade 4 fatty liver.
  • 2021-11-08 SONO - abdomen
    • Fatty liver.
    • Hypoechoic lesion, 1.72x0.93cm in pericholecystic region, suspected focal fatty sparying. Suggest follow up.
      
    • Left renal cyst.
  • 2021-08-25 Tc-99m MDP whole body bone scan with SPECT
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the skull, maxilla, upper L-spine, bilateral sternoclavicular junctions, shoulders, elbows, wrists, hands, knees, and feet.
  • 2021-08-18 MRI - pelvis
    • S/P hysterectomy.
      
    • Suspected hematoma (1.5cm) around left aspect of vaginal stump, suggest follow up.
    • Left pelvic cavity cystic lesion, suspected lymphocele, suggest follow up.
    • Bone lesion in right sacrum, 1cm, bone metastasis? suggest bone scan study.
  • 2021-05-17 MRI - pelvis
    • S/P hysterectomy.
      
    • Small peritoneal nodule (0.48cm) in lower pelvic cavity, carcinomatosis? Suggest follow up.
    • Suspected hematoma (1.3cm) around left aspect of vaginal stump, suggest follow up.
    • Suspected lymphocele in left pelvic cavity, suggest follow up.
  • 2020-10-31 Gynecologic ultrasonography
    • ATH + BSO
    • Suspected Lt adnexal cyst (58mmx42mm), no blood flow
  • 2020-09-17 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Endometrium, uterus, staging surgery — Endometrioid carcinoma, grade 2
        
      • Myometrium, uterus, ditto — Tumor invasion, more than half thickness, leiomyomas
        
      • Cervix, uterus, ditto — Free of tumor invasion, Nabothian cyst
        
      • Ovary, left, ditto — Free of tumor invasion, hemorrhagic corpus luteum
        
      • Fallopian tube, left, ditto — Free of tumor invasion
        
      • Ovary, right, ditto — Free of tumor invasion, hemorrhagic corpus luteum
        
      • Fallopian tube, right, ditto — Free of tumor invasion
        
      • Lymph node, left external iliac, dissection — Tumor metastasis (3/10) with extracapsular extension (3/3)
        
      • Lymph node, left oburator, ditto — Tumor metastasis (5/9) without extracapsular extension (0/5)
        
      • Lymph node, right external iliac, ditto — Tumor metastasis (1/5) without extracapsular extension (0/1)
        
      • Lymph node, right oburator, ditto — Tumor metastasis (2/12) without extracapsular extension (0/2)
        
      • Lymph node, left para-aortic, ditto — Free of tumor metastasis (0/7)
        
      • Parametrium, bilateral — Free of tumor
        
      • Cul-de sac tumor, excision — Endometrioid carcinoma
        
      • Serosal nodule, uterus — Endometrioid carcinoma
        
      • Vaginal stump — Free of tumor
        
      • AJCC Pathologic stage — pT3aN1a (if cM0), stage IIIC1 (FIGO stage IIIC1)
        
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: staging surgery (TAH, BSO and BPLND)
        
      • Specimens include: Uterus, bilateral ovaries and fallopian tubes, pelvic LNs and cul-de sac tumor
        
      • Specimen size:
        • uterus: 15.2 x 12.3 x 7.5 cm in size, and 552 gm in weight contains myomas and one serosal nodule
          
        • right ovary: 3.6 x 1.8 x 1.4 cm
          
        • left ovary: 3.4 x 2.2 x 1.2 cm
          
        • right tube: 6.5 cm in length; 0.6 cm in diameter
          
        • left tube: 6.9 cm in length; 0.7 cm in diameter
          
      • Tumor site: endometrium, from fundus to endocervix
        
      • Tumor size: 11.6 x 8.3 x 4.2 cm
        
      • The myometrium: up to 3.2 cm in thickness
        
      • The cervix : mucoid cysts
        
      • Adnexa (bilateral): not invaded by tumor
        
      • Lymph nodes: left external iliac LNs; left obturator LNs; right external iliac LNs, right obturator LNs and left para-aortic LNs
        
      • cul-de sac tumor: one small piece, 2.4 x 1.8 cm
        
      • Serosal nodule of uterus: 1.2 x 0.8 x 0.7 cm
        
    • MICROSCOPIC EXAMINATION
      
    • Histology type: Endometrioid carcinoma
      
    • Histology grade: Grade 2
      
    • Depth of invasion: More than half thickness of myometrium
      
    • Lymphovascular invasion: Present
      
    • The cervical stroma involvement:: absent
      
    • Resection margins of the cervix: Free, 3.2 cm away from tumor cells
      
    • Additional pathologic findings: N/A
      
    • Lymph nodes: tumor metastasis (11/43) with extracapsular extension (3/11) in total number
      
    • Vaginal stump: 0.8 cm, free
      
    • Immunohistochemistry: WT-1(-), ER(+), PR(+), PAX-8(+) and vimentin(+, scatter) for tumor cells
      
    • Cul-de sac tumor: endometrioid carcinoma
      
    • Serosal nodule of uterus: Endometrioid carcinoma
  • 2020-08-28 MRI - pelvis
    • Findings
      • Diffuse soft tissue tumor, up to 8.8cm in the uterine cavity (fundus, body to the eneocervical region), suspected endometiral malignancy.
      • Soft tissue tumors in the cul-de-sac with ascites, suspected tubal or ovarian involvement.
      • There are T2 hypointensity tumors, up to 1.8cm in the uterine myometrium, suspected uterine myomas.
      • There are diffuse enlarged lymph nodes in bilateral obturator, intenal, external and common iliac regions, could be due to metastatic lymph nodes.
      • Non-enhancing nodules in bilateral kidneys, suspected renal cysts.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M0(M_value) STAGE: III (Stage_value)
      • Diffuse soft tissue tumors in the uterine cavity with diffuse enlarged lymph nodes in the pelvic cavity, suspected endometrial malignancy with lymph nodes metastasis.
      • Soft tissue tumors in the cul-de-sac with ascites, suspected tubal or ovarian involvement. cstage T3N1M0.
        
  • 2020-08-21 Patho - endometrium curretage/biopsy
    • Endometrium, uterus, D&C — Adenocarcinoma
  • 2020-08-15 Gynecologic ultrasonography
    • Bilateral adnexae: free
    • Suspected endometrial hyperplasia
    • Uterine myoma
  • 2020-06-27 Gynecologic ultrasonography
    • Bilateral adnexae: free
    • EM: 22.6m
    • Uterine myoma
• chemoimmunotherapy
  • 2022-10-06 - docetaxel 75mg/m2 135mg 1hr + carboplatin AUC 5 550mg 2hr
  • 2022-09-15 - bevacizumab 7.5mg/kg 570mg 1.5hr + docetaxel 75mg/m2 135mg 1hr + carboplatin AUC 5 550mg 2hr
  • 2022-08-25 - bevacizumab 7.5mg/kg 570mg 1.5hr + docetaxel 75mg/m2 135mg 1hr + carboplatin AUC 5 550mg 2hr
  • 2022-08-04 - bevacizumab 7.5mg/kg 590mg 1.5hr + docetaxel 60mg/m2 100mg 1hr + carboplatin AUC 5 560mg 2hr
  • 2021-02-02 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 600mg 2hr
  • 2021-01-12 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 600mg 2hr
  • 2020-12-22 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 600mg 2hr
  • 2020-12-01 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 600mg 2hr
  • 2020-11-10 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr
  • 2020-10-20 - paclitaxel 160mg/m2 270mg 3hr + carboplatin AUC 5 450mg 2hr

[assessment]

Mosarla RC, Vaduganathan M, Qamar A, Moslehi J, Piazza G, Giugliano RP. Anticoagulation Strategies in Patients With Cancer: JACC Review Topic of the Week. J Am Coll Cardiol. 2019;73(11):1336-1349. doi:10.1016/j.jacc.2019.01.017

Johnstone C, Rich SE. Bleeding in cancer patients and its treatment: a review. Ann Palliat Med. 2018;7(2):265-273. doi:10.21037/apm.2017.11.01

• There has been an observation of vaginal bleeding possibly caused by bevacizumab. A transfusion might be necessary if there is a significant loss of blood (which is not the case for this patient HGB 11.0 g/dL 2022-10-06).

• Tranexamic acid has not been studied in advanced cancer, but it reduces mortality due to bleeding by approximately one-third. A reduction of approximately one-third in blood loss and transfusion requirements has been seen in meta analyses of its use in elective surgery as well.

  • ref: Ker K, Edwards P, Perel P, et al. Effect of tranexamic acid on surgical bleeding: Systematic review and cumulative meta-analysis. BMJ 2012;344:e3054.
  • ref: Ker K, Prieto-Merino D, Roberts I. Systematic review, meta-analysis and meta-regression of the effect of tranexamic acid on surgical blood loss. Br J Surg 2013;100:1271-9.

• No dose-response has been seen for tranexamic acid’s therapeutic effect, and the recommended dose is 10 mg/kg per dose given intravenously every 6-8 hours, with no benefit to doses above 1 gram.

  • ref: Hunt BJ. The current place of tranexamic acid in the management of bleeding. Anaesthesia 2015;70 Suppl 1:50-3, e18.

701453252

221007

Pancreatic cancer, adenocarcinoma, pT2N2M1, stage IV with liver mets with Paclitaxel and Gemcitabine Gastric cancer, adenocarcinoma, pT2N3aM0, stage IIIa Malignant neoplasm of unspecified site of left female breast

• past history
  • Pancreatic cancer, adenocarcinoma, pT2N2M1, stage IV with liver metastasis s/p pancreaticoduodenectomy, Level 3 mesopancreas dissection, cholecystectomy and wedge biopsy of liver, laparotomy on 2021/01/19 & s/p palliative chemotherapy with Paclitaxel and Gemcitabine
  • Gastric cancer, adenocarcinoma, pT2N3aM0, stage IIIa s/p totally laparoscopic distal gastrectomy (TLDG) with D2 lymphadenectomy (LND) on 2018/07/16 & s/p adjuvant chemotherapy + radiotherapy
  • Left breast cancer, intraductal papilloma with ductal carcinoma in-situ, pTis, stage 0 s/p excision on 2018/11/30 & s/p hormone therapy with Femara since 2019/02/15 + radiotherapy till 2019/04/10
  • Peptic ulcer more than 10 years ago
  • Hypertension for years without medical control
  • Severe narrowing of left C5/6 and C6/7 neural foramina, caused by protusion disc plus compressin of left C6 and C7 nerve roots, then left upper and lower limbs muscle weakness
• op history
  • Left femur intertrochanteric displaced fracture, with posteromedial involvement to lesser trochanter status post open reduction and internal fixation with Gamma nail on 2022/09/23
  • s/p lumbar spine (L4/5) surgery in 2011 and s/p cervical spine (C3) surgery in 2014
  • C/S in 1986.
• exam findings
  • 2022-10-06 CT - abdomen
    • Findings
      • S/P gastric and pancreas operation.
      • Heterogeneous density of liver with some poor enhancing nodules.
      • Multiple nodules at bil. lungs. Left pleural effusion with adjacent lung collapse.
      • Soft tissues in peritoneal cavity.
      • Mild dilatation of IHDs.
      • Massive ascites.
      • General subcutaneous edema.
      • Enlarged LNs at mediastinum, mesentery and retroperitoneum.
    • Impression
      • S/P gastric and pancreas operation. In favor of peritoneal seeding, LNs, lung and liver metastases. Ascites and pleural effusion.
  • 2022-09-26 Patho - bone biopsy/curetting
    • Labeled as “breast cancer, suspected mets; left femur fracture”, ORIF with Gamma nail — fractured bone tissue with no metastatic carcinoma in this specimen.
    • IHC stains: CK (-), GATA-3 (-).
  • 2022-09-23 Pelvis-THR & Lt. Hip Lat
    • Left femoral intertrochanteric fracture, s/p ORIF
    • Acceptable alignment
  • 2022-09-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (117 - 31) / 117 = 73.50%
      • M-mode (Teichholz) = 73.4
    • Dilated LA
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild PR, TR
    • Mild Pulmonary HTN
    • Redundent mitral chordae tendinae
  • 2022-08-03 TS-1 (1-1); 08-24 (1-2)
  • 2022-07-27 Abdominal CT
    • There is a 1.3cm nodule with enhanced wall and low density center in S3 liver.
    • There are tiny nodules in bilateral lung base. Pneumobilia noted.
    • There is a 1.0cm enlarged lymph node in paraaortic region.
    • stable disease.
  • 2022-07-25 Visit Yuli TzuChi hospital due to fall down on 20220721.
    • X-ray showed left medial curneiform, left 2~4th metatarsal base linear fracture.
  • 2022-05-12 Onivyde + 5-Fu/LV (7); 05-25 (8); 06-08 CEA: 28, CA 19-9: 3676, Onivyde + 5-Fu/LV (9); 06-22 (10); 07-06 (11); 07-20 (12)
  • 2022-04-21 CT - abdominal
    • Metastatic tumor in S3 liver is likely.
    • Pneumobilia.
    • Metastatic tumors in bilateral lung base is likely;
    • S/P L4-5 disc spacer implantation.
    • The liver tumor lesion was similar in size (1.2 cm -> 1.5 cm). So called lung lesions were very small (less than 0.5mm, need to follow up).
    • Stable condition.
  • 2022-02-17 Onivyde + 5-Fu/LV (2); 03-03 (3); 03-17 (4); 03-31 (5); 04-14 (6)
  • 2022-02-04 Onivyde + 5-Fu/LV (1), 80% dose, use TS-1 to replace CI 5-Fu (due to port-A on right thigh and relative need help in daily activity due to chronic leg problem).
  • 2022-01-17 Hb 7.8 g/dL -> PRBC 2 u
  • 2021-12-08 Gemzar + Nab Paclitaxel (6/D15); 12-16 (7/D1); 12-29 (7/D8); 111-01-05 (7/D15), CEA 10.5 ng/mL, CA 19-9: 414 U/mL
  • 2021-11-30 CT - chest and abdominal
    • A 1.2 cm rim-enhancing nodular lesion in the S3 of liver, suspicious metastasis. Tiny nodular opacity in lateral segment of RML of the lung.
    • Discuss with patient about her condition and treatment options. Keep current chemotherapy and suggest patient weekly chemotherapy first for better efficacy. If patient can not return to clinics weekly, consider change to 2nd line chemotherapy with Onivyde + 5-Fu/LV. She prefer to keep current treatment because she also had some difficulty in using continuous infusion.
  • 2021-08-18 Gemzar + Nab Paclitaxel (4/D1); 08-30 CEA 3.1 ng/mL, CA 19-9: 185 U/mL; 09-01 Gemzar + Nab Paclitaxel (4/D8); 09-15 (4/D15); 09-29 (5/D1); 10-11 CEA: 3.8 ng/mL, CA 19-9: 219.1 U/mL; 10-13 (5/D8); 10-27 (5D15); 11-10 (6/D1); 11-24 (6/D8); CEA 6.0 ng/mL, CA 19-9 294.7 U/mL
  • 2021-08-04 CT - chest
    • A tiny nodular opacity in lateral segment of RML of the lung, less than 3 mm in size, which was too small to be characterized.
    • A small L.N. in Lt. para-aortic retroperitoneum, showed decreased nodal size compared with prior CT images on 2021/04/28.
    • Pneumobilia in the liver.
  • 2021-07-28 CXR
    • Opacity in right medial mid-lung.
  • 2021-05-12 SONO - breast
    • No evidence of local recurrence.
  • 2021-05-03 Gemzar + Nab Paclitaxel (1/D1); 05-19 (1/D8); 06-02 (1/D15); 06-16 (2/D1); 06-30 (2/D8), CEA 3.9 ng/mL, CA 19-9 307.9 U/mL; 07-14 (3/D15)
  • 2021-04-28 CT - abdomen
    • Metastatic lymphadenopathy in paraaortic region.
  • 2021-02-18 TS-1 (1), 2 weeks on and 1 week off; 03-29 CEA 14.9 ng/mL, CA 19-9 4812 U/mL, 04-01 Gemzar (1/D1); 04-12 (1/D8)
  • 2021-01-19 Open PD and partial hepatectomy
    • Pancreas, head, pancreaticoduodenectomy, ductal adenocarcinoma (pT2N2); Liver, wedge biopsy, ductal adenocarcinoma, metastatic (x2); Gallbladder, cholecystectomy, chronic cholecystitis with cholesterolosis; Lymph node, regional, lymphadenectomy, adenocarcinoma, metastatic (1/2); Lymph node, regional, ALN, lymphadenectomy, adenocarcinoma, metastatic (4/9); CDX-2 (+), CK7 (-) and CK20 (-).
    • Pancreatic cancer with liver mets. Palliative IV chemotherapy with Gemzar + Abraxane was suggested but she took TS-1 due to her preference of oral chemotherapy after detailed discussion.
  • 2021-01-12 PES
    • GERD LA A
  • 2020-12-31 CT - chest
    • No active or space occupying lesion was found in the lung.
    • Increased soft tissue mass in hepatoduodenal ligament and portocaval space of middle abdomen, associated with IHDs dilation, suspect metastatic LAPs.
  • 2020-12-07 MRI - brain
    • old infarction.
    • no definite brain mets.
  • 2020-11-23 Mamography
    • Category 0 (according to ACR BI-RADS categories for mammographic lesions): (a) From chart record: Received left breast intraductal papilloma (IDP) excision on 2018-11-30, pathology revealed: intraductal papilloma with ductal carcinoma in-situ (pTis). (b) Post operative changes ofleft breast. (c) Benign calcification in left breast UOQ (upper outer quadrant). (d) Recommend sonography as complementation.
  • 2020-11-23 CT - abdominal
    • Slight more dilated biliary tree than before. Otherwise, stationary status.
  • 2020-08-27 Chest/Abdomen CT
    • Post distal gastrectomy for gastric cancer as told.
    • No apparent radiological sign of local recurrence or distant metastasis noted from present imaging scope.
    • Known post excision for left breast malignancy. Favor no apparent recurrence.
    • Mild scars in LUL (left upper lung) lingular lobe.
  • 2020-03-10 PES at Yuli hospital
    • BII, GERD.
  • 2018-11-30 Patho
    • Breast, left, ductography and excision, intraductal papilloma with ductal carcinoma in-situ (pTis).
    • ER (+++,98%), PR (+++,90%), Her-2/neu (0, negative), ki67 (+, 3%), p63 (reduced myoepithelial cells) and CK5/6 (loss of expression in DCIS)
  • 2018-11-30? SONO - breast
    • Scar at the LT breast. Several uneven size breast cysts, cystic lesions and fibroadenomas noted in both breasts, favor benign findings. No nipples retraction, bil. No abnormal lymphadenopathy in bilateral axillary regions.
    • Chest X-ray: Mild emphysematous lungs but apparent active lung lesion.
• consultation
  • 2022-09-24 Orthopedics
    • Q
      • left hip painful disability
      • no HI, no ILOC
      • NKDA
      • PH: gastric (stage III) and pancreatic cancer (stage IV) f/u at HuaLien TzuChi Hospital s/p OP and C/T
      • OP hx: cervical and lumbar spondylosis s/p OP with left side weakness and paresthesia
    • A
      • 68 y/o female
        • past history:
          • gastric (stage III) and pancreatic cancer (stage IV) f/u at HuaLien TzuChi Hospital s/p operation (2018 and 2019) and chemotherapy
          • cervical spondylosis S/P anterior instrumentation of C3
          • Severe spinal stenosis at C5/6 level, caused by posterior central disc protusion. Compression of cervical cord.
          • Severe narrowing of left C5/6 and C6/7 neural foramina, caused by protusion disc. Compressin of left C6 and C7 nerve roots. =＞ Left upper and lower limb muscle weakness
          • Lumbar spondylosis s/p instrumentation of L4/L5
        • Allergy: NKDA
        • No current anti-platelet/anti-coagulation medication usage
        • NPO: since 0900
        • Subjective fall down at home last night, left hip painful swelling and deformity
          • NO ILOC, no head/chest/abdomen trauma
        • PE:
          • Inspection: Left hip flexion deformity
        • Palpation: Left hip tenderness, aggravated when motion
        • Motion: difficult on LEFT hip motion
        • Distal sensation: intact
        • Circulation: Capillary refill time <2sec, dorsalis pedis pulse(+)
        • X-ray:
          • Left femoral intertrochanteric fracture, with posteromedial involvement to lesser trochanter
      • Plan:
        • Arrange 2D cardiac echo for preoperative evaluation
        • Blood transfusion if Hb <10 mg/dL
        • Pain control
        • High mortality risks of hip fracture (50% if non-operation in one year; 20% if operation in one-year) had detail explained to family and patient
        • Arrange ORIF with Gamma nail today
• SOP
  • 2022-09-28 Hemato-Oncology
    • Impression:
      • Pancreatic cancer, adenocarcinoma, pT2N2M1, stage IV with liver mets
      • Gastric cancer, adenocarcinoma, pT2N3aM0, stage IIIa
      • Breast cancer, Tis, stage 0
    • Suggestion:
      • Explain to patient about the chemotherapy (Regimen: Abraxane + Gemzar) for her pancreatic caner - benefit / side effects were informed. Questions were all answered. She agreed with the chemotherapy. Breast surgeon suggest hormone therapy (AI) + radiation for her breast cancer in situ. Keep AI.
      • Educate patient about the side effects of chemotherapy, return to clinic or ER if any discomfort.
      • Symptomatic treatment. Add H2 blocker for epigastric pain and educate self care.
    • Keep current chemotherapy and suggest patient keep weekly chemotherapy first for better efficacy. Change to 2nd line chemotherapy with Onivyde + 5-Fu/LV. Might need use TS-1 or UFUR to replace CI 5-Fu (due to port-A on right thigh and relative need help in daily activity due to chronic leg problem).
    • Explain to patient about her CT - stable disease. Keep TS-1 as maintenance and also for her recent leg fracture. Consider change to Cisplatin + 5-Fu if disease progression.
• chemoimmunotherapy 2022-10-06 ~ undergoing - TS-1

[assessment]

• Following the administration of 10 units of human insulin, the blood sugar level decreased from 404mg/dL to 155mg/dL.
• Since the blood sugar level has returned to relative normal, current ‘insulin 10 units QD’ might be switched to PRN in order to prevent hypoglycemia.
• To determine the pattern of blood sugar levels, please continue to monitor them.

700972259

221006

{HCC with lung & bone metastasis, suspected a large tumor at L5 vertebral body, R paravertebral / R perivertebral spaces}

• past history
  • Mitral valve prolapse,
  • Hepatitis B carrier,
  • Gastric ulcer,
  • chronic rhinitis s/p radiofrequency turbinoplasty on 20081202,
  • Duodenal ulcer induce peritonitis with pneumoperitonium post Laparoscopic simple closure on 20090830,
  • HBV related liver cirrhosis, child A
  • Hepatocellular carcinomas, bilateral, cT3N0M0 stage IIIa, Barcelona Clinc Liver Cancer stage B diagnosis on 20200107
    • 1st TACE on 20200107 and 2nd TACE 20200206.
• lab data
  • AFP
    • 2022-03-18 16.9 ng/mL
    • 2022-03-07 12.2 ng/mL
    • 2022-01-05 11.0 ng/mL
    • 2021-11-23 24.6 ng/mL
    • 2021-09-06 32.5 ng/mL
    • 2021-06-22 49.7 ng/mL
    • 2021-02-16 6.3 ng/mL
    • 2020-12-29 3.2 ng/mL
    • 2020-10-27 3.6 ng/mL
    • 2020-10-27 3.9 ng/mL
    • 2020-08-18 7.1 ng/mL
    • 2020-04-20 3.2 ng/mL
    • 2020-03-05 3.6 ng/mL
    • 2020-02-05 2.7 ng/mL
    • 2019-12-09 2.8 ng/mL
    • 2019-09-16 3.0 ng/mL
    • 2019-01-09 3.0 ng/mL
    • 2018-05-28 12.7 ng/mL
    • 2018-03-03 1.3 ng/mL
    • 2017-12-04 2.1 ng/mL
• exam finding
  • 2022-09-26 ECG
    • Normal sinus rhythm
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-09-12 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal varices, F1Cb, Li-m, RCS(-), nipple sign(-)
      • Portal hypertensive gastropathy
      • Congestive duodenitis
      • Duodenal scars with bulb deformity
    • Suggestion
      • Pursue CLO test
      • OPD follow-up
  • 2022-09-01 CT - abdomen
    • Bil. diffuse HCCs s/p TACE with viable tumors.
    • No evidence of tumor rupture.
    • Partial thrombosis of left portal vein.
    • Lung and bony metastases.
  • 2022-06-30 CT - abdomen
    • Bil. diffuse HCCs s/p TACE with viable tumors.
    • Partial thrombosis of left portal vein.
    • Lung and bony metastases.
  • 2022-06-30 Knee RT
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography.
  • 2022-06-30 Femur RT
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography.
  • 2022-06-16 MRI - pelvis
    • Findings
      • Mass lesions in L5 vertebral body, right sacral ala, right iliac tuberosity, and right acetabulum. Enhancement after contrast administration.
      • Post-OP change at L4-S1. Right neuroforaminal narrowing and lateral recess effacement at L5-S1.
      • Multiple mass lesion in both hepatic lobes.
    • Impression
      • c/w HCCs with bone metastasis, involving L5, sacrum, and right pelvis
  • 2022-03-08 CT - abdomen, pelvis
    • With and without contrast enhancement CT of abdomen – whole:
      • There are diffuse enhancing tumors in both lobes of liver, s/p TACE with multiple viable tumors.
      • Unremarkable change of the spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
      • Post-op at L4-5 spine.
      • There is destructive bone lesion in right pelvis, paraspinal region, L4/5 level, could be due to metastasis, progression.
      • Diffuse lung emphysema.
      • Right lower lung nodule, suspected lung metastasis. Stationary.
    • Impression:
      • Diffuse HCCs s/p TACE with viable tumors.
      • Bone and spine metastasis in right pelvis, post-op at L4/5 level, progression.
      • Stationary of RLL nodule, suspected lung metastasis.
  • 2022-01-29 MRI - L-spine
    • Without- and with-contrast MRI of lumbar spine, including sagittal T2W FSE, sagittal T1W, coronal STIR, axial T2W and axial T1W images (3 mm thickness for sagittal images and 4 mm thickness for the others) reveal:
      • A huge poorly enhancing tumor involving L5 vertebral body, mainly right part, intraspinal space and paraspinal region. S/P operation, TPSs and prosthesis, with susceptibility artifacts.
      • Progressive tumor invasion into intraspinal space and along anterolateral aspect along right iliac wing. General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis at L1-2.
      • Gr I spondylolisthesis, end-plate degeneration, disc collapse with general bulging, hypertrophic yellow ligaments, enlarged facets and superimposed tumor invasion causing moderate spinal canal stenosis and bilateral moderate to severe neuroforaminal narrowing at L4-5, more severe on right side.
      • No intramedullary lesion.
    • IMP:
      • L5 vertebral body metastasis, progressive change as compared with MRI on 20211222.
  • 2022-01-12 Patho - interveterbral disc
    • pathologic diagnosis
      • L5 spinal tumor, excision + frozen section — Metastatic hepatocellular carcinoma
        
    • microscopic examination
      • Microscopically, the section shows a picture of metastatic adenocarcinoma characterized by tumor cells with eosinophilic cytoplasm, bile pigment, arranged in nest or pesudoglandular pattern, hemorrhage, focal necrosis and bone invasion.
        
      • Immunohistochemical stains of CK7(-), CK20(-), Hepa-1(+), arginase(-) and TTF-1(-) for tumor.
      • According to clinical information and above histopathologic findings, it indicated a case of metastatic hepatocellular carcinoma, grade 2
  • 2022-01-07 CT - lung/mediastinum/pleura
    • HCC at both lobes of liver with stationary size and extension.
    • Tiny nodules at both lungs. Lung mets is favored. Stable.
  • 2022-01-06 Tc-99m MDP whole body bone scan
    • Increased activity in the L5 spine. Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
    • Mildly increased activity in the lower T-spines. Degenerative change may show this picture. However, please follow up bone scanto rule out other possibilities.
    • A hot spot in the anterior aspect of left 2nd rib. The nature is to be determined (post-traumatic change? other nature?). Please also follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, right sternoclavicular junction and bilateral hips, compatible with benign joint lesions.
  • 2022-01-05 Chest PA/AP view
    • S/P port-A implantation.
    • Several small nodular opacity projecting at right upper lung are suspected. Follow up is indicated. Otherwise, Please correlate with CT.
  • 2021-12-22 MRI - L-spine
    • suspected a large tumor at the right L5 vertebral body, right paravertebral and right perivertebral spaces.
    • herniated disc in the L4/5 disc
  • 2021-11-29 CT - abdomen, pelvis
    • Bil. diffuse HCCs s/p TACE with viable tumors. Lung and bony metastases.
  • 2021-09-07 CT - abdomen, pelvis
    • Diffuse HCCs s/p TACE with viable tumors, progression.
    • Bone metastasis, L-S.
    • Stationary RML nodule, 0.4cm. Diffuse bilateral lung emphysema.
  • 2021-06-01 CT - abdomen, pelvis
    • Liver cirrhosis with multiple HCC at both lobes of liver, the tumor extension is stationary.
    • Right lower lobe nodule. Stable.
  • 2021-04-09 KUB
    • Fecal material store in the colon.
    • Disk space narrowing and Marginal osteophyte formation at right lateral aspect of L4-5 is suspected. Please correlate with L-spine lateral view.
  • 2021-02-16 CT - abdomen, pelvis
    • LIver cirrhosis with multiple HCC s/p TACE and targeted therapy with tumor progression.
  • 2021-02-09 Abdominal Ultrasonography
    • Cirrhosis of liver
    • Hepatic tumor, multiple, probably hepatoma
  • 2020-10-20 CT - abdomen, pelvis
    • Liver cirrhosis wiht multiple HCC at both lobes of liver, in progression.
  • 2020-09-29 Abdominal Ultrasonography
    • Cirrhosis of liver
    • Hepatic tumor, multiple, probably TAE effect of hepatoma(S3)
  • 2020-08-13 CT - abdomen, pelvis
    • Bil. HCCs s/p TACE with viable tumors (up to 2.0cm, increaed tumor number but decreased tumor size).
  • 2020-04-24 Abdominal Ultrasonography
    • Liver cirrhosis
    • Hepatic tumors, favor HCC s/p TAE
  • 2020-04-23 CT - abdomen, pelvis
    • HCC s/p TACE
    • Tiny nodule at right middle lobe, intrafissural nodule is considered.
  • 2020-03-05 CT - liver, spleen, biliary duct
    • Bil. HCCs s/p TACE with viable tumors (up to 2.5cm).
    • A nodule (3.7mm) in RML.
  • 2020-01-27 KUB
    • Bilateral clear psoas shadows. Unremarkable bowel gas pattern. Radiopaque density at left upper abdomen, probably post-TAE at left hepatic lobe. Degenerative change of the spine with marginal spur formation.
  • 2020-01-14 Abdominal Ultrasonography
    • Cirrhosis of liver
    • Hepatic tumor, probably HCC post TAE effect
    • Pleural effusion, left
  • 2019-12-25 CT - liver, spleen, biliary duct
    • Multiple HCCs in S2-3 of the liver are highly suspected.
      
    • Three HCCs in S7, S4/5, and S4 are also suspected.
    • Please correlate with AFP.
    • AJCC 8th edition, CT staging of HCC: T3N0Mx
  • 2017-02-07 Abdominal Echo
    • Cirrhosis of liver
    • Calcified spot of liver
• consultation
  • 2022-01-05 Radiological Diagnosis
    • Q
      • for TAE
      • This 69-year-old male, a pt of HBV carrier with liver cirrhosis, hepatocellular carcinoma, bilateral with lung & bone mets. He was admitted due to right hip pain for 2 months ago and L-spine MRI showed suspected a large tumor at the right L5 vertebral body, right paravertebral and right perivertebral spaces.herniated disc in the L4/5 disc. We need expertise to evaluate his condition thanks!
    • A
      • According to the clinical condition and imaging findings, TAE is indicated.
  • 2020-04-22 Hemato-Oncology
    • Q
      • This 68 year-old man had medical history with HBV carrier with liver cirrhosis; PPU s/p simple closure ; GERD ; Hepatocellular carcinoma, bilateral, cT3N0M0 stage IIIa, Barcelona Clinc Liver Cancer stage B, status post 3rd Transcatheter arterial chemoembolization. Due to the 3/5 Abd CT showed Bil. HCCs s/p TACE with viable tumors (up to 2.5cm). A nodule (3.7mm) in RML. He recevied TACE of HCCs at both hepatic lobes on 20200421. So we need you evaluation and suggestion of this patient.
    • A
      • Objective
        • This 68 y/o male, a pt of HCC Dx in Dec 2019 s/p TACE x 3 on 1/7, 2/6, 4/21 20. Abd CT (3/5 20) showed Bil. HCCs s/p TACE with viable tumors (up to 2.5cm). A nodule (3.7mm) in RML. Dz in progress seems to be noted. AFP (4/20 20): 3.2
        • Albumin (4/20 20):4.2, Bil-T:0.54, PT:10.6, no ascites, no encephalopathy, Child-Pugh classification: A.
      • Suggestion
        • May do chest CT to evaluate the underlying lung mets.
        • If lung mets is confrimed, will suggest systemic therapy ( eg: Nexavar or Lenvima ) with or w/o immunotherapy wt Nivolumab (Nivo is no longer reimbursed by NHI since April 2020).
        • Palliative C/T offers little benefit to pt wt mets HCC & rarely recommended & may be the last resort of Tx.
• surgical operation
  • 2022-01-11
    • Surgery
      • excision of malignant tumor lumbar 5
      • posterior spinal fusion with instrumentation
      • microscopy
      • fluoroscopy
      • CUSA
    • Finding
      • lumbar 5 spinal metastatic lesion from malignant tumor of liver
      • after excision of the metastatic lumbar bone invasion, mesh and autograft bone from adjacent spinal process for posterior spinal bone fusion.
      • posterior spinal instrumentation was done by L4 and S1 bilateral pedicle screws and rods.
  • 2022-01-10 Embolization (TAE) - extremity
    • TAE of RIGHT sacral tumor via right common femoral artery puncture using Seldinger technique.
    • IMP: A hypervascular tumor at RIGHT sacral region s/p TAE.
  • 2020-04-21 Embolization (TAE) - abdomen
    • TACE of bil. HCCs via right common femoral artery puncture using Seldinger technique
    • IMP: HCCs at both hepatic lobes s/p TACE.
  • 2020-02-06 Embolization (TAE) - abdomen
    • TACE of bil. HCCs via right common femoral artery puncture using Seldinger technique
      
    • IMP: HCCs at both hepatic lobes s/p TACE.
  • 2020-01-07 Embolization (TAE) - abdomen
    • TACE of left HCCs via right common femoral artery puncture using Seldinger technique
    • IMP: HCCs at left hepatic lobe s/p TACE.
• radiotherapy
  • 2022-02-09 ~ 2022-02-24 - 3600cGy/12 fractions (6 MV photon) to para-L5 metastasis.
• chemoimmunotherapy
  • 2022-10-05 - nivolumab 40mg 1hr + oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
  • 2022-09-13 - oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
  • 2022-08-30 - oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
  • 2022-08-16 - oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
  • 2022-08-02 - oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
  • 2022-07-18 - oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
  • 2022-06-29 - oxaliplatin 85mg/m2 139mg 2hr + leucovorin 200mg/m2 300mg 2hr D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 + fluorouracil 600mg/m2 980mg 22hr D1-2
  • 2022-06-15 - oxaliplatin 85mg/m2 138mg 2hr + leucovorin 200mg/m2 300mg 2hr D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 + fluorouracil 600mg/m2 970mg 22hr D1-2
  • 2022-05-30 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 + fluorouracil 600mg/m2 980mg 22hr D1-2
  • 2022-04-28 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 + fluorouracil 600mg/m2 980mg 22hr D1-2
  • 2022-04-15 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr D1-2 + fluorouracil 400mg/m2 600mg 10min D1-2 + fluorouracil 600mg/m2 980mg 22hr D1-2
  • 2022-03-31 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr D1 + fluorouracil 400mg/m2 650mg 10min D1 + fluorouracil 2800mg/m2 4600mg 46hr D1-2
  • 2022-03-18 - oxaliplatin 70mg/m2 100mg 2hr + leucovorin 400mg/m2 650mg 2hr D1 + fluorouracil 400mg/m2 650mg 10min D1 + fluorouracil 2800mg/m2 4600mg 46hr D1-2
  • 2021-08-26 - cisplatin 40mg/m2 67mg 2hr + fluorouracil 1000mg/m2 3380mg 46hr
  • 2021-08-10 - cisplatin 40mg/m2 67mg 2hr + fluorouracil 1000mg/m2 3340mg 46hr
  • 2021-07-27 - cisplatin 40mg/m2 67mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
  • 2021-07-10 - cisplatin 40mg/m2 68mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
  • 2021-06-15 - cisplatin 40mg/m2 67mg 2hr + fluorouracil 1000mg/m2 3390mg 46hr
  • 2021-05-31 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3380mg 46hr
  • 2021-05-10 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3300mg 46hr
  • 2021-04-23 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3340mg 46hr
  • 2021-04-09 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3360mg 46hr
  • 2021-03-25 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3360mg 46hr
  • 2021-03-12 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
  • 2020-12-05 ~ 2021-02 - Stivarga (regorafenib) 160mg QD
  • 2020-06-02 ~ 2020-11 - Nexavar (sorafenib) 400mg BIDAC

220630

[assessment]

• A slight increase in AFP has been observed
  • 2022-03-18 16.9 ng/mL
  • 2022-03-07 12.2 ng/mL
  • 2022-01-05 11.0 ng/mL
• The use of sorafenib and regorafenib was conducted from 2020-06 to 2021-02, nivolumab could also be considered optionally.

220531

[assessment]

• This patient has been diagnosed with advanced HCC with spine mets and suspected lung mets. He underwent excision of the malignant tumour near L5 in January 2022, and a CT scan in March 2022 revealed the progressive destruction of bone at right pelvis.
• Previously, he has received sorafenib (2020-06 ~ 2020-10), rorafenib (2020-12 ~ 2021-02), cisplatin with 5-Fu (2021-08 ~ 2021-02), and now FOLFOX4 (since 2022-03). Additionally, he had 4 TAEs on 2020-01-07, 2020-02-06, 2020-04-21, and 2022-01-10 (sacral).
• Multikinase inhibitors and first line systemic chemotherapy have been tried. These treatments have been shown to be some effective in published studies. ( https://pubmed.ncbi.nlm.nih.gov/33869060/ ) Despite some studies showing a relatively limited efficacy of chemotherapy. ( https://bmccancer.biomedcentral.com/track/pdf/10.1186/s12885-018-5173-0.pdf )
• There are several second line treatments for advanced HCC including cabozantinib. ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8863772/ ) However, these drugs are rarely covered by national health insurance currently for advanced HCC.
• The lab data on 2022-05-30 showed grossly normal results. No issue with active prescription.

220106

{drug interaction}

combination use of H2 antagonist (Famotidine) and PPI (Rabeprazole) might enhance gastric acid suppression, might also increase the potential risk of Clostridioides difficile infection.

references: - https://accpjournals.onlinelibrary.wiley.com/doi/epdf/10.1002/phar.1665 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246810/pdf/ciaa545.pdf

700336877

221005

• exam findings
  • 2022-10-03 KUB
    • S/P metalic autosuture at the rectum.
    • Few calcification projecting at left renal area are noted.
  • 2022-10-03 CXR
    • Patchy opacity projecting at left upper lung zone and multiple nodular opacity projecting in both lung are noted that may be metastases. Please correlate with CT.
  • 2022-09-30 SONO - nephrology
    • Bilateral renal stones
    • Right renal cyst
  • 2022-09-09 MRI - brain
    • Left frontal tumor with mass effect. Suspected high-grade glioma.
  • 2022-09-07 CT - brain
    • an intra-axial tumor in the left frontal lobe. suspected GBM.
    • a large tumor in the left frontal region. Please correlate with contrast-enhanced study or MRI.
    • 12mm midline shift to the right side.
  • 2022-09-07 CXR
    • Patch density at LUL.
    • Multiple nodules at bil. lungs.

700704174

221005

{colon cancer}

[objective]

• past history
  • Type 2 diabetes mellitus was diagnosed for months.
    • Kludone MR 60mg 1# po BID
    • Galvus Met 1# po BID
    • Zulitor F.C 4mg 0.5# po QN
  • Hepatitis B carrier, fatty liver for 10+ years under regular follow up at NTUH
    • Baraclude 0.5mg 1# po QDAC
  • History of operation:
    • Laparoscopic anterior resection and anastomosis-malignant on 2019/10/14.
• lab data
  • UGT1A1 showed 1:67
  • 2022-06-15 P.jiroveci DNA (Bronchial washing) Undetectable
  • 2022-06-13 Aspergillus Ag Negative
    
  • 2022-06-13 Aspergillus Ag Value 0.09 Ratio
    
  • 2022-06-09 MTBC PCR NOT DETECTED
    
  • 2022-06-09 MTBC PCR Value <131 CFU/ml
    
  • 2022-06-06 Aspergillus Ag Negative
    
  • 2022-06-06 Aspergillus Ag Value 0.11 Ratio
    
  • 2022-06-06 Anti-ds DNA Antibody <0.5 IU/ml
    
  • 2022-06-06 Anti-cardiolipin-IgM 2.1 MPL U/mL
    
  • 2022-06-06 Anti-Cardiolopin IgG 0.8 GPL-U/mL
    
  • 2022-06-06 Anti-ENA Sm 2.0 EliA U/ml
    
  • 2022-06-06 Anti-ENA RNP 0.5 EliA U/ml
    
  • 2022-06-06 Anti-ENA(Jo-1) EliA U/ml
    
  • 2022-06-06 Anti Jo-1 antibody <0.3 EliA U/ml
    
  • 2022-06-06 Anti-ENA (Scl-70) EliA U/ml
    
  • 2022-06-06 Anti-ENA Scl-70 Ab <0.6 EliA U/ml
    
  • 2022-06-06 Anti ENA(Ro,La) EliA U/ml
    
  • 2022-06-06 Anti-ENA SS-A(Ro) 0.3 EliA U/ml
    
  • 2022-06-06 Anti-ENA SS-B(La) <0.3 EliA U/ml
    
  • 2022-06-06 PR3 Negative IU/ml
    
  • 2022-06-06 PR3 Value <0.2 IU/ml
    
  • 2022-06-06 MPO Negative
    
  • 2022-06-06 MPO Value <0.2 IU/ml
    
  • 2022-06-06 ANA Negative
    
  • 2022-06-04 Cryptococcus Ag Negative
    
  • 2022-06-04 RF <10 IU/mL
    
  • 2022-06-03 LA1 39.5 sec
    
  • 2022-06-03 LA2 34.0 sec
    
  • 2022-06-03 LA1/LA2 ratio 1.0
    
  • HbA1c
    • 2022-06-30 HbA1c 6.4 %
      
    • 2022-04-07 HbA1c 6.9 %
      
    • 2022-01-10 HbA1c 6.5 %
      
    • 2021-11-11 HbA1c 8.2 %
      
    • 2021-09-07 HbA1c 8.9 %
      
    • 2021-04-12 HbA1c 7.5 %
      
    • 2021-01-14 HbA1c 8.3 %
      
    • 2020-10-22 HbA1c 6.6 %
      
    • 2020-07-31 HbA1c 7.2 %
      
    • 2020-05-07 HbA1c 8.1 %
      
    • 2020-02-14 HbA1C 7.7 %
      
    • 2019-10-06 HbA1C 10.7 %
      
  • CEA
    • 2022-06-24 CEA 7.40 ng/mL
      
    • 2022-05-24 CEA 4.26 ng/mL
      
    • 2022-04-15 CEA 2.44 ng/mL
      
    • 2022-03-18 CEA 1.79 ng/mL
      
    • 2022-02-16 CEA 2.21 ng/mL
      
    • 2022-01-19 CEA 2.04 ng/mL
      
    • 2021-12-22 CEA 2.49 ng/mL
      
    • 2021-12-03 CEA 2.57 ng/mL
      
    • 2021-11-16 CEA 3.33 ng/mL
      
    • 2021-10-20 CEA 3.76 ng/mL
      
    • 2021-09-28 CEA 2.28 ng/mL
      
    • 2021-09-07 CEA 3.19 ng/mL
      
    • 2021-07-16 CEA 2.98 ng/mL
      
    • 2021-06-24 CEA 2.27 ng/mL
      
    • 2021-06-02 CEA 3.22 ng/mL
      
    • 2021-04-20 CEA 3.43 ng/mL
      
    • 2021-03-09 CEA 8.40 ng/mL
      
    • 2021-02-05 CEA 6.039 ng/ml
      
    • 2020-11-06 CEA 1.313 ng/ml
      
    • 2020-08-07 CEA 0.761 ng/ml
      
    • 2020-04-15 CEA 1.183 ng/ml
      
    • 2019-12-31 CEA 1.97 ng/mL
      
    • 2019-10-04 CEA 2.38 ng/mL
• exam finding
  • 2022-09-29 CXR
    • Linear and nodular infiltration over both lung are noted. please correlate with clinical condition and CT to R/O lypmphangitic carcinomatosis.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-07-29 Whole body PET scan
    • 1. In comparison with the previous study on 2021/02/24, the previous FDG avid lesion in the C7 spine is a little less evident. However, the FDG avid lesions in the T1 spine, in some right paratracheal and bilateral pulmonary hilar lymph nodes, in diffuse small focal areas in bilateral lung fields and in bilateral adrenal glands are either new or more evident. Multiple metastatic lesions should be considered first.
         
    • 2. Increased FDG uptake in the left aspect of mandible. Osteonecrosis may show this picture. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • 3. Increased FDG uptake in the region about prostate. The nature is to be determined. Please correlate with other clinical findings for further evaluation.
    • 4. Increased FDG uptake in the left shoulder, compatible with arthritis.
  • 2022-06-16 Nerve Conduction Velocity, NCV; Electromyography, EMG
    • Finding (Motor nerve conduction study)
      • Normal distal latency with reduced MNCV and normal CMAP amplitude in the bilateral median nerves.
      • Normal distal latency with reduced MNCV and normal CMAP amplitude in the bilateral ulnar nerves
    • Conclusion
      • Sensorimotor demyelinating polyneuropathy with secondary axonal loss (suspect chemotherapy superimposed with diabetes related). Please correlate with the clinical presentations.
  • 2022-06-09 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/03/10, the lesion in the lower C-spine is slightly more evident, compatible with bone metastasis in slight progression.
    • No prominent change is noted in other bone lesions. Suspected benign lesions in bilateral rib cages, mandible, lower L-spine, bilateral shoulders and knees.
  • 2022-06-10 Patho - lung transbronchial biopsy
    • Lung, LUL, bronchoscopic biopsy — metastatic adenocarcinoma, consistent with colorectal origin
    • Sections show bronchial mucosa with neoplastic glandular cells infiltrating in muscular layer.
    • The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), and TTF-1(-). The results are consistent with metastatic colorectal adenocarcinoma.
  • 2022-06-08 Body fluid cytology - bronchial washing
    • Smears show histiocytes, benign bronchial cells and clusters of atypical hyperchromatic cells with increased N/C ratio.
    • Malignancy is suspected.
    • Please correlate with the clinical presentation.
  • 2022-06-08 Patho - esophageal biopsy
    • EC junction, biopsy — squamous hyperplasia and moderate chronic inflammation.
  • 2022-06-08 MRI - C-spine
    • IMP: Bony metastasis at C7 vertebral body, causing intrapsinal and paraspinal involvement as described. Stationary or mild progression as compared with MRI on 20220311.
  • 2022-06-08 Esophagogastroduodenoscopy (EGD)
    • Diagnosis
      • Reflux esophagitis LA grade A
      • Suspected Barett’s esophagus, s/p biopsy
      • Superficial gastritis, s/p CLO test
      • Duodenal ulcer scar, bulb
    • Suggestion
      • Pursue the result of pathology report and CLO test
  • 2022-06-08 Bronchoscopy
    • Bronchoscopic diagnosis:
      • 1. LUL acute bronchitis
      • 2. No endobronchial lesion
      • 3. Chronic hypertrophic rhinitis
  • 2022-06-07 CT - abdomen, pelvis
    • 1. Post-op at the colon. Rim enhanced nodule (1.6cm) in left paracolic region, stationary.
    • 2. Suspected adrenal metastasis.
    • 3. Diffuse bilateral lung interstitial infiltrates, suspected lymphangitic carcinomatosis.
  • 2022-05-31 CT - lung
    • pulmonary lypmphangitic carcinomatosis, metastatic adrenal tumors, and metastatic Lt supraclavicular and Rt paratracheal LNs, in progression compared with CT on 2022/03/09.
  • 2022-05-24 Walking 6 minutes
    • Conclusion
      • Obstructive ventilatory impairment with both large and small airway involved,resulting dynamic hyperinflation.
      • Fluctuated O2 saturation at resting, with early and prolonged desaturation during exercise, with SaO2 91% nadir
      • during exercise. Emphysema or DPLD with SAD was considered.
    • Suggestion:
      • 1. Check and treat underlying small airway diseases
      • 2. May try bronchodialtor targeting the small airways if symptomatic
      • 3. Exercise training
      • 4. Breahing control wtih purse-lip breathing during exercise
      • 5. f/u HRCT
      • 6. f/u 6-12 months later
  • 2022-05-24 Pulmonary Function Test, PFT
    • Moderate obstructive ventilatory impairement, with both large and small airway involved with partial reversibility
    • Low IC, TLC
    • No hyperinflation, no air-trapping.
    • Normal diffusion capacity
    • High airway resistance
    • Favor COPD, mainly chronic bronchitis
  • 2022-05-10 SONO - articular peripheral soft tissue
    • Impression And Suggestions:
      • Mild left shoulder supraspinatus tendiniti
      • Pain at terminal ranges of motion, compatible with left shoudler adhesive capsulitis.
  • 2022-05-09 CXR
    • Linear infiltration over both lung are noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2022-05-06 SONO - abdomen
    • Diagnosis
      • 1. Fatty liver, mild
      • 2. Renal cyst, left
      • 3. pancreatic body masked by gas.
    • Suggestion
      • 1. encourage exercise and diet adjustment.
  • 2022-03-11 MRI - C-spine
    • Findings
      • 1. General bulging disc with central disc protrusion, posterolateral osteophytes and enlarged facets causing spinal canal stenosis and bilateral neuroforaminal narrowing at C3-4-5-6, most severe at C5-6.
      • 2. Collapse of C7 vertebral body with T1- and T2-hypointensity and poor enhancement. Similar intensity also noted in its spinous process, indicating bony metastasis. Posterior bony displacement causing spinal canal stenosis and cord compression also noted.
      • 3. No intramedullary abnormality.
    • IMP:
      • Bony metastasis at C7 vertebral body. Stationary as compared with MRI on 20210726.
  • 2022-03-10 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2021/11/24, no prominent change is noted in the lesion in the lower C-spine, compatible with bone metastasis in stationary status.
  • 2022-03-09 CT - abdomen, pelvis
    • Findings
      • 1. Prior CT identified a rim enhancing lesion and fat component measuring 1.9 x 1.7 cm in left paracolic gutter space is noted again, stable in size and feature. Benign lesion is highly suspected. Follow up is indicated.
      • 2. Prior CT identified One enlarged node measuring 1.2 cm in aortocaval space is not noted in the current CT.
      • 3. Adenoma 1.3 cm and hyperplasia in left adrenal gland show stationary.
      • 4. A renal cyst measuring 0.9 cm in left upper pole is noted.
    • Impression
      • There is no evidence of tumor recurrence.
  • 2021-11-24 Tc-99m MDP whole body bone scan
    • The lesion of increased tracer uptake in a lower C-spine comes to less evident compared to the previous study on 2021-07-27, and no new lesion of increased tracer uptake is noted, suggesting partial response to current therapy.
  • 2021-11-23 MRI - C-spine
    • 1. C7 metastasis, seems stationary
    • 2. Small C4/5/6 central HIVDs with combined spinal canal stenoses.
  • 2021-11-19 CT - abdomen, pelvis
    • Findings
      • 1. Prior CT identified a rim enhancing lesion and fat component measuring 1.9 x 1.7 cm in left paracolic gutter space is noted again, stable in size and feature. Benign lesion is highly suspected. Follow up is indicated.
      • 2. One enlarged node measuring 1.2 cm in aortocaval space is noted.
      • 3. Adenoma 1.3 cm and hyperplasia in left adrenal gland show stationary.
      • 4. A renal cyst measuring 0.9 cm in left upper pole is noted.
    • IMP:
      • 1. One enlarged node 1.2 cm in aortocaval space is noted.
  • 2021-08-25 SONO - abdomen
    • fatty liver, mild
  • 2021-07-28 CT - abdomen, pelvis
    • 1. Prior CT identified a rim enhancing lesion and fat component measuring 1.9 x 1.7 cm in left paracolic gutter space is noted again, stable in size and feature. Benign lesion is highly suspected. Follow up is indicated.
         
    • 2. Prior CT identified several enlarged nodes in para-aortic space and para-cava space are not noted again that may be metastatic nodes S/P C/T show complete response.
  • 2021-07-27 Tc-99m MDP whole body bone scan
    • 1. Prominently increased activity in a lower C-spine. Bone metastasis may show this picture.
    • 2. Mildly increased activity in the lower L-spines. Degenerative change is more likely. Please correlate with other imaging modalities for further evaluation.
    • 3. Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • 4. Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • 5. Increased activity in bilateral shoulders and knees, compatible with benign joint lesions.
  • 2021-07-26 MRI - C-spine
    • indication: Sigmoid cancer with lymph node metastasis s/p Laparoscopic anterior resection and anastomosis-malignant on 2019/10/14, pT3N2bM0, stage IIIC s/p adjuvant chemotherapy with tumor recurrence and C7 spine metastasis, rcTxN0M1a, r-staging IVA
    • Bony metastasis at C7 vertebral body.
  • 2021-03-23 SONO - abdomen
    • probably fatty liver
  • 2021-03-17 MRI, C-spine:
    • bony spinal canal stenosis in the middle and lower C-spine.
    • degenerative change in the middle and lower C-spine disc spaces
    • a heterogeneous enhancing tumor at C7 vertebral body.
      
    • degerative change at lower C-spine facet joints.
  • 2021-03-09 sigmoidoscopy:
    • negative finding up to D-colon.
    • no evidence of local recurrence.
  • 2021-02-27 whole body PET scan:
    • a glucose hypermetabolic lesion in the rectal region, probably tumor recurrence.
      
    • glucose hypermetabolic lesion at the C7 spine, probably tumor with distant metastasis.
    • increased FDG uptake in bilateral pulmonary hilar regions and the right shoulder, benign change is more likely.
    • s-colon cancer s/p treatment with tumor recurrence and C7 spine metastasis, rcTxN0M1a, r-staging IVA (AJCC 8th edi.)
  • 2021-02-22 CT, abdomen:
    • tumor seeding in left paracolic gutter space is suspected. the differential diagnosis include epiploic appendagitis or omentum infarction.
    • metastatic nodes in para-aortic space and para-cava space are suspected.
  • 2020-05-07 CT, abdomen, pelvis:
    • colon cancer s/p operation. focal fat stranding at LUQ without interval change.
    • left adrenal nodule (1.3cm) without interval change.
  • 2020-05-07 sigmoidoscopy: no evidence of recurrence
  • 2019-10-16 patho:
    • sigmoid colon, laparoscopic sigmoid colectomy - adenocarcinoma
    • lymph node, mesocolic, dissection - positive for tumor metastasis (8/18) with extracapsular extension (6/8)
    • AJCC pathologic stage - pT3N2bMx, stage IIIC at least B.
  • 2020-01-16 CT, abdomen:
    • colon cancer s/p operation. focal fat stranding at LUQ.
    • left adrenal nodule (1.3cm).
  • 2019-10-14 laparoscopic anterior resection and anastomosis-malignant, finding:
    • sigmoid cancer 533cm near D-S junction with nearly total obstruction
    • splenic flexure was fully mobilized
  • 2019-10-03 colonofiberoscopy: an ulcerative lesion with lumen narrowing at 30 cm to 40 cm from anal verge and biopsy was done. impression: suspicion of sigmoid colon tumor.
  • 2019-10-03 CT, abdomen:
    • wall thickening of sigmoid colon, 4.4 cm in length, with perifocal fat stranding.
    • sigmoid colon cancer T3N1MX.
  • 2019-09-20 screening for malignant neoplasm, colon: stool occult blood test positive
• consultation
  • 2022-10-05 Oral and Maxillofacial Surgery
    • Q
      • for osteonecrosis of jaw evaluate
      • This 58-year-old man patient is a case of adenocarcinoma of sigmoid with obstruction post laparoscopic anterior resection pT3N2bM0 stage IIIC for twelfth FOLFOX6 adjuvant chmotherapy; ECOG: 1, and Xgavex therapy, now, his tooth loss one, so we need your help for osteonecrosis of jaw evaluate. Thank you.
    • A
      • The exam will be arranged today.
  • 2021-09-13 Metabolism and Endocrinology
    • Q
      • This 57-year-old man patieitn is a case of Sigmoid cancer with LN metas s/p Laparoscopic, pT3N2bM0, stage IIIC s/p C/T with recurrence and boneas, rcTxN0M1a, r-staging IVA. He was admitted for chemotherapy with Avastin(C8)/FOLFIRI(C5D1) from 2021/09/09~2021/09/11. This time, for Type 2 diabetes mellitus with OHA control (Kludone MR 60mg 0.5# po QDAC, Galvus Met 1# po BID, Tulip F.C 20mg 1# po QD), But, HbA1c progression(20210412 showed 7.5%, 20210907 showed 8.9%). Now, for evaluate Type 2 diabetes mellitus with OHA control therapy. Thank you.     
    • A
      • S: We were consulted for blood sugar control.
      • O
        • BH: 163 cm, BW: 63 Kg
        • Diet: DM diet 1800 kcal/day
        • Medication in OPD: Kludone 1# BID, GalvusMet 1# BID
        • Medication during hospitalization: same as above
        • PE: no cushingoid appearance
        • Na: 140, K: 4.0
        • AST/ALT: 13/7
        • BUN/Cr: 13/0.66 (eGFR: 132.23)
        • F/S:
          • Date 210909 210910
          • QDAC - 253
          • QLAC - -
          • QNAC 246
          • HS -
        • Blood glucose: 238 mg/dL
        • HbA1c: 7.5 -> 8.9
        • Urine ACR: 0.03
        • OPH OPD: in LMD (no record)
        • ACTH/cortisol (8am): 14.2/10.79 (2020/05)
        • PRA/aldo: 0.23/100 (2020/05)
        • Urine VMA/catecholamine: within normal range (2020/05)
        • DHEA-S: 198 (2020/05)
        • Testosterone: 343.59 (2020/05)
        • Abd. CT: (2021/07/28)
          • 1. Adenoma 1.3 cm in left adrenal gland shows stationary.
          • 2. Hyperplasia of left adrenal gland is also noted.
      • A:
        • 1. Type 2 DM, poor control
        • 2. Left adrenal adenoma and hyperplasia
        • 3. Recurrent sigmoid CA
      • Suggestions:
        • 1. Check F/S TIDAC + HS (please confirm timed quantification of each meal)
        • 2. DC GalvusMet, Kludone
        • 3. Give Apidra 3U TIDAC and adjust with correction scales
          • F/S < 080, Apidra hold
          • F/S 081~100, Apidra -2U
          • F/S 201~250, Apidra +1U
          • F/S 251~300, Apidra +2U
          • F/S > 300, Apidra +3U
        • 4. Give Tresiba 8U HS and adjust as below
          • F/S QDAC < 100 (for 1 day), Tresiba -2U
          • F/S QDAC > 150 (for consecutive 3 days), Tresiba +2U (each adjustment is for the day)
        • 5. Adrenal incidentaloma survey is not feasible for now (steroid use on 20210909 and will be discharged on 20210912). We will arrange in OPD later.
        • 6. Adrenal gland malignancy or metastasis should be ruled out: check DHEA-S
        • 7. Meta-OPD F/U, contact us if any problem
  • 2021-04-21 Neurology
    • Q
      • Vertigo was noted since 2021/3 post chemotherapy, we need your help for further management, thanks a lot.
    • A
      • S
        • Persistent transient vertigo episodes aggravate by lying down or fast head movement and relieved by avoiding head movement for about 1 month. Minimal tinnitus without ear infection also present. Headache, limb weakness or clumsiness was denied. Vertigo association with body position change is also denied
      • O
        • Consciouenss: clear, E4V5M6
        • Language: normal
        • Visual field: normal
        • EOM: free , no nystagmus
        • HINTs exam: intact
        • Pupil: 3.0/3.0 mm, Light reflex: +/+
        • Face: symmetrical
        • Muscle power: full
        • DTR: ++/++
        • Coordination: FNF & HKS intact, no truncal titubation
        • BabinskI sign: down/down
        • Sensory: decrease pinprick distal finger and toes
        • Gait: intact
      • Impression:
        • BPPV, suspected chemotherapy side effect
      • Plan
        • 1. Meclizine 25mg 1# BID or Diphenidol 25mg 1# tid
        • 2. May arrange MRA brain with/without contrast to rule out brain metastasis
  • 2021-04-20 ENT
    • Q
      • Vertigo was noted since 2021/3 post chemotherapy, we need your help for further management, thanks a lot.
    • A
      • S
        • Vertigo for 1 month.
        • Spinning(+), imbalance(-) neck soreness(-), headache(-) hearing loss (-) tinnitus(+, mild, R, jijijiao) Recent URI(-)
        • Duration: secs
        • Aggravates: when lying down
        • Reliever : remain still
        • Association : nausea(-) vomiting(-)
      • PE
        • Ear drum: intact
        • VFT
          • No spontaneous, positional, positioning nystagmus
          • finger nose finger: ok
          • Rapid alternative movement: ok
          • Romberg test: ok
          • Steping test: ok
          • Tandem gait: ok
        • Dix-Hallpike test: left geotropic torsional nystagmus s/p Epley maneuver
      • Imp: L p-BPPV
      • Plan:
        • 1. Educated patient about BPPV
        • 2. ENT OPD f/u if s/s persist
  • 2021-03-16 Oral and Maxillofacial Surgery
    • Q
      • Now, for Xgavex therapy, for evaluate tooth for prevention ONJ. Thank you.
    • A
      • S
        • After examining the patient’s dental condition based on panoramic film and intraoral examination, retained root of tooth 16 and apical lesion of tooth 37 was noted.
      • O:
        • 1. Retained root of tooth 16
        • 2. Apical periodontitis of tooth 36 with percussion
        • 3. Benign looking calcification of right mandibluar angle
      • A:
        • 1. Retained root of tooth 16
        • 2. Chronic apical lesion of tooth 36
      • P:
        • 1. Explain the findings to the patient
        • 2. Suggest dental extraction of retained root of tooth 16 and dental root canal treatment of tooth 36
  • 2021-03-15 Dentistry
    • Q
      • Now, for Xgavex therapy, for evaluate tooth for prevention ONJ. Thank you.
    • A
      • Intra-oral examination, a gum boil over lower left molar area is noted .
      • Further root canal therapy or extraction mightbe necessary , suggest consult the oral sergery section for sure.
  • 2021-03-15 Neurosurgery
    • Q
      • Whole body PET scan on 2021/02/24 showed: 1. A glucose hypermetabolic lesion in the rectal region, probably tumor recurrence. 2. Glucose hypermetabolic lesion at the C7 spine, probably tumor with distant metastasis. Now, for evaluate C7 spine metastasis therapy. Thank you.
    • A
      • Suggest arrange C-spine MRI with and without enhancement for further evaluation.
      • Radiotherapy for the suspected metastatic lesion of cervical spine is also the treatment of option.
• chemoimmunotherapy
  • 2022-08-25 - irinotecan 120mg/m2 180mg 90min + leucovorin 300mg/m2 450mg 2hr + fluorouracil 300mg/m2 450mg 10min + fluorouracil 2000mg/m2 3000mg 46hr
  • 2022-08-02 - irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 400mg/m2 600mg 10min + fluorouracil 2400mg/m2 3700mg 46hr
  • 2022-07-11 - bevacizumab 5mg/kg 300mg + irinotecan 150mg/m2 220mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 3800mg 46hr
  • 2022-06-15 - irinotecan 120mg/m2 200mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-11-19 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-10-26 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-10-04 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-09-09 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-08-18 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-07-23 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-06-30 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-06-07 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-05-13 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-04-20 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-04-02 - bevacizumab 5mg/kg 400mg + irinotecan 120mg/m2 230mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-03-18 - irinotecan 120mg/m2 200mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
  • 2020-04-13 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 678mg 2hr + fluorouracil 2800mg/m2 4748mg 40hr
  • 2020-03-30 - oxaliplatin 85mg/m2 143mg 2hr + leucovorin 400mg/m2 675mg 2hr + fluorouracil 2800mg/m2 4737mg 40hr
  • 2020-03-16 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 678mg 2hr + fluorouracil 2800mg/m2 4750mg 40hr
  • 2020-03-02 - oxaliplatin 85mg/m2 143mg 2hr + leucovorin 400mg/m2 673mg 2hr + fluorouracil 2800mg/m2 4700mg 40hr
  • 2020-02-17 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 669mg 2hr + fluorouracil 2800mg/m2 4684mg 40hr
  • 2020-02-03 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4750mg 40hr
  • 2020-01-15 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 669mg 2hr + fluorouracil 2800mg/m2 4600mg 40hr
  • 2021-04-02 ~ undergoing - Xgeva (denosumab) 120mg SC (self-paid)
  • 2021-12-02 ~ 2022-06-13 - Xeloda (capecitabine) 500mg BID
  • 2021-03-18 ~ 2021-11-19 - FOLFIRI, + avastin (bevacizumab) since 2021-04-02
  • 2019-11-04 ~ 2020-04-13 - FOLFOX (7 times)

[not posted?]

• no IHC stains (MSI, MMR) from patho report, no KRAS/NRAS/BRAF/HER2/NTRK found.
• adjuvant treatment with FOLFOX 6 months s/p laparoscopic anterior resection.
• the elevated CEA and CA199, together with PET and MRI imaging in Feb~Mar 2021 showed spine metastasis. the startup FOLFOX might not work anymore.
• shift to FOLFIRI + bevacizumab + denosumab since Apr 2021. the former two are 2nd-line treatment and the last one is for the bone mets.
  • prior to the use of denosumab, dentist has been consulted for evaluating osteonecrosis of the jaw, ONJ.
• patients with the UGT1A1 7/7 genotype may be at increased risk for developing GI toxicity and myelosuppression. dose reduction should be considered in this setting.
• the treatments are followed the NCCN guidelines, no issue found.

[assessment]

• The patient has been experiencing coughing with sticky sputum and shortness of breath over the past week. He is currently being treated with imipenem-cilastatin. A CXR performed on 2022-09-29 revealed infiltration of both lungs and blunted costal-phrenic angles. The results of previous PET and CT images suggested the presence of pulmonary lymphomatic carcinomatosis.
• Blood sugar levels during this hospital stay remained acceptable, however HbA1c slightly increased during the last quarter (2022-09-22 7.0% <- 2022-06-30 6.4%).
• There has been a loss of more than 15 kilograms in the last five months (2022-10-04 49.7kgw <- 2022-05-06 66kgw; 2022-10-05 albumin 2.9g/dL). An increase in intake should be beneficial for this patient.

220804

[assessment]

• 2022-07-29 Whole body PET scan showed the FDG avid lesions in the T1 spine, in some right paratracheal and bilateral pulmonary hilar lymph nodes, in diffuse small focal areas in bilateral lung fields and in bilateral adrenal glands are either new or more evident.

• In recent months, CEA lab data showed an increasing trend

  • 2022-07-21 CEA 8.47 ng/mL
    
  • 2022-06-24 CEA 7.40 ng/mL
    
  • 2022-05-24 CEA 4.26 ng/mL
    
  • 2022-04-15 CEA 2.44 ng/mL
    
  • 2022-03-18 CEA 1.79 ng/mL

• F/S blood sugar level were 200 +- 20 mg/dL, body weight loss: 57kg <- 66kg (2022-06), empagliflozin 25mg QDPC or canagliflozin 100mg QDAC might be an optional add-on.

220712

[assessment]

• HbA1c trend shows that blood sugar level control is improving.
  • 2022-06-30 6.4 %
    
  • 2022-01-10 6.5 %
    
  • 2021-11-11 8.2 %
    
  • 2021-09-07 8.9 %
    
  • 2019-10-06 10.7 %
    
• TPR, BP, SpO2 were stable except for asymptomatic slight tachycardia (114 pulse/min).
• No issue with active prescription.

{visiting the patient}

• I visited the patient at approximately 13:25 2022-07-12.
• The patient stated:
  • 1. Despite various visits to the orthopaedic and rehabilitation OPD, the pain in the left shoulder and arm has not improved. (morphine mitigates the pain)
  • 2. It is difficult for him to sleep well at night because he feels hot. With earlier chemotherapy, this is not the case.
  • 3. During chemotherapy, he still feels nauseated, but after returning home, the nausea has improved and is tolerable.
  • 4. He has nonproductive coughs, and sometimes feels “stagnant” when breathing, and he cannot speak too fast or too long.
  • 5. He feels that his physical strength is not as good as before, so he does not want to exercise or even walk as he once did.
  • 6. When morphine was used at night, the pain became less severe and the sleep became more restful. He asked if it would be possible overdose or become addicted to morphine by taking it.
• I explained to the patient:
  • 1. Morphine is not likely to cause overdose or addiction based on the current dosage and usage.
  • 2. I encourged the patient to maintain a regular exercise regimen in order to keep muscle strength.
• No other medication-related questions raised by the patient.
• It appeared that his lung function was gradually deteriorating. Regular follow-up might be necessary.

210726

[colon cancer]

• adjuvant treatment with FOLFOX 6 months s/p laparoscopic anterior resection on 2019-10-14 inhibited the tumor for 1+ year.
• the elevated CEA and CA199, together with PET and MRI imaging in Feb~Mar 2021 showed spine metastasis, meaning the startup FOLFOX might not work anymore.
• shift to FOLFIRI + bevacizumab + denosumab since Apr 2021. the former two are 2nd-line treatment and the last one is for the bone mets.
  • prior to the use of denosumab, dentist has been consulted for evaluating osteonecrosis of the jaw, ONJ.
  • the slight elevated CEA and CA199 in 2021 July probably hinted a decreasing response to the current treatment.
• MMR proficient, pembrolizumab or novolumab might not be indicated.
• EGFR(+), cetuximab or panitumumab might be indicated.
• BRAF V600E lab data not found, vemurafenib, dabrafenib, encorafenib might not be indicated.
• regorafenib might be indicated for the next-line treatment (after having 5-FU, OX, IRI based chemo regimen and anti-VEGF agent while KRAS wild type, under the scope of benefits of NHI).

[type 2 DM]

• lab data showed serum glucose (AC) ranging 142~191mg/dL, HbA1c 6.6~8.3% since May 2020.
• prescribed anti-DM agents such as metformin, gliclazide, vildagliptin were listed in PharmaCloud, could be set as ‘self-carried’ items if needed.

[dyslipidemia]

• triglyceride, cholesterol total lab data were within normal range these months, no special issue found.

[assessment]

• no IHC stains (MSI, MMR) from patho report, no KRAS/NRAS/BRAF/HER2/NTRK found.
• adjuvant treatment with FOLFOX 6 months s/p laparoscopic anterior resection.
• the elevated CEA and CA199, together with PET and MRI imaging in Feb~Mar 2021 showed spine metastasis. the startup FOLFOX might not work anymore.
• shift to FOLFIRI + bevacizumab + denosumab since Apr 2021. the former two are 2nd-line treatment and the last one is for the bone mets.
  • prior to the use of denosumab, dentist has been consulted for evaluating osteonecrosis of the jaw, ONJ.
• the treatments are followed the NCCN guidelines, no issue found.

210315

{felt fatigue in prior chemo}

• visiting the patient at 09:47 on 2021-03-15, he is wide awake, this patient has not been administrated chemo regimen yet since this admission, in prior to the chemo course, consultations for C7 spinal segment and ONJ are arranged (based on his PET scan outcome).

• he says he felt fatigue after chemo been started 2-3 days in the prior course.

• HbA1c 8.3% and serum glucose (AC) 191mg/dL reported on 2021-01-14, no newer data available, could be followed up if necessary.

700856538

221005

• lab data
  • 2022-03-18 EGFR基因突變檢測
    
  • 2022-03-18 EGFR specimen number S2022-3327
    
  • 2022-03-18 EGFR G719X not detected
    
  • 2022-03-18 EGFR Exon19 del detected
    
  • 2022-03-18 EGFR S768I not detected
    
  • 2022-03-18 EGFR T790M not detected
    
  • 2022-03-18 EGFR Exon20 ins not detected
    
  • 2022-03-18 EGFR L858R not detected
    
  • 2022-03-18 EGFR L861Q not detected
    
  • 2022-03-16 PD-L1 (22C3) specimen number S2022-3327
    
  • 2022-03-16 PD-L1 (22C3) TPS < 1%
    
  • 2022-03-14 Anti-HCV Nonreactive
    
  • 2022-03-14 Anti-HCV Value 0.05 S/CO
    
  • 2022-03-14 HBsAg Nonreactive
    
  • 2022-03-14 HBsAg (Value) 0.34 S/CO
    
  • 2022-03-14 Anti-HBs 23.31 mIU/mL
    
  • 2022-03-14 P.jiroveci DNA (Quality) Positive
    
  • 2022-03-09 Aspergillus Ag Value 0.15 Ratio
• exam finding
  • 2022-09-28 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/07/07, the lesion in the lower T-spine is a little less evident, indicating response to current therapy or benign lesion in resolution.
    • Suspected benign lesions in the skull, bilateral rib cages, L5-sacrum junction, bilateral shoulders, hips, knees, and right foot.
  • 2022-09-27 CT - chest
    • Dx: Right middle lobe Lung cancer, adenocarcinoma, T4N1M1c with brain, bone metastasis, ECOG 1,
    • Findings
      • Lungs:
        • s/p RML lobectomy with surgical staple line over anterior lung region, along anterior major fissure.
        • a 6mm nodule in LUL and a 3mm nodule in RUL.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels:
        • Aorta: normal appearance of thoracic aorta and central pulmonary arteries.
        • Heart: normal in size of cardiac chambers.
      • Pleura: a small loculated effusion along anterior Rt major fissure
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents:
        • normal appearance of gallbladder. no focal lesion in visible portion of the liver, spleen, both adrenal glands, pancreas, and kidney. no enlarged lymph node.
      • Visualized bones: no destructive lytic or blastic change even at T9 spinal process depicted on 2022/03/09 MRI exam.
        • nonenhanced axial brain CT shows: no space taking in the brain.
    • Impression:
      • post op change in Rt lung. LUL 6mm nodule and RUL 3mm nodule.
  • 2022-09-26 CXR
    • increased density over of Rt hilar shadow s/p RML lobectomy with surgical staple line over perihilar lung region
    • Rt phrenic peak
  • 2022-07-07 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/03/03, the lesion in the lower T-spine is a little more evident.
    • Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
  • 2022-07-06 MRI - brain
    • no evidence of brain metastasis.
  • 2022-07-05 CT - chest
    • post op change in Rt lung. no abnormal new nodule or mass in both lungs.
  • 2022-03-09 MRI - T-spine
    • Bony metasatsis at spinous process of T9 vertebral body. (due to a lung cancer in RLL?)
  • 2022-03-08 Patho - lung total/lebe/segmental
    • Pathologic Diagnosis:
      • Lung, right, middle lobe, lobectomy —- Adenocarcinoma, poorly differentiated
      • Lung, right, upper lobe, wedge resection —- Adenocarcinoma, by direct invasion
      • Lymph node, group No.2+4, lymphadenectomy —- Negative for malignancy (0/2)
      • Lymph node, group No.7, lymphadenectomy —- Negative for malignancy (0/1)
      • Lymph node, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
      • AJCC 8th edition pTNM Pathology stage: pStage IVA, pT3N0M1a
    • Microscopic Description
      • Tumor Focality:Separate tumor nodules of same histopathologic type (intrapulmonary metastases) in same lobe
        
      • Histologic Type (select all that apply): Invasive adenocarcinoma, solid predominant (60 %);
        • The immunohistochemical stains reveal TTF-1(+), CDX2(focal weak +), CD56(focal +), and p40(-).
        • Other subtypes present (specify subtype(s), may also include percentages): acinar: 30%; micropapillary: 10%.
          
      • Histologic Grade: G3: Poorly differentiated
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Present (PL2)
      • Lymphovascular Invasion (select all that apply): Present, Lymphatic and Venous
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 0.2 cm
        • Specify closest margin:
          • RML: bronchial resection margin
          • RUL: wedge resection margin: 0.3 cm
            
      • Treatment Effect: No known presurgical therapy
      • Regional Lymph Nodes: group 2+4: 0/2; group 7: 0/1; group 9: 0/1
      • Extranodal Extension: Not identified
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): absent
          • Primary Tumor (pT): pT3: separate tumor nodule(s) in the same lobe as the primary
          • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): pM1a: Separate tumor nodule(s) in contralateral lobe; tumor with pleural or pericardial nodules or malignant pleural (or pericardial) effusion
      • Additional Pathologic Findings (select all that apply): None identified
  • 2022-03-04 MRI - brain
    • Brain metastases, right frontal periventricular white matter and right frontal cortex.
  • 2022-03-04 Cardiopulmonary Exercise Testing
    • Conclusion
      • submaximal exercise
      • low exercise capacity (VO2 52%, WR 77%)
      • low stroke volume response during exercise
      • slow HR response
      • small airway disease (FVC 86%, FEV1 77%, MMEF 53%)
      • normal respiratory muscle strength (MIP 84%, MEP 96%)
    • Suggestion:
      • treat underlying condition
      • survey and treat cardiac function
      • small airway disease, give bronchodilator
      • arrange pulmonary rehab with exercise training
  • 2022-03-03 Tc-99m MDP whole body bone scan
    • Prominently increased activity in the lower T-spine. The nature is to be determined. Please correlate with other imaging modalities for further evaluation and to rule out the possibility of bone metastasis.
    • Mildly increased activity in the L5-sacrum junction. Degenerative change may show this picture.
    • Some faint hot spots in the skull and bilateral rib cages (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2022-03-02 Patho - lung transbronchial biopsy
    • Lung, RML, CT-guide biopsy — adenocarcinoma, poorly differentiated
    • Sections show solid nests and acinar glandular cells infiltrating in a fibrotic stroma with focal tumor necrosis.
    • The immunohistochemical stains reveal CK7(+), CK20(-), TTF-1(+), CDX2(focal +), p40(-), and CD56(focal +). The results are supportive for the diagnosis.
  • 2022-03-02 CXR
    • A well defined mass (36 mm) over RML, favor a malignant tumor
    • Rt apicolateral pneumothorax s/p transthoracic needle biopsy of RML nodule.
  • 2022-02-07 CT - abdomen, pelvis
    • History and indication:
      • A case of rectal carcinoid (NET) s/p TAMIS local excision
    • Findings
      • A pathcy density (4.5cm) at RML with pericardial invasion. Some nodules at bil. lungs.
      • S/P rectal operation.
      • Right renal angiomyolipoma (3.0cm).
      • Left adrenal nodule (7mm).
      • Right liver cyst (4mm).
      • Metastases in spine.
      • Normal appearance of spleen, pancreas.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T: T3 (T_value) N: N0(N_value) M: M1c (M_value) STAGE: IVB (Stage_value)
  • 2022-02-07 Sigmoidoscopy
    • Diagnosis
      • Post OP scar, rectum
      • Mixed hemorrhoid
    • Suggestion
      • OPD f/u
    • Complication
      • No immediate complication
  • 2021-01-04 CT - abdomen
    • S/P rectal operation.
    • Right renal angiomyolipoma (3.0cm).
    • Left adrenal nodule (7mm).
    • A nodule (23mm) at RML.
  • 2019-11-04 CT - abdomen
    • S/P rectal operation.
    • Right renal angiomyolipoma (3.0cm).
    • Left adrenal nodule (7mm).
    • A small nodule (3mm) at RLL.
  • 2019-10-28 Sigmoidfiberscopy
    • Normal mucosal appearance without focal lesion from rectum to near splenic flexure colon (60cm AAV).
    • Previous surgical scar at middle rectum was seen and is fine.
  • 2019-07-05 Surgical pathology level V
    • Rectum, transanal minimally invasive surgery with local excision — Neuroendocrine tumor, G1 (carcinoid)
    • Pathologic Stage: pT1bNx(cMx); Stage I if N0 and cM0
    • The sections show following features:
      • Histologic type and grade: Neuroendocrine tumor, G1 (carcinoid)
        
      • Mitotic rate: <2 mitosis/10 high power fields
        
      • Ki-67 labeling index: <3%
        
      • Tumor extension: Tumor invades the submucosa
        
      • Margins: All margins are uninvolved by tumor
        • Distance of tumor from closest margin: 2 mm
          
      • Lymphvascular invasion: Not identified
        
      • Perineural invasion: Not identified
        
      • IHC: Synaptophysin(+), chromogranin A(-), Ki-67= 1%
        
  • 2019-06-24 CT - abdomen
    • A hepatic cyst 5 mm in S8 is suspected. Please correlate with sonography.
    • An angiomyolipoma 3.2 x 2.5 cm in right kidney lower pole.
    • Submucosal lesion 1 cm in the rectum is suspected.
  • 2019-06-24 Sigmoidfiberscopy
    • Indication: SMT at rectum was noted
    • Findings: The scope was advanced to 30cm AAV. A hard submucosal tumor, 1.5cm in size is locted at low rectum (8cm AAV, right lateral site).
    • Diagnosis: A hard submucosal tumor, 1.5cm in size is locted at low rectum (8cm AAV, right lateral site).
    • Suggestion: TAMIS local excision
  • 2019-06-03 Miniprobe Endoscopic Ultrasound
    • Pre-EUS diagnosis
      • Rectal SMT 　　- Endoscopic Findings
      • A hemispherical lesion with intact mucosa at middle rectal, at the level of 10 cm AAV. 　　- EUS Findings EUS using miniprobe 2R showed a slightly hyperechoic tumor arising from deep mucosa or submucosa, sized 11.2 mm. The consistency of the tumor was elastic firm, and there was no pillow sign. 　　- Diagnosis
      • Rectal submucosal tumor, nature indeterminate 　　- Comment
      • Recommend ESD or transanal surgery for en-blac resection of the tumor.
  • 2019-05-04 Bone densitometry - Hip
    • Left hip, BMD is 0.574 gms/cm2, about 2.1 SD below the peak bone mass (72%) and 1.6 SD below the mean of age-matched people (76%).
    • IMP: Osteopenia
  • 2019-05-03 SONO - abdomen
    • diagnosis
      • Fatty liver, mild
      • Liver cyst, S6.
    • suggestion
      • encourage exercise and diet control
  • 2019-05-03 Flow-volume curve
    • Mild restrictive ventilatory impairment
  • 2019-05-03 Colon fiberoscopy
    • Findings
      • A 1 cm SMT was noted at 10 cm.
      • The scope was inserted to cecum smoothly. Some liquid stool was noted in the colon.
    • Diagnosis
      • Internal hemorrhoid, mild
      • Submucosal tumor, rectum
  • 2018-04-18 Gynecologic ultrasonography
    • S/P lapacoscopy
    • Bilateral ovarian cyst, Suspected endometrioma
    • Uterine myoma
    • Mild Adenomyosis
  • 2018-01-10 Gynecologic ultrasonography
    • Mild Adenomyosis
    • Bilateral ovarian cyst (endometrioma)
  • 2017-10-18 Gynecologic ultrasonography
    • Mild Adenomyosis
    • Lov cyst
• consultation
  • 2022-08-31 Chinese Medicine
    • Q
      • This 49-year-old woman who with past history of
        • 1. significant of rectal cancer status post transanal microscopic surgery on 2019/07/04
        • 2. Right middle lobe Lung cancer, adenocarcinoma, T4N1M1c with brain, bone metastasis, ECOG 1,
          • EGFR mutation: L858R (-), exon 19 (+), ALK(), PD-L1: <1% diagnosed on 2022-03-22, with Giotrif since 20220325. The lung cancer treatment regimen as below:
            • 1st chemotherapy with TKIs with Giotrif since 2022-03-25.
            • Angiogenesis inhibitor C1 Cyramza since 2022-03-22.
              
      • Tracing back the past history, she was referred to chest surgery department because of a pathcy density (4.5cm) noted at RML under abdominal CT on 2022/02/07. According to herself, she received regular outpatient clinic follow up in colorectal department after ectal surgery, and on this February, he was found to have a pathy dendity under abdominal CT. Therefore, she was referred to chest surgery department for further evaluation. On admission, she made no specific complaint. No obvious illnes was told. Physical examination showed no obvious heart murmur. Breath sounds were clear. Chest movements were symmetric. Abdomen was soft, No tenderness nor rebounding pain was observed. Under the impression of solitary lung nodule, she was admitted for further survey.  
      • Mutation report reveal Exon 19 deteced, TKI with Afatinib 30mg 1# QDAC was prescribed. Arrange Angiogenesis inhibitor C1 Ramu 500mg on 2022-03-22, C2 Cyaramza 500mg (charge) on 2022-04-20. There were no fever or chills, no short of breath, no chest pain. Under diagnosis of Lung cancer, adenocarcinoma, T4N1M1c with brain, bone metastasis, she was admitted for on schdule for chemotherapy .     
      • For cancer fatigue, we sincerly your help.
    • A
      • Treatment
        • 1st chemotherapy with TKIs with Giotrif since 20220325.
        • Angiogenesis inhibitor C1 Cyramza since 2022-03-22.
          • C2 Cyaramza 500mg (charge) on 2022-04-20.
          • C3 Cyaramza 500mg (charge) on 2022-07-02.
          • C4 Cyaramza 500mg chemotherapy on 2022-08-03.
      • Past history
        • Rectal cancer status post transanal microscopic surgery on 2019/07/04
        • Right middle lobe Lung cancer, adenocarcinoma, T4N1M1c with brain, bone metastasis, ECOG 1, EGFR mutation: L858R (-), exon 19 (+), ALK(), PD-L1: <1% diagnosed on 2022-03-22, with TKIs with Giotrif since 20220325.
  • 2022-07-07 Metabolism and Endocrinology
    • Q
      • for Cortisol; 0.53 ug/dL 
        • Free-T4 0.83 ng/dL            
        • TSH 0.249 uIU/mL          
          
        • ACTH <5.0 pg/mL  
      • History: Hyperthyroidism, Goiter, rectal carcinoid (NET) s/p TAMIS local excision
    • A
      • This 49-year-old female was a case of right middle lobe lung adenocarcinoma, T4N1M1c with brain, bone metastasis, ECOG 1, was admitted for following up and chemotherapy. We were consulted for low cortisol level and abnormal TFT.
      • O:
        • BW: 56.1 kg
        • HR: 65-100
        • Possible related medication: dexamethasone, clobestasol
        • AST/ALT: 13/16
        • BUN/Cr: 11/0.64
        • Na: 143, K: 4.0
        • TSH/FT4: 0.249/0.83
        • T3: unavailable
        • ACTH/Cortisol: < 5.0/0.53
        • ECG: normal sinus rhythm (2022/03)
      • A:
        • Physiological response of steroid use.
        • Abnormal TFT, DDx: sick euthyroid syndrome, secondary hypothyroidism
      • Suggestions:
        • No need of any supplement of steroid or thyroxine
        • Check T3 and complete pituitary function (IGF-1, FSH/LH, E2, prolactin) in the next lab.
        • Contact us if needed. I’d like to follow up this patient.
  • 2022-07-07 Dermatology
    • Q
      • for paronychia.
    • A
      • This patient suffered erytehamtous patches on bil palme-soles for days.
      • Imp: Hand foot sym
      • Suggestion:
        • Sinpharderm * 1 tubes/bid
        • Topsym cream * 4 tubes/bid
  • 2022-03-09 Thoracic Medicine
    • Q
      • For chemotherapy and target therapy
      • This 49-year-old patient with underlying stage 4 lung cancer has brain metastasis. She had received video assisted thoracoscopic right middle lobe lobectomy on 2022/03/07. We need your help to evaluate if she could receive chemotherapy. Thank you!
    • Impression:
      • Lung cancer, adenocarcinoma, T4N1M1c, stage IVB, with bone, brain metastasis
    • Suggestion:
      • EGFR mutation test
      • Bone RT if severe bone pain
      • We will take over this case after chest tube removed
  • 2022-03-08 Radiation Oncology
    • Q
      • For radiotherapy
    • A
      • S: For radiotherapy due to lung adenocarcinoma with brain metastasis.
        • PI: The patient is a case of adenocarcinoma of the lung, RML, with brain metastasis, s/p 3D VATS, RML lobectomy + RUL wedge + RLND on 2022-03-07. Referred for radiotherapy due to brain metastases.
          
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM(-); HTN(-)
        • Other disease: carcinoid tumor of rectum (?)
        • Previous RT Hx: (-)
      • O: ECOG: 1
        • PE: neck and bil SCF: neg; chest: status on chest tube drainage.
        • CT scan of abdomen (2022-2-7): A pathcy density (4.5cm) at RML. Some nodules at bil. lungs. Lung cancer should be ruled out. S/P rectal operation. Right renal angiomyolipoma (3.0cm). Left adrenal nodule (7mm).
        • CXR (2022-03-01): A well defined mass (36 mm) over Rt central midlung zone, RML, favor a malignant tumor. Nodular opacitiy projecting over tLt lower lung zone due to nipple shadow. Normal shape and size of heart. Costophrenic angles are preserved
        • Bone scan (2022-03-03): Prominently increased activity in the lower T-spine. The nature is to be determined. Please correlate with other imaging modalities for further evaluation and to rule out the possibility of bone metastasis.
        • MRI of brain (2022-03-04): Brain metastases, right frontal periventricular white matter and right frontal cortex.
        • Pathology (S2022-03327, 2022-3-4): Lung, RML, CT-guide biopsy—adenocarcinoma, poorly differentiated
        • Operation (2022-03-07): 3D VATS, RML lobectomy + RUL wedge + RLND. Finding:
          • One tumor lesion was noted over RML, size about 2.0cm in diameter which invade across the horizontal fissure to RUL s/p RML lobectomy + RUL wedge.
          • visceral and parietal pleura tumor seeding
          • abolished bronchioarterial plane which has been devided together.
          • stiff, enlarge and not well-capsuled subcarina and paratrachea lymph node suspected metastasis.
          • one 24 Fr. straight chest tubes were inserted via right 8th ICS.
      • A: Adenocarcinoma of the lung, RML, with brain metastasis, s/p 3D VATS, RML lobectomy + RUL wedge + RLND.
      • P: Radiotherapy is indicated for this patient with the following indicators: brain metastasis
        • Goal: palliation
        • Treatment target and volume: metastatic brain tumors
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 3000cGy/10 fractions of the metastatic brain tumors
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her brother. They understand and would like to receive radiotherapy, The treatment planning of radiotherapy will be started at 1500, 2022-3-11.
• chemoimmunotherapy
  • 2022-08-18 ~ undergoing - Giotrif (afatinib) 30mg/tab 1# QOD
  • 2022-09-26 - Cyramza (ramucirumab) 500mg 1.5hr
  • 2022-08-29 - Cyramza (ramucirumab) 500mg 1.5hr
  • 2022-08-02 - Cyramza (ramucirumab) 500mg 1.5hr
  • 2022-07-08 - Cyramza (ramucirumab) 500mg 1.5hr
  • 2022-04-20 - Cyramza (ramucirumab) 500mg 1.5hr
  • 2022-03-22 - Cyramza (ramucirumab) 500mg 1.5hr

700504868

221004

• lab data

  • 2022-06-30 EGFR specimen number S2022-09386
    
  • 2022-06-30 EGFR G719X not detected
    
  • 2022-06-30 EGFR Exon19 del not detected
    
  • 2022-06-30 EGFR S768I not detected
    
  • 2022-06-30 EGFR T790M detected
    
  • 2022-06-30 EGFR Exon20 ins not detected
    
  • 2022-06-30 EGFR L858R detected
    
  • 2022-06-30 EGFR L861Q not detected
    
  • 2022-05-30 ASMA Positive ; 1:80
    
  • 2022-05-30 AMA Positive ; 1:20
    
  • 2022-05-26 Factor IX assay 78.2 %
    
  • 2022-05-26 Factor VIII assay 103.4 %
    
  • 2022-05-26 Cryoglobulin Negative
    
  • 2022-05-23 ANA Speckled 1:80
    
  • 2022-05-23 Von willebrand factor 224.8 %
    
  • 2022-05-21 PR3 Negative IU/ml
    
  • 2022-05-21 PR3 Value <0.2 IU/ml
    
  • 2022-05-21 MPO Negative
    
  • 2022-05-21 MPO Value <0.2 IU/ml
    
  • 2022-05-21 Anti-ENA SS-A(Ro) 89 EliA U/ml
    
  • 2022-05-21 Anti-ENA SS-B(La) 0.3 EliA U/ml
    
  • 2022-05-21 Anti-ds DNA Antibody 0.8 IU/ml
    
  • 2022-05-21 Anti-Cardiolopin IgG 1.9 GPL-U/mL
    
  • 2022-05-21 Anti-cardiolipin-IgM 62 MPL U/mL
    
  • 2022-05-21 Anti-ENA Sm 2.2 EliA U/ml
    
  • 2022-05-21 Anti-ENA RNP 0.6 EliA U/ml
    
  • 2022-05-19 RF 364.8 IU/mL
    
  • 2022-05-19 C3 118.3 mg/dL
    
  • 2022-05-19 C4 <8 mg/dL
    
  • 2022-05-19 IgG (blood) 1143 mg/dL
    
  • 2020-08-05 PD-L1(22C3) specimen number S2020-09426
    
  • 2020-08-05 PD-L1(22C3) TPS >= 1% and <50%
    
  • 2020-07-30 ROS1 specimen number S2020-09426
    
  • 2020-07-30 ROS1 not detected
    
  • 2020-07-27 ALK IHC specimen number S2020-09426
    
  • 2020-07-27 ALK IHC Negative
    
  • 2020-07-24 EGFR specimen number S2020-09426
    
  • 2020-07-24 EGFR G719X Not detected
    
  • 2020-07-24 EGFR Exon19 del Not detected
    
  • 2020-07-24 EGFR S768I Not detected
    
  • 2020-07-24 EGFR T790M Not detected
    
  • 2020-07-24 EGFR Exon20 ins Not detected
    
  • 2020-07-24 EGFR L858R detected
    
  • 2020-07-24 EGFR L861Q Not detected
    
  • 2020-07-09 Anti-HCV NONREACTIVE
    
  • 2020-07-09 Anti-HCV Value 0.06 S/CO
    
  • 2020-07-09 HBsAg NONREACTIVE
    
  • 2020-07-09 HBsAg (Value) 0.13 S/C value
    
  • 2020-07-09 Anti-HBs 14.17 mIU/mL

• exam finding

  • 2022-10-03 KUB
    • Compression fracture of T11-L2.
    • Stool retention in the bowel.
  • 2022-09-25 CXR
    • Lt pleural thickening?
    • increased opacity over Lt lower hemithorax with obliteration of hemidiaphgram and Lt shift of heart
    • a poorly defined nodular opacity at RUL, and subtle LUL nodule, stationary
    • Osteoblastic metastasis in many vertebrae
    • Mild dextroscoliosis of the T-spine
      
    • mild cardiomegaly
  • 2022-09-26 SONO - chest
    • No pleural effusion.
    • Left lower lung consolidation.
  • 2022-09-16 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/05/16, all the previous bone lesions are more eivdent and some new bone lesions are noted, suggesting multiple bone metastases in progression.
  • 2022-09-15 MRI - T-spine
    • Known a case of lung cancer. Abnormal enhancing lobulated mass lesion (>4.2cm) over left lateral mass of T2-T3-T4 and spinous process, causing severe spinal stenosis and compression of thoracic cord. Abnormal marrow enhancement of T2-T3 vertebral bodies. Compatible with metastases.
    • Also abnormal enhancing lesions over T9 & T12 spinous process.
    • Also abnormal marrow enhancement of T12 and L1 vertebral bodies. Favor metastatic lesions.
  • 2022-09-14 Eelectroencephalogram, EEG
    • This EEG study recorded background alpha rhythm (8-9 Hz) and plenty beta activity with occasional transient diffuse slow waves.
    • No epileptiform discharge. Please correlate with clinical features
  • 2022-09-14 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
    • Finding
      • MNCV: difficult access to right hand due to IV site. delayed CMAPs onset latency of bilateral peroneal nerves; slow motor conduction velocity of left median, bilateral ulnar nerves across elbow, bilateral peroneal and left tibial nerves
      • SNCV: slow sensory conduction velocity of bilateral ulnar and right median nerves
      • F-wave: delayed responses of bilateral peroneal and tibial nerves
      • H-reflex: delayed responses of bilateral lower limbs
      • Thermal quantitative sensory test showed abnormal warm and cold threshold in left lower limb
    • Conclusion
      • This NCV study suggested bilateral lumbosacral radiculopathy, bilateral ulnar neuropathy across elbow and bilateral median distal neuropathy.
      • Thermal quantitative sensory test suggested small fiber neuropathy.
      • Please correlate with clinical features.
  • 2022-09-13 Humerus Lt
    • avalsion fracture of proximal humerus, involving greater tuberosity, with suspect combined radiolucency
  • 2022-09-07 CXR
    • Lt pleural thickening with minimal pleural effusion
    • large LLL retrocardiac tumor opacity and a poorly defined nodular opacity at RUL, and subtle LUL nodule, stationary
    • Osteoblastic metastasis in many vertebrae
    • Mild dextroscoliosis of the T-spine
      
    • mild cardiomegaly
  • 2022-08-12 CT - lung/mediastinum/pleura
    • Findings
      • Soft tissue mass at left lower lobe up to 7.5cm with attachment with parietal and visceral pleura is found. In comparison with CT dated on 2022-04-26, the lesion is stationary.
      • Several irregular shaped patch/mass at right upper lobe and other lobes. Stable.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Mild left pleural effusion is found.
      • Calcified coronary arteries is found.
      • Small lymph nodes are found at both sides of the mediastinum.
    • Imp
      • LEFT LOWER LOBE lung cancer with lung to lung meta. Mediastinal lymphadenopathy and bone meta. These lesions are stationary.
  • 2022-08-05 MRI - brain
    • Indication: Lung cancer, LLL, adenocarcinoma, cT4N2M1c, with brain metastasis, with TKI Giotrif since 2020/07/16, Cyramza C1 since 2020/08/05 with disease progression and brain metastasis (n＝3); ECOG ＝1. s/p Brain RT on 2022/6/01.
    • Findings
      • multiple enhancing nodules at the left frontal cortex, left occipital cortex, and right anterior insula, compatible with brain metastases. Most of the tumors are stationary or smaller. But the one at left anterior frontal lobe is enlarged (1.3m) with increased extent of vasogenic edema.
      • mild brain atrophy with prominent sulci, fissures and dilated ventricles.
      • multiple nonspecific hyperintense patches in T2WI at bilateral periventricular white matter, leukoaraiosis is considered.
      • no midline shift nor brain herniation.
      • no abnormal bright up on DWI.
      • unremarkable skull base and calvarial vault.
    • Impression:
      • Multiple brain metastases, the one at left anterior frontal lobe is enlarged (1.3cm).
      • Brain atrophy and leukoaraiosis.
  • 2022-06-09 Patho - bronchus biopsy
    • Lung, left, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show neoplastic acinar glandular cells infiltrating in a fibrotic stroma with focal tumor necrosis.
  • 2022-06-08 Whole body PET scan
    • Glucose hypermetabolic lesions in the left lower lung as well as left pleural effusion, compatible with the primary lung cancer with malignant pleural effusion.
      
    • Glucose hypermetabolic lesions in several lung lobes, highly suspected lung cancer with lung to lung metastases.
      
    • Glucose hypermetabolic lesions in bilateral pulmonary hilar and mediastinal lymph nodes, highly suspected lung cancer with regional lymph nodes metastases.
      
    • Glucose hypermetabolic lesions in the left adrenal region and multiple skeleton as above-mentioned, highly suspected lung cancer with distant metastases.
    • Increased FDG uptake in the right lobe of the thyroid gland, probably lung cancer with thyroid metastasis or another primary cancer of thyroid, suggesting further investigation.
      
    • Left lower lung cancer with left pleura, bilateral lung lobes, bilateral regional lymph nodes, left adrenal and multiple bone mets, cT4N3M1c, stage IVB (AJCC, 8th ed.), by this F-18 FDG PET scan.
      
  • 2022-05-16 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2021/12/24, two lesions in the left 11th costovertebral junction and in a upper T-spine are new, and the nature is to be determined, suggesting follow-up with bone scan in 3-6 months for investigation.
      
    • Other lesions in the posterior aspect of the left 8th and 9th ribs, respectively, T12 spine, L3 spine, right femoral trochanter, bilateral shoulders, and S-I joints show slightly less evident.
  • 2022-05-14 MRI - brain
    • Enlarged bi-frontal cortical/subcortical nodules with increased perifocal edema at right, another small residual nodule in left anterior part, artifact? stationary.
  • 2022-04-26 CT - chest
    • LLL cancer T4N3M1b, increase in size of priamry tumor and stationary of lung to lung metastatic lesion, left pleura and spine metastases, but newly developed left ribs metastasis as compared with previous CT study on 2021/12/23.
  • 2021-12-24 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2020/12/23, the lesions in the posterior aspect of the left 8th and 9th ribs, some middle and lower T-spines and L3 spine are a little more prominent. Bone metastases in a little more progression should be watched out. Please correlate with other clinical findings for further evaluation.
      
    • No prominent change is noted in other bone lesions.
  • 2021-12-23 CT - chest
    • left lower lobe lung cancer with lung to lung meta and lumbar spine meta. stationary.
  • 2021-12-22 MRI - brain
    • Regressed Small bi-frontal cortical nodules, a residual nodule in left or artifact?
  • 2021-08-26 CT - chest
    • Left lower lobe mass with enlargement. Either tumor progression or mucus impaction is suspected. Suggest contrast enhanced study.
    • Right upper lobe and right lower lobe and left lower lobe nodules. Stationary. cT4N3M1b.
  • 2021-03-11 CT - chest
    • right upper lobe and left lower lobe lung cancer with lung to lung and bone meta. Stable. cT4N3M1b.
  • 2020-12-23 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2020/07/15, one faint hot spot in the posterior aspect of the left 8th rib comes to less evident, but the other faint hot spot in the post. aspect of the left 9th rib becomes more prominent, suggesting bone mets with mixed response to current therapy.
      
    • Increased activity in the T12 spine shows more evident compared with the previous study on 2020/07/15, the nature still is to be determined (bone mets, DJD, or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in L3 spine, bilateral shoulders and S-I joints.
  • 2020-12-24 CT - chest
    • Left lower lobe lung cancer with lung to lung meta and bone meta. T4N3M1b, in regression.
  • 2020-09-29 CT - chest
    • LLL cancer T4N3M1b, significant in regression of lung tumors and
    • metastatic mediastinal and hilar LAP, but stationary of left pleural and spine metastases as compared with previous CT study on 2020/07/13.
  • 2020-07-15 Tc-99m MDP whole body bone scan
    • A hot spot in the posterior aspect of the left 8th rib and a faint hot spot in the post. aspect of the left 9th rib, malignancy with bone mets may be considered.
    • Increased activity in the T12 spine and L3 spine, the nature is to be determined (bone mets, DJD, or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in bilateral shoulders and S-I joints.
  • 2020-07-14 MRI - brain
    • Small bifrontal cortical nodules, favor metastases.
  • 2020-07-13 Patho - lung transbronchial biopsy
    • Lung, ? side, needle biopsy—adenocarcinoma, moderately differentiated
      
    • Sections show solid nests and glandular tumor cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
  • 2020-07-13 CT - chest
    • Findings
      • Lungs and large airways:
        • an irregular, large, soft-tissue tumor (at least 70 mm in largest dimension) in LLL, involving the hilum, inferior pulmonary artery and vein, and adjacent mediastinum and pericardium.
        • multiple nodular lesions of varying sizes in bilateral lungs up to 36 mm at RUL due to lung to lung metastasis.
      • Mediastinum and hila: metastatic LAPs in stations 5, 7, and left 10.
      • Vessels: mild coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
    • Impression:
      • LLL cancer T4N3M1b, stage IVA.
  • 2020-07-09 SONO - chest
    • Left side moderate amount of pleural effusion, 600cc serosangious fluid was aspirated for analysis.
    • Pleural biopsy was not done due to INR:2.51.
  • 2020-07-01 CXR
    • Several nodular opacity projecting in the both upper lung are suspected. Please correlate with CT.
    • Massive left side Pleura effusion is suspected.
    • Spondylosis with scoliosis of the T-spine with convex to right side

• consultation

  • 2022-09-28 Rehabilitation
    • Q
      • for bedside rehabilitation
      • This 76-year-old woman was a case with past hsitory of Rheumatoid arthritis and hypertension and a case of Lung cancer, adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasis, ECOG 1, diagnosedand on 2020-08; T4: LLL mass with bilateral lung to lung; N2: right mediastinal LAPs; M1C: brain, bone, lung to lung metasatsis; EGFR mutation: L858R (+), exon19(-), ALK(-).
      • Tracing back the past history, she suffered from cough productive of whitish sputum for many months, chest tightness and exertional dyspnea for 2-3 months. She visited our chest OPD for help, chest x-ray films and showed Several nodular opacity projecting in the both upper lung are suspected. massive left side Pleura effusion is suspected, than was arranged admission on 2020-07-17.
      • After admissin, arranged sonography of chest, left side moderate amount of pleural effusion, 600cc serosangious fluid was aspirated for analysis. The 2nd chest echo on 20200710 displayed L’t pleural effusion, lung mass s/p pigtail insertion. Arranged CT guiding biopsy on 20200713 and pathology disclosed non-small cell lung cancer initially, then adenocarcioma was confirmed after speciall stain. Brain MRI was done and disclosed small bifrontal cortical nodules, favor metastases. Whole body bone scan also done 20200715 and disclosed multiple bone metastases in the left rib and spine. The lung cancer, adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasislung cancer stage was T4N3M1b, stage IV was diagnosed.
      • We well explained the treatment to the lung cancer and after disscussion with her familes member, TKI with Giotrif was prescried since 2020-07-16. EGFR: T790M detected and L858R detected. change TKI to Tagrisso (2022-07-13 ~ ).
      • This time, she suffered from Severe Chest and back pain for one week, other symptoms included cough, hemoptysis, dyspnea on exertion, nausea, poor appetite and body weight loss. Under the impression of Lung cancer, adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasis, she was admitted for pain control and radiotherapy.
    • A
      • I have called NP for more clinical information. The patient suffered from lower limbs weakness and numbness due to suspected T-spine mets after admission.
        • T spine MRI findings:
          • Known a case of lung cancer. Abnormal enhancing lobulated mass lesion (>4.2cm) over left lateral mass of T2-T3-T4 and spinous process, causing severe spinal stenosis and compression of thoracic cord. Abnormal marrow enhancement of T2-T3 vertebral bodies. Compatible with metastases.
          • Also abnormal enhancing lesions over T9 & T12 spinous process.
          • Also abnormal marrow enhancement of T12 and L1 vertebral bodies. Favor metastatic lesions.
        • He could walk on admission, but was bed-ridden or wheelchair bounded now.
          • MP over lower limbs
          • Before 20220911: 5/5
          • On 20220912: 2/2
          • After 20220913: 0/0
        • Due to lower limbs weakness and numbness, we were consulted for further rehabilitation training.
      • PE
        • 2022/09/28 12:40 T/P/R: 38.0C / 95bpm / 20bpm BP:120/59mmHg
        • height: 163.5 Body weight: 57.6 BMI:21.5
        • Consciousness: clear
        • Cognition: intact, oriented to time, person and place, could follow orders
        • Speech: no aphasia, no obvious dysarthria
        • Swallowing: take general diet without choking
        • Sphincter: Foley+, stool incontinent; preserve anal sensation and contraction
        • MP: R L

        •   (C5) Deltoid/Biceps            5         4

        •   (C6) Wrist extensor            5         4

        •   (C7) Triceps                   5         4

        •   (C8) Flex. dig. profundus      5         5

        •   (T1) Hand intrinsics           5         5 

        •   (L2) Iliopsoas                 0         0

        •   (L3) Quadriceps                0         0

        •   (L4) Tibialis ant.             0         0

        •   (L5) Ext. hallu. longus        0         0

        •   (S1) Gastrocnemus              0         0

      • AP and LAT. views of left humerus show: avalsion fracture of proximal humerus, involving greater tuberosity, with suspect cpmbined radiolucency
        • -> left arm sling protection
      • Sensory: bilateral lower limbs numbness below T10
      • Functional status: could sit-up under maxA
      • BADL: eating and grooming minA; toileting, bathing, and dressing needs maxA
      • DTR: decrease in bilateral lower limbs
      • Barbinski: positive/negative
      • MRS: 5 (need followed up)
    • Assessment
      • Lung cancer, adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasis, ECOG 1
      • Malignant pleural effusion
      • hypertension
      • Chronic obstructive pulmonary disease
      • Encounter for antineoplastic immunotherapy
      • T-spine mets, T2-4, T9, T12-L1
      • SCI, ASIA B, level T9
    • Plan
      • Rehabilitation programs: Bedside PT, OT rehabilitation programs
      • Goal: improve ADL, muscle power and endurance
  • 2022-09-28 Infectious Disease
    • A
      • The patinet is case of adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasis.
      • S/C: oxacillin-resistatant Stapylococcus capitis
      • Agree with your use of zyvox. Please adjust antibiotic according to culture results and clinical conditions.
  • 2022-09-16 Radiation Oncology
    • Q
      • for L spine lesions, arrange radiotherapy
    • A
      • This patient has suffered from lower limb weakness, constipation and urine difficulty since last Saturday. Falling accidence with avalsion fracture of proximal humerus, involving greater tuberosity happened on last Saturday, too.
      • MRI of spine on 20220915 showed abnormal enhancing lobulated mass lesion (>4.2cm) over left lateral mass of T2-T3-T4 and spinous process, causing severe spinal stenosis and compression of thoracic cord. Abnormal marrow enhancement of T2-T3 vertebral bodies, which is compatible with metastases. Also abnormal enhancing lesions over T9 & T12 spinous process & abnormal marrow enhancement of T12 and L1 vertebral bodies are norted; metastatic lesions are all favored.
      • Palliative RT to T2-4 spines had been prescribed on 20220908 to 20220909, for 600cGy/2 fractions, and was interrupted after avalsion fracture of proximal humerus was noted. I have started RT to T2-4 spines at 3 pm today, and treatment will be continued next week. Please keep dexamethsone use during spine RT and increase dose if necessary. The recovery of muscle power may not be complete because the dueration of spinal cord compression.
  • 2022-09-13 Neurology
    • Q
      • for numbness of lower limbs for 2-3 days
    • A
      • According to the patient’s statement, she was able to walk last week when admission. However she suffered from progressive lower limbs weakness and numbnesss since admission. Left lower limb was worse than the right. In addition, she complained of abnormal sensation below nipple and urinary difficulty. Middle back and chest diffuse pain was also noted since last week. Hands numbness was also noted.
        • NE E4V5M6
        • CNs: intact
        • MP upper >4/>4, lower 3/2-3
        • DTR 2+/2+
        • sensation: below nipple parethesia with distal prominence, normal proprioception
        • FNF: no dsymetria
      • brain MRI in 2022/08: Multiple brain metastases, the one at left anterior frontal lobe is enlarged (1.3cm).
        • impression: bilateral lower limbs numbness and weakness with urinary retention. suspect myelopathy below T4, suspected new organic brain lesion
      • suggestion:
        • Do T-spine MRI with/without contrast enhancement (including whole spine saggital view) if feasible
        • consider to repeat brain MRI if negative spine MRI findings
        • do NCV (upper /lower limb motor and sensory nerve conduction study, F-wave, H-reflex) and QST to survey possible polyneuropathy
        • EEG should be considered if seizure or nonconvulsive seizure was suspected
  • 2022-09-12 Orthopedics
    • Q
      • Painful limitation of left shoulder was noted due to slipping (fall down) at the toilet tonight. Left humoral head fracture was noted on X-ray. So, we would like to request your expertise for further management. Thank you.
    • A
      • Left shoulder pain after falling down tonight
      • X-ray : Left proximal humerus GT avulsion fracture
        • Adequate pain control
        • Arm sling protection
        • Check left shoulder X-ray after R/T tomorrow
        • Explain the current condition and further management to the patient and family
  • 2022-05-16 Radiation Oncology
    • Q
      • Consult for brain radiotherapy
      • This 76-year-old woman was a case with past history of Rheumatoid arthritis and hypertension, she was not regular control. A case of Lung cancer, adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasis, ECOG 1, diagnosedand on 2020-08; T4: LLL mass with bilateral lung to lung; N2: right mediastinal LAPs; M1C: brain, bone, lung to lung metasatsis. EGFR mutation: L858R (+), exon 19 (-), ALK (-).
      • The lung cancer treatment regimen as below:
        • 1st chemotherapy with TKI Giotrif since 2020-07-16, added Cyramza C1 since 2020-08-05.
          
      • This time, she admission for chemotheapy with C15-6 Cyramza (2 vial free).
      • After admission, for lung cancer survey, brain MRI was complete that show enlarged bi-frontal cortical/subcortical nodules with increased perifocal edema at right, another small residual nodule in left anterior part.
    • A
      • Subjective:
        • History: This 76-year-old woman was a case of lung cancer, adenocarcinoma, cT4N2M1c, stage IVB with brain, bone, lung to lung metastasis, ECOG 1, diagnosed on 2020-08; EGFR mutation: L858R (+), exon 19 (-), ALK(-), under 1st target therapy with TKI Giotrif since 2020-07-16, added Cyramza C1 since 2020-08-05. This time, she was admitted for chemotherapy with C15-6 Cyramza (2 vial free). After admission, brain MRI showed enlarged bi-frontal cortical/subcortical nodules with increased perifocal edema at right, another small residual nodule in left anterior part.
          • Previous RT: s/p RT to pelvis and vaginal stump in 2016.
          • Other disease: Rheumatoid arthritis and hypertension.
          • Family history: denied.
        • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
        • Widow. Caregiver: her sons (n=3). Job: housewife. Mild or no economic stress.。
        • Language: Mandarin. Taiwanese.
        • Religion: buddism.
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2022/05/16: No SCF LNs.
        • Pathology, 2020/07/13: Lung, needle biopsy—adenocarcinoma, moderated differentiated.
        • Images:
          • Chest CT on 2022/04/26: LLL cancer T4N3M1b, increase in size of primary tumor and stationary of lung to lung metastatic lesion, left pleura and spine metastases, but newly developed left ribs metastasis as compared with previous CT study on 2021/12/23.
          • Brain MRI, 2022/05/14: Enlarged bi-frontal cortical/subcortical nodules with increased perifocal edema at right, another residual nodule in left or artifact, stationary. After IV contrast administration shows well or heterogenous enhancement of those nodules or tumors. Imp: Enlarged bi-frontal cortical/subcortical nodules with increased perifocal edema at right, another small residual nodule in left anterior part.
      • Diagnosis: Lung cancer, LLL, adenocarcinoma, cT4N2M1c, stage IVB with brain, bone, lung to lung metastasis, ECOG 1, diagnosed on 2020/08; EGFR mutation: L858R (+), exon 19 (-), ALK(-), under 1st target therapy with TKI Giotrif since 2020/07/16, Cyramza C1 since 2020/08/05 with disease progression and brain metastasis (n=3); ECOG =1.
      • Suggest:
        • Radiotherapy.
        • Goal: Palliative.
        • RT Plan may be designed as the following one:
          • Target & Volume: Metastatic brain tumors (n=3).
          • Technique: VMAT & IGRT (OBI).
          • Dose & Fractionation: 3960cGy/12 fractions.
      • Plan:
        • Palliative R/T is suggested for tumor control. Possible toxicity (malaise, IICP & hair loss) is told. CT simulation is arranged on May 16 15:30pm. Treatment will be started on Wednesday if feasible.
  • 2021-10-28 Dermatology
    • Q
      • For Pyogenic granuloma on R’t toenail for wks, severe painful
      • After admission, under the ANC: 4541 /uL. Chemotherapy C10 Cyramza total 200mg were done smoothly respectly on 20211027 and kept TKI with giotrif 30 mg/tab 1 tab PO QDAC continued given for lung cancer control. There were no nausea, vomiting, SOB or chest pain after chemotherapy. Only mild general malaise was mentioned and improved after bed reset and medica treatment.
    • A
      • This patient suffered from multiple granulation on bil fingeres and toenails for days
      • Imp: Pyogenic granuloma
      • Suggestion:
        • Arrange liq N2 Tx

• chemoimmunotherapy

• Tagrisso - osimertinib 80mg/tab 1# QD PO

  • 2022-07-13 ~ undergoing

• Cyramza - ramucirumab (NSCLC recommended dose in package insert: in combination with erlotinib, 10mg/kg Q2W IVD 60min)

  • 2022-09-20 - ramucirumab 200mg 15hr
  • 2022-05-13 - ramucirumab 200mg 15hr
  • 2022-03-15 - ramucirumab 200mg 15hr
  • 2022-02-17 - ramucirumab 200mg 15hr
  • 2021-12-21 - ramucirumab 200mg 15hr
  • 2021-11-23 - ramucirumab 200mg 15hr
  • 2021-10-27 - ramucirumab 200mg 15hr
  • 2021-04-13 - ramucirumab 200mg 15hr
  • 2021-03-02 - ramucirumab 200mg 15hr
  • 2021-01-19 - ramucirumab 200mg 15hr
  • 2020-12-22 - ramucirumab 200mg 15hr
  • 2020-11-25 - ramucirumab 200mg 15hr
  • 2020-10-27 - ramucirumab 200mg 15hr
  • 2020-09-28 - ramucirumab 200mg 15hr
  • 2020-09-03 - ramucirumab 200mg 15hr
  • 2020-08-05 - ramucirumab 200mg 15hr

• Giotrif - afatinib 30mg/tab 1# QDAC PO

  • 2020-07-16 ~ 2022-07-13

[assessment]

• There has been an active problem with hemoptysis since 2022-09-07. Ramucirumab is associated with an increased risk of hemorrhage and GI hemorrhage. Various exclusion criteria in some non-small cell lung cancer trials included a recent history of gross hemoptysis, evidence of major airway or blood vessel involvement or intratumor cavitation; the risk of pulmonary hemorrhage in patients with such criteria is not known. Monitoring should be conducted on a continuous basis.
• The use of ramucirumab has also been associated with hypertension (incidence 16% to 25%). This patient’s blood pressure level never exceeded 125mmHg during the last seven days of hospitalization. Hypertension appears to be less of a problem.
• Lab results
  • 2020-07-24 EGFR L858R detected => afatinib - 2020-07-16 ~ 2022-07-13
  • 2022-06-30 EGFR T790M detected => osimertinib - 2022-07-13 ~ undergoing
• It has been reported that sequential afatinib and osimertinib demonstrated encouraging activity in patients with EGFR mutation-positive NSCLC and acquired T790M. Activity was observed across all subgroups, including patients with poor ECOG PS or brain metastases. ECOG PS and incidence of brain metastases remained stable prior to, and after, afatinib treatment. (ref: Sequential afatinib and osimertinib in patients with EGFR mutation-positive NSCLC and acquired T790M: A global non-interventional study (UpSwinG). Lung Cancer. 2021;162:9-15. doi:10.1016/j.lungcan.2021.09.009)

700040696

221003

• exam finding
  • 2022-08-26 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • Liver cyst, small, S8
      • Parenchymal renal disease and renal cyst, bilateral, c/w ESRD
      • pancreas and spleen masked by gas.
    • Suggestion
      • Semi-annual ultrasound follow up.
  • 2022-08-03 CT - abdomen
    • History
      • 20220331 gastroscopy: One huge lumen-protruding ulcerative tumor with mucosa friability at LC side of antrum involving the angularis. The pylorus seems to be spared. IMP: Highly suspected gastric cancer, Borrmann type III, antrum LC, angularis involved.
      • 20220401 CT:gastric cancer, cT3N2M1?, cSTAGE:IVB
      • 20220413 s/p radical subtotal gastrectomy with en bloc distal pancreatectomy:Adenocarcinoma of gastric antrum with pancreas invasion, pT4bN1(cM0) stage IIIB
    • Indication: FU
    • Findings:
      • S/P subtotal gastrectomy
        • Prior CT identified One enlarged node measuring 1.5 x 1 cm in right lower pelvis is noted again, stationary. Follow up is indicated.
      • Prior CT identified three enhancing round-shaped lymph nodes in left inguinal area (size: < 5 mm) are noted again, stationary. Follow up is indicated.
        • In addition, there are several ovoid-shaped enlarged nodes with fatty hilum that are c/w benign reactive nodes.
      • There are several small poor enhancing lesions in both hepatic lobes and the largest one 1.4 cm in S2 that may be cysts. Please correlate with sonography.
      • Both kidney show small size, few cysts, and thin parenchyma that are c/w ESRD.
      5. There is no focal abnormality in the gallbladder, biliary system, pancreas, and spleen.
    • IMP:
      • S/P subtotal gastrectomy. There is no evidence of tumor recurrence.
        
      • Prior CT identified One enlarged node measuring 1.5 x 1 cm in right lower pelvis is noted again, stationary. Follow up is indicated.
  • 2022-07-02 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Increased pulmonary vasculature is found.
  • 2022-05-27 CXR
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2022-04-13 Patho - stomach subtotal/total (tumor)
    • Diagnosis
      • Stomach, antrum, radical subtotal gastectomy — adenocarcinoma, poorly differentiated; AJCC 8th edition: pStage IIIB, pT4bN1(if cM0) or pStage IV, pT4bN1(if cM1: by CT-finding)
      • Pancreas, body, en block distal pancreatectomy — adenocarcinoma, by direct invasion
      • Duodenum, radical subtotal gastectomy — negative for malignancy
      • Omentum, omentectomy — negative for malignancy
      • Lymph node, group 1, dissection — negative for malignancy (0/4)
      • Lymph node, group 3, dissection — negative for malignancy (0/3)
      • Lymph node, group 4, dissection — adenocarcinoma, metastatic (1/ 4)
      • Lymph node, group 5, dissection — negative for malignancy (0/1)
      • Lymph node, group 6, dissection — negative for malignancy (0/3)
      • Lymph node, group 7, 8, 9, 11p, 12, dissection — adenocarcinoma, metastatic (1/ 9)
      • Lymph node, group 14v, dissection — negative for malignancy (0/1)
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma, Lauren classification of adenocarcinoma: Intermediate type (tubular)
      • Histologic Grade: G3: Poorly differentiated,
        
      • Tumor Extension: Tumor invades adjacent structures/organs(specify): pancreas
        
      • Margins
        • Proximal margin: uninvolved by invasive carcinoma: 3.4 cm
        • Distal margin: uninvolved by invasive carcinoma: 1.1 cm
        • Radial margin: uninvolved by invasive carcinoma: 0.1 cm
        • Pancreatic resection margin: 0.7 cm
      • Lymphovascular Invasion: present
        
      • Perineural Invasion: present
        
      • Regional Lymph Nodes: please see diagnosis
        
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply) :absent
          
        • Primary Tumor (pT): pT4b: Tumor invades adjacent structures/organs
        • Regional Lymph Nodes (pN): pN1: Metastasis in one or two regional lymph nodes
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0 or cM1(CT-finding)
      • Additional Pathologic Findings
        • Intestinal metaplasia: present
        • Low-grade dysplasia: present
        • High-grade dysplasia: absent
        • Helicobacter pylori-type gastritis: absent
        • Autoimmune atrophic chronic gastritis: absent
          
        • Polyp(s): absent
          
      • A Schwannoma, measuring 0.2 x 0.1 cm, is seen in muscularis propria of pylorus.
      • The immunohistochemical stains reveal S-100(+), SMA(-), CD34(-), Desmin(-) and CD117(-).
  • 2022-04-12 Whole body PET scan
    • Glucose hypermetabolism in the antrum of the stomach, compatible with primary gastric malignancy.
    • Glucose hypermetabolism in the region about the lower end of the esophagus. The nature is to be determined (inflammatory process? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in a focal area in the right lower pelvis, possibly more benign in nature. However, please follow up other imaging modalities for further evaluation and to rule out the possibility of malignnacy or metastasis of low FDG uptake.
    • Increased FDG accumulation in the colon and rectum. Physiological FDG accumulation is more likely.
  • 2022-04-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (121 - 51.2) / 121 = 57.69%
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mild tricuspid regurgitation, trivial aortic and mitral regurgitation
    • Impaired LV relaxation
    • Dilated LA, LV hypertrophy
  • 2022-04-07 Colonoscopy
    • Colon polyp, Paris classification 0-IIa, sigmoid colon, s/p cold polypectomy and Sureclip*2
    • Diverticulum, ascending colon
    • Internal hemorrhoid
  • 2022-03-31 CXR
    • Increase bilateral lung markings.
    • Thoracic spondylosis.
  • 2022-03-31 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
    • Left ventricular hypertrophy with repolarization abnormality
  • 2022-03-31 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA grade A
    • Highly suspected gastric cancer, Borrmann type III, antrum LC, angularis involved, s/p biopsy*6 pieces
      
  • 2022-03-30 Peropheral Vascular Test - AV fistula
    • clinical diagnosis: S/P left radiocephalic AV fistula, interval duplex F/U
    • S/P left radiocephalic AV fistula, VF at inflow radial artery 655-738 ml/min, anastomotic diameter 6.0x10.8 mm, juxta-anastomotic segment 7.1 mm, proximal cephalic vein aneurysmal formation 23.2 mm without thrombus within, then cephalic vein 7.0 mm with PS 68 cm/s, A-puncture site diameter 10.8 mm (depth 2.4 mm), intervening segment 3.0 mm (relatively reduced) with mosaic flow pattern and pressure build-up PS 201.6 cm/s, Vpuncture site 8.9 mm (depth 2.2mm), cubitobasilic vein 6.0mm, upper arm basilic vein 6.2mm, continuous flow pattern over draining basiloaxillary vein indicating no overt outflow obstruction
    • Recommendation: Preemptive PTA to stenotic cubital cephalic vein to avoid further aneurysmal formation of upstream cephalic vein
    • Suggestion: PTA
  • 2021-11-03 Peropheral Vascular Test - AV fistula
  • 2021-02-24 Peropheral Vascular Test - AV fistula
  • 2020-09-30 Peropheral Vascular Test - AV fistula
  • 2018-09-03 Impedance audiometry
    • Tymp: R’t type B, L’t type A.
    • ART: Bil absent.
    • PTA
      • Reliability: fair
      • Average: R’t 69 dB HL.
      • R’t moderate to profound mixed type HL (BC 1k & 4k Hz masking dilemma).
      • L’t severe to profound mixed type HL.
  • 2017-05-11 CT - abdomen
    • Atrophy of kidneys with cysts (1.3-2.4cm). Bil. hydronephrosis and hydroureter. Distention of urinary bladder.
  • 2017-03-04 SONO - Nephrology
    • Finding:
      • Size Shape
        • R’t: 8.68 cm, uneven surface
        • L’t: 8.98 cm, uneven surface
      • Cortex
        • R’t: Echogenicity: increased; Thickness: decreased
        • L’t: Echogenicity: increased; Thickness: decreased
      • Pyramid:
        • R’t: prominent
        • L’t: prominent
      • Sinus
        • Not Dilated
      • Cyst
        • R’t: cortical, single,0.9cm in the middle kidney
        • L’t: cortical, parapelvic, multiple
        • L’t: cortical, parapelvic, multiple, 3 cystic lesions, the largest one is 2.5 cm in the middle kidney
      • Stone
        • None
      • Mass
        • None
    • Interpretation
      • Bilateral small kidneys with chronic parenchymal changes.
      • Bilateral renal cysts.
• consultation
  • 2022-04-06 Urology
    • Q
      • For evaluation of possible bladder cancer
      • This is a 66 y/o man who was admitted to our hospital due to UGI bleeding.
      • Abdominal CT on 20220401 revealed T3N2M1?, Stage:III or IVB.
      • We suspect the involvement of the bladder due to thickening of the bladder wall and enlargement of lymph nodes near the bladder.
      • Please kindly assist to evaluate the patient and advise us on the management of the condition.
    • A
      • I have visit this patient and his family. The studies were checked.
      • After recheck the CT scan, the right pelvic nodule could be right distal ureter in my opinion.
      • Due to no hydronephrosis, smooth bladder wall and no gross hematuria, cancer from urinary tract is not likely.
      • Please check urine cytology 3 sets in different days first. Cystoscopy or ureteroscopic exams could be the next step if abnormal finding.
      • Otherwise you may treat his gastric cancer first. Uro. clinic follow up is indicated. Thanks for your consultation.
  • 2022-03-31 Nephrology
    • Q
      • This is 66 y/o man who has underlying disease of
        • ESRD under H/D W246
        • Otitis media, unspecified, left ear
        • Sensorineural hearing loss, bilateral
        • AKI with obstructive uropathy s/p temporary HD and transurethral incision of bladder neck was done at WanFang Hospital
      • The patient was admitted due to upper GI bleeding.
      • We need you to arrange him to accept hemodialysis on QW246
    • A
      • We will arrrange HD QW246. Please prescribe EPO 5000U qW4 if Hb<11.
• surgical operation
  • 2022-04-13
    • Surgery
      • radical subtotal gastectomy with en block distal pancreatectomy
      • D2 LN dissection
    • Finding
      • distal gastric ulcerative mass with direct invasion to pancreas body
      • multiple LN was noted
• radiotherapy
  • 2022-05-24 ~ 2022-06-?? - RT to the stomach and adjacent lymphatic drainage area: 16.2 Gy/ 9 fx.
• chemoimmunotherapy
  • 2022-09-15 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2400mg 3250mg 46hr (adjuvant FOLFOX)
  • 2022-08-31 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2400mg 3280mg 46hr (adjuvant FOLFOX)
  • 2022-08-31 - oxaliplatin 80mg/m2 110mg 2hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2400mg 3300mg 46hr (adjuvant FOLFOX)
  • 2022-08-31 - oxaliplatin 70mg/m2 70mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2400mg 3200mg 46hr (adjuvant FOLFOX)
  • 2022-06-27 - fluorouracil 200mg/m2 280mg 24hr D1-3 (adjuvant CCRT)
  • 2022-06-20 - fluorouracil 200mg/m2 280mg 24hr D1-5 (adjuvant CCRT)
  • 2022-06-13 - fluorouracil 200mg/m2 290mg 24hr D1-5 (adjuvant CCRT)
  • 2022-06-08 - fluorouracil 200mg/m2 290mg 24hr D1-3 (adjuvant CCRT)
  • 2022-05-30 - fluorouracil 200mg/m2 290mg 24hr D1-3 (adjuvant CCRT)
  • 2022-05-26 - fluorouracil 200mg/m2 290mg 24hr D1-2 (adjuvant CCRT)

==========

2022-10-03

[drug identification]

requesting drug identification for 3 items.

the 2 items are identified as following while the other 1 item remains unknown.

• Vemlidy (tenofovir 25mg)
• U-Cal (calcium carbonate 500mg)
• Folic acid 5mg

these drugs will be sent back to ward by an in-hospital porter.

2022-05-30

[drug identification]

Total 3 drugs for identification.

The 2 identified items has been shown as following while the other 1 items still remain unknown:

• A-Cal (calcium carbonate, CaCO3, 500mg)
• Folic acid 5mg

These drugs will be sent back to ward by the in-hospital porter.

700054037

221003

• diagnosis
  • Left pyriform sinus cancer, cT2N0M0, stage II status post laryngomicrosurgery on 2019-3-11 and complicated extraction of tooth*13 on 2019-03-13
  • Left tongue cancer, pT3N0M0, stage III, status post left tongue cancer excision and left neck dissection on 2019-02-22
  • Hypopharyngeal squamous cell carcinoma, moderately differentiated s/p laryngomicrosurgery on 2022-05-11, pT3N0M0, stage III and Tracheostomy + Port-A implantation on 2022-05-18
  • Carrier of viral hepatitis B
• exam finding
  • 2022-08-11 PD-L1 (22C3)
    • Tumor Proportion Score (TPS) assessment: TPS < 1%
  • 2022-08-11 PD-L1 28-8 IHC
    • Tumor cell (TC) staining assessment: TC < 1%
    • Percent of PD-L1 expression in tumor cells (TC): < 1%
  • 2022-08-11 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana) - S2022-8227
      • Tumor type: Squamous cell carcinoma
      • Tumor location: Hypopharynx
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
        
      • Adequate tumor cells present (>=50 viable tumor cells): Yes,
        
    • Result:
      • 1. Tumor cell (TC) staining assessment: TC category: TC < 1%
           
      • 2. Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • 1. TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • 2. IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-08-04 Nasopharyngoscopy
    • smooth nasopharynx and oropharynx; regression of hypopharyngeal swelling compared to the previous study; thin mucosa over right arytenoid cartilage; right vocal cord fixation; fair left vocal cord movement.
  • 2022-07-28 MRI - larynx
    • Tongue cancer Stage IV, post chemotherapy * 3 cycles
    • Findings
      • 1. S/P opeation at left part of oral tongue and left neck.
      • 2. S/P tracheosotmy.
      • 3. Diffuse swelling at hypopharynx, mild regession as comapred with MRI on 20220505.
      • 4. No enlarged lymph node.
      • 5. No abnormality at nasopharynx, oropharynx and larynx.
      • 6. Mild hypertrophic degeneration of C-spine.
    • IMP:
      • Post-operation change at left part of oral tongue without evidence of recurrence. Less swelling of the hypopharynx, as compared with MRI on 20220505. Suggest regular follow-up.
  • 2022-05-25 ECG
    • Normal sinus rhythm
    • Cannot rule out Inferior infarct, age undetermined
  • 2022-05-25 CXR
    • S/P tracheostomy
    • S/P port-A implantation.
  • 2022-05-20 Tc-99m DMP whole body bone scan
    • In comparison with the previous study on 2019/02/14, no prominent change is noted in the lesions in the middle C-spine, lower T- and lower L-spines. Degenerative change may show this picture.
    • No prominent change is noted in the previous faint hot spot in the right temporal area of the skull, possibly more benign in nature.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture. Please correlate with other clinical findings for further evaluation.
    • Increased activity in bilateral shoulders and knees, compatible with benign joint lesions.
  • 2022-05-19 Patho - stomach biopsy
    • Duodenum, 2nd portion, biopsy — Compatible with ulcer
    • Microscopically, the sections show a picture of mucosal erosion with inflammatory cells infiltrate, compatible with ulcer. Follow up
  • 2022-05-12 Patho - larynx biopsy
    • Hypopharynx, right, biopsy — Squamous cell carcinoma, moderately differentiated
    • Section shows a piece of squamous mucosa with infiltration of nests of neoplastic squamous cells.
    • The immunohistochemical stain of p16 is positive.
  • 2022-05-12 Patho - larynx biopsy
    • Esophagus, right, upper, posterior wall, biopsy — Squamous cell carcinoma, moderately differentiated
    • Section shows a piece of squamous mucosa with nests of neoplastic squamous cells in submucosa.
    • The immunohistochemical stain of p16 is positive.
  • 2022-05-05 MRI - larynx
    • The current study was compared to the prior one obtained on 2021/11/02.
    • Markedly enhancing mucosal thickening and swollen change of larynx and hypopharyngeal space. Suggest clinical correlation.
    • Post operative appearance in or at the area of left tongue, no focal mass or nodule.
    • Post LNs dissection with clips retention with metallic artifact and/or soft tissue or muscle defect, left.
    • Normal appearance of both mastoid air-cells.
    • The bilateral parotid and submandibular glands enhance as before. It is consistent with post-radiation inflammation.
    • Clear appearacne of all paranasal sinuses.
  • 2021-11-02 MRI - larynx
    • Findings
      • Post operative appearance in or at the area of left tongue, no focal mass or nodule.
      • Post LNs dissection with clips retention with metallic artifact and/or soft tissue or muscle defect, left.
      • No evident abnormal enlarged lymph node in the visible neck.
      • Heterogeneous soft tissue in the right vocal cord, posterior wall of the bilaeral hypopharynx, righy hypopharynx and bilateral aryepiglottic folds, more on the right side, seems in progression.
        
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
    • IMP:
      • Post OP at left tongue with left neck dissection. No local recurrence, no neck LAP
      • Seems in progression of bil. hypopharynx, larynx masses? need clinical check, partially due to post R/T effect?
        
  • 2021-07-15 MRI - larynx
    • Findings
      • s/p left neck lymph node dissection
      • heterogeneous enhancing soft tissue in the right vocal cord, posterior wall of the bilaeral hypopharynx, righy hypopharynx and bilateral aryepiglottic folds, more on the right side.
      • no neck LAP.
      • unremarkable change in the tongue.
      • unremarkable change at the skull base
    • IMP:
      • suspected tumors in the bilateral hypopharynx and right vocal cord.
  • 2019-02-22 Surgical pathology Level VI
    • pathologic diagnosis
      • Tongue, left, excision — Squamous cell carcinoma, moderately differentiated
      • AJCC Pathologic staging — pT3N0Mx, stage III at least
    • microscopic examination
      • Histologic Type: Squamous cell carcinoma with focal salivary gland invasion
      • Histologic Grade: G2: moderately differentiated
      • Microscopic Tumor Extension: 1.2 cm in thickness
  • 2019-02-18 Surgical pathology Level IV
    • pathologic diagnosis
      • Tumor, left pyriform sinus, biopsy — Squamous cell carcinoma
    • microscopic examination
      • Microscopically, the sections show a picture of squamous cell carcinoma characterized by some solid tumor nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrate in the stroma with scant keratin formation.
      • Immunohistochemistry shows CK5/6(+); P63(+) and CK(+) for tumor cells.
  • 2019-02-15 Upper G-I panendoscopy
    • Diagnosis: suspect larynx lesion
    • Suggestion: suggest further study to check cancer or precancer lesion at larynx
  • 2019-02-14 Tc-99m MDP whole body bone scan
    • Increased activity in the middle C-spine, lower T- and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • A faint hot spot in the right temporal area of the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and knees, compatible with benign joint lesion.
  • 2019-02-14 MRI - larynx
    • Left tongue CA, T3N0Mx stage III. Left pyriform sinus CA, T1N0Mx, stage I.
  • 2019-01-29 Surgical pathology Level IV
    • Tongue, lower, left, biopsy — Squamous cell carcinoma, p16(-)
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with stromal invasion and desmoplastic reaction. Subtle keratin formation is present.
    • IHC: p16(-).
• consultation
  • 2022-05-16 Hemato-Oncology
    • Impression:
      • Squamous cell carcinoma, moderately differentiated, of the left oral tongue, s/p wide excision and left neck dissection, stage pT3N0(cM0), stage III, s/p radiotherapy.
      • Squamous cell carcinoma of the left pyriform sinus, stage cT2N0M0 (tumor board conclusion), s/p radiotherapy, with relapse.
      • HBV
    • Suggestion:
      • If sugical intervention is not feasible, CCRT is indicated. We would like to perform chemotherapy for this case.
      • Please arrange Port-A insertion for him.
  • 2022-05-13 Radiation Oncology
    • Q
      • This is a 54 y/o male patient with history of 1. Left oral tongue, SCC, moderately differentiated s/p wide excision and left neck dissection, stage pT3N0(cM0), stage III, s/p radiotherapy on 2019-05-20. 2. Left pyriform sinus SCC, stage cT2N0M0, Completion of radiotherapy on 2019-05-20, and HBV.
      • He was regularly followed up at our hospital. At Dr. Su’s OPD on 2022/05/03, PE showed no obivious palpable neck LN. Nasopharyngoscopy revealed posterior hypopharyngeal tumor with involvement of right pyriform sinus apex, with suspected esophageal involvement, and right vocal palsy. He was admitted underwent LMS tumor mapping on 20220511. The whole procedure performed smoothly. However, dyspnea noted since 20220512, we check nasopharyngoscope revealed right vocal palsy.
      • Hypopharyngeal cancer was suspected, but the pathology data pending.
      • It was explained by Dr. Wanfu Su that a tracheostomy was necessary in order to maintain a patent airway, and because the previous dose of radiotherapy had reached its upper limit, a total laryngectomy would be needed. Therefore, chemoradiotherapy may be indicated for the patient. Consult to determine this possibility.
    • A
      • S: For discussion the salvage treatment modality.
      • A:
        • Squamous cell carcinoma, moderately differentiated, of the left oral tongue, s/p wide excision and left neck dissection, stage pT3N0(cM0), stage III, s/p radiotherapy.
        • Squamous cell carcinoma of the left pyriform sinus, stage cT2N0M0 (tumor board conclusion), s/p radiotherapy, with relapse.
      • P:
        • According to HN tumor board (2022-05-13) conclusion, salvage surgery including tracheostomy is recommended.
        • The patient already received full dose radiotherapy before, further radiotherapy of previous irradiated area with low dose CCRT without surgery is only palliative and may be not effective. The possible effects of re-irradiation were well explained to the patient and his family. The patient would like to go back for consideration including neoadjuvant chemotherapy and then make a decision.
        • Please also consult medical oncologist.
• surgical operation
  • 2022-05-18
    • Surgery
      • Tracheosotmy
    • Finding
      • Insertion of Shiley #6.
    • Procedure
      • The patient was in supine position with neck hyperextended. Skin was disinfected and draped as usual. Local anesthesia with Bosmin-rinsed Xylocaine was injected into the subcutaneous tissue and the pretracheal area layer by layer. A vertical skin incision was made in the midline of lower neck. Subcutaneous tissue, fascia and strap muscles were seperated, then the thyroid gland was seen and hooked upwards with thyroid hooks. The tracheal rings were cut in longitudinal direction. A oval-shaped window was made at the 2 nd to 3 rd rings. A Shiley #6 cuffed tracheostomy tube was inserted. The patient tolerated the above procedure well.
  • 2022-05-11
    • Surgery
      • Laryngomicrosurgery for tumor mapping      
    • Finding
      • upper esophageal posterior wall mass
      • hypopharyngeal (postcricoid) tumor, with right AE fold involvement
    • Procedure
      • The patient lay in supine position and general anesthesia was set up via EGTA. The neck was slightly extended with shoulder-roll. Rigid laryngoscope was applied gently with fixation of chest support. Microscope was use for the microlaryngoscopic procedure. Upper esophageal posterior wall mass and postcricoid tumor, with right AE fold involvement. Compression with Bosmin-rinsed cotton balls was used for hemostasis and removed thereafter. The patient standed the whole procedure well.   
  • 2019-03-13
    • Diagnosis
      • Deep caries of multiple teeth
    • PCS
      • 92014C
    • Finding
      • Multiple deep caries and retained roots of tooth 11,12,13,14,16,18,21,22,23,27,36,37 and 38.
    • Procedure
      • Patient was on a supine position and anesthetized through nasal endotracheal tube in the usual method.
      • Patient head was draped and nasal endotracheal tube was secured at the patient’s forehead area.
      • Patient’s mouth was soaked with aqueous b-iodine solution.
      • Patient’s mouth, lower face, neck and shoulder areas were disinfected with aqueous b-iodine solution
      • Patient’s body and head, except operation fields, were draped in the usual manner with 2-layer sterilized sheets.
      • Excess aqueous b-iodine solution in patients mouth was suctioned and a 4*8 gauze was placed at the patients throat to prevent fluid from entering patient’s airway.
      • Several cartridges of 1.8ml local anesthetic solution containing with 0.01mg epinephrine were injected into the operation fields for local hemostasis.
      • Complicated extraction of of tooth 11,12,13,14,16,18,21,22,23,27,36,37 and 38 was done carefully
      • Primary closure of the surgical wound with 3-0 and 4-0 Vicryl
      • After all the procedures were done, plenty of N/S was used to irrigate the oral cavity.
      • Patient regained consciousness smoothly and gradually after the operation was completed.
  • 2019-03-11
    • Diagnosis
      • Hypopharyngeal CA, Lt.
    • PCS
      • 66032B
    • Finding
      • FK oral retractor failed to approach left hypopharynx
      • LMS approach for tumor mapping, pyriform sinus posterior wall biopsy done
    • Procedure
      • The patient lay in supine position and general anesthesia was set up via EGTA. The neck was slightly extended with shoulder-roll. FK oral retractor was used first but failed to approach left hypopharynx. Rigid laryngoscope was applied gently with fixation of chest support. Microscope was use for the microlaryngoscopic procedure. left pyriform sinus posterior wall tumor mapping done by microforcep. Compression with Bosmin-rinsed cotton balls was used for hemostasis and removed thereafter. The patient standed the whole procedure well.
  • 2019-02-22
    • Diagnosis
      • left tongue cancer
    • PCS
      • 71013A
    • Finding
      • 1.7x1.5x1.2cm tumor at the junction of left mouth floor and ventral tongue, excision with adequate safty margin.
      • Excision of left neck lymph nodes from level I to level IV.
      • IJV, SAN and SCM were preserved well.
    • Procedure
      • He was in supine position with neck hyperextended. General anesthesia was set via nasal endotracheal tube. Then he was disinfected and draped as usual. The skin incision with neck and lower lip extension was made. The left side skin flaps were developed in the subplatysmal plane as far as the midline neck anteriorly, trapezius muscle laterally, clavicle inferiorly, and mandible superiorly. After the flaps were completely elevated, the SCM muscle was dissected out, then the whole lymphoareolar tissue with the lymph nodes were dissected carefully off the carotid artery sheath. Several lymph nodes were noted at level IV, III,II, The internal jugular vein, vagus nerve and spinal accessory nerve were identified and preserved, One JP ball was inserted for drainage and the wound was closed in 2 layers. Thee the oral cavity was disinfected and irrigated. The tumor invaded the junction of mouth floor and left ventral tougue. The whole tongue and mouth floor was removed as a whole with adequate safty margin. After hemostasis, the tongue was sutured anteriorposteriorly, NG tube was inserted for feeding.
• chemoimmunotherapy
  • 2022-09-30 - docetaxel 60mg/m2 100mg 1hr D1 + cisplatin 60mg/m2 100mg 24hr D1 + fluorouracil 750mg/m2 1300mg 24hr D1-5
  • 2022-09-01 - docetaxel 60mg/m2 100mg 1hr D1 + cisplatin 60mg/m2 100mg 24hr D1 + fluorouracil 750mg/m2 1300mg 24hr D1-5
  • 2022-08-10 - docetaxel 60mg/m2 100mg 1hr D1 + cisplatin 60mg/m2 100mg 24hr D1 + fluorouracil 750mg/m2 1300mg 24hr D1-5
  • 2022-07-15 - docetaxel 60mg/m2 100mg 1hr D1 + cisplatin 60mg/m2 100mg 24hr D1 + fluorouracil 750mg/m2 1300mg 24hr D1-5
  • 2022-06-23 - docetaxel 60mg/m2 100mg 1hr D1 + cisplatin 60mg/m2 100mg 24hr D1 + fluorouracil 750mg/m2 1300mg 24hr D1-5
  • 2022-06-09 - docetaxel 35mg/m2 60mg 1hr D1 + cisplatin 30mg/m2 50mg 2hr D1 + fluorouracil 2000mg/m2 3500mg 46hr
  • 2022-06-02 - docetaxel 35mg/m2 60mg 1hr D1 + cisplatin 30mg/m2 50mg 2hr D1 + fluorouracil 2000mg/m2 3500mg 46hr

[note]

Locally advanced squamous cell carcinoma of the head and neck ( https://www.uptodate.com/contents/locally-advanced-squamous-cell-carcinoma-of-the-head-and-neck-approaches-combining-chemotherapy-and-radiation-therapy )

• Systemic Therapy Regimen
  • Agents with proven activity in squamous cell head and neck cancer that are most commonly included in either induction or concurrent chemotherapy regimens include the platinum compounds (cisplatin, carboplatin), fluorouracil, and taxanes (docetaxel, paclitaxel).
  • Induction chemotherapy - Multiple clinical trials have established that three drug combinations of cisplatin, fluorouracil, plus a taxane are the preferred approach for induction chemotherapy.
    • Initial clinical trials found that cisplatin and fluorouracil (PF; cisplatin, 100 mg/m2, and fluorouracil, 1000 mg/m2/day continuous 24-hour infusion for five days) given every three weeks as induction chemotherapy induced higher rates of complete response and better survival compared with two cycles of an earlier cisplatin and bleomycin-based regimens or regimens using two cycles of cisplatin with shorter infusions of fluorouracil.
    • Subsequent randomized trials found that the addition of a taxane (docetaxel, paclitaxel) to PF induction chemotherapy enhanced the effectiveness of induction chemotherapy used with radiation therapy (RT) alone or with RT plus concurrent chemoradiation. In contrast, a small randomized trial in larynx/hypopharynx cancer did not show a benefit from the addition of cetuximab to induction chemotherapy that included docetaxel and cisplatin followed by accelerated RT with or without concurrent cetuximab.

[assessment]

• Nincort Oral Gel (triamcinolone) is used for the treatment of chemotherapy-induced oral ulcers, while Baraclude (entecavir) is utilized for the treatment of HBV infections.
• The laboratory results on 2022-09-27 were grossly normal except for a slight pancytopenia.

chemotherapy induced oral ulcer is treated with Nincort Oral Gel (triamcinolone) and hepatitis B is surpressed using Baraclude (entecavir)

700358478

221003

{Adenocarcinoma of splenic flexure colon with obstruction, and liver, lung, bone metastasis with carcinomatosis, cT3N2bM1c, stage IVC status post colostomy on 2021-10-06}

• exam findings
  • 2022-09-01, -08-15 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
    • Findings
      • The NCV study showed slowing sensory conduction velocity in bilateral ulnar nerves. The F wave study showed prolonged latency in left tibial nerve. The H reflex study showed both prolonged.
    • Conclusion
      • The above findings suggest bilateral ulnar neuropathy and bilateral lumbosacral radiculopathy. Advise clinical correlation.
  • 2022-08-16 MRI - brain
    • Known a case of colon cancer. No metastatic lesion of brain parenchyma.
    • Moderate periventricular small vessel disease. NO acute ischemic infarct.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
    • Short segmental moderate stenosis of left distal ICA (cavernous segment).
  • 2022-07-14 CT - abdomen, pelvis
    • S/P colon operation. Mild decreased size of lung and liver metastases. Multiple bony metastases.
    • Enlargement of prostate. Mild dilatation of abdominal aorta (3.8cm) with mural thrombus.
  • 2022-06-27 CT - lung/mediastinum/pleura
    • Findings
      • Lungs:
        • multiple randomly distributed pulmonary nodules of varying sizes (up to 13mm at lingula, lower lobes predominance) due to metastases.
        • extensive, bilateral upper lobe predominant, centrilobular emphysema, in the lungs. and subpleural paraseptal emphysema
        • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels: moderate coronary arterial calcification
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Chest wall and visible lower neck: diffuse blastic change in bones of thoracic cage, with focal expansile blastic change of left 5th rib.
      • Visible abdominal contents: small metastatic lesions in the liver.
    • Impression:
      • colon cancer with lung, liver, and bones metastases, in progression of lung metastases compared with CT on 2022/04/15
  • 2022-06-16 CXR
    • S/P port-A implantation.
    • Multiple osteoblastic bony metastases in the ribs and spine are noted.
    • A nodular opacity projecting in the left lower lung is suspected. Please correlate with CT.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2022-04-16 Chest AP - portable
    • S/P port-A implantation.
    • Multiple osteoblastic bony metastases in the ribs and spine are noted.
    • A nodular opacity projecting in the left lower lung is suspected. Please correlate with CT.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2022-04-15 CT - abdomen, pelvis
    • Splenic flexure colon cancer with multiple metastatic nodes in the adjacent omentum and mesentery, multiple metastases in the liver, lung and bone S/P C/T show partial response.
    • RCC 2.4 cm at left kidney lower pole shows stationary.
    • The differential diagnosis include angiomyolipoma (lipid-poor). Follow up is indicated.
  • 2022-03-31 Chest PA erect view
    • Multiple osteoblastic bony metastases in the ribs and spine are noted.
    • A nodular opacity projecting in the left lower lung is suspected. Please correlate with CT.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2022-03-11 Bronchial dilation test
    • Moderate obstructive ventilatoryimpairment without significant reversibility
    • FEV1/FVC = 45%, FVC = 96%, FEV1 = 54%
  • 2022-03-10 Chest PA
    • Multiple osteoblastic bony metastases in the ribs and spine are noted.
    • A nodular opacity projecting in the left lower lung is suspected.
  • 2022-01-19 CT
    • Findings:
      • Prior CT identified lobulated segmental wall thickening in the splenic flexure colon is noted again, mild decreasing in size.
        • In addition, prior CT identified multiple metastatic nodes in the surrounding mesentery and omentum are noted again, decreasing in size.
      • Prior CT identified mutliple metastases on both hepatic lobes are noted again, decreasing in size.
        • The size of S5 metastasis in prior and current CT is measured 3.1 cm and 2.5 cm, respectively.
      • Prior CT identified mutliple metastases on both lung are noted again, decreasing in size.
        • The size of LUL metastasis in prior and current CT is measured 2 cm and 1.5 cm, respectively.
      • Prior CT identified multiple osteoblastic bony metastases in the L-spine and bilateral ilium are noted again, increasing density that may be bony metastases with progressive disease.
      • Prior CT suspected renal cell carcinoma measuring 2 cm in left kidney lower pole is noted again, stable in size.
        • The differential diagnosis include angiomyolipoma (lipid-poor).
      • Abdominal aorta aneurysm measuring 3.3 cm in diameter with atherosclerotic change and mural thrombosis is noted.
        • Right common iliac artery also shows aneurysm 1.7 cm in diameter with mild mural thrombus formation.
      • Adenoma 0.9 cm in left adrenal gland it noted.
    • Impression:
      • Splenic flexure colon cancer with multiple metastatic nodes in the adjacent omentum and mesentery, and multiple metastases in the liver and lung S/P C/T show partial response.
      • Multiple bony metastases show more osteoblastic change.
      • RCC 2 cm at left kidney lower pole shows stationary. The differential diagnosis include angiomyolipoma (lipid-poor). Follow up is indicated.
  • 2021-09-29 CT
    • Findings:
      • There is lobulated segmental wall thickening in the splenic flexure colon measuring 1.7 cm in wall thickness, causing lumen narrowing that is compatible with adenocarcinoma with impending obstruction.
        • In addition, there are multiple metastatic nodes in the surrounding mesentery and omentum, and the largest one 2.2 cm.
      • There are mutliple poor enhancing masses on both hepatic lobes and the largest one measuring 3.1 cm in S5 that are compatible with liver metastases.
      • There are several osteoblastic change of the L-spine and bilateral ilium that are compatible with bony metastases.
      • Abdominal aorta aneurysm measuring 3.3 cm in diameter with atherosclerotic change and mural thrombosis is noted.
        • Right common iliac artery also shows aneurysm 1.7 cm in diameter with mild mural thrombus formation.
      • There are few small soft tissue nodules in both lower lung that are compatible with lung metastases.
      • There is a well-defined heterogeneous poor enhancing mass measuring 2 cm in left kidney lower pole that may be RENAL CELL CARCINOMA. The differential diagnosis include metastasis.
        • Please correlate with contrast enhanced dynamic CT or MRI.
      • Adenoma 0.9 cm in left adrenal gland it noted.
      • Imaging stage: T3N2bM1c stage IVC
  • 2021-09-28 Patho - Colon biopsy
    • Colon, splenic flexure, biopsy - Adenocarcinoma, moderately differentiated
    • The secvtions show a picture of adenocarcinoma, composed of columnar neoplastic cells, arranged in glandular patterns with desmoplastic stromal reaction.
    • IHC, tumor cells reveal: EGFR(-), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
  • 2021-09-23 CT
    • Imaging stage: T4N2M1
    • Imp: Colon cancer at splenic flexure with liver, lung and bone mets.
• consultation
  • 2022-08-13 Neurology
    • Q
      • This 73 year-old man patient is a case of Colon cancer with obstruction and splenic, liver, lung and bone metastases, T3N2bM1b, stage IVB s/p T loop colostomy on 2021/10/06 s/p chemotherapy with FOLFIRI/Avastin, SD. He was admitted for palliative chemotherapy with Avastin(C16)/FOLFIRI(C10D1) from 2022/08/12~2022/08/14.
      • This time, dizziness with bilateral lower limbs weakness for 2 months. Now, for evaluate examination of dizziness with bilateral lower limbs weakness. Thank you.
    • A
      • The patient had chronic unsteady gait.
        • Cranial nerve: intact
        • motor: intact
        • sensory: intact
        • Romberg (+)
        • FNF: bilateral dysmetria
      • Imp:
        • suspect cerebellar dysfunction + suspected peripheral sensory nerve disease
      • P:
        • Arrange brain MRI with/without contrast if no contraindication.
        • Arrange NCV upper and lower limbs (motor + sensory + F + H)
        • Try suzin 1# HS
        • Check TSH, Free T4, ANA, HbA1C, Anti SSA/SSB, Vit B12, folic acid
  • 2022-03-14 Thoracic Medicine
    • Underlying disease:
      • Colon cancer with multiple lung meta, ribs mets, bone mets, cT3N2M1c, stage IV
      • Heavy smoking (quited), with COPD, centrilocular emphysema, PFT showed: moderate obstruction, involving both large and small sized airways
      • Baseline hypoxemia, room air SaO2 only 94%
      • Old TB with LUL calcinfied granuloma.
    • Suggestion:
      • Favor chest tight due to (1) rib mets with pain, (2) COPD, (3) abdominal distension with diaphragm dysfunction, (4) possibly GERD
      • Add Foster 2 puff BID, spiriva 2 puff HS (from Adult-Aerochamber)
      • Self-paid Adult-Aerochamber recommended
      • Try Topaal for GERD
      • Pain relief
      • Avoid constipation
• surgical operation
  • 2021-10-06 T loop colostomy
    • Splenic flexure colon cancer with obstruction, and liver, lung, bone metastasis with carcinomatosis, cT3N2bM1c, stage IVC
    • RUQ stoma with stent
  • 2017-12-11 Biopsy prostate (punch)
    • Prostatic hyperplasia with urinary retention
    • Finding
      • DRE: stiffness Rt> Lt but not hard nodule, may be huge adenoma
      • Hypertrophy of prostate with high bladder neck, enlarged median lobe
      • Moderate trabeculation of bladder
      • intraoperative impression: prostate volume >100cc
      • 52g retrieved
• chemotherapy regimen
  • 2022-09-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4500mg 46hr
  • 2022-09-07 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
  • 2022-08-26 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
  • 2022-08-12 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
  • 2022-07-28 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
  • 2022-07-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
  • 2022-06-29 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
  • 2022-06-16 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4500mg 46hr
  • 2022-06-01 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4500mg 46hr
  • 2022-05-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4500mg 46hr
  • 2022-04-27 - irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2022-04-15 - irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2022-03-29 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2022-03-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2022-02-22 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2022-01-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2022-01-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2021-12-22 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2021-12-09 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2021-11-25 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2021-11-12 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
  • 2021-10-26 - irinotecan 120mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 300mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • Ref UpToDate - FOLFIRI plus bevacizumab chemotherapy for metastatic colorectal cancer

[assessment]

• Irinotecan has been reported with following adverse drug reactions and incidences: dizziness (15% to 21%), drowsiness (9%).
• Neurology studies on 2022-09-01 showed slowing sensory conduction velocity in bilateral ulnar nerves and prolonged latency in left tibial nerve.
• A walking stick is being prepared by the Discharge Planning Service Center.

220908

[assessment]

• It is recommended to prescirbe the patient-carried diphenidol (25mg/tab) 1# TIDPC (currently TID) according to the package insert.

220630

[assessment]

• 2022-06-27 CT showed lung mets in progression, however tumor markers decreased slightly (CEA: 2022-06-24 2235 ng/mL <- 2022-06-14 2447 ng/mL; CA199: 2022-06-24 3344 U/mL <- 2022-06-14 3614 U/mL).
• Lung mets have been developed. Oxaliplatin is rarely associated with pulmonary toxicity. For patients with unexplained pulmonary symptoms, oxaliplatin is recommended to be withheld until interstitial lung disease or pulmonary fibrosis is excluded.
  • Oxaliplatin-induced Pulmonary Toxicity: A Rare but Serious Complication. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188452/
  • Oxaliplatin-Induced Pulmonary Toxicity in Gastrointestinal Malignancies: Two Case Reports and Review of the Literature. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4441996/
  • Pulmonary Fibrosis Secondary to Oxaliplatin Treatment: From Rarity to Reality: A Case Study and Literature Review. https://link.springer.com/article/10.1007/s40487-020-00127-z

220617

[assessment]

• A partial response was seen on the CT image of 2022-04-15 (compared to 2022-01-19), however some biomarker levels have continued to rise.
• Biomarkers time series:
  • CEA
    • 2022-06-14 2447 ng/mL
    • 2022-05-25 2039 ng/mL
    • 2022-04-27 2063 ng/mL
    • 2022-03-30 3132 ng/mL
    • 2022-02-16 1956 ng/mL
    • 2022-01-18 771 ng/mL
  • CA199
    • 2022-06-14 3614 U/mL
    • 2022-05-25 2383 U/mL
    • 2022-04-27 2758 U/mL
    • 2022-03-30 2837 U/mL
    • 2022-02-16 2376 U/mL
    • 2022-01-18 1089 U/mL
• The creatinine level on 2022-06-14 increased to 1.43 mg/dL slightly above ULN and a record high, which might need to be kept in check.
• SpO2 96%, TPR, BP were stable since this hospitalization. No issue with active prescription.

220602

[assessment]

• During the past five months, the patient’s body weight has increased by more than ten kilograms (84.2 kgw 2022-06-01 <- 71.5 kgw 2022-01-05), and insomnia remained on the patient’s medical problem list in recent hospital stays even when lorazepam has been prescribed. The use of steroids (both systemically and inhalationally) can result in these side effects.
  • Steroid-Induced Sleep Disturbance and Delirium: A Focused Review for Critically Ill Patients. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7357890/
  • Steroid-induced mental disorders in cancer patients: a systematic review. https://doi.org/10.2217/fon-2017-0306
• Pharmacotherapy should not be the sole treatment of insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is the preferred first-line treatment for chronic insomnia in adults. The evidence base is stronger for CBT-I than for medications. When used, medications should be combined with healthy sleep habits and CBT-I, when appropriate and available.
  • The effectiveness of non-pharmacological sleep interventions for people with chronic pain: a systematic review and meta-analysis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9092772/

220428

[assessment]

• Recent two consecutive CT scans have indicated a partial response of splenic flexure colon cancer to the current regimen. However, there is an enlarged tumor on the lower pole of the left kidney that might need to be addressed (2.4cm 2022-04-15 <- 2.0cm 2022-01-19, a 20% increase in diameter in 3 months).
• The CEA and CA199 levels on 2022-04-27 fell to 2063ng/mL (from 3132ng/mL on 2022-03-30) and 2758U/mL (from 2837U/mL on 2022-03-30), which were both positive signs.
• In three months, the body weight increased by ten kilograms (81.2 kgw 2022-04-27 <- 71.5 kgw 2022-01-05). According to lab data on 2022-04-27, liver and kidney function, serum electrolytes, and blood cell counts were all within normal ranges. Cachexia is still a diagnosis.
• The current chemotherapy regimen FOLFIRI plus bevacizumab is generally well tolerated by the patient and respiratory symptoms have been managed with corresponding medication.

220415

[assessment]

• Currently there are no new CT images (last 2022-01-19) or CEA or CA199 readings (last 2022-03-30) since the last hospitalization.
• Lab results on 2022-04-12 concerning liver function, renal function, serum electrolytes, and blood cell counts were grossly normal.
• The current chemotherapy regimen FOLFIRI is generally well tolerated by the patient and respiratory symptoms have been managed with corresponding medication.

220330

[assessment]

• The evidences were inconsistent, with CT images (2022-01-19) showing improvement and lab data readings (CEA from 869 to 3132 ng/mL, CA199 from 1089 to 2837 U/mL, since 2022) showing deterioration, following T loop colostomy (2021-10-06) and FOLFIRI plus bevacizumab (since mid Nov 2021).
• pMMR (colon biopsy pathology 2021-09-28), certain kind of drugs e.g. nivolumab or pembrolizumab might not be preferred.
• Cetuximab or panitumumab may be appropriate in this patient with a left-sided tumor if the RAS WT is confirmed.
• When BRAF V600E mutation is proven, then BRAF inhibitors, e.g. encorafenib, dabrafenib + trametinib, could also be considered optionally.

220217

[assessment]

• CT images on 2022-01-19 showed some improvement based on decreasing in mass size and/or density, CEA and CA199 data revealed the same trend p/s colostomy and FOLFIRI treatment, however both the lab readings doubled within just a month could hint the disease is acquiring resistence after 4 months treatment.
• pMMR, certain kind of drugs e.g. nivolumab or pembrolizumab might not be preferred.
• if RAS WT proven, cetuximab or panitumumab might be applicable for this left-sided tumor patient.

701179785

221003

{vancomycin trough concentration}

• There was a trough concentration of 9.4 mg/L recorded on 2022-10-03 in this patient treated with U-Vanco (vancomycin) 1000mg QW15 (based on his renal function) since 2022-09-25.

• It appeared to be effective (CRP 15.84mg/dL 2022-10-03 <= 29.58mg/dL 2022-09-22) when vancomycin was used, however, it is recommended that serum vancomycin trough concentrations should always be kept above 10 mg/L to avoid resistance development. For a pathogen with an MIC of 1 mg/L, the minimum trough concentration would have to be at least 15 mg/L to generate the target AUC (Area under the curve): MIC of 400. (ref: Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society Of Infectious Diseases Pharmacists. Clin Biochem Rev. 2010;31(1):21-24.)

• Changing the current administration frequency from QW15 to QW135 is recommended to increase the concentration to at least 10 mg/L. Thank you!

700052326

220930

• BH 172, BW 109.2, BMI 36.9

• past history

  • 3-V coronary artery disease
    • s/p PTCA with stenting for 2 times in 2005-10 & 2006-02 at Cardinal Tien Hospital;
    • s/p PTCA with stenting for LAD instent restenosis in 2006-08 at TPE TCH;
    • s/p PTCA with bare-metal stenting for RCA and LAD on 2011-09-28;
    • s/p PTCA with stenting for middle RCA and PL branch on 2012-02-08;
    • s/p PTCA with stenting for D1 & LAD on 2012-09-05.
    • 2VD with LAD-D1 and RCA stenosis on 2015-06-01, Medical treatment was suggested due to no severe stenosis or occlusion was found.
  • Hypertensoin under medical control for 10+ years
  • Hyperlipidemia under statin control for 10+ years
  • Type II DM for years
  • Old left radial liniar fracture
  • Diverticulitis of ascending colon and local perforation with conservation treatment on 2022-01.

• family history

  • 1. Father died of acute myocardial infarction at age 64, hypertension with diabetes.
  • 2. Grandfather and younger brother: heart disease, unknown type.
  • 3. Mother: hypertension.    

• lab data

  • CEA
    • 2022-09-27 CEA 6.67 ng/mL
      
    • 2022-08-30 CEA 9.69 ng/mL
      
    • 2022-08-03 CEA 14.95 ng/mL
      
    • 2022-07-05 CEA 20.39 ng/mL
      
    • 2022-06-07 CEA 22.12 ng/mL
      
    • 2022-05-04 CEA 27.26 ng/mL
      
    • 2022-04-01 CEA 39.36 ng/mL
      
    • 2022-03-25 CEA 38.05 ng/mL
      
  • All-RAS
    • 2022-04-29 Detected
      • KRAS codon 12 GGT > GCT, p.G12A
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment.
        • Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • BRAF
    • 2022-04-29 Not Detected
      • There was no variant detected in the BRAF gene
        • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment.
        • Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.

• exam finding

  • 2022-08-31 CT - abdomen
    • History:
      • Recurrent RUQ pain for times, intermittent
      • 20220111 CT: Diverticulitis of ascending colon with perforation and abscess s/p medication (0111~0120) and LGI bleeding (0124~0126)
      • 20220401 CEA: 39.36 ng/mL (< 5).
      • 20220401 CT: Locally advanced ascending colon cancer with abscess and partial obstruction, carcinomatosis s/p exploratory laparotomy with right hemicolectomy on 2022/04/06, pT4aN2bM1c, Stage IVC
    • Findings:
      • S/P right hemicolectomy
      • Prior CT identified multiple enlarged nodes in celiac trunk, hepatoduodenal ligament, mesentery, para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain and bilateral interal iliac chain are noted again, mild decreasing in size that are c/w metastatic nodes (non-regional) S/P C/T with partial response.
      • A hepatic cyst measuring 1.3 x 0.7 cm in S3 is noted.
    • Impression:
      • Non-regional metastatic nodes S/P C/T show partial response.
      • Detailed findings, please see description.
  • 2022-05-11 Chest XR
    • S/P Port-A infusion catheter insertion.
    • Normal appearance of trachea and bil. main bronchus.
    • Normal size of heart.
    • Clear both lung field.
  • 2022-04-08 Chest XR
    • Right catheterization to SVC in position.
    • S/P NG tube indwelling.
    • Ground glass opacities in bil. lungs.
    • S/P operation.
  • 2022-04-07 Patho - colon segmental resection for tumor
    • pathologic diagnosis
      • Ascending colon, right hemicolectomy — Adenocarcinoma, poorly differentiated, with abscess formation
        
      • Resection margins, right hemicolectomy — Free
        
      • Lymph nodes, mesocolic, right hemicolectomy — Metastatic adenocarcinoma (7/14)
        
      • Pathology stage: pT4aN2b(cM1a); Stage IVA
    • microscopic examination
      • Histology: Adenocarcinoma with abscess formation
        
      • Histology Grade: Poorly differentiated
        
      • Depth of invasion: Pericolic soft tissue
      • Angiolymphatic invasion: Present and extensive
      • Perineural invasion: Present
        
      • Tumor cell budding: High
        
      • Margins
        • Proximal and distal margins: Uninvolved
        • Circumferential (radial) margin: Uninvolved
      • Lymph node metastasis, mesocolic: Metastatic adenocarcinoma (7/14)
      • Extranodal involvement: Present
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT4a (Tumor invades through serosa)
        • Regional Lymph Nodes (pN): pN2b (seven or more regional lymph nodes are positive)
        • Distant Metastasis (pM): cM1a
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: Two tubulovillous adenoma and tumor emboli in submucosal vascular channels
      • Tumor regression grading S/P CCRT: N/A
      • IHC: EGFR(+), MLH1(+), PMS2(focal +), MSH2(+), MSH6(+)
      • Appendix: Submucosal abscess and granulation tissue
  • 2022-04-07 Chest XR
    • S/P ET tube inserted in position with cuff inflation.
    • Right catheterization to SVC in position.
    • S/P NG tube indwelling.
    • Right pleural effusion.
    • Ground glass opacity in bilateral lower lungs.
  • 2022-04-04 CT - abdomen, pelvis
    • Findings:
      • Wall thickening of A-colon with adjacent fat stranding and regional LAP. Enlarged LNs at mediastinum and along aorta/ IVC and bil. iliac vessels.
      • Grade 4 fatty liver.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Distention of gallbladder.
      • Intact bony structures.
      • Minimal ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of coronary arteries.
      • Partial atelectasis at right basal lung.
    • Impression:
      • Wall thickening of A-colon with adjacent fat stranding and regional LAP. Enlarged LNs at mediastinum and along aorta/IVC and bil. iliac vessels.
      • Grade 4 fatty liver.
      • Distention of gallbladder.
  • 2022-04-03 Electrocardiography, ECG
    • Sinus rhythm with Premature atrial complexes
    • Moderate voltage criteria for LVH, may be normal variant
    • Anteroseptal infarct
    • T wave abnormality, consider lateral ischemia
  • 2022-04-01 CT - abdomen, pelvis
    • Findings:
      • There is lobulated enhancing wall thickening at the ascending colon that may be adenocarcinoma. The differential diagnosis include diverticulitis. Please correlate with colonoscopy. In addition, there are multiple enlarged nodes in right side mesocolon (the largest one measuring 2.8 cm) and mesentery root that may be metastatic nodes?
      • There are multiple enlarged nodes in celiac trunk, hepatoduodenal ligament, para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain and bilateral interal iliac chain. Metastatic nodes (non-regional) are highly suspected.
      • There is symmetrical wall thickening of the ascending colon with surrounding fatty stranding and free gas bubbles that is c/w prior acute diverticulitis with perforation and abscess S/P treatment with residual change. In addition, The free gas bubbles show directly attached right transverse abdominis muscle that may be muscle invasion.
      • A hepatic cyst measuring 1.3 x 0.7 cm in S3 is noted.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
      • There is no evidence of ascites.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • Adenocarcinoma of the proximal ascending colon with lymph nodes metastases is highly suspected.
      • If ascending colon cancer is finally proved by pathology. According to American Joint Committee on Cancer(AJCC) staging system, 8th edition for colon cancer: T4a N2b M1a, Stage:IVA
  • 2022-01-25 Sigmoidoscopy
    • Indication：Blood in the stool
    • Premedication: Buscopan 20mg + Alfentanil 0.25mg IV
    • Anesthesia: No anesthesia
    • The scope reach the sigmoid colon. Multiple diverticula at S colon
    • Internal hemorrhoid was noted.
    • Diagnosis
      • Diverticulosis, S colon
      • Internal hemorrhoid
    • Complication
      • No immediate complication
  • 2022-01-11 CT - abdomen, pelvis
    • Findings
      • Wall edema at ascending colon with pericolonic fatty infiltrates and fluid, suspected ascending colon diverticulitis.
      • There are outpouching lesions in the sigmoid colon, suggesting sigmoid diverticulosis.
      • Presence of gallbladder sludge.
      • Liver cyst, 1.3cm in left lobe liver.
      • Unremarkable change of the spleen, pancreas and both kidneys.
      • There are multiple enlarged lymph nodes in the paraaortic region and common iliac and obturator regions. suspected lymphoma.
    • Impression:
      • Colon diverticulosis.
      • Suspected ascending colon diverticulitis, suggest clinical correlation.
      • Multiple enlarged lymph nodes in the paraaortic region and common iliac and obturator regions. Suspected lymphoma. Suggest further study.
    • Imaging Report Form for Colorectal Carcinoma
      • Imaging stage: T4aN2M1a, stage IVA
  • 2021-11-12 Myocardial perfusion SPECT with persantin
    • The Tl-201 stress myocardial perfusion SPECT performed after intravenous injection 60 mg of dipyridamole revealed markedly decreased perfusion of radioactivity to the apex, inferoapical wall and anterior wall and mildly to moderately decreased perfusion of radioactivity to the septum, inferolateral wall and posterior wall. The Tl-201 redistribution myocardial perfusion SPECT revealed partial reperfusion of radioactivity to the apex, inferoapical wall and anterior wall and reperfusion of radioactivity to the septum, inferolateral wall and posterior wall.
    • IMPRESSION: Probably severe myocardial ischemia with possible a portion of infarction at the apex, inferoapical wall and anterior wall and mild to moderate myocardial ischemia at the septum, inferolateral wall and posterior wall.
  • 2021-11-12 2D transthoracic echocardiography
    • Mildly abnormal LV systolic function with hypokinesia to akinesia of mid-anterior to apical segments
    • Dilated LA and LV
  • 2021-10-26 Electrocardiography, ECG
    • Normal sinus rhythm
    • Anteroseptal infarct, age undetermined
  • 2017-11-10 Renal ultrasound
    • Bilateral parenchymal renal disease.

• consultation

  • 2022-04-09 Infectious Disease
    • Findings:
      • Consultation for Finibax antibiotic
      • A-colon cancer with local abscess and partial obstruction case.
      • Fever persists for nearly one week despite Brosym use.
      • Serial CxR film shows newly developed right pleural effusion and LLL infiltrates, which hard to say pneumonia or not.
      • No significant culture report available yet.
      • White count 15110 yesterday and CRP level up to 26 today.
      • Brosym is replaced by Finibax ysterday.
    • Suggestion:
      • Continue Finibax for 5 days first.
      • Check drainage fluid and blood culture report.

• multiteam

  • 2022-04-07 Social Service
    • Reason: Economic issues such as medical care, nursing care, daily necessities, etc.
    • Processing status: open
    • Family status: 20220406 Talk with the case brother
      • The case is unmarried. After the stent was installed in the heart in 2013, he is unemployed and his last job is a car salesman.
      • The family has a history of heart disease. His grandfather, his father, his elder brother and his elder sister all died of heart disease. The mother of the case is 84 years old and has four sons and two daughters. The case is ranked fifth, and they are twin brothers. The second brother of the case, married and living in Linkou, was estranged from the case’s family and did not provide assistance. The second sister of the case is married and works as a general electronics company operator. The brother-in-law of the second sister is a bus driver. The two have a son. The nephew of the case is married and has a young son.
      • The case does not have labor insurance and private insurance, and the house is owned by the case and the case brother.
      • The younger brother is a Reha bus driver with a monthly income of about 33,000 yuan. After the case fell ill, the second sister assisted in taking out medical insurance and had a heart stent installed in our hospital. The case and the mother’s living expenses all depend on the younger brother’s income. .
    • Main Issue: Economic Issue
  • 2022-04-06 PreOp Evaluation
    • Fever before operations: No  
    • CNS：Consciousness: Clear and alert  
    • Respiratory system: Lung disease: No
    • Breathing sound: Clear
    • Cardiovascular System: Cardiovascular disease: Yes
    • Diabetes mellitus: Yes, Good control
    • Malignant neoplasm: No
    • Bleeding tendency: Nil  
    • Other infectious disease: No
    • Plavix discontinued for 3 months   

• surgical operation

  • 2022-04-06
    • Surgery
      • EXP LAP with right hemicolectomy
    • Finding
      • A colon tumor with invasion to right side abdominal wall, with abscess, invade to gerota fascia, colohepatic ligment and partial obstruction.
      • Enlarge LN over ileocecal artery
      • Tumor invasion to ileum.

• radiotherapy

  • 2022-06-28 ~ 2022-07-22 CCRT 5000cGy/25 fractions (15 MV photon) to PA & pelvic LAPs

• chemoimmunotherapy

  • 2022-09-29 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 75mg/m2 170mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
  • 2022-09-13 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 190mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
  • 2022-08-30 - oxaliplatin 85mg/m2 190mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
  • 2022-08-18 - oxaliplatin 85mg/m2 190mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
  • 2022-08-05 - oxaliplatin 75mg/m2 170mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
  • 2022-07-22 - oxaliplatin 75mg/m2 170mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
  • 2022-07-07 - oxaliplatin 75mg/m2 170mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
  • 2022-06-23 - oxaliplatin 65mg/m2 150mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2800mg 24hr D1-2
  • 2022-06-09 - leucovorin 400mg/m2 950mg 2hr + 5-Fu 1200mg/m2 2800mg 24hr D1-2
  • 2022-05-26 - leucovorin 400mg/m2 950mg 2hr + 5-Fu 1200mg/m2 2800mg 24hr D1-2

[assessment]

• A mild pancytopenia was observed on 2022-09-27, but the scheduled chemotherapy should not be suspended
• The underlying conditions T2DM and HTN appeared to be under control during this hospitalization.
• A downward trend in CEA levels has been observed, which is encouraging and suggests the current regimen is working.
  • 2022-09-27 CEA 6.67 ng/mL
    
  • 2022-08-30 CEA 9.69 ng/mL
    
  • 2022-08-03 CEA 14.95 ng/mL
    
  • 2022-07-05 CEA 20.39 ng/mL
    
  • 2022-06-07 CEA 22.12 ng/mL
    
  • 2022-05-04 CEA 27.26 ng/mL
    
  • 2022-04-01 CEA 39.36 ng/mL

220831

[assessment]

• In patients with renal failure (acute or chronic), the renal clearance of metformin is decreased, and there is an associated risk of lactic acidosis. Some patients who receive intravenous contrast may experience a deterioration of renal function (contrast-induced nephropathy). Intravenous studies using a single dose of metformin in normal subjects show that metformin is excreted as unchanged drug in the urine and does not undergo hepatic metabolism (no metabolites have been identified in humans) or biliary excretion. The patient does not appear to have renal impairment (2022-08-30 creatinine 0.59 mg/dL, eGFR 154.55, BUN 12 mg/dL). For CT scanning, metformin might be temporarily held, although the risk of lactic acidosis is less likely to occur in this patient.
• Dapagliflozin is primarily glucuronidated to become the inactive 3-O-glucuronide metabolite (60.7%). The metabolites are mainly inactive, although dapagliflozin is not recommended in patients with a creatinine clearance below 45mL/min and is contraindicated in patients with creatinine clearance below 30mL/min, temporarily hold the drug for CT scanning could be a preventive option which might be over aversion to the risk.

220819

[assessment]

• There was a study demonstrated that empirically eliminating 5-FU bolus and LV from first line palliative therapy with mFOLFOX6 in mCRC resulted in no significant difference in median PFS or OS. Despite reduced growth factor utilization, the non-bolus arm demonstrated a favorable safety profile with less treatment-related hematologic grade >= 3 AE. It suggested consideration of empirically eliminating 5-FU bolus and LV from the mFOLFOX6 regimen to avoid additive toxicities without negatively impacting efficacy. Reference: Impact of empirically eliminating 5-fluorouracil (5-FU) bolus and leucovorin (LV) in patients with metastatic colorectal cancer (mCRC) receiving first-line treatment with mFOLFOX6. DOI: 10.1200/JCO.2020.38.15_suppl.4022 Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020) 4022-4022. https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.4022
• Because this patient is receiving a 5-FU-bolus-removed regimen, leucovorin might also be removed or reduced to no more than 200mg/m2.

220725

[assessment]

• The patient was admitted to receive his scheduled FOLFOX regimen.
• Cardiovascular adverse reactions reported for oxaliplatin include chest pain (5%), edema (10%), flushing (3%), peripheral edema (5%), and thromboembolism (2%); and for fluorouracil, angina pectoris, cardiac arrhythmia, cardiac failure, cerebrovascular accident, ischemic heart disease, local thrombophlebitis, myocardial infarction, vasospasm, and ventricular ectopy.
• For this patient with a history of previous myocardial infarction and chronic ischemic heart disease, oxaliplatin is titrated up from 65 mg/m2 to 75 mg/m2 (still less than the standard 85 mg/m2), and the 5-Fu bolus is skipped.
• QT prolongation and ventricular arrhythmias have been reported after oxaliplatin. ECG monitoring is recommended if therapy is initiated in patients with heart failure, bradyarrhythmias, coadministration of drugs known to prolong the QT interval, and electrolyte abnormalities. There is no abnormality in the serum potassium level (2022-07-19), which was 3.5 mmol/L. Earlier ECG 2022-04-03 showed: 1) Anteroseptal infarct; 2) T wave abnormality, consider lateral ischemia.
• CEA and CA199 keep declining since April 2022. 2022-07-05 CEA 20.39 ng/mL (<- 38) , CA199 12.38 U/mL (<- 20).
• The patient’s blood sugar level fluctuates between 89 and 147 mg/dL, never exceeding 150 mg/dL during this hospitalization. There is no need to adjust his hypoglycemic agents urgently.
• TPR, BP, SpO2 readings were relatively stable. No issue with active prescription. It might be necessary to follow up with an ECG and/or cardiac ultrasound on a regular basis.

220610

[assessment]

• The patient was admitted to receive his scheduled FOLFOX regimen.
• CEA and CA199 keep declining since April 2022.
• Other lab results (2022-06-07) indicated that the readings were grossly normal.
• No issue with active prescription.

220527

[assessment]

• This is an economically disadvantaged patient who has been unemployed for many years and relies on relatives for financial support. He was diagnosed with stage IV A-colon cancer with mets in the first quarter of 2022, underwent right hemicolectomy in April of that year and was subsequently admitted to receive his first FOLFOX treatment.
• TPR, BP, (2022-05-27) lab results (2022-05-26) were generally not bad. Self-carried items in active prescription are used to treat underlying health conditions.
• The patient has a KRAS mutation (2022-04-29 detected) and may not benefit from anti-EGFR antibody treatment.
• No issue with current medication.

700943429

220929

• past history
  • The patient had cervical cancer stage I s/p for 6 years ago
  • history of operation: laparoscopic cervical resection and myoma resection for 6 years ago
  • Denied recent traveling history
  • Blood transfusion history: NIL
  • Regular medications or herb：no     
• exam finding
  • 2022-06-24 Patho - stomach subtotal/tatal (tumor)
    • Diagnosis
      • Stomach, antrum, laparoscope radical subtotal gastectomy —- Poorly cohesive carcinoma, non-signet-ring cell type
      • Duodenum, laparoscope radical subtotal gastectomy —- Negative for malignancy
      • Margin: free
      • Lymph node, group 1, dissection —- Negative for malignancy (0/4)
      • Lymph node, group 3, dissection —- Metastatoc carcinoma (3/7)
      • Lymph node, group 4, dissection —- Negative for malignancy (0/9)
      • Lymph node, group 5, dissection —- Metastatic carcinoma (1/1)
      • Lymph node, group 6, dissection —- Negative for malignancy (0/13)
      • Lymph node, group 7, 8, 9, 11, 12, dissection —- Negative for malignancy (0/13)
      • Lymph node, group 14v, dissection —- Negative for malignancy (0/2)
      • AJCC 8 th edition p T N M Pathology stage: pStage IIIA, pT3N2(if cM0)
    • Gross Description:
      • Procedure: laparoscope radical subtotal gastectomy
      • Specimen size: Greater curvature: 11.5 cm, Lesser curvature: 8.5 cm, Duodenum: 0.5 cm
      • Tumor site: (check that apply): Antrum, lesser curvature
      • Tumor size: 2.0 x 1.5 cm
      • Gross configuration: Type III: Ulcerated with poorly defined infiltrative margins
      • Sections are taken and labeled as:
        • A1-2: proximal resection margin;
        • A3: distal resection margin;
        • A4: stomach, non-tumor;
        • A5-8: tumor;
        • B: lymph node, group 1;
        • C: lymph node, group 3;
        • D1-2: lymph node, group 4;
        • D3: omentum;
        • E: lymph node, group 5;
        • F: lymph node, group 6;
        • G1-2: lymph node, group 7, 8, 9, 11, 12;
        • H: lymph node, group 14v.
    • Microscopic Description:
      • Histologic Type: Lauren classification of adenocarcinoma: Diffuse type (WHO(2019) poorly cohesive carcinoma, non-signet-ring cell type); The immunohistochemical stains reveal CK(+) and Her-2/neu (Ab): Negative (0)
      • Histologic Grade: G3: Poorly differentiated, undifferentiated
      • Tumor Extension: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
      • Margins
        • Proximal margin: uninvolved by invasive carcinoma: 2.9 cm
        • Distal margin: uninvolved by invasive carcinoma: 4.5 cm
        • Radial margin: uninvolved by invasive carcinoma: 0.2 cm
      • Lymphovascular Invasion: present
        
      • Perineural Invasion: present
        
      • Regional Lymph Nodes: please see diagnosis
        
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): absent
          
        • Primary Tumor (pT): pT3: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
        • Regional Lymph Nodes (pN): pN2: Metastasis in three to six regional lymph node
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
      • Additional Pathologic Findings
        • Intestinal metaplasia: present
        • Low-grade dysplasia: present
        • High-grade dysplasia: present
        • Helicobacter pylori-type gastritis: absent
        • Autoimmune atrophic chronic gastritis: absent
          
        • Polyp(s): absent
  • 2022-06-10 Doppler color flow mapping
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 17) / 80 = 78.75%
      • M-mode (Teichholz) = 77
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild MR, TR
  • 2022-05-27 CT - abdomen
    • History:
      • Epigastric fullness for days, Fasting epigastralgia
      • Belching and acid reflux, nausea(+), Decreased appetite(+), Weight loss(+)
      • 20220518 gastroscopy: A 2-3cm A2 ulcer was noted at angle, s/p biopsy, path:Intramucosal adenocarcinoma and gastric ulcer
    • Findings:
      • There is mild wall thickening at the gastric low body-antrum, measuring 0.9 cm in wall thickness.Please correlate with gastroscopy.
        • In addition, There is no enlarged node in the perigastric area.
      • There are several enhancing lesions in the uterus, the largestone measuring 5 cm in size, that may be myomas. Please correlate with GYN. sonography.
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T2 (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:I(Stage_value)
  • 2022-05-18 Patho - stomach biopsy
    • PATHOLOGIC DIAGNOSIS
      • Stomach, angle, biopsy — Intramucosal adenocarcinoma and gastric ulcer
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of multiple small pieces of gray-white soft tissue, labeled angle of stomach, measuring up to 0.4 x 0.2 x 0.2 cm. All for section.
    • MICROSCOPIC EXAMINATION
      • The sections show intramucosal adenocarcinoma, composed of gastric mucosal tissue with columnar to cuboidal neoplastic cells, arranged in glandular and cribriform patterns with focal stromal invasion. Gastric ulcer with necrosis and inflammatory exudate can be identified also.
  • 2022-05-18 SONO - abdomen
    • gallbladder polyp
  • 2021-12-22 Patho - colorectal polyp
    • Intestine, large, cecum, (A), biopsy removal — tubular adenoma
    • Intestine, large, transverse colon, (B), polypectomy —tubular adenoma
      
    • Intestine, large, transverse colon, (C), polypectomy —tubular adenoma
• surgical operation
  • 2022-06-23
    • Surgery
      • laparoscope radical subtotal gastectomy with D2 LN dissection
    • Finding
      • 2 x 1.8 cm ulcerative mass at antrum lesser curvature
      • regional LN at LN 3, 5 & 8
• chemoimmunotherapy
  • 2022-09-28 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
  • 2022-09-12 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
  • 2022-08-29 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
  • 2022-08-15 - oxaliplatin 70mg/m2 90mg 2hr + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr

700192852

220928

{Primary peritoneal serous carcinoma (omentum, ileum, colon, appendix involvement), pT3cN0M0, FIGO stage IIIC s/p Optimal (R1) debulking surgery (TAH + BSO + BPLND + PALNS + OMENTECTOMY + CYTOLOGY) + CUSA + Right hemicolectomy (Terminal ileum + Appendix + ascending/transverse colon resection) on 20210111.}

[objective]

• lab data
  • CA125
    • 2022-07-19 CA-125 669.52 U/ml
      
    • 2022-06-13 CA-125 957.5 U/mL
      
    • 2022-06-10 CA-125 1194.15 U/ml
      
    • 2022-05-27 CA-125 1918.48 U/ml
      
    • 2022-04-22 CA-125 823.98 U/ml
      
    • 2022-02-11 CA-125 85.56 U/ml
      
    • 2020-12-29 CA-125 254.73 U/ml
      
    • 2020-12-11 CA-125 394.4 U/mL
      
    • 2018-09-08 CA 125 8.2 U/mL
      
  • CA199
    • 2022-07-19 CA-199 451.52 U/ml
      
    • 2022-06-10 CA-199 551.82 U/ml
      
    • 2022-05-27 CA-199 480.27 U/ml
      
    • 2022-02-09 CA-199 66.817 U/ml
      
    • 2020-12-29 CA-199 371.190 U/ml
      
    • 2020-12-11 CA-199 166.87 U/mL
      
    • 2018-09-10 CA-199 9.123 U/ml
• exam finding
  • 2022-08-09 SmallIntestine
    • Segmental dilatation of proximal small bowel, suspected partial obstruction
  • 2022-07-11 Abdomen standing
    • S/P nasogastric tube insertion
    • Few segment of bowel in the middle abdomen show air-fluid level.
  • 2022-06-17 Small Intestinal Series
    • Dilated haustration of the jejunum and ileum and stomach as well as the doudenum is found.
    • The peristasis of the small intestine is retarded.
    • The transit time is 24 hours.
    • Imp: Paralytic ileus with delayed peristasis.
  • 2022-06-15 CT - abdomen, pelvis
    • Tumor seeding in the proximal jejunum induce bowel obstruction is highly suspected.
    • Carcinomatosis.
    • Metastatic nodes in the mesentery and para-aortic space.
    • Tumor seeding at the sigmoid colon and terminal ileum at the pelvis show stationary.
  • 2022-04-27 Small Intestine
    • Some indentation at bowel loop.
    • The passage time is about 4 hours.
  • 2022-04-25 CT - liver, spleen, biliary duct, pancreas
    • Suspected peritoneal seeding and liver/lung metastases.
    • Wall thickening of S-colon.
  • 2022-04-22 Patho - stomach biopsy
    • Stomach, pyloric ring, biopsy — ulcer with Helicobacter infection
  • 2022-04-22 Esophagogastroduodenoscopy
    • Diagnosis
      • Gastric ulcer, H2, pyloric ring, s/p biopsy
      • Suboptimal study due to much food residue in stomach and duodenum, probable due to bowel obstruction below 2nd portion
      • Reflux esophagitis LA Classification grade A
    • Suggestion
      • NG decompression
      • Small bowel series
  • 2022-04-15 KUB
    • Stool retention in the bowel.
  • 2022-04-01 KUB
    • Fecal material store in the colon.
  • 2022-01-21 Patho - soft tissue debridment
    • Ileum, exploratory laparotomy with segmental bowel resection with end to end anastomosis — benign perforated ileum with external tumor seeding and muscular invasion as well as necrotic acute inflammatory exudates containing tumor nests.
      • One of three peri-ileal lymph nodes (1/3) show tumor metastasis (2 x 1 mm).
      • IHC stains: CK20 (-): non-intestinal origin, PAX-8 (+), WT-1 (+), Napsin-A (-), p53 (aberrant type): compatible with serous carcinoma.
    • Labeled as ‘cut end 2’, exploratory laparotomy with segmental bowel resection with end to end anastomosis — Free.
    • Labeled as ‘cut end’, exploratory laparotomy with segmental bowel resection with end to end anastomosis — Free.
    • Labeled as ‘peritoneum tumor’, excision — serous carcinoma (4 x 3 mm).
      • IHC stains: CK20 (-), PAX-8 (+), WT-1 (+), Napsin-A (-), p53 (aberrant type).
        
  • 2022-01-20 CT - abdomen, pelvis
    • Pneumoperitoneum. Focal wall thickening of ileum suspected malignancy.
  • 2021-01-11 Pathology at VGHTPE
    • Recurrence from primary peritoneal serous carcinoma (omentum, ileum, colon, appendix involvement), pT3cN0M0, FIGO stage IIIC, s/p Optimal (R1) debulking surgery (TAH + BSO + BPLND + PALNS + OMENTECTOMY + CYTOLOGY) + CUSA + Right hemicolectomy (Terminal ileum + Appendix + ascending/transverse colon resection)
    • PAX-8 (+), WT-1 (+), Napsin-A (-), p53 (aberrant type)
  • 2020-12-25 Small Intestinal Series
    • Normal haustration of the jejunum and ileum.
    • The peristasis of the small intestine is intact.
    • No evidence of stenotic or obstructive lesion in the study.
    • The transit time is 120 minutes.
    • Suggest clinical correlation
  • 2020-12-11 Gynecologic ultrasonography
    • Suspected Lt ovarian cyst
    • Uterine myoma
  • 2020-12-01 KUB
    • Stool retention in the bowel.
  • 2020-08-19 CT - abdomen, pelvis
    • Infectious colitis is suspected.
    • Please correlate with stool routine and culture, or colonoscopy.
  • 2019-04-01 SONO - breast
    • Right breast cyst and fibroadenoma. Suggest follow up.
    • BI-RADS2. benign finding
  • 2018-09-08 EKG
    • Sinus bradycardia with Premature atrial complexes
    • Prolonged QT
    • Abnormal ECG
  • 2018-09-08 SONO - breast
    • Suspected right breast tumor
    • Right fibroadenoma as described
    • Suggestion: tissue study
    • BI-RADS: suspicious abnormality, biopsy should be considered
  • 2018-09-08 Mammography
    • Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative.-annual screening.
  • 2018-09-08 Low-dose CT - lung cancer screening
    • Lungs: Nodular lesion at left upper lobe up to 4.7mm in largest dimension.
• consultation
  • 2022-06-15 General and Gastrointestinal Surgery
    • A
      • She suffered from had acute abdomen pain with fever due to ca involved small bowel with perforation and adhesions status post op 4 months ago
      • P.E showed soft abdomen, no muscle guarding, no local tendderness but severe abdomen distention
      • tumor markers and image studies in favor of cancer metastasis
      • Further C/T or immonotherapy is idicated
      • Give PN if oral feeding can not proceed
  • 2022-02-09 thoracic surgery
    • Q
      • This 60 year-old female had past history of 1) Myomectomy 20 years ago. 2) Primary peritoneal serous carcinoma (omentum, ileum, colon, appendix involvement), pT3cN0M0, FIGO stage IIIC, s/p Optimal (R1) debulking surgery (TAH + BSO + BPLND + PALNS + OMENTECTOMY + CYTOLOGY) + CUSA + Right hemicolectomy (Terminal ileum + Appendix + ascending/transverse colon resection) on 20210111. This time, she suffered from abdomen pain since 20220120 morning. She was brought to our ER, her consciousness remained E4V5M6. KUB showed calcification in LUQ, suspected left renal stone. Abdomen CT revealed pneumoperitoneum due to hollow organ perforation and carcinomatosis. After GS was consulted and suggested emergency survey was indicated. She underwent Exp. lap. with primary repair, lysis of adhesions, segmental bowel resection with end to end anastomosis excision of peritoneal tumor and multiple drainage on 20220120.
      • We need your expertise in evaluation and performing CVC insertion to facilitate TPN infusion in the immediate future.
    • A
      • I will arrange central venous catheterization. Thanks for your consultation.
  • 2022-01-20 gastroenterological surgery
    • Q
      • abdomenial pain VAS 4-7, no fever, nausea +, no diarrhea, deny tarry or bloody stool
      • PH: peritoneal cancer s/p op in Jan 2021 at Taipei Veterans General Hospital
      • allergy: aspirin
      • s/p 2 doses of covid vaccine
    • A
      • Acute left abdominal pain with fever with chillness for days
      • P.E showed diffuse local tenderness with muscle guarding esp left abdomen
      • Lab and CT in favor of pneumoperitoneum due to hollow organ perforation and carcinomatosis
      • Emergency op is indicated
• past history
  • Myomectomy 20 years ago.
  • Primary peritoneal serous carcinoma (omentum, ileum, colon, appendix involvement), pT3cN0M0, FIGO stage IIIC s/p Optimal (R1) debulking surgery (TAH + BSO + BPLND + PALNS + OMENTECTOMY + CYTOLOGY) + CUSA + Right hemicolectomy (Terminal ileum + Appendix + ascending/transverse colon resection) on 20210111.
• surgical operation
  • 2022-01-20
    • Surgery
      • Exp. lap. with primary repair,lysis of adhesions,segmental bowel resection with end to end anastomosis excision of peritoneal tumor and multiple drainage.
    • Finding
      • Bowel perforation of upper jejunum, 1.5cm in diameter, cause?
      • Severe adhesions and desmoplastic reaction over lower abdomen with focal or segmental bowel ischemic chnage and serosal tear
      • Multiple small nodules ove peritoneum and mesencary
      • A lot of turbid fluid over intraabdominal spaces, 100ml in amount
• chemoimmunotherapy
  • 2022-09-09 - pembrolizumab 200mg 1.5hr
  • 2022-08-23 - liposome doxorubicin 40mg/m2 50mg 2hr
  • 2022-08-16 - pembrolizumab 200mg 1.5hr
  • 2022-07-26 - pembrolizumab 200mg 1.5hr + liposome doxorubicin 40mg/m2 57mg 2hr
  • 2022-07-05 - pembrolizumab 200mg 1.5hr
  • 2022-06-28 - liposome doxorubicin 40mg/m2 50mg 2hr
  • 2022-06-15 - pembrolizumab 200mg 1.5hr
  • 2022-05-30 - liposome doxorubicin 40mg/m2 57mg 2hr
  • 2022-05-24 - pembrolizumab 200mg 1.5hr
  • 2022-05-03 - pembrolizumab 200mg 1.5hr + liposome doxorubicin 40mg/m2 57mg 2hr

==========

2022-06-27

• Hyperphosphatemia (7.5mg/dL 2022-06-26) might possibly due to tumor lysis syndrome?
• The hyperphosphatemia usually resolves within 6 to 12 hours if kidney function is intact. If kidney function is intact (creatinine 0.48 mg/dL, BUN 12 mg/dL 2022-06-26), phosphate excretion can be increased by saline infusion, although this can further reduce the serum calcium concentration by dilution.

2022-04-25

• Lab data on 2022-04-21, liver and kidney functions, serum electrolytes and blood cell counts were grossly normal, however the ca125 level of 823 U/mL was a record high.
• The use of a platinum based regimen, specifically paclitaxel/carboplatin Q3W, is recommended for serous carcinoma of either low grade or high grade. The addition of bevacizumab can also be considered.
• Acid reflux remains an active issue since 2022-04-22. Some H2 antagonists or PPIs may provide some relief. The prescription for pantoprazole 40mg IVD QD has been made.
• This patient is allergic to aspirin, which is not currently prescribed.

700695787

220927

• past history
  • Hypertension
  • Hyperlipidemia
  • Type II Diabetes Mellitus
  • Chronic kidney disease, stage III
  • Benign Prostatic Hyperplasia
• exam finding
  • 2022-09-26 CXR
    • Ground glass opacity in bilateral lower lungs.
    • Cardiomegaly.
    • Atherosclerosis of the aorta.
  • 2022-09-26 CT - abdomen
    • Splenomegaly with some low attenuations suspected infarcts.
    • Partial consolidation at LLL. Left pleural effusion.
    • Mild distention of left renal pelvis.
    • Some LNs (up to 1.1cm) at retroperitoneum.
    • Gallbladder stone (0.7cm).
    • Cardiomegaly.
  • 2022-06-20 SONO - nephrology
    • Left hydronephrosis
    • Left renal stone
    • Bilateral renal cysts
  • 2022-05-09 Effective renal plasma flow, ERPF
    • The ERPF values of the right kidney and the left kidney are 154.5 ml/min and 79.1 ml/min, respectively (normal reference range of ERPF: > 150 ml/min in each kidney for adults). There is decreased renal plasma flow to the left kidney.
    • Delayed radiotracer washout from the right kidney is noted, indicating obstructive uropathy in the right kidney.
    • It is indeterminate for obstructive uropathy of the left kidney because of diminished left renal function. Please correlate with other clinical findings for further evaluation.
  • 2022-04-27 Intravenous pyelogram, IVP
    • No evidence of urolithiasis.
  • 2022-03-28 SONO - nephrology
    • Parenchymal renal disease with enlarged parenchyma, bilateral, suspect diabetic nephropathy
    • Hydronephrosis, left
    • Simple cyst, bilateral
  • 2021-10-18 ECG
    • Sinus rhythm with 1st degree A-V block
    • Voltage criteria for left ventricular hypertrophy
    • Abnormal ECG

[assessment]

• Currently, there are antiglycemic agents (Januvia, sitagliptin 100mg, PO QD; Loditon, metformin 850mg, PO BID) on the active prescription list. On 2022-09-26, a blood glucose level of 300mg/dL was recorded prior to dinner. The use of Dibose (acarbose 100mg/tab, available in stock) 1# TID might be initialized if two or more consecutive data points exceed 200mg/dL.

700811991

220927

• lab data
  • 2022-09-09 Anti-HBc Reactive
    
  • 2022-09-09 Anti-HBc-Value 4.74 S/CO
    
  • 2022-09-09 Anti-HBs 8.30 mIU/mL
    
  • 2022-08-25 HBsAg Negative
    
  • 2022-08-25 HBsAg Value 0.538
    
  • 2022-08-25 Anti-HCV Negative
    
  • 2022-08-25 Anti-HCV Value 0.0352
• exam finding
  • 2022-09-16 CXR
    • Multiple nodules at bil. lungs.
  • 2022-08-30 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • Detected (KRAS codon 12 GGT>GTT, p.G12V)
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-08-28 Standing KUB
    • Degeneration and spondylosis of L-S spine.
  • 2022-08-25 Patho - colon segmental resection for tumor
    • Diagnosis:
      • Intestine, large, sigmoid colon, left hemicolectomy — Moderately differentiated adenocarcinoma
      • Proximal anastomosis: Negative for malignancy
        
      • Distal anastomosis: Negative for malignancy
        
      • Lymph node, regiona, dissection — Metastatic adenocarcinoma (4/18)
      • AJCC 8th edition pathology stage: T3N2a( cM1); AJCC stage IVA, at least
    • Gross Description:
      • Procedure: Left hemicolectomy
      • Tumor Site: Sigmoid colon
      • Tumor Size: 4.8x 3.5 cm.
        
      • Macroscopic Tumor Perforation: Not identified
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins:
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Involved
        • Lymphovascular Invasion: Present
          
        • Perineural Invasion: Not identified
        • Tumor Budding:
          • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2)
          • Intermediate score (5-9)
      • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
      • Tumor Deposits: Not identified
        • Specify number of deposits: N/A
      • Regional Lymph Nodes
        • Number of Lymph Nodes Involved/Examined: 4 / 18, with extranodal extension
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition):
        • TNM Descriptors (required only if applicable) (select all that apply)
          • m (multiple primary tumors) r (recurrent) y (posttreatment)
        • Primary Tumor (pT):
          • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN):
          • pN2a: Four to six regional lymph nodes are positive
        • Distant Metastasis (pM):
          • N/A
  • 2022-08-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 33) / 108 = 69.44%
      • M-mode (Teichholz) = 69
    • Normal LV systolic function with normal wall motion.
    • LV diastolic dysfunction Gr 2.
    • Normal RV systolic function.
    • Mild MR; mild TR; aortic valve sclerosis.
  • 2022-08-23 Flow Volume Curve
    • Mild obstructive pulmonary function impairment
  • 2022-08-22 CXR
    • Multiple nodules at bil. lungs.
  • 2022-08-22 CT - abdomen
    • History
      • 73 y/o 2022-07-17 abdominal pain off and on for a period of time
      • PI : diarrhea (-) constipation (-) BW loss (-) appetite : good, relieving factor (-)
      • PHx : HTN (+) DM (+) Op. (+) prostate hypertrophy CAD s/p stenting
    • Imp
      • Suspected colon cancer at rectosigmoid colon with lung meta and regional lymph nodes
    • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value)
  • 2022-08-11 Patho - colon biopsy
    • R-S junction, 20 cm AAV, biopsy — Adenocarcinoma, moderately differentiated
    • The sections show adenocarcinoma, moderately differentiated, composed of columnar neoplastic cells, arranged in glandular, cribriform, and papillary patterns with desmoplastic stromal reaction.
    • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
  • 2022-08-10 Colonoscopy
    • Suspected colon cancer, 20cm AAV, s/p biopsy
    • Internal hemorrhoid
• chemoimmunotherapy
  • 2022-09-26 - irinotecan 120mg/m2 150mg 90min + leuocovrin 300mg/m2 450mg 2hr + fluorouracil 2400mg/m2 3700mg 46hr

[assessment]

• Pathology performed in late August 2022 revealed the disease to be characterized by pMMR, EGFR(+), KRAS codon 12 mutations, without BRAF mutations.
  • pMMR => it would be less prominent in the effect of pembrolizumab or nivolumab +- ipilimumab.
  • mutated RAS => the effect of anti-EGFR antibody treatment (e.g., panitumumab, cetuximab) might be mitigated.
  • lack of BRAF codon 600 mutatation => encorafenib might not be the choice.
• The blood pressure appears to be under control (with bisoprolol and nicorandil); however, the blood sugar appears to be a little higher (with metformin and vildagliptin). The addition of a hypoglycemic agent is not urgently required yet.

700155901

220926

• exam finding
  • 2022-09-13, -09-06, 09-02, 08-24, 08-19, 08-10, 08-05 CXR
    • Blunting of bilateral costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Atherosclerotic change of aortic arch
  • 2022-08-05, -07-11 Abdomen - standing (diaphragm)
    • Increase soft tissue density of the right lower abdomen is noted that is c/w local recurrent tumor after correlate with prior CT on 20220625.
    • Spondylosis with scoliosis of the L-spine with convex to left side
  • 2022-07-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 23) / 93 = 75.27%
      • M-mode (Teichholz) = 75
    • Dilated LA
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild PR, TR
  • 2022-07-11 KUB
    • Increase soft tissue density of the RLQ abdomen is suspected. Please correlate with CT for further evaluation.
    • Ascites is suspected.
  • 2022-07-11 Patho - uterus with or without SO
    • DIAGNOSIS: Tissue, pelvic, biopsy — malignant tumor, high-grade
    • Microscopically, it shows mlaignant tumor composed of high-grade tumor cells arranged in solid architacture and focal glandular differentiation. The tumor shows nuclear hyperchromasia, pleomorphism, and mitotic activity.
    • Immunohistochemical stain reveals CK (focal +), PXA-8(+), WT-1(-), CK20(-).
  • 2022-07-05 Gynecologic ultrasonography
    • Suspected pelvis mass: (1) 197x122mm (2) 64x41mm
    • Ascites (+)
  • 2022-06-25 CT - abodmen
    • S/P hysterectomy with minimal ascites. Some recurrent tumors (up to 13.3cm) in peritoneal cavity.
  • 2022-02-18 SONO - abdomen
    • Two hepatic cysts in S6/7 and S5 are suspected. Follow up is indicated.
    • S/P cholecystectomy.
  • 2022-02-04 CT - abdomen
    • History:
      • Endometrial carcinosarcoma S/P hysterectomy and adjuvant chemo and radiotherapy
    • Impression
      • There are two poor enhancing lesion measuring 0.4 cm in S6/7 and 0.6 cm in S5 and of the liver that may be metastases or cysts? Please correlate with sonography and MRI.
  • 2021-10-15 MRI - pelvis
    • S/P hysterectomy and oophorectomy. Suggest follow up.
    • Suspected R/O left renal cyst.
  • 2021-09-02 Pure tone audiometry, PTA
    • Reliability FAIR
    • Average RE 28 dB HL / LE 30 dB HL
    • bil normal to moderate SNHL
  • 2021-07-22 Gynecologic ultrasonography
    • ATH + BSO
    • no obvious uterine or ovarian lesion
  • 2021-07-12 Patho - uterus with or without SO
    • PATHOLOGIC DIAGNOSIS
      • Uterus, endometrium, staging surgery — carcinosarcoma, poorly differentiated
        
      • Uterus, myometrium, staging surgery — Involved by carcinosarcoma (< 1/2 thickness) — intramural myomas
        
      • Uterus, cervix, staging surgery — endocervical polyp
        
      • Ovary and fallopian tubes, right, staging surgery — Involved by carcinosarcoma
        
      • Ovary and fallopian tubes, left, staging surgery — Negative for malignancy
        
      • Lymph node, left iliac, dissection — Negative for malignancy (0/2)
        
      • Lymph node, left obturator, dissection — Negative for malignancy (0/4)
        
      • Lymph node, right iliac, dissection — Negative for malignancy (0/2)
        
      • Lymph node, right obturator, dissection — Negative for malignancy (0/5)
        
      • Lymph node, left paraaortic, dissection — Negative for malignancy (0/1)
        
      • Lymph node, right paraaortic, dissection — Negative for malignancy (0/3)
        
      • Omentum, omentectomy— Positive for carcinosarcoma
        
      • AJCC 8th edition Pathology stage: pT3aN0M1; FIGO IVB, AJCC stage IVB
        
      • Additional Pathologic Findings — Carcinosarcoma with heterologous rhabdomyosarcomatous differentiation (S2021-08805)
        
      • Ancillary Studies: IHC stain — vimentin( +), ER(-), PR:+(moderate, 60%), CK(+), SMA (-)
        
  • 2021-07-06 MRI - pelvis
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE:Ia(Stage_value)
    • Impression:
      • Prominent soft tissue in the uterine cavity, suspected endometrial malignancy, if proven malignancy, cstage T1aN0M0.
      • Utereine myoma.
      • Enhancing lesion in right ischial bone, suggest bone scan correlation.
  • 2021-07-06 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, endometrial curettage — Carcinosarcoma with heterologous rhabdomyosarcomatous differentiation
      
    • IHC: CK(+ for epithelial component), Vimentin(+ for sarcomatous component), Desmin(+ for rhabdomyoblasts), and Myogenin(+ for rhabdomyoblasts).
      
  • 2021-07-05 Gynecologic ultrasonography
    • bilateral adnexae: free
    • endometrial hyperplasia: 51.4mm (RI: 0.24)
  • 2021-03-13 SONO - nephrology
    • a 0.61cm hyperecholic lesion without acoustic shadow in the cortex of middle portion, left kidney, suspect hypercalcification lesion
    • Interpretation: Bilateral parenchymal renal disease
    • A calcification lesion, left kidney
  • 2020-05-07 SONO - nephrology
    • Left renal stones.
    • Parenchymal renal disease.
  • 2019-08-22 SONO - abdomen
    • Mild fatty liver. S/P cholecystectomy. Suspected left renal angiomyolipoma

[assessment]

• The blood pressure and blood sugar levels are within the normal range.

• Human albumin 20g QD, furosemide 20mg QD, and spironolactone 25mg BID are currently being used to control patient edema.

• Blood pressure and blood sugar are grossly in normal range.

• Human albumin 20g QD, furosemide 20mg QD, spironolactone 25mg BID are currently applied to cope with the patients edema.

700316910

220926

• exam finding
  • 2022-09-25 CT - abdomen
    • Rectal cancer s/p operation.
    • Bony metastases at sacrum and pelvic bones with adjacent tructures invason causing left hydronephrosis/hydroureter. Multiple LNs, liver and lung metastases. General subcutaneous edema.
  • 2022-09-25 KUB
    • Bony destruction of sacrum and pelvic bones.
    • Presence of ileus.
  • 2022-09-25 CXR
    • Multiple nodules at bil. lungs.
  • 2022-07-14 CXR
    • Patch density at right lower lung zone.
  • 2022-07-14 KUB
    • Degeneration of bony structures.
    • Some lucent lesions in bony structures.
    • Deformity of right pubic bone.
    • Stool retention in bowl.
  • 2022-07-14 ECG
    • Normal sinus rhythm
    • T wave abnormality, consider inferolateral ischemia
    • Abnormal ECG
  • 2021-12-10 Peripheral Vascular Test - vein, lower limbs
    • Clinical diagnosis: left leg edema, pelvic cancer
    • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
      • Lower limbs R_CFV R_SFV R_PV R_PTV R_SV L_CFV L_SFV L_PV L_PTV L_SV
      • Spontaneous signal N N N N N N N N N N
        
      • Respiratory changes N N N N N A A A A A
      • Cough response N N N N N N N N N N
      • Compression study N N N N N N N N N N
      • Right Left N N N N N N N N N N
    • Report:
      • Thrombus : None
      • Varicose vein : None
    • Right side:
      • SVC: 11.3 mmHg ; 12.7 mmHg ;
      • MVO/SVC: 89 % ; 83 % ;
      • Average MVO/SVC: 86 %
    • Left side:
      • SVC: 8.0 mmHg ; 10.3 mmHg ;
      • MVO/SVC: 75 % ; 66 % ;
      • Average MVO/SVC: 70 %
    • Conclusion:
      • There was no evidence of DVT detecetd at both lower limbs venous system.
      • Loss of respiratory change of venous flow at left CFA, PFA, SFA and popliteal vein, consider left iliofemoral venous stenosis or obstruction. A large perforator vein anastomosed the left PTV and left LSV at left lower calf level was detected.
      • Bilateral saphenofemoral venous junction (LSV) and saphenopopliteal venous junction (SSV) were competent without venous reflux.
      • The measured MVO/SVC at right thigh was normal (86%). However, the measured MVO/SVC ratio at left thigh was 70%, compatible with left iliofemoral venous stenosis or obstruction.
  • 2021-11-15 MRI - L-spine
    • Findings
      • Large area of Bone destructions at S1-2-3, mainly at left, with neuroformen impingement.
      • No evident bony destructive lesion at T-spine.
      • Normal cord size and signal intensity.
    • Impression
      • Favor large area of sacral bone metastases.
  • 2021-11-15 CT - abdomen
    • Rectal cancer s/p operation. Bony metastases at sacrum with adjacent tructures invason causing left hydronephrosis/hydroureter. Multiple lung metastases.
  • 2021-11-15 KUB + L-spine Lat
    • increased air in nondistended loops of small bowel over abdomen and pelvic
    • large osteolytic change at sacrum especially left side due to metastasis, in progression as compared with previous images on 20210714.
  • 2021-03-02 CT - abdomen
    • Post-op at the colon.
    • Destructive lesion in the sacrum, suspected metastasis.
    • RLL nodule, suspected lung metastasis.
    • Gallbladder stones.
    • Suspected liver cysts.
  • 2021-01-05 CT - abdomen
    • Recurrent colon cancer at sacrum. Suggest further treatment.
  • 2020-10-13 CT - abdomen
    • No evidence of recurrent tumor in the study.
  • 2020-08-20 Tc-99m MDP whole body bone scan with SPECT
    • Increased activity in the sacrum and adjacent left S-I joint. Bone metastasis should be considered. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular juntions and knees, compatible with benign joint lesions.
  • 2020-08-18
    • Subtle osteolytic lesion in the left side 1st and 2nd sacrum is noted that is compatible with bony metastasis after correlate with prior CT on 2020-04-28 and MRI on 2020-07-17 from TSGH. Please correlate with clinical condition.
  • 2020-07-21 CT - chest
    • a tiny RUL-S3 perifussural nodule, stationary, favor an intrapulmonary LN. no mediastinal tumor.
  • 2020-04-28 CT - abdomen
    • Post-op at the colon. Suggest follow up.
    • GB stones.
    • Liver cysts.
  • 2020-02-04 SONO - abdomen
    • Mild fatty liver.
    • There are several hepatic cysts in both lobes and the largest one is measured about 1.7 cm in size at S6.
    • A gallstone measuring 0.64 cm.
  • 2019-10-29 CT - abdomen
    • Clinical history:
      • 57 y/o male patient with rectal CA, ypT3N1b (3/12) cM0, stage IIIB Dx in July 2017 at ShuangHo Hospital s/p CCRT at ShuangHo Hospital & s/p Op in Oct 2017 by Dr Xiao GuangHong, s/p post-Op adjuvant Oxaliplatin (self-paid) / HDFL IV Q2W x 12 finishing in May 2018, Rectum, laparoscopic LAR (20171025): AdenoCA, MD, LNs, mesorectal, dissection: Metastatic adenocarcinoma (3/12) Pathology stage: ypT3N1b(cM0), stage IIIB.
      • Rectal cancer, cT3N1M0; stage III s/p CCRT at 10 cm from AV at ShuangHo Hospital
    • Impression
      • Post-op at the colon. suggest follow up.
      • Liver cysts.
      • GB stone.
  • 2019-08-08 CT - chest
    • Pleura traction at right upper lobe, right upper lobe nodule. These two findigs are stationary.
  • 2019-07-30 SONO - abdomen
    • Mild fatty liver.
    • There are several hepatic cysts in both lobes and the largest one is measured about 1.7 cm in size at S6.
    • A gallstone measuring 0.86 cm and a polyp 0.21 cm.
  • 2019-05-07 CT - abdomen
    • No evidence of recurrent tumor in the study.
    • Cystic duct stone.
  • 2019-02-12 CT - chest
    • The peripheral tiny nodule at RUL is pleural fat protrudining and indenting the lung.
    • no interval change of a tiny nodule (about 2mm) at RUL.
  • 2018-08-14 SONO - hepatobiliary
    • Small hepatic cysts, up to 1.28 cm. A gallstone.
  • 2018-05-29 CT - chest
    • Tiny nodules (2.2mm, 3.6mm) at RUL.
  • 2018-05-24 CT - abdomen
    • S/P operation.
    • Liver cysts (0.5-1.6cm).
    • Gall stone (6mm).
  • 2017-10-26 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Rectum, laparoscopic LAR — Adenocarcinoma, moderately differentiated
      • Resection margins: Free
        
      • Lymph nodes, mesorectal, dissection — Metastatic adenocarcinoma (3/12)
        
      • Pathology stage: ypT3N1b(cM0), stage IIIB
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: Moderately differentiated
      • Depth of invasion: To perirectal soft tissue
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Not identified
      • Discontinuous extramural tumor extension: Not identified
      • Circumferential (radial) margin of rectum: Uninvolved, 10 mm from the margin
      • Lymph node metastasis, mesorectal: Metastatic adenocarcinoma (3/12)
      • Extranodal involvement: Not identified
        
      • Pathological TNM Stage: ypT3N1b(cMx)
        
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified
      • TNM descriptors: y (Post-treatment)
        
      • Tumor regression grading S/P CCRT: Grade 2 (partial response)
      • Proximal and distal margins: Free of tumor
      • IHC for mismatch repair proteins:
        • MSH6: Intack nuclear expression
        • PMS2: Intack nuclear expression
• surgical operation
  • 2021-12-28 bil. lumbar sympathetic block
    • pain management procedural note
      • The patient lay prone on a radiolucent table with a pillow under the upper abdomen.
      • The site of vertebral bodies were marked out with the X-ray beam in the postero-anterior axis.
      • The double end-plate at border of L2 vertebral body was corrected by angling the intensifier.
      • The X-ray beam was gently rotated obliquely away from the spine, until the edge of the transverse process along the border of vertebral body.
      • A mark was made.
      • After local anesthetic infiltration, a 22G, 150 mm long needle was inserted along the X-ray beam.
      • The angle of the needle was adjusted to obtain tunnel view, and the needle was poised to contact the anteriolateral border of the vertebral body.
      • Contrast medium was injected to assure the proper needle tip position in both P-A and lateral X-ray views.
      • Then 5 ml of 0.5% buivacaine  was injected.
      • The other targeted sites were proceeded in the same manner.
      • complication nil    
      • blood loss <1ml 
  • 2018-06-06 Closure of enterostomy or Colostomy (loop or double-barrel)
    • PCS code: 73020C
    • Finding
      • Loop ileostomy at Right abdomen
  • 2017-10-25 Restorative proctectomy with colo-analanastomosis
    • PCS code: 74213B
    • Finding
      • Rectal cancer s/p CCRT with tumor shrinkage remaining a scar at 6 cm from AV
      • Narrow pelvis
• chemoimmunotherapy
  • 2021-05-31 - bevacizumab 5mg/kg 400mg 1.5hr + irinotecan 170mg/m2 330mg 90min + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr
  • 2021-03-16 - irinotecan 170mg/m2 330mg 90min + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr

[assessment]

• The addition of a PPI might be beneficial in the event of stool OB 4+ (2022-09-25) and suspicion of GI bleeding.
• A temporary hold on NSAIDs (diclofenac, patient-carried) may also be an option in this situation.
• Diclofenac adverse reactions and incidences - Gastrointestinal: nausea (3% to 14%), abdominal pain (4% to 7%), constipation (8%), diarrhea (6%), duodenal ulcer, dyspepsia (2%), flatulence (2% to 3%), gastric ulcer, gastrointestinal hemorrhage, gastrointestinal perforation, heartburn, upper abdominal pain (3%), vomiting (3% to 6%).

700377487

220926

{multiple myeloma}

• exam finding
  • 2022-09-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 32) / 80 = 60%
    • Normal LV systolic function with abnormal septal wall motion due to RV pressure overload.
    • Hypertrophic cardiomyopathy without outflow tract obstruction, dilated LA; LV diastolic dysfunction Gr 3 (restrive pattern).
    • Dilated RA and RV; Impaired RV systolic function with free wall hypokinesia.
    • Mild to moderate MR; moderate to severe TR.
    • Possible moderate pulmonary hypertension, estimated PASP: 40 mmHg (systemic systolic pressure: 95mmHg).
    • Engorgement of IVC with poor inspiratory collapse, consider fluid overload.
    • Dilated aortic root and ascending aorta.
    • Minimal pericardial effusion.
  • 2022-09-22 CXR
    • Ground glass opacity in RLL.
    • Normal appearance of trachea and bil. main bronchus.
    • Cardiomegaly.
    • Widening of mediastinum.
  • 2022-09-15 L-spine 4 views (including sacrum)
    • mild spondylolisthesis at L4-5
    • Unremarkable change in the width of the bony spinal canal
      
    • mild anterior spur formation at the L-spine
    • moderate decreased disc space in the L4/5 disc
    • Unremarkable change in the paravertebral region
    • compression fractures at L1, T12 and T11 vertebral bodies
  • 2022-08-18 Uroflow
    • Q max: fair
    • flow pattern: normal
  • 2022-08-18 Bladder Sosography
    • PVR: 11.35mL (postvoided residual)
  • 2022-07-21 Transrectal Ultrasound of Prostate, TRUS-P
    • Findings
      • Prostate
        • Size of prostate: 3(T)cm x 4.6(L)cm x 4.6(AP)cm = 34cc
        • Size of adenoma: 2(T)cm x 2.4(L)cm x 3.4(AP)cm = 0.9cc
    • Seminal vesicles：
      • L
        • Size：L’t1.7 x 0.6 cm
        • Vas deferens：Normal
        • Cyst：No
        • Abscess：No
        • Tumor：No
      • R
        • Size：R’t1.5 x 0.4 cm
        • Vas deferens：Normal
        • Cyst：No
        • Abscess：No
        • Tumor：No
    • Diagnosis
      • Benign prostatic hyperplasia
  • 2022-06-30 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-06-18 SONO - Nephrology
    • Chronic parenchymal renal disease.
    • Right renal cysts, cortical and parap
  • 2022-06-17 SONO - abdomen
    • Parenchymal liver disease
    • Gallbladder stones
    • Cholecystopathy
    • Bilateral renal cysts
    • Splenomegaly
    • Splenic hyperechoic lesion, nature? suspected hemangioma
    • Minimal ascites
    • Bilateral pleural effusion
  • 2022-06-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 21) / 91 = 76.92%
      • M-mode (Teichholz) 77
    • Dilated LA,Ao,RA,RV,PA,IVC
    • Biventricular hypertrophy
    • Poor RV systolic function
    • Adequate LV systolic function, abnormal septal wall motion due to RV failure
    • Impaired LV relaxation
    • Moderate MR,PR
    • Severe TR
    • Minimal amount pericardial effusion, No tamponade, No pericardial constriction at present
    • Paroxysmal atrial fibrillation or MAT rhythm
  • 2022-06-14 ECG
    • Atrial fibrillation with rapid ventricular response
    • Left axis deviation
    • Anterior infarct, age undetermined
    • Abnormal ECG
  • 2022-05-06 Ultrasound of male genital organs
    • Scrotal soft tissue edema
    • Enlarged Right epididymis without vascularity, epididymitis was not likely
  • 2022-05-01 KUB
    • Blunted right costophrenic angle.
    • Degeneration and spondylosis of L-S spine.
  • 2022-05-01 ECG
    • Sinus tachycardia
    • Left axis deviation
    • Anteroseptal infarct, age undetermined
  • 2022-02-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 35) / 111 = 68.47%
      • M-mode (Teichholz) 68
    • Adequate LV systolic function with normal resting wall motion
    • Moderate MR, moderate TR and trivial PR
    • Dilated LA, septal hypertrophy
    • Preserved RV systolic function
    • Dilated aortic root
  • 2022-02-14 SONO - chest
    • Bilateral trivial pleural effusion (right > left).
  • 2022-02-10 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-02-09 MRI - retroperitoneum
    • History: both lower legs edema Suspected Retroperitoneum lesion?
    • Past Hx: multiple myeloma
    • Findings
      • There is a newly-developed soft tissue mass measuring 3.8 x 2.5 cm in the lower pole of spleen with exophytic growth, showing hypointensity on T1WI, mild hyperintensity on both T2WI and DWI. However, there is no signal drop on ADC.
        • Please correlate with contrast enhanced dynamic MRI to R/O extramedullary plasmacytoma or angiosarcoma.
      • There is no retroperitoneal lesion and no extrinsic compression lesion in the IVC, bilateral iliac vein, and bilateral femoral vein.
        • The IVC, iliac vein, and femoral vein show no filling defect.
      • There is periportal lucency and gallbladder wall edema that may be hypoalbuminemia.
        • In addition, There is edematous change in the subcutaneous fat layer of anterior abdominal wall, bilateral flank area and pre-sacral space that also may be due to hypoalbuminemia. please correlate with clinical condition.
      • There is mild ascites in perihepatic and perisplenic space.
      • Mild bilateral Pleura effusion are noted.
      • There is a diverticulum measuring 2.6 cm in the medial aspect of duodenum 2nd portion, near the ampulla of Vater area. Please correlate with clinical condition.
      • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at right upper pole.
        
      • There are few gallstones and the size < 1.5 cm.
      • There is no focal abnormality in the biliary system and pancreas.
        
      • There is no evidence of lymphadenopathy.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
    • IMP:
      • Splenic mass,nature? Please correlate with contrast enhanced dynamic MRI to R/O extramedullary plasmacytoma or angiosarcoma.
        
      • There is no retroperitoneal lesion and no extrinsic compression lesion in the IVC, bilateral iliac vein, and bilateral femoral vein. The IVC, iliac vein, and femoral vein show no filling defect.
  • 2022-01-26 Peripheral Vascular Test - vein, lower limbs
    • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
      • Lower limbs R_CFV R_SFV R_PV R_PTV R_SV L_CFV L_SFV L_PV L_PTV L_SV
      • Spontaneous signal N N N N A N N N N A
      • Respiratory changes N N N N N N N N N N
      • Cough response N N N N N N N N N N
      • Compression study N N N N N N N N N N
      • Right Left N N N N N N N N N N
    • Report:
      • Right side:
        • SVC: 11.8 mmHg ; 14.2 mmHg ;
        • MVO/SVC: 90 % ; 86 % ;
        • Average MVO/SVC: 88 %
      • Left side:
        • SVC: 8.6 mmHg ; 10.9 mmHg ;
        • MVO/SVC: 100 % ; 91 % ;
        • Average MVO/SVC: 95 %
    • Conclusion:
      • No venous thormbosis at bilateral deep and superficial venous system
      • No varicose vein at both GSV/SSV with mild venous reflux reponse with sponteanous reversal flow
      • Marked interstititla edema at both calf site, plese correlate with serum albumin level or renal function
      • The MVO/SVC ratio showed no significant venous obstruction at iliac iven or IVC level
  • 2022-01-25, -01-24 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-01-24 ECG
    • Left axis deviation
    • Anteroseptal infarct , age undetermined
    • Prolonged QT
    • Non-specific intra-ventricular conduction delay
  • 2021-10-07 Patho - bone marrow biopsy
    • Clinical finding: R/I MM recurrence
    • Ciinical diagnosis: C90.00 Multiple myeloma not having achieved remission
    • DIAGNOSIS: Bone marrow, rigth ileum, biopsy — Multiple myeloma
      
    • Microscopically, it shows 90% cellularity of bone marrow with diffuse proliferation of plasma cells admixed with some myeloid and erythroid cells and occsaional megakaryocytes. No blast is seen. It is compatible with multiple myeloma.
      
    • Immunohistochemical stain reveals CD138(diffuse +), MPO(foal+), CD71(focal+), Kappa chain (-), lambda chain (+), CD34(-), CD117(-), TdT(-),and CD20(-).
  • 2021-08-16 SONO - nephrology
    • slightly enlargement of both kidneys
    • right renal cysts
    • gall stones? > 3 stones
    • spleen tumor?
  • 2021-07-23 Myocardial perfusion SPECT with persantin
    • Probably mild myocardial ischemia at the apex.
    • Reverse redistribution of radioactivity to the basal lateral wall, either normal variant or myocardial ischemia may show this picture.
  • 2021-07-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (98.3 - 35.3) / 98.3 = 64.09%
      • M-mode (Teichholz) 64.1
    • Dilated aortic root
    • Thickening of IVS
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Mild MR, AR, TR and PR
    • No regional wall motion abnormalities
  • 2021-07-19 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2018-12-13 Surgical pathology Level IV
    • Clinical diagnosis
      • Multiple myeloma, without mention of remission; Anemia, unspecified.
    • Diagnosis
      • Bone marrow, side? biopsy — Multiple myeloma
    • Sections show 80-100 % cellularity. There are diffuse interstitial infiltrates and aggregates with immature plasma cells. The plasma cells accounts for about 80-100% of all nucleated cells. Megakaryocytes are found about 0-5/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells.
    • Immunohistochemical stains reveal CD138(+), CD20(-), Kappa light chain(-), and Lambda light chain (+). The Ki-67 is < 1%.
• consultation
  • 2022-06-15 Cardiology
    • Q
      • for heart failure & dyspnea
      • This 64-yera-old man, a patient of multiple myeloma S/P C/T. He was admitted due to dyspnea & heart failure and acute hepatitis. Fever 37.9 degree C without chills was noted at home.
      • pt is taking Houttuynia cordata for 2 days and both lower legs edema and laboratory showed NT-pro BNP: > 25000, hs-Troponin I:1571, CK-MB:128. We need expertise to evaluate his condition thanks!
    • A
      • This is a 64 years old man who has HBV carrier under entecavir, multiple myeloma and this time was admitted for acute kidney injury, acute hepatitis, acute heart failure. He is taking of herbal medication.
      • We were consulted for acute on chornic heart failure.
      • S:
        • self complaint bilateral lower limbs edema, SOB just after receiving immuno-target therapy (new) in Feb 2022
        • no Chest tightness, no PND, no orthopnea
      • P/E:
        • Conjunctiva : pale
        • Chest : coarse breathing sounds,
        • Heart : no audible murmur
        • Extremities : 4+ pitting edema up to scrotum
      • Vital sign
        • BT: 36.8 RR: 18 BP: 90/60 HR: 80 SpO2: 99% under NC 3L/m
        • Chest : coarse breathing sounds
        • Heart : tachycardia
        • Extremities: 4+ pitting edema up to scrotum
      • Labs
        • Hb: 8.6 MCV: 105
        • WBC: 22k CRP: 9 neutrophil:81%, band : 5.1%
        • PLT: 61
        • Albumin : 3.2 Globulin : 5.3
          
        • T.bilirubin : 1.09 (05/30) –> 2.19 (06/14)
        • GOT: 19 –>2472 ; GPT: 9 –> 1630
        • INR: 1.24 –> 1.92
        • BUN: 30 (05/30) –> 60 (06/14)
        • Cr: 1.88–> 3.80
        • NT-proBNP: 6013–> >25000
        • hsTrop : 182 —>1040 ; CPK/CKMB: 1571/12.8
        • Na/K: 129/6.0
      • Urine analysis : pyuria; bacteriuria
      • CXR: cardiomegaly
      • 2022/06/15 Echocardiography:
        • LVEF 77%, LV:45/24, IVS/PW:19/14, LA:50, dilated LA,Ao,RA,RV,PA,IVC, biventricular hypertrophy, poor RV systolic function, adequate LV systolic function, abnormal septal wall motion due to RV failure, impaired LV relaxation, moderate MR,PR, severe TR, minimal amount pericardial effusion, No tamponade, No pericardial cons
      • MRI (02/2022) –> RA/RV dilatation.
      • EKG:
        • Af
        • Poor R wave progression
        • Q-wave in antero-septal leads.
      • Previous immune and target therapy history
        • Daratumumab
        • Bortezomib
      • Impression
        • Heart failure with preserved EF, H2FPEF score: 6,
        • Acute on chronic renal failure with oliguria.
        • Proxysmal Af with CHADVASC score 1 point
        • Acute hepatits, etiology? congestive liver, acute HBV reactivation or herbal medication related
        • Urinary tract infection under brosym
        • Macrocytic anemia
      • Suggestion
        • Restrict salt and water intake
        • Push up IV lasix dosage to increase urine output, such as IV lasix 2amp Q8H or Q6H.
        • Consult nephrologist for acute on chronic renal failure with oliguria. This might be the major etiology of generalized edema.
  • 2022-05-04 Infectious Disease
    • Q
      • For redness, swelling, pain, and blisters on the inner thighs, suspected cellulitis
      • This 64-year-old man, a patient of multiple myeloma, IgG Lambda Dx in Sep 2010 at our H S/P C/T. He was admitted due to pain at thights. He complained of redness, swelling, pain, and blisters on the inner thighs since 20220427. We need expertise to evaluate his condition thanks!
    • A
      • 64-year-old multiple myeloma male patient has bilateral medial thigh and scrotal cellulitis with severe sepsis.
        • Blood culture showed raoultella ornithinolytica bacteremia on May 1.
        • Under ceftazidime use, there is clinical improvement with defervescence, more stable vital signs and partial resolution of local erythema and swelling.
      • Suggestion:
        • Continue ceftazidime.
        • Add ciprofloxacin 400mg iv qd as combination therapy.
        • Arrange scrotal echo.
        • Needle aspiration of bullae fluid and send for bacterial culture (maintain bullae skin intact).
  • 2022-02-17 Infectious Disease
    • A
      • This 64-yera-old man, a patient of multiple myeloma S/P C/T. The blood culture yielded Serratia marcescens S/P Tapimycin for 7 days. but repeat blood culture via port-A later fever with chills on 20220217 morning. Cr: 1.87
      • Suggestion:
        • Agree with your use of finibax for Serratia marcescens bacteremia.
        • Consider to remove the Prot-A if persistent fever.
        • Arrange CV-echo to exlcude endocaridits.
  • 2022-02-14 Nephrology
    • Q
      • for both lower legs edema R/O nephrotic syndrome
      • This 64-year-old man, a patient of Multiple myeloma not having achieved remission S/P C/T. He was admitted due to dyspnea & both lower legs edema. Owing to dyspnea & both lower legs edema progression were noted and high NT-proBNP (5207) and Albumin 2.7–>3.2 post Albumin support. We need expertise to evaluate his condition thanks!
    • A
      • This 64 years old male patient of MM not having achieved remission. He was admitted to Dyspnea and lower leg edema progression. Consult for nephrotic syndrome.
      • Lab data :
        • Albumin: 3.2, BUN:22, cre:1.65
        • Na: 142, K: 4.3, Uric acid: 5.6, LDH: 179
        • PE: slight dyspena under nasal 3 L, Bilateral lower limb edema +++
        • Chest echo : bilateral pleural effusion (rt>lt)
        • Cardiac echo :LVEF: 68%, normal resting wall motion
        • MRI retroperitonium : splenic mass, no retroperitoneal lesion
      • Impression:
        • Nephrotic syndrome? due to multiple myeloma?
      • Suggestion:
        • Check urine for analysis
        • Check UPCR, UACR, lipid profile
        • Keep albumin + diuretic
        • Check ANA, ANCA, antiGBM, antidsDNA, C3, C4, HBV, HCV, syphilis, cryoglobulin, serum free light chain, IgA, IgM, IgE
  • 2022-02-11 Cardiology
    • Q
      • for high NT-proBNP & suspected heart failure
    • A
      • PMH: case of multiple myeloma s/p Daratumumab QW plus Bortezomib / Dexa
      • S: shortness of breath for 3 days, bilateral lower limbs edema noted for about half month. coincide with target therapy. denied of chest pain or discomfort.
        • P/E:
          • 2 consecutive days fever
          • abdominal type respiration, N/C support 5L/m
          • chest : reduced breathing sounds over bilateral lower lungs fields, inspiratory crackles
          • heart : regular heart beats, apical systolic murmur
          • Extremities : 4+ pitting edema
        • Labs
          • PCT:5.27, Blood culture: GNB
          • pro BNP: 5200
          • BUN/Cr: 27/1.59
        • I/O: +380+loss
          • albumin : 2.7–>3.3 (albumin supplement)
        • Current medication
          • po aldactone 1#bid
          • iv tapimycin
        • Recent medication
          • albumin + iv lasix
        • EKG:
          • 2022/01/24 QS wave in V1-3, poor R wave progression
        • CXR: bilateral pleural effusion (right>left) + perihilar congestion
        • Echo (07/21) :EF: 65%
      • Impression
        • heart failure with educed or preserved LVEF(?) or noncardiogenic lung edema
        • GNB sepsis
        • Multiple myeloma
        • prior hypoalbuminemia 2.7 –>3.3
      • Suggestion:
        • Arrange 2D echography to assess the LV function deterioration or not
        • Restrict salt and water intake, Iv lasix use with keep negative I/O balance, record BW. To precise record I/O, consider foley insertion
        • maintain serum albumin level at upper limit at least 3.5 mg/dL to avoid lower level of oncotic pressure
        • Chest echo and thorcacocentesis if possible.
        • F/u electrolyte and renal function
          
        • Treat sepsis first and underlying as your expertise.
• chemoimmunotherapy
  • 2022-01-26 - daratumumab 16mg/kg 1300mg 4hr
  • 2022-01-21 - bortezomib 1.3mg/m2 2.5mg SC 5min
  • 2022-01-18 - daratumumab 18mg/kg 1296mg 7hr + bortezomib 1.3mg/m2 2.5mg SC 10min
  • 2022-01-15 - bortezomib 1.3mg/m2 2.5mg SC 5min
  • 2022-01-12 - daratumumab 8mg/kg 631mg 4hr
  • 2022-01-11 - daratumumab 600mg 4hr + bortezomib 1.3mg/m2 2.5mg SC 1hr

[assessment]

• 2022-09-23 2D transthoracic echocardiography showed dilated RA and RV, impaired RV systolic function and possible moderate pulmonary hypertension.
• Vasoreactive patients with pulmonary arterial hypertension may benefit from high dose calcium channel blockers, although this treatment may cause hypotension as an adverse reaction. (ref: https://doi.org/10.1093/eurheartj/ehac237 ) The patient’s recent blood pressure reading is approximately 100/75. Adding CCB immediately would not be recommended at this time.

700813596

220922

{adenocarcinoma of rectosigmoid, not completed}

• exam finding
  • 2022-08-08, -08-04 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-06-16 Whole body PET scan
    • Multiple glucose hypermetabolic lesions in the right and left lobes of the liver, compatible with multiple liver metastases.
    • Multiple glucose hypermetabolic lesions in the abdominal left and right paraaortic areas. Multiple lymph node metastases should be considered first.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-06-04 CT - abdomen
    • Colon cancer s/p operation. Multiple liver metastases (mild progression).
  • 2022-01-14 CT - abdomen
    • Three liver metastases S/P C/T show complete response.
    • Two liver metastase S/P C/T show stable disease.
  • 2021-09-03 CT - abdomen
    • Five newly-developed liver metastases are suspected.
    • Please correlate with sonography and MRI.

701353650

220921

[subjective]

• bloody stool since 2021-02
• tenesmus since 2021-03

[objective]

• exam findings
  • 2022-07-14 Sigmoidoscopy
    • Rectal cancer s/p OP with anastomostic leakage, with healing
  • 2022-07-08 CT - abdomen
    • There is no focal wall thickening at the rectum. Please correlate with colonoscopy.
    • S/P ileostomy at RMQ abdominal wall.
  • 2022-05-09 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Tumor, rectum, Robotic assisted TaTME (s/p CCRT) — Adenocarcinoma, residual
      • Resection margins, ditto — Free from tumor
      • Lymph nodes, mesocolic, dissection — Tumor metastasis (11/17) with extracapsular extension (2/11)
      • AJCC pathologic stage — ypT3N2b, stage IIIC, if cM0
    • MICROSCOPIC EXAMINATION
      • Histology: adenocarcinoma
      • Histology Grade: G2, moderately differentiated
        
      • Depth of invasion: pericolonic fat
      • Angiolymphatic invasion: present
      • Perineural invasion: present
      • Discontinuous extramural tumor extension: absent
      • Circumferential (radial) margin of rectosigmoid: not involved
      • Lymph node metastasis, mesocolic: tumor metastasis (11/17)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: present (2/11)
      • Pathological TNM Stage: ypT3N2b
      • Type of polyp in which invasive carcinoma arose: N/A
      • TNM descriptors: y
        
      • Tumor regression grading S/P CCRT: G3
  • 2022-04-12 CT - abdomen
    • Mild regression of rectal cancer.
  • 2022-04-12 Sigmoidoscopy
    • Findings:
      • Rectal cancer s/p CCRT at 5 cm from AV , (right lateral ~ left anterior)
      • DRE: relative fixed (DRE = digital rectal examination)
    • Diagnosis:
      • Rectal cancer s/p CCRT with significant tumor regression
  • 2022-01-28 Cardiopulmonary Exercise Testing
    • conclusions
      • maximal exercise/ submaximal exercise
      • normal exercise capacity ( VO2 102%, WR 114%)
      • normal stroke volume response during exercise
      • normal ventilatory function ( FVC 99%, FEV1 103%)
      • normal respiratory muscle strength (MIP 95%, MEP 73%)
    • suggestions:
      • treat underlying condition
      • arrange pulmonary rehab with exercise training for his CCRT with decline of activity
  • 2021-12-29 CT
    • Findings
      • There is wall thickening at the rectum measuring 2 cm in wall thickness that is c/w adenocarcinoma.
        • In addition, at least six enlarged lymph nodes in the perirectal space and adjacent mesocolon are noted.
      • There are several hepatic cysts in left lobe and the largest one 3.7 cm in size at S2/4.
    • Impression (Imaging stage): T3N2aM0, stage IIIB
  • 2021-12-24 Patho - colon biopsy
    • Rectum , 4 cm from AV, biopsy - Adenocarcinoma.
    • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
• surgical operation
  • 2022-05-06
    • Surgery
      • Robotic assisted TaTME
    • Finding
      • Rectal cancer s/p CCRT with tumor regression
      • Tumor location : 5 cm from Av   
      • Anastomosis using circular staple CDH 33 at dentate line
• radiotherapy
  • 2022-01-13 ~ 2022-02-25 - 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectal tumor bed area
• chemoimmunotherapy
  • 2022-09-20 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg 4300mg 46hr
  • 2022-09-01 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg 4300mg 46hr
  • 2022-08-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg 4300mg 46hr
  • 2022-08-04 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 430mg/m2 730mg 10min + fluorouracil 2400mg 4300mg 46hr
  • 2022-07-21 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 430mg/m2 730mg 10min + fluorouracil 2400mg 4300mg 46hr
  • 2022-07-05 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 430mg/m2 730mg 10min + fluorouracil 2400mg 4375mg 46hr
  • 2022-06-21 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 750mg 2hr + fluorouracil 430mg/m2 750mg 10min + fluorouracil 2400mg 4300mg 46hr
  • 2022-04-15 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 750mg 2hr + fluorouracil 430mg/m2 750mg 10min + fluorouracil 2400mg 4300mg 46hr
  • 2022-03-25 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 750mg 2hr + fluorouracil 430mg/m2 750mg 10min + fluorouracil 2400mg 4300mg 46hr
  • 2022-03-09 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 750mg 2hr + fluorouracil 430mg/m2 750mg 10min + fluorouracil 2400mg 4300mg 46hr
  • 2022-02-18 - leucovorin 20mg/m2 35mg 10min D1 + fluorouracil 400mg/m2 700mg 10min D1 (CCRT)
  • 2022-02-16 - leucovorin 20mg/m2 35mg 10min D1-D3 + fluorouracil 400mg/m2 700mg 10min D1-D3 (CCRT)
  • 2022-01-18 - leucovorin 20mg/m2 35mg 10min D1 + fluorouracil 400mg/m2 700mg 10min D1 (CCRT)
  • 2022-01-17 - leucovorin 20mg/m2 35mg 10min D1 + fluorouracil 400mg/m2 700mg 10min D1 (CCRT)
  • 2022-01-12 - leucovorin 20mg/m2 35mg 10min D1-D3 + fluorouracil 400mg/m2 700mg 10min D1-D3 (CCRT)

[assessment]

2022-09-14 S-GOT/AST 43 U/L
2022-08-31 S-GOT/AST 40 U/L
2022-08-16 S-GOT/AST 33 U/L
2022-08-01 S-GOT/AST 31 U/L
2022-07-18 S-GOT/AST 27 U/L
2022-06-29 S-GOT/AST 24 U/L
2022-06-15 S-GOT/AST 20 U/L

2022-09-14 S-GPT/ALT 48 U/L
2022-08-31 S-GPT/ALT 42 U/L
2022-08-16 S-GPT/ALT 34 U/L
2022-08-01 S-GPT/ALT 34 U/L
2022-07-18 S-GPT/ALT 26 U/L
2022-06-29 S-GPT/ALT 20 U/L
2022-06-15 S-GPT/ALT 18 U/L

• In the last three months, both AST and ALT have increased.

• Oxaliplatin has been associated with hepatotoxicity, including elevated transaminases and alkaline phosphatases. Peliosis, nodular regenerative hyperplasia or sinusoidal abnormalities, perisinusoidal fibrosis, and veno-occlusive lesions have been detected on liver biopsy. Patients with portal hypertension or increased liver function tests, which cannot be attributed to liver metastases, should be evaluated for hepatic vascular disorders.

220217

[assessment]

• current treatment introduced just about a month, have to wait and see the response.
• available CEA, CA199 readings never outranged normal limits, might not sensible enough for this patient.
• Zoloft (sertraline 50mg QD) and Rivotril (clonazepam 0.5mg HS) are prescribed for the anxiety.
• no drug allergy recorded in database, no issue with current medication.

700382077

220920

• lab data
  • 2022-09-19 Varicella-zoster virus PCR Undetectable
    
  • 2022-09-15 EB VCA IgG Positive Ratio
    
  • 2022-09-15 EB VCA IgG Value 6.3 Ratio
    
  • 2022-09-14 EB VCA IgM Negative Ratio
    
  • 2022-09-14 EB VCA IgM Value 0.2
    
  • 2022-09-14 VZV IgM Negative Ratio
    
  • 2022-09-14 VZV IgM Value 0.1 Ratio
    
  • 2022-09-12 RPR/VDRL Nonreactive
    
  • 2022-09-12 HBsAg Nonreactive
    
  • 2022-09-12 HBsAg (Value) 0.28 S/CO
    
  • 2022-09-12 Anti-HBc Reactive
    
  • 2022-09-12 Anti-HBc-Value 3.65 S/CO
    
  • 2022-09-12 Anti-HCV Nonreactive
    
  • 2022-09-12 Anti-HCV Value 0.06 S/CO
    
  • 2022-09-12 CMV IgM Nonreactive
    
  • 2022-09-12 CMV IgM Value 0.19 Index
    
  • 2022-09-12 CMV_IgG Reactive
    
  • 2022-09-12 CMV_IgG Value 87.1 AU/mL
    
  • 2022-09-12 HIV Ab-EIA Nonreactive
    
  • 2022-09-12 Anti-HIV Value 0.07 S/CO
    
  • 2022-09-12 Anti HTLV I/II Nonreactive
    
  • 2022-09-12 Anti HTLV I/II Value 0.07 S/CO

[assessment]

• Hyperuricemia is noted (serum uric acid readings have been around 9mg/dL in 2022), allopurinol or febuxostat might be indicated.

• Febuxostat differs from allopurinol in a number of ways:

  • It is not a purine base analog; because of the non-purine structure, febuxostat inhibits both reduced and oxidized forms of xanthine oxidase and has minimal effects on other enzymes involved in purine and pyrimidine metabolism.
  • Dose adjustment is not needed in patients with mild to moderate renal impairment.
  • There are fewer drug-drug interactions with febuxostat than with allopurinol.
  • It is quite a bit more expensive than allopurinol, at least partly because allopurinol is available as a generic preparation.

• Feburic (febuxostat 80mg/tab) 0.5# QD is recommended.

• In the last half year, serum creatinine readings have been around 2 mg/dL, indicating altered kidney function. (170cm, 78kg -> eGFR 40mL/min/1.73m2, CrCl 40~45mL/min)

• Fluconazole for candidiasis, prophylaxis - Hematologic malignancy patients or hematopoietic cell transplant (HCT) recipients who do not warrant mold-active prophylaxis: Oral 400 mg once daily. If the CrCl value is less than 50 mL/minute, the dosage is recommended to be reduced by 50%. The current dose is 300mg per day, which is less than 400mg, so no urgent adjustment is necessary.

• As phenytoin is an inducer of CYP3A4 and P-glycoprotein and apxaban is metabolized predominantly by CYP3A4 and a P-gp substrate, the former may decrease the serum concentration of the latter.

• Another direct oral anticoagulant Lixiana (edoxaban) undergoes minimal CYP metabolism (still an p-gp substrate) might be an alternative to Eliquis (apixaban). Edoxaban can be administered 30mg once daily for patients with CrCl 15 to 50 mL/minute.

• As dexlansoprazole’s pharmacokinetics are not expected to be altered in patients with renal impairment, dose adjustment is not likely to be necessary.

220913

[assessment]

• Hyperuricemia is noted (serum uric acid readings have been around 9mg/dL in 2022), allopurinol or febuxostat might be indicated.

• Febuxostat differs from allopurinol in a number of ways:

  • It is not a purine base analog; because of the non-purine structure, febuxostat inhibits both reduced and oxidized forms of xanthine oxidase and has minimal effects on other enzymes involved in purine and pyrimidine metabolism.
  • Dose adjustment is not needed in patients with mild to moderate renal impairment.
  • There are fewer drug-drug interactions with febuxostat than with allopurinol.
  • It is quite a bit more expensive than allopurinol, at least partly because allopurinol is available as a generic preparation.

• Feburic (febuxostat 80mg/tab) 0.5# QD is recommended.

• In the last half year, serum creatinine readings have been around 2 mg/dL, indicating altered kidney function. (170cm, 78kg -> eGFR 40mL/min/1.73m2, CrCl 40~45mL/min)

• Fluconazole for candidiasis, prophylaxis - Hematologic malignancy patients or hematopoietic cell transplant (HCT) recipients who do not warrant mold-active prophylaxis: Oral 400 mg once daily. If the CrCl value is less than 50 mL/minute, the dosage is recommended to be reduced by 50%. The current dose is 300mg per day, which is less than 400mg, so no urgent adjustment is necessary.

• As phenytoin is an inducer of CYP3A4 and P-glycoprotein and apxaban is metabolized predominantly by CYP3A4 and a P-gp substrate, the former may decrease the serum concentration of the latter.

• Another direct oral anticoagulant Lixiana (edoxaban) undergoes minimal CYP metabolism (still an p-gp substrate) might be an alternative to Eliquis (apixaban). Edoxaban can be administered 30mg once daily for patients with CrCl 15 to 50 mL/minute.

• As dexlansoprazole’s pharmacokinetics are not expected to be altered in patients with renal impairment, dose adjustment is not likely to be necessary.

701192939

220920

• exam findings
  • 2022-09-19 Tc-99m MDP whole body bone scan
    • Increased activity in the L5 spine and sacrum, the nature is to be determined (post-traumatic change, DJD or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in both rib cages, some T- and L-spine, bilateral shoulder, S-I joints, and hips.
  • 2022-09-15 CT - chest
    • Esophageal cancer at lower third with tumor regression. However, extensve miliary lung meta is found which progressed signficantly.
    • Mediastinal lymphadenopathy, stable.
  • 2022-09-13 CXR
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • Atherosclerotic change of aortic arch
    • Pleura thickening in bilateral apical lung area.
  • 2022-08-09 CXR
    • Atherosclerotic change of aortic arch
    • Pleura thickening in bilateral apical lung area.
  • 2022-06-15 CT - abdomen, pelvis
    • 1. S/P feeding jejunostomy at left upper pelvis.
    • 2. S/P drainage tube insertion via right upper abdominal wall and the tip located at left pelvis.
  • 2022-06-09 CXR
    • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • biapical fibrothoraces
    • reticular opacities over RUL based on plain image
  • 2022-06-07 MRI - brain
    • No brain nodule or metastasis.
  • 2022-06-06 Whole body PET scan
    • Glucose hypermetabolic lesions in the middle esophagus, compatible with the primary esophageal cancer.
      
    • Glucose hypermetabolic lesions in bilateral mediastinal space and celiac chain lymph nodes, highly suspected cancer with regional lymph nodes involvement, suggesting biopsy for investigation.
      
    • Glucose hypermetabolic lesions in the left pulmonary hilar region and left supraclavicular fossa, probably reactive nodes or metastatic lymph nodes, suggesting further investigation.
      
    • Increased FDG accumulation in bilateral kidneys and ureters, probably physiological uptake of FDG.
      
    • Middle esophageal cancer, cTxN3M0, stage IVA (AJCC, 8th ed.), by this F-18 FDG PET scan.
      
  • 2022-06-04 CT
    • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T3N2M0
  • 2022-06-02 Patho - esophageal biopsy
    • DIAGNOSIS:
      • A. Labeled as “Esophagus, 40 cm from incisor”, biopsy (A)— squamous mucosa with high grade dysplasia.
      • B. Labeled as “Esophagus, 35-38 cm from incisor”, biopsy (B)— squamous cell carcinoma, moderately differentiated. IHC stains: p40 (+), CK5/6 (+), Ki-67: 90%.
      • C. Labeled as “Esophagus, 20 cm from incisor”, biopsy (C)— squamous mucosa with low grade dysplasia.
    • MICROSCOPIC DESCRIPTION:
      • A. Section shows squamous mucosa with high grade dysplasia.
      • B. Section shows squamous cell carcinoma, moderately differentiated.
        • IHC stains: p40 (+), CK5/6 (+), Ki-67: 90%. Muscularis propria is not present in this biopsy specimen.
      • C. Section shows squamous mucosa with low grade dysplasia.
  • 2022-06-02 2D transthoracic echocardiography
    • Adequate LV,RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild MR
  • 2022-06-01 ECG
    • first degree AV block
  • 2022-02-11 Patho - esophageal biopsy
    • Esophagus, 28 cm below the incisor, biopsy — High-grade dysplasia
      • The sections show a picture of high-grade dysplasia, composed of squamous epithelim with basal cells proliferation, and atypical cell extends up into upper third of the epithelium. Suggest follow up.
    • Esophagus, 32-35 cm below the incisor, biopsy — Squamous cell carcinoma, moderately differentiated.
      • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Ulcer and granulation tissue are present.
  • 2022-02-10 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA grade A
      • Esophageal tumor, middle esophagus, suspected esophageal cancer, post biopsy (A)
      • Esophageal mucosal lesion, upper esophagus, s/p biopsy (B)
      • Superficial gastritis
      • Gastric angiodysplasia, low body, GC site
    • Suggestion
      • Refer to chest surgeon
  • 2022-02-10 SONO - abdomen
    • Diagnosis
      • Suspected fatty infiltration of pancreas
      • Suboptimal examination of liver due to poor echo window
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
      • Because of poor echo window, infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months.
• consultation
  • 2022-06-08 Radiation Oncology
    • Q
      • This 72-year-old male patient with underlying reflux esophagitis (LA grade A) were noted complained dysphagia since 2022-02. Under the impression of esophageal cancer, he was admitted for complete cancer staging and port-A catheter implanation and laparoscopic jejunostomy on 20220609. The disgnosis was esophageal squamous cell carcinoma with mediastinal lymphadenopathy, cT3N3M0, stage IVA. However, the patient wants to discahrge after the surgery done on 20220609 due to personal reason. We recommend CCRT to be arranged during OPD f/u. As a reason, we need your expertise to evaluate this patient and arranged radiotherapy for him. Thank you very much for your kind help!
    • A
      • 1. Subjective:
        • I. Previous RT: denied.
        • 2. Other disease: reflux esophagitis (LA grade A).
        • 3. Family history: denied.
          • A. Habit: Alcohol: wine and beer for 40 yr; Smoking: 2 PPD for 40 yr; betel nut: 80#/day for 40 yr.
          • B. Married. Caregiver: his son (n=2), daughter (n=1), wife. Job: Labor. Mild economic stress.
          • C. Language: Taiwanese. Mandarin.
          • D. Religion: Buddism.
      • 2. Objective:
        • I. General Condition-ECOG: 1.
        • 2. PE, 2022/06/08: No palpable SCF LNs.
        • 3. Pathology, 2022/02/21: Esophagus, 32-35 cm below the incisor, biopsy — Squamous cell carcinoma, moderately differentiated; 28 cm below the incisor, biopsy — High-grade dysplasia.
        • 4. 2022/06/02: A. Labeled as “Esophagus, 40 cm from incisor”, biopsy (A) — squamous mucosa with high grade dysplasia. B. Labeled as “Esophagus, 35-38 cm from incisor”, biopsy (B) — squamous cell carcinoma, moderately differentiated. IHC stains: p40 (+), CK5/6 (+), Ki-67: 90%. C. Labeled as “Esophagus, 20 cm from incisor”, biopsy (C) — squamous mucosa with low grade dysplasia.
        • V. Images:
          • A. PES, 2022/02/20: One ulcerative mucosa lesion with elevated margin and mucosal nodularity/irregularity was noted at middle esophagus, 32-35cm below the incisor, R/O esophageal cancer: s/p biopsy for eight pieces(A). One slightly elevated mucosa lesion with nodularity was noted at upper esophagus, about 28cm below the incisor, s/p biopsy for multiple pieces(B).
          • B. EUS, 2022/06/02: EUS with UM-25R to the main lesion (35-38 cm) showed hypoechoic lesion involve 4th layer of esophageal wall with 1.7 cm in max thickness. EUS to the lesion at 30 cm lesion revealed a hypoechoic area at 2nd layer of esophageal wall measured 0.26 cm. No change in others lesions. At least 9 para esophageal lymph nodes were detected by EUS. Dx: Esophageal cancer, 35-38 cm, T3N3Mx, s/p biopsy. Rule out dysplastic esophageal lesion, 40 cm, s/p biopsy. Rule out dysplasitc esophageal lesion, 20 cm, s/p biopsy .
          • C. Chest CT, 2022/06/04: Minimal bronchiectatic change over right lower lobe with peribronchovascular infiltration is found. Mild bilateral apical pleural thickening is noted. Long segmental wall thickening at middle to lower esophagus is found up to 6.7cm in largest dimension. Some mediastinal lymphadenopathy is noted at both sides. (n＝5) There are also some calcified lymph nodes at bilateral mediastinum. No evidence of bilateral pleural effusion. IMP: cT3N2.
          • D. Brain MRI, 2022/06/07: negative.
          • E. PET, 2022/06/06: There were focal or nodular lesions of increased FDG uptake in the middle esophagus (SUVmax early: 26.58, delay: 46.59), bilateral mediastinal space (SUVmax early: 6.55, delay: 11.68), left pulmonary hilar region (SUVmax early: 5.00, delay: 7.65), left supraclavicular fossa (SUVmax early: 3.13, delay: 6.78), and celiac chain lymph nodes (SUVmax early: 4.69, delay: 5.54).IMP: cN3M0.
      • 3. Diagnosis: Esophageal cancer, L/3, MD squamous cell carcinoma, cT3N3 (cM0), with paraesophageal and perigastric LAP metastasis at least, scheduled port-A catheter implantation and laparoscopic jejunostomy on 06/09; ECOG =1.
      • 4. Suggest: Radiotherapy.
      • 5. Goal: Curative (pre-operative).
      • 6. RT Plan may be designed as the following one:
        • I. Target & Volume: esophageal tumor, LAPs.
        • 2. Technique: VMAT and IGRT (OBI).
        • 3. Dose & Fractionation: 5040cGy/28 fractions, with concurrent chemotherapy.
      • 7. Plan: CCRT is suggested for tumor control. Possible toxicity (esophagitis, pneumonitis) is told. CT simulation is arranged on June 14 15:30pm. Treatment will be started 2-3 days later. Diet education and psychological support is given.
  • 2022-06-08 Hemato-Oncology
    • A
      • Impression:
        • 1. lower third esophageal squamous cell carcinoma with mediastinal lymphadenopathy, cT3N3M0, stage IVA
      • Suggestion:
        • 1. Please check HbsAg, AntiHbc, Anti HCV
        • 2. Arrange port A insertion
        • 3. We will discuss with patient about further treatment. Arrange our OPD after discharge.
        • 4. Thanks for your consultation. If there is any problem, please feel free to let us known.
  • 2022-06-02 Gastroenterology
    • A
      • EUS for esophageal SCC staging is indicated.
      • Already arrange EUS on 20220602 10:30.
• radiotherapy
  • 2022-06-17 ~ 2022-07-25 - 4680cGy/26 fractions (15 MV photon) to stomach, anastomosis and regional lymphatics (CCRT)
• chemoimmunotherapy
  • 2022-07-29 cisplatin 60mg/m2 100mg 4hr + fluorouracil 800mg/m2 1300mg 24hr D1-4
  • 2022-07-01 cisplatin 60mg/m2 100mg 4hr + fluorouracil 800mg/m2 1300mg 24hr D1-4
    • ref: U2D - Trimodality therapy with cisplatin plus fluorouracil chemotherapy with concurrent radiotherapy followed by surgery for esophageal and esophagogastric junction cancer

220729

[assessment]

• In active prescriptions, all oral drugs can be administered by nasogastric tube.
• It is recommended to monitor for hearing loss prior to (each dose of, if possible) cisplatin; audiometry as clinically indicated.
• An assessment of neurologic function prior to each course of chemotherapy might be beneficial.
• There is no issue with the active prescription.

701345085

220920

{Mucinous adenocarcinoma of the sigmoid colon with uterus invasion, stage pT4bN2bM0, stage IIIC, s/p LAR in 2017, with local regional recurrence s/p concurrent chemoradiotherapy}

• exam finding
  • 2022-09-15 CT - abdomen, pelvis
    • Colon cancer s/p operation with local recurrence and adjacent structures invasion (stable).
    • Some LNs (up to 1.4cm) at pelvic cavity and paraaortic region (stable).
    • Grade 5 fatty liver.
  • 2022-04-28 CT - abdomen, pelvis
    • Colon cancer s/p operation.
    • Increased soft tissues in pelvic cavity suspected tumor recurrence.
    • Some LNs (up to 1.4cm) at paraaortic region c/w metastases.
    • Grade 5 fatty liver.
  • 2022-01-19 CT - abdomen, pelvis
    • History and Indication:
      • 2017/07 at CGMH keelung: Mucinous adenocarcinoma of the sigmoid colon with direct invasion the uterus, pT4bN2b (8/61).
      • 2021/09 at CGMH keelung: Adenomyosis s/p subtotal hysterectomy + right oophrectomy, and appendectomy.
      • 2021/11 at CGMH keelung: Pelvic tumor with colonic obstruction s/p T-loop colostomy 2021/11/02
    • Findings:
      • 1. S/P LAR with autosuture retention over the sigmoid colon.
        • Wall thickening in the rectosigmoid colon, below and beyond autosuture, is noted that may be local recurrent adenocarcinoma of the colon. Please correlate with colonoscopy.
      • 2. prior MRI identified ill-defined soft tissue mass in the uterine cervix area and left adnexa is noted again, stable in size.
      • 3. Prior MRI identified multiple enlarged nodes in the perirectal space, left interal iliac chain, left common iliac chain, para-aortic space and para-cava space ar noted again, stable in size.
      • 4. S/P colostomy at right transverse colon.
      • 5. The uterus shows enlarged in size and mild heterogeneous density. please correlate with clinical condition.
      • 6. There is no focal lesion in both lung and mediastinum.
      • 7. There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & right kidney.
           
        • There is no evidence of ascites.
          
        • There is no bowel wall thickening, and no bowel obstruction.
          
        • The abdominal aorta and IVC are grossly unremarkable.
          
        • There is no evidence of intrinsic or extrinsic bladder mass.
          
        • There is no focal lesion over the mesentery and omentum.
    • IMP:
      • 1. Local recurrent colon cancer in the rectosigmoid, below and beyond prior autosuture, is highly suspected. Please correlate with colonoscopy.
      • 2. Local recurrent rectosigmoid cancer with uterine cervix area and left adnexa involvement show stable in size.
      • 3. Multiple metastatic lymph nodes show stable in size.
  • 2021-12-09 SONO - abdomen
    • Diagnosis
      • Mass lesion, lower abdomen, c/w tumor recurrence
      • Hydronephrosis, bilateral, suspected mass effect due to tumor
      • Incomplete study of liver
    • Suggestion
      • Please corelated with other images.
  • 2021-11-19 Cardiopulmonary Exercise Testing, CPX
    • summary:
      • low exercise capacity (VO2 57%, WR 71%)
      • normal stroke volume response during exercise
      • slow HR response, 68%
      • normal ventilatory function (FVC 93%, FEV1 102%)
      • low respiratory muscle strength (MIP 108%, MEP 54%)
    • suggestions:
      • treat underlying condition
      • survey and treat slow HR response, such as thyroid function or drugs
      • arrange pulmonary rehab with exercise training
  • 2021-11-05 MRI - pelvis
    • History and Indication:
      • 2017/07 at CGMH keelung: Mucinous adenocarcinoma of the sigmoid colon with direct invasion the uterus, pT4bN2b (8/61).
      • 2021/09 at CGMH keelung: Adenomyosis s/p subtotal hysterectomy + right oophrectomy, and appendectomy.
      • 2021/11 at CGMH keelung: Pelvic tumor with colonic obstruction s/p T-loop colostomy 2021/11/02
    • Findings:
      • 1. There is an ill-defined soft tissue mass in the uterine cervix area and left adnexa measuring 6.6 x 5.5 cm in size, showing mild hyperintensity on both T2WI and DWI, and mild enhancement, causing mild left hydroureteronephrosis and delayed contrast excretion of left kidney that may be local tumor recurrence with distal ureter invasion induce obstructive uropathy. Please correlate with retrograde pyelography.
      • 2. S/P LAR with autosuture retention over the sigmoid colon.
        • Wall thickening in the sigmoid colon, just beyond autosuture, is noted that may be left adnexa mass with sigmoid colon invasion? Please correlate with colonoscopy.
        • The differential diagnosis include local tumor recurrence of the sigmoid colon with outward extension, left adnexa and uterine invasion?
          
      • 3. There are multiple enlarged nodes in the perirectal space, left interal iliac chain, left common iliac chain, para-aortic space and para-cava space that are c/w metastatic nodes.
      • 4. S/P colostomy at right transverse colon.
      • 5. The uterus shows enlarged in size and heterogeneous hypointensity on T2WI at right lateral aspect of the body and fundus that may be adenomyosis.
        • However, the left lateral aspect of the uerine body and fundus shows heterogeneous mild hyperintensity on T2WI and DWI, and contrast enhancement that may be tumor invasion?
      • 6. There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & right kidney.
        • There is no evidence of ascites.
        • The abdominal aorta and IVC are grossly unremarkable.
          
    • IMP:
      • 1. Local tumor recurrence at the uterine cervix area and left adnexa with direct sigmoid colon invasion and left distal ureter invasion induce obstructive uropathy.
      • 2. Multiple metastatic lymph nodes.
      • 3. Tumor invasion in left lateral aspect of the uterine body and fundus are highly suspected.
  • 2021-11-02 Colonoscopy
    • Diagnosis
      • Rectal tumor, with lumen stenosis nearing obstruction, 10cm above anal verge, s/p biopsy
      • Mixed hemorrhoid
    • Suggestion
      • F/U pathology report
    • Complication：
      • No immediate complication
  • 2021-09-22 PET (CGMH Keelung)
    • Findings
      • 1. Main tumor status: rectum (SUV 2.18, score 2)
      • 2. Regional LN status: not found
      • 3. Distant site status: uterine mass (SUV 3.83, score 2)
    • Impression:
      • 1. Compatible with recurrent colon cancer in post-operative status, tentative stage rT0N0M0 (AJCC 2017).
      • 2. Rectum lesion, probably bowel physiological uptakes.
      • 3. Uterine lesion, uterine myoma may show this picture.
    • Suggesstion:
      • Please correlate with other image and clinical findings.
    • Comment: Score 0 = normal; Score 1 = benign lesion; Score 2 = equivocal lesion; Score 3 = possible malignancy; Score 4 = high probability of malignancy
  • 2021-09-22 Pathology (CGMH Keelung)
    • biopsy date 2021/09/10
    • DX:
      • Uterus, endometrium, uncomplicated subtotal hysterectomy —- Proliferative phase
      • Uterus, myometrium, uncomplicated subtotal hysterectomy —- Adenomyosis
      • Fallopian tube, bilateral, prophylactic salpingectomy —- No pathological diagnosis made.
  • 2021-09-22 Pathology (CGMH Keelung)
    • biopsy date 2021/09/10
    • DX:
      • Appendix, appendectomy —- Mucinous adenocarcinoma, in favor of metastatic mucinous adenocarcinoma of colorectal origin (Reference: S2017G-09314 and S2017G-10251)
    • GROSS D:
      • The specimen submitted is an appendix measuring 8.0 cm in length and 1.5 cm in maximal diameter, fixed in formalin. The external surface is smooth. The cut surface reveals a narrowed lumen filled with mucoid material. The wall is markedly thickened with a mucoid appearance. The mesoappendix is not inflamed. Sections of the tip portion and representative cross sections are taken.
    • MICRO D:
      • Sections of appendix show nearly totally infiltrated by a mucinous adenocarcinoma. Based on the history, metastatic mucinous and signet-ring cell adenocarcinoma is favored.
• surgical operation
  • 2021-11-02
    • Surgery
      • T loop colostomy        
    • Finding
      • 1. Pelvic tumor with colonic obstruction, suspected rectal cancer
      • 2. Dilation of colon and severe adhesion around midline laparotomy
      • 3. RUQ stoma with stent
      • 4. Previous surgery:
        • <1> Sigmoid mucinous adenocarcinoma, pT4bN3a s/p LAR on 2017
        • <2> Adenomytosis s/p total hysterectomy with right salpingo-oophorectomy, appendectomy on 2021/09, appendix pathology: metastatic Sigmoid mucinous adenocarcinoma
    • Procedure
      • The patient was placed in supine position and general endotracheal anesthesia was induced. The abdomen was prepped and draped in standard sterile fashion. The ostomy site was marked about halfway between the umbilicus and right costal margin, 3 to 5 cm lateral to the linea alba. A short transverse incision was made over the previously marked ostomy site in the right upper quadrant. This was deepened through the subcutaneous tissues and hemostasis was achieved with electrocautery. The anterior rectus sheath was encountered and cut, exposing the rectus muscle. This was opened by muscle-splitting in a direction parallel to the rectus muscle. Hemostasis was achieved. The posterior sheath and peritoneum were identified and incised, and then the peritoneum was entered. The massive distended transverse colon was immediately encountered. The omentum was swept cephaled and the transverse colon was delivered into the incision. A window was created under the colon by dividing the mesentery adjacent to the colon wall with clamps and ligating with 3-0 silk ties. Hemostasis was checked. A plastic bridge was placed at this point. Moist pads were placed and the colon was opened along a taenia. Succus and air were aspirated. The colostomy was matured with multiple interrupted mucocutaneous suture of 4-0 monopril. The colostomy was well formed and viable. A colostomy bag was placed. The patient tolerated the procedure well and was taken to the POR in stable condition.  
  • 2021-09
    • Operation: subtotal hysterectomy + R’t oophrectomy, appendectomy.
• radiotherapy
  • 2021-11-22 ~ 2021-12-30 - 4500cGy/25 fractions (15 MV photon) of the pelvic to paraaortic area
• chemoimmunotherapy
  • 2022-05-25 ~ undergoing - FOLFIRI + bevacizumab
  • 2022-02-08 ~ 2022-04-28 - FOLFIRI (5 times)
  • 2021-11-22 ~ 2021-12-20 - FL (400mg/m2, CCRT) (2 times)
  • 2017 ~ ???? - adjuvant chemothoerapy 12 times.

                                   

701390560

220920

• exam finding
  • 2022-09-01 CTA - chest
    • Left pleural effusion. MIld
    • No evidence of pulmonary embolism nor aortic dissection is found.
    • Right renal cyst. 9.3cm
  • 2022-07-28 Pure Tone Audiometry
    • PTA:
    • Reliability FAIR
    • Average RE 6 dB HL / LE 6 dB HL
    • bil WNL
  • 2022-07-01 CXR
    • s/p right chest tube in place, its tip directed superiorly projecting over 4th intercostal space
    • expansion of Rt lung with platelike lung atelectasis over Rt lower lung zone
  • 2022-06-29 Patho - thymus tumor
    • diagnosis
      • Thymus, excision — Squamous cell carcinoma of thymus, poorly differentiated,
        • AJCC 8th edition: pStage IVA, pT1aNxM1a
      • F2022-00304 - Pericardium, biopsy — Thymic squamous cell carcinoma, metastatic
    • microscopic description
      • Sections show sheets of poorly differentiated carcinoma infiltrating in fibrous stroma. Focal squamous cell differentiation is seen.
        • The immunohistochemical stains reveal CD5(+), CD20(-), p40(+), CD117(+), CK19(+), TdT(-), CD56(equivocal), and Synaptophysin(equivocal). The in situ hybridization for EBER is negative. The results are in favor of thymic squamous cell carcinoma. The tumor has invaded to the peripheral thymus tissue. The tumor capsule is focally ruptured.
      • F2022-00304 - Section shows fibrous tissue with metastatic carcinoma.
        • The immunohistochemical stains reveal CD5(+), CD20(-), p40(+), CD117(+), CK19(+), and TdT(-). The results are consistent with metastatic thymic squamus cell carcinoma.
  • 2022-06-29 Frozen Section
    • Preliminary diagnosis: Pericardium, biopsy — metastatic tumor
  • 2022-06-28 ECG
    • Normal sinus rhythm
    • Left axis deviation
  • 2022-05-18 CT at Cathay General Hospital
    • Anterior mediastinal tumor, size about 5.0cm in diameter, anoterior to aortic root.
    • suspected thymoma.
• surgical operation
  • 2022-06-29 VATS excision of mediastinal tumor and PP window.
    • One mass lesion was noted over anterior mediastinum, anterior to ascending aorta, size about 5.0cm in diameter. Multiple pleural military lesions over left pleural cavity and pericardium.
    • Frozen section of pericardial nodule: carcinoma.
    • One 24 Fr. straight chest tube was inserted via right 7th ICS.
• radiotherapy
  • 2022-07-29 ~ 2022-09-06 - at 4500cGy/25 fractions of the thymus tumor bed area.
• chemoimmunotherapy
  • 2022-09-19 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 6 600mg 2hr
  • 2022-08-25 - cisplatin 40mg/m2 65mg 2hr (CCRT)
  • 2022-08-18 - cisplatin 40mg/m2 65mg 2hr (CCRT)
  • 2022-08-11 - cisplatin 40mg/m2 65mg 2hr (CCRT)
  • 2022-08-04 - cisplatin 40mg/m2 65mg 2hr (CCRT)
  • 2022-07-29 - cisplatin 40mg/m2 60mg 2hr (CCRT)

[assessment]

• Losartan might be held temperately due to a drop in blood pressure (2022-09-20 09:21 96/56mmHg).

• Blood glucose levels were elevated (2022-09-20 06:40 236 mg/dL). If the reading remains high over the next two days, then antiglycemic interventions might be necessary.

700823225

220919

• exam finding
  • 2022-08-29 CXR
    • Enlargement of cardiac silhouette.
    • Spondylosis with scoliosis of the T-spine with convex to right side
      
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-06-09 Whole body PET scan
    • In comparison with the previous study on 2021/12/08, the glucose hypermetablism in the confluent right neck and right supraclavicular lymph nodes (Deauville score 5) are a little more evident. However, no prominent glucose hypermetablism was noted in the previous FDG avild lesions in the tonsils and left neck lymph nodes.
      
    • Mild glucose hypermetablism in the right hip joint, compatible with arthritis.
      
    • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
  • 2022-06-08 CT - neck
    • Progressive enlargement of LAP of right neck and regression of LAP at left neck, as compared with CT scna on 20211127.
  • 2022-06-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 36) / 112 = 67.86%
    • Indeterminated LV filling pressure; impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild MR; mild TR.
    • Thick epicardial fat.
  • 2022-06-07 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • T wave abnormality, consider inferior ischemia
  • 2022-06-07 CXR
    • Enlargement of cardiac silhouette.
    • Spondylosis with scoliosis of the T-spine with convex to right side
      
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2021-12-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (70 - 26) / 70 = 62.88%
    • Normal LV systolic function with normal wall motion.
    • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 1.
    • Normal RV systolic function.
    • Aortic valve sclerosis with trivial AS; mild MR; mild TR; mild PR.
    • Small pericardial effusion without tamponade and constriction sign.
  • 2021-12-08 Whole body PET scan
    • Glucose hypermetablic lesions in bilateral lateral walls of oropharynx (Deauville score 5), compatible with the primary lymphoma.
      
    • Glucose hypermetablic lesions in bilateral cervical lymph nodes, right SCF and ICF lymph nodes (Deauville score 5), highly suspected lymphoma with lymph node regions involvement.
      
    • Glucose hypermetablic lesions in a right axilla lymph node (Deauville score 2) and right hip joint (Deauville score 3), probably benign in nature.
  • 2021-12-07 ECG
    • Normal sinus rhythm
    • Right bundle branch block
  • 2021-12-06 CXR
    • Cardiomegaly.
    • Tortuous thoracic aorta.
    • No mediastinal widening.
    • Obliteration of left CP angle.
    • Scoliosis and spondylosis of T-L spine.
  • 2021-12-06 Patho - gingival/oral mucosa biopsy
    • Oropharynx, left, punch biopsy — Diffuse large B-cell lymphoma, GCB type
      
    • Section shows squamous mucosa with ulcer and infiltration of large pleomorphic tumor cells.
    • The immunohistochemical stains reveal CK(-), LCA(+), CD3(-), CD20(+), CD10(+), BCL2(-), BCL6(+), MUM1(+), CyclinD1(-), CD56(-), p63(-), and p16(-). The Ki-67 is about 80%. The results are in favor of GCB type of diffuse large B-cell lymphoma.
  • 2021-12-03 Nasopharyngoscopy
    • L oropharyngeal cancer with bil neck mets
  • 2021-11-29 Lymph Node Aspiration
    • indication: suspect L oropharyngeal cancer with neck mets
    • Malignancy, positive for carcinoma
  • 2021-11-29 Pure Tone Audiometry, PTA
    • Tymp bil type C
    • ART bil absent
    • PTA:
      • Reliability FAIR
      • Average RE 59 dB HL // LE 69 dB HL
      • RE mild to profound SNHL
      • LE moderate to profound SNHL
  • 2021-11-27 CT - neck
    • Enlarged lymph nodes at both sides of neck with left palatine lesion. Oropharyngeal cancer with bialetral metastatic LAPs should be first considered until proved otherwise.
  • 2021-11-26 Nasopharyngoscopy
    • huge firm level II NM (infection was told and repeated pus aspiration at 中和LMD)
    • fiber = L tonsillar granular tumor with touch bleeding, ENT local tx done
• consultation
  • 2021-12-07 Oral and Maxillofacial Surgery
    • Q
      • For dental evaluation
      • A case of oropharyngeal tumor with bilateral metastatic LAPs
      • This is a 80 y/o female patient denied systemic disease. This time, she was admitted for cancer work up due to left oropharyngeal tumor with bilateral metastatic LAPs. The left oropharyngeal biopsy pathologic report was pending, but the pathologic report of left neck LN revealed positive for malignancy. Neck CT disclosed enlarged LN at both sides of neck with left palatine lesion. Oropharyngeal cancer with bialetral metastatic LAPs should be first considered until proved otherwise. Due to left oropharyngeal cancer with bil. metastatic LAPs impressed, we need your expertise for pre-RT dental evaluation. Thank you very much!!
    • A
      • This is a 80 y/o female who suffered from Oropharyngeal cancer.
      • O: No obvious tooth decay or residual root is noted
      • P:
        • Teach her how to do home care and OHI (oral hygiene instruction)
        • Suggest scaling at LDC regularly

700999537

220919

[Chief Complaint] for chemotherapy                                         

[Present Illness] This 46-year-old female patient had invasive carcinoma of no special type with focal micropapillay pattern of the right breast cancer, pT2N1M0, stage IIB, ER (postive, +++95%), RP (postive, +++80%), Her-2/Neu(equivocal, 2+), s/p MRM and ALND on 2017/11/30, post chemotherapy with AC 4 times since 106/12-107/03/13. Adjuvant chemotherapy with Taxotere on 108/04/04-6/6 and radiotheratpy.

On 2020/12/01, microinvasive carcinoma of the left breast, AJCC 8 th edition, Pathology stage: pT1miN0; Anatomic stage IA; Prognostic stage IA if cM0. Margins: Negative, Closest margin (7 mm from deep margin). ER (Ab): Positive (60%, moderate intensity), PR (Ab): Negative, HER-2/Neu (Ab): Positive (score= 3+), s/p left partial mastectomy and sentinel lymph node biopsy, radiotherapy (Radiotherapy with 5000cGy/25 ractions of the left breast, and 6000cGy/30 fractions of the left breast tumor bed (scar) area), and status during endocrine therapy.

Followed CT on 2022/1/28 which revealed Four Metastases on both hepatic lobes are highly suspected. Her-2 overexpressed liver metastases were confirmed after liver biopsy. Bone scan revealed a hot spot in the left humeral head, some faint hot spots in bilateral rib cage, upper T-spine, L2-3 spines, lower L-spine, sacrum, bilateral sternoclavicular junctions, upper portion of the sternum, shoulders, and knees in whole-body survey.

Then she recevied C1 Herceptin, Perjenta (840mg) for loading dose on 2022/2/14, Taxotere on 2022/2/15. C2 Herceptin, Perjenta on 2022/3/7 Taxotere on 2022/3/8. C3 Herceptin, Perjenta on 2022/3/28 Taxotere on 2022/3/29. C4 Herceptin and Perjenta on 2022/4/18,Taxotere on 2022/4/19. Followed CT of chest was performed on 5/2 revealed almost resolution of metastatic hepatic tumors (with a small residual lesion in S6) compared with abdominal CT on 1/28.minimal nonspecific RML inflammation and subtle small nodules inlower lobes of lungs, susggest f/u. Chemotherapy with C5 Herceptin + Perjenta (420mg) on 2022/5/9.Taxotere on 2022/5/10. C6 Herceptin + Perjenta (420mg) on 2022/5/30.Taxotere on 2022/5/31 C7 Herceptin + Perjenta (420mg) on 2022/6/20.Taxotere on 2022/6/21 C8 Herceptin + Perjenta (420mg) on 2022/7/11.Taxotere on 2022/7/12.

Followed up CT of chest on 2022/8/8 revealed 1.almost resolution of metastatic hepatic tumors (with a small residual low lesion in S6) compared with CT on 5/4 and 2.two small nodules in Rt lung still visualized, susggest f/u.

C9Herceptin + Perjenta (420mg) on 2022/8/29 and Taxotere on 2022/8/30

This time, she was admitted for chemotherapy on 2022/9/18.

• past history
  • disease
    • right breast cancer, cT2N0M0,stage II
    • HBV
  • operation
    • partial mastectomy and sentinel lymphnode biopsy on 2017-11-30
• exam finding
  • 2022-08-08 CT - chest
    • indication: breast ca with liver metastases
    • findings:
      • Lungs: two centrilobular nodules at peripheral of RUL and RLL.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: s/p Rt mastectomy.
      • Visible abdominal-pelvic contents:
        • liver: small residual low attenuated lesion in S6 and no more visible tumors in other segments. many small hepatic cysts also are visible.
        • a gall bladder stone, 1.4 cm.
        • unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node.
      • Visualized bones: unremarkable
    • Impression:
      • almost resolution of metastatic hepatic tumors (with a small residual low lesion in S6) compared with CT on 20220504.
      • two small nodules in Rt lung still visualized, susggest f/u.
  • 2022-07-20 SONO - abdomen
    • Diagnosis
      • Liver tumor, right lobe
      • Liver cysts
      • GB stone
    • Suggestion
      • Remission (at least partial) of hepatic metastasis was noted compared to previous echo study. Correlate with CT scan if clinically indicated
  • 2022-05-04 CT - chest
    • Impression:
      • almost resolution of metastatic hepatic tumors (with a small residual lesion in S6) compared with abdominal CT on 20220128.
      • minimal nonspecific RML inflammation and subtle small nodules in lower lobes of lungs, susggest f/u.
  • 2022-03-18 Nasopharyngoscopy
    • findings: smooth NPx, oropharynx, hypopharynx; Bil. ant. nasal septum blood clot
    • conclusion: epistaxis
  • 2022-02-11 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2017/11/22, the hot spot in the left humeral head and some faint hot spots in bilateral rib cage are new. The nature is to be determined (post-traumatic change? bone metastases? other nature?). Please correlate with other clinical findings for further evaluation.
    • The lesions in the L2-3 spines, lower L-spine and sacrum are slightly more evident. Degenerative spine disease in a little more severe status may show this picture. However, please follow up bone scan for further evaluation and to rule out other possibilities.
    • No prominent change is noted in the hot spot in the left temporal region of the skull.
  • 2022-01-28 CT - abdomen
    • Four Metastases on both hepatic lobes are highly suspected.
    • The differential diagnosis include HCCs and cholangiocarcinoma.
    • Please correlate with AFP, CEA, CA199 and CA153.
  • 2022-01-19 SONO - abdomen
    • Diagnosis
      • Hepatic tumors, probable metastatic tumors
      • Liver cyst
      • GB stone
    • Suggestion
      • Further investigation of hepatic metastasis
  • 2021-11-05 Gynecologic ultrasonography
    • uterine myoma
  • 2021-07-14 SONO - abdomen
    • Diagnosis
      • Fatty liver, mild
      • Liver cyst
  • 2021-01-13 SONO - abdomen
    • Diagnosis
      • Fatty liver, mild
      • Liver cyst
      • GB stone
  • 2020-11-30 Patho - breast mastectomy with regional lymph nodes
    • pathologic diagnosis
      • Breast, left, partial mastectomy — Microinvasive carcinoma
        
      • Resection margin, breast, left, partial mastectomy — Free
        
      • Lymph node, sentinel, left axillary, SLNB — Negative for malignancy (0/2)
        
      • AJCC 8 th edition, Pathology stage: pT1miN0; Anatomic stage IA; Prognostic stage IA if cM0
        
    • microscopic examination
      • Histologic type: Microinvasive carcinoma
        
      • Size of invasive carcinoma: 0.1 x 0.1 x 0.1 cm
        
      • Histologic grade (Nottingham histologic score): Only microinvasion present (Not graded)
        
      • Tumor Focality: Three foci of microinvasive carcinoma
        
      • Skin involvement: Absent
        
      • Ductal carcinoma in situ: Present, intermediate grade
        
      • Size of DCIS: 1.0 x 0.8 x 0.7 cm
        
      • Margins: Negative, Closest margin (7 mm from deep margin)
        
      • Nodal status (sentinel): Negative (0/2)
        • number of lymph node examined: 2
          
        • number with macrometastases (>2mm): 0
          
        • number with micrometastases (>0.2~2mm and/or >200 cells): 0
          
        • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
          
      • Treatment Effect: No presurgical neoadjuvant therapy received
        
      • Lymphovascular invasion: Absent
        
      • Perineural invasion: Absent
        
    • immunohistochemical study
      • ER (Ab): Positive (60%, moderate intensity)
        
      • PR (Ab): Negative
        
      • HER-2/Neu (Ab): Positive (score= 3+)
        
      • Ki-67: 15%
        
      • p63: Loss of myoepithelial cells in invasive component
  • 2020-11-26 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential static images over the chest revealed two focal areas of increased accumulation of radioactivity at the left axilla.
    • Impression: Probably twp sentinel lymph nodes at the left axillary region.
  • 2020-11-13 Patho - breast biopsy
    • Breast tumor, left (12, 1.5), core needle biopsy — Ductal carcinoma in situ, intermediate grade
      
    • Microscopically, the sections show a picture of ductal carcinoma in situ, intermediate grade characterized by some dilated ducts fill with intermediate grade atypical epithelial cells without necrosis and preserved outer myoepithelial cells.
    • Immunohistochemistry of CK5/6 and P63 show preserved myoepithelial cell;
      • ER(strong, diffusely), PR(+, 1-5%);
      • Her2/neu(+, Dako score 3+).
      • Besides, microcalcification is also noted in non-tumor breast tissue.
  • 2020-08-28 Gynecologic ultrasonography
    • uterine myoma
  • 2020-07-13 Mammography
    • Indication: Right breast cancer status post mastectomy on 2017-11-30
    • Final assessment: BI-RADS category 2, Benign finding.
  • 2020-07-13 SONO - breast
    • S/P right mastectomy.
    • Right chest wall hypoechoic tumor, suggest follow up.
    • Developed left breast 12’ region hypoechoic tumor, 0.78x0.47cm, may consider biopsy.
    • BIRADS 4a
  • 2019-11-15 SONO - breast
    • Left fibroadenomas
    • S/P right breast operation
    • BI-RADS: 2. benign finding
  • 2017-11-30 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Breast, right, radical mastectomy — Invasive carcinoma of no special type with focal micropapillay pattern
      • Resection margin: Free
      • Lymph node, right axilla, lymphadenecomy — Metastatic carcinoma (3/11)
        
      • Pathology stage: pT2N1(cM0), stage IIB
    • IMMUNOHISTOCHEMICAL STUDY (Reference: S2017-18231)
      • ER (Ab): Positive (+++ 95%)
      • PR (Ab): Positive (+++ 80%)
      • HER-2/Neu (Ab): Equivocal (2+)
        • FISH STUDY (Reference: S2017-18231) Her2/neu Dual probe FISH: NO amplification
      • Ki-67: 60%
      • p53: pOSITIVE (70%)
  • 2017-11-30 Frozen section
    • Malignant female breast neoplasm, upper-outer quadrant;
    • Sentinel lymph nodes, frozen section — Metastatic invasive carcinoma (2/4)
  • 2017-11-30 Lymphoscintigraphy
    • Probably one sentinel lymph node at the right axillary region.
  • 2017-11-18 SONO - hepatobiliary
    • Gallbladder stone (1.25cm).
  • 2017-11-06 Surgical pathoogy Level IV
    • Clinical diagnosis: Lump or mass breast;
    • Diagnosis
      • Breast, right, core biopsy — Infiltrating ductal carcinoma.
      • IHC stains: E-cadherin (+), ER (+,), PR: (+), Her2/neu: equivocal (score=2+), Ki-67: 60%, p53: 70%.
        • Her2/neu Dual probe FISH: NO amplification. (sent out test by Taipei Institute of pathology.)
  • 2017-08-05 Mammography
    • Regional plemorphic microcalcifications noted in inner upper portion of right breast(posterior third), suggest biopsy.
    • BI-RADS: Category 4b: intermediate suspicion-biopsy should be considered.
  • 2017-08-05 Bone densitometry - hip
    • osteopenia
  • 2017-08-05 Flow-volume curve
    • mild lung restriction
  • 2017-08-05 Colon fiberoscopy
    • Colitis with ulcer, sigmoid colon, s/p biopsy
    • Internal hemorrhoid
  • 2017-08-05 Upper GI panendoscopy
    • Reflux esophagitis, lower esophagus, LA clasification grade A 　　- Rule out Barrett’s esophagus, s/p biopsy 　　- Ectopic gastric mucosa, upper esophagus 　　- Superficial gastritis, antrum

700065031

220916

[assessment]

• Tritace (ramipril) is a member of angiotensin-converting enzyme inhibitors (ACEI) and Sevikar (amlodipine + olmesartan) contains a member of angiotensin II receptor blockers (ARB). Angiotensin II Receptor Blockers may enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Angiotensin II Receptor Blockers may increase the serum concentration of Angiotensin-Converting Enzyme Inhibitors. Coadministration of these two medications is not recommended. Adapine (nifedepine 30mg) 1# QD might be an alternative to replace Sevikar.

220915

{Olfactory Neuroblastoma}

• lab data
  • 2022-04-13
    • Anti-HBc Reactive
      
    • Anti-HBc-Value 5.56 S/CO
      
    • Anti-HBs 861.40 mIU/mL
      
    • HBsAg Nonreactive
    • HBsAg Value 0.00 IU/mL
    • Anti-HCV Nonreactive
      
    • Anti-HCV Value 0.07 S/CO
      
  • 2022-04-02
    • Protein, total 6.6 g/dL
      
    • Albumin 47.1 %
      
    • Alpha-1 4.1 %
      
    • Alpha-2 13.1 %
      
    • Beta 17.9 %
      
    • Gamma 17.8 %
      
    • M-peak Negative
      
    • A/G Ratio 0.9
      
    • Haptoglobin 351 mg/dL (30~200)
      
  • 2022-04-01
    • B2-microglobulin 4.89 mg/L
      
  • 2022-03-31
    • Ferritin 1475.4 ng/mL
      
    • Fe (Iron-bound) 35 ug/dL
      
    • TIBC 271 ug/dL
    • UIBC 236 ug/dL
    • DBI/TBI 21.21 %
• exam finding
  • 2022-09-14 CT - brain
    • no acute intracranial hemorrhage
    • mucosal thickening in the right nasopharyngeal roof
    • increased soft tissue in the anterior skull base of the sphenoidal sinus and lateral walls of the bilateral ethoidal sinuses.
  • 2022-09-13 Nasopharyngoscopy
    • Rt malignancy optic nerve tumor s/p op and CCRT. uneven NPX.
  • 2022-09-03 Nasopharyngoscopy
    • Scope: smooth NPx, oropharynx, larynx, hypopharynx
    • There’s no nasal septum
    • diffuse prominent vessels with oozing over left inferior turbinate and left lateral nasal wall
    • crust and necrotic tissue over right lateral nasal wall
    • s/p surgicel covered over left inferior turbinate and left lateral nasal wal
  • 2022-08-15 Acoustic radiation force impulse, ARFI
    • results
      • Median 1.75 m/s
      • IQR 0.14 m/s
      • IQR/Median 7.9 %
      • Metavir Score ：F2
    • ref
      • degree of liver fibrosis, NHI def; Device ref value (LOGIQ E10)
      • F0 ARFI < 1.3 m/s F0 ARFI < 1.35 m/s
      • F1 1.3 <= ARFI < 1.5 m/s F1 1.35 ~ 1.66 m/s
      • F2 1.5 <= ARFI < 1.81 m/s F2 1.66 ~ 1.77 m/s
      • F3 1.81 <= ARFI < 1.98 m/s F3 1.77 ~ 1.99 m/s
      • F4 1.98 <= ARFI F4 1.99 < ARFI
  • 2022-08-15 SONO - abdomen
    • Parenchymal liver disease
    • Hepatic cysts, bilateral lobes
    • Parenchymal renal disease and renal cysts, both
    • Splenomegaly, moderate
    • Ascites, minimal
  • 2022-07-29 SONO - kidney
    • Bilateral chronic change of both kidneys.
    • Bilateral renal cysts.
  • 2022-07-25 ECG
    • Normal sinus rhythm
    • Right bundle branch block
  • 2022-07-20 MRI - nasopharynx
    • suspected tumor recurrence in the lateral walls of the bilateral ethoidal sinuses.
    • focal mucosal thickening in the right nasopharynx
  • 2022-07-18 CT - abdomen
    • complete regression of right 12th rib soft tissue lesion is found.
    • hepatic and renal cysts
  • 2022-04-13 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2022-04-11 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 33 dB HL // LE 38 dB HL
    • RE normal to severe SNHL (Sensorineural hearing loss)
    • LE normal to profound SNHL(Sensorineural hearing loss)
  • 2022-03-30 Patho - soft tissue biopsy / simple excision (non lipoma)
    • Soft tissue, right 12th rib, biopsy — Small blue round cell tumor, compatible with metastatic neuroblastoma
    • Microscopically, the sections show a picture of small blue round cell tumor with apoptosis and focal tumor necrosis.
    • Immunohistochemistry shows CK(-), LCA(-), CD56(+), S-100(-), synaptophysin (-) and chromogranin-A(-) for tumor.
    • According to above histopathologic finding and patient’s past history, it is compatible with metastatic olfactory neuroblastoma. Clinical correlation is needed.
  • 2022-03-30 Abdominal Ultrasonography
    • Diagnosis
      • Parenchymal liver disease, suspected early cirrhosis
      • Liver cyst, S7
      • Bilateral renal cysts
      • Splenomegaly
    • Suggestion
      • Ultrasound follow up
  • 2022-03-28 CT - abdomen, pelvis
    • Soft tissue lesion encasing right 12th rib is found. Nature? Suggest contrast enhanced study.
  • 2022-03-26 CT - abdomen, pelvis
    • Diverticulosis in the A-colon and cecum.
  • 2022-03-26 CT - brain
    • bone destruction in the walls of the right maxillary sinus and right ethmoidal sinus, anterior skull base.
    • increased soft tissue in the bilateral frontal, bilateral ethmoidal and bilateral maxillary sinuses.
  • 2022-03-26 Nasopharyngoscopy
    • Scope: Right pulsatile nasal tumor with oozing, nature?
    • Left nose: also some soft tissue or blood clot with oozing
  • 2020-11-13 Patho - paranasal biopsy
    • Diagnosis
      • A. Labeled as “right nasal tumor”, biopsy — malignant round blue cell tumor.
        • IHC stains: CK (-), CD56 (+), granzyme B (-), CD3 and CD20: no predominant sub-population; p16 (-), EBV(-), CD99 (-). feature suggestive of olfactory neuroblastoma, high grade.
          
      • B. Labeled as “right nasopharynx tumor tumor”, biopsy — malignant round blue cell tumor.
        • IHC stains: CK (-), CD56 (+), granzyme B (-), CD3 and CD20: no predominant sub-population; p16 (-), EBV(-), CD99 (-). feature suggestive of olfactory neuroblastoma, high grade.
          
    • Microscopic Description
      • A. Section shows benign respiratory eoithelium lined tissue with irregular nests of large round blue cells demonstrating marked crush artifact and small amount of neurofibrillary-like structure.
        • Mitosis is 0-1/HPF.
      • B. Section shows benign respiratory eoithelium lined tissue with irregular nests of large round blue cells demonstrating marked crush artifact and small amount of neurofibrillary-like structure.
        • Mitosis is 0-1/HPF.
  • 2020-11-09 MRI - nasopharynx
    • IMP: D/D: NPC, Inverted palliloma with SCC.
  • 2020-11-06 Nasopharyngoscopy
    • Epistaxis
    • Right chronic sinusitis with polyposis
    • Right nasal tumor with unknown etiology
• consultation
  • 2022-09-03 ENT
    • Q
      • epigastaxis at bilateral nostril since tonight after nose-picking
      • Denied trauma
      • 2020-12 LinKou CGMH diagnosed Olfactory Neuroblastoma
      • Hx of epistaxis
      • NKA
      • PH: HT, Rt malignancy optic nerve tumor s/p op and CCRT last Dec. at CGMH
      • 2022-02-25 CT 1. No contrast extravasation (CE), neither pseudoaneurysm (PSA) 2. Hyperemic area lateral to the left pterygoid plate could be acute inflammation change or tumor vessels. 3. S/P change with soft tissue thickening surround the anterior skull base and fovea ethmoidale. 4. Thickening of mucoperiosteum of paranasal sinus, suggestive of chronic sinusitis. 5. Bone destrction/errsion of the right maxillary antral walls, right ethmoid lateral wall and roof. 6. Effacement of the bil. nasopharyngeal recess. 7. A score 2 LN at left neck zone II 8. Left mastoid focal mastoiditis at lower part. 9. No definite active lesion in the scanned lungs and intracranial cavity; IMP: 1. S/P change with soft tissue thickening surround the anterior skull base and fovea ethmoidale. 2. No contrast extravasation (CE), neither pseudoaneurysm (PSA)
    • A
      • S: Bil. epistaxis since this evening
        • According to the patient and medical record:
        • Right olfactory neuroblastoma s/p op and CCRT at CGMH in 2020/12
        • massive epistaxis history in 2022/02, TAE was suggested by CGMH but not done
        • intermittent epistaxis since then
        • under chemotherapy due to metastatic neuroblastoma (Rib) since 2022/04 (Dr. Xia HeXiong), but hold recently due to impaired renal and marrow function
      • O:
        • oral cavity and oropharynx: mild blood clots over post. pharyngeal wall
        • Scope: smooth NPx, oropharynx, larynx, hypopharynx
        • There’s no nasal septum
        • diffuse prominent vessels with oozing over left inferior turbinate and left lateral nasal wall
        • crust and necrotic tissue over right lateral nasal wall
      • A:
        • epistaxis
      • Plan:
        • s/p surgicel covered over left inferior turbinate and left lateral nasal wall
        • ENT OPD f/u and suggest back to CGMH for further treatment amd management
        • treat anemia, electrolyte imbalace (Na, K), prolonged APTT, impaired renal function as your expertise
        • supportive care
        • Education done: if bleeding again, keep head downward and mouth open, if persistent bleeding, back to hospital soon
        • Observation for bleeding at ER at least for 1 hour
  • 2022-08-01 Nephrology
    • Q
      • He was admitted of hematuria since 20220725. We follow laboratory data revealed elevated renal function was found (Cre 4.6mg/dL, BUN 43mg/dL), suspect chemotherapy side effects or another cause?
      • We also arranged kidney echo, report showed 1. Bilateral chronic change of both kidneys. 2. Bilateral renal cysts. Now, he still has dark urine today. We need your expertise and evaluation! Thanks a lot! NP楊采諭/VS陳亨翔
    • A
      • Subj/Obj
        • This 51-year-old man patient suffered from right neck mass with mild nasal oozing in 2020/11. Nasopharynx MRI on 2020/11/10 showed NPC, Inverted palliloma with SCC. Right nasal tumor bipsy on 2021/11/13 and pathology showed olfactory neuroblastoma. Right supraomothyoid neck dissection on 2020/12/10. Endoscopic caniofacial ersection, bilateral nasoseptal flap for skull base reconstruction, facia lata transfer on 2020/12/15.
        • Chemotherapy with EP (VP-16 60mg/m2, CDDP 60mg/m2) from 2021/01/07~2021/3/13 for 3 cycles. VMAT radiotherapy from 2021/01/25~2021/03/19 for 6996 cGy/33 fractions. He is also received chemotherapy with EP (Etoposide 80mg/m2 x3, CDDP 25mg/m2 x3) on 2022/4/13(C1), on 2022/5/9(C2), 2022/06/02(C3), 2022/6/24(C4), 2022/07/15(C5).
        • This time, he suffers from fever to 39.5C at home, and his grandson was confirmed case with COVID-19 virus infection before. He also has dark urine since this morning. He came to our emergency for help. At the ER, laboratory data revealed hematuria and bacteriuria (bacteria:2+ /HPF, Leucocyte Ester:1+, Sediment-RBC: >=100 /HPF), elevated CRP (7.89 mg/dL).
        • WBC 2.21, Hb 8.5, Plt 19, Na 142, K 2.9 BUN 43, Cr 1.2 -> 4.6
      • Impression
        • AKI stage 3, due to sepsis or chemotherapy related
        • Neutropenic fever
        • thromocytopenia suspect chemotherapeutic agents induced
        • Hematuria suspect thrombocytopenia related
      • Suggestion
        • check FeNa, urine Na, urine osmo
        • arrange renal echo
        • adequate hydration
        • avoid nephrotoxic agents
        • record I/O and body weight QD
        • recheck urinalysis
        • correct thrombocytopenia
        • follow up renal function , electrolytes and total CO2
  • 2022-03-31 Hemato-Oncology
    • Q
      • This 51-year-old male has past history of
        • 1. Right malignancy optic nerve tumor under operation and CCRT
        • 2. Hypertension under medication control.
      • This time, he was admitted with a chief complaint of right waist soreness for two weeks. The sumptom got worsen thus he came to our ER for help.
      • At ER, laboratory data revealed elevation CRP (9.08 mg/dL), Lymphocyte: 9.3 %, normalcytic anemia of HB 8.7 g/dL and impaired renal function of creatinine 1.94 mg/dL.
      • Abdomen CT revealed soft tissue lesion encasing right 12th rib is found.
      • Under the impression of 1) suspect soft tissue lesion of right 12th rib, 2) Hematuria, he was admitted to INF ward for further evaluation and treatment on 2022/03/28.
      • During hospitalization, laboratory data revealed uric acid: 10.1 mg/dL, LDH: 2172 U/L. We need your expertise to evaluate, sincerely thanks.
    • A
      • Impression:
        • Soft tissue lesion encasing right 12th rib
        • Hematuria, cause to be determined
        • Right olfactory neuroblastoma, high grade s/p operation and CCRT at CGMH
        • Hypertension
        • CKD
      • Suggestion:
        • pending soft tissue biopsy result
        • check Ca, total bilirubin/direct bilirubin, haptoglobin, serum eletropheresis (protein EP), Beta-2 microglobulin, check urine cytology
        • may apply CGMH medical history (olfactory neuroblastoma) if patient want to treat in our hospital
        • thanks for your consultation, we would like to follow up this case. If there is any problem, please feel free to let us known.
• chemoimmunotherapy
  • 2022-05-09 ~ undergoing - etoposide + carboplatin
  • 2022-04-13 - etoposide
  • 2021-01-07 ~ 2021-03-13 - etoposide (3 times)

[note]

• Tumors that show good differentiation are generally easy to diagnose, but identification of the diagnostic, morphological features is difficult when a tumor is poorly differentiated, therefore, no definitive diagnosis may be possible. Differential diagnosis of small round cell tumors is particularly difficult due to their undifferentiated or primitive character. (Round Cell Tumors: Classification and Immunohistochemistry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686981/ )
• For sinonasal undifferentiated carcinoma (SNUC) with neuroendocrine features, small cell, high-grade olfactory esthesioneuroblastoma, or sinonasal neuroendocrine carcinoma (SNEC) histologies, systemic therapy should be a part of the overall treatment. Consider a clinical trial and referral to a major medical center that specializes in these diseases. (Head and Neck Cancers NCCN Evidence Blocks Version 1.2022 - February 14, 2022. p.109)
  • Carboplatin/etoposide +- concurrent RT
  • Cisplatin/etoposide +- concurrent RT
  • Cyclophosphamide/doxorubicin/vincristine (followed by RT-based treatment) (category 2B)

[assessment]

• Poor liver and kidney function. Since the end of July 2022, the serum creatinine level has remained above 4 mg/dL, while the BUN level has followed the same trend and reached 90 mg/dL on 2022-09-14. A high AST/ALT ratio is noted, as AST reached 139 U/L and ALT remained at 13 U/L (2022-06-14).
• PLT has decreased to 6210^3/uL (2022-09-15) from 16710^3/uL (2022-09-02). Thrombocytopenia is a common complication in liver disease and can adversely affect the treatment, limiting the ability to administer therapy and delaying planned procedures because of an increased risk of bleeding. There is a history of epistaxis in this patient and he tends to pick his nose frequently.
• Hepatic encephalopathy might be the cause of the patient’s diminished expression and hearing ability, which is currently being treated with LACTUL (lactulose).
• The use of ramipril (in the active prescription currently) in patients with ascites (in case if it develops) due to cirrhosis or refractory ascites should be avoided; however, if the use cannot be avoided, monitor blood pressure and renal function carefully to ensure that renal failure does not occur rapidly (AASLD [Runyon 2013]).

[drug identification]

• Total 2 drugs for identification.
• The 1 identified items has been shown as following while the other 1 items still remain unknown:
  • Through (sennoside 12mg) tab: Laxative, Stimulant
    • Indication: Constipation
      • Relieves occasional constipation (irregularity); generally causes bowel movement in 6 to 12 hours
• These drugs will be sent back to ward by the in-hospital porter.

220816

[assessment]

• Coadministration of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers may enhance their adverse or toxic effects. US labeling states that concurrent use of telmisartan and ramipril is specifically not recommended. Canadian labeling states that irbesartan and eprosartan are contraindicated for use with ACE inhibitors in patients with diabetic nephropathy, and Canadian labeling for ramipril/hydrochlorothiazide states use with angiotensin II receptor antagonists (ARBs) is contraindicated in patients with diabetes with end organ damage, moderate to severe renal impairment (GFR less than 60 mL/min), hyperkalemia, or hypotensive congestive heart failure. It is not clear if any other combination of an ACE inhibitor and an ARB would be any safer. If such a combination must be used, monitor patients extra closely for a greater-than-expected response to the combination, including monitoring of blood pressure, renal function, and potassium concentrations.
• Atanaal (nifedipine 5mg/cap) 2# TIDAC is listed in active prescription. Adapine (nifedipine 30mg/tab) 1# QD might be a better alternative since it has a prolonged release mechanism, which may result in less fluctuation in concentration.

220812

[Angiotensin-Converting Enzyme Inhibitors / Angiotensin II Receptor Blockers]

• Hypertension is observed (SBP 165 +- 20 during this hospital stay).
• Blood creatinine level remains above 4mg/dL since end of July. 2022-08-12 Cre 4.33 => eGFR 15, CrCl 17.
• Sevikar (amlodipine 5mg + olmesartan 20mg) 1# QD and Tritace (ramipril 10mg) 1# QD have been prescribed. Ramipril is an angiotensin-converting enzyme inhibitor and olmesartan is an angiotensin II receptor blocker.
• Studies showed that the combination of an ACE inhibitor and an ARB can lead to worse renal outcomes. Reference: Misra S, Stevermer JJ. ACE inhibitors and ARBs: one or the other - not both - for high-risk patients. J Fam Pract. 2009;58(1):24-27.
• Recommendation
  • 1. DC Tritace
  • 2. Replace Sevikar with Norvasc (amlodipine 5mg) 1# QD, mild to severe kidney impairment: no dosage adjustment necessary
  • 3. Start administering Entresto (sacubitril 97mg + valsartan 103mg) 36 hours after the last dose of Tritace. Initial 0.5# QD for eGFR <30 mL/minute/1.73m2 patients.

220627

[assessment]

• The patient has recurrent small blue round cell tumor, olfactory neuroblastoma, high grade, with metastatic lesion around the right 12th rib. He is receiving etoposide + carboplatin chemotherapy for his disease.
• The patient’s HGB has been low several times since this May. Lab data also showed high haptoglobin (351 mg/dL 2022-04-02) and high ferritin (1475.4 ng/mL 2022-03-31).
  • 2022-06-21 HGB 6.4 g/dL
    
  • 2022-06-14 HGB 6.8 g/dL
    
  • 2022-05-04 HGB 5.5 g/dL
    
• Anemia, which can impair functional status, is commonly seen in patients with cancer as a complication of both the illness and its treatment with chemotherapy. The incidence of anemia increases significantly with age. Hb levels can be raised with either ESAs or RBC transfusions.
  • ESAs are indicated for patients who have mildly to moderately symptomatic chemotherapy-associated anemia who have no other potentially correctable causes of the anemia, an Hb level <=10 g/dL prior to therapy, and no contraindications to the use of an ESA (eg, prior history of thromboses, surgery, prolonged periods of immobilization or limited activity, or uncontrolled hypertension).
  • RBC transfusion is recommended for patients whose clinical condition indicates the need for immediate correction of the Hb level (eg, severely symptomatic, cardiopulmonary compromise, and need for a rise in Hb before the two to four weeks or more that it may take for ESAs to take effect), and for patients who have established general risk factors for thromboembolic events or uncontrolled hypertension and thus are poor candidates for ESAs.

700129413

220916

• present illness
  • 2022-09-15 adminnote
    • The 75-year-old female who has history of hypertension and hyperlipidemia with medication control, regular follow-up at Taipei City Hospital YangMing Branch for years.
    • According the patient, she suffered from many bruises noted after lifting heavy objects about three weeks ago, she went to the Clinic for help. At Clinic, the lab showed thrombocytopenia, so she was transferred to NTUH and steoid therapy (30 mg/day, NTUH 20220722). Due to the personal reason, so she came to our Hematology Oncology OPD for help and steoid therapy increase dose to 60 mg/day since 20220803. But it seemed not change the platelet count much. The medication was changed to dexamethasone at last visit.
    • She regular follow-up Hematology Oncology OPD, then the lab of platelet level lower (Plt: 3000/uL), add Danzol on 2022/09/07.
    • This time, she is admitted for mabthera therapy (low dose 100 mg/week). According the family, the patient’s sugar poor control, so regular follow-up Metabolism OPD, and the patient suffered from fatigue, weakness and appetite change, lethargy for one week, then worsening symptoms and consciousness drowsy since this morning. And suspect a tooth is shaking noted, and bleeding noted last night.
• past history
  • hypertension and hyperlipidemia with medication control, regular follow-up at Taipei City Hospital YangMing Branch for years.
• VsNote
  • 2022-09-15
    • A patient of ITP with platelet count 3 k/cumm at OPD (current medication with steroid, CSA and Danazol)
    • Admitted for low dose Mabthera.
    • She was found with drowsy and slow response, no headache, corena with LR (+), bilateral.
    • On touch Glucose > 500
    • Assessment
      • Suspected ICH (arrange emergency brain C.T.) (ICH = Intracranial Hemorrhage)
      • Suspected HHNK (aggressive surgar control with RI) (HHNK = hyperglycemic hyperosmolar nonketotic coma)
• diagnosis
  • 2022-09-15 adminnote
    • Immune thrombocytopenic purpura
    • Essential (primary) hypertension
    • Hyperlipidemia, unspecified
    • Type 2 diabetes mellitus without complications
    • Liver disease, unspecified
    • Other specified diseases of liver
    • Constipation, unspecified
• exam finding
  • 2022-09-15 ECG
    • Sinus tachycardia
    • ST & T wave abnormality, consider inferolateral ischemia
    • Abnormal ECG
  • 2022-08-22 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • Liver cyst, left lobe
    • Suggestion
      • Please survey hepatitis B and hepatitis C
  • 2022-08-16 Patho - bone marrow biopsy
    • The sections show normocellular marrow (25%). M/E ratio = 10:1 in CD71 stain. The myeloid cells show good maturation with neutrophilia. The megakaryocytes are increased in number and left shift. No increased CD34+ blasts. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2022-08-15 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH, may be normal variant
  • 2022-08-15 CXR
    • A nodular opacity projecting in the left lower lung is suspected. Follow up is indicated. Otherwise, Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.

[not completed]

• F/S records and administered insulin units
  • Date QDAC basal bolus QLAC bolus QNAC bolus HS
  • Unit mg/dL unit unit mg/dL unit mg/dL unit
  • 2022-09-17 184 12 7 - - - -
  • 2022-09-16 157 12 7 256 8 141
    
  • 2022-09-15 435
• F/S records and administered insulin units
  • Date QDAC basal bolus QLAC bolus QNAC bolus HS
  • Unit mg/dL unit unit mg/dL unit mg/dL unit
  • 2022-07-20 184 12 7 - - - -
  • 2022-07-19 157 12 7 256 8 141 7
  • 2022-07-18 277 12 7 360 7 316 7
  • 2022-07-17 105 12 7 301 7 361 7
  • 2022-07-16 265 12 7 274 7 179 7
  • 2022-07-15 060 0 0 280 7 186 7 (QDPC 190 mg/dL, after taking sugar)
  • 2022-07-14 189 12 7 281 7 319 7
  • 2022-07-13 - - - - - 376 7

[assessment]

• Blood sugar levels are poorly controlled. The 2022-09-14 Metabolism and Endocrinology OPD prescribed oral hypoglycemic agents - Galvus Met 1# BID and Relinide 1# TIDAC15 might be added to the active medication list as patient-carried items (hold Galvus temporally for the scheduled brain CT due to its metformin content).

700884793

220915

• exam finding
  • 2022-08-08 CT - abdomen
    • History and indication
      • cholangiocarcinoma
    • Findings
      • A cystic lesion (4.3cm) at left kidney. Tiny liver and renal cysts.
      • Invisible gallbladder. S/P CBD stenting with pneumobilia.
    • IMP:
      • S/P CBD stenting with pneumobilia.
      • No interval change of peritoneal lesions.
  • 2022-07-06 CT - abdomen
    • History and indication
      • tea color urine for 10 days due to obstructive jaundice
      • SGOT: 103, SGPT: 141, HBsAG (-), antiHCV(-) (2022-01)
      • 20220114 CT: Cholangiocarcinoma at the CHD is noted.
        • Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected.
        • cT2N2M1, cStage:IV
      • 20220214 CBD tumor, serosa, laparotomy — Poorly cohesive carcinoma with signet-ring cell differentiation
    • Findings:
      • Prior CT identified soft tissue lesions in the omentum at LUQ abdomen are noted again, stationary.
      • Prior CT identified several enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, and para-aortic space (non-regional nodes) are noted again, mild decreasing in size.
      • S/P metalic stent implantation from CHD to duodenum.
      • S/P cholecystectomy.
      • Pneumobilia on left lobe IHD is noted.
      • There is no evidence of IHD dilatation.
      • A renal cyst measuring 4 cm in left upper pole is noted.
      • Abdominal aorta shows atherosclerosis and ectasia 2.2 cm.
      • There is no focal lesion in both lung and mediastinum.
      • Prior CT identified few hepatic cysts in both lobes are noted again, stable in size. The largest one 0.8 cm in S8.
        
    • Impression
      • Prior CT identified soft tissue lesions in the omentum at LUQ abdomen are noted again, stationary.
  • 2022-05-24 KUB
    • S/P clips projecting at the liver hilum.
    • S/P metalic stent implantation at CHD, CBD and duodenum.
    • Pneumobilia on left lobe IHDs.
    • Fecal material store in the colon.
  • 2022-05-23 Endoscopic Retrograde CholangioPancreatography, ERCP
    • diagnosis
      • Malignant biliary stricture s/p FCSEMS (Kaffes stent, 5 cm and 8 mm ) (FCSEMS = Fully Covered, Self Expanding Metal Stent)
      • Chronic cholangitis
      • Juxta-papillary diverticulum
      • Reflux esophagitis, Gr. A
    • suggestion
      • f/u amylase & lipase
  • 2022-05-22 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-05-12 SONO - abdomen
    • Liver cyst, right lobe
    • Post cholecystectomy
    • Mild left IHD dilatation
    • Pneumobilia, left
    • Post CBD stenting
    • Renal cyst, left kidney
  • 2022-05-04 CT - abdomen
    • Pneumobilia on left lobe IHD is noted.
    • Carcinomatosis is suspected. Please correlate with ascites cytology.
  • 2022-04-20 Cholangiography
    • Cholangiography via PTCD catheter administration revealed:
      • Patency of the catheter and stent.
      • S/P operation with retention of surgical clips.
  • 2022-04-18 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
  • 2022-04-18 Endoscopic Retrograde CholangioPancreatography, ERCP
    • diagnosis
      • Biliary stricture s/p plastic stent exchange
      • Chronic cholangitis
      • Reflux esophagitis Gr.A
    • suggestion
      • f/u amylase & lipase
  • 2022-03-12 Percutaneous transhepatic cholangio drain, PTCD (drainage)
    • The necessarity and risks of the procedure was well explanined to patient family before the PTCD. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
    • Dilatation of the biliary tree (by CT images). S/P CBD stenting.
    • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree via left IHD smoothly.
    • No procedure-related complication during the whole procedure.
  • 2022-03-09 CXR
    • Atherosclerotic change of aortic arch
  • 2022-03-09 CT - abdomen
    • Cholangiocarcinoma at the CHD and metastatic nodes show stationary.
    • Mild ascites is noted.
  • 2022-02-15 Patho - duodenum biopsy
    • PATHOLOGIC DIAGNOSIS
      • CBD tumor, serosa, laparotomy — Poorly cohesive carcinoma with signet-ring cell differentiation
      • Gallbladder, open cholecystectomy — Chronic cholecystitis and free from tumor
      • Lymph nodes, post-pancreatic region (LN 16), frozen section — Free from tumor metastasis (0/11)
    • MICROSCOPIC EXAMINATION
      • CBD tumor, serosa: poorly cohesive carcinoma characterized by tumor cells arranged in linear or individual pattern with signet-ring cell differentiation.
        • Immunohistochemistry of CK(+), CK7(+), CK20(+, focal) and CDX2(+) for tumor.
      • Gallbladder: chronic cholecystitis with serosal hemorrhage and free from tumor invasion
      • Lymph nodes, post-pancreatic region (LN 16): free from tumor metastasis (0/11)
  • 2022-02-14 CXR
    • S/P operation with retention of surgical clips.
    • S/P Port-A infusion catheter insertion.
    • S/P CBD stenting.
    • Right CVP inserted to SVC in position.
    • Ground glass opacity in RLL.
  • 2022-01-26 SONO - abdomen
    • CBD wall thickening with upstram ductal dilatation
    • pneumobilia, both lobes
    • stent in the CBD
    • pancreatic cystic lesion
    • Prob. Parenchymal liver disease
  • 2022-01-25 Body fluid cytology
    • Bile duct brushing: atypia
  • 2022-01-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 26) / 87 = 70.11%
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild MR, TR
  • 2022-01-24 Endoscopic Retrograde CholangioPancreatography, ERCP
    • diagnosis
      • Biliary stricture s/p brushing cytology & plastic stent placement
      • Chronic cholangitis
      • Reflux esophagitis Gr.A
    • suggestion
      • f/u amylase & lipase
  • 2022-01-14 CT - abdomen
    • Cholangiocarcinoma at the CHD is highly suspected.
      • Please correlate with CEA, CA199, ERCP and biopsy.
      • Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected.
      • According to American Joint Committee on Cancer(AJCC)staging system, 8th edition for bile duct cancer: T2 N2 M1, Stage:IV
    • Mild wall thickening at the gastric antrum and duodenum is noted. Please correlate with gastroscopy.
  • 2022-01-14 SONO - abdomen
    • Parenchyaml liver disease
    • Hepatic cyst
    • Bilateral IHD dilatation
    • Bilateral renal cysts
    • Pancreatic cyst
  • 2019-11-17 ECG
    • Sinus bradycardia
    • Left anterior fascicular block
    • Nonspecific ST abnormality
  • 2018-08-06 CT - abdomen
    • Distention of urinary bladder with irregular wall. Enlargement of prostate.
    • A cystic lesion (4.0cm) at left kidney.
• consultation
  • 2022-04-20 Radiation Oncology
    • Q
      • This is a 71 year-old male had past histories of
        • BPH s/p RaSP + bil TAPP on 2018/12/05.
        • Polyp status post polypectomy on 2019/11/12.
        • Common bile duct poorly cohesive carcinoma with signet-ring cell differentiation, pT4N0M0, stage IIIB.
        • Unresectable Bile duct tumor status post open cholecystectomy and port-A insertion on 2022/02/14.
        • Cholangitis with dilatation of the biliary tree. S/P CBD stenting.Percutaneous Transhepatic Cholangiography and Drainage on 2022/03/12.
        • He was regular follow up at our GI OPD.
        • Due to ERCP revealed Biliary stricture s/p plastic stent exchange on 20220418, we need arrange cholangiography, thank you~
    • A
      • According to the clinical condition and imaging findings, cholangiography is indicated.
  • 2022-03-12 Radiation Oncology
    • Q
      • This 71-year-old male,a case of Common bile duct poorly cohesive carcinoma with signet-ring cell differentiation, pT4N0M0, stage IIIB under XRT since 20220301, chemotherapy with 5-FU (200mg/m2) on 20220307~20220311. Spiking fever was noted on 20220311 morning, laboratory test revealed hyperbilirubinemia. Empiric antibiotics with Flumarin was administered. We need your expertise for further management, thanks.
    • A
      • According to the clinical condition and imaging findings, PTCD is indicated.
  • 2022-02-15 Radiation Oncology
    • Q
      • He was admitted for CBD tumor resection.
      • Because of unresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein.
      • The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14.
      • Pathology report was pending.
      • After explanation, he preferred neoadjuvant CCRT
      • After CCRT surgery will be asssessed in the future.
      • Therefore, we need your expertise to evaluate, manage his current condition.
    • A
      • Subjective:
        • History: This is a 71 years old male suffered from obstructive jaundice s/p ERCP with Biliary stricture s/p brushing cytology & plastic stent placement on 2022/01/24. He was admitted for CBD tumor resection. Because of unresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein was noted during OP. The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14. Pathology report was pending. Neoadjuvant CCRT was suggested by Tumor Board.
          • Previous RT: denied.
          • Other disease: BPH s/p RaSP+bilateral TAPP on 2018/12/05. Polyp status post polypectomy on 2019/11/12.
          • Family history: denied.
        • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
        • Widower. Caregiver: his only son. Job: retired business. Mild economic stress.
        • Language: Mandarin. Taiwanese.
        • Religion:
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2022/02/15: No SCF LAPs.
        • Pathology, 2022/2/14, pending.
        • OP finding: distended GB and dilated proximal CBD; an indurated hard tumor at distal CBD with serosa, right hepatic artery and portal vein invasion, tumor extended to pancreatic head; multiple LN at para-aorta and hepatoduodenal ligament and common hepatic artery.
        • Images:
          • CT, 2021/12/17: There is mild wall thickening (8 mm in wall thickness) and abrupt narrowing at the CHD, causing marked dilatation of proximal CHD and both lobe IHDs. Cholangiocarcinoma at the CBD is highly suspected. There are several enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, and para-aortic space (non-regional nodes) that may be metastatic nodes. Imp: 1. Cholangiocarcinoma at the CHD is highly suspected. Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for bile duct cancer: T2 N2 M1, Stage:IV
          • CXR, 2022/01/17: No metastasis.
          • CA199: 103.38 (2022/1/15).
      • Diagnosis:
        • Cholangiocarcinoma, distal CBD with serosa, right hepatic artery and portal vein invasion with gastrohepatic ligament, hepatoduodenal ligament and para-aortic space s/p brushing cytology & plastic stent placement on 2022/01/24, s/p open cholecystectomy and port-A insertion on 2022/02/14; ECOG: 1.
      • Suggest: Radiotherapy.
      • Goal: Curative (Preoperative).
      • RT Plan:
        • Target & Volume: CBD tumor and LAPs.
        • Technique: VMAT & IGRT.
        • Dose & Fractionation: 4500cGy/25 fractions.
      • Plan: CCRT is suggested for locoregional control. CT simulation is arranged on Feb 22 09:30 am. Possible treatment toxicity (radiation gastritis and enteritis) is told. Diet education & psychological support is given.
  • 2022-02-14 Gastroenterology
    • Q
      • For changing of biliary tract metallic stent evaluation and management.
      • This is a 71 years old male had past histories of
        • BPH s/p RaSP + bil TAPP on 2018/12/05.
        • Polyp status post polypectomy on 2019/11/12.
      • ERCP with Biliary stricture s/p brushing cytology & plastic stent placement on 2022/01/24.
      • He was admitted for CBD tumor resection.
      • Because of nonresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein.
      • The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14.
      • After explanation, he preferred neoadjuvant chemotherapy, and for biliary tract management, metallic stent was suggested.
      • Therefore, we need your help to performed the procedure (ERCP)
    • A
      • Please confirm if he needs Radiation therapy or not before metalic stenting.
  • 2022-01-25 General and Gastrointestinal Surgery
    • Q
      • Suspected cholangiocarcinoma for further management
      • This is a 71 years old male had past histories of 1.) BPH s/p RaSP + bil TAPP on 20181205. 2.) Polyp status post polypectomy on 20191112.
      • This time, due to he suffered from jaundice and tea color urine for 10+ days. There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastirc pain, no tarry/bloody stool, no TOCC found. He visited to our GI OPD for help. At GI OPD, follow up blood test that showed hyperbilirubinemia, no leukocystosis nor PT prolong found. Abdominal sonography wsa done revealed parenchyaml liver disease; hepatic cyst; bilateral IHD dilatation; bilateral renal cysts and pancreatic cyst. Abdominal CT with contrast was also done for further survey which revealed cholangiocarcinoma at the CHD is highly suspected. ERCP was arrnged and showed 1. Biliary stricture s/p brushing cytology & plastic stent placement 2. Chronic cholangitis 3. Reflux esophagitis Gr.A. So we need you evaluation and suggestion of this patient. Thank you very much ~
    • A
      • Assessment
        • A case impressed of CBD tumor with obstruction suspected malignancy
      • Suggestion
        • arrange f/u cardiopulmonary function
        • check tumor marker of CEA, CA199
        • triflow training (self-paid)
        • arrange GS OPD on 20220208
        • planing for further operation with total CBD resection after TBI < 6
• surgical operation
  • 2022-02-14
    • Surgery
      • open cholecystectomy
      • port-A insertion
    • Finding
      • distended GB and dilated proximal CBD
      • an induration hard tumor at distal CBD with serosa, right hepatic atery and portal vein invasion, tumor extended to pancreashead
      • multiple LN at pararota and hepatoduodenal ligament adn common hepatic artery
  • 2022-12-05 Suprapubic prostatectomy
    • pre-op, post-op diagnosis: BPH
    • PCS code: 79404C
    • findings: adenoma 51 gm was resected, bilateral mixed type.
• radiotherapy
  • 2022-03-01 ~ 2022-04-08 - 5000cGy/25 fractions (15 MV photon).
• chemoimmunotherapy
  • 2022-09-14 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 660mg 2hr + fluorouracil 2400mg 3970mg 46hr (neoadjuvant FOLFIRINOX, Q2W)
  • 2022-08-31 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3950mg 46hr
  • 2022-08-17 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
  • 2022-07-29 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
  • 2022-07-14 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
  • 2022-06-28 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 640mg 2hr + fluorouracil 2400mg 3800mg 46hr
  • 2022-06-14 - oxaliplatin 70mg/m2 100mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3800mg 46hr
  • 2022-05-19 - oxaliplatin 60mg/m2 90mg 2hr + irinotecan 140mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3800mg 46hr
  • 2022-05-03 - oxaliplatin 60mg/m2 90mg 2hr + irinotecan 140mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3700mg 46hr
  • 2022-03-28 - fluorouracil 200mg/m2 300mg 24hr D1-2
  • 2022-03-21 - fluorouracil 200mg/m2 300mg 24hr D1-2
  • 2022-03-17 - fluorouracil 200mg/m2 300mg 24hr D1-2
  • 2022-03-07 - fluorouracil 200mg/m2 300mg 24hr D1-2

701361745

220915

[tube feeding]

The capsule of Nexium (esomeprazole 40mg/tab) should be opened and the small granules poured into drinking water before tube feeding can begin.

700883303

220914

[objective]

• exam finding
  • 2022-08-01 CT - abdomen
    • Findings
      • s/p LAR with autosuture retention.
      • Infra-renal aortic aneurysm up to 3.1cm in largest dimension is found.
      • Low density area at both lobes of liver are found up to 12.1cm at right lobe. LIver meta is considered. In comparison with CT dated on 2022-04-15, the metastastic lesions are stationary.
      • Some lymphadenopathy are found at hepatic hilum and retroperitoneal region.
      • There is no ascites accumulation at abdominal cavity.
      • Herniation of the small intestines at RLQ is found. No strangulation is found.
      • There is stone at dependent portion of GB. GB stone(s) are noted.
      • Visible chest
        • Diffuse nodular lesions (n>50) are found at both lungs. Stable.
        • Calcified coronary arteries is found.
        • Borderline heart size is found.
        • There is no evidence of destructive bone lesion.
        • Suggest clinical correlation
    • Imp:
      • s/p LAR.
      • Metastatic lesions at both lobes of liver and both lungs. Stationary in size and numbers.
  • 2022-04-15 CT - abdomen
    • Multiple metastases on both hepatic lobes and Multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space S/P C/T show stable disease .
  • 2022-01-07 CT - abdomen, pelvis
    • finding
      • Prior CT idenified multiple metastases on both hepatic lobe are noted again, mild decreasing in size (the largest one measuring 13 cm (the largest dimension) at S4 and residual right lobe at prior CT and 12.6 cm in current CT).
      • Prior CT identified multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space are noted again, mild decreasing in size.
    • impression
      • Multiple metastases on both hepatic lobes and multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space S/P C/T show partial response.
  • 2021-08-25 CT - abdomen, pelvis
    • finding
      • Prior CT idenified multiple metastases on both hepatic lobe are noted again, mild decreasing in size (the largest one measuring 16.6 cm in the largest dimension at S4 and residual right lobe at prior CT and 13 cm in current CT).
      • Prior CT identified multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space are noted again, mild decreasing in size.
    • impression
      • Multiple metastases on both hepatic lobes and Multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space S/P C/T show partial response.
  • 2021-05-21 MRA - brain
    • IMP: No evidence of brain metastasis. Old ischemic insults as descibed. Intracranial artherosclerosis. General brain atrophy.
  • 2021-05-20 CT - abdomen, pelvis
    • IMP: Rectal cancer s/p operation. Right abdominal wall hernia. Mild decreased size of liver and LNs metastases.
  • 2021-02-17 CT - abdomen, pelvis
    • Multiple metastases on both hepatic lobes and the largest one measuring 16.6 cm at S4 and residual right lobe.
    • Multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space.
  • 2019-10-28 M-mode Echo
    • Dilated LA and LV; Mildly abnormal LV sytstolic function with global hypokinesia
    • Septal hypertrophy
    • Trivial MR, mild AR, trivial TR and trivial PR
    • Preserved RV systolic function
  • 2019-10-24 CT - brain
    • Impression: Brain atrophy with old left basal ganalia lacunar brain infarcts. Arteriosclerosis.
  • 2018-07-02 Whole body PET scan
    • At least five glucose hypermetablic lesions in both lobes of the liver, rectal cancer with liver mets should be considered.
      
    • At least two glucose hypermetablic lesions in the LLQ and RLQ of abdomen, rectal cancer with tumor seeding should be considered, suggesting further investigation.
    • Mild glucose hypermetabolism in the mediastinal lymph node and left SCF lymph node, reactive change may show such a picture.
    • Rectal cancer s/p treatment, cTxNxM1b-1c, stage IVB-IVC (AJCC, 8th ed.), by this F-18-FDG PET/CT scan.
  • 2018-06-28 CT - abdomen
    • S/P operation with liver metastases.
    • Gall stones (3-10mm).
    • Small bowel ileus.
  • 2018-06-15 CT - abdomen
    • Post-op at the colon and liver.
    • Liver metastasis.
    • Prominent soft tissue density in RLQ around the terminal ileum, suspected tumor seeding. Suggest follow up.
  • 2018-02-20 CT - abdomen
    • Compatible with rectal cancer with liver meta s/p op. over liver and rectum. No focal tumor is found.
  • 2017-11-15 Abdominal Ultrasonography
    • Diagnosis
      • Parenchymal liver disease
      • Possible liver cyst with calcification
      • Possible surgical artefact in liver dome
      • GB sludge ball with marked distention of GB
      • Poor postprandial contraction of GB, suggestive of obstruction of GB
    • Suggestion
      • Refer to GS for evaluation of cholecystectomy
  • 2017-10-30 Abdominal Ultrasonography
    • GB stones with distended GB, with cholecystopathy; equivocal echo
    • Murphy sign
    • Possible cystic duct stone
    • Dilated bilateral IHD
    • Suboptimal examination of liver and CBD
    • Parenchymal renal disease
  • 2017-10-29 CT - abdomen
    • Distal CBD stone (6mm) with biliary obstruction. Gall stones (7-11mm).
  • 2017-07-28 CT - abdomen
    • Rectal CA wtih liver metastasis, s/p operation
    • Increased perirectal soft tissue.
  • 2017-07-06 CT - lung/pleura
    • Fracture of right clavicle, 4th-9th ribs with pneumothorax and subcutaneous emphysema. Right hemothorax.
    • Gall stones (8-10mm).
  • 2017-04-21 Surgical pathology Level VI
    • pathological diagnosis
      • Large intestine, rectum, LAR — Adenocarcinoma, moderately differentiated
        
      • Resection margins: Free of tumor
      • Lymph nodes, mesorectal, LAR — Metastatic adenocarcinoma (4/34)
        
      • Liver, S7, S5 and S3, partial hepatectomy — Metastatic adenocarcinoma (see path: S2017-05994)
      • Pathology stage: Stage IV (pT3N2aM1)
    • microscopic examination
      • Histology: Adenocarcinoma
        
      • Histology Grade: Moderately differentiated
      • Depth of invasion: Perirectal soft tissue
      • Angiolymphatic invasion: Present; Extramural venous invasion: Present
        
      • Perineural invasion: Not identified
        
      • Discontinuous extramural tumor extension: Not identified
        
      • Circumferential (radial) margin of rectum: Uninvolved, 1.5 mm from the margin
      • Lymph node metastasis, mesorectal: Metastatic adenocarcinoma (4/34)
      • Extranodal involvement: Present
        
  • 2017-04-21 Surgical pathology Level V
    • Liver, S7, S5, S3 & S3, segmental hepatectomy + partial hepatectomy — Metastatic adenocarcinoma, colorectal origin
  • 2017-04-18 M-mode Echo
    • Dilated LA and LV
    • Thick IVS and LVPW
    • Normal LV and RV contractility
    • LV Grade 1 diastolic dysfunction
    • Mild AR, mild MR
  • 2017-04-13 CT - abdomen
    • Rectal cancer with LNs and liver metastases
    • Cstage T3N2aM1a
  • 2017-04-06 Surgical pathology Level IV
    • Rectum, biopsy — Adenocarcinoma. IHC stain of EGFR (+).
    • IHC stains: PMS2 (+), MSH6 (+), using tissue block (S2017-5995T1)
  • 2017-04-05 Colonoscopic polypectomy
    • Endoscopic examination of rectum and colon was done and the scope has been inserted up to the level of cecum. One 8 mm Is polyp is noted at A-colon 70 cm from anal verge, polypectomy done (A), another similar lesion is seen at the 30 cm, polypectomy (B) done. An annular uclerative tumor mass nearly occupying the whole circumferential lumen is noticed at the rectum 7 cm to the anus, Bx done.
• consultation
  • 2021-05-20 Neurology
    • The patient presented with acute left limbs weakness with right side deviation of gait since 3 days ago. He denied limbs numbness, slurred speech, facial asymmetry.
    • Impression
      • recurrent right subcortical stroke or left cerebellar stroke
    • Suggestion
      • Arrange MRA brain with/without contrast, EKG
      • Keep bokey
      • Normal saline Hydration
      • Keep SBP<220 or DBP<120 mmHg in acute stroke
      • Check D-dimer for rule out Trousseau’s syndrome.
• chemoimuunotherapy
  • 2022-09-13 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-08-24 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-07-29 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-07-08 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-05-11 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-04-14 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-03-15 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-02-15 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-01-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2022-01-05 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-12-14 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-11-18 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-10-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-10-06 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-09-13 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-08-26 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-08-06 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-07-22 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-06-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-05-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-05-04 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-04-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-03-31 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
  • 2021-03-04 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)

[assessment]

• CEA lab data

  • 2022-08-19 CEA 2066.02 ng/mL
    
  • 2022-07-22 CEA 1882.44 ng/mL
    
  • 2022-06-15 CEA 1801.03 ng/mL
    
  • 2022-05-03 CEA 1288.14 ng/mL
    
  • 2022-04-06 CEA 1470.23 ng/mL
    
  • 2022-02-11 CEA 864.46 ng/mL
    
  • 2021-12-28 CEA 740.59 ng/mL
    
  • 2021-11-09 CEA 555.92 ng/mL
    
  • 2021-09-29 CEA 525.75 ng/mL

• According to CT scan impressions, the disease had responded to the current treatment (bevacizumab + FOLFIRI) introduced in early March 2021 and remains stable in the recent half year. However, CEA readings have also increased over the past 12 months.

• Upon confirmation that the disease has acquired resistance, regorafenib might be considered as a subsequent treatment option.

• The underlying condition HTN appears to be well controlled during this hospitalization. There are no updated hyperlipidemia lab results available for the past two years that could be ordered if clinically indicated.

220415

[assessment]

• Recent CT images (2021-08-25, 2022-01-07) showed partial resonses, however lab data showed elevated biomarker levels (CEA 1470ng/mL 2022-04-06 from 525 2021-09-29, CA199 1087U/mL 2022-04-07 from 465 2021-08-19).
• Current chemotherapy regimen, FOLFIRI plus bevacizumab, has been in use since 2021-03-04 and it should be still effective according to above mentioned exam results.
• Lab results on 2022-04-06 concerning liver function, renal function, serum electrolytes, and blood cell counts were grossly normal.
• Hypertension is one of the underlying health conditions that is well managed based on the TPR records during this hospital stay with the prescribed Sevikar (amlodipine + olmesartan).
• Hyperlipidemia is also listed as a diagnosis and treated with Crestor (rosuvastatin) currently, however, there is no follow up lab data for more than six months. It is recommended that a blood lipid test be performed.

210621

{Rectal Cancer}

[initial presentation]

• 2017-04-07 tenesmus with bloody stool for more than 1 year.

[definite diagnosis]

• 2017-04-07 diagnosed with rectal cancer.

[disease extent]

• 2017-04-14 proved adenocarcinoma of low rectum with right liver metastasis, cT3N2M1a, stage IVa, suggest LAR with protective ileostomy and partial hepatectomy.
• 2017-04-21 pT3N2aM1(4/34), stage IVa, with rectal anastomotic leak s/p debridement. RAS WT.
• 2018-07-05 PET showed liver metastases and may peritoneal seeding, stage IVb-c

[treatment]

• 2017-06-23 mFOLFOX6 started
• 2017-08-18 hold chemotherapy due to chest contusion injury and cholecystitis
• 2017-11-07 closure of colostomy on 2017-10-19
• 2018-02-27 refused adjuvant therapy
• 2021-03-04 Avastin with FOLFIRI Q2WK started

[effect and side effect]

• 2018-06-26 CT showed suspected liver metastases
• 2018-06-28 small bowel obstruction to ER
• 2021-02-17 CT, ABD:
  • Multiple metastases on both hepatic lobes and the largest one measuring 16.6 cm at S4 and residual right lobe.
  • Multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space.
• 2021-05-20 CT, ABD:
  • Rectal cancer s/p operation. Right abdominal wall hernia. Mild decreased size of liver and LNs metastases.
• CEA (ng/mL)
  • 2021-05-19 2259
  • 2021-04-26 1870
  • 2021-03-29 3623
  • 2021-01-29 3951
• CBC 2021-05-21 WBC, RBC, PLT all in acceptable range.

[ongoing problem]

Objective:

• 2019-10-24 CT, Brain: Brain atrophy with old left basal ganalia lacunar brain infarcts. Arteriosclerosis.
• 2021-05-21 MRA, Brain:
  • No evidence of brain metastasis. Old ischemic insults. Intracranial artherosclerosis. General brain atrophy.
• 2021-05-20 D-dimer 1291ng/mL(FEU)
• bokey (aspirin, 100mg QD) in active medication.

Assessment:

• biomarker hint increased probability of inappropriate blood clots.
• no related clinical symptom recorded.
• Trousseau’s syndrome not been concluded yet.

Suggestion:

• keep following up clinical signs indicating the syndrome.

Objective:

• BP 141/93 at 10:55 on 06-21 (this is the only record for now during this hospitalization)
• sevikar (amlodipine 20mg, olmesartan 5mg) 0.5 tab QD in active medication.

Assessment:

• too few data points to tell the trend.
• preliminary interpretation: BP still in acceptable range.

Suggestion:

• keep monitor BP and collect more data points

Objective:

• Cholesterol total 110mg/dL (2020-07-08)
• Triglyceride 51mg/dL (2020-07-08), 91mg/dL (2019-10-25)
• crestor (rosuvastatin 10mg) QD in active medication.

Assessment:

• gathered data showed the stable condition.
• no new lab data since 2020 Aug.

Suggestion:

• update lab data.

701432687

220914

• exam finding
  • 2022-08-29 KUB
    • Post-op with metallic wire retention in upper abdomen.
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
  • 2022-08-25 CT - abdomen
    • Indication
      • Adenocarcinoma of pancreas with peritoneal seeding, cT3NxM1, stage IV s/p laparoscopic Op wt peritoneal tumor excision on 20220803 & s/p laparoscopic gastrojejunostomy on 20220624 at Taipei City Hospital ZhongXing Branch.
  • 2022-08-04 Patho - peritoneum biopsy
    • diagnosis
      • FsA: peritoneum 1, biopsy— Metastatic adenocarcinoma, moderately differentiated
      • FsB: peritoneum 2, biopsy— Aggregation of foamy histiocytes with focal metastatic adenocarcinoma
    • microscopic description
      • A: Section shows fibroadipose tissue with metastatic moderately differentiated adenocarcinoma. The immunohistochemical stains reveal CK7(+), CK20(-), CDX2(focal +), WT-1(-), and Calretinin(focal weak +). The results are consistent with pancreatic origin. Please correlate with the clinical presentation and image study to exclude other origin.
      • B: Section shows fibroadipose tissue with aggregation of foamy histicoytes and multinucleated giant cells. Focal metastatic moderately differentiated adenocarcinoma is seen.
  • 2022-08-03 Frozen Section
    • Preliminary diagnosis:
      • FsA: peritoneum 1, biopsy— Metastatic adenocarcinoma
      • FsB: peritoneum 2, biopsy— Aggregation of foamy histiocytes with focal metastatic adenocarcinoma
  • 2022-07-26 Upper GI series
    • UGI series revealed obstruction of duodenum, 3rd portion.
  • 2022-07-26 Patho- pancreas biopsy
    • Labeled as “pancreas”, clinically: 1.8 cm pancreatic uncinate process mass on MRI, needle biopsy — bland pancreatic acinar tissue and bland islet tissue. Please repeat biopsy.
    • IHC stains: CA19-9 (+), CK19 (+), synaptophysin (- to equivocal), CD56 (- to equivocal), Ki-67: <5%.
  • 2022-07-25 Endoscopic Ultrasonography, EUS
    • Pancreatic tumor, uncinate process, s/p EUS-FNA with ROSE
    • s/p gastroenterostomy
  • 2022-07-23 MRI - brain
    • No metastatic lesion over left cerebellar lobe.
  • 2022-07-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 25) / 75 = 66.67%
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA; LV diastolic dysfunction, Gr 1
    • Trivial MR, trivial TR and trivial PR
    • Preserved RV systolic function
  • 2022-07-20 Whole body PET scan
    • The pancreatic tumor at ucinate process shown on the previous abdomen MRI reveals glucose hypermetabolism, and the nature is to be determined (pancreatic head malignancy, lymphoma, or others ?), suggesting biopsy for investigation.
      
    • Glucose hypermetabolism in the muscle layer of the right umbilical region, the nature is to be determined also (post-traumatic change, lymphoma, or others ?), suggesting biopsy for investigation.
      
    • Probably reactive nodes in the right mediastinum and bilateral pulmonary hilar regions.
    • Inhomogenously increased FDG uptake in the left cerebellum, the nature is to be determined (normal variants, lymphoma, or other nature ?). Please correlate with other clinical findings for further evaluation.
    • Probably physiological uptake of FDG in the colon.
  • 2022-07-19 Flow volume loop
    • poor performance
    • mild restrictive ventilatory impairment
  • 2022-07-12 MRI - pancreas
    • History and indication:
      • Duodenum obstruction suspected P-head tumor
      • Addendum Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T1c(T_value) N:N0(N_value) M:M0(M_value) STAGE:IA(Stage_value)
  • 2022-07-11 Endoscopic Ultrasonography, EUS
    • Suspicious pancreatic head (uncinate process) tumor or duodenal tumor with duodenal obstruction, s/p biopsy (A)
    • Enlarged major papilla, suspected tumor involvement, s/p biopsy (B)
    • Suspect GB polyp
    • S/p gastrojejunostomy
    • GERD LA Gr.A
  • 2022-07-08 CXR
    • Tortous aorta with calcification is noted.
  • 2022-07-08 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
• surgical operation
  • 2022-08-03
    • Surgery
      • laparoscopic examination
      • excision of peritoneal tumor, malignancy
    • Finding
      • ascites(-)
      • multiple small seeding tumors over right paracolic gutter, frozen section: adenocarcinoma
• chemoimmunotherapy
  • 2022-09-13 - gemcitabine 700mg/m2 1000mg 30min + carboplatin AUC 4 200mg 2hr + fluorouracil 1500mg/m2 2000mg 46hr (Due to economic difficulties, the self-paid FOLFIRINOX shifted to Gemzar + PF)
  • 2022-08-24 - oxaliplatin 60mg/m2 90mg 2hr + irinotecan 150mg/m2 220mg 1.5hr + leucovorin 400mg/m2 590mg 2hr + fluorouracil 2400mg/m2 3500mg 46 (pre-Op neoadjuvant FOLFIRINOX, 5-FU initialized at a lower dose)

[assessment]

• Serum uric acid lab data

  • 2022-09-13 Uric Acid 10.1 mg/dL
    
  • 2022-09-01 Uric Acid 9.0 mg/dL
    
  • 2022-08-11 Uric Acid 4.8 mg/dL
    

• There is a history of gout in this patient, and his serum uric acid level is elevated. One option might be to prescribe Feburic (febuxostat 80mg) 0.5# QD for at least seven days.

• Lab data: serum creatinine (2022-09-13 2.14 mg/dL <- 2022-09-01 1.20 mg/dL), BUN (2022-09-13 39 mg/dL <- 2022-09-01 23 mg/dL). The patient’s renal function is declining.

• Male, age 58, 160cm, 45kg => BMI 17.6kg/m2, CrCl 24mL/min, eGFR 32~38mL/min/1.73m2

• As this patient is mildly thin, an increase in intake is recommended in order to prevent malnutrition and build up some reserve for future treatment.

• The use of carboplatin has been associated with renal adverse reactions, including decreased creatinine clearance (27%), and increased blood urea nitrogen (14% to 22%). In the next chemotherapy cycle, it might be an option to reduce the dose.

701432850

220914

{not completed}

• exam finding
  • 2022-09-12 CXR
    • Port-A catheter inserted its tip projecting over carina via left subclavian vein.
    • enlarged cardiac silhoutte may be due to dilated cardiac chamber (LAD) and prominent cardiophrenic angle mediastinal fat pad/ supine position
    • Dilation of pulmonary trunk
    • Rt and Lt subpulmonary effusion
    • hazy increased opacities over both lungs with poor defination of perihilar and lower lobes vessels
  • 2022-09-08 Visceral Angiography over 2 vessels
    • DSA of celiac trunk, SMA and IMA via right common femoral artery puncture revealed:
      • A tumor stain at splenic flexure of colon.
      • No evidence of active bleeding.
  • 2022-09-08 CXR
    • Port-A catheter inserted its tip projecting over carina via left subclavian vein.
    • enlarged cardiac silhoutte may be due to dilated cardiac chamber (LAD) and prominent cardiophrenic angle mediastinal fat pad/ supine position
    • Dilation of pulmonary trunk
    • Rt and Lt subpulmonary effusion
    • reticular opacities over both lungs
    • Elevation of both hemidiaphragms
  • 2022-09-07 Patho - colon biopsy
    • Colorectum, splenic flexure, biopsy — Adenocarcinoma.
  • 2022-09-06 CXR
    • appropriately positioned gastric tube
    • Port-A catheter inserted its tip projecting over carina via left subclavian vein.
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • enlarged cardiac silhoutte may be due to dilated cardiac chamber (LAD) and prominent cardiophrenic angle mediastinal fat pad/ supine position
    • Dilation of pulmonary trunk
    • Rt and Lt subpulmonary effusion
    • reticular opacities over both lungs may be due to interstitial lung edema
  • 2022-09-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 41.6) / 111 = 62.52%
    • Thickened AV with mild AR
    • Normal MV with mild MR
    • Concentric LVH, normal LV wall motion
    • Preserved LV and RV systolic function
    • Mild PR, mild TR, normal IVC size
    • Moderate pulmonary hypertension
  • 2022-09-05 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Prolonged QT
    • Abnormal ECG
  • 2022-09-05 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Prominence of bilateral hilar shadows are noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and follow-up.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-08-06 SONO - Nephrology
    • No significant abnormality from echography for both kidneys
    • Urinary retention, suspected neurogenic bladder
  • 2022-07-19 SONO - chest
    • Bilateral thorax: minimal amount pleural effusion; thoracocentesis was not performed due to high risk of complications.
  • 2022-07-18 SONO - abdomen
    • parenchymal renal disease, both
    • pleural effusion, bilateral
  • 2022-07-15 CT - lung
    • Findings
      • Diffuse nodularity at bilateral upper lobes is found. suspected colon cancer meta.
      • Increased pulmonary vasculature is found.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • There is moderate bilateral pleural effusion.
      • Extensive bilateral chest wall soft tissue swelling is found. suspected hypoalbuminemia related.
    • Imp:
      • Diffuse nodularity at bilateral upper lobes is found. suspected colon cancer meta.
      • Bilateral moderate pleural effusion and chest wall swelling is found.
  • 2022-07-14 Whole body PET scan
    • A glucose hypermetabolic lesion in the left upper abdomen. Colon malignancy near the splenic flexure should be watched out. Please correlate with other clinical findings for further evaluation.
    • A glucose hypermetabolic lesion in the midline pelvic region about sigmoid colon. The nature is to be determined (inflammatory process? malignancy? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Increased FDG uptake in bilateral neck muscles. Physiological FDG uptake is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-07-12 Patho - colorectal polyp
    • Colon, transverse, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (loss), MSH6 (+), MSH2(+), MLH1 (loss).
  • 2022-07-11 Colonoscopy
    • Probable colon cancer with partial obstruction, proximal T colon, s/p biopsy(A)
    • Suspect colon polyp with focal malignant change, Paris classification 0-Ip, RS junction, s/p biopsy(B)
    • S/p right hemicolectomy
  • 2022-07-08 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Prolonged QT
    • Abnormal ECG
• consultation
  • 2022-09-12 Cardiology
    • Q
      • For adjusted BP medication
      • This 60 years old female patient had underlying history of DM, hypertension, CHF, CKD stage 5, Right distal foot wet gangrene with local heat s/p BK and Colon cancer under chemotherapy.
      • Hospitalization, shock status with bleeding tedency. transferred to ICU for monitoring.
      • During ICU course, anti-hypertensive agents are combine with to control BP. however, Blood pressure are out of control.
      • We need your spcecialist to adjusted BP medication. Thanks.
    • A
      • For this patient, the present treatment have reaches to maximal dose of anti-HTN agents
      • only catapress 1 bid can be used for BP control
      • For dilysis patient, some patient has intractable hypertension despite of current regimen
      • You can ask nephrologist to increase the ultrafiltration amount, which might contribute the BP lowering effect
      • The target BP is set as 140-150 mmHg
      • If all treatment is effective, you will ask patient or family to buy minoxidil. minoxidil is relatively powerful for BP control.
  • 2022-09-09 Radiation Oncology
    • Q
      • passage bloody stool around 210g suspected tumor bleeding, so we need your help for evaluation. Thanks!!
    • A
      • According to the clinical condition and imaging findings, angiography is indicated.

[assessment]

• The patient’s blood pressure has been around 190(+-10)/90(+-10), despite taking the following antihypertensive agents as part of the active prescription:

  • Chenday (labetalol 25mg) 0.5# PRNQ12H
  • Apresoline (hydralazine 50mg) 1# Q6H
  • Sevikar (amlodipine 5mg + olmesartan 20mg) 1# BID
  • Doxaben (doxazosin 4mg) 1# Q12H
  • Syntrend (carvedilol 25mg) 1# BID

• Clonidine can be used for chronic hypertension as an alternative agent. It is not recommended for initial management but may be considered as additional therapy for resistant hypertension in patients who do not respond adequately to combination therapy with preferred agents (ACC/AHA [Whelton 2018]). We have in stock Catapres (clonidine 0.075mg) currently. Oral form immediate release: Initial 0.1 mg twice daily; increase dose in increments of 0.1 mg/day at weekly intervals based on response and tolerability; usual dose range: 0.2 to 0.6 mg/day in 2 divided doses. The manufacturer’s labeling includes a maximum daily dose of 2.4 mg; however, doses >0.6 mg/day are generally not used.

• In an alternative attempt to lower the blood pressure, currently used Sevikar might also be replaced with Adapine (nifedipine 30mg) 1# BID and Micardis (telmisartan 80mg) 1# QD.

• Minoxidil (not available in stock) can also act as an alternative adjunctive agent. It should be reserved for patients with resistant hypertension who do not respond adequately to an optimized 4-drug regimen, ideally consisting of a thiazide-like diuretic (eg, chlorthalidone) and a mineralocorticoid-receptor antagonist (eg, spironolactone). It can be used in combination with a beta-blocker to prevent reflex tachycardia. Fluid retention may occur and may require additional diuretic therapy (ACC/AHA [Whelton 2018]; Brook 2022). Oral form initial: 5 mg once daily, increase dose gradually in intervals of >= 3 days; usual effective dose: 10 to 40 mg/day in 1 to 3 divided doses; maximum dose: 100 mg/day in 1 to 3 divided doses. During therapy, if supine diastolic pressure is reduced <30 mm Hg, administer total daily dose once daily; if supine diastolic pressure is reduced >30 mm Hg, administer in divided doses (ACC/AHA [Whelton 2018]; manufacturer’s labeling).

701207878

220913

[assessment]

• Time serial serum creatinine, cyclosporine trough concentration and cyclosporine daily dose log:
  • Date // cre // trough // cyclosporine daily dose
  • 2022-09-12 1.83 163.7 200mg = 100mg 1# BID, PO
  • 2022-09-11 200mg = 100mg 1# BID, PO
  • 2022-09-10 200mg = 100mg 1# BID, PO
  • 2022-09-09 1.41 200mg = 100mg 1# BID, PO
  • 2022-09-08 200mg = 100mg 1# BID, PO
  • 2022-09-07 1.20 200mg = 100mg 1# BID, PO
  • 2022-09-06 200mg = 100mg 1# BID, PO
  • 2022-09-05 1.11 193.8 200mg = 100mg 1# BID, PO
  • 2022-09-04 200mg = 100mg 1# BID, PO
  • 2022-09-03 200mg = 100mg 1# BID, PO
  • 2022-09-02 200mg = 100mg 1# BID, PO
  • 2022-09-01 69.1 200mg = 100mg 1# QD + 100mg 1# BID first dose, PO
  • 2022-08-31 0.94 50mg = 25mg 2# QD, PO
  • 2022-08-30 50mg = 25mg 2# QD, PO
  • 2022-08-29 0.93 50mg = 25mg 2# QD, PO
  • 2022-08-28 50mg = 25mg 2# QD, PO
  • 2022-08-27 50mg = 25mg 2# QD, PO
  • 2022-08-26 1.22 50mg = 25mg 2# QD, PO
  • 2022-08-01 109.6 125mg = 100mg 1# QD + 25mg 1# QD, PO
  • 2022-07-31 150mg = 100mg 1# QD + 25mg 1# BID, PO
  • 2022-07-30 150mg = 100mg 1# QD + 25mg 1# BID, PO
  • 2022-07-29 0.68 150mg = 100mg 1# QD + 25mg 1# BID, PO
  • 2022-07-28 0.74 118.3 125mg = 100mg 1# QD + 25mg 1# QD, PO
  • 2022-07-27 125mg = 100mg 1# QD + 25mg 1# QD, PO
  • 2022-07-26 125mg = 100mg 1# QD + 25mg 1# QD, PO
  • 2022-07-25 0.85 126.9 100mg = 100mg 1# QD, PO
  • 2022-07-24 100mg = 100mg 1# QD, PO
  • 2022-07-23 0.83 100mg = 100mg 1# QD, PO
  • 2022-07-22 100mg = 100mg 1# QD, PO
  • 2022-07-21 0.77 487.1 200mg = 100mg 1# BID, PO
  • 2022-07-20 200mg = 100mg 1# BID, PO
  • 2022-07-19 200mg = 100mg 1# BID, PO
  • 2022-07-18 0.82 220.0 200mg = 200mg QD, IVD
  • 2022-07-17 200mg = 200mg QD, IVD
  • 2022-07-16 200mg = 200mg QD, IVD
  • 2022-07-15 0.73 162.0 200mg = 200mg QD, IVD
  • 2022-07-14 200mg = 200mg QD, IVD
  • 2022-07-13 0.71 200mg = 200mg QD, IVD
  • 2022-07-12 200mg = 200mg QD, IVD
  • 2022-07-11 0.80 172.6 200mg = 200mg QD, IVD
  • 2022-07-10 200mg = 200mg QD, IVD
  • 2022-07-09 200mg = 200mg QD, IVD
  • 2022-07-08 0.67 200mg = 200mg QD, IVD
  • 2022-07-07 82.7 180mg = 180mg QD, IVD
  • 2022-07-06 180mg = 180mg QD, IVD
  • 2022-07-05 150mg = 150mg QD, IVD
  • 2022-07-04 0.65 77.0 150mg = 150mg QD, IVD
  • 2022-07-03 150mg = 150mg QD, IVD
  • 2022-07-02 150mg = 150mg QD, IVD
  • 2022-07-01 0.59 130mg = 130mg QD, IVD
  • 2022-06-30 130mg = 130mg QD, IVD
  • 2022-06-29 0.56 130mg = 130mg QD, IVD
  • 2022-06-28 130mg = 130mg QD, IVD

220907

[assessment]

• Alprazolam is metabolized by the enzyme CYP3A4 and the antifungal drugs itraconazole, ketoconazole, posaconazole, and voriconazole are strong inhibitors of this enzyme, which can increase the serum concentration of alprazolam.

• Each member of the azole class exhibits a unique spectrum of activity, although fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole all demonstrate similar activity against most Candida species. (ref: Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1-e50. doi:10.1093/cid/civ933 )

• While fluconazole is a less strong (i.e. moderate) CYP3A4 inhibitor than voriconazole, it might be a suitable substitute for voriconazole if no other considerations are taken into account. Additionally, a change from 2# to 1# of alprazolam might also be considered.

220906

[assessment]

• On 2022-09-05, blood was drawn about one hour before the time of administration for cyclosporine TDM. It is recommended that blood be drawn within half an hour of the time of administration. As of the latest monitoring result, the level is 193.8 ng/mL, which is generally considered to be within the reasonable range (100 to 400 ng/mL). Based on changes in serum creatinine, renal function appears to be slowly declining (but still within normal range). It might take less time to achieve a concentration greater than 400ng/mL by consecutive daily doses of 200mg than it did in mid-July. A retest is recommended after three days to determine if the dose should be adjusted.

• Time serial serum creatinine, cyclosporine trough concentration and cyclosporine daily dose log:

  • Date // cre // trough // cyclosporine daily dose
  • 2022-09-06 200mg = 100mg 1# BID, PO
  • 2022-09-05 1.11 193.8 200mg = 100mg 1# BID, PO
  • 2022-09-04 200mg = 100mg 1# BID, PO
  • 2022-09-03 200mg = 100mg 1# BID, PO
  • 2022-09-02 200mg = 100mg 1# BID, PO
  • 2022-09-01 69.1 200mg = 100mg 1# QD + 100mg 1# BID first dose, PO
  • 2022-08-31 0.94 50mg = 25mg 2# QD, PO
  • 2022-08-30 50mg = 25mg 2# QD, PO
  • 2022-08-29 0.93 50mg = 25mg 2# QD, PO
  • 2022-08-28 50mg = 25mg 2# QD, PO
  • 2022-08-27 50mg = 25mg 2# QD, PO
  • 2022-08-26 1.22 50mg = 25mg 2# QD, PO
  • 2022-08-01 109.6 125mg = 100mg 1# QD + 25mg 1# QD, PO
  • 2022-07-31 150mg = 100mg 1# QD + 25mg 1# BID, PO
  • 2022-07-30 150mg = 100mg 1# QD + 25mg 1# BID, PO
  • 2022-07-29 0.68 150mg = 100mg 1# QD + 25mg 1# BID, PO
  • 2022-07-28 0.74 118.3 125mg = 100mg 1# QD + 25mg 1# QD, PO
  • 2022-07-27 125mg = 100mg 1# QD + 25mg 1# QD, PO
  • 2022-07-26 125mg = 100mg 1# QD + 25mg 1# QD, PO
  • 2022-07-25 0.85 126.9 100mg = 100mg 1# QD, PO
  • 2022-07-24 100mg = 100mg 1# QD, PO
  • 2022-07-23 0.83 100mg = 100mg 1# QD, PO
  • 2022-07-22 100mg = 100mg 1# QD, PO
  • 2022-07-21 0.77 487.1 200mg = 100mg 1# BID, PO
  • 2022-07-20 200mg = 100mg 1# BID, PO
  • 2022-07-19 200mg = 100mg 1# BID, PO
  • 2022-07-18 0.82 220.0 200mg = 200mg QD, IVD
  • 2022-07-17 200mg = 200mg QD, IVD
  • 2022-07-16 200mg = 200mg QD, IVD
  • 2022-07-15 0.73 162.0 200mg = 200mg QD, IVD
  • 2022-07-14 200mg = 200mg QD, IVD
  • 2022-07-13 0.71 200mg = 200mg QD, IVD
  • 2022-07-12 200mg = 200mg QD, IVD
  • 2022-07-11 0.80 172.6 200mg = 200mg QD, IVD
  • 2022-07-10 200mg = 200mg QD, IVD
  • 2022-07-09 200mg = 200mg QD, IVD
  • 2022-07-08 0.67 200mg = 200mg QD, IVD
  • 2022-07-07 82.7 180mg = 180mg QD, IVD
  • 2022-07-06 180mg = 180mg QD, IVD
  • 2022-07-05 150mg = 150mg QD, IVD
  • 2022-07-04 0.65 77.0 150mg = 150mg QD, IVD
  • 2022-07-03 150mg = 150mg QD, IVD
  • 2022-07-02 150mg = 150mg QD, IVD
  • 2022-07-01 0.59 130mg = 130mg QD, IVD
  • 2022-06-30 130mg = 130mg QD, IVD
  • 2022-06-29 0.56 130mg = 130mg QD, IVD
  • 2022-06-28 130mg = 130mg QD, IVD

220729

{recommended cyclosporine daily dose to maintain a stable and reasonable trough concentration}

• Time serial cyclosporine daily dose and its trough concentration log:
  • Date // trough conc ng/mL // cyclosporine daily dose mg
  • 2022-07-29 200mg ~ 100mg BID
  • 2022-07-28 118.3 100mg ~ 100mg QD
  • 2022-07-27 100mg ~ 100mg QD
  • 2022-07-26 100mg ~ 100mg QD
  • 2022-07-25 126.9 100mg ~ 100mg QD
  • 2022-07-24 100mg ~ 100mg QD
  • 2022-07-23 100mg ~ 100mg QD
  • 2022-07-22 100mg ~ 100mg QD
  • 2022-07-21 487.1 200mg ~ 100mg BID
  • 2022-07-20 200mg ~ 100mg BID
  • 2022-07-19 200mg ~ 100mg BID
  • 2022-07-18 220.0 200mg ~ 200mg QD
  • 2022-07-17 200mg ~ 200mg QD
  • 2022-07-16 200mg ~ 200mg QD
  • 2022-07-15 162.0 200mg ~ 200mg QD
  • 2022-07-14 200mg ~ 200mg QD
  • 2022-07-13 200mg ~ 200mg QD
  • 2022-07-12 200mg ~ 200mg QD
  • 2022-07-11 172.6 200mg ~ 200mg QD
  • 2022-07-10 200mg ~ 200mg QD
  • 2022-07-09 200mg ~ 200mg QD
  • 2022-07-08 200mg ~ 200mg QD
  • 2022-07-07 82.7 180mg ~ 180mg QD
  • 2022-07-06 180mg ~ 180mg QD
  • 2022-07-05 150mg ~ 150mg QD
  • 2022-07-04 77.0 150mg ~ 150mg QD
  • 2022-07-03 150mg ~ 150mg QD
  • 2022-07-02 150mg ~ 150mg QD
  • 2022-07-01 130mg ~ 130mg QD
  • 2022-06-30 130mg ~ 130mg QD
  • 2022-06-29 130mg ~ 130mg QD
  • 2022-06-28 130mg ~ 130mg QD
• According to the above records, 175 mg per day is more likely to maintain a trough concentration within a reasonable and relatively stable range.

220722

{cyclosporine concentration}

• On 2022-07-21, the cyclosporine trough concentration in this patient reached a record high of 487 ng/mL, which is generally considered to be above the normal range.
• The following adverse reactions and incidences have been reported with systemic use of the drug. Percentages indicate the highest frequency, regardless of indication or dosage. Monitoring these signs might be helpful.
  • Cardiovascular: Hypertension (13% to 53%)
  • Endocrine & metabolic: Hirsutism (21% to 45%)
  • Gastrointestinal: Gingival hyperplasia (4% to 16%)
  • Genitourinary: Urinary tract infection (21%)
  • Infection: Viral infection (16%)
  • Nervous system: Headache (2% to 15%)
  • Neuromuscular & skeletal: Tremor (21% to 55%)
  • Renal: Nephrotoxicity (25% to 38%)
• In the hospital, capsules containing 100mg and 25mg are available.
• The recommended dose for oral administration is 100mg for one day followed by 150mg (100mg + 2 x 25mg) for the next two or three days, followed by another TDM to determine whether it is necessary to titrate the dose up to 175mg per day.

220719

{cyclosporine trough concentration}

• A trough concentration of 220 ng/mL of cyclosporine was observed on 2022-07-18, which is considered adequate; however, the concentration momentum remains upward.

220715

{post-transplant immunization}

• Hematopoietic cell transplant (HCT) recipients should be immunized against a number of pathogens such as pneumococcus, Haemophilus influenzae, tetanus, and others once they are likely to mount an immune response.
• Most live virus vaccines are avoided altogether during the first 24 months following HCT.
• Certain ones (eg, measles, mumps, and rubella vaccine) are indicated 24 months following HCT in patients who do not have active graft-versus-host disease and who are not receiving immunosuppressive agents.

{cyclosporine trough concentration}

As of 2022-07-14, the trough concentration of cyclosporine was 162 ng/mL, which is considered to be an acceptable level.

220713

{Cyclosporine trough concentration follow-up}

• Cyclosporine trough concentration on 2022-07-11 reached 172.6 ng/mL, which was within the range of 100 to 400 ng/mL where the majority of individuals demonstrate optimal responses.

220708

{Cyclosporine (ciclosporin) concentration}

• There appears to have been an error in entering the time of blood collection as 2022-07-07 00:00 by the system, and the concentration of ciclosporin was recorded as 82.7 ng/mL.
• Ciclosporin has been titrated up to 200 mg per day (2020-07-05 09:15 150mg, 2020-07-06 09:17 180mg, 2020-07-07 09:14 180mg, 2020-07-08 08:38 200mg).
• It should be expected that the new dose (200 mg QD) will reach a steady state at blood levels of more than to 100 ng/mL. This can be checked next Monday (2022-07-11) by TDM.

220707

{cyclosporine trough concentration}

• Most individuals display optimal response to cyclosporine with trough whole blood levels 100 to 400 ng/mL. The trough concentration on 2022-07-04 was 77 ng/mL with 150mg IVD administered each day. Please recheck the clinical response to determine if dosage needs to be adjusted.

220614

{MDS, RAEB-1}

• present illness
  • This 29-year-old man with past history of PMH of depression, insomnia, acute pancreatitis s/p treatment, GERD. His last dose of COVID vaccination was AZ in November 2021.
  • He was admitted due to chest pain and chest tightness which then accidently discovered thrombocytopenia and anemia on 20220217.
• past history
  • acute pancreatitis
  • GERD
  • depression, insomnia
• exam finding
  • 2022-03-14 Patho - bone marrow biopsy
    • Bone marrow, post iliac creast, biopsy — Refractory anemia with excess blasts (RAEB-1)
    • Microscopically, the bone marrow shows hypercellularity with hemopoietic components accounting for about 80~90% of the marrow space, and M/E ration of 2-3:1. Megakaryocytes are midly increased in quantity. Focal excess of blast (5%-9%) is noted and highlighted by CD117 and CD34.
    • Immunohistochemical stain reveals MPO(+), CD71(+), CD138(<3%), CD20(<5%), CD10(focal+), TdT(-) and CD68(diffuse +).
    • NOTE: Please correlate with flowcytometry, peripheral blood and molecular cytogenetic study.
  • 2022-02-17 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with myelodysplastic syndrome.
    • The sections show hypercellular marrow (90%). The M/E ratio = 2:1. Erythroid hyperplasia with megaloblastoid changes in CD71 stain. The megakaryocyte is slightly decreased in number and a few small megakaryocytes can be found. The MPO+ myeloid cells shows left shift and scattered immature myeloid cells in interstitium are present. An increase in CD68+ monocytes (10%), no CD34+ blasts, and increased CD117+ immature cells constitue 20% of marrow cells are evident. The finding is compatible with myelodysplastic syndrome. Suggest bone marrow smear evaluation and clinic correlation.
  • 2020-12-17 CT - abdomen, pelvis
    • Grade C pancreatitis.
    • Grade 4 fatty liver.
• lab data
  • 2022-06-13
    • EB VCA IgG Positive Ratio
      
    • EB VCA IgG Value 5.6 Ratio
      
    • VZV IgG Positive Index
      
    • VZV-G Value 2.7 Index
      
  • 2022-06-10
    • RPR/VDRL Nonreactive
      
  • 2022-06-10
    • CMV_IgG Reactive
      
    • CMV_IgG Value 179.4 AU/mL
      
    • CMV IgM Nonreactive
      
    • CMV IgM Value 0.16 Index
      
    • HIV Ab-EIA Nonreactive
      
    • Anti-HIV Value 0.05 S/CO
      
    • Anti HTLV I/II Nonreactive
      
    • Anti HTLV I/II Value 0.08 S/CO
      
  • 2022-04-15
    • HLA A-high rsolution 11:01
    • HLA A-high rsolution -
      
    • HLA B-high rsolution 13:01
    • HLA B-high rsolution 35:01
    • HLA C-high rsolution 03:03
    • HLA C-high rsolution 03:04
    • HLA DR-high rsolution 09:01
    • HLA DR-high rsolution 14:05
  • 2022-03-04
    • JAK2-single site mutation Undetectable
      
    • FLT3-D835 mutation Undetectable
      
  • 2022-03-03
    • BCR/abl Undetectable
  • 2022-02-24
    • FLT3/ITD mutation Undetectable
      
    • NPM1 mutation Undetectable
      
    • ANA Negative
      
  • 2022-02-23
    • LA1 35.2 sec
      
    • LA2 34.7 sec
      
    • LA1/LA2 ratio 1.0
      
    • Anti-ds DNA Antibody <0.5 IU/ml
      
    • Anti-ENA Sm 0.7 EliA U/ml
      
    • Anti-ENA RNP <0.3 EliA U/ml
      
    • Anti-Cardiolopin IgG <0.5 GPL-U/mL
      
    • Anti-cardiolipin IgM 2.0 MPL U/mL
      
    • Anti-β2-glycoprotein-I Ab <0.6 U/mL
      
    • RF <10 IU/mL
      
    • C3 135.1mg/dL
      
    • C4 30.8 mg/dL
      
    • Direct Coomb Test Negative
    • Indirect Coomb Test Negative
  • 2022-02-18
    • MPO stain Positive(3+)
      
    • CAE stain Positive
      
    • ANAE stain Negtive
      
    • CD2 NA
      
    • CD3 0.38
      
    • CD4 NA
      
    • CD5 0.32
      
    • CD7 48.01
    • CD8 NA
      
    • CD10 1.24
      
    • CD11b 20.93
    • CD13 93
      
    • CD14 1.14
      
    • CD15 NA
      
    • CD16 4.2
      
    • CD19 11.63
    • CD19/kappa NA
      
    • CD19/Lambda NA
      
    • CD20 0
      
    • CD23 NA
      
    • CD25 NA
      
    • CD33 99
      
    • CD34 2.11
      
    • CD38 NA
      
    • CD56 0.06
      
    • CD103 NA
      
    • CD117 72.82
    • CD138 NA
      
    • FMC7 NA
      
    • HLA-DR 91.75
    • MPO NA
      
    • TdT NA
      
    • HBsAg Nonreactive
      
    • HBsAg (Value) 0.38 S/CO
      
    • Anti-HCV Nonreactive
      
    • Anti-HCV Value 0.08 S/CO
      
    • Anti-HBc Nonreactive
      
    • Anti-HBc-Value 0.11 S/CO
      
    • Anti-HBc IgM Nonreactive
      
    • Anti-HBc IgM Value 0.10 S/CO
      
    • Anti-HBs 0.00 mIU/mL
• chemoimmunotherapy
  • 2022-04-15 ~ undergoing - azacitidine

[assessment]

Dosage of ATG as part of the conditioning regimen in allogeneic PBSCT from matched sibling donors in patients with hematologic malignancies

• As can be seen, 4.5~6mg/kg of ATG was used in allogeneic PBSCT from siblings who had been matched, specifically:
  • ATG plus CsA, MTX, and MMF for GVHD prophylaxis with the following details: 3 mg/kg CsA continuous intravenous drip, started on day 21, changed to orally when GI function recovered with a dose of 5 mg/kg administered as 2 divided doses, and CsA trough concentration maintained at 200-300 ng/mL; 15 mg/m2 MTX on day 1 and 10 mg/m2 MTX on days 3, 6, and 11; 0.25 g MMF twice a day, starting on day 21 and continuing to day 30 for 1 month; and 4.5 mg/kg ATG divided in day 23, day 22, and day 21.
    • ref: Antithymocyte Globulin for Matched Sibling Donor Transplantation in Patients With Hematologic Malignancies: A Multicenter, Open-Label, Randomized Controlled Study. https://pubmed.ncbi.nlm.nih.gov/32650683/
    • ref: Antithymocyte Globulin for Matched Sibling Donor Transplantation in Patients With Hematologic Malignancies (letter to the editor). https://pubmed.ncbi.nlm.nih.gov/33104439/
  • rATG was administered to 40 patients at an intravenous dose of 5 mg/kg divided over day 5 and day 4 before graft infusion.
    • ref: Reduced risk of chronic GVHD by low-dose rATG in adult matched sibling donor peripheral blood stem cell transplantation for hematologic malignancies. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6944670/
  • an ATG dose <6 mg/kg is sufficient for GVHD prophylaxis, while higher doses impair disease control and outcome.
    • ref: Impact of antithymocyte globulin doses in reduced intensity conditioning before allogeneic transplantation from matched sibling donor for patients with acute myeloid leukemia: a report from the acute leukemia working party of European group of Bone Marrow Transplantation. https://pubmed.ncbi.nlm.nih.gov/29330391/

220519

• present illness
  • This 29-year-old man with past history of PMH of depression, insomnia, acute pancreatitis s/p treatment, GERD. His last dose of COVID vaccination was AZ in November 2021.
  • He was admitted due to chest pain and chest tightness which then accidently discovered thrombocytopenia and anemia on 20220217.
• past history
  • acute pancreatitis
  • GERD
  • depression, insomnia
• exam finding
  • 2022-03-14 Patho - bone marrow biopsy
    • Bone marrow, post iliac creast, biopsy — Refractory anemia with excess blasts (RAEB-1)
    • Microscopically, the bone marrow shows hypercellularity with hemopoietic components accounting for about 80~90% of the marrow space, and M/E ration of 2-3:1. Megakaryocytes are midly increased in quantity. Focal excess of blast (5%-9%) is noted and highlighted by CD117 and CD34.
    • Immunohistochemical stain reveals MPO(+), CD71(+), CD138(<3%), CD20(<5%), CD10(focal+), TdT(-) and CD68(diffuse +).
    • NOTE: Please correlate with flowcytometry, peripheral blood and molecular cytogenetic study.
  • 2022-02-17 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with myelodysplastic syndrome.
    • The sections show hypercellular marrow (90%). The M/E ratio = 2:1. Erythroid hyperplasia with megaloblastoid changes in CD71 stain. The megakaryocyte is slightly decreased in number and a few small megakaryocytes can be found. The MPO+ myeloid cells shows left shift and scattered immature myeloid cells in interstitium are present. An increase in CD68+ monocytes (10%), no CD34+ blasts, and increased CD117+ immature cells constitue 20% of marrow cells are evident. The finding is compatible with myelodysplastic syndrome. Suggest bone marrow smear evaluation and clinic correlation.
  • 2020-12-17 CT - abdomen, pelvis
    • Grade C pancreatitis.
    • Grade 4 fatty liver.
• chemoimmunotherapy
  • 2022-04-15 ~ undergoing - azacitidine

[assessment]

• This 29-year-old male was diagnosed with MDS, RAEB-1 during Feb, Mar 2022 and has been receiving azacitidine since April 2022.
• There is also a possibility of acute leukemia, the patient has been admitted for further evaluation.
• The underlying diseases are treated with corresponding drugs. No issue with current medication.

700065931

220912

• exam finding
  • 2022-09-09 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Borderline ECG
  • 2022-09-09 Neck soft tissue
    • Increased prevertebral soft tissu thickness. Please correlate with CT.
  • 2022-09-09 CXR
    • Lung markings: increased density in the right lower lung field.
    • blurred right hemidiaphram
    • blunting right costophrenic angle 2022-09-01 Nasopharyngoscopy
    • Findings
      • blood clot at left anterior nasal cavity, bloody discharge at left nasopharynx, bi nasopharynx smooth, multiple whitish spots coating on hypopharynx and supraglottis, favor candidiasis; supraglottis mild edema
    • Conclusion
      • NPC s/p treatment
      • Suspected pharynx and larynx candidiasis
  • 2022-08-31 CXR
    • There is diffuse osteoblastic bony metastases in the T-spine and L-spine?
  • 2022-08-25 Patho - lymph node region resection
    • Labeled as “right axillary lymph nodes”, clinical history of nasopharyngeal carcinoma, dissection — metastatic poorly differentiated squamous cell carcinoma (10/10).
    • IHC stains: CK5/6 (+), p40 (+), p16 (-), EBV (-).
  • 2022-08-25 Nasopharyngoscopy
    • Findings
      • Nasopharynx: smooth
      • Larynx and hypopharynx: epiglottis and bi arytenoid and bi false cord edema, airway small but adequate
    • Conclusion
      • supraglottic edema, suspected RT and intubation trauma related
  • 2022-08-22 Tc-99m MDP whole body bone scan with SPECT
    • Highly suspected cancer with multiple bone metastases in the sternum, both rib cages, scapulae, and several T- and L-spine.
    • Increased tracer uptake in the sacrum, bilateral multiple pelvic bones, S-I joints, and bilateral femurs, bone metastases should be considered, suggesting follow-up with bone scan in 3 months for investigation.
  • 2022-08-19 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-08-18 SONO - chest
    • Diagnosis:
      • Pleural effusion, milk like, favor chylothorax.
      • Chest echography was performed first. The suitable intercostal space was selected and located.
      • Catheter was inserted with negative pressure smoothly.
      • Right side pleural effusion was drawn smoothly.
      • Watch out BP after tapping.
    • Suggestion:
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR. TG and amylase.
  • 2022-08-17 CT - lung
    • occlusion of Rt IJV, subclavian and innominate vein, with pleural effusion.
    • bony metastasis and suspect metastatic LNs in axillary regions and mediastinum.
  • 2022-08-17 CXR
    • reticular opacities at LUL due to fibrotic change
    • extensive consolidation over Rt lower lobe and possibly increased opacity over Lt retrocardiac lower lobe
    • mild enlarged cardiac silhoutte
    • widening of Rt paratracheal stripe
  • 2022-08-17 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Borderline ECG
  • 2022-07-25 MRI - nasopharynx
    • No local NPx tumor recurrence.
    • Post OP/RT in right parotid gland, with soft tissue swelling and well post contrast enhancement, stationary
    • Sternal notch and chest wall lesion, more likely infection, improved, but seems extending to the mediastinum.
      
  • 2022-07-18 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • Gastric subepithelial leison (SEL), antrum AW
    • Suggestion
      • No evident esophageal lesion on endsocopy
      • Consider EUS study for the gastric SEL
  • 2022-07-06 Whole body PET scan
    • Glucose hypermetabolic lesions disappear in soft tissues in the suprasternal notch and presternal area compared with the previous study on 2022-01-21, indicating response to current therapy. However, glucose hypermetabolism becomes more evident in the lower portion of the esophagus, and the nature is to be determined (inflammation or other nature?). Please correlate with other clinical findings for further evaluation.
    • Suspected benign lesions in the left aspect of maxilla, in bilateral axillary lymph nodes, and in the proximal portion of right femoral shaft.
    • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
    • No abnormally increased FDG uptake is evidently delineated elsewhere.
  • 2022-06-10 CXR
    • S/P port-A implantation.
    • Fibrosis of left upper lung is noted. Please correlate with clinical history to rule out old inflammatory process.
  • 2022-05-23 Nasopharyngoscopy
    • NPC s/p treatment
    • No evidence of tumor recurrence at nasopharynx
  • 2022-03-10 Nasopharyngoscopy
    • NPC s/p treatment
    • No evidence of tumor recurrence at nasopharynx
    • Lower neck/upper chest wall recurrence under CCRT
  • 2022-01-26 Patho - lymphnode biopsy
    • Tissue, lower neck, subcutaneous, biopsy — Nasopharyngeal carcinoma, non-keratinizing and undifferentiated
      
    • The specimen submitted consists of 9 tissue fragments measuring up to 0.7x 0.6x 0.3 cm in size, fixed in formalin. Grossly, they are grayish and solid.
    • Microscopically, it shows nasopharyngeal carcinoma characterized by diffuse sheets or syncytia of non-keratinizing invasive carcinoma infiltrated by lymphoplasmacytic cells.The tumor shows nuclear hyperchromasia, pleomorphism and high N/C ratio.
    • Immunohistochemical stain reveals CK(+), P40(+), and p16(-).
  • 2022-01-21 Whole body PET scan
    • Mild glucose hypermetabolism in the soft tissues in the suprasternal notch and presternal area, in a right axillary lymph node, in two left axillary lymph nodes and in the lower portion of the esophagus. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the proximal portion of right femoral shaft. The nature is to be determined (post-traumatic change? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in a focal area in the left aspect of maxilla. Dental problem is more likely.
    • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
  • 2022-01-03 SONO - articular peripheral soft tissue
    • Finding:
      • Heterogeneous hypoechoic poor-defined mass noted over the subcutaneous layer of left SCM at sternal head area, without increased signal under power Doppler.
    • Impression And Suggestions:
      • A poor-defined subcutaneous soft tissue mass, located superficial to the left SCM, sternal head, without increased signal under power Doppler.
  • 2021-12-07 MRI - nasopharynx
    • No local nasopharynx tumor recurrence.
    • Post OP/RT in right parotid gland, with soft tissue swelling and well post contrast enhancement, need follow up.
    • Sternal notch and chest wall lesion, more likely infection.
  • 2021-12-07 SONO - abdomen
    • A hepatic hemangioma or calcification 0.31 cm in S8.
    • A gallbladder polyp 2.3 mm is highly suspected.
      
  • 2021-08-17 MRI - nasopharynx
    • No nasopharynx tumor recurrence.
    • Post OP/RT in right parotid gland, with soft tissue swelling and well post contrast enhancement, need follow up.
    • Chronic mastoiditis.
  • 2021-06-24 Pure tone audiometry
    • Tymp RE type B, LE type C
    • PTA:
      • Reliability FAIR
      • Average RE 35 dB HL / LE 20 dB HL
    • RE normal to severe MHL
    • LE normal to severe SNHL
  • 2021-04-22 Patho - salivary gland resection
    • pathologic diagnosis
      • Parotid gland, right, parotidectomy — Lymphoepithelial carcinoma involving margins.
      • Superior margin to?, excision — Lymphoepithelial carcinoma involving margin
        
      • Tissue around trigus, excision — benign parotid gland
        
      • Deep lobe of parotid, excision — Lymphepithelial carcinoma involving margin.
        
    • microscopic description
      • Both salivary lymphoepithelial carcinoma and nasopharyngeal lymphoepithelial carcinoma have the same morphology.
  • 2021-04-20 EKG
    • Sinus tachycardia with occasional Premature ventricular complexes
    • Left axis deviation
    • Inferior infarct, age undetermined
  • 2021-04-16 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal ulcer, ECJ, s/p biopsy
      • Reflux esophagitis LA Classification grade B
      • Duodenal shallow ulcers, bulb
      • Duodenal ulcer scar, bulb
      • Gastric erosion, antrum, LC
      • Gastric subepithelial lesion, antrum, AW-GC
      • Superficial gastritis, s/p CLO test
    • Suggestion
      • Persue biopsy result
  • 2021-04-08 Whole body PET scan
    • Some mild glucose hypermetabolic lesions in the right parotid gland. The nature is to be determined (metastases/malignancy of low FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
    • A glucose hypermetabolic lesion in the lower portion of the esophagus. The nature is to be determined (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
  • 2021-03-26 Pathology - lymph node
    • Malignancy
    • R’t parotid nodules: one wet and one dry smears show lymphocytes, acinar clusters, and some atypical epithelial clusters with enlarged nuclei and prominent nucleoli, suggestive of carcinoma, and metastatic maybe first considered according to past history.
  • 2021-02-22 MRI - nasopharynx
    • C/W NPC s/p treatement without local reurrence. However, progressive enlargement of right parotid lesions is noted. Suggest further evaluation. Left mastoiditis.
  • 2021-02-22 SONO - abdomen
    • Fatty liver.
    • Gallbladder polyps.
  • 2020-08-06 MRI - nasopharynx
    • No nasopharynx tumor recurrence.
    • Several small nodulated lesions in right parotid gland, stationary in sizes.
  • 2020-02-04 MRI - nasopharynx
    • No nasopharynx tumor recurrence.
    • Several small nodulated lesions in right parotid gland, stationary in sizes.
  • 2019-06-14 MRI - nasopharynx
    • Several small lymph nodes in the right parotid gland, stationary in sizes.
  • 2019-02-19 MRI - nasopharynx
    • NPC, post CCRT. No local tumor recurrence. No neck LAP. A right parotid gland nodule or LN.
  • 2018-08-02 MRI - nasopharynx
    • NPC, post CCRT. No local tumor recurrence. No neck LAP.
  • 2018-04-10 MRI - nasopharynx
    • NPC s/p CCRT with post treatment change.
    • Chronic maxillary sinusitis and left mastoiditis.
  • 2017-11-20 MRI - nasopharynx
    • NPC s/p CCRT with post treatment change.
    • Chronic maxillary sinusitis and left mastoiditis.
  • 2017-08-16 MRI - nasopharynx
    • NPC s/p CCRT with tumor regression.
  • 2017-02-23 Whole body PET scan
    • Glucose hypermetabolism in the nasopharyngeal roof, compatible with primay nasopharyngeal malignancy.
    • Glucose hypermetabolism in bilateral retropharyngeal lymph nodes, bilateral neck level II-V lymph nodes and bilateral supraclavicular lymph nodes. Lymph node metastases may show this picture.
    • Mild glucose hypermetabolism involving the right shoulder, right sternoclavicular junction and left hip, compatible with benign joint lesion such as arthritis.
  • 2017-02-17 MRI - nasopharynx
    • Tumor location/size
      • Bilateral nasopharyngeal roof
      • Size (largest dimension): 34 mm
    • Tumor invasion:
      • T1 (nasopharynx)
    • Neck lymph node:
      • Retropharynx: Rt(+)/Lt(+); Supraclavicular: Rt(+)/Lt(+)
      • Level I: Rt(-)/Lt(-); Level II: Rt(+ab)/Lt(+ab); Level III: Rt(-)/Lt(+ab); Level IV: Rt(-)/Lt(-); Level V: Rt(+ab)/Lt(+ab); Lvele VI: Rt(-)/Lt(-); Level VII: Rt(-)/Lt(-)
        • -: short axis<10 mm,
        • a: short axis>=10 mm;
        • b: long axis >= 15 mm,
        • c: cluster of >= 3 nodes with short axis >= 7 mm,
        • e: extracapsular spread,
        • n: necrosis
    • Distant metastasis in this study:
      • No or equivocal
    • Imaging stage according to AJCC 7th edition:
      • nasopharyngeal tumor.
    • Impression:
      • nasopharyngeal tumor, suspected lymphoma or others.
  • 2017-02-15 Surgical pathology Level IV
    • Nasopharynx, biopsy — Nasopharyngeal carcinoma, non-keratinizing and undifferentiated (WHO type 2b)
    • IHC stain — CK(+)
    • Microscopically, section shows nasopharyngeal carcinoma characterized by diffuse sheets or syncytia of non-keratinizing invasive carcinoma closely infiltrated by prominent lymphoplasmacytic cells. Nuclei are vesicular with indistinct cell margins, prominent eosinophilic nucleolus and scattered mitotic figures. Desmoplasia is absent or minimal.
• consultation
  • 2022-08-25 ENT
    • Q
      • This 59-year-old man with past history of
        • Nasopharyngeal carcinoma, cT1N3bM0, stage IVB s/p CCRT and adjuvant chemotherapy with PF on 2017; Recurrence nasopharyngeal carcinoma over subcutaneous tissue of lower neck, rcT0N0M1, stage IVC, s/p CCRT on 2022/03/18 and adjuvant chemotherapy with PF three times again since 2022/04~2022/06.
        • Lymphoepithelial carcinoma of Right parotid with peri-salivary gland tissue invasion, pT3cN0M0, s/p parotidectomy with positive and CCRT on 2021/04~2021/07
        • Hypothyroidism under thyroxin control.
      • This time, he had face/neck and chest wall swelling, orthopnea (cough at night), distended neck veins, collateral circulation, swelling over bilateral axillas and dyspnea for several weeks.
      • Under the impression of SVC syndrome, he is admitted to our ward for further evaluation and management.
      • 20220817 Chest CT:
        • Occlusion of Rt IJV, subclavian and innominate vein, with pleural effusion
        • Bony metastasis and suspect metastatic LNs in axillary regions and mediastinum
      • S
        • He was regularly followed up at your ward, and he would arrange to follow your ward again on 20220822.
        • He had done right axillary LN dissection on 20220824. He was found the foreign on his throat, when he was inbutation for operation.
        • He also complained that he was hard to swollen in recent several days.
      • We would like to consult your expertise for recurrent NPC further evaluation and management. Thanks in advance and have a nice day.
    • A
      • SOB after intubation.
      • Scope:
        • Nasopharynx: smooth
        • Larynx and hypopharynx: epiglottis and bi arytenoid and bi false cord edema, airway small but adequate
      • Imp: Supraglottic edema, suspected RT and intubation trauma related
      • Plan:
        • IV steroid for 5-7 days, monitor airway
  • 2022-08-19 General and Gastrointestinal Surgery
    • Q
      • We would like to consult your expertise for his axillary LN biopsy further evaluation and management.
    • A
      • Due to suspected that bilateral axillary LN metastasis and related SVC syndrome. Axillary LN biopsy is consulted.
      • O:
        • vital signs: stable, no fever
        • PE: no central vein stenosis
          
        • lab data: see chart
      • A: suspected that bilateral axillary LN metastasis
      • P: I will arrange axillary LN biopsy, R’t on 20220824
• surgical operation
  • 2022-01-26
    • Surgery
      • Lower neck and chest wall mass incisinal biopsy        
    • Finding
      • Lower neck and chest wall swelling and induration
  • 2021-04-21
    • Surgery
      • Parotidectomy. right
    • Finding
      • Several indurated nodules over right parotid gland
      • Sacrificed of right greater auricular nerve
  • 2020-12-24
    • Surgery
      • total excision
    • Finding
      • skin tumor
• radiotherapy
  • 2022-08-25 ~ 2022-09-05 - 2100cGy/7 fractions (6 MV photon) to low pelvis & hips.
  • 2022-03-16 ~ 2022-03-18 - boost 1050cGy/3 fractions to lower neck and pre-sternal soft tissue tumor due to slow regression
  • 2022-02-15 ~ 2022-03-15 - 6000cGy/20 fractions (6 MV photon) to lower neck and pre-sternal soft tissue tumor
  • 2021-05-24 ~ 2021-07-05 - 6000cGy/30 fractions (6 MV photon) to Rt parotid bed and regional lymphatics
  • 2017-03-08 ~ 2017-04-26 - 7140cGy/34 fractions (6 MV photon) to NPX & neck LAPs
    • Cisplatin: 2017-03-10, 2017-03-16, 2017-03-23, 2017-03-30, 2017-04-06, 2017-04-13, 2017-04-20, 2017-04-24.
    • Radiation mucositis, grade 2; pharyngitis, grade 2; dermatitis, grade 2; N/V, grade 0; esophagitis, grade 1.
• chemoimmunotherapy
  • 2022-08-31 - cisplatin 80mg/m2 130mg 2hr D1 + gamcitabine 1250mg/m2 2100mg 30min D1
  • 2022-06-10 - cisplatin 80mg/m2 140mg 3hr D1 + fluorouracil 1000mg/m2 1790mg 24hr D1-4 (PF Q4W)
  • 2022-05-06 - cisplatin 80mg/m2 140mg 3hr D1 + fluorouracil 1000mg/m2 1790mg 24hr D1-4 (PF Q4W)
  • 2022-04-07 - cisplatin 80mg/m2 140mg 3hr D1 + fluorouracil 1000mg/m2 1800mg 24hr D1-4 (PF Q4W)
  • 2022-03-16 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
  • 2022-03-09 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
  • 2022-03-02 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
  • 2022-02-23 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
  • 2022-02-16 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
  • 2021-06-30 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
  • 2021-06-23 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
  • 2021-06-16 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
  • 2021-06-09 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
  • 2021-06-02 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
  • 2021-05-26 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)

[assessment, not posted]

• An elevated level of D-dimer has been observed.
  • 2022-09-12 D-dimer 3998.90 ng/mL(FEU)
    
  • 2022-09-07 D-dimer 2014.01 ng/mL(FEU)
    
  • 2022-08-26 D-dimer 2846.63 ng/mL(FEU)
    
  • 2022-08-23 D-dimer 3582.31 ng/mL(FEU)
    
  • 2022-08-19 D-dimer 4672.59 ng/mL(FEU)
• In patients with VTE and cancer (cancer associated thrombosis [CAT]) there is a higher risk for recurrence as well as a higher risk for major bleeding than in patients with VTE without cancer. Because DOACs have not been compared head-to-head among patients with cancer, apixaban or LMWH may be the preferred option in patients with luminal GI malignancies who place higher value on avoiding GI major bleeding, whereas others may elect the convenience of oncedaily DOAC therapy (edoxaban or rivaroxaban). However, LMWH has the potential advantages of bypassing the GI system in patients with nausea or mucositis and may be more easily dose-adjusted in patients with thrombocytopenia due to cancer therapy.
  • ref: Stevens SM, et al. Executive Summary: Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021;160(6):2247-2259. doi:10.1016/j.chest.2021.07.056
  • Executive Summary - https://journal.chestnet.org/action/showPdf?pii=S0012-3692%2821%2901507-5
• Eliquis (apixaban) has been introduced since 2022-09-01. (Superior Vena Cava Syndrome suspected? 2022-08-17 CT).

701346860

220907

[objective]

• past history
  • DM(-), HTN(-)
  • Arrhythmia/tachycardia s/p ablative surgery at WanFang Hospital
  • Facial herpes zoster reactivation s/p medical therapy neurotin and methylcobalamin
  • Appendectomy and neck mass excision 40 years ago
• lab data
  • 2021-12-30 Anti-HBs 254.35 mIU/mL
    
  • 2021-12-30 Anti-HBc Reactive
    
  • 2021-12-30 Anti-HBc-Value 4.38 S/CO
    
  • 2021-12-30 HBsAg Nonreactive
    
  • 2021-12-30 HBsAg (Value) 0.68 S/CO
    
  • 2021-12-30 Anti-HCV Nonreactive
    
  • 2021-12-30 Anti-HCV Value 0.05 S/CO
• exam finding
  • 2022-07-15 CT - abdomen, pelvis
    • History: Endometrium serous adenocarcinoma, high grade, T1N0M0, stage I s/p Staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection) on 2021/12/22 s/p concurrent chemoradiotherapy
    • Findings:
      • 1. S/P hysterectomy.
      • 2. Disc space narrowing at L5/S1.
      • • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • Impression:
      • S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2022-02-24 Hearing Test
    • PTA, Pure-tone Audiometry
      • Reliability FAIR
      • Average R’t 23 dB HL // L’t 21 dB HL
      • Bil normal to moderately severe SNHL
  • 2022-01-27 KUB
    • Diffuse bowel dilatation with barium retention. Stationary.
  • 2022-01-21 KUB
    • Diffuse small bowel dilatation.
    • Retention of barium in the bowel loops.
  • 2022-01-19 Small intestine
    • Small bowel ileus.
    • The passage time is more than 24 hours.
  • 2022-01-02 CT - abdomen, pelvis
    • S/P hysterectomy. Small bowel ileus and the transtitional zone.
    • Distention of stomach.
  • 2022-01-02 EKG
    • Sinus rhythm with short PR
    • Nonspecific ST abnormality
  • 2021-12-22 Patho - uterus (with or without SO) neoplastic
    • Pathologic diagnosis
      • Uterus, endometrium, staging surgery — Serous carcinoma, high-grade
        
      • Uterus, myometrium, total hysterectomy
        • — Involved by serous carcinoma (< 1/2 thickness)
          
        • — Intramural myoma
          
      • Uterus, cervix, total hysterectomy
        • — Endocervix involved by tumor
          
        • — Cervical stromal not involvement
          
        • — Free of cervical margin
          
      • AJCC 8th edition Pathology stage: pT1aN0(if cM0); FIGO IA; AJCC stage IA
    • Microscopic Examination
      • Histology type: Serous carcinoma
        
      • Histology grade: High-grade
        
      • Depth of invasion: 2 mm (invade <1/2 thickness of the myometrial wall)
        
  • 2021-12-10 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, EM sampling — serous adenocarcinoma, high grade
    • IHC stains: p53 (aberrant type), WT-1 (+), CK20 (-), PAX-8 (-), ER (-, 0%), PR (-, 0%).
      
  • 2021-12-09 Gynecologic ultrasonography
    • Endometrial hyperplasia(EM:30.1mm), suspected endometrial malignancy
    • thickness of the posterior wall: 0.47cm
• consultation
  • 2022-01-20 General and Gastrointestinal Surgery
    • Q
      • This is a 71 y/o female, G5P3AA2 (NSD*3) with the past history of cardiac arrhythmia s/p ablative surgery. She is just discharged from our hospital due to endometrial cancer pT1aN0(if cM0); FIGO IA s/p staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection) on 2021/12/22 and subsequently admitted again due to post-operative ileus. However, she suffered from abdominal fullness since yesterday morning and had colicky abdominal pain. She recalled only eating pumpkin porridge yesterday morning. She vomited once this early morning at 2AM. She denied diarrhea, fever, coffee ground or bloody emesis. Because of the severe discomfort, she was brought to our ER. At the ER, KUB showed presence of ileus. Thus, primperan was given and she was kept on NPO. Due to the above problem, she is admitted for further management and close observation.
      • Abdominal to pelvis CT showed S/P hysterectomy. Small bowel ileus and the transtitional zone. Distention of stomach. As a result, we need your help and expertise for assessment and management of her ileus.
    • A
      • Assessment
        • Ms. Chen had been found with postoperative intestinal obstruction. Small bowel series disclosed small bowel obstructin.
      • Suggestion
        • Please keep NPO, iv fluid, and maybe NG decompression if vomiting
        • F/u KUB subsequently
        • Surgical intervention is preserved only if peritonitis or failed conservative treatment.
  • 2022-01-05 General and Gastrointestinal Surgery
    • Q
      • This is a 71 y/o female, G5P3AA2 (NSD*3) with the past history of cardiac arrhythmia s/p ablative surgery. This time, she is just discharged from our hospital due to endometrial cancer pT1aN0(if cM0); FIGO IA s/p staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection) on 2021/12/22. However, she suffered from abdominal fullness last night and felt nausea but did not vomit. She recalled only eating steamed bun and vegetables. Because of the severe discomfort, she was brought to our ER. At the ER, KUB showed presence of ileus. Blood exam showed mildly elevated WBC 11K, band form 1.9%, CRP 0.42. Empiric antbiotics of Brosym was given. Abdominal CT showed S/P small bowel ileus and distention of stomach. Thus, NG decompression (2150/day), dulcolax 1# prnq4h and primperan was given and she was kept on NPO use. Due to the above problem, she is admitted for further management and close observation.
    • A
      • Assessment
        • Mrs. Chen had received operation and discharged recently. However, intestinal obstruction is suspicious. PE showed soft palpation.
      • Suggestion
        • Please keep current treatment and f/u KUB subsequently
        • Conservative treatment at first
  • 2021-12-31 Radiation Oncology
    • S:
      • For postoperative radiotherapy due to serous carcinoma of the uterine endometrium.
      • PI: This 71-year-old woman, G5P3AA2, menopausal at 50 years old. She had history of cardiac arrhythmia s/p ablative surgery. MRI of pelvis (2021-12-13) showed lobulated tumor, 5.8cm in the uterine cavity (body), suspected endometrial malignancy . She then noted fresh red vaginal spotting again on 2021/12/17. She underwent staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection) on 12/22/2021.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM(-); HTN(-)
      • Allergy(-)
      • Travel hx(-)
      • Other disease: heart disease
      • Previous RT Hx: (-)
    • O:
      • ECOG: 0
      • PE: neck and bil SCF: neg; abdomen: a longitudinal surgical scar; bil low limbs: no edema.
      • MRI of pelvis (2021-12-13): Lobulated tumor, 5.8cm in the uterine cavity (body), suspected endometrial malignancy. Unremarkable change of the liver, spleen, pancreas and both kidneys. No enlarged lymph node in the paraaortic region. Minimal ascites in the pelvic cavity. Bulging disc at L5-S1. Impression: Lobulated tumor in the uterus, suspected endometrial malignancy. If proven malignancy, T1N0M0. Post-op proven endometrial malignancy.
      • CXR (2021-12-21): No active lung lesion. No cardiomegaly.
      • Operation (2021-12-22): Staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection)
      • Ascites (N2021-04522, 2021-12-23): neg.
      • Pathology (S2021-19117, 2021-12-28):
        • Uterus, endometrium, staging surgery — Serous carcinoma, high-grade.
        • Uterus, myometrium, total hysterectomy — Involved by serous carcinoma (<1/2 thickness) — Intramural myoma.
        • Uterus, cervix, total hysterectomy — Endocervix involved by tumor — Cervical stromal not involvement — Free of cervical margin.
        • AJCC 8th edition Pathology stage: pT1aN0(if cM0); FIGO IA; AJCC stage IA.
        • Lymphovascular Invasion: Present
      • CXR (2021-12-31): No active lung lesion. Normal heart size and contour. S/P port-A insertion via left subclavian vein.
    • A:
      • Serous carcinoma, high-grade, of the uterine endometrium, AJCC 8th edition Pathology stage: pT1aN0(cM0); FIGO IA; AJCC stage IA, s/p staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection).
    • P: Systemic therapy and vaginal brachytherapy is indicated for this patient with the following indicators: serous carcinoma, high-grade, of the uterine endometrium, stage: pT1aN0(cM0); FIGO IA
      • Goal: curative
      • Treatment target and volume: vaginal cuff mucosa surface
      • Technique: IVRT
      • Preliminary planning dose: 600cGy to vaginal cuff mucosa surface x 5 fractions by IVRT.
        
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and would like to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2022-1-21.
  • 2021-12-31 Hemato-Oncology
    • this 71 year old woman is a case of endometrium serous adenocarcinoma, high grade, pstageIA.
    • for invasive stageIA case, systemic therapy is indicated.
    • we will discuss with patient for systemic chemotherapy (self pay palitaxel 175mg/m2 + self pay carboplatin AUC target 6) Q3W.
    • arrange our OPD after discharge.
• surgical operation
  • 2021-12-22 Staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection)
• radiotherapy
  • 2022-02-22 ~ 2022-04-12 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa area by IVRT.
• chemoimmunotherapy
  • 2022-09-06 - paclitaxel 175mg/m2 210mg 3hr + carboplatin AUC 5 300mg 2hr
  • 2022-08-16 - paclitaxel 175mg/m2 210mg 3hr + carboplatin AUC 5 300mg 2hr
  • 2022-07-14 - paclitaxel 175mg/m2 210mg 3hr + carboplatin AUC 5 300mg 2hr
  • 2022-06-24 - paclitaxel 175mg/m2 210mg 3hr + carboplatin AUC 5 300mg 2hr
  • 2022-06-07 - paclitaxel 175mg/m2 210mg 3hr + carboplatin AUC 5 300mg 2hr (paclitaxel 240mg -> 210mg for leukocytopenia)
  • 2022-04-25 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 300mg 2hr
  • 2022-03-30 - cisplatin 40mg/m2 60mg 3hr (CCRT)
  • 2022-03-23 - cisplatin 40mg/m2 60mg 3hr (CCRT)
  • 2022-03-16 - cisplatin 40mg/m2 60mg 3hr (CCRT)
  • 2022-03-09 - cisplatin 40mg/m2 60mg 3hr (CCRT)
  • 2022-03-02 - cisplatin 40mg/m2 60mg 3hr (CCRT)
  • 2022-02-24 - cisplatin 40mg/m2 55mg 3hr (CCRT)

[assessment]

• Leukocytopenia is anticipated to be mitigated as a result of reducing the dosage of Paclitaxel and adding G-CSF.

220817

[assessment]

• There is no evidence of tumor recurrence found by 2022-07-15 CT.

220608

[assessment]

• According to lab results on 2022-06-02, WBC, RBC, and HGB were slightly lower, however this should not affect the chemotherapy.
• The D-dimer reading gradually decreased to near normal levels, which might be considered as a good sign
  • 2022-05-30 674.30 ng/mL(FEU)
  • 2022-05-05 774.52 ng/mL(FEU)
  • 2022-02-22 907.50 ng/mL(FEU)
  • 2022-02-15 1010.02 ng/mL(FEU)
  • 2022-01-21 1793.51 ng/mL(FEU)
  • 2022-01-08 3883.44 ng/mL(FEU)
• Chronic viral hepatitis B as well as constipation are currently treated with Baraclude (entecavir) and magnesium oxide, respectively.
• BP 141/68 (2022-06-07 15:50) -> 102/58 (2022-06-07 20:48), please keep track of its drop rate.

220426

[assessment]

• The patient has endometrial serous carcinoma of high grade, s/p surgery on 2021-12-22, and CCRT during late February to the end of March in 2022. She has been administered paclitaxel + carboplatin as of this hospital stay.
• The CBC and WBC results reported on 2022-04-20 and liver and kidney function, serum electrolytes reported on 2022-04-13 were grossly normal. Chronic viral hepatitis B is managed with Baraclude (entecavir) 0.5mg QDAC.
• For those with human epidermal growth factor receptor 2-overexpressing (HER2 data not found yet), addition of trastuzumab to current chemotherapy might be considered optionally.

700513871

220906

• exam finding
  • 2022-08-18 Fluid cytology - dialysate
    • after IP: 10cc, yellow, turbid
    • Smears show neutrophils, lymphocytes, and atypical, pleomorphic hyperchromatic cells.
    • Malignancy is favored.
  • 2022-08-15 Fluid cytology - dialysate
    • before IP: 13 cc, light-yellow, clear
    • Smears show necrotic debris, neutrophils, lymphocytes, and clusters of pleomorphic cells.
    • Malignancy is favored.
  • 2022-08-12 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2022-05-23 Fluid cytology - ascites
    • after IP C/T: adenocarcinoma, degenerated;
    • Many lymphocytes, mesothelial cells, and few degenerated adenocarcinoma cells present.
  • 2022-05-16 Patho - peritoneum biopsy
    • Peritoneum tumor, laparoscopic excision — Metastatic poorly-differentiated carcinoma
    • Microscopically, the sections shows a poorly-preserved specimen with almost crush artifact and only a few pleomorphic, patternless, well-preserved tumor cells, which immunohistochemistry of CK(-), PAX-8(+, focal), WT-1(-, cytoplasmic staining) and P53 does not have aberrant expression. However, PAX-8 IHC stain is mainly used for renal carcinoma, thyroid carcinoma and gynecologic carcinoma. According to radiologic findings, metastatic poorly-differentiated carcinoma with gynecologic origin should be first considered. Clinical correlation is advised.
  • 2022-05-11 Flow volume loop
    • moderate restrictive impairment
  • 2022-05-11 2D transthoracic echocardiography
    • 1. Sub-optimal echo window
    • 2. Normal AV with mild AR
    • 3. Normal MV with no MR
    • 4. Concentric LVH
    • 5. Preserved LV and RV systolic function
    • 6. Mild PR, mild TR, normal IVC size
  • 2022-05-10 Whole body PET scan
    • 1. A focal area of increased FDG uptake in the midline lower pelvic region about uterus. Malignancy of the uterus should be watched out. Please correlate with other clinical findings for further evaluation.
    • 2. Multiple glucose hypermetabolic lesions in the abdominal and pelvic cavities and a glucose hypermetabolic lesion in the midline anterior lower abdominal wall, compatible with multiple metastatic lesions. Please also correlate with other clinical findings for further evaluation.
  • 2022-05-09 Cell block
    • Peritoneal carcinomatosis with ascites.
    • The smears and cell block show lymphocytes, reactive mesothelial cells and some pleomorphic atypical cell clusters, suggestive of malignancy, but uncertain origin due to limited ICC stains. Immunocytochemistry shows PAX-8(-), WT-1(-, cytoplasmic staining), ER(-), CD10(-) and P53(+) for pleomorphic cell. Confirmatory biopsy is advised for further evaluation.
  • 2022-05-09 Gynecologic ultrasonography
    • 1. Suspected Ascites:(+)
    • 2. Endometrial thickening.(Em:2.14), endometrial (+fluid)
    • 3. Suspected endometrial mass
  • 2022-05-06 Patho - esophageal biopsy
    • Esophagus, 23cm below incisors, s/p biopsy — benign squamous mucosa with abundant granular cytoplasm, suggestive of glycogenosis.
  • 2022-05-06 Patho - colorectal polyp
    • Colon, descending colon, post Biopsy removal — Hyperplastic polyp
  • 2022-05-05 CT - liver, spleen, biliary duct, pancreas
    • Peritoneal carcinomatosis with ascites.
  • 2022-05-04 Fluid cytology - ascites
    • Smears show atypical hyperchromatic and pleomorphic tumor cells.
      
    • Malignancy is favored. Please correlate with the clinical presentation.
  • 2022-05-03 SONO - abdomen
    • Diagnosis
      • 1. Parenchymal liver diseae
      • 2. Ascites, moderate amount
      • 3. Hepatic cyst
    • Suggestion
      • abdominal paracentesis
  • 2018-03-31 CT - abdomen
    • Right UVJ stone (4.5mm) with obstructive uropathy. Right renal stones (2-4mm).
• consultation
  • 2022-05-20 Hemato-Oncology
    • Q
      • for neoadjuvant chemotherapy with IP + systemic
      • This 77 y/o female patient has the history of hypertension. This time, due to mild epigastric pain and abdominal fullness were noted. Abdominal sonography was done that showed ascites. Abdominal paracentesis was done and the analysis showed exudate; abdominal sonography showed 1.Prob. Liver cirrhosis 2.Ascites, moderate amount 3.hepatic cyst.
      • Abdominal CT showed Peritoneal carcinomatosis with ascites. Ascites cytology showed Smears show atypical hyperchromatic and pleomorphic tumor cells. Malignancy is favored. Further whole body PET was performed and showed 1) A focal area of increased FDG uptake in the midline lower pelvic region about uterus. Malignancy of the uterus should be watched out. Please correlate with other clinical findings for further evaluation. 2) Multiple glucose hypermetabolic lesions in the abdominal and pelvic cavities and a glucose hypermetabolic lesion in the midline anterior lower abdominal wall, compatible with multiple metastatic lesions. Please also correlate with other clinical findings for further evaluation.
      • Laparoscopic exam was performed on 20220516 and operation finding showed peritoneal carinomatosis including 4 quadrant and small bowel mesentry. PCI: 13/39. laparoscope intraabdominal tumor excision with biopsy was performed and pathology pending. We need your help for further management for neoadjuvant IP + systemic chemotherapy. Thanks for your time!!
    • A
      • Impression:
        • 1. Peritoneal carcinomatosis and malignant ascites, origin unkown, s/p laparoscope intraabdominal tumor excision, PD tube inserted and Port-A insert on 20220516
        • 2. HTN
      • Suggestion:
        • 1. Keep best supportive care and nutrition support.
        • 2. Pending pathology result. We will discuss with patient about further neoadjuvant IP + systemic chemotherapy.
        • 3. Thanks for your consultation. We wound like to follow up this case. If there is any problem, please feel free to let us known.
  • 2022-05-09 Obstetrics and Gynecology
    • Q
      • Tumor maker with CA 125 showed 476.8 U/ml. So we need you evaluation and suggestion of this patient.
    • A
      • S
        • 77 y/o, female, G2P2(C/S)
        • Hx: Admitted due to abdominal fullness
      • O:
        • CA125: 485
        • sono: uterus: AVF: 57x37mm, endometrial mass 20x19mm, EM:21.4mm
        • bilaterla adnexa free
        • Abdominal CT showed Peritoneal carcinomatosis with ascites.
        • Ascites cytology showed Smears show atypical hyperchromatic and pleomorphic tumor cells.
      • IMP:
        • Peritoneal carcinomatosis and malignant ascites, origin unknown
      • P:
        • Please informed us the result of cell block
  • 2022-05-06 Obstetrics and Gynecology
    • A
      • CT of pelvis/abdomen report not mention about GYN lesion
      • no adnexa mass; UT : myoma?
      • might check CEA/CA125/CA199 first
      • suggest ascites sent for cell block to check the origin of malignancy
      • Please connect us, if GYN origin likely by cell block, thank you.
• chemoimmunotherapy
  • 2022-09-06 - paclitaxel 50mg/m2 80mg IVD 3hr + carboplatin AUC 2 100mg IVD 2hr + docetaxel 30mg/m2 40mg IP 1hr + carboplatin 100mg IP 1hr + gentamicin 40mg IP + NaHCO3 70mg/mL 40mL IP
  • 2022-08-16 - paclitaxel 50mg/m2 87mg IVD 3hr + carboplatin AUC 2 100mg IVD 2hr + decetaxel 30mg/m2 40mg IP 1hr + carboplatin 100mg IP 1hr + gentamicin 40mg IP + NaHCO3 70mg/mL 40mL IP
  • 2022-06-17 - paclitaxel 50mg/m2 87mg IVD 3hr + carboplatin AUC 2 100mg IVD 2hr + decetaxel 30mg/m2 40mg IP 1hr + carboplatin 100mg IP 1hr + gentamicin 40mg IP + NaHCO3 70mg/mL 40mL IP
  • 2022-05-19 - paclitaxel 50mg/m2 87mg IVD 3hr + carboplatin AUC 2 120mg IVD 2hr + decetaxel 30mg/m2 40mg IP 1hr + carboplatin 120mg IP 1hr + gentamicin 40mg IP + NaHCO3 70mg/mL 40mL IP

[assessment]

• 2022-09-05 creatinine 2.62, CrCl 15mL/min, eGFR 18.8.
• febuxostat for patient with CrCl <30 mL/minute: Initial: 20 to 40 mg once daily (manufacturer’s labeling; expert opinion). Observational studies in patients with hyperuricemia have reported safety and tolerability of 60 and 80 mg/day; a careful titration may be considered in patients unresponsive to standard doses. The recommended dose is 0.5# (40mg) QD if no other clinical considerations exist.
• entecavir for patient with CrCl 10 to <30 mL/minute: Administer 30% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 72 hours. There is no urgent need to adjust the dosage of Baraclude as it is currently prescribed as 0.5mg 1# QOD.
• furosemide for patient with eGFR <=30 mL/minute/1.73m2: Higher doses may be required to achieve desired diuretic response due to decreased secretion into the tubular fluid. However, single doses >160 to 200 mg IV (or oral equivalent) are unlikely to result in additional diuretic effect

220815

[assessment]

• As a result of renal impairment, drug doses have been adjusted. There is no issue with active prescription.

700563751

220906

• diagnosis
  • 2022-09-02 discharge
    • 1: suspect left breast cancer with left axillary LNs and hepatic metastases
    • 2: Dyspnea, unspecified
• lab data
  • HBV, HCV
    • 2022-09-02 HBsAg (NuMe) Negative
      
    • 2022-09-02 HBsAg Value (NuMe) 0.443
      
    • 2022-09-02 Anti-HCV (NuMe) Negative
      
    • 2022-09-02 Anti-HCV Value (NuMe) 0.0345
      
    • 2022-09-01 HBsAg Nonreactive
      
    • 2022-09-01 HBsAg (Value) 0.25 S/CO
      
    • 2022-09-01 Anti-HCV Nonreactive
      
    • 2022-09-01 Anti-HCV Value 0.09 S/CO
      
    • 2022-08-30 Anti-HBc Nonreactive
      
    • 2022-08-30 Anti-HBc-Value 0.95 S/CO
• exam finding
  • 2022-09-02 Patho - breast biopsy
    • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 40%, intermediate intensity), PR(-, 0%, ), Her2/neu: positive (score=3+), Ki-67(25 %), CK5/6 (-), p63 (-).
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2022-09-02 SONO - breast
    • Left breast tumor with diffuse microcalcifications, suspected malignancy, suggest biopsy.
    • Enlarged left axillary lymph nodes, suspected metastatic lymph nodes.
    • BI-RADS: Category 5: highly suggestive of malignancy - appropriate action should be taken.
  • 2022-09-02 Mammography
    • Left breast microcalcifications with axillary lymph nodes, suspected malignancy with lymph nodes metastasis.
    • BI-RADS: Category 5: highly suggestive of malignancy - appropriate action should be taken.
  • 2022-09-01 Patho - stomach biopsy
    • Stomach, low body, biopsy — Chronic gastritis, H pylori present
  • 2022-09-01 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p random biopsy at low body, GC
  • 2022-08-30 CTA - chest
    • indication
      • Dyspnea for 2 wks
    • findings
      • Lung: a suspect ground-glass nodule at posterior RUL (5mm) and a lobular opacity at peripheral of LUL
      • Chest wall and visible lower neck: small and enlarged LNs at Lt axilla. abnormal enhancing mass in left breast. a well-defined Rt thyroid nodule 10mm
      • Visible abdominal contents: mild ascities at RUQ of abdomen. hepatomegaly with ill-defined hypodense lesions in both lobes.
    • impression
      • Lt breast cancer with left axillary LNs and hepatic metastases.
      • no pulmonary embolism.
      • LUL lobular opacity and RUL GGO 5mm, nature to be determined, suggest follow up. (GGO: ground glass opacity)
  • 2022-08-30 ECG
    • Sinus tachycardia
    • Possible Left atrial enlargement
  • 2022-08-30 CXR
    • Atherosclerotic change of aortic arch

[assessment]

• There is no anti-HBc test result available yet, HBV immune status remains unknown. ( https://med.stanford.edu/content/dam/sm/liver/documents/resources/guides/cdc_pub.pdf )
• The immunization of susceptible patients should be strongly considered at the time of cancer diagnosis. (ref: Torres HA, etc. Reactivation of hepatitis B virus and hepatitis C virus in patients with cancer. Nat Rev Clin Oncol 2012; 9:156-66; PMID:22271089; http://dx.doi.org/10.1038/nrclinonc.2012.1 )
• All unvaccinated patients with cancer aged 19 to 59 years and those >=60 years old with risk factors (eg, diabetes mellitus, chronic liver disease, hepatitis C, hemodialysis, and other risk factors) should receive the hepatitis B vaccine. (ref: Murthy N, etc. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(7):229-233. Published 2022 Feb 18. doi:10.15585/mmwr.mm7107a1 ). As with other vaccines, cancer patients may have suboptimal response to the hepatitis B vaccine. Regimens that include doubling the standard antigen dose or administering additional doses may increase response rates but, given the limited data with these alternative regimens, this approach cannot be routinely recommended.

700137025

220905

• exam finding
  • 2022-09-02 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 28) / 93 = 69.89%
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Mild TR and moderate sclerotic AS (TR = tricuspid regurgitation; AS = aortic stenosis)
  • 2022-08-20 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/P NG tube placement.
    • Osteopenia of the bony structure is noted.
    • Increased pulmonary vasculature is found.
  • 2022-08-18 Patho - colorectal polyp
    • Intestine, large, hepatic flexure to A-colon, biopsy— signet ring cell carcinoma
    • Microscopically, it shows signet ring cell carcinoma composed of proliferation of malignant tumor cells arranged in solid architecture, and signet-ring cell diffferentiation.
    • Immunohistochemical stain— EGFR(+), MLH1(+), MSH2(+), MSH6(+), PMS2(-)
  • 2022-08-17 Colonoscopy
    • Diagnosis
      • Colon ulcerative mass, hepatic flexure to A-colon, s/p biopsy
      • Pseudopolyps, T-colon
      • Melanosis coli
      • Internal hemorrhoid
    • Suggestion
      • Please pursue pathology report
    • Complication
      • No immediate complication
  • 2022-08-16 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Ulcer with chronic inflammation, H pylori NOT present
  • 2022-08-13 CT - abdomen, pelvis
    • Imaging Report Form for Colorectal Carcinoma
    • Impression (Imaging stage): T:4a(T_value) N:1b(N_value) M:____(M_value) STAGE:IIIB(Stage_value)
  • 2022-08-13 CXR
    • 1. Unremarkable change in the visible trachea
    • 2. Normal cardiac size; mediastinal widening
    • 3. Lung markings: small patches in the left upper lung field and right middle lung fields.
    • 4. Normal bilateral hemidiaphrams
    • 5. Blunting bilateral costophrenic angles
    • 6. Unremarkable change in bilateral clavicles
  • 2022-07-26 CT - brain
    • No acute infarct, No ICH. Brain atrophy. Atherosclerosis.
  • 2022-07-26 ECG
    • Normal sinus rhythm
    • Incomplete right bundle branch block
    • Borderline ECG
  • 2022-07-13 Percutaneous transluminal angioplasty, PTA
    • clinical diagnosis:
      • AVF dysfunction
    • Indication
      • The patient was referred with swelling of left arm and left forearm. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
    • Approach
      • Percutaneous access was performed through the av shunt fistula where a 6F sheath was inserted.
    • Procedure
      • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 50cc. The patient was treated with dormicum (Dosage=1.5 mg).
    • Finding Summary
      • Left Radio cephalic AVF, draining axillary vein : 91% stenosis. AV fistula.
      • Left Radio cephalic AVF, draining basilic vein : 75% stenosis. AV fistula.
    • Intervention Summary
      • Left Radio cephalic AVF, draining axillary vein, Pre-DS = 91%
        • MLD/RVD=0.65/7.18 mm → 6.08/7.13 mm, Post-DS = 15%.
        • Guide Wire: Terumo Radifocus 0.035 150cm.
        • Balloon: Boston Mustang. 8.0 X 60 mm. Pressure: 8 atmospheres.
      • Left Radio cephalic AVF, drainig basilic vein, Pre-DS = 75%
        • MLD/RVD=1.69/6.87 mm → 6.31/6.84 mm, Post-DS = 8%.
        • Guide Wire: Terumo Radifocus 0.035 150cm.
        • Balloon: Bard Conquest. 7.0 X 40 mm. Pressure: 6 atmospheres.
    • In conclusion :
      • 1. S/P PTA for left radiocephalic AVF, draining axillary vein, successful, from 91% to 15% residual stenosis
      • 2. S/P PTA for left radiocephalic AVF, draining basilic vein, successful, from 78% to 5% residual stenosis
  • 2022-07-11 MRA - brain
    • Brain atrophy.
  • 2022-07-11 CXR
    • Elevation of both hemidiaphragms
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • mild enlarged cardiac silhoutte due to prominent pericardial fat/ prominent cardiophrenic angle mediastinal fat pad
    • Clean lung fields based on plain image
    • Costophrenic angles are preserved
    • marginal spurs of multiple vertebral bodies
    • Joint space narrowing at bilateral glenohumeral joints, may be inflammatory arthritis
  • 2022-07-11 CT - brain
    • Brain atrophy. Atherosclerosis.
  • 2022-06-24 Peropheral Vascular Test - AV fistula
    • clinical diagnosis: AVF dysfunction
    • 1. Access type: Native
    • 2. Site:Left radiocephalic AVF
    • 3. Clinical problem: Swelling of left forearm and left arm
    • 4. Age of vascular access:
    • 5. Result:
      • The venous Duplex study revealed a left radiocephalic AVF. The cephalic veinw as patent, with aneursymal dilatation at the cannulation sites. The venous diameter at A cannulation site and V cannulation site were 21.5mm and 14.7~10.2mm. Upstream draining basilic vein was patent. Upstream draining cephalic vein at left arm level was patent but with vessel tortousity.
      • The estimated flow volume measuerd at the feeding radial artery was 877 ml/min.
      • The measured MVO/SVC ratio at right amr level was 100%, indicated no significant right central vein stenosis or occlusion.
        • Right side:
          • SVC: 1.3 mmHg ;
          • MVO/SVC: 100 % ;
      • Suggestion:
        • Left central vein stenosis or oclusion is highly suspected according to the physical examination and clinical presentation.
        • IV DSA and PTA prn is recommended. However, her family refused further IV DSA study.
    • 6. Suggestion: PTA
  • 2022-06-13 CXR
    • Cardiomegaly and tortuosity of the thoracic aorta.
    • Widening of the mediastinum.
    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
    • Osteopenic change.
  • 2022-03-26 CXR
    • Elevation of both hemidiaphragms may be due to expiratory phase.
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • mild enlarged cardiac silhoutte due to prominent pericardial fat/ prominent cardiophrenic angle mediastinal fat pad
    • Clean lung fields based on plain image
    • Costophrenic angles are preserved
    • marginal spurs of multiple vertebral bodies
  • 2022-01-08 ECG
    • Sinus rhythm with sinus arrhythmia with occasional Premature ventricular complexes
    • Otherwise normal ECG
  • 2021-12-01 CT - abdomen
    • History and Indication: 89 y/o, 2021/11/29 coming here due that she is told to have abnormal liver fucntion test with elevated ALP & GGT, so request CT study
    • Hx of ESRD on HD since 2007-05-09
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • 1. There is asymmetrical wall thickening at distal ascending colon, near hepatic flexure, that may be adenocarcinoma. Please correlate with colonoscopy.
      • 2. Both kidney show small size and thin parenchyma that are c/w ESRD.
      • 3. Two small gallstones are noted.
      • 4. The liver shows mild irregular contour that may be early cirrhosis? please correlate with clinical condition.
      • 5. Compression fracture of L1 vertebral body. Mild Disc space narrowing with marginal osteophyte formation and vacuum phenomenon from L2 to S1.
      • 6. Hyperplasia of bilateral adrenal gland are noted.
      • 7. There is no focal abnormality in the biliary system, pancreas, and spleen.
           
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel obstruction.
          
        • The abdominal aorta and IVC are grossly unremarkable.
          
        • There is no evidence of intrinsic or extrinsic bladder mass.
          
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Adenocarcinoma of the distal ascending colon is suspected. Please correlate with colonoscopy.
  • 2021-10-22 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • GB polyps
      • C/W ESRD
      • Fatty infiltration of pancreas
      • Suboptimal exam of liver due to poor echo window
    • Suggestion
      • Please correlate with other image study and clinical condition
      • Regular f/u
  • 2021-05-07 CT - coronary artery calcium socre, without contrast
    • Nonenhanced ECG-gated CT for calcium scoring was obtained using 64-slice multidetector row CT scanner showed:
      • 1. Calcification of the coronary arteries. (LAD＝17, LCX＝4, RCA＝55). Total calcium score＝76
      • 2. Unremarkable of the pericardium.
      • 3. The heart size is normal. Calcified aortic valve and mitral valve is found.
      • 4. The visible lung fields are intact.
      • 5. There is no evidence of mediastinal LAP at visible field.
      • 6. Patent airway at the examing field.
  • 2021-05-03 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (73 - 19) / 73 = 73.97%
    • 1. Normal LV systolic function with normal wall motion.
    • 2. Concentric LVH; LV diastolic dysfunction Gr 1.
    • 3. Normal RV systolic function.
    • 4. Aortic valve calcification with moderate AS (AVA(Doppler) = 1.07 cm² , Mean aortic pressure = 10 mmHg), mild AR; mild MR; mild TR; mild PR
      • Note: Aortic regurgitation (AR); Pulmonary regurgitation (PR); Mitral regurgitation (MR); Tricuspid regurgitation (TR)
  • 2021-02-10 Pure Tone Audiometry, PTA
    • Tymp:
      • R’t perforation; L’t type A.
    • ART:
      • R’t ipsi CNT, contra absent.
      • L’t ipsi absent, contra CNT.
    • PTA
      • Reliability FAIR
      • Average RE 85 dB HL; LE 41 dB HL.
      • R’t moderately severe to profound mixed type HL.
      • L’t mild to moderately severe SNHL.
  • 2021-02-05 CT - brain
    • Brain atrophy. Suspected empty sella.
  • 2021-02-01 Myocardial perfusion SPECT with persantin
    • 1. Probably normal variant or mild stress-induced ischemia in apical anteroseptal wall, basal inferior wall, and basal inferoseptal wall of LV.
    • 2. No post-stress dilatation of LV.
  • 2020-10-30 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (51.9 - 14.4) / 51.9 = 72.25%
    • 1. Eccentric LVH.
    • 2. Normal RV & LV systolic function. No regional wall motion abnormalities.
    • 3. Impaired LV relaxation.
    • 4. Calcified aortic valve, with moderate aortic stenosis (AVA 1.16 cm2).
    • 5. Mild tricuspid regurgitation.
  • 2019-02-11 Doppler flowmetry - perivasculary
    • 1. Access type: native
    • 2. Site: left AVF
    • 3. Clinical problem: difficult to gain hemostasis
    • 4. Age of vascular access:
    • 5. Result:
      • Left radiocephalic fistual with aneurysmal dilatation at arterial and vein cannulation site
      • Vessel size =16-18.4 mm, outflwo cephalic vein at forearm is very tortuous and duplicated ,
      • Vein cannulation site = 10.2-10.9 mm, juxta-area =6.8 mm , only small draining vein at cephalci vein junction
      • Estiamted volume flow from feeding brachial artery =1250-1320 ml/min
      • Adjust needle cannulation site
    • 6. Suggestion: Clinical follow up
  • 2019-01-02 Bone densitometry - spine
    • L-spines BMD (AP view) performed by DXA revealed:
      • AP L-spines, BMD of L1-4 0.757 gms/cm2, about 2.4 SD below the peak bone mass (74%) and 0.4 SD above the mean of age-matched people (110%).
      • Other detailed data described in the attached reports.
    • IMP: osteopenia
  • 2018-02-14 Doppler color flow mapping, M-mode Echo
    • 1. Normal chamber size
    • 2. Normal LV and RV contractility
    • 3. Impaired LV relaxation
    • 4. Aortic valve calcification with mild AS
• consultation
  • 2022-09-02 Nephrology
    • Q
      • for H/D QW 2.4.6
      • This 89-year old woman, a patient of A- colon of signet ring cell carcinoma, Immunohistochemical stain — EGFR(+), MLH1(+), MSH2(+), MSH6(+), PMS2(-). She was admitted for staging work-up. We need expertise to evaluate her condition thanks!
    • A
      • We will arrrange HD QW246.
      • Please prescribe EPO 5000U QW4 if Hb <11.
  • 2022-08-18 Oral and Maxillofacial Surgery
    • Q
      • She was admitted for suspect UGIB (Upper Gastrointestinal Bleeding). This time, for loose upper dentures. So we need you evaluation and suggestion of this patient.
    • A
      • For evaluation of mobility of upper bridge
      • Hx:
        • 1. epilepsy 2. ESRD 3. HCVD 4. Parkinsonism 5. Hypothyroidism.
      • O:
        • 1. Mibility of 12xx22 was noted.
        • 2. Poor cooperation was noted.
        • 3. Poor oral hygiene was noted.
      • A: Periodontitis of tooth 12, 22
      • P:
        • 1. Explain the current finding to patient
        • 2. Suggest reevulation of extraction on OPD after her general condition is stable.
  • 2022-08-15 Nephrology
    • Q: Regular HD day 2,4,6 was noted, we need your evaluation and arranged Hemodialysis
    • A: We will arrrange HD QW246. Please prescribe EPO 5000U qW4 if Hb <11.

[assessment]

• Evista (raloxifene) might decrease the absorption of Eltroxin (levothyroxine). It is recommended to shift Evista from QD to QL or QN. Or monitor for reduced effects of levothyroxine (ie, signs and symptoms of hypothyroidism) and reduced serum concentrations of thyroxine if raloxifene and levothyroxine are concomitantly administered.
• Takepron (lansoprazole) should not be ground, but soaked in water and tube-fed with small granules.
• Keppra (levetiracetam) could be administered 500 mg to 1 g every 24 hours (currently 250mg BID in active prescription); a supplemental dose of 250 to 500 mg is recommended post each hemodialysis session (currently HD QW246). (ref: Bahte SK, Hiss M, Lichtinghagen R, Kielstein JT. A missed opportunity - consequences of unknown levetiracepam pharmacokinetics in a peritoneal dialysis patient. BMC Nephrol. 2014;15:49. doi:10.1186/1471-2369-15-49.)
• Midodrine 2mg QW246 is used to prevent hypotension caused by hemodialysis; the patient’s blood pressure during this hospitalization was essentially acceptable.

700912048

220905

• exam finding
  • 2022-08-01 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Compatible with sarcomatoid carcinoma with nearly total tumor necrosis
    • The sections show sheets of spindle to polygonal tumor cells with pleomorphic nuclei and nearly total tumor necrosis.
    • IHC shows following features: CK(-), CK7(-), Vimentin(+), Hepatocyte(-) and Arginase-1(-).
  • 2022-07-27 CT - abdomen
    • Findings:
      • 1. There are several poor enhancing masses on both hepatic lobes and the largest one measuring 7.1 cm in S2/3.
        • HCCs are highly suspected.
        • The differential diagnosis include cholangiocarcinoma.
        • There are filling defects in the right atrium, IVC, left hepatic vein, both lobes and main trunk portal vein, splenic vein, and superior mesenteric vein that may be tumor thrombosis?
      • 2. The liver shows irregular contour and atrophy of segment 4 that is consistent with cirrhosis.
        • A hepatic cyst measuring 1.5 cm in S6 is noted.
      • 3. S/P cholecystectomy, splenectomy and hysterectomy.
    • Impression:
      • HCCs on both hepatic lobes are highly suspected.
      • The differential diagnosis include cholangiocarcinoma.
      • Biopsy is indicated.
      • There are filling defects in the right atrium, IVC, left hepatic vein, both lobes and main trunk portal vein, splenic vein, and superior mesenteric vein that may be tumor thrombosis?
  • 2022-07-25 SONO - abdomen
    • Hepatic tumors, bilateral lobes, suspected HCC
    • Hepatic cyst, right lobe
    • Parenchymal liver disease
    • Main portal vein and splenic vein thrombosis
  • 2022-01-25 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2021-12-16 Polysomnography, PSG
    • Conclusion:
      • RDI: 40.6/hr
      • 1. Severe obstructive sleep apnea syndrome with moderate desaturation during sleep.
      • 2. Sleep efficiency: poor
    • Suggestion:
      • 1. CPAP is indicated for this case, pressure: 9cmH2O
  • 2021-11-07 Polysomnography, PSG
    • Conclusion:
      • RDI: 40.6/hr
      • 1. Severe obstructive sleep apnea syndrome with moderate desaturation during sleep.
      • 2. Sleep efficiency: poor
    • Suggestion:
      • 1. Refer to ENT/OS for upper airway evaluation.
      • 2. Non-Supine position would be better
      • 3. Evaluate heart function.
      • 4. Body weight reduction.
      • 5. CPAP is indicated for this case
  • 2021-10-29 CXR
    • elongated and tortuosity of thoracic aorta
    • moderate enlarged cardiac silhoutte due to prominent pericardial fat/prominent mediastinal fat pad
  • 2021-03-09 Cardiac Catheterization
    • In conclusion
      • 1. Patent coronary artery
      • 2. LVEF 77.5% and LVEDP 28mmHG, favor diastolic heart failure.
    • Recommendation
      • DC anti-PLT agent.
  • 2021-02-05 Myocardial perfusion SPECT with persantin
    • 1. Probably moderate to severe myocardial ischemia at the anteroapical wall and anteroseptal wall.
    • 2. Mild reverse redistribution of radioactivity to the lateral wall, either normal variant or myocardial ischemia may show this picture.
  • 2021-01-21 2D transthoracic echocardiography
    • 1. Adequate LV systolic function with normal resting wall motion
    • 2. Dilated LA, concentric LVH; diastolic dysfunction, Gr 1
    • 3. Trivial MR, trivial TR and trivial PR
    • 4. Mild pulmonary hypertension
    • 5. Preserved RV systolic function
  • 2021-01-19 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy or dysplasia.
    • IHC stains: CD117: 1%, CD34: 1%. MPO: 40-50%, CD61: 2-5%; CD71: 25-30%.
  • 2019-09-16 SONO - abdomen
    • poor echo window: please see discription
    • fatty liver, moderate (incomplete exam of liver)
    • poor visualization of pancreas/spleen/ vessels
    • GB sac not seen
  • 2019-08-13 SONO - abdomen
    • Fatty liver, mild
    • Hepatic cyst
    • Invisible GB
    • Pleural effusion, left
    • Minimal left subphrenic fluid collection, post drainage
    • Pancreas not shown
  • 2019-08-07 CT - abdomen
    • Left pleural effusion with adjacent lung collapse.
    • S/P splenectomy.
    • An encapsulated fluid collection (5.8x9.7cm) at left subphrenic region.
  • 2019-08-06 Echo for abdomen
    • Fatty liver, mild
    • Fluid collection, LUQ of abdomen
    • Pleural effusion, left
    • Hepatic cyst
    • Postcholecystectomy
  • 2019-08-06 Doppler color flow mapping, M-mode Echo
    • Septal hypertrophy. Dilated LA.
    • Normal RV & LV systolic function. No regional wall motion abnormalities.
    • Impaired LV relaxation.
    • Mild mitral regurgitation.
    • Mild tricuspid regurgitation.
  • 2019-05-17 Surgical Pathology Level IV
    • clinical diagnosis
      • Splenomegaly; Thrombocytopenia, unspecified; Unspecified endocrine disorder; Corticoadrenal insufficiency;
    • pathologic diagnosis
      • Bone marrow, biopsy— negative for malignancy
    • Microscopically, it shows normal cellularity (50%), 2:1 of M:E ration, mature trilineage compnents and presence of occasional megakaryocytes.
    • Immunohistochemical stain reveals CD34(-), CD117(-), MPO(+), CD61(focal+) and CD71(+).
  • 2018-09-28 Surgical Pathology Level III
    • clinical diagnosis
      • Caculus of gallbladder with acute cholecystitis without mention of obstruction;
    • pathologic diagnosis
      • Gallbladder, laparoscopic cholecystectomy —- Chronic cholecystitis and cholelithiasis
    • Section shows gallbladder mucosal tissue with invaginated sinus mucosa, marked chronic inflammation and pigmented stone fragments.
  • 2018-07-23 Multiple Sleep Test
    • diagnosis
      • mild OSAS (AHI 14)
    • suggest
      • lateral posture during sleeping
      • body weight reduction
      • f/u PSG one year later
  • 2018-06-21 H Reflex
    • Comments
      • MNCV: normal
      • SNCVL normal
      • F-wave: normal
      • H-reflex: normal.
    • Conclusion
      • This is a normal lowerl limb NCV study.
      • Please correlate with clinical features.
  • 2018-05-29 Sialoscintigraphy
    • Impression
      • 1. Normal uptake function of bilateral parotid glands and impaired uptake function of bilateral submandibular glands.
      • 2. The tracer excretion after acid stimulation was fair to good at four main salivary glands.
    • Comment
      • Salivery gland uptake: normal > 0.25%, 0.2%–0.25% (mild), 0.15% - 0.2% (moderate), 0.1%-0.15% (marked), and <0.1% (severe).
  • 2018-05-24 SONO - abdomen
    • Diagnosis
      • Fatty liver,severe
      • Propable chronic liver parenchymal disorders (Please correlate with liver function test)
      • Suspected GB stone
      • Splenomegaly
      • Suboptimal examination of liver due to poor echo window caused by liver
      • Fatty change
    • Suggestion
      • OPD f/u
      • Please correlate with other image
      • Follow liver function test and AFP
      • Part of liver,especially liver dome was diffcult of approach
      • Because of fatty liver change and poor echo window,infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
• consultation
  • 2022-08-03 General and Gastrointestinal Surgery
    • Q
      • The 57 y/o woman has IPT s/p sleenectomy and cholangiocarcinoma was diagnosis this time, due to massive thrombosis (CT: filling defects in the right atrium, IVC, left hepatic vein, both lobes and main trunk portal vein, splenic vein, and superior mesenteric vein that may be tumor thrombosis.) and protal vein thrombosis, so we need your help for surgical assessment.
    • A
      • S: The 57 y/o woman has IPT /p sleenectomy on 1080725 and cholangiocarcinoma was diagnosis this time, due to massive thrombosis (CT: filling defects in the right atrium, IVC, left hepatic vein, both lobes and main trunk portal vein, splenic vein, and superior mesenteric vein that may be tumor thrombosis.) and protal vein thrombosis. Surgical intervention is consulted.
      • O: vital signs: stable, no fever
        • abdomen: soft, flat, normal bowe sound, no tenderness
      • A: bilateral liver cholangiocarcinoma with IVC and Portal vein thombosis,
      • P: Surgical intervention is not suggested due to impossible en-bloc resection
  • 2022-07-28 Radiation Oncology
    • Q
      • for arrange CT quiding liver biopsy
      • This is a 57-year-old woman with past medical hostories of: 1) Adrenocortical insufficiency; 2) Hypertensive heart disease with heart failure; 3) Idiopathic Thrombocytopenic Purpura s/p splenectomy; 4) Type 2 DM; 5) COPD; 6) Type 2 DM; 7) Severe obstructive sleep apnea syndrome with moderate desaturation during sleep.
      • She regular at chest/CV/Meta/Oncology OPD follow up.
      • This time, she suffered from poor appetite, body weight loss about 10Kg/6 months. She visited to our Chest OPD regular follow up. Blood test was done that showed abnormal liver functions. She was refer to our GI OPD for management. At GI OPD, hepatitis markers with HBsAg, Anti HCV were follow up that showed negative finding. Autoimmune hepatitis profile with IgG, ANA, ASMA, AMA, IgG4 that showed ANA 1:160. Abdominal sonography was performed which revealed hepatic tumors, bilateral lobes, suspected HCC; hepatic cyst, right lobe; parenchymal liver disease and main portal vein and splenic vein thrombosis. Explained this condition to herself, she understood. Under the impression of Suspect HCC. She was admitted to our GI ward for management and further survey.
        
      • Now, due to abdominal CT showed suspect HCCs on both hepatic lobes with right atrium, IVC, left hepatic vein, both lobes and main trunk portal vein, splenic vein, and superior mesenteric vein thrombosis. The differential diagnosis include cholangiocarcinoma.
      • We need your further survey for liver biopsy.
    • A
      • According to the clinical condition and imaging findings, biopsy is indicated.
  • 2022-07-28 Dermatology
    • Q
      • After admission, she complained about severe lower legs redness (LMD diagnosis: Vasculitis) but now symptoms intensify. Now, we need your further survey. Thanks a lot!!!
    • A
      • This patient suffered from brownish patches on bil legs for months.
      • Imp: Stasis Dermatitis
      • Suggestion:
        • 1. Sinpharderma 1 tube/bid
        • 2. Topsym cream 4 tubes/bid

220804

[assessment]

• Patients with acute portal vein thrombosis should be started on low molecular weight heparin to achieve rapid anticoagulation, with a switch to an oral anticoagulant (warfarin or possibly a direct-acting oral anticoagulant [DOAC]) once the patient’s condition has stabilized and no invasive procedures are planned.

• Patients with chronic portal vein thrombosis when treated with anticoagulation, enoxaparin is more often used rather than warfarin because of its shorter duration of action, less variability in anticoagulation, decreased need for monitoring, and decreased difficulty when managing patients around the time of liver transplantation. An alternative is to use an oral anticoagulant.

• If warfarin is used, goal INR can be set as 2 to 3. (2022-08-03 INR 1.24)

• Enoxaparin (in active prescription now) used for venous thromboembolism treatment in patients with active cancer:

  • Months 1 to 6: SUBQ: Initial: 1 mg/kg every 12 hours (this patient is 80 kgw => 80mg Q12H) or 1.5 mg/kg once daily (120mg QD; now 60mg Q12H in active prescription) for a total duration of 3 to 6 months. Twice-daily dosing may be more efficacious than once-daily dosing based on post hoc data (60mg Q12H is better than 120mg QD).
  • Maintenance beyond 6 months: considering continuing anticoagulation beyond 6 months in select patients due to the persistent high risk of recurrence in those with active cancer; consider risk versus benefit of bleeding and recurrence.
  • No issue with active prescription.

• Direct oral anticoagulant (DOAC) therapy is an alternative to enoxaparin or warfarin for treating chronic portal vein thrombosis.

  • The patient has good renal function (2022-08-03 Cre 0.53, eGFR 126), so, except for edoxaban (CrCl >95 mL/minute: edoxaban use is not recommended due to increased risk of ischemic stroke compared to warfarin), any of dabigatran, rivaroxaban, apixaban, or betrixaban might be a candidate for treatment.
  • In the case of Child-Pugh B or C, both rivaroxaban and betrixaban are contraindicated, so dabigatran or apixaban might be a better alternative, even if the patient has a slightly deteriorated liver function. (reference: https://www.ahajournals.org/doi/10.1161/JAHA.120.017559 )
  • Dabigatran has not been studied in patients with active cancer (ACCP [Stevens 2021]; ASCO [Key 2020]).
  • Apixaban might be used in patients with active cancer (eg, metastatic disease or receiving chemotherapy) (ACCP [Stevens 2021]; Agnelli 2020; Leader 2020; McBane 2019).

• Apixaban oral 10 mg twice daily for certain duration followed by 5 mg twice daily.

  • Optimal duration of therapy is unknown and is dependent on many factors, such as presence of provoking events, patient risk factors for recurrence and bleeding, and individual preferences.
  • Provoked venous thromboembolism: 3 months (provided provoking risk factor is no longer present).
  • Unprovoked venous thromboembolism or provoked venous thromboembolism with a persistent risk factor: >=3 months depending on risk of venous thromboembolism (VTE) recurrence and bleeding.
  • All patients receiving indefinite therapeutic anticoagulation with no specified stop date should be reassessed at periodic intervals.

701269412

220905

• diagnosis
  • 2022-08-19 discharge
    • 1: Malignant neoplasm of extrahepatic bile duct
    • 2: Cholangitis
    • 3: Obstruction of bile duct
    • 4: Essential (primary) hypertension
    • 5: Enlarged prostate with lower urinary tract symptoms
• past history
  • 1. Cholangiocarcinoma T3N2M1, stage IV (Diagnosed on 20220728, Liver and peritoneum mets)
  • 2. Hypettension
  • 3. Duodenal ulcer
  • 4. Nasal cavity benign neoplasm s/p OP
  • 5. BPH
• lab data
  • CA199
    • 2022-09-05 CA199 >19090.00 U/mL
      
    • 2022-07-22 CA199 >19680.00 U/mL
• exam finding
  • 2022-09-05 SONO - abdomen
    • Diagnosis (Poor echo window, Pancreas and CBD masked by bowel)
      • Parenchymal liver disease
      • Liver tumor (6.89cm and 3.69cm), rigth lobe
      • Dilated bilateral IHD
      • Gallbladder sludge
      • s/p biliary stent.
      • Ascites, moderate
    • Suggestion
      • Please correlated with other image study
  • 2022-09-03 CT - abdomen
    • Indication
      • cholangiocarcinoma with Liver and peritoneum metachest tighness, malnutrition with elevation of bilirubin and ALT level suspected tumor progress and further mets
    • Findings
      • 1. Progression of mass lesion around gallbladder and CBD. Infiltration lesions in S8 of liver.
      • 2. Dilation of IHDs. s/p biliary stent.
      • 3. Progression of peritoneal carcinomatosis.
      • 4. Progression of ascites.
      • 5. No bony destructive lesion on these images.
    • Impression
      • c/w cholangiocarcinoma with liver and peritoneum metastasis, in progression;
      • DDx: gallbladder cancer
  • 2022-09-02 Ascites tapping
    • About 3000ml brown asictes was drained.
  • 2022-08-17 CXR
    • Patchy opacity projecting in the right upper lung is suspected. Please correlate with CT.
  • 2022-08-17 Ascites tapping
    • About 3000ml yellow cloudy asictes was drained.
  • 2022-08-15 Body fluid cytology - ascites
    • Smears show lymphocytes, reactive mesothelial cells, and atypical hyperchromatic cells with prominent nucleoli.
    • Malignancy is suspected.
  • 2022-08-12 SONO - abdomen
    • Parenchymal liver disease
    • Liver tumor (0.3cm and 2.7cm), rigth lobe, unknwon etiology.
    • GB tumor
    • Prominent left IHD
    • suspicious, peritoneal carcinomatosis
    • pancreas masked by bowel.
    • Ascites, severe.
  • 2022-08-12 Ascites tapping
    • About 3000ml yellow nontransparent asictes was drained.
  • 2022-08-11 ECG
    • Sinus tachycardia
    • Left axis deviation
    • Septal infarct, age undetermined
  • 2022-08-11 CXR
    • Patchy opacity projecting in the right upper lung is suspected. Please correlate with CT.
  • 2022-07-28 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with cholangiocarcinoma
    • The sections show a picture of adenocarcinoma, composed of nests, cords, and single large pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation is present.
    • IHC shows: CK7(+), CK19(+), CK20(-), and Hepatocyte(focal +). The finding is compatible with cholangiocarcinoma.
  • 2022-07-27 Endoscopic ultrasound guided fine needle biopsy, EUS-FNB
    • Suspect gall bladder cancer with biliary obstruction, s/p CH-EUS and EUS FNB
  • 2022-07-25 Endoscopic Retrograde CholangioPancreatography, ERCP
    • After standard sphincterotomy, one plastic biliary stents with Boston Scientific 7 Fr. 12 cm are placed for free drainage.
    • diagnosis: Biliary duct stricture s/p EST & plastic stents (Boston Scientific 7 Fr. 12 cm)
    • suggestion: f/u amylase & lipase
  • 2022-07-23 CT - abdomen
    • indication: Jaundice
    • Imp:
      • Soft tissue mass at distal CBD and cystic duct with obliterating biliary tree with dilated IHDs and CBD, cholangiocarcinoma is favored.
      • Liver mets and diffuse cancerous peritonitis is found. Suggest tissue proof.
    • Imaging Report Form for Cholangiocarcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N2(N_value) M:M1(M_value)
  • 2022-07-23 SONO - abdomen
    • Diagnosis
      • GB tumor
      • Bil IHDS & CHD dilatation
      • Parenchymal liver disease
      • Ascites, trivial amount
    • Suggestion
      • CECT study
  • 2022-07-22 CXR
    • Compression fracture of T spine.
  • 2022-07-22 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Abnormal ECG
• consultation
  • 2022-08-02 Hemato-Oncology
    • Q
      • This 66 year-old male has the histories of 1. Hypettension. 2. Duodenal ulcer. 3. Nasal cavity benign neoplasm post biopsy. He was regullar follow up at GI LMD. He ever came to GI LMD due to body weight lose 6kgs for a year and tea colored urine, clay stool and poor appetite for a week. Blood analysis showed no leukocytosis (9.42*10^3/uL), but left shift (SEG: 80.3 %), elevated hepatobiliary enzyme (AST:148 U/L,ALT:327 U/L, TBI:12.19mg/dl, r-GT:390 U/L,ALP:317 IU/L). HBsAg and Anti-HCV were nonreactive. Abdominal CT was performed on 20220723 and reported cholangiocarcinoma T3N2M1, stage IV. Liver biopsy pathology showed Cholangiocarcinoma. So we need you evaluation and suggestion of this patient. Thank you very much ~
    • A
      • Recommendation:
      • palliative chemotherapy maybe helpful for this patient
      • port-A implantation if patient agree chemotherapy
  • 2022-08-01 Urology
    • Q
      • This time, he sufferred from dysuria. So we need you evaluation and suggestion of this patient. Thank you very much ~
    • A
      • The patient reported urinary frequency with small amount. U/A is clean.
      • He had OAB (overactive bladder, may due to disease or medication realted) and we will prescribed antimuscarinic for him.
      • If symptoms did not improved may contact further evaluation
  • 2022-07-28 Radiation Oncology
    • Q
    • Abdominal CT was performed on 20220723 and reported cholangiocarcinoma T3N2M1, stage IV. We need arrange CT Guide Biopsy of liver, thank you~
    • A
    • According to the clinical condition and imaging findings, biopsy is indicated.
• chemoimmunotherapy
  • 2022-08-12 - fluorouracil 1000mg/m2 1500mg 22hr D1-5 + cisplatin 100mg/m2 150mg 3hr D2

701370041

220905

• exam finding
  • 2022-09-03 CXR
    • Left lower lung infiltrates.
    • Borderline cardiomegaly.
    • Tortuous thoracic aorta with intimal calcification.
    • Thoracic spondylosis.
  • 2022-07-25, -07-21 CXR
    • small Lt pleural effusion and Rt subpulmonary effusion
    • Linear band subsegmental atelectasis at Lt lung base
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
      
    • appropriately positioned gastric tube
  • 2022-07-20 CT - abdomen, pelvis
    • History: bloody stool
    • Findings:
      • 1. There is segmental circumferrential wall thickening at the sigmoid colon, measuring 5.5 cm in length and 1.6 cm in maximal wall thickness. Adenocarcinoma is highly suspected.
        • In addition, There is a soft tissue mass measuring 4 cm in width at the adjacent mesocolon that may be exophytic tumor or metastatic node?
      • 2. There is a poor enhancing lesion measuring 5.3 cm in left kidney lower pole with suggestive central soft tissue nodular component that may be cyst or cystic tumor? Please correlate with sonography and contrast-enhanced dynamic CT.
           
      • 3. There are bilateral Pleura effusion (more severe on left side) and passive atelectasis in left posterior basal lung.
      • 4. S/P nasogastric tube insertion
      • 5. There is mild ascites in right perihepatic space, left para-colic gutter space, and pelvis. please correlate with clinical condition or ascites cytology.
      • 6. The urinary bladder shows small size, mild wall thickening., gas content and S/P Foley’s catheter insertion.
      • 7. Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4, L4-5 and L5-S1.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N1a (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
  • 2022-07-19 Patho - colon biopsy
    • Colon, 18 cm to 22 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
      
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2022-07-19 CXR
    • appropriately positioned gastric tube
      
    • enlarged cardiac silhoutte
    • mixed crowding of vascular markings and reticular opacities over
    • left lower lung zone?
  • 2022-07-18 Colonoscopy
    • Diagnosis
      • Highly suspected colon cancer, with mild oozing, 18cm to 22cm AAV, s/p biopsy.
      • Internal hemorrhoid
    • Suggestion
      • F/U pathology report
      • CRS consultation
    • Complication
      • No immediate complication
  • 2022-07-13 ECG (ICU)
    • note: low data quality
    • Sinus tachycardia
    • Incomplete right bundle branch block
    • ST elevation consider inferior injury or acute infarct
    • ECG interpretation of ACS is based on presence of symptoms and ST elevation in Inferior leads with Reciprocal ST depression in Anterior leads and T-wave inversion in Septal leads
  • 2022-07-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 28.0) / 99.3 = 65.56%
    • 1. Sub-optimal echo window
    • 2. Normal AV/MV with no AR/MR
    • 3. Concentric LVH
    • 4. Preserved LV and RV systolic function
    • 5. No PR/TR, dilated IVC
  • 2022-07-08 CT - brain
    • A soft tissue tumor (1.5cm) at left CP angle cistern r/o meningioma.
    • Brain atrophy. Sinusitis.
• consultation
  • 2022-08-15 Dermatology
    • Q
      • At ONC ward, vital signs stable and we will explained the current condition to patient and family.Radiothist was consulted for radiotherapy and started on 2022/08/12.
      • However, his skin rash was noted during hospitalization. we need your expertise further management, thanks
    • A
      • This patient suffered from mutiple erytheamtous patches on trunk and 4 limbs for days.
      • IMp: Tinea corporis
      • Suggestion: Zalain cream * 2 tubes/bid
  • 2022-08-05 Radiation Oncology
    • Q
      • This is a 81 years old male with uderlying disease of DM, HTN, dementia. He was admission due to suffered from a consciousness change since 20220707. Palpitations, shortness of breath, dyspnea, pyuria, spiky fever and generalized malaise for 2 days were noted. Then the patient was brought to our ER for help. Con’s: E2V2M4, O2 saturation: 87%. The laboratory data showed leukcoytosis and elevated of CRP level, acute kidney injury was also noted BUN 143 / Cr 5.5. The urinlyais showed UTI picture, the CXR film showed bilateral infiltration, under the impression of sepsis, pneumonia and UTI related, then he was admission to INF ward for further management on 2022-07-10. At ward, NG insert for prevent chocking. The antibiotic Avelox plus Tapimycin on 2022/07/11. We discuss with families, they decided DNR except medication. Due to unstable hemodynamic condition, he was transferred to MICU for further treatment on 2022/07/11.
      • < MICU course 20220711-0728 > At MICU, we kept the antibiotics of Tapimycin (20220711-0720) and Ciproxin (20220712-0719). NRM was changed to V-M 12L/min and the patient was tolerant. We added inhalation medication for COPD. Cardiac echo was arranged and showed normal wall motion. Cardiologist was consulted for AF control. Diltiazem and Plavix were suggested. For weak cough function and much sputum, VEST was arranged (20220716-0726). Hypernatramia was improved after adequate IV and oral water. The patient’s respiratory pattern was getting smoother under treatment. However, brick-red stool was noted since 20220717 night. Plavix was hold. Sidmoidoscopy revealed erosion with oozing, susp tumor bleeding. Thus we consulted CRS then abdominal CT was suggested. We also explained to his family about the condition, they favor conservative treatment. The abdominal CT showed Sigmoid adenocarcinoma, cT3N1aM0, stage IIIB. We added Albumin and lasix for generalized edema and kept I/O negative. Less brick-red stool noted thus NG diet was given. Antibiotic was shifted to Curam (20220721~). Under stable condition, he was transferred back to ordinary ward on July 27, 2022.
      • < Ward course 7/28~ > After he was transferred to our ward, we kept Curam for prophylactic treatment. Smooth respiratory under nasal cannula used. We consulted Oncology for colon cancer evaluation and management. Intermittent brick-red stool and black stool passage under Transamin iv treatment. L-PRBC transfusion was done for Anemia. The general condition was improvment and stationary. Today, he will be transferred to the oncology ward and taken over by oncologist chief Chang for further cancer further management on Aug 03, 2022. At ONC ward, vital signs stable and we explianed the current condition to patient and family, they agree the radiotherapy therapy. We need your expertise for radiotherapy evaluation, thanks.
    • A
      • This 81 y/o male sufferred from bloody stool. The abdominal CT showed Sigmoid adenocarcinoma, cT3N1aM0, stage IIIB. Due to poor general condition, surgery or chemotherapy is not feasible, according to his daughter.
      • Palliative RT for bleeding control and obstruction prevention is indicated. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 54 Gy/ 30 fx. However, due to he’s bed-ridden now, his daughter will ask if he can stay at the ward during the whole radiotherapy course. If he can, CT-simulation will be arranged accordingly. Thank you very much.
  • 2022-07-18 Colon and Rectal Surgery
    • Q
      • Episodes of bloody stool passaged and Hgb drop was noted, LPRBC 2U *2 days(20220717-0718) and sigmoidoscopy of 20220718 which showed suepected cancer with bleeding related (about 20cm AAV). We need your expert to evaluate his condition. Thank a lot!
    • A
      • wait sigmoidoscopy report
      • Blood transfusion and resuscitation as needed
      • suggest CT to evlaution if cancer is highly suspected.
  • 2022-07-13 Cardiology
    • Q:
      • We need your expertise for evaluation and suggestion of elevated hsTnI and AF medication. Thanks a lot!
      • hs-Troponin I                      
        • 2022-07-08 21:39 11899.3 pg/mL          
        • 2022-07-09 00:11 13997.4 pg/mL          
        • 2022-07-09 06:57 12819.3 pg/mL          
        • 2022-07-09 20:18 11471.6 pg/mL       - A
      • This is a 81 years old man who was admitted for urosepsis with pneumonia. Has consent for DNR. We were consulted for elevated trop and Af
      • Cardiac echo 20220713 EF: 65%
        • 1. Sub-optimal echo window
        • 2. Normal AV/MV with no AR/MR
        • 3. Concentric LVH
        • 4. Preserved LV and RV systolic function
        • 5. No PR/TR, dilated IVC
  • 2022-04-07 Orthopedics
    • Q
      • fell down on the groung
      • lower back pain, bil hip pain, right knee pain
      • could not weight bearing
      • ILOC (-), head injury (-)
      • Allergy: -
      • Past history: dementia, DM, HTN
      • Exposure (TOCC): denied
      • Trauma hx: denied
    • A
      • 81 y/o M
      • A: right knee pain and right ankle pain, suspected patella and ankle fracture
      • P: long leg splint and OPD follow-up

[assessment]

• Na (2022-09-04 132 mmol/L <- 2022-09-03 126 mmol/L), K (2022-09-04 3.9 mmol/L <- 2022-09-03 6.1 mmol/L). Hyperkalemia and hyponatremia have been alleviated.
• In spite of the fact that AKI in July has improved, kidney function has decreased over the past week. (Cre 2022-09-03 1.35 mg/dL <- 2022-08-24 1.03 mg/dL, BUN 2022-09-03 33 mg/dL <- 2022-08-24 27 mg/dL)
• If the patient’s kidney function deteriorates, the dose of tranexamic acid, Fylin (pentoxifylline), Glucophage (metformin), and Feburic (febuxostat) listed in active prescription might need to be adjusted.

701431395

220905

{Lung cancer at right lower lung, adenocarcinoma, with multiple brain metastasis, cT4N0M1b, stage IV, with mukltiple brain metastasis, PD-L1: TC < 1%, IC < 1%, TPS < 1 %, EGFR E19 deletion and T790M (+)}

• lab data
  • 2022-07-07 HBsAg Nonreactive
    
  • 2022-07-07 HBsAg (Value) 0.29 S/CO
    
  • 2022-07-07 Anti-HBs 263.06 mIU/mL
  • 2022-07-07 Anti-HCV Nonreactive
    
  • 2022-07-07 Anti-HCV Value 0.20 S/CO
• exam finding
  • 2022-09-02, -08-29 CXR
    • Patchy opacity of the right lower lung zone and several nodular opacity projecting at both lung are noted that may be primary lung cancer with lung to lung metastases. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Patchy consolidation of the right middle lung zone is suspected. Please correlate with clinical condition or CT.
  • 2022-08-26 KUB
    • S/P wires projecting at the midline abdominal and pelvic wall.
    • Fecal material store in the colon.
    • Compression fracture of T12 vertebral body.
  • 2022-08-24 MRI - C-spine
    • heniated discs in the C3/4, C4/5, C5/6 and C6/7 discs, more on the C6/7 disc.
    • spinal canal stenosis at the middle and lower C-spine.
  • 2022-08-22 MRI - L-spine
    • After IV contrast administration shows well or heterogenous enhancement at C4,5 bodies, metastases?
  • 2022-08-22 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Poor wave progression V1~4
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2022-07-26 PD-L1 IHC
    • Tumor cell (TC) staining assessment: TC < 1%
    • Percentage of 28-8 expressing tumor cells (%TC): 0%
  • 2022-07-26 PD-L1 22C3
    • Tumor Proportion Score (TPS) category: TPS < 1%
  • 2022-07-26 PD-L1 (SP142)
    • Result:
      • Tumor cell (TC) staining assessment: TC category: TC < 1%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-07-26 ROS1 FISH
    • ROS1 fluorescent-in-situ hybridization report - rearrangement of ROS1 gene is NOT detected. Patient with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
  • 2022-07-26 EGFR mutation
    • Two mutations were detected at exon 19 (Del) and exon 20 (T790M) of EGFR gene in this specimen.
  • 2022-07-12 Tc-99m MDP whole body bone scan with SPECT
    • 1. Mildly increased activity in the lower C-spine, lower T-spine and L5-sacrum junction. Degenerative change is more likely.
    • 2. Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • 3. A faint hot spot in the anterior aspect of left 1st rib. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • 4. Increased activity in bilateral shoulders, left wrist, bilateral hips and right knee, compatible with benign joint lesions.
  • 2022-07-11 Patho - lung wedge biopsy
    • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
  • 2022-07-09 CXR
    • Patchy opacity of the right lower lung zone and several nodular opacity projecting at both lung are noted that may be primary lung cancer with lung to lung metastases. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-07-09 MRI - brain
    • Multiple bil. brain and upper left brain stem metastases, more prominent at left cerebellum and left frontal lobe.
  • 2022-07-07 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Poor wave progression V1~4
    • Abnormal ECG
• consultation
  • 2022-08-26 Rehabilitation
    • A
      • Due to 4 limbs weakness, we were consulted for bedside PT rehabilitation programs.
      • MP:
        • RUL/RLL: 4/3 LUL/LLL: 4/3 (before Radiotherapy, MP was 2-3/3; 4/3)
      • Functional status: needs min assistance
      • BADL: needs miin assistance
      • Assessment
        • Lung cancer at right lower lung, adenocarcinoma
        • HTN
        • HIVD, heniated discs in the C3/4, C4/5, C5/6 and C6/7 discs, more on the C6/7 disc.
      • Plan
        • arrange rehab OPD after discharge for further Rehabilitation programs: PT rehabilitation programs
      • Goal: improve endurance and muscle strength
    • 2022-08-30 supplement
      • The discharge plan was posponed due to unstable condition and fever. We were consulted today for arrangement of rehab training.
      • Fever 38.1-38.3’C with chillness was noted when I visited.
      • Consciousness: intact
      • Cognition: intact, oriented, could follow orders
      • Mobility: lying on bed due to discomfort and general weakness.
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: improve endurance and muscle strength
  • 2022-08-24 Radiation Oncology
    • Q
      • Brain MRI (20220709): Multiple bil. brain and upper left brain stem metastases, more prominent at left cerebellum and left frontal lobe. Consult radiation oncology for CT-guide biopsy at right lung the report showed RLL lung mass, s/p CT-guided biopsy. Minimal pneumothorax on 20220709. The biopsy report showed adenocarcinoma, moderately differentiated, immunohistochemical stains reveal TTF-1(+) and Napsin A(+), PD-L1: TC < 1%, IC < 1%, TPS < 1 %, EGFR E19 deletion and T790M (+). And received radiotherapy with dose: 660cGy/2 fractions (6 MV photon) to brain metastasis, 2022/07/29-2022/08/01, then RT dose: 2310cGy/7 fractions (6 MV photon) to brain metastasis, 2022/08/01-2022/08/08, RT dose: 3960cGy/12 fractions (6 MV photon) to brain metastasis, 2022/08/08- 2022/08/15, the targeted therapy as Afatinib 1tab QOD since 2022/08/09.
      • This time, she came to radiation oncology OPD foloow-up, then complaints bilateral lower limbs weakness and lethargy for two weeks, and suspect intramedullary metastasis and spinal cord compression, so she was transferred to our ER for help. At ER, followed-up chest X-ray showed a mass lesion in right lower lung zone, the L-spine MRI (20220822) showed: no obvious spinal cord mass or nodule. After IV contrast administration shows well or heterogenous enhancement at C4,5 bodies, metastases? we already arrange the C-spine MRI on 20220824. So we need your help, thanks a lot!!
    • A
      • O
        • Past Hx: HTN(-); no DM.
        • Initial presentation with clonus over right side.
        • Lung nodule noted in 2022-04; Brain CT on 2022-06-16: multiple bran metastasis.
        • Rt hemiweakness for 1-2 months.
        • 2022/07/11 PATHO-Lung wedge biopsy: adenocarcinoma, moderately differentiated.
        • immunohistochemical stains reveal TTF-1(+) and Napsin A(+), PD-L1: TC < 1%, IC < 1%, TPS < 1 %; EGFR Exon 19 deletion and T790M (+).
        • 2022/07/12 bone scan: 1. Mildly increased activity in the lower C-spine, lower T-spine and L5-sacrum junction. Degenerative change is more likely. 2. Increased activity in the maxilla and mandible. Dental problem may show this picture. 3. A faint hot spot in the anterior aspect of left 1st rib. The nature is to be determined (post-traumatic change? other nature?).
        • 2022/07/09 MRI: Brain: Multiple bil. brain and upper left brain stem metastases, more prominent at left cerebellum and left frontal lobe.
        • She has suffered from bilateral lower limbs weakness and lethargy for two weeks.
        • C-T-L spine MRI on 20220822: T-L spines: No obvious spinal cord mass or nodule. Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture at T12, old. No evident tumor like bony destructive lesion. Presence of spondylolisthesis at L5/S1 was found.
        • C-Spine: No obvious spinal cord mass or nodule. After IV contrast administration shows well or heterogenous enhancement at C4,5 bodies, metastases?
        • C spine MRI with contrast, 20220824: high SI change on T2WI in the C6-7 cord; degeerative change in the C-spine disc spaces; moderate decreased disc spaces in the C3/4, C4/5, C5/6 and C6/7 discs. Herniated discs in the C3/4, C4/5, C5/6 and C6/7 discs caused mild anterior indentation on the C3-4, C4-5 and C5-6 cord; severe indentation on the C6-7 cord and moderate left C6-7 foraminal stenosis. Unremarkable change in the bone marrow signal intensity. Degenerative change in the C-spine facet joints. IMP: 1. heniated discs in the C3/4, C4/5, C5/6 and C6/7 discs, more on the C6/7 disc. 2. spinal canal stenosis at the middle and lower C-spine.
      • Imp: Lung cancer, RLL, adenocarcinoma, with multiple brain metastasis, cT4N0M1b, with multiple brain metastasis, ECOG =2;
        • s/p brain RT for 3960cGy/12 fx, 2022/7/29 to 8/15;
        • under targeted therapy as Afatinib 1tab QOD since 2022/08/15.
        • Herniated discs in the C3/4, C4/5, C5/6 and C6/7 discs caused mild anterior indentation on the C3-4, C4-5 and C5-6 cord; severe indentation on the C6-7 cord and moderate left C6-7 foraminal stenosis.
      • Plan: Please consult Rehabilitation & NS for further evaluation. I will F/U this patient at my OPD and arrange follow-up brain MRI for her. Thanks very much for your consultation.
  • 2022-07-08 Radiation Oncology
    • Q
      • For lung CT-guide biopsy
      • The 89 y/o woman has hypertension with Sevikar control at Central Clinic & Hospital. She also has rectal cancer in age 60 at Central Clinic & Hospital, stage unknown.
      • She has SOB and fatigue noted in 2022-04, check CXR showed nodule at Central Clinic & Hospital, and then took some bronchodilator and anti-cough medicine control. Suddenly unable to lift right hand during meal time on 20220612 and sent to Central Clinic & Hospital for help.
      • The brain CT showed brain metastasis. She denied BW loss within 3 months. Now, she need family support for walk. She came to our neuro OPD and refered to ONC OPD on 20220630. Under the impression of suspect lung cancer with brain mets, so she was admitted on 20220707.
    • A
      • This 89-year-old patient is a case of right lung mass, suspected malignancy. CT-guided biopsy is indicated.
      • Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
• radiotherapy
  • 2022-08-08 ~ 2022-08-15 - 3960cGy/12 fractions (6 MV photon) to brain metastasis
  • 2022-08-01 ~ 2022-08-08 - 2310cGy/7 fractions (6 MV photon) to brain metastasis
  • 2022-07-29 ~ 2022-08-01 - 660cGy/2 fractions (6 MV photon) to brain metastasis
• chemoimmunotherapy
  • 2022-08-09 ~ Giotrif (afatinib 30mg/tab) 1# QOD

[assessment]

• 2022-08-30 blood culture result Escherichia coli is currently treated with flomoxef with no issue.
• 2022-08-30 semifluid stool OB 2+, HGB has been declining (2022-09-05 9.8 g/dL <- 2022-08-22 11.8 g/dL). Possible GI bleeding is treated with pantoprazole 40mg IVD QD currently.
• BUN/creatinine ratio increases due to a low serum creatinine level (2022-09-05 0.28 mg/dL <- 2022-07-07 0.63 mg/dL) along with a normal BUN level (2022-09-05 17 mg/dL). This elevation in the BUN-to-creatinine ratio is one of the suggestive clinical signs of decreased kidney perfusion (semifluid stool, two to five bowel movements per day in late Aug, volume depletion?).
• The downtrend in serum creatinine might also be related to muscle loss and/or malnutrition (2022-09-05 albumin 2.8 g/dL).
• 2D transthoracic echocardiography for heart and flow volume loop and volume time curve for lung were recommended since afatinib is reported relating to cardiovascular and pulmonary toxicity, baseline establishment might be necessary. An ECG recorded on 2022-08-22 indicated possible left atrial enlargement, which might be due to mitral stenosis, mitral regurgitation, or aortic stenosis, which could also be examined with heart doppler sonography.
• Under Apidra, the blood sugar level remains between 130 and 220 during this hospitalization, there is no urgent need to adjust the dose.

700463704

220902

• present illness
  • 1. Hepatitis B carrier,
  • 2. Hepatocellular carcinoma, pT2NxMx, stage II, BLCL A, Child-pugh A s/p S5 segmentectomy with cholecysectomy on 2013/02/01,
  • 3. Recurrent HCC s/p S8 segmentectomy, rpT3N0M0,s tage IIIA on 2020/07/08.
  • 4. Recurrent HCC s/p TACE 7 times on 2015/11/5 ~ 2021/11/26.
• exam finding
  • 2022-08-22 CXR
    • Mass lesions in both lung zones
    • Right pleural effusion
  • 2022-08-08 CT - chest
    • Findings
      • Lungs:
        • multiple nodules of variable sizes throughout both lungs due to metastases, with relaxation atelectasis of RLL and RML.
        • moderate Rt pleural effusion.
        • further increase in size of a large metastatic tumor at Rt anterior chest wall involving adjacent mediastinum as compared with the previous CT on 20220611.
      • HCC, s/p many surgical resections. further progression of recurrent tumors in both hepatic lobes with tumor thrombi in left portal vein.
      • unremarkable of the spleen, pancreas, both kidneys, and both adrenal glands. no ascites or emlarged lymph nodes.
    • Impression:
      • recurrent HCC with lung and chest wall metastases, further in progression as compared with the previous CT on 2022/06/11.
  • 2022-08-04 Tc-99m MDP whole body bone scan with SPECT
    • 1. Mildly increased activity in some L-spines. Degenerative change may show this picture.
    • 2. Some faint hot spots in bilateral rib cages and increased activity in the sternum. The nature is to be determined. Please correlate with other clinical findings and follow up bone scan for further evaluation.
    • 3. Increased activity in bilateral shoulsers, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-06-11 CT - abdomen
    • Findings
      • 1. HCC, s/p operation. Progression of recurrent tumors in both hepatic lobes.
      • 2. Tumor thrombi in left portal vein.
      • 3. Right chest wall mass lesion, in progression.
      • 4. No ascites, nor extraluminal free air.
      • 5. No bony destructive lesion on these images.
    • Impression
      • Recurrent HCCs, in progression
      • Left portal vein thrombosis
      • Right chest wall metastasis, in progression
  • 2022-06-11 CXR
    • Focal upward bulging of right diaphragm is noted. please correlate with clinical condition or CT.
  • 2022-04-01 Patho - pleural/pericardial biopsy
    • Labeled as “R superior chest wall tumor”, CT-guided biopsy — poorly differentiated carcinoma.
    • IHC stains: CK (+), GATA-3 (+), mammoglobin (-), E-cadherin (-), hepatocyte (-), Arginase-1 (-), AFP (-), ER (-), PR (-), Her2/neu: negative (score = 0), Ki-67: 90%.
    • Section shows soft tissue with infiltration of trabeculae of poorly differentiated carcinoma.
  • 2022-04-01 CXR
    • Focal upward bulging of right diaphragm is noted. please correlate with clinical condition or CT.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-03-21 CT - chest
    • Findings
      • Lungs: subtle mosaic attenuation in both lower lobes and posterior both Lt upper lobe. old calcified LN in the left anterior prevascular space, sequela of previous TB infection
      • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Chest wall: Rt thyroid lobe calcification 11 mm.
        • a well-defined soft-tissue mass with cystic and solid components (16x27x16 mm) at Rt paramedian superior anterior chest wall (beneath the pectoralis msucle).
      • Visible abdo > S/P resection of right lobe liver.
        • poor enhancing iInfiltrative tumor in left lobe liver and enhancing tumor (2 cm) in S7 liver due to recurrent HCCs.
        • Presence of central portal venous thrombosis.
      • unremarkable of the spleen, adrenal glands, pancreas, and kidneys.
      • Visualized bones: unremarkable.evaluation.
    • Impression:
      • Rt superior anterior chest wall mass, metastatic tumor or a primary intercostal chest lesion.
  • 2022-02-26 CT - abdomen
    • Findings
      • S/P resection of right lobe liver.
      • Infiltrative tumor in left lobe liver, enhancing tumor (2cm) in S7 liver, could be due to recurrent HCCs.
      • Presence of portal venous thrombosis, progression.
    • Impression:
      • S/P resection of right lobe liver.
      • Recurrent HCCs with progression of portal venous thrombosis.
  • 2022-01-10 MRI - liver, spleen
    • Findings:
      • 1. There are two ill-defined masses, measuring 2.4 cm in S7 dome and 3.1 x 2.7 cm in S4 of the liver. During dynamic study, two masses show contrast enhancement in arterial phase images and no significant evidence of contrast washout in portal venous phase and delayed phase images.
        • HCCs are highly suspected.
        • In addition, The S4 lesion shows hypointensity on T1WI and it directly connected with left portal vein thrombosis.
        • Recurrent HCC at S4 with directly invasion causing portal vein tumor thrombsis is highly suspected.
      • 2. Prior CT suspected Two ill-defined poor enhancing area in left lobe liver are not noted in the current MRI that are c/w flow artifacts.
      • 3. Prior CT identified an ill-defined enhancing lesion measuring 2.9 x 2.6 cm in S2/3 of the liver at arterial phase images is not noted in the current MRI and the mechanism may be hyperemia (compensatory increased arterial flow in arterial phase images secondary to portal vein thrombosis).
           
      • 4. The liver shows irregular contour and atrophy of segment 4 that is consistent with cirrhosis.
        • There is mild esophageal varices that may be portal hypertension.
      • 5. S/P cholecystectomy. S/P partial resection of S5 and S8 of the liver.
    • Impression:
      • 1. Two recurrent HCCs on S7 dome and S4 are suspected.
           
      • 2. Recurrent HCC at S4 causing left lobe portal vein tumor thrombosis is highly suspected.
  • 2022-01-05 CT - abdomen
    • Findings:
      • 1. There are three ill-defined iso-hypodense lesion, measuring 2.4 cm in S7 dome, 2.9 x 2.6 cm in S2/3, and 3.2 x 2.6 cm in S4, of the liver. During dynamic study, all masses show contrast enhancement in arterial phase images and Eqivocal contrast washout in portal venous phase and delayed phase images.
           
        • HCCs are highly suspected.
      • 2. Two ill-defined poor enhancing area in left lobe liver are suspected and non-enhancement of left portal vein.
        • Please correlate with MRI to R/O infiltrative type HCCs with tumor thrombosis in left portal vein.
      • 3. The liver shows irregular contour and atrophy of segment 4 that is consistent with cirrhosis.
        • There is mild esophageal varices that may be portal hypertension.
      • 4. S/P cholecystectomy. S/P partial resection of S5 and S8 of the liver.
    • Impression:
      • 1. Three recurrent HCCs on both hepatic lobes are suspected.
           
      • 2. Infiltrative type HCCs at left hepatic lobe with tumor thrombosis in left portal vein are suspected.
      • Please correlate with MRI.
  • 2021-10-04 MRI - liver, spleen
    • Findings
      • HCC s/p operation and TACE. Some small marginal enhancing nodules (up to 1.7cm) in both hepatic lobes.
    • IMP:
      • HCC s/p operation and TACE. Some small marginal enhancing nodules (up to 1.7cm) in both hepatic lobes c/w tumor recurrence.
  • 2021-09-29 SONO - abdomen
    • Hepatic tumor suspected HCC (inconspicuous)
    • Liver cirrhosis
    • post cholecystectomy
  • 2021-08-14 CT - abdomen
    • Findings
      • s/p cholecystectomy and S5 resetion.
      • Hypervascular hepatic tumor at S4 of liver up to 1.94cm in largest dimension. Suggest closely follow up.
      • The portal vein and IVC are patent.
      • Another low density lesion at dome about 2.0cm in largest dimension. HCC?
      • Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis. Suggest clinical correlation
    • Imp:
      • Suspected hepatic tumors at S4 and S5 of liver. Suggest correlate with other findings.
  • 2021-06-11 SONO - abdomen
    • 1. A hypoechoic lesion 1.49 cm in S2/3 of the liver is noted that may be tumor or fat sparing area. Please correlate with contrast enhanced dynamic CT or MRI.
    • 2. S/P partial resection of S7-8 of the liver and cholecystectomy.
  • 2021-03-08 MRI - liver, spleen
    • HCC s/p operation and TACE without enhancing tumor.
  • 2021-03-08 SONO - abdomen
    • Liver lesion, nature?
    • Liver cirrhosis, mild fatty liver
    • Post cholecystectomy
    • Fatty pancreas
  • 2021-02-01 MRI - liver, spleen
    • HCC s/p operation and TACE. A recurrent HCC (1.8cm, srs8, img23) at liver dome.
  • 2020-11-28 CT - abdomen
    • Liver cirrhosis with HCC s/p S5 and S8 op. with borderline enhanced region at S7 just near previous TACE region. Suggest closely follow up.
  • 2020-09-08 SONO - abdomen
    • S/P cholecystectomy and partial resection of S7-8 of the liver.
  • 2020-07-09 Patho - liver partial resection
    • pathologic diagnosis
      • 1. Liver, S8, segmental hepatectomy — Hepatocellular carcinoma, recurrent
           
      • 2. Pathologic Staging: rpT3Nx; Stage IIIA at least
    • microscopic examination
      • 1. Histologic Type: Hepatocellular carcinoma, trabecular type with focal intratumoral fibrosis
           
      • 2. Histologic Grade: Poorly differentiated (G3)
           
      • 3. Tumor Necrosis: Present
           
      • 4. Tumor Capsule: Encapsulated with focal infiltrative border
           
      • 5. Tumor Extension: Tumor confined to liver
           
      • 6. Large Vessel Invasion: Not identified
           
      • 7. Small Vessel Invasion: Present
           
      • 8. Perineural Invasion: Not identified
           
      • 9. Pathologic Staging (rpTNM): Stage IIIA at least (rpT3Nx)
           
      • 10. Margins
            
        • 10.1 Parenchymal Margin: Free, 1.6 cm from closest margin
          
        • 10.2 Hepatic Capsule: Uninvolved by invasive carcinoma
          
      • 11. Additional Pathologic Findings: Small cell and large cell changes
            
      • 12. Hepatitis (specify type): Hepatitis B
            
      • 13. Ishak Modified HAI Grading: Score=3 (interphase hepatitis = 1/4, confluent necrosis = 0/6, focal necrosis = 0/4, portal inflammation = 2/4) (Corresponding Metavir A1, mild activity)
            
      • 14. Ishak Staging: F6 (Corresponding Metavir F4, cirrhosis)
            
      • 15. Fatty Change: Present (10%)
  • 2020-05-30 CT - abdomen
    • Hepatic tumor at dome, recurrent HCC is considered.
  • 2020-05-23 SONO - abdomen
    • Liver tumor: suspect HCC
    • Liver cirrhosis, mild fatty liver
    • post cholecystectomy
  • 2020-02-14 SONO - abdomen
    • Findings:
      • 1. Status post partial resection of S5/8 of the liver.
        • The residual liver shows normal in size and echogenicity without focal lesion.
          
        • Portal vein flow: patent.
        • Bile ducts: not dilated.
      • 2. Status post cholecystectomy.
      • 3. The pancreatic head and body shows normal in size and texture.
        • The pancreatic tail is obscured by overlying bowel gas.
      • 4. The spleen shows normal in size and echogenicity without focal lesion.
      • 5. Abdominal aorta and IVC show unremarkable finding.
      • 6. There is no evidence of para-aortic lymphadenopathy or ascites.
      • 7. Both kidney show normal echopattern and size.
        • There is no evidence of stone or hydronephrosis.
    • Impression:
      • 1. S/P cholecystectomy and partial resection of S5/8 of the liver.
      • 2. Otherwise, no significant abnormal finding is noted.
  • 2019-10-05 CT - abdomen
    • HCC s/p operation and TACE without viable tumor.
  • 2019-08-26 SONO - abdomen
    • HCC, Status post partial right segmentectomy (S5/8)
    • Liver tumors?
    • Liver cirrhosis
    • Status post cholecystectomy
  • 2019-06-08 CT - abdomen
    • HCC s/p operation and TACE without viable tumor.
  • 2019-03-04 SONO - abdomen
    • Liver cirrhosis
    • Status post cholecystectomy
    • Status post partial right segmentectomy (S5/8)
  • 2018-12-01 CT - abdomen
    • HCC s/p operation and TACE without viable tumor.
  • 2018-09-07 SONO - abdomen
    • Suspected chronic liver parenchyma disease (Please correlate with liver function)
    • Suspected early cirrhosis
    • C/w partial segmentectomy,right liver
    • S/p cholecystectomy
    • Suboptimal examination of liver due to poor echo window
  • 2018-07-16 SONO - abdomen
    • Liver cirrhosis
    • Liver nodules?
    • Status post cholecystectomy
  • 2018-06-16 CT - abdomen
    • Liver cirrhosis.
    • HCC s/p wedge resecion. No local recurrence
  • 2018-03-17 CT - abdomen
    • HCC s/p operation and TACE with minimal viable tumor.
  • 2018-01-08 SONO - abdomen
    • HCC s/p segmentectomy
    • Liver lesions, nature?
    • Parenchymal liver disease
    • Status postcholecystectomy
  • 2017-12-23 CT - abdomen
    • HCC s/p operation and TACE. A residual HCC (1.5cm) at S8 of liver.
  • 2017-09-30, 2017-07-08, 2017-04-15 SONO - abdomen
    • liver cirrhosis/ incomplete exam of liver
    • GB sac not seen
  • 2017-01-24 SONO - abdomen
    • Liver cirrhosis
    • Post cholecystectomy
• surgical operation
  • 2020-07-08
    • Surgery
      • S8 resection
      • adhesivelysis
    • Finding
      • S8 recurrent tumor 5.5 x 5.0 x 3.5 cm
      • severe adhesion of liver and T-colon and diaphragm due to previous operation
      • mild liver cirrhosis
  • 2014-03-27 Hemorrhoidectomy
    • Hemorrhoids with a papillar lesion at 7 oclock position, another at 3 oclock position.
  • 2013-02-01 S5 segmentectomy with cholecysectomy
• Transarterial Chemoembolization, TACE
  • 2022-01-14 Embolization (TAE, TACE) - doxorubicin
  • 2021-11-26 Embolization (TAE, TACE) - doxorubicin
  • 2021-02-18 Embolization (TAE, TACE) - doxorubicin
  • 2020-06-09 Embolization (TAE, TACE) - doxorubicin
  • 2018-04-13 Embolization (TAE, TACE)
  • 2018-01-19 Embolization (TAE, TACE)
  • 2016-09-02 Embolization (TAE, TACE)
  • 2015-11-05 Embolization (TAE, TACE)
• chemoimmunotherapy
  • 2022-08-15 - cisplatin 40mg/m2 80mg 2hr + fluorouracil 2000mg/m2 4000mg 22hr (2002-08-08 CT progressive disease)
  • 2022-08-01 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-07-18 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-07-04 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-06-20 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-06-06 - oxaliplatin 80mg/m2 150mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-05-23 - oxaliplatin 70mg/m2 140mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-03-19 ~ 2022-05-10 - sorafenib 200mg/tab 2 BIDAC
  • 2022-03-11 - nivolumab 100mg 1hr
  • 2022-02-08 - nivolumab 100mg 1hr
  • 2022-01-14 - nivolumab 100mg 1hr
  • 2021-12-03 ~ 2021-12-31 - sorafenib 200mg/tab 1 BIDAC
  • 2021-02-26 ~ 2021-10-26 - sorafenib 200mg/tab 1 BIDAC
  • about one year, when? - lenvatinib

[assessment]

• Cisplatin was introduced during the last hospital stay (2022-08-15), but there are no hearing test records (e.g. pure tone audiometry) available. Prior to accumulating too much dose, it is recommended to obtain a baseline measurement.

220823

• present illness
  • 1. Hepatitis B carrier,
  • 2. Hepatocellular carcinoma, pT2NxMx, stage II, BLCL A, Child-pugh A s/p S5 segmentectomy with cholecysectomy on 2013/02/01,
  • 3. Recurrent HCC s/p S8 segmentectomy, rpT3N0M0,s tage IIIA on 2020/07/08.
  • 4. Recurrent HCC s/p TACE 7 times on 2015/11/5 ~ 2021/11/26.
• exam finding
  • 2022-08-22 CXR
    • Mass lesions in both lung zones
    • Right pleural effusion
  • 2022-08-08 CT - chest
    • Findings
      • Lungs:
        • multiple nodules of variable sizes throughout both lungs due to metastases, with relaxation atelectasis of RLL and RML.
        • moderate Rt pleural effusion.
        • further increase in size of a large metastatic tumor at Rt anterior chest wall involving adjacent mediastinum as compared with the previous CT on 20220611.
      • HCC, s/p many surgical resections. further progression of recurrent tumors in both hepatic lobes with tumor thrombi in left portal vein.
      • unremarkable of the spleen, pancreas, both kidneys, and both adrenal glands. no ascites or emlarged lymph nodes.
    • Impression:
      • recurrent HCC with lung and chest wall metastases, further in progression as compared with the previous CT on 2022/06/11.
  • 2022-08-04 Tc-99m MDP whole body bone scan with SPECT
    • 1. Mildly increased activity in some L-spines. Degenerative change may show this picture.
    • 2. Some faint hot spots in bilateral rib cages and increased activity in the sternum. The nature is to be determined. Please correlate with other clinical findings and follow up bone scan for further evaluation.
    • 3. Increased activity in bilateral shoulsers, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-06-11 CT - abdomen
    • Findings
      • 1. HCC, s/p operation. Progression of recurrent tumors in both hepatic lobes.
      • 2. Tumor thrombi in left portal vein.
      • 3. Right chest wall mass lesion, in progression.
      • 4. No ascites, nor extraluminal free air.
      • 5. No bony destructive lesion on these images.
    • Impression
      • Recurrent HCCs, in progression
      • Left portal vein thrombosis
      • Right chest wall metastasis, in progression
  • 2022-06-11 CXR
    • Focal upward bulging of right diaphragm is noted. please correlate with clinical condition or CT.
  • 2022-04-01 Patho - pleural/pericardial biopsy
    • Labeled as “R superior chest wall tumor”, CT-guided biopsy — poorly differentiated carcinoma.
    • IHC stains: CK (+), GATA-3 (+), mammoglobin (-), E-cadherin (-), hepatocyte (-), Arginase-1 (-), AFP (-), ER (-), PR (-), Her2/neu: negative (score = 0), Ki-67: 90%.
    • Section shows soft tissue with infiltration of trabeculae of poorly differentiated carcinoma.
  • 2022-04-01 CXR
    • Focal upward bulging of right diaphragm is noted. please correlate with clinical condition or CT.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-03-21 CT - chest
    • Findings
      • Lungs: subtle mosaic attenuation in both lower lobes and posterior both Lt upper lobe. old calcified LN in the left anterior prevascular space, sequela of previous TB infection
      • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Chest wall: Rt thyroid lobe calcification 11 mm.
        • a well-defined soft-tissue mass with cystic and solid components (16x27x16 mm) at Rt paramedian superior anterior chest wall (beneath the pectoralis msucle).
      • Visible abdo > S/P resection of right lobe liver.
        • poor enhancing iInfiltrative tumor in left lobe liver and enhancing tumor (2 cm) in S7 liver due to recurrent HCCs.
        • Presence of central portal venous thrombosis.
      • unremarkable of the spleen, adrenal glands, pancreas, and kidneys.
      • Visualized bones: unremarkable.evaluation.
    • Impression:
      • Rt superior anterior chest wall mass, metastatic tumor or a primary intercostal chest lesion.
  • 2022-02-26 CT - abdomen
    • Findings
      • S/P resection of right lobe liver.
      • Infiltrative tumor in left lobe liver, enhancing tumor (2cm) in S7 liver, could be due to recurrent HCCs.
      • Presence of portal venous thrombosis, progression.
    • Impression:
      • S/P resection of right lobe liver.
      • Recurrent HCCs with progression of portal venous thrombosis.
  • 2022-01-10 MRI - liver, spleen
    • Findings:
      • 1. There are two ill-defined masses, measuring 2.4 cm in S7 dome and 3.1 x 2.7 cm in S4 of the liver. During dynamic study, two masses show contrast enhancement in arterial phase images and no significant evidence of contrast washout in portal venous phase and delayed phase images.
        • HCCs are highly suspected.
        • In addition, The S4 lesion shows hypointensity on T1WI and it directly connected with left portal vein thrombosis.
        • Recurrent HCC at S4 with directly invasion causing portal vein tumor thrombsis is highly suspected.
      • 2. Prior CT suspected Two ill-defined poor enhancing area in left lobe liver are not noted in the current MRI that are c/w flow artifacts.
      • 3. Prior CT identified an ill-defined enhancing lesion measuring 2.9 x 2.6 cm in S2/3 of the liver at arterial phase images is not noted in the current MRI and the mechanism may be hyperemia (compensatory increased arterial flow in arterial phase images secondary to portal vein thrombosis).
           
      • 4. The liver shows irregular contour and atrophy of segment 4 that is consistent with cirrhosis.
        • There is mild esophageal varices that may be portal hypertension.
      • 5. S/P cholecystectomy. S/P partial resection of S5 and S8 of the liver.
    • Impression:
      • 1. Two recurrent HCCs on S7 dome and S4 are suspected.
           
      • 2. Recurrent HCC at S4 causing left lobe portal vein tumor thrombosis is highly suspected.
  • 2022-01-05 CT - abdomen
    • Findings:
      • 1. There are three ill-defined iso-hypodense lesion, measuring 2.4 cm in S7 dome, 2.9 x 2.6 cm in S2/3, and 3.2 x 2.6 cm in S4, of the liver. During dynamic study, all masses show contrast enhancement in arterial phase images and Eqivocal contrast washout in portal venous phase and delayed phase images.
           
        • HCCs are highly suspected.
      • 2. Two ill-defined poor enhancing area in left lobe liver are suspected and non-enhancement of left portal vein.
        • Please correlate with MRI to R/O infiltrative type HCCs with tumor thrombosis in left portal vein.
      • 3. The liver shows irregular contour and atrophy of segment 4 that is consistent with cirrhosis.
        • There is mild esophageal varices that may be portal hypertension.
      • 4. S/P cholecystectomy. S/P partial resection of S5 and S8 of the liver.
    • Impression:
      • 1. Three recurrent HCCs on both hepatic lobes are suspected.
           
      • 2. Infiltrative type HCCs at left hepatic lobe with tumor thrombosis in left portal vein are suspected.
      • Please correlate with MRI.
  • 2021-10-04 MRI - liver, spleen
    • Findings
      • HCC s/p operation and TACE. Some small marginal enhancing nodules (up to 1.7cm) in both hepatic lobes.
    • IMP:
      • HCC s/p operation and TACE. Some small marginal enhancing nodules (up to 1.7cm) in both hepatic lobes c/w tumor recurrence.
  • 2021-09-29 SONO - abdomen
    • Hepatic tumor suspected HCC (inconspicuous)
    • Liver cirrhosis
    • post cholecystectomy
  • 2021-08-14 CT - abdomen
    • Findings
      • s/p cholecystectomy and S5 resetion.
      • Hypervascular hepatic tumor at S4 of liver up to 1.94cm in largest dimension. Suggest closely follow up.
      • The portal vein and IVC are patent.
      • Another low density lesion at dome about 2.0cm in largest dimension. HCC?
      • Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis. Suggest clinical correlation
    • Imp:
      • Suspected hepatic tumors at S4 and S5 of liver. Suggest correlate with other findings.
  • 2021-06-11 SONO - abdomen
    • 1. A hypoechoic lesion 1.49 cm in S2/3 of the liver is noted that may be tumor or fat sparing area. Please correlate with contrast enhanced dynamic CT or MRI.
    • 2. S/P partial resection of S7-8 of the liver and cholecystectomy.
  • 2021-03-08 MRI - liver, spleen
    • HCC s/p operation and TACE without enhancing tumor.
  • 2021-03-08 SONO - abdomen
    • Liver lesion, nature?
    • Liver cirrhosis, mild fatty liver
    • Post cholecystectomy
    • Fatty pancreas
  • 2021-02-01 MRI - liver, spleen
    • HCC s/p operation and TACE. A recurrent HCC (1.8cm, srs8, img23) at liver dome.
  • 2020-11-28 CT - abdomen
    • Liver cirrhosis with HCC s/p S5 and S8 op. with borderline enhanced region at S7 just near previous TACE region. Suggest closely follow up.
  • 2020-09-08 SONO - abdomen
    • S/P cholecystectomy and partial resection of S7-8 of the liver.
  • 2020-07-09 Patho - liver partial resection
    • pathologic diagnosis
      • 1. Liver, S8, segmental hepatectomy — Hepatocellular carcinoma, recurrent
           
      • 2. Pathologic Staging: rpT3Nx; Stage IIIA at least
    • microscopic examination
      • 1. Histologic Type: Hepatocellular carcinoma, trabecular type with focal intratumoral fibrosis
           
      • 2. Histologic Grade: Poorly differentiated (G3)
           
      • 3. Tumor Necrosis: Present
           
      • 4. Tumor Capsule: Encapsulated with focal infiltrative border
           
      • 5. Tumor Extension: Tumor confined to liver
           
      • 6. Large Vessel Invasion: Not identified
           
      • 7. Small Vessel Invasion: Present
           
      • 8. Perineural Invasion: Not identified
           
      • 9. Pathologic Staging (rpTNM): Stage IIIA at least (rpT3Nx)
           
      • 10. Margins
            
        • 10.1 Parenchymal Margin: Free, 1.6 cm from closest margin
          
        • 10.2 Hepatic Capsule: Uninvolved by invasive carcinoma
          
      • 11. Additional Pathologic Findings: Small cell and large cell changes
            
      • 12. Hepatitis (specify type): Hepatitis B
            
      • 13. Ishak Modified HAI Grading: Score=3 (interphase hepatitis = 1/4, confluent necrosis = 0/6, focal necrosis = 0/4, portal inflammation = 2/4) (Corresponding Metavir A1, mild activity)
            
      • 14. Ishak Staging: F6 (Corresponding Metavir F4, cirrhosis)
            
      • 15. Fatty Change: Present (10%)
  • 2020-05-30 CT - abdomen
    • Hepatic tumor at dome, recurrent HCC is considered.
  • 2020-05-23 SONO - abdomen
    • Liver tumor: suspect HCC
    • Liver cirrhosis, mild fatty liver
    • post cholecystectomy
  • 2020-02-14 SONO - abdomen
    • Findings:
      • 1. Status post partial resection of S5/8 of the liver.
        • The residual liver shows normal in size and echogenicity without focal lesion.
          
        • Portal vein flow: patent.
        • Bile ducts: not dilated.
      • 2. Status post cholecystectomy.
      • 3. The pancreatic head and body shows normal in size and texture.
        • The pancreatic tail is obscured by overlying bowel gas.
      • 4. The spleen shows normal in size and echogenicity without focal lesion.
      • 5. Abdominal aorta and IVC show unremarkable finding.
      • 6. There is no evidence of para-aortic lymphadenopathy or ascites.
      • 7. Both kidney show normal echopattern and size.
        • There is no evidence of stone or hydronephrosis.
    • Impression:
      • 1. S/P cholecystectomy and partial resection of S5/8 of the liver.
      • 2. Otherwise, no significant abnormal finding is noted.
  • 2019-10-05 CT - abdomen
    • HCC s/p operation and TACE without viable tumor.
  • 2019-08-26 SONO - abdomen
    • HCC, Status post partial right segmentectomy (S5/8)
    • Liver tumors?
    • Liver cirrhosis
    • Status post cholecystectomy
  • 2019-06-08 CT - abdomen
    • HCC s/p operation and TACE without viable tumor.
  • 2019-03-04 SONO - abdomen
    • Liver cirrhosis
    • Status post cholecystectomy
    • Status post partial right segmentectomy (S5/8)
  • 2018-12-01 CT - abdomen
    • HCC s/p operation and TACE without viable tumor.
  • 2018-09-07 SONO - abdomen
    • Suspected chronic liver parenchyma disease (Please correlate with liver function)
    • Suspected early cirrhosis
    • C/w partial segmentectomy,right liver
    • S/p cholecystectomy
    • Suboptimal examination of liver due to poor echo window
  • 2018-07-16 SONO - abdomen
    • Liver cirrhosis
    • Liver nodules?
    • Status post cholecystectomy
  • 2018-06-16 CT - abdomen
    • Liver cirrhosis.
    • HCC s/p wedge resecion. No local recurrence
  • 2018-03-17 CT - abdomen
    • HCC s/p operation and TACE with minimal viable tumor.
  • 2018-01-08 SONO - abdomen
    • HCC s/p segmentectomy
    • Liver lesions, nature?
    • Parenchymal liver disease
    • Status postcholecystectomy
  • 2017-12-23 CT - abdomen
    • HCC s/p operation and TACE. A residual HCC (1.5cm) at S8 of liver.
  • 2017-09-30, 2017-07-08, 2017-04-15 SONO - abdomen
    • liver cirrhosis/ incomplete exam of liver
    • GB sac not seen
  • 2017-01-24 SONO - abdomen
    • Liver cirrhosis
    • Post cholecystectomy
• surgical operation
  • 2020-07-08
    • Surgery
      • S8 resection
      • adhesivelysis
    • Finding
      • S8 recurrent tumor 5.5 x 5.0 x 3.5 cm
      • severe adhesion of liver and T-colon and diaphragm due to previous operation
      • mild liver cirrhosis
  • 2014-03-27 Hemorrhoidectomy
    • Hemorrhoids with a papillar lesion at 7 oclock position, another at 3 oclock position.
  • 2013-02-01 S5 segmentectomy with cholecysectomy
• Transarterial Chemoembolization, TACE
  • 2022-01-14 Embolization (TAE, TACE) - doxorubicin
  • 2021-11-26 Embolization (TAE, TACE) - doxorubicin
  • 2021-02-18 Embolization (TAE, TACE) - doxorubicin
  • 2020-06-09 Embolization (TAE, TACE) - doxorubicin
  • 2018-04-13 Embolization (TAE, TACE)
  • 2018-01-19 Embolization (TAE, TACE)
  • 2016-09-02 Embolization (TAE, TACE)
  • 2015-11-05 Embolization (TAE, TACE)
• chemoimmunotherapy
  • 2022-08-15 - cisplatin 40mg/m2 80mg 2hr + fluorouracil 2000mg/m2 4000mg 22hr
  • 2022-08-01 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-07-18 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-07-04 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-06-20 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-06-06 - oxaliplatin 80mg/m2 150mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-05-23 - oxaliplatin 70mg/m2 140mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-03-19 ~ 2022-05-10 - sorafenib 200mg/tab 2 BIDAC
  • 2022-03-11 - nivolumab 100mg 1hr
  • 2022-02-08 - nivolumab 100mg 1hr
  • 2022-01-14 - nivolumab 100mg 1hr
  • 2021-12-03 ~ 2021-12-31 - sorafenib 200mg/tab 1 BIDAC
  • 2021-02-26 ~ 2021-10-26 - sorafenib 200mg/tab 1 BIDAC
  • about one year, when? - lenvatinib

[assessment]

• Apresoline (hydralazine) and Sevikar (amlodipine + olmesartan) reduced blood pressure from 181/108 (2022-08-22 19:46) to 153/87 (2022-08-23 08:44).
• If cellulitis of lower limbs is still a diagnosis, then parenteral antibiotics without an indication for MRSA in higher risk patients could be:
  • cefazolin 1 to 2 g IV Q8H
  • oxacillin 1 to 2 g IV Q4H

700994233

220901

• family history
  • mother: cervical cancer
  • father: parkinson’s disease
• lab data
  • 2022-08-25 Anti-HBc Reactive
    
  • 2022-08-25 Anti-HBc-Value 5.79 S/CO
    
  • 2022-08-25 Anti-HBs 58.45 mIU/mL
    
  • 2022-08-19 HBsAg Nonreactive
    
  • 2022-08-19 HBsAg (Value) 0.42 S/CO
    
  • 2022-08-19 Anti-HCV Nonreactive
    
  • 2022-08-19 Anti-HCV Value 0.09 S/CO
• exam finding
  • 2022-08-26 Patho - liver biopsy needle/wedge
    • Liver, EUS-FNB — Adenocarcinoma, pancreatobiliary type, moderately differentiated
    • The sections show a picture of adenocarcinoma, pancreatobiliary type, moderately differentiatrf, composed of liver tissue with nests, cords, and single cuboidal to low columnar neoplastic cells with glandular differentiation in fibrous stroma. Intracellular and extracellular mucin secretion can be found.
    • IHC shows: CK7(+), CA19-9(+), CK20(-), and CDX2(-).
  • 2022-08-26 Needle Aspiration Cytology - pancreas
    • Indication: suspected pancreas cancer with liver metastasis, T3N2M1, stage IV
    • Pathologic diagnosis: pancreatic tumor, suspicious for malignancy
  • 2022-08-26 Endoscopic Ultrasonography, EUS
    • 1. Pancreatic body tumor, s/p CH-EUS & EUS/FNB (B)
    • 2. Liver tumor, favor metastatic lesion, s/p CH-EUS & EUS/FNB (A)
    • 3. Suspected SMV thrombus or tumor direct invasion to SMV
  • 2022-08-22 CT - abdomen
    • Findings
      • A poor enhancing tumor (2.7x4.7cm) in pancreatic body and tail with adjacent fat stranding.
      • Multiple liver tumors.
      • Some soft tissues in peritoneal cavity with ascites.
      • Some LNs at retroperitoneum.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:IV(Stage_value)
  • 2022-08-19 Esophagogastroduodenoscopy, EGD
    • erosive esophagitis LA Classification grade A
    • superficial gastritis, post CLO test
    • gastric erosions, multiple, whole stomach
  • 2022-08-19 SONO - abdomen
    • Liver tumors, multiple, nature?
    • Parenchymal live disease
    • Borderline splenomegaly
    • Minimal ascites
    • Gall stones

[note]

• 2022-09-01 Pilian (cyproheptadine 4mg/tab) 1# TID - off-label: Decreased appetite secondary to chronic disease; Serotonin syndrome; Spasticity associated with spinal cord damage
  • Efficacy and Tolerability of Cyproheptadine in Poor Appetite: A Multicenter, Randomized, Double-blind, Placebo-controlled Study - https://sci-hub.se/10.1016/j.clinthera.2021.08.001
  • Cyproheptadine: Drug information - https://www.uptodate.com/contents/cyproheptadine-drug-information (2022-09-01)
    • Dosing: Adult
      • Appetite, decreased secondary to chronic disease
        • Appetite, decreased secondary to chronic disease (off-label use): Oral: Initial: 2 mg 4 times per day for 1 week, then 4 mg 4 times per day (Homnick 2004; Homnick 2005).
      • Serotonin syndrome, moderate
        • Serotonin syndrome (serotonin toxicity), moderate (off-label use):
          • Note: Reserve for patients with agitation despite discontinuation of serotonergic agent(s), adequate sedation (eg, with a benzodiazepine), and supportive care (Boyer 2005; Sun-Edelstein 2008).
          • Oral: Initial: 12 mg once followed by 2 mg every 2 hours until clinical response. Maintenance: 4 to 8 mg every 6 hours as needed. Maximum dose: 32 mg/day (Boyer 2005; Sun-Edelstein 2008).
      • Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
    • Dosing: Kidney Impairment: Adult
      • No dosage adjustment provided in manufacturer’s labeling. However, elimination is diminished in renal insufficiency.
    • Dosing: Hepatic Impairment: Adult
      • No dosage adjustment provided in manufacturer’s labeling.

701037871

220830

{hypopharynx squamous cell carcinoma, cT3N1M0}

• diagnosis
  • 2022-08-16 discharge diagnosis
    • 1: Squamous cell carcinoma, posterior wall of hypopharynx, cT3N1M0, stage III status post port-A catheter implantation, tracheostomy, and laparoscopic gastrostomy and on 2022-07-21
    • 2: Ventral hernia status post repair of ventral hernia on 2022-08-04
    • 3: Bilateral pleural effusion status post left pigtail catheter insertion on 2022-07-26, and right pigtail catheter insertion on 2022-07-27
    • 4: Liver S6 hemangioma
    • 5: Subcutance emphysema
    • 6: Occlusion and stenosis of right middle cerebral artery
    • 7: Atrial fibrillation
    • 8: Type 2 diabetes mellitus without complications
    • 9: Pyuria( urine culture no growth on 2022-07-24)
    • 10: Systemic lupus erythematosus
    • 11: Hypertension
    • 12: Hyperlipidemia
    • 13: Diarrhea, unspecified
    • 14: Insomnia, unspecified
    • 15: Gout, unspecified
• exam finding
  • 2022-08-26 SONO - chest
    • 1. left side small amount of pleural effusion
    • 2. right side moderate amount of pleural effusion over dependent portion, 400cc serosangious fluid was aspirated for analysis.
  • 2022-08-24 CXR
    • left shoulder: Prior arthroplasty
    • Port-A catheter inserted into SVC via left subclavian vein.
    • enlarged cardiac silhoutte; old fracture of multiple Lt ribs
      
    • Rt greater than Lt bilateral pleural effusions
    • Consolidation and volume reduce over Rt upper lobe
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
  • 2022-08-24 CT - brain
    • Old cerebral infarcts. Mild general brain atrophy. Hypopharyngeal tumor.
  • 2022-08-24 ECG
    • Atrial fibrillation
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-08-12 CXR
    • S/P port-A implantation.
    • S/P endotracheal intubation with the tip beyond the carina
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-08-02 CT - abdomen
    • 1. S/P gastrostomy.
    • 2. Bilateral chest wall subcutaneous emphysema.
    • 3. Liver tumors, r/o hemangiomas.
    • 4. Dense calcification in right lobe liver.
    • 5. Bilateral pleural effusion with basal lung atelectasis.
    • 6. L2-3 compression fractures.
  • 2022-07-29 CXR
    • enlarged cardiac silhoutte; old fracture of multiple Lt ribs
      
    • Subcutaneous emphysema in the right and left neck and chest wall in regression
    • bilateral pleural effusions s/p pigtail drains placement
  • 2022-07-19 Whole body PET scan
    • 1. Glucose hypermetabolism in the posterior wall of the hypopharynx, compatible with primary hypopharyngeal malignancy.
    • 2. Glucose hypermetabolism in some focal areas in the right retropharyngeal and right neck level II areas. Metastatic lymph nodes may show this picture. Please correlate with other clinical findings for further evaluation.
    • 3. Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammatory process may show this picture.
    • 4. Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • 5. No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-07-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (107 - 38) / 107 = 64.49%
    • 1. Preserved LV systolic function with normal wall motion
    • 2. Dilated LA, LV and RV hypertrophy
    • 3. c/w RHD with multiple valve involvement (RHD: rheumatic heart disease)
    • 4. Mild MR, TR and moderate to severe AR
    • 5. Impaired RV systolic function
  • 2022-07-14 Patho - esophageal biopsy
    • Hypopharynx, posterior wall, biopsy — Compatible with squamous cell carcinoma and ulcer
    • Microscopically, the sections show a picture of high grade dysplasia of squamous epithelium with focal squamous cell carcinoma in situ, ulcer with inflammatory exudate and necrotic debris, and inflamed, scant stroma with focal epithelial budding or few isolated nest, compatible with squamous cell carcinoma, moderately differentiated.
    • Immunohistochemistry of P16 (-), CK(+), P63(+) and P53(+, diffuse) for tumor. Clinical correlation is advised.
  • 2022-07-13 CT - neck
    • Thickening wall with enhancement at hypopharynx more severe at right side, suspected hypopharyngeal malignancy, suggest further study.
  • 2022-07-13 ECG
    • Atrial fibrillation
    • Nonspecific ST and T wave abnormality
  • 2022-07-13 CXR
    • Increase bilateral lung markings.
    • Mild cardiomegaly.
    • Tortuous thoracic aorta with intimal calcification.
    • Thoracic spondylosis.
    • Post-op at left proximal humerus.
    • Old fractures at left ribs.
  • 2022-07-13 Neck soft tissue
    • No radiopaque foreign body noted.
    • No evidence of prevertebral soft tissue swelling.
  • 2022-07-13 Nasopharyngoscopy
    • smooth NPx, OPx, bulging of R arytenoid (unable to see vocal cord, NBI+), mild saliva pooling at HPx
  • 2022-07-13 Esophagogastroduodenoscopy, EGD
    • Findings
      • Ulcerative change of the mucosa at the posterior wall of hypopharynx with easy touched bleeding with edematous change of the surrounding mucosa. Even the fine-caliber endoscopy couldn’t pass the upper esophageal sphincter.
    • Diagnosis
      • Suspect hypopharynx or esophageal malignancy with obstuction of esophagus, s/p biospy
    • Suggestion
      • neck to chect CT scan
      • monitor her respiratory condition, the risk of apsiration is high. consider intubation if the bleeding persisted
  • 2022-06-11 CT - lung
    • Suspected bil. bronchiolitis.
  • 2022-06-11 Abdomen - supine (diaphragm)
    • S/P NG tube indwelling.
    • Compression fracture of L1-3.
  • 2022-06-11 MRA - brain
    • Brain atrophy with multiple old lacunar brain infarcts.
  • 2022-06-11 ECG
    • Atrial fibrillation with rapid ventricular response
    • LVH with ST T changes
  • 2022-06-10 CXR
    • elongated and tortuosity of thoracic aorta and diffuse calcified atherosclerotic change at aortic arch and D-aorta. dilated ascending aorta
    • mild enlarged cardiac silhoutte due to dilated cardiac chamber (LAD) and prominent cardiophrenic angle mediastinal fat pad
    • coliosis of the spine
    • Lt shoulder prior hemiarthroplasty
    • old fracture of many Lt ribs
    • Compression fracture of L1-L3 vertebral bodies
  • 2022-05-16 Swallowing video fluoroscopy
    • Abnormal contour of hypopharynx.
    • Easy chocking during swallowing.
  • 2022-05-12 Nasopharyngoscopy
    • smooth NPx, OPx, HPx, R vocal palsy, mild saliva pooling at HPx
  • 2022-05-05 Neurosonology
    • 1. Mild (to moderate) atheromatous lesions in bilateral CCA bifurcations; mild atheromatous lesions in bilateral middle to distal CCA.s
    • 2. Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • 3. Poor bilateral temporal windows for transcranial insonation.
  • 2020-12-15 Knee Bilat. standing
    • Osteoarthritis change of both knees with joint space narrowing and marginal spur formation. Osteopenia of visible bones. Loose bodies in the right knee joint.
  • 2020-09-17 ECG
    • Atrial flutter with variable A-V block
    • ST & T wave abnormality, consider inferior ischemia
  • 2020-07-30 CXR
    • cardioemgaly; and mediastinal widening
    • s/p post-OP change in the left humeral bone; and fractures in the left middle ribs.
  • 2020-07-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (128 - 50) / 128 = 60.94%
    • 1. Adequate LV systolic function with normal resting wall motion
    • 2. RHD with mild MR; dilated LA (RHD: rheumatic heart disease)
    • 3. Aortic valve calcification with mild to moderate AS; moderate AR
    • 4. mild MR, trivial TR
    • 5. Preserved RV systolic function
    • 6. Atrial fibrillation at the exam
  • 2020-05-26 Neurosonology
    • 1. Moderate (to severe) atheromatous lesions in R CCＡbifurcation; mild (to moderate) atheromatous lesions in R proximal CCA, L distal CCA to CCA bifurcation; mild atheromatous lesions in L middle CCA, R middle to distal CCA, R ICA, R ECA and R subclavian artery.
    • 2. Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • 3. Poor bilateral temporal windows for transcranial insonation.
    • 4. Normal bilateral ophthalmic arterial flows
  • 2018-06-19 CT - brain
    • Lacunar infarcts, brain atrophy, and intracranial arteriosclerosis
  • 2018-06-06 Color Transcranial Doppler Sonographic diagnosis:
    • 1. Mild (to moderate) atheromatous lesions in bilateral CCA bifurcations; mild atheromatous lesions in bilateral distal CCAs and right subclavian artery. Irregular heart beats.
    • 2. Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • 3. Poor bilateral temporal windows for transcranial insonation.
  • 2018-06-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (103 - 35.6) / 103 = 65-44%
      • Dilated LA
      • Septal hypertrophy
      • Adequate LV and RV performance
      • AV sclerosis with moderate AR ; mild AS
      • Calcified mitral annulus and mitral valve with mild to moderate MR; mild TR and PR
      • Possibly mild pulmonary HTN
      • No regional wall motion abnormalities
      • Atrial fibrillation
  • 2018-06-05 MRA - brain
    • recent lacunar infarct, Rt thalamus.
    • Multiple old lacunar infarcts, deep cerebral hemisphere and pons. Intracranial ICAs and VAs atherosclerosis.
    • Brain atrophy.
    • Bilateral subcortical and periventricular white matter change (leukoaraiosis).
  • 2018-06-05 CT - brain
    • A recent infarct in right centrum semiovale
    • Lacunar infarcts, brain atrophy, and intracranial arteriosclerosis
  • 2018-06-05 ECG
    • Atrial fibrillation
• consultation
  • 2022-08-02 Oral and Maxillofacial Surgery
    • Q
      • The 76 year-old female with the underlying of
        • 1. HTN
        • 2. SLE
        • 3. type II diabetes mellitus
        • 4. Atrial flutter
        • 5. Old CVA of right side
        • 6. Dysphagia had problem of swollow.
      • The patient had had difficulty in swallowing for 2 months. She visited OPD today for changing of nasogastric tube. She can not restore the new NG tube after the old one removed. The she brought to our ER and ENT with the trying of re-on NG tube but in vain. The CT revealed thickening wall with enhancement at hypopharynx more severe at right side, suspected hypopharyngeal malignancy. So she was admitted to our ward for further management and survey. Panendoscopy show suspect hypopharynx or esophageal malignancy with obstuction of esophagus, s/p biospy. Pathology show Hypopharynx squamous cell carcinoma, cT3N1M0. Then tracheostomy, prot-A and gastrostomy were performed on 2022/07/21. Post operation, she was admitted to SICU for intensive care. After treatment, we started try collar mask trainning, and tried over night well since 2022-07-29. Under stable hemodynamic status, she was transferred to ward for care on 2022-08-01.
      • Further CCRT will be arranged, so we need consult you for pre-RT dental evaluation and management. Thank you very much.
    • A
      • we are consulted for dental evaluation prior to definitive CCRT for hypopharyngeal cancer.
      • As she depends on oxygen treatment via tracheostomy. Bedside physical examination was done.
      • No periodontal disease of full mouth or deep carious teeth were noticed.
      • Plan:
        • 1. Explain the findings to the patient and her daughter
        • 2. Oral hygiene reinforcement
  • 2022-08-02 Relabilitation
    • Q
      • Since esophageal malignancy was also suspected accoring to the report of upper gastrointestinal endoscopy, CS was consulted for evaluation of gastrostomy or jejunostomy. With the impression of hypopharyngeal tumor, the patient was admitted for further evaluation and management.
        
    • A
      • Due to deconditioning, we were consulted for bedside PT rehabilitation programs.
      • Premorbid status
        • wheelchair bound
          
        • heavy hygeiene: maximal assistance
      • Physical examination
        • 2022/08/01 20:11 T/P/R: 36.9℃ / 87bpm / 19bpm BP:114/54mmHg
        • Body weight: 58
        • Consciousness: E4VTM6
        • Cognition: mostly intact; could follow orders
        • Speech: could not speak due to tracheostomy
        • Swallowing: Gastrostomy (+)
        • Sphincter: Foley (+), stool incontinence
        • MP:
          • RUL3 LUL3
          • RLL2 LLL2
        • Functional status: needs max assistance
        • BADL: needs max assistance
      • Assessment
        • 1. Squamous cell carcinoma, s/p tracheostomy, prot-A and gastrostomy on 2022/07/21
        • 2. HTN
        • 3. SLE
        • 4. type II diabetes mellitus
        • 5. Atrial flutter
        • 6. Old CVA of right side
             
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
  • 2022-07-20 Radiation Oncology
    • Q
      • We would like to consult your expertise on arrangement of CCRT for the patient, thank you!
    • A
      • S: For CCRT due to hypopharyngeal carcinoma.
        • PI: The patient with the underlying of 1. HTN 2. SLE 3. type II diabetes mellitus 4. Atrial flutter 5. Old CVA of right side 6. Dysphagia. She can not restore the new NG tube after the old one removed. The she brought to our ER and ENT with the trying of re-on NG tube but in vain. The CT scan revealed thickening wall with enhancement at hypopharynx more severe at right side, r/o hypopharyngeal malignancy. Referred for CCRT.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (quit); Smoking (-); Betel nut (-).
        • Personal Hx: DM(-); HTN(-)
        • Allergy(-)
        • Travel Hx(-)
        • Other disease: SLE
        • Previous RT Hx: (-)
      • O:
        • ECOG: 1
        • PE: neck and bil SCF: neg.
        • CXR (2022-7-13): Increase bilateral lung markings. Mild cardiomegaly. Tortuous thoracic aorta with intimal calcification. Thoracic spondylosis. Post-op at left proximal humerus. Old fractures at left ribs.
        • UGI endoscopy (2022-7-13): Suspect hypopharynx or esophageal malignancy with obstuction of esophagus, s/p biopsy.
        • CT scan of neck (2022-7-13): Thickening wall with enhancement at hypopharynx more severe at right side, r/o hypopharyngeal malignancy, suggest further study.
        • Pathology (S2022-11210, 2022-7-18): Hypopharynx, posterior wall, biopsy — Compatible with squamous cell carcinoma and ulcer. Immunohistochemistry of P16 (-), CK(+), P63(+) and P53(+, diffuse) for tumor.
        • PET (2022-7-19): 1.Glucose hypermetabolism in the posterior wall of the hypopharynx, compatible with primary hypopharyngeal malignancy. 2.Glucose hypermetabolism in some focal areas in the right retropharyngeal and right neck level II areas. Metastatic lymph nodes may show this picture.
      • A: Squamous cell carcinoma of the hypopharynx, p16(-), stage cT4aN2bM0 (IVA).
      • P: Radiotherapy is indicated for this patient with the following indicators: advanced stage hypopharyngeal carcinom
        • Goal: curative
        • Treatment target and volume: hypopharyngeal tumor to bilateral neck
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the hypopharyngeal tumor to bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor bed to right neck involved nodal lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started 1330, 2022-7-27.
        • Please consult Dental department for pre-RT dental evaluation and management.
  • 2022-07-15 Cardiology
    • Q
      • After admitted, she was diffcultly swallowing, nutrition supplement under PPN, we will arrange operation with gastrostomy on next W1. The patient recevid Digoxin and Eliquis for Atrial flutter and Old CVA. We need your help for anti-coagulation therapy. Thank you very much!!
    • A
      • S
        • This is a 76 years old lady who was admitted for hypopharynx more severe at right side, suspected hypopharyngeal malignancy. We were consulted for anticoagulant medication.
      • O
        • BP 140/63 HR 84
        • Heart: IRRHB with systolic murmur, Gr II
        • EKG: Permenant Af
        • CxR borderline cardiomegaly
      • As patient is undergoing to receive head and neck operation, a major operation with high bleeding risk procedure (2 days risk of major bleed 2-4%)
      • current problems
        • 1. Atrial fibrillation
        • 2. History of mitral valve stenosis and aortic stenosis
        • 3. diffcultly swallowing; suspected hypopharyngeal malignancy
        • 4. Suspected CAD (because of coronary artery calcification by chest CT)
      • Suggestion
        • 1. becauase of patient could not swallowing, she stop Eliquis. maybe shift to enoxaparin 50mg SC Q12H for prevent AF related stroke and for possible CAD.
        • 2. If patient operation, please stop enoxaparin for one dose (stop enoxaparin 12 hours)
        • 3. Arrange 2D echo because of hx of AS. MS, and possible CAD
        • 4. check BW QD and consider check I/O if pulmonary edema
        • 5. difficulty in swallowing might lead to dehydration, now on TPN, it still risk of fluid overload, maybe check CxR prn if dyspnea or Q3~4Days
        • 6. if AF HR>110, amiodarone IV is indication.
  • 2022-07-14 Thoracic Surgery
    • A
      • Hpopharyngeal tumor was seen and biopsy was done.
      • Since sophageal malignancy could not be ruled out, I will arrange admission for further evaluation and management.
  • 2022-07-13 ENT
    • A
      • Dysphagia, unable to swallow.
      • Scope: smooth NPx, OPx, bulging of R arytenoid (unable to see vocal cord, NBI+), mild saliva pooling at HPx
      • Imp: Hypopharynx tumor, suspect malignancy
      • Plan:
        • 1. Pending esophageal biopsy
        • 2. Gastrostomy for nutrition, patient’s family member agreed
        • 3. ENT OPD f/u for esophageal biopsy report, futher tx if proved malignancy
• surgical operation
  • 2022-08-04 Repair of ventral hernia
  • 2022-07-21 Port-A catheter implantation, tracheostomy, and laparoscopic gastrostomy
    • Finding
      • 1. A 7.0-French Polysite port inserted through left cephalic vein toward superior vena cava for about 20cm long.
      • 2. The port implanted at upper chest below lateral 1/3 of left clavicle.
      • 3. Tracheostomy tube: 7.0mm ID Rota-Trach Tracheostomy Tube.
      • 4. Gastrostomy tube: Cook PEG-24-PULL-S.
      • 5. Percutaneous endoscopic gastrostomy converted to laparoscopic gastrostomy due to incapability of the upper gastrointestinal endoscope to pass the esophagus.
      • 6. One liver tumor noted over S6, suspected hemangioma (in GS doctor’s opinion).
      • 7. Estimated blood loss: 10ml.
  • 2018-06-13 L3 compression fracture
    • Compression of with collapse of the body height 60%
• radiotherapy
  • 2022-08-12 ~ - at 1000cGy/5 fractions of the hypopharyngeal tumor to bilateral neck.
• chemoimmunotherapy
  • 2022-08-24 - cisplatin 30mg/m2 45mg 2hr (CCRT)
  • 2022-08-17 - cisplatin 30mg/m2 45mg 2hr (CCRT)
  • 2022-08-12 - cisplatin 30mg/m2 45mg 2hr (CCRT)

[assessment]

• For the patient’s underlying heart condition, Eliquis (apixaban 5mg) 1# BID had been prescribed by our OPD for routine refilling prior to this hospital stay. The drug is recommended and can also be administered with nasogastric tube.

700945739

220826

• exam finding
  • 2022-08-26 Whole body PET scan
    • 1. A glucose hypermetabolic lesion in the pancreatic head. Primary malignancy in the pancreatic head may show this picture. Please correlate with other clinical findings for further evaluation.
    • 2. Mild glucose hypermetabolism in some abdominal paraaortic lymph nodes. Either inflammatory process or metastatic lymph nodes of low FDG uptake may show this picture.
    • 3. A mild glucose hypermetabolic lesion in the upper lobe of left lung. The nature is to be determined (inflammation? primary lung malignancy or lung metastasis of low FDG uptake? other nature?). Please also correlate with other clinical findings for further evaluation.
    • 4. Mild glucose hypermetabolism in the midline anterior abdominal wall, compatible with post-operative inflammation.
    • 5. Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • 2022-08-05 Patho - gallbladder (benign lesion)
    • Gallbladder, laparoscopic cholecystectomy — Chronic cholecystitis and cholelithiasis
  • 2022-08-04 CXR
    • S/P right pig-tail catheter indwelling.
    • S/P operation.
    • S/P NG tube indwelling.
    • Right catheterization to SVC in position.
    • S/P Port-A infusion catheter insertion.
    • Ground glass opacity in bilateral lower lungs.
  • 2022-07-28 Flow Volume Loops
    • Mild restrictive ventilatory impairment
  • 2022-07-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 33) / 81 = 59.26%
    • 1. Adequate LV systolic function with normal resting wall motion
    • 2. Trivial MR and trivial TR
    • 3. LV diastolic dysfunction, Gr 1
    • 4. Preserved RV systolic function
  • 2022-07-26 MRI - pancreas
    • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage) : T:T2(T_value) N:N1(N_value) M:M0(M_value) STAGE:IIB(Stage_value)
  • 2022-07-23 CT - abdomen
    • Findings
      • A poor enhancing tumor (3.0cm) at pancreatic head with biliary obstruction and p-duct dilatation. Some small LNs at retroperitoneum.
      • Grade 4 fatty liver.
      • Right renal angiomyolipoma (1.2cm).
      • Distention of gallbladder with stones (2-4mm).
    • IMP:
      • Suspected pancreatic head cancer with biliary obstruction and p-duct dilatation. Grade 4 fatty liver. Right renal angiomyolipoma (1.2cm). Gallbladder stones (2-4mm).
  • 2022-07-23 SONO - abdomen
    • Fatty liver, moderate
    • GB stone, mutliple
    • Dilated CBD
  • 2022-04-11 Patho - stomach biopsy
    • Gastric polyp, body, biopsy — Compatible with fundic gland polyp
  • 2022-04-08 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA grade ASuperficial gastritis
    • Gastric polyps, body and fundus, s/p biopsy
  • 2022-04-08 SONO - abdomen
    • 1. Fatty liver, severe
    • 2. GB stone
    • 3. Renal tumor, suspicious angiomyolipoma of the right kidney
    • 4. Renal calcinosis, left
    • 5. pancreatic body masked by gas

700876297

220825

{Rt breast cancer with Rt axillary LNs, lungs, and liver metastases}

[objective]

• Lab findings
  • 2022-05-27 Patho - breast mastectomy with regional lymph nodes
    • pathologic diagnosis
      • Tumor, R’t breast, MRM —- Invasive carcinoma of no special type with focal ductal carcinoma in situ, high grade
      • Resection margins, ditto — Free, closest margin 0.1 cm from base
      • Skin, R’t breast, MRM — Skin ulcer with tumor
      • Nipple, R’t breast, MRM — Free from tumor
      • Lymph nodes, R’t level I/II, dissection — Tumor metastasis (2/18) without extracapsular extension (0/2)
      • AJCC Pathologic Anatomic Stage — ypT4bN1a, cM1, Stage IV and Prognostic Stage — Stage IV
    • microscopic examination
      • Histologic type: Invasive carcinoma of no special type with focal ductal carcinoma in situ, high grade with focal tumor necrosis
      • Size of invasive carcinoma: multiple foci measured up to 5.1 x 2.5 cm
      • Histologic grade (Nottingham histologic score): Grade III (score 9) including [(A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 3 and (C) Mitotic count: score 3]
      • Margins: Free, closest margin 0.1 cm from base
      • Nodal status: tumor metastasis (2/18)
      • Treatment Effect: post C/T (y)
      • Lymphovascular space invasion: present
      • Perienural invasion: present
  • 2022-05-11 MRI - c-spine
    • Findings
      • Lower vertebral body height, end-plate degeneration, disc collapse with general bulging, posterolateral osteophytes and enlarged facets causing mild canal stenosis and left moderate neuroforaminal narrowing at C5-6-7.
      • No intramedullary abnormality.
    • IMP:
      • Cervical spondylosis, esp C5-6-7 with left neuroforaminal narrowing.
  • 2022-05-05 CT - lung/mediastinum/pleura
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Abnormal skin thickening and nodular lesion up to 1.1cm at right breast is found. In comparison with CT dated on 2022-01-07, marked regression is found.
        • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
        • Small lymph nodes are found at right axillary region. In regression.
        • Fibrotic change at left upper lobe is found. In regression.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Very low density lesion with marginal enhancement at S4 of liver is found. Liver meta is considered. In regression.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • Imp:
      • Right breast cancer with right axillary lymph nodes, lung meta and liver meta. All of the tumor activity regression.
  • 2022-05-05 SONO - breast
    • Diagnosis
      • Bil. fibroadenomas
      • Right breast cancer
  • 2022-05-05 Mammography
    • Mammography of bilateral breasts with craniocaudal (CC) and mediolateral oblique (MLO) views shows:
      • Composition: The breast tissue is heterogeneously dense, and this may decrease the sensitivity of mammography.
      • Ill-defined mass density at right upper breast, associated with nipple retraction and skin thickening, compatible with breast cancer.
      • No definite enlarged axillary lymph node.
    • Final assessment:
      • BI-RADS category 6, Known Biopsy-proven malignancy. Surgical excision should be considered when clinically appropriate.
      • Right breast cancer.
      • BI-RADS: 6. known biopsy-proven malignancy
  • 2022-01-17 CT - lung/mediastinum/pleura
    • Rt breast cancer with Rt axillary LNs, lungs, and liver metastases, in regression compared with CT on 20211104.
  • 2021-11-04 CT - lung/mediastinum/pleura -Right huge breast cancer with lung meta. Sacrum invasion and liver mets. Stationary.
  • 2021-10-15 CT - abdomen - liver, spleen, biliary duct, pancreas
    • Right breast cancer with right axillary lymph nodes and lung metastases.
    • One metastasis or primary lung cancer in LUL of the lung is suspected.
    • One liver metastasis is highly suspected.
  • 2021-10-15 Tc-99m MDP whole body bone scan with SPECT
    • Increased activity in the lower L-spines and bilateral S-I joints. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in the anterior aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?).
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, elbows, wrists, hips and knees, compatible with benign joint lesions.
  • 2021-10-11 Patho - breast, right, core biopsy; lymph node, right axillary, core biopsy
    • Invasive carcinoma, no special type, NST.
    • IHC stains (using lymph node tissue block S2021-14022):
      • ER (+, 90%, strong intensity),
      • PR (+, 90%, strong intensity, breast mass; +, 50%, strong intensity, lymphonode biopsy),
      • Her2/neu: positive(score=3+),
      • Ki-67 (90%),
      • E-cadherin (+).
  • 2021-10-11 SONO - breast
    • Right breast tumor with enlarged axillary lymph nodes, suspected right breast malignancy, suggest follow up.
    • BI-RADS: Category 5: highly suggestive of malignancy - appropriate action should be taken.
• chemoimmunotherapy
  • 2022-08-24 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
  • 2022-08-03 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
  • 2022-07-13 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
  • 2022-06-20 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
  • 2022-04-18 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
  • 2022-03-22 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
  • 2022-03-02 - trastuzumab 600mg SC 5min + pertuzumab 840mg 1hr + docetaxel 75mg/m2 120mg 1hr
  • 2022-02-07 - docetaxel 60mg/m2 98mg 1hr
  • 2022-01-07 - doxorubicin 60mg/m2 95mg 10min + cyclophosphamide 600mg/m2 950mg 1hr (AC)
  • 2021-12-17 - doxorubicin 60mg/m2 95mg 10min + cyclophosphamide 600mg/m2 950mg 1hr (AC)
  • 2021-11-26 - doxorubicin 60mg/m2 95mg 10min + cyclophosphamide 600mg/m2 950mg 1hr (AC)
  • 2021-11-26 - doxorubicin 50mg/m2 80mg 10min + cyclophosphamide 600mg/m2 950mg 1hr (AC)

220621

[assessment]

• The ongoing THP (docetaxel + trastuzumab + pertuzumab) since early March 2022 appears to be effective according to a CT scan on 2022-05-05 that all of the tumor activity regression.
• On the basis of the lab results reported on 2022-06-20, the patient is expected to be able to tolerate the current regimen as in the past.
• The patient’s TPR, BP, and SpO2 remain stable since being hospitalized, except for intermittent episodes of tachycardia.

220323

{Rt breast cancer with Rt axillary LNs, lungs, and liver metastases}

[objective]

• Lab findings
  • 2022-01-17 CT - lung/mediastinum/pleura
    • Rt breast cancer with Rt axillary LNs, lungs, and liver metastases, in regression compared with CT on 20211104.
  • 2021-11-04 CT - lung/mediastinum/pleura -Right huge breast cancer with lung meta. Sacrum invasion and liver mets. Stationary.
  • 2021-10-15 CT - abdomen - liver, spleen, biliary duct, pancreas
    • Right breast cancer with right axillary lymph nodes and lung metastases.
    • One metastasis or primary lung cancer in LUL of the lung is suspected.
    • One liver metastasis is highly suspected.
  • 2021-10-15 Tc-99m MDP whole body bone scan with SPECT
    • Increased activity in the lower L-spines and bilateral S-I joints. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in the anterior aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?).
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, elbows, wrists, hips and knees, compatible with benign joint lesions.
  • 2021-10-11 Patho - breast, right, core biopsy; lymph node, right axillary, core biopsy
    • Invasive carcinoma, no special type, NST.
    • IHC stains (using lymph node tissue block S2021-14022):
      • ER (+, 90%, strong intensity),
      • PR (+, 90%, strong intensity, breast mass; +, 50%, strong intensity, lymphonode biopsy),
      • Her2/neu: positive(score=3+),
      • Ki-67 (90%),
      • E-cadherin (+).
  • 2021-10-11 SONO - breast
    • Right breast tumor with enlarged axillary lymph nodes, suspected right breast malignancy, suggest follow up.
    • BI-RADS: Category 5: highly suggestive of malignancy - appropriate action should be taken.
• Medication
  • 2022-03-02 ~ ongoing - docetaxel + trastuzumab + pertuzumab
  • 2022-02-07 - docetaxel
  • 2021-11-05 ~ 2022-01-07 - AC (doxorubicin/cyclophosphamide)
• THP (docetaxel + trastuzumab + pertuzumab) regimen for HER2-positive metastatic breast cancer (source: UpToDate)
  • Cycle length: Every 21 days.
  • Duration of therapy: Until disease progression or unacceptable toxicity.
  • Drugs
    • Pertuzumab - loading dose
      • 840 mg IV
      • Dilute in 250 mL NS and administer over 60 minutes. DO NOT mix with D5W and DO NOT infuse as an IV push or bolus.
      • Cycle 1: Day 1
    • Pertuzumab
      • 420 mg IV
      • Dilute in 250 mL NS and administer over 30 to 60 minutes. DO NOT mix with D5W and DO NOT infuse as an IV push or bolus.
      • Cycle 2 and after: Day 1
    • Trastuzumab - loading dose
      • 8 mg/kg IV
      • Dilute in 250 mL NS and administer over 90 minutes for the loading dose. DO NOT mix with D5W and DO NOT infuse as an IV push or bolus.
      • Cycle 1: Day 1
    • Trastuzumab
      • 6 mg/kg IV
      • Dilute in 250 mL NS and administer over 30 to 90 minutes. DO NOT mix with D5W and DO NOT infuse as an IV push or bolus.
      • Cycle 2 and after: Day 1
    • Docetaxel
      • 75 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
  • Pretreatment considerations:
    • Emesis risk
      • LOW (10 to 30% risk of emesis).
    • Prophylaxis for infusion reactions
      • Premedicate with dexamethasone prior to docetaxel administration. Premedication is not routinely indicated for pertuzumab. Most clinicians do not routinely premedicate prior to the first trastuzumab dose. However, patients may be instructed to self-administer acetaminophen or an NSAID if flu-like symptoms develop within 24 hours of drug administration.
    • Vesicant/irritant properties
      • Docetaxel is an irritant but can cause significant tissue damage; avoid extravasation.
    • Infection prophylaxis
      • In the original study, the risk of febrile neutropenia was 14%. The decision to use primary prophylaxis with hematopoietic growth factors should be individualized, and considered for patients who may be at risk for increased complications from prolonged neutropenia.
    • Dose adjustment for baseline liver or renal dysfunction
      • Docetaxel should not be administered to patients with a serum bilirubin above the ULN or to patients with transaminase elevations >1.5 times the ULN in conjunction with alkaline phosphatase >2.5 times the ULN.
    • Cardiopulmonary issues
      • Trastuzumab and pertuzumab are associated with cardiotoxicity; assess baseline LVEF prior to therapy and then as clinically indicated. Patients with a baseline LVEF <50% were excluded from the study. Trastuzumab may cause serious pulmonary toxicity and should be used with caution in patients with preexisting pulmonary disease.
    • Dose adjustment for known drug interactions
      • Caution is needed when administering docetaxel with strong CYP3A4 inhibitors. Although specific dose recommendations are not available, the United States Prescribing Information suggests close monitoring for toxicity and consideration of docetaxel dose reduction if coadministration with a strong CYP3A4 inhibitor cannot be avoided.
  • Monitoring parameters:
    • Obtain CBC with differential and platelet count prior to each treatment cycle.
    • Assess electrolytes and liver and renal function prior to each treatment cycle.
    • It is recommended to observe the patient for one hour after the initial dose of pertuzumab and for 30 minutes after all subsequent doses for signs of infusion reactions.
    • Assess cardiac function at baseline and then as clinically indicated. In the clinical trial, LVEF was measured at screening and then every nine weeks.
    • Assess changes in neurologic function prior to each cycle of docetaxel.
    • Patients with renal impairment, hyperuricemia, and bulky tumors are at risk for TLS and should undergo correction of dehydration and lowering of high serum uric acid levels prior to treatment initiation, and be closely monitored for TLS during and after treatment.
  • Suggested dose modifications for toxicity:
    • Myelotoxicity
      • Reduce docetaxel dose by 25% for subsequent cycles in patients who develop severe prolonged neutropenia (<500/microL lasting seven days or more), febrile neutropenia, or a grade 4 infection (ie, an infection with life-threatening consequences).
    • Hepatotoxicity
      • A 20% dose reduction in the dose of docetaxel may be needed for patients who develop significant alterations in transaminases and alkaline phosphatase during therapy.
    • Cardiotoxicity
      • Hold both trastuzumab and pertuzumab if the LVEF drops to <40% or if the LVEF is 40-45% with a 10% or greater absolute decrease below baseline.[4] Guidelines for managing cardiac dysfunction during therapy with HER2-targeted agents are available.
    • Pulmonary toxicity
      • Discontinue trastuzumab for serious pulmonary toxicity.
    • Infusion reactions
      • Respond as clinically indicated with supportive care and possible discontinuation of therapy for severe reactions.
    • Cutaneous, mucosal, and neurologic toxicity
      • For severe or cumulative cutaneous reactions (erythema and desquamation), grade 3 or 4 stomatitis, or moderate neurosensory signs and/or symptoms, reduce docetaxel dose by 25%. Discontinue if toxicity persists.

[assessment]

• As compared to the CT images taken on 2021-11-04, the CT images taken on 2022-01-17 have revealed a partial response to the disease under AC (doxorubicin + cyclophosphamide) regimen administrated during early November 2021 to early January 2022
• Currently, the patient receives THP (docetaxel + trastuzumab + pertuzumab) since early March 2022.
• Before the administration of the THP regimen, studies of the heart (echocardiography, 2021-11-05) and lung (CT, 2022-01-17) have been performed to obtain baseline information. Estimated LVEF 61% (based on the echocardiography) and no obvious abnormal laboratory readings were reported on 2022-03-23.

220208

[assessment]

• endocrine therapy e.g. tamoxifen might be preferred to aromatase inhibitors
• trastuzumab, pertuzumab might also be considered if no contraindications

700374742

220823

• diagnosis
  • 2022-07-26 discharge diagnosis
    • 1: Malignant neoplasm of middle third of esophagus
    • 2: tonsillar fossa tumor with lateral pterygoid muscle with lateral nasopharynx invasion, any node(s) and clinically overt ENE, T4bN3bM0, STAGE:IVB
      • TPF for head and neck cancer
• lab data
  • Magnesium
    • 2022-07-21 Mg (Magnesium) 1.2 mg/dL
      
    • 2022-06-30 Mg (Magnesium) 2.7 mg/dL
      
    • 2022-06-27 Mg (Magnesium) 1.2 mg/dL
      
    • 2022-06-06 Mg (Magnesium) 2.0 mg/dL
      
    • 2022-06-02 Mg (Magnesium) 1.4 mg/dL
      
    • 2022-05-18 1.5 mg/dL
    • 2022-04-29 2.2 mg/dL
    • 2022-04-28 1.2 mg/dL
    • 2022-04-13 1.4 mg/dL
    • 2022-03-17 1.5 mg/dL
    • 2022-03-14 1.5 mg/dL
    • 2021-11-05 1.6 mg/dL
    • 2021-11-03 1.3 mg/dL
    • 2021-10-25 1.4 mg/dL
    • 2021-10-18 1.6 mg/dL
    • 2021-10-04 1.6 mg/dL
    • 2021-09-27 1.5 mg/dL
    • 2020-06-08 1.7 mg/dL
      
    • 2020-06-03 1.8 mg/dL
      
    • 2020-05-30 1.8 mg/dL
      
    • 2020-05-29 2.1 mg/dL
      
    • 2020-05-28 1.5 mg/dL
      
  • CEA
    • 2022-04-28 10.607 ng/ml
    • 2022-02-23 4.299 ng/ml
    • 2021-12-01 3.934 ng/ml
    • 2020-08-11 2.202 ng/ml
• exam finding
  • 2022-07-22 MRI - nasopharynx
    • 1. Right tonsillar cancer size enlarged, which invades right soft palate and extends laterally to encase right proximal ICA (internal carotid artery) and ECA (external carotid artery).
    • 2. Right neck lymphadenopathy with ENE (extranodal extension), enlarged.
    • 3. Post-irradiation change with/without tumor involvement, right lateral nasopharynx, right lateral pterygoid and temporalis muscles.
    • 4. Progressively swelling of right AE fold (aryepiglottic fold, 杓狀會厭皺襞).
  • 2022-07-21 CXR
    • Scoliosis of the T-spine with convex to right side.
    • Atherosclerotic change of aortic arch
    • A nodular opacity projecting in the right upper lung is suspected. Please correlate with CT.
    • Emphysematous change of both lung field
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2022-03-16 MRI - nasopharynx
    • The current study was compared to the prior one obtained on 20210924.
    • Knwon a case of right tonsillar cancer S/P treatment. Still mild mucosal thickening of right palatine fossa. Also swollen change of right A-E fold with enhancement. Suggest clinical correlation to rule out inflammatory change or recurrence.
    • Right mastoiditis.
    • The bilateral parotid and submandibular glands enhance as before. It is consistent with post-radiation inflammation.
    • Clear appearacne of all paranasal sinuses.
  • 2022-03-15 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20200605, the lesions in the lower T-spines and some L-spines are stationary. Degenerative change may show this picture.
    • Some new faint hot spots in the posterior aspect of right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please correlate with the clinical history and follow up bone scan for further evaluation.
    • No prominent change is noted in the previous faint hot spots in the skull and the lesion in the right femoral shaft, possibly more benign in nature.
    • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral hips and right knee, compatible with benign joint lesions.
  • 2022-03-09 Nasopharyngoscopy
    • rt arytenoid swelling, limited airway, suggest tracheostomy
    • rt tonsil and mouth floor, p16(-), ct2N2bM0, stage IVa + esophagus ca
  • 2022-02-22 SONO - abdomen
    • A polyp 4.5 mm and multiple stones (< 6 mm) of the gallbladder are noted.
  • 2022-01-12 SONO - head and neck, soft tissue
    • right neck mass, suspected malignancy
    • right neck level II, large, heterogenous mass lesion (tender+), s/p FNA
  • 2021-11-30 MRI - larynx
    • Regressed right tonsil CA, stationary of right carotid and posterior cervical LAPs with central necrotic change.
  • 2021-09-30 CT - lung/mediastinum/pleura
    • Consolidation over posterior segment of right upper lobe.
    • No evidence of metastatic lesion in the current study.
  • 2021-09-28 Patho - gingival/oral mucosa biopsy
    • Observed
      • Hx of R tonsil + mouth floor, esophageal ca s/p incomplete CCRT
        
      • Mouth floor lesion
    • Diagnosis
      • Labeled as ‘mouth floor lesion’, biopsy — squamous cell carcinoma.
        
      • Section shows squamous cell carcinoma.
  • 2021-09-28 L-N aspiration
    • R level V LAP, 3*3cm, firm, hard - squamous cell carcinoma
  • 2020-10-23 Patho - esophageal biopsy
    • Esophagus, 30 cm below incisor, biopsy - squamous cell hyperplasia
  • 2020-10-05 CT - lung/mediastinum/pleura
    • RUL infection D/D includes TB or bacteria severe emphysema and fibrotic change in lower lobes.
  • 2020-07-28 Patho - esophageal biopsy
    • A. Labeled as “the lesion needed to ablate is localized at the 19 cm to 35 cm. Random Bx is done (A) as marking at the 19 cm.”, biopsy — squamous mucosa with low grade dysplasia and necrosis.
      
    • B. Labeled as ‘There is some ablated esophageal tumor tissue retrieved for patho exam (B)’, biopsy - benign squamous mucosa with moderate acute inflammation.
  • 2020-06-30 Patho - tonsil biopsy
    • A. Right side tonsil, frozen section + tonsillectomy — Squamous cell carcinoma, moderately differentiated
      • IHC: CK5/6(+); P16(-), HPV(-) and P63(+) for tumor cells.
    • B. Mouth floor tumor, above wharton’s duct, FS + excision — Squamous cell carcinoma, moderately differentiated characterized by epithelial hyperplasia with high grade dysplasia and focal stromal invasion.
  • 2020-06-30 Frosen section
    • A. Right side tonsil, frozen section — Squamous cell carcinoma
      
    • B. Mouth floor, ditto — Mild to focal moderate dysplasia
  • 2020-06-29 CT - neck
    • imaging reort form for oropharynx carcinoma
    • Imaging stage: T2N2bM0, stage IVA
  • 2020-06-24 Nasopharyngoscopy
    • Rt NP cyst, Rt tonsils with induration, mouth floor tumor?, hypopharynx cyst.
  • 2020-06-09 Whole body PET scan
    • Mild glucose hypermetabolism involving the middle portion of the esophagus, compatible with primary esophageal malignancy of low FDG uptake. However, no prominent abnormal focal FDG uptake was noted in the lower portion of the esophagus.
    • Mild glucose hypermetabolism in the right tonsil and stomach. The nature is to be determined (inflammatory process? other nature?).
    • Mildly increased FDG uptake in the right anterior neck muscle. Either physiological FDG uptake or mild inflammation may show this picture.
  • 2020-06-08 Miniprobe Endoscopic Ultrasound
    • Esophageal cancer, middle esophagus, EUS estimated stage T1b~T2N1Mx
    • Suspected early esophageal cancer, lower esophagus, EUS estimated stage T1bN1Mx
  • 2020-06-06 CT - lung/mediastinum/pleura
    • u/3 thoracic esophageal cancer T? no evidence of mediastinal invasion, no LAP (N0) and M0.
    • diffuse emphysema, could be related to smoking and fibrotic change in LLL, RLL, and LUL, sequela of prior infection?
    • moderate 3V-CAD.
  • 2020-06-01 Patho - esophageal biopsy
    • pathologic diagnosis
      • A. Lower esophagus, biopsy — High grade dysplasia at least, suspicious for malignancy
        
      • B. Middle esophagus, biopsy — Squamous cell carcinoma, moderately differentiated
    • microscopic examination
      • A. Lower esophagus: thick epithelium shows high grade dysplasia and few subepithelial connective tissue without tumor invasion. It is still suspicious for malignancy. Repeat biopsy is advised for further evaluation.
        
      • B. Middle esophagus: squamous cell carcinoma, moderately differentiated characterized by thick epithelium with high grade dysplasia and a few tumor nests infiltrated in inflamed stroma.
        • IHC: CK5/6(+); P16(-), HPV(-), CD34(equivocal) and P63 (+) for tumor cells.
• consultation
  • 2021-09-30 Radiation Oncology
    • This 53-year-old man previously:
      • MDSCC of Rt tonsil and mouth floor, p16(-), cT2N2bM0, stage IVa, s/p CCRT
      • MDSCC of esophagus M/3, p16(-). cT1b~T2N1M0
    • 2020-06-06 ~ 2020-09-09 RT to the bil. neck, Rt tonsil, LAPs: 50y/ 25fx. The whole esophagus and adjacent lymphatic drainage area: 45y/ 25fx. Postponed since 2020-09-10 because he wanted to take a rest.
    • This time, he suffered from tonsillar fossa tumor with Lateral pterygoid muscle with lateral nasopharynx invasion, Any node(s) and clinically overt ENE, T4bN3bM0, stage IVB. FNA were performed on 2021-09-27. The Labeled as ‘mouth floor lesion’, biopsy (2021-09-29) proved squamous cell carcinoma.
    • Palliative CCRT is indicated. Plan to deliver at least 50 Gy/ 25 fx to the Rt tonsillar tumor, LAPs, and Rt neck level I~III. However, after explanation, he is still afraid of the side effects, such as mucositis or xerostomia, and still need more time to consider whether to have radiotherapy. If he makes up his mind to have radiotherapy, please inform us so we can make arrangement for him. Thank you very much.
  • 2021-09-28 ENT
    • PHx: R tonsil and mouth floor, p16(-), cT2N2bM0, stage IVa; Esophagus cancer, M/3, p16(-), cT1b-T2N1M0 with incomplete CCRT tx
    • Oral: mouth floor whitish lesion s/p biopsy
    • Neck: right level V induration s/p FNA
    • Imp:
      • Right neck mass, suspect malignancy
      • Mouth floor lesion, suspect malignancy
    • Plan:
      • Pending pathology report
      • If unsatisfactory, may consider arrange right neck LAP biopsy under LA
  • 2021-09-22 ENT
    • Local finding: a 3-4 cm indurated non-movable mass with tenderness over R neck level V. A wart-like lesion over midline of floor of mouth.
    • Scope: smooth nasopharynx, oropharynx and hypopharynx. Medialization of right lateral pharyngeal wall. Patent airway.
    • Neck CT a rim-enhanced irregular mass over R level V, increase in size compared to previous study in 2020-06.
    • Neck sono: a heterogenous mass over R neck level V.
    • Impression: Suspect nodal metastasis with or withour necrosis; Mouth floor lesion. Poor nutrition and dehydration.
    • Plan: Admission to Oncology IPD for supportive treatment and further cancer work-up was suggested.
    • NG placement is suggested.
  • 2020-10-27 Radiation Oncology
    • This 52 y/o male patient was diagnosed with
      • MDSCC of Rt tonsil and mouth floor, p16(-), cT2N2bM0, stage IVa
      • MDSCC of esophagus M/3, p16(-). cT1b~T2N1M0
    • s/p incomplete CCRT [20200806 ~ RT to the bil. neck, Rt tonsil, LAPs: 50y/ 25fx. The whole esophagus and adjacent lymphatic drainage area: 45y/ 25fx. Postponed since 20200910 because he wanted to take a rest.]
    • He was admitted due to poor nutrition and pneumonia.
    • To resume CCRT is indicated for double cancer treatment. However, after discussion, he refused to resume CCRT right now and said he will come back for further treatment when he feels better.
  • 2020-05-30 Nephrology
    • This 51 y/o man of chronic alcoholism presented with hypokalemia, hypomagnesemia, and hypocalcemia.
    • PE revealsed severe malnutrition with muscle wasting. The ABG was not remarkable.
    • Hypo-K, hypo-Mg and hypo-Ca are commonly seen in patients with alcoholism and malnutrition, probably due to chronic low intake.
    • This triple electrolyte deficiency is not related to renal tubular dysfunction. Only IV or oral supplements with these electrolytes are needed.
      
    • I will follow up this patient.
• surgical operation
  • 2020-07-27 Endoscopic radiofrequency ablation with Barrx 360 express RFA cathether
  • 2020-06-30 Right side tonsil tumor, wide excision; Mouth floor tumor, above wharton’s duct, excision
• radiotherapy
  • 2021-10-06 ~ 2021-10-29 RT to the Rt neck LAPs and tonsilar tumor: 36 Gy/ 18 fx
  • 2020-08-06 ~ 2020-09-09 RT to the bil. neck, Rt tonsil, LAPs: 50y/ 25fx. The whole esophagus and adjacent lymphatic drainage area: 45y/ 25fx.
• chemotherapy
  • 2022-07-22 - docetaxel 40mg/m2 59mg 1hr + cisplatin 40mg/m2 59mg 2hr + fluorouracil 1000mg/m2 2980mg 46hr
  • 2022-06-27 - docetaxel 40mg/m2 59mg 1hr + cisplatin 40mg/m2 59mg 2hr + fluorouracil 1000mg/m2 2980mg 46hr
  • 2022-06-02 - docetaxel 40mg/m2 58mg 1hr + cisplatin 40mg/m2 58mg 2hr + fluorouracil 1000mg/m2 2900mg 46hr
  • 2022-05-18 - docetaxel 40mg/m2 58mg 1hr + cisplatin 40mg/m2 58mg 2hr + fluorouracil 1000mg/m2 2900mg 46hr
  • 2022-04-29 - docetaxel 40mg/m2 59mg 1hr + cisplatin 40mg/m2 59mg 2hr + fluorouracil 1000mg/m2 2990mg 46hr
  • 2022-04-14 - docetaxel 40mg/m2 58mg 1hr + cisplatin 40mg/m2 58mg 2hr + fluorouracil 1000mg/m2 2920mg 46hr (cisplatin 40 <- 50)
  • 2022-03-17 - docetaxel 40mg/m2 60mg 1hr + cisplatin 50mg/m2 79mg 2hr + fluorouracil 3170mg/m2 2920mg 46hr (TPF - https://pubmed.ncbi.nlm.nih.gov/20878112/ for head and neck cancer)
  • 2021-11-03 - cisplatin 40mg/m2 60mg 2hr (CCRT)
  • 2021-10-25 - cisplatin 40mg/m2 60mg 2hr (CCRT)
  • 2021-10-18 - cisplatin 40mg/m2 60mg 2hr (CCRT)
  • 2021-10-07 - cisplatin 40mg/m2 60mg 2hr (CCRT)
  • 2020-09-01 - cisplatin 40mg/m2 60mg 2hr (CCRT)
  • 2020-08-25 - cisplatin 40mg/m2 60mg 2hr (CCRT)
  • 2020-08-18 - cisplatin 40mg/m2 60mg 2hr (CCRT)
  • 2020-08-11 - cisplatin 40mg/m2 60mg 2hr (CCRT)

[assessment]

• Weight loss 17 kgw during the past 6 months (2022-08-22 37 kgw <- 2022-03-14 54 kgw), 173 cm, BMI = 12.4 kg/m2, severe thinness. The patient has a history of alcoholism, malnutrition and hypomagnesemia are suspected. NAKO NO.5 has been prescribed.
• Hyperuricemia is observed (2022-08-22 blood uric acid 9.3 mg/dL), Euricon (benzbromarone 50mg/tab) 1# QD might be considered.

220606

[assessment]

• The patient was diagnosed with stage IVB esophageal cancer in June 2020, and he underwent partial CCRT in September of the following year. Following the last dose of cisplatin received at the beginning of November of 2021, the patient started receiving TPF on 2022-03-17.
• Last images in March 2022 revealed mild mucosal thickening in the right palatine fossa, and the lesions in the lower T-spine and some L-spine areas have remained stationary, An update image studye might be helpful.
• A steady rise in the CEA level has been observed:
  • 2022-04-28 10.607 ng/ml
  • 2022-02-23 4.299 ng/ml
  • 2021-12-01 3.934 ng/ml
  • 2020-08-11 2.202 ng/ml
• Hypomagnesia has been noted since 2020-05, possibly caused by undernutrition (BMI 15), electrolyte supplements may be beneficial (MgO 500g PO BID and Nako No.5 500mL IVD BID have been prescribed).

220519

[assessment]

• This patient was diagnosed with stage IVB esophageal cancer, he had surgery in June, July 2020, and incomplete CCRT the following September. After receiving the last dose of cisplatin in early November of 2021, the patient began receiving TPF on 2022-03-17.
• Images in March 2022 revealed mild mucosal thickening in the right palatine fossa, and the lesions in the lower T-spine and some L-spine areas have remained stationary. A slow pace of progress might be likely?
• CEA level continues to rise steadily, lab data:
  • 2022-04-28 10.607 ng/ml
  • 2022-02-23 4.299 ng/ml
  • 2021-12-01 3.934 ng/ml
  • 2020-08-11 2.202 ng/ml
• Records available in the hospital indicated that blood magnesium levels were almost always below the lower limit of normal. He was found to have been an alcohol dependent for years. The patient with BMI 15 (height of 175 cm, weight of 46 kg) might be undernourished. It is common to observe hypomagnesemia in patients suffering from alcoholism and malnutrition. The need for a lifestyle change cannot be overstated.
• The components of the current regimen contain 5-Fu and cisplatin, which might also cause a low magnesium level. If hypomagnesemia becomes symptomatic, MgSO4 injection might be considered.

220429

[assessment]

• After receiving last cisplatin in early November of 2021, this patient began receiving TPF from 2022-03-17.
• Lab data results: serum Mg 1.2 mg/dL (2022-04-28), CEA 10.607 ng/ml (2022-04-28) <- 4.299 (2022-02-23) <- 3.934 (2021-12-01) <- 2.202 (2020-08-11).
• CEA is increasing in trend, which needs to be addressed.
• Hypomagnesemia is frequently a result of magnesium depletion, which is often caused by gastrointestinal or renal losses.
  • One of the main dose-limiting side effects of fluoropyrimidines such as FU (and its oral prodrugs capecitabine and ftorafur-uracil [UFT]) is diarrhea.
  • It is also possible that renal loss could be caused by medications such as diuretics (loop and thiazide), antibiotics (aminoglycoside, amphotericin, pentamidine), calcineurin inhibitors, cisplatin, antibodies targeting epidermal growth factor (EGF) receptors (cetuximab, panitumumab, matuzumab), which are not prescribed currently. (5-FU and cisplatin are in recent regimen.)
  • Alcoholism is also a cause of renal loss. According to the consultation with mental health clinic 2020-05-30, the patient might be alcohol dependent.
  • The use of MgSO4 injection might be considered if there are no contraindications.

700929934

220819

{DLBCL stage IV}

• exam finding
  • 2022-06-06 Automated perimetry
    • clinical diagnosis: glaucoma
    • Report: VF on 06/06/2022 (od) tunnel vision only (os) arcuate scotoma, MD -26.03/-6.48 dB
  • 2022-06-02 CT - abdomen, pelvis
    • Finding
      • Some enlarged LNs at retroperitoneum along aorta and IVC.
      • Wall edema of rectum.
      • A small cystic lesion (0.6cm) at pancreatic tail.
      • A calcified nodule (0.5cm) at RML. Right minimal pleural effusion.
      • Gallbladder stones (2-6mm).
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • Some enlarged LNs at retroperitoneum along aorta and IVC suspected lymphoma.
      • Gallbladder stones (2-6mm). Wall edema of rectum.
  • 2022-05-24 Patho - bone marrow biopsy - negative for malignancy
    • Bone marrow, iliac, clinically: DLBL, biopsy — Negative for malignancy.
    • IHC stains: CD3: <2%; CD20: <2 %; bcl-2: <2%, bcl-6: (-); MUM-1: (-) (of the nucleated cells).
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2022-05-21 CT - brain
    • Brain atrophy
  • 2022-05-21 Micro-sonography
    • glaucoma od > os
    • 229/224um, no sub RPE infiltration ou
    • 54/82um, VCDR 0.82/0.58, IS thining
    • GCC loss od
  • 2022-05-21 Optical Coherence Tomography
    • c/d: 0.9 od, 0.4 os, media clear, no infiltration noted ou
  • 2022-05-18 Whole body PET scan
    • Glucose hypermetabolism in lymph nodes from head to bilateral upper thighs, compatible with lymphoma with involvement of lymph node regions on both sides of the diaphragm.
      
    • Glucose hypermetabolism in the left upper lung pleura, right lower lung, left lobe of the liver, spleen, several C-, T- and L-spine, sacrum, and bilateral iliac bones, highly suspected lymphoma with diffuse involvement of multiple extralymphatic organs.
    • Diffuse large B-cell lymphoma, stage IV (AJCC, 8th ed.), by this F-18 FDG PET scan.
  • 2022-05-16 CXR
    • Boderline cardiomegaly
    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-05-10 Patho - lymph node region resection
    • Lymph node, right level Ib, excisional biopsy — Diffuse large B-cell lymphoma
      
    • Histology type: diffuse large B-cell lymphoma with atypical large lymphoid cells with nucleoli and totally effacement of nodal architecture
    • Immunohistochemistry: CK(-), CD3(-), CD20(+), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+, focal), C-MYC(-, <30%) , Ki-67: 80% for tumor
  • 2022-05-06 CT - neck
    • Finding
      • Multiple enlarged, homogeneously enhancing lymph nodes at bilateral level I, II, III, IV, V, as well as bilateral mediastinum. There are multiple enlarged lymph nodes in bilateral parotid glands as well. Lymphoma should first be considered.
      • Bilateral symmetric pharyngeal mucosa.
      • Normal size and normal enhancement pattern of bilateral submandibular glands.
    • Impression
      • Consider lymphoma. Suggest further evaluation.
  • 2022-05-05 Nasopharyngoscopy
    • smooth NPx, OPx, HPx
  • 2017-10-12 Pure Tone Audiometry, PTA
    • R’t: mild to profound mixed type HL
    • L’t: mild to severe mixed type HL
• lab data
  • Anti-HBc 2022-05-21 Reactive, 8.51 S/CO
  • HBsAg 2022-05-16 Reactive, 4785.50 S/CO
  • Anti-HCV 2022-05-16 Nonreactive 0.07 S/CO
• consultation
  • 2022-05-20 Ophthalmology
    • Objective
      • BV of right eye > left eye for over 1 year
      • recently diagnosed DLBCL with initial presentation of bilateral sunmadibular gland enlargement
      • phx: DM, HTN under bokey
      • ophx: glaucoma under combigan for 1 year
      • BCVA OD 0.3(0.5x+0.75/-2.0x85) OS 0.5(0.6x+1.25/-0.75x75)
      • PT: 20/19 mmHg
      • pupil: 3.5 mm+/+, 3mm+/+, rapd + od
      • EOM: full and free
      • Lid: lago os , imcomplete blinjing os
      • conj: pterygium at 3 o’c od, np os
      • K: cl od, inf spk os
      • AC: deep and clear ou
      • Lens: NS 2+ OD＞OS
      • F’d: c/d: 0.9 od, 0.4 os, media clear, no infiltration noted ou
    • Assessment:
      • glaucoma od > os
      • lagophthalmos os due to left CN 7 palsy
    • Plan
      • combigan 1gtt bid ou + sinomin 1gtt qid os + duratears qid os
      • we will arrange OCT and VF later for optic neuropahty od
• chemoimmunotherapy
  • 2022-07-29 - rituximab 375mg/m2 690mg 8hr D1 + cyclophosphamide 750mg/m2 1378mg 30min D2 + doxorubicin 50mg/m2 91mg 30min D2 + prednisolone 60mg/m2 5mg/tab 11tab BID D2-6 (R-CHOP, vincristine not avaliable then)
  • 2022-07-07 - rituximab 375mg/m2 690mg 8hr D1 + cyclophosphamide 750mg/m2 1378mg 30min D2 + doxorubicin 50mg/m2 91mg 30min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 11tab BID D2-6 (R-CHOP)
  • 2022-06-16 - rituximab 375mg/m2 690mg 8hr D1 + cyclophosphamide 750mg/m2 1378mg 30min D2 + doxorubicin 50mg/m2 91mg 30min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 11tab BID D2-6 (R-CHOP)
  • 2022-05-25 - rituximab 375mg/m2 690mg 8hr D1 + cyclophosphamide 750mg/m2 1380mg 30min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-4 (R-COP)

[assessment]

• TPR, BP were stable during this hospital stay.
• Blood sugar 2022-08-18 17:10 236 mg/dL, 2022-08-19 08:21 249 mg/dL. If diabetes is confirmed, since the patient has normal kidney function (based on 2022-08-18 laboratory results), then metformin 500mg BID could be considered.

220530

[assessment]

• Diffuse large B-cell lymphoma involving both sides of the diaphragm, stage IV (PET 2022-05-18), no evidence of involvement of the central nervous system yet (CT 2022-05-21).
• BCL2(+), BCL6(+), however C-MYC less than 30% (pathology 2022-05-10), might not be regarded as a ‘double/triple hit’ lymphoma. LDH 384U/L, anti-HBc reactive (2022-05-21), HBsAg reactive (2022-05-16). No anti-HBs, IgM anti-HBc, Epstein-Barr virus results were found.
• RCHOP might be indicated in patients with DLBCL. For patients who are too frail to withstand even R-mini-CHOP, treatment with a systemic steroid, with or without rituximab, might improve the patient’s performance status (PS) and enable subsequent treatment with R-mini-CHOP or single chemotherapeutic agents.
  • S-GPT/ALT, S-GOT/AST were both slightly elevated (2022-05-20). Cyclophosphamide, doxorubicin, and vincristine dosages may need to be adjusted for preexisting liver dysfunction (not applicable to this patient at present).
  • As the patient has ‘Three Hypers’ and borderline cardiomegaly as well as increased interstitial lines in both lungs (CXR 2022-05-16), decreased cardiopulmonary function could be expected. LVEF should be evaluated prior to initiation of RCHOP. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation.
• HBsAg(+), anti-HBc(+), elevated ALT, AST levels suggest infection with HBV. Antiviral prophylaxis might be considered prior to initiating rituximab treatment.
• HR (102 -> 65 pulse/min) and SBP (142 -> 92mmHg) have fallen sharply 2022-05-23 08:45 which should be addressed. Amlodipine and/or valsartan might be temporarily suspended.

701196422

220817

• exam finding
  • 2022-08-17 CXR
    • Bilateral pleural effusion.
    • Ground glass opacities in bil. lungs.
    • Normal appearance of trachea and bil. main bronchus.
    • Intact bony structure(s).
  • 2022-08-16 MRI - brain
    • Multiple bilateral cerebellar, cerebral and left upper brain stem metastases, with slight regression in cerebelli and cerebral hemispheres, but seems stationary or mild progression in left upper brain stem when compared with 2022/06/07 MRI.
  • 2022-08-16 SONO - chest
    • symptom: dyspnea
    • indication: effusion
    • clinical diagnosis
      • right breast ca
      • bilateral pleural effusion
    • Echo Diagnosis
      • Left thorax: moderate amount pleural effusion s/p drainage of 860 cc, serosanguinous pleural effusion.
      • Right thorax: small amount pleural effusion; thoracocentesis was not performed due to high risks of complications.
  • 2022-08-15 CXR
    • Bilateral pleural effusion.
    • Ground glass opacities in bil. lungs.
    • Normal appearance of trachea and bil. main bronchus.
    • Compression fracture of T12.
  • 2022-08-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (30.9 - 11.9) / 30.9 = 61.49%
    • 1. Normal AV with no AR
    • 2. Normal MV with mild MR
    • 3. Normal LV chamber size and wall thickness
    • 4. Preserved LV and RV systolic function
    • 5. No PR, trivial TR, normal IVC size
    • 6. Large amount of left pleural effusion, right side deviation of heart and poor para-sternal window
  • 2022-07-25 CXR
    • Bilateral pleural effusion.
    • Focal calcification of left pleura.
    • Compression fracture of spine.
    • Normal appearance of trachea and bil. main bronchus.
    • Ground glass opacities in bil. lungs.
  • 2022-07-25 SONO - chest
    • Echo diagnosis: Bilateral pleural effusion (Left: small and Right: small to moderate), post left diagnostic thoracentesis and bilateral therapeutic thoracentesis.
  • 2022-07-04 CXR
    • Bilateral pleural effusion.
    • Ground glass opacities in bil. lungs.
    • Multiple nodules at bil. lungs.
    • Compression fracture of spine.
  • 2022-07-04 SONO - chest
    • Echo diagnosis: Bilateral pleural effusion (Left: minimal and Right: moderate to massive), s/p right diagnostic and therapeutic thoracentesis.
  • 2022-06-13 SONO - chest
    • Echo diagnosis: Bilateral pleural effusion (Left: minimal to small and Right: moderate to massive), post right diagnostic and therapeutic thoracentesis.
  • 2022-06-07 MRI - brain
    • Clinical information: Lt breast advanced ca with spine mets
    • DCIS (Ductal Carcinoma in Situ) was told after CNB (core needle biopsy) at Taipei Medical University Hospital on 2015-08-11 without treatment.
    • Findings:
      • 1. Numerous intra-axial faintly enhancing lesions with perifocal edema in bilateral cerebral and cerebellar hemispheres, and midbrian and brain stem, with the largest one about 20 mm at right occipital lobe. Increased in size and number of these metastatic lesions, as compared with MRI on 20220302.
      • 2. Multifocal peritumoral edema.
  • 2022-06-02 SONO - abdomen
    • Gallbladder stones (0.37-0.99cm).
    • Splenomegaly.
    • Right pleural effusion.
  • 2022-06-02 CT - lung/mediastinum/pleura
    • Residual breast tumor at right side with lung meta, bone mets, stationary.
    • Bilateral massive pleural effusion.
  • 2022-04-18 CXR
    • Bilateral pleural effusion.
    • Normal appearance of trachea and bil. main bronchus.
    • Compression fracture of T12.
    • Ground glass opacities in bil. lungs.
  • 2022-03-11 CT - lung/mediastinum/pleura
    • Compatible with breast cancer with lung and bone mets, the lung mets is stationary.
    • Bilateral pleural effusion with stationary extension.
  • 2022-03-11 SONO - abdomen
    • 1. Prior sonography identified An ill-defined hypoechoic lesion 3.19 cm in S7 liver is noted again, mild decreasing in size to 2.86 cm. Follow up is indicated.
         
    • 2. Several gallstone are noted.
    • 3. The spleen shows enlarged in size (long axis: 13.2 cm).
  • 2022-03-02 MRI - brain
    • C/W multiple brain metastases, progressive change as compared with MRI on 20211108.
  • 2022-01-24 CXR
    • Lung markings: opacification in the bilateral lower lung fieldl small nodular lesions in the bilatearl lung fields.
    • blurred bilateral hemidiaphrams
    • blunting bilateral costophrenic angles
  • 2022-01-24 Neck
    • increased density in the C2 vertebral body. Nature?
  • 2022-01-24 Nasopharyngoscopy
    • Multiple petechiae were found at posterior pharyngeal wall and arytenoid
    • No active bleeder and foreign body was found
  • 2021-12-23 CT - abdomen
    • S/P left breast operation.
    • Multiple bony metastases.
    • Some nodules at bil. lungs. Bil. pleural effusions.
    • Splenomegaly.
  • 2021-12-06 SONO - abdomen
    • 1. Irregular hypoechoic lesion, 3.19x2.68cm in S7 liver, progression.
    • 2. GB stone.
  • 2021-12-02 Patho - intradermal nervus
    • Skin, trunk, total excision — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (-, 0%), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67 (30%), GATA-3 (+).
      
    • Section shows skin tissue with irregular neoplastic ducts infiltration. Margins free (0.1 cm from closest side margin and 0.3 cm from deep margin.
  • 2021-11-08 MRI - brain
    • C/W multiple brain metastases, regression in sizi and number as compared with MRI on 20210508, but with progressive white matter edema in right posterior temporal-occipital lobe.
  • 2021-09-24 CT - abdomen
    • 1. Multiple bony metastases.
    • 2. Flow artifact in S7 liver.
    • 3. Splenomegaly and a hemangioma 1.2 cm in the spleen.
  • 2021-08-31 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20200908, some new bone lesions are noted and some previous bone lesions are more evident. The scintigraphic findings suggest multiple bone metastases in progression.
  • 2021-08-31 SONO - abdomen
    • 1. Prior sonography identified An ill-defined hypoechoic lesion 2.48 cm in S7 liver is noted again, mild decreasing in size to 2.18 cm. Follow up is indicated.
    • 2. A gallstone 1.45 cm is suspected.
    • 3. The spleen shows enlarged in size (long axis: 13.35 cm).
  • 2021-08-03 MRI - brain
    • 1. Brain metastases, slight regression in right hippocampus, bil. cerebellar hemispheres and left IAC.
    • 2. Seems stationary of bil. cerebral nodules.
  • 2021-06-08 CT - lung
    • breast ca with lung, pleura, and bones metastasis, in regression of pleural effusion and stationary of lung and bony metastases as compared with previous CT study 2021/03/22
  • 2021-06-08 SONO - abdomen
    • 1. An ill-defined hypoechoic lesion 2.48 cm in S7 liver is noted that may be tumor or pseudolesion? Please correlate with contrast enhanced dynamic CT or MRI.
    • 2. A gallstone 1.79 cm is suspected.
    • 3. The spleen shows prominence in size (long axis: 11.38 cm).
  • 2021-05-08 MRI - brain
    • Brain metastases, progression in right hippocampus, bil. cerebellar hemispheres and left IAC.
  • 2021-03-22 SONO - breast
    • 1. Right breast tumors, suspected malignancy with axillary lymph node metastasis.
    • 2. Right breast skin thickening.
    • 3. Left breast tumor, suspected fibroadenoma. Suggest follow up.
    • BI-RADS 6. known biopsy-proven malignancy
  • 2021-03-22 CT - lung
    • breast ca with lung, pleura, and bones metastasis, in prgression of lung and pleural metastases as compared with previous CT study 2020/12/22
  • 2021-01-27 MRI - brain
    • multiple brain metastasis, decrease in sizes and numbers.
  • 2020-12-22 CT - lung
    • breast ca with lung, pleura, and bones metastasis, stationary of as compared with previous CT study 2020/09/11.
  • 2020-10-28 MRI - brain
    • multiple brain metastasis, increase in sizes and numbers.
  • 2020-09-11 CT - lung
    • Compatible with left breast cancer with lung and bone mets.
    • Enhanced breast nodules at right side, in regression.
  • 2020-09-08 Tc-99m MDP whole body bone scan
    • The scintigraphic findings suggest multiple bone metastases. In comparison with the previous study on 2019/09/27, most of the previous bone lesions are less evident except some bone lesions in the left S-I joint and right femur are a little more evident.
  • 2020-08-06 T-L spine AP+ Lat.
    • Pathologic compression fracture of T8,9,12, and L1,5
    • Blastic metastasis of bony structures
  • 2020-07-22 MRI - brain
    • multiple brain metastasis, decrease in sizes and numbers.
  • 2020-06-19 CT - lung
    • Compatible with breast cancer over both sides with lung, bone meta and pleural effusion. The main mass at left breast and right bresat tumors decreased in size.
    • The lung meta regressed.
  • 2020-06-19 SONO - abdomen
    • A hypoechoic nodule (1.59x1.66cm) at S7 of liver.
    • Gallbladder stones (0.51-0.92cm).
    • Splenomegaly.
  • 2020-06-19 SONO - breast
    • Left breast cancer
    • Bil. fibroadenomas
    • Suspected right breast tumor (#1)
  • 2020-04-20 MRI - brain
    • Numerous brain metastases.
  • 2020-03-11 CT - lung
    • breast ca with lung, pleura, and bones metastasis, in regression of lung metastasis and primary tumors, but in progression of bones metastasis as compared with previous CT study.
  • 2020-03-03 2D transthoracic echocardiography
    • 1. Normal chamber size
    • 2. Normal LV and RV contractility
    • 3. Mitral valve prolapse, mild MR
    • 4. Mild TR
  • 2020-03-03 SONO - abdomen
    • Fatty liver, mild to moderate
    • Suspect focal liver lesion or fatty liver related change, S7/8
    • Gall stone
    • Splenomegaly
    • Bilateral pleural effusion
  • 2019-10-31 CXR
    • Ground glass opacities in bil. lungs.
    • Bilateral pleural effusion.
  • 2019-10-27 CXR
    • Diffuse nodules in bilateral lungs.
    • Consolidations in bilateral lungs.
    • Progression of right pleural effusion as compare with CXR on 2019-10-22.
    • No cardiomegaly.
    • Compression fractures at lower T-spine.
  • 2019-10-22 CXR
    • Ground glass opacities and nodules in bil. lungs.
  • 2019-10-21 CXR
    • Presence of nodules at bil. lungs
    • Bilateral pleural effusion.
  • 2019-10-04 M-mode Echo
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 25) / 80 = 68.75%
    • Adequate LV,RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Limited echo window due to breast Ca wound
  • 2019-10-01 Whole body PET scan
    • 1. The FDG PET findings are compatible with left breast malignancy with right breast, multiple lung, liver, bone and lymph node metastases as mentioned above. Please correlate with other clinical findings for further evaluation.
    • 2. A small focal area of increased FDG uptake in the left hemisphere of the cerebellum. A metastatic lesion can not be ruled out.
  • 2019-09-27 Tc-99m MDP whole body bone scan
    • The scintigraphic findings suggest multiple bone metastases.
  • 2019-09-26 CT - lung
    • Left breast cancer with skin invasion.
    • Mediastinal lymphadenopathy and right breast, diffuse bone and lung mets.
  • 2019-09-24 MRI - T-spine
    • Findings
      • 1. Mild scoliosis of thoracicolumbar vertebral column.
      • 2. Diffuse osteolytic lesions with abnormal soft tissue intensity and compression involving T2-12 and L1-4 vertebral bodies (visible in these images), with collapse of T3 and T12 vertebral body, and compromise of neuroforamina at T11-T12-L1 levels.
    • Imp:
      • Diffuse bony and lung metastases as aforementioned.
• consultation
  • 2022-08-14 Neurology
    • Q
      • no blurred vision aura before visual defect, seeing things white, lasts 30 minutes and recovered spontaneously
    • A
      • This 43 y/o woman has a history of breast cancer with bone and brain metastatsis. She complained of left visual field defect noted since this morning. The symptom may fluctuate but the patient claimed that she may not pay attention to it. Frequent dizziness was also noted for a few days. I was consulted for further evaluation.
      • O
        • NE E4V5M6 cachexia
        • CNs: left homonymous hemianopia
        • MP: >4
        • sensation: intact
        • FNF: no dysmetria
        • brain MRI in 2022/06: multiple metastases, bilateral occpital lobes involvement and right side worse
      • impression:
        • visual field defect caused by metastatses
      • suggestion:
        • control underlying disease progression
        • neurology OPD follow-up for EEG and VEP study
        • consider antiseizure medication after evaluation or clinical seizure witnessed.
  • 2022-08-14 Ophthalmology
    • Q
      • no blurred vision aura before visual defect, seeing things white, lasts 30 minutes and recovered spontaneously
    • A
      • S: Left homonymous side photopsia for 2-3 hrs, painless, with persistent left VF defect now
        • Deneid fever
        • Lab data : pancytopenia
        • phx: breast caner with lung, bone, liver, LN, skin and brain mets with right occipital lobe involved
        • ophx: denied
        • nka
      • O:
        • VAcNC: OD 20/70 OS 20/100
        • IOP:14/16mmHg
        • pupil: 3mm+/+, 3mm+/+, no rapd
        • EOM: full and free
        • Confrontation test: left homonymous hemianopia
        • Red desaturation test: intact ou
        • conj: np ou
        • K: cl ou
        • AC: shallow/clear ou
        • Lens: cl ou
        • fundus : c/d: 0.7 margin clear, vessels perfusion ok, no break ou
      • A:
        • Left homonymous hemianopia c/w brain metastasis with right occipital lobe
      • P:
        • Control underlying disease + correct pancytopenia
        • Consider further brain image as your expertise
        • oph opd f/u for VF if condition stable, if bv/pain/neurologic defect/any symptom worsen, come back earlier
  • 2022-03-19 Ophthalmology
    • Q
      • Patient complained of suspected glaucoma at our ophthalmic clinic and would like to seek expertise from ophthalmic doctor.
    • A
      • S: left homonymous side photopsia and transient vision loss recently, and prolonged duration today, improving now
      • O
        • phx: breast ca with brain mets with right occipital lobe involved
        • ophx: enlarged cupping ou
        • BCVA: OD 0.4(0.8x0/-1.0x95) OS 0.6(1.0x-0.25/-0.5x70)
        • PT: 16/14 mmHg
        • pupil: 3mm+/+, 3mm+/+, no rapd
        • EOM: full and free, nystagmus in lateral gaze ou with fast pahse to lateral
        • confrontation test: inf temp VFD os?
        • conj: np ou
        • K: cl ou
        • AC: shallow/clear ou
        • LEns: cl ou
        • c/d: 0.7 inf notch od?, margin clear
      • A:
        • favor occipital seizure
      • P:
        • explain current condition and no fundus exam due to shallow AC to the patient, opd f/u for OCT and VF test(111/4/18) for preglaucoma and occipital lobe mets
        • if the symptoms prolong or persist, if any neurologic sign show up, come back eariler
        • opd f/u on W2
  • 2022-01-24 ENT
    • Q
      • CC.hemoptysis one time this morning
      • foreign body sensation in throat
      • throat pain(-), dizziness(-)
      • Onset: ate drug
      • Px. breast cancer under therapy treatment
      • TOCC: nil
      • vaccine: denied
    • A
      • Subjective:
        • hemoptysis one time this morning
        • foreign body sensation in throat
        • No hemoptysis and lump sensation now.
      • Scope:
        • Multiple petechiae were found at posterior pharyngeal wall and arytenoid
        • No active bleeder and foreign body was found
    • Plan:
      • Treat her thrombocytopenia as your expertise
      • Please give Broen-C TID
  • 2020-10-24 ENT
    • Q
      • fever for 3 days with sore throat and greenish rhinorrhea
      • denied chest pain, SOB, abd pain, diarrhea, dysuria
    • A
      • Water’s view: fluid accumulation over bilateral maxillary sinuses.
      • Local finding: no neck tenderness; fair mouth opening; no enlarged tonsils; injected posterior oropharyngeal wall; erythematous abrasive change over philtrum; yellowish crust with some blood clot in bilateral nasal cavity.
      • Scope: blood clot with yellowish mucus discharge over bilateral nasal cavity with post-nasal dripping; erosive change over nasopharynx, suspect post-RT change; smooth oropharynx and hypopharynx, erythematous change of epiglottis; patent airway; sputum noted in trachea.
      • Impression: acute nasopharyngitis and acute sinusitis, suspected pneumonia.
    • Plan:
      • Suggest admission to department of infecious disease or oncology for intravenous antibiotic treatment.
      • Please prescribe Broen-C, cough mixture, allegra, and biomycin ointment (for the philtrum wound) as symptomatic treatment.
      • Culture of nasal discharge was done.
• chemotherapy
  • 2022-08-16 - Enhertu (fam-trastuzumab deruxtecan-nxki) 5.4mg/kg 200mg 90min
  • 2022-07-25 - Kadcyla (ado-trastuzumab) 3.6mg/kg 120mg 90min
  • 2022-07-04 - Kadcyla (ado-trastuzumab) 3.6mg/kg 120mg 90min
  • 2022-06-13 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
  • 2022-05-23 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
  • 2022-05-02 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
  • 2022-04-11 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
  • 2022-03-16 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
  • 2022-02-23 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
  • 2022-01-19 - Kadcyla (ado-trastuzumab) 3.6mg/kg 120mg 90min
  • 2021-12-29 - Kadcyla (ado-trastuzumab) 120mg 90min
  • 2021-11-29 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
  • 2021-10-27 - Kadcyla (ado-trastuzumab) 3.6mg/kg 120mg 90min
  • 2021-09-08 - Kadcyla (ado-trastuzumab) 3.6mg/kg 150mg 90min
  • 2021-08-18 - Kadcyla (ado-trastuzumab) 150mg 90min
  • 2021-07-28 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2021-07-07 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2021-06-16 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2021-05-26 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2021-05-05 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2021-04-14 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2021-03-24 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2021-03-03 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2021-02-10 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2021-01-20 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-12-30 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-12-09 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-11-18 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-10-27 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-10-07 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-09-16 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-08-26 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-08-05 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-07-15 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-06-24 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-06-03 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-05-06 - Herceptin (trastuzumab) 600mg SC 5min
  • 2020-04-15 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-03-25 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
  • 2020-03-04 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr + docetaxel 60mg/m2 82mg 1hr + carboplatin AUC 6 300mg 2hr
  • 2020-02-03 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr + docetaxel 60mg/m2 80mg 1hr + carboplatin AUC 6 300mg 2hr
  • 2020-01-06 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr + docetaxel 75mg/m2 100mg 1hr + carboplatin AUC 6 300mg 2hr

[assessment]

• During this hospitalization, the patient is receiving her first dose of Enhertu.
• 2022-08-15 2D transthoracic echocardiography prior to having Enhertu showed baseline LVEF = (LVEDV - LVESV) / LVEDV = (30.9 - 11.9) / 30.9 = 61.49%
• Hypoalbuminemia is observed (2022-08-17 2.4 g/dL, normal 3.5 ~ 5.7). For humans, deruxtecan plasma protein binding is approximately 97% and the blood-to-plasma ratio is approximately 0.6, in vitro. Low albumin might potentially increase unbound deruxtecan concentration.
• Enhertu is classified as having a moderate emetic risk according to the NCCN guidelines, premedication palonosetron has been administered as the antiemetic agent.
• Recommended antiemetics for days 2-4: (reference: Rugo HS, Bianchini G, Cortes J, Henning JW, Untch M. Optimizing treatment management of trastuzumab deruxtecan in clinical practice of breast cancer [published online ahead of print, 2022 Aug 11]. ESMO Open. 2022;7(4):100553. doi:10.1016/j.esmoop.2022.100553 )
  • 1st cycle:
    • dexamethasone 4mg or 8mg daily +- metoclopramide 10mg PO TID or
    • 5-HT3 RA [e.g. granisetron (1-2 mg PO QD or 0.1 mg/kg IV QD)]
  • Subsequent cycles:
    • If adequate, repeat above.
    • If not (e.g. grade >= 1 for >= 3 days), give
      • aprepitant (80mg PO) + 5-HT3 RA +- dexamethasone (8mg) or
      • dexamethasone (8mg QD) +- metoclopramide (10mg PO TID)

700887906

220816

• lab data
  • Creatinine
    • 2022-07-22 Creatinine 2.24 mg/dL
      
    • 2022-07-15 Creatinine 2.53 mg/dL
      
    • 2022-07-12 Creatinine 4.16 mg/dL
      
    • 2022-06-21 Creatinine 2.03 mg/dL
      
    • 2022-05-30 Creatinine 2.20 mg/dL
      
    • 2022-05-09 Creatinine 1.69 mg/dL
      
    • 2022-04-30 Creatinine 2.07 mg/dL
      
    • 2022-04-27 Creatinine 1.98 mg/dL
      
    • 2022-04-21 Creatinine 1.49 mg/dL
      
    • 2022-04-18 Creatinine 1.75 mg/dL
      
    • 2022-04-16 Creatinine 3.63 mg/dL
      
    • 2022-04-15 Creatinine 3.95 mg/dL
      
    • 2022-04-14 Creatinine 2.33 mg/dL
      
    • 2022-04-12 Creatinine 1.86 mg/dL
      
    • 2022-02-28 Creatinine 1.81 mg/dL
      
    • 2022-02-15 Creatinine 1.65 mg/dL
      
    • 2021-11-10 Creatinine 1.93 mg/dL
      
    • 2021-09-23 Creatinine 2.35 mg/dL
      
    • 2021-07-08 Creatinine 2.21 mg/dL
      
    • 2021-04-08 Creatinine 1.77 mg/dL
      
    • 2021-01-11 Creatinine 2.05 mg/dL
      
    • 2020-11-05 Creatinine 1.74 mg/dL
      
    • 2020-09-01 Creatinine 1.7 mg/dL
      
    • 2020-08-21 Creatinine 2.1 mg/dL
      
    • 2020-08-20 Creatinine 2.2 mg/dL
      
    • 2020-08-14 Creatinine 3.1 mg/dL
      
    • 2020-08-12 Creatinine 2.2 mg/dL
      
    • 2020-08-04 Creatinine 1.8 mg/dL
      
    • 2020-07-10 Creatinine 1.7 mg/dL
      
    • 2020-06-15 Creatinine 1.7 mg/dL
      
    • 2020-06-15 Creatinine 1.7 mg/dL
      
    • 2020-05-29 Creatinine 1.9 mg/dL
      
    • 2020-04-11 Creatinine 1.8 mg/dL
      
    • 2020-04-09 Creatinine 1.6 mg/dL
      
    • 2020-02-14 Creatinine 1.5 mg/dL
      
    • 2020-02-07 Creatinine 1.4 mg/dL
      
    • 2020-02-04 Creatinine 1.4 mg/dL
      
    • 2020-01-07 Creatinine 1.5 mg/dL
• exam findings
  • 2022-07-22 ECG
    • Sinus rhythm with 1st degree A-V block
  • 2022-07-19 MRI - liver, spleen
    • Multiple liver tumors suspected metastases.
    • S/P left nephrectomy. S/P right PCN.
    • A soft tissue nodule (1.5cm) at umbilical region suspected tumor seeding.
    • Some LNs at retroperitoneum.
  • 2022-07-15 CT - abdomen, pelvis
    • Multiple liver tumors suspected metastases.
    • S/P left nephrectomy and cystectomy. S/P right PCN.
    • A soft tissue nodule (1.5cm) at umbilical region suspected tumor seeding.
    • Some LNs at retroperitoneum.
  • 2022-07-15 KUB
    • S/P right pig-tail catheter indwelling.
  • 2022-07-12 ECG
    • Sinus rhythm with 1st degree A-V block
  • 2022-05-30 KUB
    • S/P PCN catheter drainage, right side.
    • Lumbar spondylosis.
  • 2022-05-30 CXR
    • Increased bilateral lung markings.
  • 2022-05-21 CT - abdomen, pelvis
    • 1. S/P left nephrectomy and cystectomy. S/P PCN drainage, right side.
    • 2. Enlarged lymph nodes in right lower abdome around IVC, suspected metastatic lymph nodes.
  • 2022-05-20 SONO - nephrology
    • s/p left nephrectomy
  • 2022-05-09 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • Tumor type: Infiltrating urothelial carcinoma, high-grade
      • Tumor location: Prostate
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark ULTRA
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: [ V ] Pass, [ ] Fail
      • Adequate tumor cells present (>=50 viable tumor cells): [ V ] Yes, [ ] No
    • Result:
      • 1. Tumor cell (TC) staining assessment:
        • 1. TC category: TC < 1%
        • 2. Percentage of PD-L1 expressing tumor cells (%TC): < 1% (optional)
      • 2. Tumor-infiltrating immune cell (IC) staining assessment:
        • 1. IC category: IC < 1%
        • 2. Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): < 1% (optional)
    • Note:
      • 1. TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • 2. IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-04-15 Patho - urinary bladder partial/total resection
    • PATHOLOGIC DIAGNOSIS:
      • 1. Urinary bladder, Robotic-assisted radical cystoprostatectomy ( s/p TURBT) — Urothelial carcinoma in situ — No residual papillary urothelial carcinoma
      • 2. Prostate, RARC — Involved by infiltrating urothelial carcinoma, high-grade (at prostatic stroma) — Positive for tumor at apex margin
      • 3, Seminal vesicles, bilateral, RARC — Negative for malignancy
      • 4. Ureter, right, RARC — Negative for malignancy
           
      • 5. Ureter, left, RARC — Negative for malignancy
           
      • 6. Lymph node, right common iliac, dissection —- Negative for malignancy (0/1)
      • 7. Lymph node, right internal iliac, dissection —- Negative for malignancy (0/2)
      • 8. Lymph node, left external iliac, dissection —- Negative for malignancy (0/1)
      • 9. Lymph node, rleft external iliac, dissection —- Negative for malignancy (0/3)
      • 10. Vas deferens, left, RARC — Negative for malignancy
            
      • 11. Vas deferens, right, RARC — Negative for malignancy
            
      • 12. AJCC 8th edition Pathology stage: pT4aN0(if cM0); AJCC pathologic stage IIIA
    • MICROSCOPIC EXAMINATION (for urinary bladder):
      • 1. Histological type, Urothelial: Papillary urothelial carcinoma, invasive
      • 2. Histological grade: For urothelial carcinoma, other variants, or divergent differentiation: High grade
  • 2022-04-13 2D transthoracic echocardiography
    • Normal chamber size
    • Thickening of IVS
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with trivial AR, mild MR, TR and PR
    • No regional wall motion abnormalities
  • 2022-04-12 ECG
    • Sinus rhythm with 1st degree A-V block
  • 2022-04-08 Tc-99m MDP whole body bone scan with SPECT
    • 1. In comparison with the previous study on 2020/08/18, the lesions in the middle and lower C-spines are a little more evident. Degenerative change in a little more severe status may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • 2. No prominent change is noted in the lesions in the lower T-spine, some L-spines, L5-sacrum junction, compatible with degenerative change
    • 3. Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • 4. The previous some faint hot spots in bilateral rib cages are stationary, probably more benign in nature.
    • 5. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, left elbow, bilateral wrists, knees and ankles. Benign joint lesions are more likely.
  • 2022-03-01 Patho - urinary bladder TURBT
    • DIAGNOSIS:
      • A: Urinary bladder, TURBT — Non-invasive papillary urothelial carcinoma, high grade — Muscularis proria present without tumor
      • B: Urinary bladder, deep cut, TURBT — Negative for malignancy — Muscularis proria present without tumor
    • MICROSCOPIC DESCRIPTION:
      • A: Section shows high grade papillary urothelial carcinoma with focal cauterized artifact. No subepithelial invasion is found. Focal muscular layer is seen without tumor.
        
      • B: Section shows smooth muscular tissue without tumor.
  • 2022-02-28 CT - abdomen, pelvis
    • Wall thickening of urinary bladder.
  • 2021-09-24 Patho - urinary bladder TURBT
    • PATHOLOGIC DIAGNOSIS
      • 1. Urianry bladder, “tumor”, left, TURBT — Non-invasive papillary urothelial carcinoma, high-grade
           
      • 2. Urinary bladder, “deep cut”, TURBT — Non-invasive papillary urothelial carcinoma, high-grade
           
    • MICROSCOPIC EXAMINATION
      • 1. Histologic type: Papillary urothelial carcinoma, non-invasive
           
      • 2. Histologic grade: High-grade
           
      • 3. Tumor configuration: Papillary
           
      • 4. Muscularis propria: Present
           
      • 5. Lymphovascular invasion: Not identified
           
      • 6. Microscopic tumor extension: Tumor is non-invasive
           
      • 7. Specimen labeled “deep cut”: Non-invasive papillary urothelial carcinoma, high-grade
           
      • 8. Additional pathologic findings: Necrotizing inflammation
  • 2021-07-09 Patho - urinary bladder TURBT
    • DIAGNOSIS:
      • 1. Urinary bladder, “tumor”, TUR-BT — Infiltrating urothelial carcinoma, high-grade — Muscularis propria present and no tumor involvement
           
      • 2. Urinary bladder, “deep cut”, TUR-BT — Negative for malignancy — Muscularis propria present and no tumor involvement
  • 2021-04-09 urinary bladder biopsy
    • PATHOLOGIC DIAGNOSIS
      • 1. Urianry bladder, “tumor”, lateral wall, left, TURBT — Non-invasive papillary urothelial carcinoma, high-grade
           
      • 2. Urinary bladder, “tumor base”, TURBT — Free
           
    • MICROSCOPIC EXAMINATION
      • 1. Histologic type: Papillary urothelial carcinoma, non-invasive
           
      • 2. Histologic grade: High-grade
           
      • 3. Tumor configuration: Papillary
           
      • 4. Muscularis propria: Present
           
      • 5. Lymphovascular invasion: Not identified
           
      • 6. Microscopic tumor extension: Tumor is non- invasive
           
      • 7. Specimen labeled “tumor base”: Free of tumor
           
      • 8. Additional Pathologic findings: Necrotizing granulomatous inflammation
  • 2021-02-01 MRI - lower abdomen
    • 1. S/P left nephrectomy.
    • 2. Focal mucosal thiekening at urinary bladder base, suggest cystoscope correlation.
  • 2021-01-12 Patho - urinary bladder TURBT
    • PATHOLOGIC DIAGNOSIS
      • 1. Urianry bladder, “bladder tumor”, TURBT — Non-invasive papillary urothelial carcinoma, high-grade
           
      • 2. Urinary bladder, “tumor base”, TURBT — Free
           
    • MICROSCOPIC EXAMINATION
      • 1. Histologic type: Papillary urothelial carcinoma, non-invasive
           
      • 2. Histologic grade: High-grade
           
      • 3. Tumor configuration: Papillary and flat
           
      • 4. Muscularis propria: Present
           
      • 5. Lymphovascular invasion: Not identified
           
      • 6. Microscopic tumor extension: Tumor is non-invasive
           
      • 7. Specimen labeled “tumor base”: Free of tumor
  • 2020-11-06 Patho - urinary bladder TURBT
    • DIAGNOSIS:
      • A. Urinary bladder, bladder tumor, TURBT — Urothelial carcinoma (low grade) invading submucosa. Muscularis propria present and not invaded.
        • IHC stain: GATA-3 (+), SMA (highlights +, muscle layer).
          
      • B. Urinary bladder, tumor base, TUR-BT — Free. Muscularis prorpia present and not invaded.
        
    • MICROSCOPIC DESCRIPTION:
      • A. Section shows multiple pieces of low grade invasive carcinoma, invading submucosa. Muscularis propria present and not invaded.
        • IHC stain: GATA-3 (+), SMA (highlights +, muscle layer).
          
      • B. Section show musculkaris propria and free of malignancy.
  • 2020-08-28 MRI - kidney, adrenals
    • 1. S/P Lt nephrectomy. There is no evidence of tumor recurrence.
    • 2. There is mild wall thickening in left lateral aspect of the urinary bladder. Please correlate with cystoscopy.
  • 2020-08-18 Tc-99m MDP whole body bone scan with SPECT
    • 1. In comparison with the previous study on 2019/10/22, the lesions in the middle and lower C-spines, lower T-spine, some L-spines and L5-sacrum junction are either stationary or a little less evident. Degenerative change may show this picture.
    • 2. Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • 3. The previous some faint hot spots in bilateral rib cages are a little less evident, probably more benign in nature.
    • 4. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, left elbow, bilateral wrists, knees and ankles. Benign joint lesions are more likely.
  • 2020-08-11 Patho - urinary bladder TURBT
    • PATHOLOGIC DIAGNOSIS
      • 1. Bladder tumor, posterior wall, TURBT — Invasive papillary urothelial carcinoma, high grade
           
        • Muscularis propria, ditto — Absent
          
      • 2. Tumor base — Free from tumor
           
      • 3. Previous scar at left U/O — Chronic cystitis, compatible with scar
           
        • Muscularis propria, ditto — Present
          
      • 4. Previous TURBT scar at 5 o’clock bladder neck — Ulcer with fibrosis
           
        • Muscularis propria, ditto — Absent
          
    • MICROSCOPIC EXAMINATION
      • 1. Bladder tumor at posterior wall: invasive papillary urothelial carcinoma, high grade characterized by the pleomorphic tumor cells arranged in papillary or nest growth pattern with subepithelial invasion. Immunohistochemistry shows GATA-3(+), Uroplakin-II(+, scatter) and CK20(-) for tumor cells. Besides, Muscularis propria is absent in the limited specimen.
      • 2. Tumor base: muscularis propria only and free from tumor.
           
      • 3. Previous scar at left U/O: chronic cystitis, compatible with scar. Besides, muscularis propria is present and free from tumor.
           
      • 4. Previous TURBT scar at 5 o’clock bladder neck: ulcer with stromal fibrosis. Muscularis propria is absent.
  • 2020-05-29 Patho - urinary bladder TURBT
    • DIAGNOSIS:
      • A. Urinary bladder, “1. bladder tumornear UO”, TURBT — Urothelial carcinoma (high grade), invading muscularis propria.
        • IHC stains: CK20 (diffuse +, whole layer), CD44 (-), SMA highlights muscularis propria with tumor invasion.
          
      • B. Urinary bladder, “2. bladder tumor at the prostatic urethra”, TURBT — Urothelial carcinoma (high grade), invading submucosa.
        
      • C. Urinary bladder, “3. deep cut of bladder tumor near UO”, TURBT — free, muscularis propria present and not invaded.
        
    • MICROSCOPIC DESCRIPTION:
      • A. Section shows multiple pieces of urothelial carcinoma composed of papillary structures lined by urothelial cells with enlarged, hyperchromatic nuclei, high N/C ratio and mitoses up to 3/HPF. Tumor invades muscularis propria. IHC stains: CK20 (diffuse +, whole layer), CD44 (-), SMA highlights muscularis propria with tumor invasion.
        
      • B. Section shows urothelial carcinoma (high grade), invading submucosa.
        
      • C. Section shows soft tissue with no tumor, muscularis propria present and not invaded.
  • 2020-04-13 Patho - kidney partial/total resection
    • PATHOLOGIC DIAGNOSIS
      • 1. Renal calyx, left, nephroureterectomy — Invasive papillary urothelial carcinoma, high-grade
           
      • 2. Renal pelvis, ditto — Free of tumor
           
      • 3. Renal parenchyma, ditto — Tumor invasion
           
      • 4. Renal hilum, ditto — Tumor emboli present
           
      • 5. Perinephric fat, ditto — Free of tumor invasion
           
      • 6. Gerota’s fascia, ditto — Free of tumor invasion
           
      • 7. Ureter, ditto — Non-invasive papillary urothelial carcinoma, high-grade
           
      • 8. Ureter cutting end＆ bladder cuff, ditto — Free of tumor
           
      • 9. Lymph node, dissection — Free of tumor including hilum (0/1) and peri-renal fat (fat only)
           
      • 10. AJCC Pathologic Staging — ypT3N0 (if cM0), stage III
  • 2020-02-24 MRI - kidney, adrenals
    • Left renal caliceal tumor, regression as compare with CT study on 2019-07-17.
  • 2019-10-24 Effective renal plasma flow (ERPF)
    • 1. The ERPF of the right kidney was 161.3 ml/min, and the ERPF of the left kidney was 80.8 ml/min (normal reference range of ERPF: > 150 ml/min in each kidney for adults).
    • 2. After furosemide administration, the radiotracer washout was smooth from bilateral kidneys, indicating no definite evidence of obstructive hydronephrosis. Please correlate with other clinical findings for further evaluation.
  • 2019-10-22 Whole body bone scan with SPECT
    • 1. Increased activity in the middle and lower C-spines, lower T-spine and L5-sacrum junction. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • 2. Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • 3. Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • 4. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, elbows wrists, knees and ankles. Benign joint lesion is more likely.
  • 2019-10-04 Surgical pathology Level IV
    • DIAGNOSIS:
      • Kidney, left upper calyceal, biopsy —Non-invasive papillary urothelial carcinoma, high grade
    • MICROSCOPIC DESCRIPTION:
      • Section shows high grade papillary urothelial carcinoma. No subepithelial invasion is found. Please correlate with the clinical presentation and further examination is suggested.
• consultation
  • 2022-07-15 Urology
    • A
      • S
        • This 68-year-old male had history of
          • 1. Bladder urothelial carcinoma,cT2N0M0 s/p TUR-BT for 8 times on 2020/05/29, 2020/08/10, 2020/11/06, 2020/11/06, 2021/01/12, 2021/04/09, 2021/07/09, 2021/09/24, 2022-03-01 s/p intravesical chemotherapy, s/p gemcitabine + carboplatin, s/p radiotherapy.
          • 2. Left renal pelvis urothelial carcinoma, ypT3N0cM0, stage III s/p neoadjuvant chemotherapy and laparoscopic nephroureterectomy with bladder cuff resection on 2020/4/10; Recurrent tumor found in right side by cystoscopy on 2022/02/16
          • 3. Chronic kidney disease.   
          • 4. Bladder cancer s/p robotic-assisted radical cystectomy and right PCND on 2022/04/18, 2022/06/21; Urothelial cell carinoma, pT4aN0M0 stage IIIA.
        • He was just diacharged from our hospital due to dislodgement of right PCN. Revision of right PCN was done on 7/13. Severe right flank pain was noted for one day. The pain was associated with respiration.
        • He denied fever/chillness, nor turbid urine from PCN bag.
      • O
        • PE: right flank tenderness, no rebound pain, no muscle guarding
        • Lab data:
          • WBC 14.54k without bandemia (N/L: 85.6/6.2%), Hb 8.8 g/dL; Plt 303 k/uL
          • creatinine: 2.53 (improved) CRP 12.4 mg/dL
          • U/A clear; leuckocyte esterase 1+; NIT -; RBC 10-19/HPF;WBC 6-9/HPF; bac 1+/HPF
        • Abdominal CT: no urinoma, no fat stranding of right kidney, suspected new lesion at liver and a tumor above umbilicus
      • Imp:
        • UTI, metastatic UC
      • Suggestion:
        • antibiotics treatment with cephalexin and pain control with regular tramacet
        • OBS for one night and OPD follow up
  • 2022-04-15 Nephrology
    • Q
      • For hemodialysis evaluation
      • The 63 year-old male patient this admission impression of bladder cancer, he received of: 1. RARC + pelvic LN dissection; 2. Right PCN on 20220414. Post operation then transfer to SICU for care. RIght PCN dysfunction was found, PCN re-do was done, The CRE: 2.33->3.95. we need your help for this patient under hemodialysis evaluation, Thanks a lot.
    • A
      • Consult for HD evaluation
      • O
        • WBC:16.95, Band: 13.3, CRP::7.91
        • BUN/Cre: 32/1.86(4/12)->24/2.33(4/14)->34/3.95(4/15)
        • PH: 7.39, PCO2: 38, PO2:169, HCo3:23.0
        • Na: 143, K:3.9, Ca:1.89
        • U/O:273ml
      • Impression:
        • Acute kidney injury stage 2 related to obstructive uropathy
      • Suggestion
        • No emergent HD indication.
        • Follow up U/O and renal function, ABG, electrolyte
        • If persistant oliguria, refractory metabolic acidosis, hyperkalemia, fluid overload, we will arrange HD
  • 2022-04-15 Radiological Diagnosis
    • Q
      • for right PCN dusfunction ( Arrange antegrade pyelography )
      • The 69 year-old male patient this admission impression of bladder cancer, he received of: 1. RARC + pelvic LN dissection; 2. Right PCN on 20220414. Post operation then tranfer to SICU for care. However, rigth PCN dysfunction was found. bed side echo showed rigth hydronephrosis, we need your help for this patient under antegrade pyelography examination, Thank`s a lot.
    • A
      • According to the clinical condition and imaging findings, PCN is indicated.
• surgical operation
  • 2022-04-14
    • 1. RARC + pelvic LN dissection
    • 2. Right PCN
  • 2022-03-01 TURBT
  • 2021-09-24 Trnasurethral resection of bladder tumor
  • 2021-07-09 TURBT
  • 2021-01-12 TURBT + flexible URS of right ureter
  • 2020-11-06 TURBT + Right URS and DBJ insertion
  • 2020-08-10 TURBT
  • 2020-05-29 TURBT
  • 2020-04-10 Laparoscopic transperitoneal nephroureterectomy + bladder cuff resection left
• chemoimmunotherapy
  • 2022-08-09 - vinblastine 3mg/m2 2mg 10min + doxorubicin 30mg/m2 40mg 24hr + carboplatin AUC 4 200mg 2hr
    • due to high blood creatinine level, MVAC (methotrexate (hold) + vinblastine + doxorubicin + cisplatin (changed to carboplatin))
  • 2022-07-12 - pembrolizumab 100mg 30min
  • 2022-06-21 - pembrolizumab 100mg 30min
  • 2022-05-30 - pembrolizumab 100mg 30min
  • 2022-03-03 - mitomycin-C 30mg/m2 1hr intravesical
  • 2021-11-10 - cisplatin 30mg/m2 1hr intravesical
  • 2021-11-03 - doxorubicin 30mg/m2 1hr intravesical
  • 2021-10-20 - mitomycin-C 30mg/m2 1hr intravesical
  • 2021-10-13 - cisplatin 30mg/m2 1hr intravesical
  • 2021-10-02 - doxorubicin 30mg/m2 1hr intravesical
  • 2021-09-24 - mitomycin-C 30mg/m2 1hr intravesical
  • 2021-08-25 - mitomycin-C 30mg/m2 1hr intravesical
  • 2021-08-18 - doxorubicin 30mg/m2 1hr intravesical
  • 2021-08-11 - cisplatin 30mg/m2 1hr intravesical
  • 2021-08-04 - mitomycin-C 30mg/m2 1hr intravesical
  • 2021-07-28 - doxorubicin 30mg/m2 1hr intravesical
  • 2021-07-21 - cisplatin 30mg/m2 1hr intravesical
  • 2021-07-09 - mitomycin-C 30mg/m2 1hr intravesical
  • 2021-06-02 - gemcitabine 1000mg 1hr intravesical
  • 2021-05-26 - gemcitabine 1000mg 1hr intravesical
  • 2021-05-15 - gemcitabine 1000mg 1hr intravesical
  • 2021-05-03 - gemcitabine 1000mg 1hr intravesical
  • 2021-04-24 - gemcitabine 2000mg 1hr intravesical
  • 2021-04-17 - gemcitabine 1000mg 1hr intravesical
  • 2021-04-09 - doxorubicin 30mg/m2 1hr intravesical
  • 2021-03-10 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
  • 2021-02-24 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
  • 2021-02-03 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
  • 2021-01-27 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
  • 2021-01-20 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
  • 2021-01-13 - cisplatin 30mg/m2 1hr intravesical
  • 2020-12-23 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
  • 2020-12-16 - cisplatin 30mg/m2 1hr intravesical
  • 2020-12-09 - cisplatin 30mg/m2 1hr intravesical
  • 2020-12-02 - cisplatin 30mg/m2 1hr intravesical
  • 2020-11-25 - cisplatin 30mg/m2 1hr intravesical
  • 2020-11-17 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
  • 2020-11-06 - cisplatin 30mg/m2 1hr intravesical
  • 2020-10-14 - cisplatin 30mg/m2 1hr intravesical
  • 2020-10-07 - cisplatin 30mg/m2 1hr intravesical
  • 2020-09-30 - cisplatin 30mg/m2 1hr intravesical
  • 2020-09-23 - cisplatin 30mg/m2 1hr intravesical
  • 2020-09-16 - doxorubicin 30mg/m2 1hr intravesical
  • 2020-09-08 - doxorubicin 30mg/m2 1hr intravesical
  • 2020-08-21 - gemcitabine 1000mg/m2 30min + carboplatin 280mg 4hr
  • 2020-08-11 - doxorubicin 30mg/m2 1hr intravesical
  • 2020-07-28 - gemcitabine 1000mg 1hr intravesical
  • 2020-07-11 - cisplatin 35mg/m2 3hr IVD
  • 2020-07-10 - gemcitabine 1000mg/m2 30min + cisplatin 35mg/m2 3hr
  • 2020-06-24 - gemcitabine 1000mg/m2 30min
  • 2020-06-16 - cisplatin 35mg/m2 3hr IVD
  • 2020-06-15 - gemcitabine 1000mg/m2 30min + cisplatin 35mg/m2 3hr
  • 2020-05-30 - doxorubicin 30mg/m2 1hr intravesical
  • 2020-04-09 - doxorubicin 30mg/m2 1hr intravesical
  • 2020-02-25 - gemcitabine 1000mg/m2 30min
  • 2020-02-18 - gemcitabine 1000mg/m2 30min
  • 2020-02-07 - gemcitabine 1000mg/m2 30min + cisplatin 70mg/m2 3hr
  • 2020-01-21 - gemcitabine 1000mg/m2 30min
  • 2020-01-14 - gemcitabine 1000mg/m2 30min
  • 2020-02-07 - gemcitabine 1000mg/m2 30min + cisplatin 70mg/m2 3hr

[assessment]

• 2022-08-16 stool OB 4+ with tranexamic acid and pantoprazole administrated.
• Naproxen might be held temporarily for NSAIDs cause an increased risk of serious gastrointestinal adverse events, including bleeding, ulcers, and perforations of the stomach and intestines.

220726

[assessment]

• 2022-07-22 CFP 19.28 mg/dL, Ceftriaxone 200mg QD IVD has been administrated. 2022-07-23 urine culture showed after 48 hours < 1000 CFU/mL, body temperature touched 39.4 degree 2022-07-26 09:43.
• CrCl is 25 mL/min, no dose adjustment is needed for the drugs in active prescription.
• If recent extended spectrum beta-lactamase (ESBL) isolated, then meropenem or imipenem might be an option.

701393637

220816

• past history
  • essential thromobocythemia under hydroxyurea & anagrelide for yrs & spleen infartion s/p lower molecular heparin since 2019-04, now no more LMWH & hydroxyurea & anagrelide Tx.
• exam finding
  • 2022-08-15 ECG
    • Sinus tachycardia
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
  • 2022-08-15 Transfer
    • transferred from Cardinal Tien Hospital (2022-08-15) due to sepsis & pneumonia, anemia R/O GI bleeding, thrombocytopenia and left pevic fracture S/O ORIF (Open reduction internal fixation) on 20220805 and antibiotic with Mepem/Fluco was given for sepsis blood culture (Yeast-like and Cryptococcus neoformans (ARD), peumonia (sputum culture: acinetobacter pittii) and fungemia.
  • 2022-08-14 CT - brain (at Cardinal Tien Hospital?)
    • no definite brain lesion.
  • 2022-08-11 CT - chest (at Cardinal Tien Hospital?)
    • mild bilateral pleural effusion
  • 2022-08-02 SONO - abdominal (at Cardinal Tien Hospital?)
    • splenomegaly (17.5 cm)
  • 2022-08 Culture (at Cardinal Tien Hospital)
    • blood culture Yeast-like and Cryptococcus neoformans (ARD),
    • peumonia (sputum culture: Acinetobacter pittii) and fungemia.
  • 2022-07-16 CXR
    • Increased infiltration in both lungs
    • Borderline enlarged cardiac sihoutte
  • 2022-07-16 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH, may be normal variant
    • Nonspecific ST abnormality
    • Abnormal ECG
  • 2022-07-04 JAK2 single site mutation
    • target: JAK2 gene (p.V617F)
    • presence of mutation
  • 2022-06-20 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2022-06-20 SONO - abdomen
    • Right renal cyst.
  • 2022-03-21 CT - abdomen (at Cardinal Tien Hospital?)
    • splenomegaly.
  • 2022-03-11 Bone marrow (at ChangHua Christian Hospital)
    • JAK2 V617F.
    • hypocellular marrow with fibrosis.
    • Gr II myelofibrosis by reticulin & trichrome stain.
    • No BCR/ABL fusion gene.
    • No occult mets carcinoma cell found by cytokeratin immunostain.
• consultation
  • 2022-08-15 Infectious Disease
    • Q
      • This 70-year-old woman, intermitent fever with chills S/P ABX treatment at Cardinal Tien Hospital. She was transferred to our hospital on 20220518.
      • The blood culture yielded yeast-like & sputum culture: Acinetobater pittii moderate. We need expertise to evaluate her condition thanks!

[assessment]

• High serum osmolality 320 mOsm/Kg (2022-08-15), hydration with 0.45% NaCl 500mL BID.
• Antimicrobial meropenem and fluconazole have been prescribed for Acinetobacter pittii and Cryptococcus neoformans respectively.
• 2022-08-15 PLT 41 *10^3/uL. In the case of active bleeding, patients with thrombocytopenia should be transfused with platelets immediately to maintain platelet counts above 50,000/microL in most bleeding situations, including disseminated intravascular coagulation (DIC).
• Drug dosages in active prescriptions have been adjusted in accordance with the patient’s current renal function (2022-08-15 creatinine 1.21 mg/dL).
• There are no issues with the medication at present.

701007135

220815

{oropharyngeal cancer}

• exam finding
  • 2022-08-12 CT - abdomen, pelvis
    • Few stones in the distal CBD, causing mild dilatation of the proximal CBD, CHD, and IHDs, are suspected. Please correlate with ERCP.
  • 2022-08-12 CXR
    • Tortous aorta with calcification is noted.
    • Emphysematous change over both lungs.
    • Osteopenia of the bony structure is noted.
  • 2022-07-13 Percutaneous gall bladder drainage
    • Distention of the gallbladder (by US images). S/P NG tube indwelling.
  • 2022-07-12 SONO - abdomen
    • Diagnosis
      • Gallbladder sludge
      • CBD dilatation
      • Cholecystopathy
      • Fatty liver, mild
      • Renal stone, right kidney
      • Small amount ascites
      • Bilateral pleural effusion
    • Suggestion
      • correlated with liver function test and clinical symptoms
  • 2022-07-08 ECG
    • Paroxysmal Atrial fibrillation
    • Low voltage QRS
    • Abnormal ECG
  • 2022-07-06 2D transthoracic echocardiography
    • Conclusion:
      • 1. Dilated RV with preserved RV systolic function; cor pulmonale?
      • 2. Preserved LV systolic function.
      • 3. Moderate TR.
      • 4. Sinus tachycardia.
  • 2022-07-05 CT - abdomen, pelvis
    • 1. Right renal stone.
    • 2. GB stones.
    • 3. Bilateral pleural effusion and ascites.
    • 4. Fatty liver.
  • 2022-07-04 CT - abdomen, pelvis
    • Dilated, swelling of the intestines with increased intestinal gas is found. Gastrogenteritis is favored.
    • Right renal staghorn stone.
    • Gallstone.
  • 2022-07-04 ECG
    • Undetermined rhythm
    • Marked ST abnormality, possible inferior subendocardial injury
    • Abnormal ECG
    • Left axis deviation
    • ST depression, consider subendocardial injury
  • 2019-12-30 CXR
    • Increased lung volumes.
    • Subsegmental ground glass opacity over Rt peripheral upper lung zone
    • Tortousity of thoracic aorta
  • 2019-03-29 CT - brain
    • Swelling of right frontal scalp.
• consultation
  • 2022-07-12 Radiological Diagnosis
    • Q
      • The 73 years old male had history of 1). renal stone S/P ESWL for five times at MMH, 2). GU, DU, gastritis. 3). Oropharyngeal cancer diagnosis on 2022-05. 4). COVID-19 infection on 20220426. According to the statement of ER and family record. He was a heavy drinker/smoker before. Denied any systemic past history before diagnosis oropharyngeal cancer. This time he suffered from SOB on 20220704. Therefore his wife call 119 and sent to our ER for evalutation. At ER, he denied fever, N/V, constipation, diarrhea. COVID-19 infection positive on 20220426. Abdominal CT showed 1. Right renal stone. 2. Bilateral pleural effusion and ascites. 3. Fatty liver. Under impress of 1). Severe sepsis with septic shock 2). AKI 3). R/O GI bleeding. He was admitted to our MICU for further treatment.
      • After admission to our MICU, empirical antibiotic with cefepime was administered for sepsis control. Hypercapenia respiratroy failure episode intubation was on 20220705. Due to intermittent fever still episode, we change to Doripenem plus Targocid on 20220706. NPO and PPI plus adequate IVF for GI bleeing. Bloodtransfusion LRP and FFP for correct thrombocytopenia and abnormal coagulation. Inotropic with levohped plus albumin for shock. Unbalane electrolye was correct. Sedative medication with Fentanyl plus ativan. However KP pneumonia was diagnosis, keep doripenem use.Abdomen echo was performed, that report showed CBD dilatation.
      • For GB stone with CBD dilatation, so we need your help for PTGBD evaluation. Thanks!
    • A
      • According to the clinical condition and imaging findings, PTGBD is indicated.

700020247

220812

{Cholangiocarcinoma, pT4N0cM0, s/p S5 segmentectomy with lymph node dissection and cholecystectomy on 2020-01-13, with T11-12 metastasis and compression fracture s/p radiotherapy to T spine in 2020-04}

• Past History
  • Medical history
    • 1. Hypertension
    • 2. Sick sinus syndrome (brady-tachy syndrome) post DDDR pacemaker in 2020/07
    • 3. Atrial fibrillation under amiodarone and Rivaroxaban
    • 4. Goiter
  • Surgical history
    • 1. Hemorrhoids, Grade III post hemorrhoidectomy on 2015/10/02
    • 2. Cholangiocarcinoma, pT4N0cM0, s/p S5 segmentectomy with lymph node dissection and cholecystectomy on 2020/01/13, with T11-12 metastasis and compression fracture s/p radiotherapy to T spine on 2020/04/01-2020/04/15 under partial response        
• exam finding
  • 2022-08-12 MRI - upper abdomen
    • History and indication:
      • 20210712 CT: recurrent CCC 2.6 cm at S6, S/P surgery
      • 20191219 CT: CCC 2.6 cm at S5 with gallbladder invasion S/P op.
    • Findings
      • 1. S/P partial resection of S5 and S6 of the liver.
        • A hepatic cyst measuring 1 cm in S5 is noted.
      • 2. S/P cholecystectomy.
      • 3. There are several renal cysts on both kidney and the largest one measuring 1.6 cm in size at right middle pole.
        • Both kidney show small size that may be chronic renal disease. Please correlate with renal function.
      • 4. Compression fracture of T10-11.
        • Mild Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5 and L5-S1.
      • 5. There is no hyper-or hypodense lesion in the biliary system, pancreas, and spleen.
        • There is no ascites or lymphadenopathy.
          
        • The abdominal aorta and IVC are grossly unremarkable.
    • IMP:
      • S/P partial resection of S5 and S6 of the liver.
      • There is no evidence of tumor recurrence.
  • 2022-07-15 Tc-99m MDP whole body bone scan
    • 1. As compared with the previous study on 2021-04-19, the lesion in the lower T-spine is a little less evident.
    • 2. No prominent change is noted in other bone lesions, possibly more benign in nature.
  • 2022-06-30 ECG
    • Atrial-paced rhythm with prolonged AV conduction
    • Prolonged QT
  • 2022-06-28 SONO - abdomen
    • S/P cholecystectomy and partial resection of S5/6/8 liver.
    • Several renal cysts on both kidney and the largest one is measured about 3.4 cm in size at right middle pole.
  • 2022-04-13 MRI - upper abdomen
    • S/P partial resection of S5 and S6 of the liver.
    • There is no evidence of tumor recurrence.
  • 2022-03-24 CT - abdomen, pelvis
    • S/P liver operation. A poor enhancing tumor (1.4cm) in S6 of liver.
    • Renal and liver cysts (up to 3.7cm).
  • 2022-03-10 SONO - abdomen
    • S/P right liver operation. S/P cholecystectomy. Bil. renal cysts.
  • 2022-01-10 CT - abdomen, pelvis
    • S/P partial resection of S5 and S6 of the liver.
    • Please correlate with contrast enhanced dynamic CT or MRI.
  • 2021-08-06 Patho - liver partial resection
    • Pathologic diagnosis
      • Liver, S6, segmentectomy — Intrahepatic cholangiocarcinoma, recurrent
        
      • Pathologic Staging: rpT3Nx; Stage IIIA if cM0
        
    • Microscopic examination
      • Histologic Type: Intrahepatic cholangiocarcinoma, recurrent
      • Histologic Grade: Moderately differentiated (G2)
      • Tumor Growth Pattern: Mass-forming
      • Tumor Necrosis: Present
      • Tumor Extension: Tumor perforating the visceral peritoneum
        
      • Perineural Invasion: Present
        
      • Pathologic Staging: rpT3Nx; Stage IIIA if cM0
        
      • Margins
        • Parenchymal Margin: Free, 1.2 cm from closest margin
          
        • Hepatic Capsule: Involved by invasive carcinoma
          
      • Non-neoplastic liver: Mild portal inflammation, portal fibrosis, and mild fatty change (5%)
        
  • 2021-07-12 CT - liver, spleen, biliary duct, pancreas
    • S/P liver operation. A recurrent tumor (2.6cm) in S6 of liver.
  • 2021-07-02 SONO - abdomen
    • S/P cholecystectomy and partial resection of S5-8 liver.
    • There is an ill-defined hypoechoic lesion 2.33 x 1.67 cm in S6 of the liver.
    • Recurrent cholangiocarcinoma is highly suspected. Please correlate with contrast enhanced dynamic MRI.
    • Several renal cysts on both kidney and the largest one is measured about 3.34 cm in size at right middle pole.
  • 2021-04-29 MRI - liver, spleen
    • Imp: s/p S5 resection with post op. change.
    • No evidence of recurrent/residual tumor in the study.
  • 2021-04-19 Tc-99m MDP whole body bone scan
    • Increased radioactivity at the T10-11 spines is old and comes to less prominent compared with the previous study on 2020-04-29, indicating partial response to current therapy.
    • Suspected benign lesions in the maxilla, mandible, lower L-spine, bilateral shoulders, sternoclavicular junctions, wrists, hips and knees.
  • 2021-03-09 CT - abdomen, pelvis
    • Suspected band like heterogenoeous hyperemic change at S5/S8 of liver is found. In comparison with CT dated on 2020-11-27, the lesion is stationary.
  • 2020-11-27 CT - liver, spleen, biliary duct, pancreas
    • Biloma in S5/8 of the liver show decreasing in size.
    • Two ovoid-shaped soft tissue lesions 1.5 x 1 cm and 1.3 x 0.8 cm in LLL of lung at lung window setting are noted that may be focal atelectasis with granuloma?
    • The differential diagnosis include metastases.
    • Follow up chest CT is indicated.
  • 2020-07-01 CT - liver, spleen, biliary duct, pancreas
    • Biloma in S5/8 of the liver is highly suspected.
    • Follow up is indicated.
  • 2020-01-14 Patho - liver partial resection
    • Pathologic diagnosis
      • Liver, S5, segmentectomy — Cholangiocarcinoma, large duct type
        
      • Lymph nodes, LN 12 and LN 8+7, dissection — No lymph node found
        
      • Gallbladder, cholecystectomy — Involved by carcinoma
        
      • Pathologic Staging: pT4Nx; Stage IIIB at least
        
    • Microscopic examination
      • Histologica Type: Cholangiocarcinoma, large duct type
        
      • Histologic Grade: G2 ( Moderately differentiated)
        
      • Tumor Growth Pattern: Mass-forming
        
      • Tumor Extension: Tumor invades gallbladder
        
      • Gall bladder margin: Uninvolved by invasive carcinoma
        
      • Lymphovascular Invasion: Present
        
      • Perineural Invasion: Present
        
      • Regional Lymph Nodes: No lymph nodes found
        
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        
      • Non-neoplastic liver: Mild portal inflammation and portal fibrosis
        
  • 2019-12-27 Surgical pathology Level V
    • Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with cholangiocarcinoma
  • 2019-12-23 Abdominal Ultrasonography
    • Hepatic tumor, right lobe, favor malignancy, r/o abscess
• consultation
  • 2020-01-15 Thoracic Medicine
    • Q
      • For left pleural effusion
      • The male patient this admission impression of HCC, he was received of S5 resection on 20200113, post operation then transfer to SICU for care. The CXR showed left pleural effusion, we need your help for this patient chest echo examination and chest tapping.
    • A
      • The chest sono on 2020-Jan-15 showed (1) consolidation over left lower lung field (2) minimal amount pleural effusion over right thorax. Thus, thoracocentesis was not perforemd.
  • 2020-01-09 General and Gastroenterological Surgery
    • Q
      • This 80 years old man has the histories of
        • 1. Lumbosacral spondylosis without myelopathy
        • 2. Neuralgia,neuritis,and radiculitis,unspecified
        • 3. Sick sinus syndrome (brady-tachy syndrome) post pacemaker on 2009/06/08
        • 4. Atrial fibrillation
        • 5. Hemorrhoids, Grade III post hemorrhoidectomy on 2015/10/02.
      • This time, he suffered from fever (BT up to 39C) for 2 days, chills, epigastric pain about two days. The abdominal CT with contrast was done which revealed A poor enhancing lesion (2.6cm) in S5 of liver. DDX: early phase abscess, hypovascular tumor; Suspected hemangiomas (3mm, 8mm) at right heaptic lobe; Renal cysts (up to 3.1cm) and tiny gallbladder stones (1-2mm). CXR showed borderline heart size enlargement. Abdominal sonography was done which revealed hepatic tumor, right lobe, favor malignancy, suspected abscess. The tumor markers (CA19-9 3096.87 IU/mL; CEA 14.43ng/mL), the liver biopsy was arranged on 2019/12/27 and pathology reported Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with cholangiocarcinoma. Chest CT showe T10-T11 spondylodiscitis and favor left lung infection with pleural effusion. no metastatic lung nodule. liver tumor, cholangiocarcinoma.
      • We need your expertise for surgical intervention of cholangiocarcinoma. Thanks.
    • A
      • This case with liver tumor with cholangiocarcinoma was impressed.
      • Suggest:
        • 1. consult CV for heart and pacemaker evaluation.
        • 2. arrange cardiopulmonary function
        • 3. we will arrange operation after data report
• surgical operation
  • 2021-08-05
    • Surgery
      • S6 resection
      • IOE
    • Finding
      • severe intraabd adhesion due to last hepatectomy
      • 2 x 1.8 x 1.5 cm well define tumor at S6 with retroperitoenal invasion
  • 2020-01-13
    • Surgery
      • S5 segmentectomy
      • cholecystectomy
      • hepato-duodenal ligament LN dissection
      • intraoperative echo
      • laparoscope
    • Finding
      • 4.5 x 4.0 x 2.5 cm tumor at S5 with GB invasion
      • no obvious LN was noted at station 12 and 8
• radiotherapy
  • 2020-04-01 ~ 2020-04-15 - 3000cGy/10 fractions (6 MV photon) to T8-12 rib, Rt 9th rib.
• chemoimmunotherapy
  • 2022-08-10 - gemcitabine 1000mg/m2 1700mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
  • 2022-07-12 - gemcitabine 1000mg/m2 1700mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
  • 2022-06-13 - gemcitabine 1000mg/m2 1700mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
  • 2022-05-16 - gemcitabine 1000mg/m2 1700mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
  • 2022-04-26 - gemcitabine 1000mg/m2 1700mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
  • 2022-04-11 - gemcitabine 900mg/m2 1500mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr

==========

2022-08-12

• There has been a slow decline in tumor markers in the past six months, which might indicate that the treatment is having a positive impact.
  • CEA
    • 2022-08-12 5.525 ng/ml
      
    • 2022-08-12 5.962 ng/ml
      
    • 2022-06-21 8.350 ng/mL
      
    • 2022-04-12 6.903 ng/ml
      
    • 2022-03-09 10.570 ng/mL
      
  • CA199
    • 2022-08-12 209.425 U/ml
      
    • 2022-08-12 242.735 U/ml
      
    • 2022-06-21 235.360 U/mL
      
    • 2022-04-12 273.730 U/ml
      
    • 2022-03-09 300.520 U/mL
      
• Blood creatinine level around 2 mg/dL since April 2022 => eGFR 35 mL/min/1.73m2, CrCl 25 mL/min. Adjustments have been made to the following items:
  • rivaroxaban for patients with atrial fibrillation, nonvalvular (to prevent stroke and systemic embolism), CrCl 15 to 50 mL/minute: 15 mg once daily with the evening meal (AHA/ACC/HRS January 2014; AHA/ACC/HRS January 2019).
  • nebivolol for patients CrCl <30 mL/minute: Initial: 2.5 mg once daily; if initial response is inadequate, may increase cautiously.
  • spironolactone for patients eGFR 30 to 50 mL/minute/1.73 m2: Initial: 12.5 mg once daily or every other day; may double the dose every 4 weeks if serum potassium remains <5 mEq/L and renal function is stable, up to a maximum target dose of 25 mg/day (ACCF/AHA Yancy 2013).

2022-07-13

• BH 160 cm, BW 68.6 kgw (2022-07-12), creatinine level around 2 mg/dL since April 2022 => eGFR 32.1 ~ 39.0 mL/min/1.73m2, CrCl 22.9 ~ 28.0 mL/min.
  • As with creatinine, BUN displayed a similar trend.
• Options for adjusting the dose of the current regimen for patients with kidney impairment
  • Carboplatin:
    • The manufacturer’s labeling recommends the following dosage adjustments for single-agent therapy
      • Baseline CrCl 41 to 59 mL/minute: Initiate at 250 mg/m2 and adjust subsequent doses based on bone marrow toxicity.
      • Baseline CrCl 16 to 40 mL/minute: Initiate at 200 mg/m2 and adjust subsequent doses based on bone marrow toxicity.
      • Baseline CrCl <=15 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling.
    • Aronoff 2007 (for dosing based on mg/m2)
      • GFR >50 mL/minute: No dosage adjustment is necessary.
      • GFR 10 to 50 mL/minute: Administer 50% of the usual dose.
      • GFR <10 mL/minute: Administer 25% of the usual dose.
  • Gemcitabine
    • Discontinue if severe renal toxicity or hemolytic uremic syndrome occur during gemcitabine treatment.
• The current dose of carboplatin is 150mg, which should remain within the acceptable range.

2022-05-17

• No abnormalities in TPR. Lab data on 2022-05-16 showed general normal readings except for elevated blood creatinine (1.66 mg/dL) and BUN (47 mg/dL).
• No issue with active prescription.

700064846

220812

• exam finding
  • 2022-07-01 CXR
    • tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
    • reticular opacities at RUL due to fibrotic change
  • 2022-06-08 CXR
    • Atherosclerotic change of aortic arch
    • Few linear and nodular infiltrations in both lung are noted. please correlate with clinical condition.
    • S/P metalic autosuture at right upper lung.
  • 2022-04-18 CT - abdomen, pelvis
    • Colon cancer s/p RAR without recurrent/residual tumor in the study.
    • s/p right upper lobe wedge resection.
    • Hepatic simple cysts..
  • 2021-11-08 KUB
    • Surgical stiches and clips over abdomen
    • Suspect left renal stone
  • 2021-10-25 Patho - lung total/lobe/segmental
    • Lung, right upper lobe, VATS RUL wedge resection — Interstitial fibrosis
    • Microscopically, sections show Interstitial fibrosis characterized by stromal fibrosis with intervening vessels and focal deposition of pigment-laden histiocytes. The lung elsewhere shows is not remarkable.
      
    • Immunohistochemical stain reveals CK(-)
  • 2021-10-22 Patho - colon segmental resection for tumor
    • indication: Adenocarcinoma of ascending colon, cT3N0M1a (lung mets, but RUL frozen show fribrosis) s/p L-right hemicolectomy
      
    • pathologic diagnosis
      • Large intestine, ascending colon, SILS Right-hemicolectomy — Adenocarcinoma, moderately differentiated
        
      • Resection margins: free
        
      • Lymph node, mesocolic, dissection — Negative for malignancy (0/16)
        
      • Lymph node, IMA / SMA, dissection — N/A.
        
      • Appendix: Negative for malignancy
        
      • Pathology stage: pT3N0 (if cM0); AJCC stage IIA
  • 2021-10-21 CXR
    • Ground glass opacity in right lung.
  • 2021-10-21 Frozen section - lung
    • Lung, RUL, frozen section— Fibrosis
  • 2021-09-28 Whole body PET scan
    • 1. A glucose hypermetabolic lesion in the middle portion of the ascending colon, compatible with primary colon malignancy. However, no prominent FDG uptake was noted in the soft tissue nodule in the upper lobe of right lung delineated in the chest CT scan. Please follow up chest CT scan for further evaluation.
    • 2. A glucose hypermetabolic lesion in the left upper abdomen just between the stomach and left lobe of the liver. A metastatic lymph node should be watched out.
    • 3. A small glucose hypermetabolic lesion in the vertebral body of T10 spine only in the delayed imaging. Please follow up other imaging modalities for further evaluation and to rule out the possibility of early bone metastasis.
    • 4. Glucose hypermetabolism in some right upper neck level II lymph nodes. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    • 5. Mild glucose hypermetabolism in right pulmonary hilar region. Inflammation may show this picture.
  • 2021-09-22 CT
    • Findings:
      • 1. There is soft tissue nodule 6 mm in RUL of the lung that may be metastasis. The differential diagnosis include primary lung cancer or lung parenchyma lymph node.
      • 2. There is mild wall thickening at the posterior aspect of the middle ascending colon measuring 1 cm in wall thickness that may be adenocarcinoma. Please correlate with colonoscopy.
      • 3. Fatty liver, grade 4-5, is noted. There are few small poor enhancing lesions on both hepatic lobes that may be cysts? The largest one measuring 0.6 cm in S6. Please correlate with sonography.
      • 4. Two small calcified renal stones in left lower pole are noted. A renal cyst measuring 3 cm in left lower pole is noted.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 N:N0 M:M1a; stage:IVA
  • 2021-09-13 Patho - colon biopsy
    • Colon, middle ascending?/cecum?, 110 cm from anal verge, biopsy (A) — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).
  • 2021-09-13 Colonoscopy
    • Diagnosis
      • 1. One ulcerative mass was noted in the middle ascending colon s/p biopsy
      • 2. Two polyps was noted in the ascending colon and sigmoid s/p polypectomy and clipped
    • Suggestion
      • F/U pathology report
  • 2021-09-13 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • Gastric ulcer, antrum, PW
      • Gastric erosion, antrum, AW
      • Duodenal erosion, bulb, LC
      • Post self-paid CLO test
    • Suggestion
      • PPI use
      • Persue CLO test result
• consultation
  • 2022-01-22 Dermatology
    • Q
      • This 59-year-old man patient is a case of Adenocarcinoma of A-colon, cT3N0M1a (0.6cm RLL nodule, suspected metastasis and liver nodules), stage IVa. He was admitted for chemotherapy with FOLFOX (C2D15).
      • This time, for right back of thigh mole and right foot thumb onychomycosis. Now, for evaluate right back of thigh mole and right foot thumb onychomycosis therapy. Thank you.
    • A
      • S: This patient suffered from dyskeratotic nails on bil sole for yrs
      • Imp: Tinea unguim
      • Suggestion:
        • Excelderm soln (sulconazole) *4 BT/Bid
• chemoimmunotherapy
  • 2022-08-11 - oxalipaltin 50mg/m2 100mg 24hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr (oxa 24hr <- 2hr)
  • 2022-07-21 - oxalipaltin 75mg/m2 150mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-06-06 - oxalipaltin 75mg/m2 150mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-05-06 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-04-15 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-03-25 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-03-02 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-02-10 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-01-21 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
  • 2022-01-07 - oxalipaltin 85mg/m2 165mg 2hr + leucovorin 400mg/m2 775mg 2hr + fluorouracil 400mg/m2 775mg 10min + fluorouracil 2400mg/m2 4660mg 46hr
  • 2021-12-17 - oxalipaltin 85mg/m2 165mg 2hr + leucovorin 400mg/m2 775mg 2hr + fluorouracil 400mg/m2 775mg 10min + fluorouracil 2400mg/m2 4660mg 46hr
  • 2021-11-26 - oxalipaltin 85mg/m2 165mg 2hr + leucovorin 400mg/m2 775mg 2hr + fluorouracil 400mg/m2 775mg 10min + fluorouracil 2400mg/m2 4660mg 46hr

[assessment]

• The patient was found to have pulmonary fibrosis in Oct 2021 (pathology and frozen section).
• Studies have found that oxaliplatin is associated with pulmonary toxicity, and some of those suggested that the drug should be withheld for unexplained pulmonary symptoms until interstitial lung disease or pulmonary fibrosis are ruled out.

700928517

220812

• exam finding
  • 2022-07-11 CT - abdomen, pelvis
    • Presacral soft tissue mass, in enlargement. Rectal cancer progression is favored.
    • One growing low density at S8 of liver is found. Liver mets is hightly suspected.
  • 2022-05-25 Patho - colon resection
    • intestine, large, proximal transverse colon, revision of T colon colostomy — compatible with prolapse of colon
  • 2022-05-17 ECG
    • Right bundle branch block
    • Left anterior fascicular block
    • Bifascicular block
  • 2022-05-17 2D transthoracic echocardiography
    • 1. Preserved LV and RV systolic function with normal wall motion
    • 2. Dilated AsAo, LA and LV, grade 1 LV diastolic dysfunction
    • 3. Moderate to severe AR
  • 2022-03-05 CT - abdomen, pelvis
    • indication: Recurrent rectal cancer with impending obstruction s/p T loop colostomy on 2021/12/08 and concurrent chemoradiotherapy
    • Soft tissue mass at presacral space, in enlargement.
    • Liver low density lesions. Simple cysts are favored.
  • 2021-12-07 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Left anterior fascicular block
  • 2021-11-23 Patho - colon biopsy
    • Rectum tumor, 6-7 cm above anal verge, biopsy — Adenocarcinoma
      
    • Immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
  • 2021-11-22 Colonoscopy
    • Diagnosis
      • Probable rectal cancer with recurrence, 6-7cm above AV, s/p biopsy for multiple pieces
    • Suggestion
      • F/U pathology report
  • 2021-11-19 CT - abdomen, pelvis
    • 1. Local recurrent tumor in the rectal fossa is suspected.
    • 2. Hemangioma 0.8 x 0.5 cm in S8 of the liver is suspected. Please correlate with sonography or MRI.
    • 3. Adenoma 2.8 x 2 cm of left adrenal gland is suspected. Please correlate with clinical condition and MRI.
  • 2021-05 CT - abdomen (at Far Eastern Memorial Hospital)
    • liver and adrenal mets.
  • 2021-02 CT - abdomen (at Far Eastern Memorial Hospital)
    • decreased size of liver mets but mildly increased size of para-aortic LAP.
  • 2020-08 CT - abdomen (at Far Eastern Memorial Hospital)
    • recurrence over liver and para-aortic LAP.
  • 2020-01 CT (at Far Eastern Memorial Hospital)
    • local recurrence over distal rectum involved with seminal vesicle.
  • 2017
    • recurrence of liver was noted, and he received the surgical intervention with segmentectomy of liver S3 on 2017-06-09.
  • 2014 initial presentation
    • indicental finding of rectal mass, liver mets was noted. without LAR, pT4bN1bM0, Stage III, s/p 1 dose of adjuvant chemotherapy.
• consultation
  • 2021-12-28 Colon and Rectal Surgery
    • Q
      • The 73 y/o man has rectal cancer, cT4bN1bM0, Stage III with many times of recurrence s/p LAR (ypT3N0) s/p chemotherapy. He was admitted for salvage CCRT. Fever noted and suspect anal fistula with pus formation, so we need your help for management. Thanks!
    • A
      • Tumor recurrence with fistula formation
      • minimal abscess now
      • Need keep fistula opening by AgNO3 and empiric antibiotics treatment
  • 2021-12-27 Urology
    • Q
      • The 73 y/o man has recurrent rectum cacner under CCRT now. Due to dysuria, so we need your help for management. Thanks!
    • A
      • S
        • Initial presentation: 2014, rectal cancer,cT4bN1bM0, Stage III with many times of recurrence s/p LAR (ypT3N0), many times of chemotherapy
        • He was admitted for salvage CCRT.
        • Chief complaint: weak stream, intermittency, abdominal straining, and nocturia (2-3/per night) in recent 1 months, no sense of incomplete voiding
      • O
        • U/A: clear
        • TPV from CT: about 50 ml
        • PE: suspected an anal fistula with pus formation
      • Suggestion:
        • check PSA
        • arange UFR/PVR on 12/29 morning
        • also consult CRS for management of anal fistula
        • precribe harnalidge QD
• surgical operation
  • 2021-12-08 T loop colostomy (at Far Eastern Memorial Hospital)
  • 2020-06-19 LAR, ypT3N0
  • 2017-06-09 surgical intervention with segmentectomy of liver S3 (which hospital ?)
• radiotherapy
  • 2021-12-20 ~ 2022-01-10 - 4000cGy/16 fractions (15 MV photon) to recurrent rectal tumor
  • 2020-03-11 ~ 2021-04-15 - 4500cGy/25 fx (at Far Eastern Memorial Hospital)
• chemoimmunotherapy
  • 2022-08-11 - irinotecan 150mg/m2 240mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 3900mg 46hr
  • 2022-07-29 - irinotecan 150mg/m2 240mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 3900mg 46hr
  • 2022-07-19 - irinotecan 150mg/m2 250mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
  • 2022-03-01 - irinotecan 150mg/m2 250mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
  • 2022-02-07 - irinotecan 150mg/m2 250mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
  • 2022-01-12 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
  • 2021-12-30 - leucovorin 20mg/m2 30mg 10min D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 (CCRT)
  • 2021-12-22 - leucovorin 20mg/m2 30mg 10min D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 (CCRT)
  • 2021-03-04 ~ 2021-05-09 - cetuximab plus FOLFOX (Oxa 85 mg/m2, LV 300 mg/m2, no bolus 5-FU, 5-FU 2600 mg/m2) for 4 doses (at Far Eastern Memorial Hospital)
    • the patient refused the further course of chemtoherapy due to intoleralbe side effect of mucositis, diarrhea, constipation, nausea and vomiting, and folliculitis over head.
  • 2020-08-18 ~ 2020-10-27 - FOLFOX * 5 (at Far Eastern Memorial Hospital)
  • 2020-03-11 ~ 2020-04-15 - weekly HDFL* 6 (CCRT) (at Far Eastern Memorial Hospital)

[note]

• When giving FOLFOX/FOLFIRI and skipping 5FU bolus, do you still give leucovorin?
  • https://www.themednet.org/when-giving-folfox-folfiri-and-skipping-5fu-bolus-do-you-still-give-leucovorin
• Impact of empirically eliminating 5-fluorouracil (5-FU) bolus and leucovorin (LV) in patients with metastatic colorectal cancer (mCRC) receiving first-line treatment with mFOLFOX6
  • https://ascopubs.org/doi/10.1200/JCO.2020.38.15_suppl.4022
• Impact of Empirically Eliminating 5-Fluorouracil Bolus and Leucovorin in Patients with Metastatic Colorectal Cancer Receiving First-Line Treatment with mFOLFOX6
  • https://britishjournalofcancerresearch.com/wp-content/uploads/2020/06/BJCR-162.pdf

[assessment]

• The 5-FU bolus is skipped since the patient has been refused treatment at Far Eastern Memorial Hospital in first half of 2021 due to intolerance of side effects.
• Vital signs and lab data during this hospitalization were generally normal.
• There is no issue with active prescription.

701391524

220811

[assessment]

• Renal function: female, age 45, weight 65, creatinine 4.43 => CrCl 16 mL/min, eGFR 12 mL/min/1.73m2.
• Levocetirizine elimination route: 168 hours post dose an average of 85.4% of a radiolabeled dose was recovered with an average of 80.8% in the urine and 9.5% in the feces. Levocetirizine for CrCl 10 to 30 mL/minute: 2.5 mg twice weekly (every 3 or 4 days).

220802

[assessment]

• Recent creatinine level trend
  • 2022-07-30 6.03 mg/dL
    
  • 2022-07-29 5.80 mg/dL
    
  • 2022-07-27 4.69 mg/dL
    
  • 2022-07-25 2.31 mg/dL
    
  • 2022-07-21 0.79 mg/dL
    
• Suspected AKI. Calculated CrCl based on Cockcroft-Gault formula is 13 mL/min, and eGFR by MDRD equation is approximate 8 mL/min/1.73m2.
• For patients with kidney impairment:
  • Cefepime for CrCl 11 to 29 mL/min: max 1 g every 12 hourse or 2 g every 24 hours, no dose adjustment is needed.
  • Cimetidine for GFR <10 mL/min: 300 mg every 8 to 12 hours, no dose adjustment is needed.
  • Levocetirizine for CrCl 10 to 30 mL/minute: 2.5 mg twice weekly (every 3 or 4 days). The current dose form is 5mg per tablet, which is difficult to administer to meet the aforementioned. Allegra (fexofenadine 60mg/tab, available in stock) is an alternative that is recommended at a dose of #1 QD.

220727

• exam findings
  • 2022-07-26 ECG
    • Sinus rhythm with 1st degree A-V block
    • Low voltage QRS
    • Borderline ECG
  • 2022-07-21 ECG
    • Right superior axis deviation
    • Anterior infarct, age undetermined
    • Nonspecific T wave abnormality
  • 2022-07-21 Gynecologic ultrasonography
    • Suspected Mild Adenomyosis
  • 2022-07-21 Pure-tone Audiometry, PTA
    • Reliabilty Fair
    • R’t : 13 dB HL
    • L’t : 19 dB HL
    • Bil WNL.
  • 2022-07-07 ECG
    • Sinus rhythm with 1st degree A-V block
    • Borderline ECG
  • 2022-06-23 MRI - brain
    • No evidenec of intracranial lesion.
  • 2022-06-23 Miniprobe Endoscopic Ultrasound
    • Endoscopic findings
      • 1. Multiple patchy esophageal lesion were noted from 42cm to 20cm. Under ME-NBI, brownish lesion with IPCL B1-2. Under lugol chromoendoscopy, multiple lugol voiding lesions were noted. Pink color sign (+)
      • 2. One raised and nodular mucosa lesion was noted at 28cm. Under ME-NBI, IPCL B-3 with large AVA was noted. Mucosa break <5mm was noted at EC junction.
    • EUS findings
      • Using EUS-DP- 25R, EUS showed a hypoechoic mucosal lesion with blurred 3rd layer at the lesion site. At least 3 lymph nodes were noted.
    • Diagnosis
      • 1. Esophageal cancer, at least cT1bN2, middle esophagus
      • 2. Rule out dysplastic esophageal lesion, diffuse middle and lower esophagus
      • 3. Reflux esophagitis
  • 2022-06-22 CT - lung/mediastinum/pleura
    • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T0N0M0
  • 2022-06-20 Patho - tonsil and/or adenoid
    • Palatine tonsil, right, tonsillectomy
      • — Well differentiated squamous cell carcinoma
      • — Margin free of tumor
    • Microscopically, section shows well differentiated squamous cell carcinoma consisting of nests and sheets of tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis. The tumor cells have eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity. The margin is free of tumor and 1~2 mm of closest margin distance.
  • 2022-06-15 Whole body PET scan
    • 1. A glucose hypermetabolism lesion in the left palatine tonsil, compatible with the primary tonsil cancer.
         
    • 2. Another glucose hypermetabolism lesion in the right palatine tonsil, the nature is to be determined, suggesting biopsy for investigation.
    • 3. Glucose hypermetabolism lesions in bilateral level III cervical lymph nodes, cancer with regional lymph nodes mets should be considered.
    • 4. A glucose hypermetabolism lesion in the left lower pelvis, the nature is to be determined also (urine, Gyn problems, or other nature ?), suggesting further investigation.
         
    • 5. Increased FDG uptake in bilateral kidneys and colon, probably physiological uptake of FDG.
    • 6. Left palatine tonsil cancer, cTxN2cM0, stage IVA at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-06-15 Patho - esophageal biopsy
    • Diagnosis
      • Esophagus, 28 cm below incisor, biopsy — well differentiated squamous cell carcinoma
    • Microscopically, section shows well differentiated squamous cell carcinoma consisting of sheets of squamous tumor cells with areas of dyskeratosis and focal stromal invasion. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
  • 2022-06-15 Patho - esophageal biopsy
    • Diagnosis
      • 1. Esophaus, 33 cm below incisor, biopsy— severe dysplasia, at least
      • 2. Esophaus, 40 cm below incisor, biopsy— mild dysplasia
    • Microscopically, section A shows severe dysplasia with squmoaus cells hyperplasia, nuclear hyperchromais and pleomorphism. There is no stromal component for evaluation of invasion. Section B shows mild dysplasia of squamous cells.
  • 2022-06-14 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Esophageal hyperemic patch, 33cm below the incisor (specimen A) and 40cm below the incisor (specimen B), s/p biopsy
      • Esophageal mucosa lesion, 28 below the insicor, s/p biopsy (C)
      • Superficial gastritis, s/p CLO test
      • Gastric erosions, prepyloric antrum
      • Duodenitits
      • Suspicious pseudodiverticulum, bulb
    • Suggestion
      • Pursue CLO test and biopsy result
  • 2022-06-13 MRI - larynx
    • Imaging Report Form for Oropharynx Carcinoma
    • Impression (Imaging stage): T2N2cM0, stage IVA
  • 2022-06-13 ECG
    • Normal sinus rhythm
    • Biatrial enlargement
    • Right superior axis deviation
    • Right ventricular hypertrophy
  • 2022-06-02 Patho - tonsil biopsy
    • Labeled as “left oropharynx”, biopsy — squamous cell carcinoma, well differentiated.
    • IHC stains: p16 (-), p40 (+), CK5/6 (+).
  • 2022-06-02 Nasopharyngoscopy
    • Findings
      • Oral cavity and oropharynx: an ulceration at L tonsillar fossa(esp L palatopharyngeal arch), a granular bulging at left velum posterior part visible from nasopharynx
      • Nasopharynx: fair via mirror/scope
    • Diagnosis
      • left oropharyngeal lesion

[assessment]

• Nasogastric tubes can be used to administer all oral medications in active prescriptions.
• Ascorbic acid included in Lyo-povigent inj may improve the absorption of iron supplement (ferrous sodium citrate) from the stomach.

700353371

220810

• past history
  • Diabetes mellitus for years under regular OHA control.
  • Hypertension for years under regular medication control.  
• exam finding
  • 2022-08-05 Pure Tone Audiometry, PTA
    • Reliabilty Fair to Poor
    • PTA
    • R’t : 30 dB HL, normal to moderately severe SNHL
    • L’t : 34 dB HL, normal to severe mixed type HL.
  • 2022-07-26 CT - neck
    • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage): T:T2/T4, N:N2C, M:M0, stage IVA
  • 2022-07-20 Patho - larynx biopsy
    • DIAGNOSIS:
      • A: Hypopharynx, pyriform sinus, right, biopsy — Squamous cell carcinoma, moderately differentiated
      • B: Oropharynx, soft palate, right, biopsy — Chronic inflammation
    • MICROSCOPIC DESCRIPTION:
      • A: Section shows squamous mucosa with invasive squamous cell carccinoma. The immunohistochemical stains reveal CK(+) and p63(+).
      • B: Section shows squamous mucosa with chronic inflammation. No invasive tumor is seen.
  • 2022-07-19 CXR
    • Tortuosity of the aorta with atherosclerotic change.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-07-14 Nasopharyngoscopy
    • smooth NPx, oropharynx, right pyriform sinus yellowish granular tumor, saliva pooling
• consultation
  • 2022-07-19 Oral and Maxillofacial Surgery
    • Q
      • This 71-year-old man has history of diabetes mellitus and hypertension over 2 years under regular medication control. The patient suffered from left mouth floor cyst suspect ranula noted in 2012-02, right buccal erythroplakia with mild uneven surface s/p biopsy on 20120325, the patho revealed minimal chronic inflammation.
      • This time, throat foreign body sensation, dysphagia, easy chocking and trismus 1.5 fingers were complained for 2 weeks. He came to our ENT OPD for help. Physical examination revealed trimus (1.5FB), soft palate fibrosis, right buccal and R soft palate erythroplakia with mild uneven surface, right pyriform sinus yellowish granular tumor, saliva pooling.
      • Under the impression of right oropharyngeal tumor and right oral lesion suspect malignancy, He was admission for lesion biopsy. We request your consultatio for dental evaluation.
    • A
      • This is a 71 y/o male who suffered from right oropharyngeal tumor and right oral lesion suspect malignancy.
      • O:
        • 1. Poor oral hygiene was noted
        • 2. Severe bone loss of tooth 27 47 and 44-33 was noted. No mobility was noted
      • A:
        • Sever periodontits of toooth 27 47 and 44-33.
      • P:
        • 1. Take panoramic film for tooth evaluation
        • 2. Suggest conservative treatment or tooth 27 47 extraction before further treatment
        • 3. OHI and teach him how to do home care
• surgical operation
  • 2022-07-20
    • Surgery
      • Laryngomicrosurgery        
      • Biopsy of oral mucosa
      • Rigid esophagoscopy
    • Finding
      • 1. Right pyriform sinus medial wall and anterior wall granular tumor
      • 2. Rigid esophagoscopy: 18cm from incisor, free of tumor
      • 3. Erythroplakia at right soft palate and right retromolar trigone
      • 4. Removal of teeth #27,47
• chemoimmunotherapy
  • 2022-08-08 - docetaxel 30mg/m2 55mg 1hr + cisplatin 40mg/m2 75mg 2hr + fluorouracil 2000mg/m2 3850mg 48hr

[assessment]

• TPR were relatively stable during this hospitalization.
• In general, blood pressure is well controlled, except for a transient episode of hypotension on 2022-08-09.
• Blood sugar levels fluctuated between 100 mg/dL and 200 mg/dL, no urgent intervention is required.
• Metoclopramide and chlorpromazine are independently associated with development of extrapyramidal symptoms (EPS) and neuroleptic malignant syndrome (NMS). The former is administered as TIDAC and the latter is administered as PRNHS, these two are not administered simultaneously, thus minimizing the risk.
• There is no issue with the active prescription.

700515879

220805

{Right upper lung adenocarcinoma, moderately differentiated with bone metastasis, stage IV}

• diagnosis
  • 1. Malignant neoplasm of unspecified part of unspecified bronchus or lung
  • 2. Lung cancer with bone metastasis, stage IV
  • 3. Essential (primary) hypertension
  • 4. Pure hypercholesterolemia
  • 5. Chronic viral hepatitis B without delta-agent
• exam finding
  • 2022-08-05 Pure Tone Audiometry, PTA
    • PTA
    • Reliability FAIR
    • Average RE 29 dB HL; LE 50 dB HL.
    • R’t normal to severe SNHL.
    • L’t mild to severe SNHL.
  • 2022-07-11 PD-L1 IHC S2022-10376
    • Tumor cell (TC) staining assessment: TC < 1%
    • Percent of PD-L1 expression in tumor cell (TC): < 1%
  • 2022-07-08 PD-L1 22C3 S2022-10376
    • Tumor Proportion Score (TPS): < 1%
  • 2022-07-08 PD-L1 SP142 S2022-10376
    • Tumor cell (TC) staining assessment: TC < 1%
      • Percentage of PD-L1 expressing tumor cells (%TC): 0%
    • Tumor-infiltrating immune cell (IC) staining assessment: IC < 1%
      • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 0%
    • Note:
      • 1. TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • 2. IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-07-08 EGFR mutation testing S2022-10376
    • No mutation was detected at exons 18 (G719X), 19 (Deletions), 20 (T790M, S768I, Insertions), 21 (L858R, L861Q) of EGFR gene in this specimen.
  • 2022-07-08 ROS1 Fluorescent-in-situ hybridization S2022-10376
    • Rearrangement of ROS1 gene is NOT detected.
  • 2022-07-08 ALK IHC S2022-10376
    • Immunostaining using ALK antibody D5F3 revealed no staining of tumor cells.
  • 2022-06-29 Pathology - lung transbronchial biopsy
    • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
  • 2022-06-28 CT - lung/mediastinum/pleura
    • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T4N3M1c
  • 2022-06-21 CXR
    • Patchy opacity projecting at right upper lung zone was noted, which might be bronchogenic carcinoma. Please correlate with CT.
    • Spondylosis of the T-spine
  • 2022-09-16 CT - abdomen, pelvis
    • S/P colon operation. A small nodule (5mm) at LUQ suspected tumor seeding. Lung and bony metastases.
  • 2022-06-09 MRI - L-spine
    • Diffuse bony metastases involving T10-S4 vertebral column and bony pelvis as described. Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L4-5 (with left HIVD). Post-operation change at L4-5.
  • 2019-07-31 L-spine AP + Lat. (including sacrum)
    • 1. post-OP change from L4 to L5; and mild scoliosis of the L-spine.
    • 2. moderate to severe decreased disc spaces in the L2/3 and L3/4 discs; and mild decreased disc space in the L1/2 disc.
    • 3. mild anterior and posterior spur formation in the L-spine
  • 2019-07-05 Doppler Flowmetry (perivasculary)
    • 1. Mild atherosclerosis of bil. infrapopliteal arteries without significant stenosis
    • 2. All triphasic flow spectrum from bil. CFA, PFA, SFA and popliteal arteries downstream to bil. PTA, ATA and DPA.
  • 2019-06-28 MRI - L-spine
    • Lumbar spondylosis with spinal canal stenosis and neuroforaminal narrowing, most severe on left side at L4-5.

[assessment]

• Molecular and/or biomarker analyses were performed on this lung adenocarcinoma patient in order to identify gene alterations. The purpose of this is to identify potentially effective targeted therapies, as well as to avoid therapies that are unlikely to provide clinical benefits. However, the performed test results showed that PD-L1 TC < 1% & IC < 1%, no EGFR mutation detected, no ROS1 rearrangement detected, no immunostained ALK. An initial treatment option might be a regimen based on carboplatin or cisplatin.
• Underlying condition HTN is well controlled during this hospitalization.

700529765

220805

• exam finding
  • 2022-08-04 KUB
    • Presence of ileus.
  • 2022-08-04 CXR
    • Presence of ileus.
    • Multiple nodules at bil. lungs.
  • 2022-08-03 KUB
    • There is fecal materials impaction in the course of colons.
    • Local ileus.
  • 2022-06-21 CXR
    • Enlarged heart shadow with tortuous aorta.
    • Multiple nodules and masses in bilateral lungs, consider metastases, enlarging.
    • Bilateral clear costophrenic angles.
  • 2022-06-21 Ribs Bilat
    • Multiple nodules and masses in both lungs, consider metastases, enlarging.
    • No definite displaced rib fracture. Clinical correlation is advised.
  • 2022-06-21 CT - brain
    • Brain atrophy. No ICH.
  • 2022-06-21 ECG
    • Sinus rhythm with premature atrial complexes
    • T wave abnormality, consider anterior ischemia
    • Prolonged QT
  • 2021-10-12 ECG
    • Normal sinus rhythm
    • T wave abnormality, consider anterior ischemia
  • 2021-10-12 CT - abdomen, pelvis
    • Hx of rectal ca without Tx. Only receiving chinese medicine
    • Diffsue wall thickening of the rectum up to 7.5cm in length and swelling of the sigmoid colon and descending colon is found. Rectal cancer with colitis at sigmoid colon is considered.
    • Lung mets.
  • 2021-10-12 CXR
    • Tortous aorta with calcification is noted.
    • Nodular lesion at right upper lobe and right lower lobe is found.
    • Osteopenia of the bony structure is noted.
  • 2020-08-04 CT - lung/mediastinum/pleura
    • RLL solid nodule (15-mm) (in favor an another primary lung cancer).
    • Lingula tiny nodule, nature to be determined.
  • 2020-08-04 Patho - colon biopsy
    • Large intestine, rectum, biopsy — Adenocarcinoma, moderately differentiated
      
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2020-08-04 SONO - abdomen
    • Hepatic cyst, multiple
    • GB stone, mutiple
    • Renal cyst, bilateral
  • 2020-08-03 Sigmoidoscopy
    • Diagnosis
      • Rectal cancer with partial obstruction, s/p Bx
      • Internal hemorrhoid
    • Suggestion
      • F/U pathology report
    • Complication
      • No immediate complication
  • 2020-08-03 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
    • Suggestion
      • PPI treatment
• consultation
  • 2021-10-14 Family Medicine
    • Q
      • for combine hospice care
      • This 78 year-old female patient who has rectal cancer, Stage IV on 2020/08, then she refusioned the surgery treatment, chemotherapy, radiotherapy.
      • This time, she suffered from watery diarrhea many times for one month due to the use of folk herbal recipes, then the symptom of waterly diarrhea progression, and poor intake, abdomen pain noted, so she was brought our ER for help.
      • The patient still refusion chemotherapy, radiotherapy, but want to combine hospice care, so we need your help, thanks a lot!!
    • A
      • Indication: rectal cancer, Stage I
      • Patient refuses cancer treatment and has no specific complaint while I visited.
      • We will arrange share to follow up.
      • She can visit FM OPD for symptom control after discharge.
  • 2020-08-04 Colorectal Surgery
    • Q
      • This 78 y/o female patient denied any systemic history before. She suffered from abdominal fullness and difficult stool passage for 4 days. She visited HoPing Hospital for help where suspected colon cancer by abdomen CT exam. High level of CRP 29 was noted. The patient then transfered to our OPD for personal reason. Denied fever, cough, chest pain, tarry stool passage, oliguria, nor limbs edema. The physical examination showed pink conjuctiva and soft abdomen. CEA on 20200729 31.7 ng/mL. Going to obtain routine blood test and further management.
      • Sigmoid scope showed rectal cancer with partial obstruction, s/p Bx; internal hemorrhoid. We would like to need your visit for professional help. Thank you very much!
    • A
      • I’ve visited this case.
      • This 78 y/o fenmale patient suffered from abdominal distension and no stool passage for 4 days and then rectal cancer with obstruction was diagnosed.
      • Stool passage (+) now and no more abdominal distension.
      • I’ve explained the necessity of surgical treatment, the patient denied any discomfort and ask for discharge today.
      • The risk of re-obstruction was told.
      • Suggest OPD F/U

[assessment]

• The patient refused to receive surgery, chemotherapy, radiotherapy.
• Elevated CRP (2022-08-04 11.68 <- 2022-08-03 8.57), normal WBC (2022-08-04 7.13). Brosym (cefoperazone/sulbactam) is prescribed.
• All the oral drugs in active prescription can be administered with nasogastric tube without issues.

700642355

220805

{ovarian cancer, pT3aN0cM0, FIGO stage IIIA2}

• exam finding
  • 2022-06-08 SONO - abdomen
    • Hydronephrosis, right
  • 2022-04-07 Patho - uterus with or without SO non-neoplastic/prolapse
    • Ovarian/ Fallopian tube/ Peritoneum Cancer Checklist
    • Diagnosis:
      • F2022-00147:
        • Ovary, left, oophorectomy —- Mucinous carcinoma
        • Ovary, right, oophorectomy —- Mucinous carcinoma
        • Fallopian tube, left, salpingectomy —- Not found
        • Fallopian tube, right, salpingectomy —- Negative for malignancy
      • S2022-05776
        • Uterus, corpus, total hysterectomy —- Negative for malignancy —- Leiomyoma
        • Uterus, endometrium, total hysterectomy —- Negative for malignancy
        • Uterus, cervix, total hysterectomy —- Negative for malignancy
        • Omentum, omentectomy —- Extravasated mucin present
      • AJCC 8th edition: pStage IIIA2, pT3aN0 (if cM0); FIGO Stage IIIA2
    • Gross description:
      • Procedure: ATH + BSO + Cytoreduction surgery + infracolic omentectomy + LN dissection
        
      • Microscopic Description:
        • Histologic Type: Mucinous carcinoma with abundant extravasated mucin; The immunohistochemical stains reveal PAX8(-), WT-1(-), PR(-), and p53(wild type).
          
        • Histologic Grade: G2: Moderately differentiated
        • Implants (required for advanced stage serous/seromucinous borderline tumors only): Not sampled
        • Other Tissue/ Organ Involvement (select all that apply): bilateral adnexal soft tissue and omentum: extravasated acellular mucin present
        • Largest Extrapelvic Peritoneal Focus (required only if applicable): omentum: Microscopic
        • Peritoneal/Ascitic Fluid: N2022-01327: Negative for malignancy
          
        • Regional Lymph Nodes: left iliac: 0/3; left obturator: 0/5; right iliac: 0/0; right obturator: 0/6; left para-aortic: 0/1; right para-aortic: 0/0.
          
        • Additional Pathologic Findings: A leiomyoma is seen.
  • 2022-04-06 Frosen Resection
    • FsA: Ovary, left, oophorectomy — mucinous adenocarcinoma
    • FsB: Ovary, right, oophorectomy — mucinous adenocarcinoma
  • 2022-04-01 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Chronic gastritis, H pylori NOT present
  • 2022-03-29 Mammography
    • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative. - annual screening.
  • 2022-03-28 CT - abdomen, pelvis
    • Right hydronephrosis and hydroureter.
    • A cystic lesion (11.4cm) at left adnexa with septation suspected mucinous tumor. A tumor (5.9cm) at uterus suspected myoma.
  • 2022-03-28 Gynecologic ultrasonography
    • pelvis mass: 116x111mm
  • 2017-07-03 MRI - nasopharynx
    • Findings
      • Multiple ovoid and round nodular lesions in Rt level III, IV, Vab (the largest lesion 21mmx20mm)
      • An heterogeneous enhancing mass, lobulated in contour (heterogeneous hyperintensity on T2WI. mixed hyper-and intermediate intensity on T1WI) in the lower neck and thoracic inlet, which is inseparable from adjacent thyroid gland.
    • Impression:
      • In favor of thyroid cancer with neck LNs metastasis.
• consultation
  • 2022-03-28 Obstetrics and Gynecology
    • Impression and plan:
      • 1. Huge ovarian mass, left side 116x111 mm, suspect malignancy.
      • 2. Uterine myoma: 69x43 mm
      • 3. Survey tumor marker CEA, CA125, CA199, AFP, SCC, D-dimer
• surigcal operation
  • 2022-04-06
    • Operation
      • 1. Enterolysis
      • 2. Excision of intraabdominal malignant tumor
    • Finding
      • s/p lower midline incision scar with severe adhesion of small bowel to abdominal wall and lower pelvic cavity.
      • Several mucinous nodules were removed
      • Washing cytology: ascites*1
  • 2022-04-06
    • Surgery
      • Right hydronephrosis and hydroureter.A cystic lesion (11.4cm) at left adnexa with septation suspected mucinous tumor.
      • Left ovarian tumor (11.4 cm), suspected malignancy.
      • Frozen: mucinous adenocarcinoma
      • Debulking surgery (ATH + BSO + Cytoreduction surgery + infracolic omentectomy + LN dissection)     - Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: enlarged, 8cm, tense contact with bladder, peritoneum dut to tumor mass accupied .
      • Adnexa:
        • LOV: 11.4x10x8cm , rupture during the operation , smooth surface.
        • ROV: 2x2x2 cystic mass , capsule not intact.
        • Fallopian tube: bilateral grossly normal
      • CDS: invisible due to tumor mass occupied
      • Ascites: bloody , minimal
      • Bilateralpelvic lymph nodes: normal(-), enlarged(-), indurated(-)
      • Omentum: grossly normal
      • Optimal debulking surgery was achieved.
      • Residue tumor: almost no residual tumors, maximal diameter < 1 cm, over rectum and peritonealwall.
      • Estimated blood loss:1000 ml
      • Blood transfusion: 4U
      • Complication: NIL
• chemoimmunotherapy
  • 2022-08-04 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 600mg 2hr
  • 2022-07-13 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 600mg 2hr
  • 2022-06-02 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 600mg 2hr
  • 2022-05-12 - paclitaxel 160mg/m2 210mg 3hr + carboplatin AUC 5 600mg 2hr

220627

[assessment]

• The body temperature was no higher than 37 degrees since the night of 2022-06-25 after administration of Tapimycin (piperacillin 4g, tazobactam 0.5g) IVD Q6H since 2022-06-24.

700653751

220805

{newly diagnosed with Endometrioid adenocarcinoma T1BN0M0 stage IB s/p Laparoscopic gynecologic oncology staging surgery}

[objective]

• lab data
  • Uric Acid
    • 2022-06-29 8.6 mg/dL
    • 2022-03-22 9.7 mg/dL
      
    • 2022-02-14 8.2 mg/dL
      
    • 2021-09-28 10.2 mg/dL
      
    • 2021-04-21 9.8 mg/dL
      
  • Hepatitis
    • 2022-02-24
      • Anti-HBs 97.17 mIU/mL Reactive
      • Anti-HBc Nonreactive 0.53 S/CO
        
      • Anti-HCV Nonreactive 0.04 S/CO
        
      • HBsAg Nonreactive 0.29 S/CO
• exam finding
  • 2022-04-28 2D transthoracic echocardiography
    • Dilated LA
    • LV apical and septal hypertrophy
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR, mild MR and TR
    • No regional wall motion abnormalities
  • 2022-03-16 Pure tone audiometry, PTA
    • Reliability FAIR
    • Average R’t 31 dB HL // L’t 35 dB HL
    • Bil normal to moderately severe SNHL.
  • 2022-02-16 Patho - uterus (with or without SO) neoplastic
    • pathologic diagnosis
      • Uterus, endometrium, laparoscopic staging surgery — Endometrioid adenocarcinoma, grade 3
        
      • Uterus, myometrium, LSC staging surgery — Involved by adenocarcinoma (more than half thickness)
        
      • Uterus, cervix, LSC staging surgery — Negative for malignancy
      • Ovaries and fallopian tubes, bilateral, LSC staging surgery — Negative for malignancy
      • Lymph node, left iliac, dissection — Negative for malignancy (0/4)
        
      • Lymph node, left obturator, dissection — Negative for malignancy (0/6)
      • Lymph node, right iliac, dissection — Negative for malignancy (soft tissue only)
        
      • Lymph node, right obturator, dissection — Negative for malignancy (0/6)
      • AJCC 8th edition Pathology stage: pT1bN0(if cM0); FIGO IB; AJCC stage IB
    • IHC: p53(wild type), p16(-), ER: positive (moderate, 40%), PR: positive (moderate, 40%)
  • 2022-02-11 MRI - pelvis
    • Soft tissue tumor in the uterine cavity, suspected endometrial malignancy, cStage T1bN0M0.
    • Suspected right ovarian cyst.
  • 2022-02-10 Gynecologic ultrasonography
    • suspected endometrial hyperplasia
    • suspected rt ovarian cyst
• past history
  • Hypertension since 2003.
  • Angina pectoris, years ago, and myocardia ischemia with patent coronary artery with myocardial bridge at middle LAD by cardiac catheterization in 2015. Now under Apixaban treatment.
  • Obstructive sleep apnea for years.
  • Diabetes mellitus, type II, under OHAs treatment.
  • Hyperlipidemia.
  • Chronic Af under medication treatment. 
• surgical operation
  • 2022-02-16
    • Surgery
      • Laparoscopic gynecologic oncology staging surgery        
    • Finding
      • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
      • Bilateral adnexa: grossly normal
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(+)
      • CDS: free
      • Adhesion between omentum and pelvic wall was noted
• radiotherapy
  • 2022-03-17 ~ 2022-05-05 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.
• chemotherapy
  • 2022-08-04 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 270mg 2hr
  • 2022-07-08 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 270mg 2hr
  • 2022-06-17 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 270mg 2hr
  • 2022-05-24 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 300mg 2hr
  • 2022-04-19 - carboplatin AUC 4 300mg 2hr (due to cisplatin caused high creatinine level)
  • 2022-03-23 - cisplatin 50mg/m2 80mg 24hr (NCCN 20211104 Uterine Neoplasms p32 ENDO-D 1/4 - carboplatin + paclitaxel)

[assessment]

• After a switch from cisplatin to carboplatin in April 2022, the blood creatinine level has returned to normal since late June 2022.
• According to available records, the level of blood uric acid was above the normal range for more than 12 months.
  • 2022-06-29 8.6 mg/dL
  • 2022-03-22 9.7 mg/dL
    
  • 2022-02-14 8.2 mg/dL
    
  • 2021-09-28 10.2 mg/dL
    
  • 2021-04-21 9.8 mg/dL
    
• For patients at a high risk of an adverse cardiovascular event or have a history of a previous cardiovascular adverse event, an initial trial of a uricosuric agent rather than febuxostat is recommended, benzbromarone 50mg/tab 1# PO QD might be considered.

220620

[assessment]

• An increase in S-GPT/ALT has been noted (2022-06-14 114 U/L <- 2022-05-31 9 U/L). The same trend could be seen in S-GOT/AST (2022-06-14 25 U/L <- 10 U/L)
  • Paclitaxel has been associated with serum aminotransferase elevations in 7% to 26% of patients, but values greater than 5 times the upper limit of normal (ULN) in only 2% of those receiving the highest doses. ( https://www.ncbi.nlm.nih.gov/books/NBK548093/ )
  • Mild and transient elevations in serum aminotransferase levels are found in up to one-third of patients taking carboplatin. However, clinically apparent acute liver injury from carboplatin is extremely rare and the characteristics of such injury have not been well defined. ( https://www.ncbi.nlm.nih.gov/books/NBK548565/ )
• The underlying condition Three-Hypers which are currently managed through oral medication and Metabolism OPD follow-up, however patient’s SBP was 91~191 and blood sugar was 123~490, both with high volatility. In terms of HbA1c, LDL, and Triglyceride, the last test results were dated in December 2021.

220524

[assessment]

• This patient was diagnosed with endometrioid adenocarcinoma in early 2022, had staging surgery in February 2022, received CCRT between March and early May 2022, and begins to receive carboplatin/paclitaxel.
• Most recent lab data reported on 2022-05-12 showed slightly decreased blood cell counts. BUN and Creatinine levels were improving (BUN 22 (2022-05-12) <- 47 (2022-04-28); Creatinine 1.28 (2022-05-12) <- 1.76 (2022-04-28)).
• The patient also has “Three-Hypers” which are managed through oral medication (prescribed as self-carried items in active order currently) and Metabolism OPD follow-up, however, in terms of HbA1c, LDL, and Triglyceride, the last test results date back to December 2021 and might need to be updated.

220419

[assessment]

• The patient has been recently diagnosed with endometrioid adenocarcinoma stage IB s/p laparoscopic gynecologic oncology staging surgery, and is receiving EBER since 2022-03-17 and cisplatin since 2022-03-23.
• Lab data on 2022-04-19 and 2022-04-12 were grossly normal. Cardiac conditions are managed with corresponding drugs. TPR readings are normal. There is no information on blood sugar levels during this hospital stay yet.

700516604

220801

• exam finding
  • 2022-07-30 CXR
    • Ground glass opacities in bil. lungs.
  • 2022-07-30 KUB
    • Stool retention in the bowel.
    • Degeneration and spondylosis of L-S spine.
  • 2022-07-21 CXR
    • lung markings: consolidation in the right lower lung field; focal increased density in the right middle lung field.
    • blurred right hemidiaphram
    • blunting bilateral costophrenic angles
  • 2022-07-14 Paracentesis
    • Ascites tapping: 3000mL orange ascites
  • 2022-07-08 Paracentesis
    • Ascites tapping: 3000mL bloody ascites
  • 2022-06-25 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-06-14 CT, CTA - chest
    • Finding
      • Filling defects of bilateral pulmonary arteries, lobar and segmental branches.
      • Dilatation of right ventricle and pulmonary trunk.
      • Small amount of pleural effusion.
      • Liver cirrhosis and ascites.
      • Increased para-aortic soft tissue density.
    • Impression
      • Pulmonary embolism, lobar and segmental branches
  • 2022-06-14 ECG
    • Normal sinus rhythm
    • Rightward axis
    • Low voltage QRS of precordial leads
    • T wave abnormality, consider inferolateral ischemia
    • Prolonged QT
    • Abnormal ECG
  • 2022-06-07 CT - abdomen, pelvis
    • Pancreatic head cancer s/p operation. Partial thrombosis of IVC.
    • General subcutaneous edema. Small amount ascites. Bil. pleural effusions.
    • Small patchy densities (0.5cm, 0.6cm) at LLL.
    • A poor enhancing nodule (2.3cm) at S6 of liver.
    • Some LNS at retroperitoneum with SMV encasement.
  • 2022-03-26 ECG
    • Sinus tachycardia
    • T wave abnormality, consider anterior ischemia
    • Abnormal ECG
  • 2022-03-10 CT - abdomen, pelvis
    • Pancreatic head cancer s/p operation.
    • Bil. pleural effusions. A small patchy density (1.0cm) at LLL suspected metastases.
    • A poor enhancing nodule (2.2cm) at S6 of liver suspected metastases.
    • Some LNS at retroperitoneum.
  • 2022-03-10 CXR
    • Increased lung markings on left lower lung with blurring of left medial diaphragm is noted. Please correlate with clinical condition.
      
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-02-18 2D transthoracic echocardiography
    • 1. Dilated RA and RV
    • 2. Adequate LV systolic function with normal wall motion
    • 3. Mild to moderate TR and PR
    • 4. Thick IVS
  • 2022-02-14 SONO - vein
    • 1. Circumferential venous thrombosis at right ostial to proximal SFV with adequate recanalization, no venous thrombosis at right CFV, PFV, middle to distal SFV, popliteal vien, PTV and LSV.
    • 2. No venous thrombosis at left lower limb venous systems.
    • 3. Venous arterialization waveforms at bilateral CFVs, consider iliac compression syndrome.
    • 4. No significant venous refluxes at bilateral lower limbs venous systems.
    • 5. The ratios of MVO and SVC of bilateral legs were within normal limits.
  • 2022-02-11 2D transthoracic echocardiography
    • 1. Preserved LV and RV systolic function with normal wall motion
    • 2. Concentric LVH, grade 1 LV diastolic dysfunction
    • 3. Mild AR, MR, PR, mild to moderate TR
    • 4. Pulmonary hypertension
    • 5. Presence of thrombus in IVC
  • 2022-02-10 CT, CTA - chest
    • INFERIOR VENA CAVA thrombus with pulmonary embolism and bialteral upper lobe patch.
    • Pancreatic cancer in the abdominal cavity with stable condition.
    • Left lower lobe nodule. stable.
  • 2021-10-27 CT - abdomen, pelvis
    • 1. A newly-developed soft tissue nodule 4 mm in LLL of the lung is noted that may be metastasis? Follow up is indicated.
    • 2. Metastasis at the mesentery with superior mesenteric artery and vein encasement is suspected. please correlate with clinical condition and tumor marker.
    • 3. Metastasis or partial volume effect 0.9 cm in the pelvis is suspected?
  • 2021-06-19 CT - abdomen, pelvis
    • s/p subtotal gastrectomy.
    • s/p pancreatic head resection.
    • Some soft tissue mass around the SMA and SMV is found. In comparison with CT dated on 2021-01-22, the lesion is stationary.
  • 2021-01-22 CT - abdomen, pelvis
    • 1. Metastasis at the mesentery with superior mesenteric vein encasement is suspected. please correlate with clinical condition, tumor marker, and MRI.
    • 2. Metastasis or partial volume effect 0.9 cm in the pelvis is suspected?
  • 2020-04-15 Esophagogastroduodenoscopy, EGD
    • Gastric bleeding prob anasmtomotic site bleeding s/p APC
    • Reflux esophagitis LA Classification grade A
    • s/p whipple operation
    • incomplete study
  • 2020-04-09 Patho - pancreas total/subtotal resection
    • pathologic diagnosis
      • Pancreas, head, pancreatico-duodenectomy —- Adenocarcinoma, moderately differentiated;
        • AJCC 8th edition: ypStage IIB, ypT3N1(if cM0), s/p pre-op neoadjuvant treatment
          
      • Small intestine, duodenuma, pancreatico-duodenectomy —- Adenocarcinoma, by direct invasion
        
      • Portal vein, segmental resection —- Adenocarcinoma, by direct invasion
        
      • Common bile duct, pancreatico-duodenectomy —- Negative for malignancy
        
      • Stomach, pyloric, partial gastrectomy —- Negative for malignancy
        
      • Gallbladder, cholecystectomy —-chronic cholecystitis —- cholelithiasis
      • Lymph nodes
        • Lymph node, group 5, 6, 8, 9, 12, 13, 14, dissection —- Negative for malignancy (0/6)
          
        • Lymph node, cystic, dissection —- Negative for malignancy (0/1)
          
        • Lymph node, lesser curvature, dissection —- Negative for malignancy (0/3)
          
        • Lymph node, greater curvature, dissection —- Negative for malignancy (0/16)
          
        • Lymph node, peri-CBD, dissection —- Negative for malignancy (0/3)
          
        • Lymph node, peri-pancreas, dissection —- Adenocarcinoma, metastatic (1/6)
          
    • microscopic examination
      • 1. Histologic Type: Ductal adenocarcinoma
           
      • 2. Histologic Grade (ductal carcinoma only): G2: Moderately differentiated
           
      • 3. Margins
        • Margins: free, closest margin: 0.1 mm; Posterior retroperitoneal (radial) margin
          
        • Distal pancreatic margin: 1.2 cm
          
        • Common bile duct margin: 2.5 cm
          
        • Gastric margin: 9 cm
          
        • Small intestinal margin: 16 cm
          
      • 4. Lymphovascular invasion: Present
           
      • 5. Perineural Invasion: Present
           
      • 6. Pathologic Staging (pTNM)
           
        • Primary Tumor (pT): pT3: Tumor ＞ 4 cm
          
        • Regional Lymph Nodes (pN): pN1: Metastasis in one to three regional lymph nodes
          
        • Specify: group 5, 6, 8, 9, 12, 13, 14: 0/6; cystic: 0/6; cystic: 0/1; lesser curvature: 0/3; greater curvature: 0/16; peri-CBD: 0/3; peri-pancreas: 1/6
          
        • Distant Metastasis (pM): if cM0
          
      • 7. Additional Pathologic Findings: Tumor, invasion to portal vein and duodenum is seen.
  • 2020-04-06 Lung flow volume curve
    • Mild restrictive pulmonary function impairment
  • 2022-04-06 2D transthoracic echocardiography
    • 1. Adequate LV systolic function with no regional wall motion abnormality at resting state
    • 2. Mild aortic, mitral and tricuspid regurgitation
    • 3. Thick IVS and LVPW
    • 4. Atheroma on ascending aorta
  • 2020-03-27 CT - lung/mediastinum/pleura
    • Finding
      • Visible abdomen
        • Soft tissue mass at pancreatic head about 4.1cm in largest dimension is found. In comparison with MRI dated on 2019-12-10, the lesion progressed.
        • The GB is well distended without soft tissue lesion
    • Imp:
      • Pancreatic head cancer, cT4N0M0, in progression.
  • 2019-12-27 2D transthoracic echocardiography
    • 1. Septal hypertrophy with indeterminate LV filling pressure and impaired RV relaxation; moderately dilated LA.
    • 2. Dilated LV with normal LV and RV systolic function.
    • 3. AV sclerosis with mild AR; mild MR.
    • 4. ild aortic root calcification with multiple protruding non-mobile atheromas (5-6 mm of thickness).
  • 2019-12-12 Surgical pathology Level V
    • clinical diagnosis
      • Malignant pancreas neoplasm, part NOS;
    • pathologic diagnosis
      • Pancreatic head, EUS/FNB — Adenocarcinoma
    • macroscopic examination
      • The specimen submitted consists of mutiple small pieces of gray-white soft tissue, labeled pancreatic head, measuring up to 3.5 x 0.1 x 0.1 cm. All for section.
    • microscopic examination
      • The sections show a picture of adenocarcinoma, composed of well to moderately differentiated polygonal to columnar neoplastic cells with occasional pleomorphic nuclei, arranged in papillary and duct-like structures. Desmoplastic stromal reaction and extensive tumor necrosis are evident.
  • 2019-12-11 Electronic Endoscopic Ultrasonography, EUS
    • position: pancreas
    • symptoms: elevated CA 19-9 and a 3-4 cm mass at the peri-panc head area 　　- Pre-EUS diagnosis: Suspected pancreatic cancer 　　- Endoscopic Findings: The major papilla looks normal.
      　　- EUS Findings
      • A 3.8x3.1 cm hyperechoic heterogeneous mass with one longitudinal cystic lesion within this tumor seen at the pancreatic head portion.
      • The mass revealed multiple small hypoechoic lesions inside. The MPD is not dilated. The vessels were not encased. The CBD measured about 8 mm in diameter. 　　- Diagnosis
      • Pancreatic tumor, head, S/P EUS/FNB perhaps SCN
  • 2019-12-10 MRI, MR cholangiography, MRCP
    • Imaging Report Form for Pancreatic Carcinoma
    • T4N0M0, stage III based on this MRI study
  • 2019-11-29 SONO - abdomen
    • diagnosis
      • 1. GB stone.
      • 2. pancreatic neck cystic lesion.
    • suggestion
      • 1. Visit GI/GS OPD if symptom revealed
      • 2. consider EUS for pancreatic cystic lesion
  • 2019-11-28 CPA - carotid phonoangiograph
    • 1. Mild atheromatous lesions in bilateral CCA bifurcatios, right ICA, right ECA and left CCA.
    • 2. Adequate total VA flow volume (108 ml/min).
    • 3. Increased RI in right VA, indicating distal stenosis.
  • 2019-11-28 Bone densitometry - hip
    • Hip BMD performed by DXA revealed:
      • Hip, BMD is 0.551 gms/cm2, about 2.4 SD below the peak bone mass (69%) and 0.2 SD below the mean of age-matched people (97%).
• consultation
  • 2022-07-04 Family Medicine
    • Q
      • for share care or hospice care
      • This 75 y/o female, a pt of pancreatic head CA, ypStage IIB, ypT3N1 cM0, Dx in Dec 2019, s/p pre-op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 4 finishing in March 2020 & s/p pancreatico-duodenectomy on 20200408 & post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T from 20200608 to 20200704 & s/p post-Op adjuvant C/T wt FOLFIRINOX IV Q2W x 8 from July 2020 to Jan 2021 & palliative C/T Abraxane 100mg / m2 + Gem 900mg/m2 D1 & 8 Q3W x 13 since 2021-02 to 2022-05.
      • Owing to disease progression noted and we explained her poor condition to her family and DNR was consented. We need expertise to evaluate her condition thanks!
    • A
      • 75 y/ o lady advanced pancrease ca.
      • DNR + ECOG 3~4
      • GI bleeding pulmonism embolim
      • Our share care would follow up. Thanks for consultation.
  • 2022-06-16 Hemato-Oncology
    • Q
      • For evaluation of current condition and the future treatment plan of pancreatic cancer
      • This is a 75 y/o patient with pancreatic head cancer who is currently hospitalized for the treatment of recurrent pulmonary embolism.
      • Please kindly assist to evaluate the patient and advise if she can proceed with palliative chemotherapy, and if DNR is a viable option should her condition worsen during the course of current treatment.
    • A
      • Impression
        • 1. Recurrent pulmonary embolism, favor cancer related
        • 2. Pancrease Adenocarcinoma, ypStage IIB, ypT3N1 cM0, Dx in Dec 2019, s/p pre-op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 4 finishing in March 2020 & s/p pancreatico-duodenectomy on 4/8 20 & post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T from 6/8 20 to 7/4 20 & s/p post-Op adjuvant C/T wt FOLFIRINOX IV Q2W x 8 from July 2020 to Jan 2021 & palliative C/T Abraxane 100mg / m2 + Gem 900mg/m2 D1 & 8 Q3W x 13 since 2021.02 to May 2022. Suspected recurrent with liver and LLL meta and Some LNS at retroperitoneum with SMV encasement. (abdominal 20200310 amd 20200607 CT), apply 3rd lines palliative chemotherapy with Onivyde (80mg/m2, give 120mg, IVF Q2W x 6) plus HDFL.
      • Suggestion
        • 1. Thanks for your consultation. We will see the patient and discuss with further treatment.
        • 2. Treat pulmonary embolism as your expertise. May consider check other etiology of hypercoagulation although we favor cancer related
  • 2022-06-14 Cardiology
    • Q
      • dyspnea on exertion for 3 days, desaturation was found yesterday at home
      • no chest pain, no odynophagia, no GI symptoms, no skin rash, no dysuria
      • Went hema opd today for chemotherapy f/u, transferred to covid-19 opd for suspected covid-19
      • 20220607 CT Pancreatic head cancer s/p operation. Partial thrombosis of IVC; General subcutaneous edema. Small amount ascites. Bil. pleural effusions. Small patchy densities (0.5cm, 0.6cm) at LLL. A poor enhancing nodule (2.3cm) at S6 of liver. Some LNS at retroperitoneum with SMV encasement.
      • PHx: pancreatic cancer, HTN, pulmonary embolism
      • NKDA
      • 2022-02-11
        • 1: Acute pulmonary embolism, bilateral
        • 2: Acute respiratory failure with hypoxia
        • 3: Inferior vena cava thrombus with pulmonary embolism and bialteral upper lobe patch.
        • 4: Circumferential venous thrombosis at right ostial to proximal Superficial femoral vein. with adequate recanalization
        • 5: pancreatic cancer of adenocarcinoma , ypStage IIB, ypT3N1 cM0 post operation and concurrent chemoradiotherapy
        • 6: Pneumonia, bilateral lung by sputum culture grewed mix flora
    • A
      • O
        • Lab Hb 10.2, WBC 6660, PLT 191k, Cre 0.90, K 4.2, ALT 23, CRP 1.97, NTproBNP 5397, hsTnI 131.5, CKMB 1.6, INR 1.68, Ddimer 7534
        • CXR 20220614 borderline heart size
      • Impression
        • Pulmonary embolism, bilateral, noted since 2022/02, –> still residual thrombi
        • Pancreatic head cancer, IVC thrombosis
        • Ascites, increasing than before (by CT images comparision)
        • right lower limb DVT in 2022/02
      • Suggestion
        • 1. Keep NOAC as OPD Or give clexane 1mg/kg sc Q12h
        • 2. If unstable hemodynamic status or desaturation is concerned, May book ICU care.
        • 3. Pulmonary embolism treatment effect is related to underlying cancer status
  • 2022-03-29 Dermatology
    • Q
      • Under the impression of left leg cellulitis. She was admitted to Infection’s ward for further evaluation and treatment on 20220326. For bilateral leg scaly and vesicle lesions, we need ypur expertsie on evaluation or some suggestion. Thank you very much!
    • A
      • This patient suffered from some erytheamtous papules on bil legs for days.
      • Imp: Pigmented purpuric dermatosus
      • Suggestion:
        • 1. Sinpharderm * 1 tube/bid
        • 2. Topsym cream * 3 tubes/bid
  • 2022-02-10 Cardiology
    • A
      • I was consulted for pulmonary embolism
      • O
        • CT scan documented
        • Cr 0.8
      • Suggestion:
        • 1. ICU admission
        • 2. Clexan 1mg/kg Q12H SC if no contraindication
  • 2022-04-10 Gastroenterology
    • A case of pancreatic cancer who request post-op nutrition support.
      • General appearance: ill looking
      • GI tract: Whipple on 20220408
      • Feeding: Sip water with NG decompression
      • Allergy: NKA
      • Past history: DM
      • Nutrition assessment:
        • BH 148cm BW 55.6kg
        • IBW 48.2kg 115% IBW, BMI 25.4, ABW 50kg
        • BEE (based on ABW) 1070kcal, TEE 1670kcal
      • Lab data: GOT 160, GPT 232, K 3.5
        
      • 20220409 Blood sugar: 408-310-262-218-204
    • According to the patient’s present conditions, parenteral nutrition will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
    • PN use suggestion
      • DC YF5 1000ml QD （RI 10U each bottle）
      • DC SMOFkabiven peri 1440ml QD
      • SMOFkabiven central 1477ml QD, 61.5ml/hr
      • Lyo-Povigent 4ml/QD（add in TPN）
      • Addaven 10ml/QD（add in TPN）
      • RI 26U/QD（add in TPN）
      • KCL 5ml/QD（add in TPN）
    • Items to be monitored when in PN use
      • 1. Do not mix other drugs with TPN
      • 2. Check BW QW5 and record I/O Q8H
      • 3. Check one touch Q6H*2days, if stable QD check
      • 4. Please control BS <200 mg/dl with RI sliding scale
      • 5. QW1 check CBC/DC
      • 6. QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
      • 7. if TPN is not sufficient, use YF5 or D10W
• chemoimmunotherapy
  • 2022-05-30 - nal-paclitaxel 125mg/m2 180mg 0.5hr + gemcitabine 1000mg/m2 1300mg 0.5hr
  • 2022-05-10 - nal-paclitaxel 125mg/m2 180mg 0.5hr + gemcitabine 1000mg/m2 1300mg 0.5hr
  • 2022-04-26 - nal-paclitaxel 125mg/m2 180mg 0.5hr + gemcitabine 1000mg/m2 1300mg 0.5hr
  • 2022-04-12 - nal-paclitaxel 125mg/m2 180mg 0.5hr + gemcitabine 1000mg/m2 1300mg 0.5hr
  • 2022-03-22 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1300mg 0.5hr
  • 2022-01-18 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
  • 2022-01-04 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
  • 2021-12-21 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
  • 2021-12-07 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
  • 2021-11-23 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
  • 2021-10-19 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
  • 2021-10-12 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
  • 2021-09-14 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
  • 2021-09-07 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
  • 2021-08-24 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
  • 2021-08-17 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
  • 2021-08-03 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
  • 2021-07-20 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
  • 2021-05-18 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
  • 2021-05-11 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
  • 2021-04-27 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
  • 2021-04-20 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
  • 2021-04-06 - nal-paclitaxel 100mg/m2 140mg 0.5hr + gemcitabine 900mg/m2 1200mg 0.5hr
  • 2021-03-30 - nal-paclitaxel 100mg/m2 140mg 0.5hr + gemcitabine 900mg/m2 1200mg 0.5hr
  • 2021-03-16 - nal-paclitaxel 100mg/m2 140mg 0.5hr + gemcitabine 900mg/m2 1200mg 0.5hr
  • 2021-02-23 - nal-paclitaxel 100mg/m2 140mg 0.5hr + gemcitabine 900mg/m2 1200mg 0.5hr
  • 2021-01-08 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3950mg 46hr
  • 2020-12-18 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
  • 2020-11-24 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
  • 2020-10-30 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3920mg 46hr
  • 2020-10-08 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3920mg 46hr
  • 2020-09-18 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3870mg 46hr
  • 2020-08-24 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 570mg 2hr + fluorouracil 2800mg/m2 4000mg 46hr
  • 2020-07-29 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 570mg 2hr + fluorouracil 2800mg/m2 4000mg 46hr
  • 2020-06-29 - fluorouracil 225mg/m2 320mg D1-5 (CCRT)
  • 2020-06-26 - fluorouracil 225mg/m2 320mg D1 (CCRT)
  • 2020-06-22 - fluorouracil 225mg/m2 320mg D1-3 (CCRT)
  • 2020-06-15 - fluorouracil 225mg/m2 320mg D1-5 (CCRT)
  • 2020-06-08 - fluorouracil 225mg/m2 320mg D1-5 (CCRT)
  • 2020-03-09 - oxaliplatin 60mg/m2 90mg 2hr + leucovorin 400mg/m2 600mg + irinotecan 90mg/m2 100mg 2hr + fluorouracial 1200mg/m2 3400mg 46hr
  • 2020-02-18 - oxaliplatin 60mg/m2 90mg 2hr + leucovorin 400mg/m2 600mg + irinotecan 90mg/m2 100mg 2hr + fluorouracial 1200mg/m2 3400mg 46hr
  • 2020-02-04 - oxaliplatin 60mg/m2 90mg 2hr + leucovorin 400mg/m2 600mg + irinotecan 90mg/m2 100mg 2hr + fluorouracial 1200mg/m2 3400mg 46hr
  • 2020-01-07 - oxaliplatin 60mg/m2 90mg 2hr + leucovorin 400mg/m2 600mg + irinotecan 90mg/m2 100mg 2hr + fluorouracial 1200mg/m2 3600mg 46hr

[assessment]

• Ceftriaxone for this CrCl >15 mL/min patient, no dosage adjustment is necessary.
• In patients (with community-acquired pneumonia in the absence of neutropenia and immunosuppressive therapy) requiring hospital admission, monotherapy with a respiratory fluoroquinolone or combination therapy with a macrolide plus either ceftriaxone, cefotaxime, or ertapenem is recommended.
• 2022-08-01 eGFR 31.79.
  • For patients with eGFR 30 to 50 mL/minute/1.73 m2, spironolactone is recommended to be initialized at 12.5 mg once daily or every other day; may double the dose every 4 weeks if serum potassium remains <5 mEq/L and renal function is stable, up to a maximum target dose of 25 mg/day.
• 2022-08-01 Creatinine 1.67 mg/dL. The following oral tranexamic acid adjustments are based on a usual recommended dose of 10 to 15 mg/kg or 1 to 1.5 g 3 to 4 times daily.
  • Serum creatinine >=1.4 to <2.8 mg/dL (>=120 to <250 micromol/L): Administer usual dose twice daily.

701432312

220801

{lung adenocarcinoma and esophageal adenocarcinoma}

[Past History]

• past history
  • C5/6 disc herniation s/p OP on 2021/10/21 and TIA in 2022/03
  • LLL adenocarcinoma s/p VATS segmentectomy on 2022/06/21
  • DM(+) in 2021/05
    • Galvus Met 50mg & 500mg 1# po QD
  • HTN(+) in 2010
    • Pravafen 40mg & 160mg 1# po QN
    • Exforge F.C 5mg & 160mg 1# po QD
    • Bokey 1# po QD
• lab data
  • 2022-07-15 Anti-HBc Reactive
    
  • 2022-07-15 Anti-HBc-Value 2.41 S/CO
  • 2022-07-15 Anti-HBs 5.12 mIU/mL
    
  • 2022-07-15 HBsAg Nonreactive
    
  • 2022-07-15 HBsAg Value 0.00 IU/mL
    
  • 2022-07-15 Anti-HCV Nonreactive
    
  • 2022-07-15 Anti-HCV Value 0.09 S/CO
• exam finding
  • 2022-06-21 CT - lung
    • LLL cacner, cT2bN1M1a, stage IVA
    • Esophagus (Lower 1/3), cT3N3M0, stage IVA.
  • 2022-06-10 Pathology
    • esophagus endoscopic biopsy — adenocarcinoma, poorly differentiated, primary or secondary,
    • the esophagus lower third, endoscopic biopsy showed metastatic adenocarcinoma, poorly differentiated, suspicious for gastric or intestinal origin.
  • 2022-05-31 Whole body PET scan
    • LLL tumor and lower esophageal tumor.
  • 2022-05-24 Whole body bone scan
    • no bone metastasis.
  • 2022-05-23 CT - brain
    • no brain metastasis.
  • 2022-05-19 Pathology
    • LLL tumor CT Guide biopsy — adenocarcinoma, poorly differentiated, lung origin.
  • 2022-05 CT at DaLin TzuChi Hospital
    • a distal esophageal tumor and another LLL lung tumor
• surgical operation
  • 2022-06-21 VATS LLL S10 segmentectomy + mediastinum lymph node dissection
    • pathology showed Adenosquamous carcinoma, poorly differentiated, pT2aN2
    • ICH stains showed CDX2 (EPR2764Y/Zeta, 100X), TTF-1 (SPT24/Leica, 250X), P40 (polyclonal/Zytomed, 100X).
• radiotherapy
  • 2022-07-21 ~
    • Plan to deliver 4500 cGy/ 25 fx to the L/2 esophagus and adjacent lymphatic drainage area.
    • Then boost the esophageal tumor and celiac LAPs to 5040 cGy/ 28 fx.
    • The preOP (lung ca.) tumor bed: around 5600 cGy/ 28 fx.
• chemoimmunotherapy
  • 2022-07-26 - paclitaxel 50mg/m2 80mg 3hr D1 + carboplatin AUC2 150mg 2hr D2
  • 2022-07 plan
    • adjuvant therapy for lung ca.
    • neo-adjuvant therapy for eso. ca

[note]

• HBV ref: https://cdn.who.int/media/docs/default-source/searo/hiv-hepatitis/training-modules/08-hbv-serological-markers.pdf
  • HBV serological markers
    • HBsAg (hepatitis B surface antigen)
      • Hallmark of infection
      • Positive in the early phase of acute infection and persists in chronic infection
      • Quantification of HBsAg is a potential alternative marker of viraemia and it is also used to monitor the response to antiviral treatment
    • Anti-HBc IgM (hepatitis B core antibody)
      • IgM subclass of anti-HBc and observed during acute infection (used to differentiate between acute and chronic HBV infection)
      • Might become positive during severe exacerbation of chronic infection
    • Anti-HBc (total)
      • Develops around 3 months after infection (most constant marker of infection)
      • Total anti-HBc (IgM, IgA and IgG) indicates resolved infection
    • HBeAg (hepatitis B e antigen)
      • Viral protein usually associated with high viral load and high infectivity
    • Anti-HBe (hepatitis B e antibody)
      • Antibody to HBeAg usually indicates decreasing HBV DNA
      • But present in the immune-control and immune-escape phases
    • Anti-HBs (hepatitis B surface antibody)
      • Neutralizing antibody that confers protection from infection
      • Recovery from acute infection (with anti-HBc IgG)
      • Immunity from vaccination
  • Hepatitis B surface antigen and antibody
    • HBsAg
      • First marker to appear following HBV infection
      • Positivity indicates presence of virus in a person’s body
      • Acute infection: Disappears within 6 months
      • Chronic infection: Persists for several years (lifelong in most)
      • Measurement of HBsAg concentration is being tried as a potential alternative marker of viremia and to monitor response to treatment, but still not well accepted
    • Anti-HBs
      • Antibody to HBsAg
      • Is a neutralizing antibody and confers protection from infection
      • Appears following clearance of acute infection
      • Does not develop in those who have chronic infection
      • Also develops in response to hepatitis B vaccine
      • Presence indicates immunity following acute infection or vaccination
      • Anti-HBs titre >10 mIU/mL is considered to be protective
      • Persists for several years (often lifelong) after infection, but disappears in a few years after immunization
  • Hepatitis B core antigen and antibody
    • HBcAg
      • An internal component of the virus
      • Present in the nucleus of infected cells
      • But, does not appears in infected person’s blood
      • Not tested in clinical settings
      • Hepatitis B vaccine does not contain this antigen
    • Anti-HBc
      • Develops in all those who get HBV infection, whether acute or chronic
      • Does not develop after immunization
      • Two types IgM and IgG
    • IgM anti-HBc
      • Appears following acute infection, and persists for up to ~6 months
      • Hence: presence indicates recent (acute) infection
      • Occasionally, detectable (in low amount) during severe exacerbation of chronic infection
    • IgG (or Total) anti-HBc
      • Develops soon after IgM anti-HBc
      • Most constant marker of exposure (current or past infection)
      • Positive total anti-HBc (IgG, IgM) with negative IgM anti-HBc in HBsAg negative indicates resolved infection
  • Hepatitis B e-antigen and antibody
    • HBeAg
      • Produced in cells where virus is actively replicating, and is secreted into the plasma
      • Usually its presence indicates high viral load and high infectivity
      • Its absence indicates lower viral load, lower HBV DNA level. But, in some, may be absent despite high viral load (due to viral mutation)
      • Associated with high risk of HBV transmission following exposure, such as needle-stick injury, mother-to-child transmission, etc
    • Anti-HBe
      • Indicates host immune response against HBeAg
      • Usually associated with reduced viral replication, lower HBV DNA titer and reduced infectivity
      • But also present in those in HBeAg-negative viral mutation
    • HBV DNA
      • Direct and accurate marker of HBV replication
      • Serum level seems to correlate with the risk of disease progression
      • Used to decide need for anti-viral drugs
      • Also used to monitor efficacy of anti-viral drug treatment
      • Unit: almost 5 copies = 1 IU

[assessment]

• Double malignancies: 1) LLL adenocarcinoma s/p VATS LLL S10 segmentectomy and mediastinum lymph node dissection on 2022-06-21; 2) Esophageal (lower 1/3) adenocarcinoma.
• Documented treatment plan: adjuvant therapy for lung ca. and neo-adjuvant therapy for eso. ca.
• Carboplatin and paclitaxel are drugs that can be used in regimens for both lung cancer and esophageal cancer. NCCN guidelines describe regimens containing these two drugs:
  • For NSCLC: carboplatin AUC 6 day 1, paclitaxel 200mg/m2 day 1, every 21 days for 4 cycles.
  • For Eso ca: carboplatin AUC 2 day 1, paclitaxel 50mg/m2 day 1, weekly for 5 weeks.
• The latter (lower doses with higher frequency administration) is initialized on 2022-07-26.
• Underlying conditions including T2DM and HTN.
  • There is good control of blood sugar levels during this hospitalization.
  • A number of data points between 2022-07-29 and 2022-07-31 showed hypotension events (SBP < 100, DBP < 60). If the hypotension occurs again, please hold Exforge (amlodipine + valsartan) temporarily.

701341214

220729

{prevent the patient from potential drug interaction: Dasatinib / Inhibitors of the Proton Pump (PPIs and PCABs)}

• Pantoprazole (PPI) might decrease the serum concentration and efficacy of dasatinib (both drugs were prescribed as QD administratered and the latter is listed as an self-carried item in active prescription).
• It is recommended not to administer proton pump inhibitors (PPIs) or potassium-competitive acid blockers (PCABs) with dasatinib. Coadministration of these agents and dasatinib might reduce dasatinib concentrations and efficacy.
• Please consider antacids taken 2 hours before or after dasatinib administration if acid-reducing therapy is needed. As an example, shift dasatinib from QD to QN.

700370302

220727

• Thrombocytopenia is treated with eltrombopag.

701433496

220727

• exam findings
  • 2022-07-22 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Prominence of bilateral hilar shadows are noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and follow-up.
    • Hypoinflation of both lung is noted.
  • 2022-07-18 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Prominence of bilateral hilar shadows are noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and follow-up.
    • Hypoinflation of both lung is noted.
    • A nodular opacity projecting in the left upper lung is suspected. Follow up is indicated. Otherwise, Please correlate with CT.
  • 2022-07-21 SONO - abdomen
    • Diagnosis
      • Hepatic tumors, multiple, bilateral lobe, suspected metastasis
      • Gall stones
      • Splenic cysts
      • Small amount ascites
    • Suggestion
      • Please correlate with other image study
  • 2022-07-18 Patho - colon biopsy
    • DIAGNOSIS:
      • Colon, SD junction, biopsy — Adenocarcinoma, moderately differentiated
        
    • MICROSCOPIC DESCRIPTION:
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2022-07-18 Colonoscopy
    • Diagnosis
      • Probable colon cancer with partial obstruction, 35cm AAV, probable at SD junction, s/p biopsy
      • Incomplete study, poor colon preparation.
    • Suggestion
      • F/U pathology report
    • Complication
      • No immediate complication
  • 2022-07-15 ECG
    • Sinus tachycardia with Premature supraventricular complexes
    • Low voltage QRS
    • Borderline ECG
  • 2022-04-27 CT (Cardinal Tien Hospital)
    • 1. consider sigmoid colon malignancy, involving length is approximately 6.2cm, imaging staging favored T4bN1bM1b if pathological proven malignancy.
    • 2. Multiple hepatic and splenic tumors, like metastases.
• consultation
  • 2022-07-20 Colorectal Surgery
    • Q
      • This 88 y/o female has history of DM, HTN under medical control and suspect colon cancer with liver metastases associated chronic diarrhea for one month under symptom control. This time, according to the families, the patient was found with fever and chillness for one day, so she was sent to our ER for help on 20220712, vital signs showed BP:121/57; PR:107; BT:38.5; RR:19; EKG showed Sinus rhythm with Premature atrial complexes; PE showed unremarkable. Lab showed Covid-19 rapid screen: positive, WBC:14.92, Neutrophil:81.7%, CRP:7.9, Lactic acid:3.1, hs-TnI:114.2, Hb:6.5, MCV:70fL, RDW-CV:22.3%, Na:133, K:2.7, BUN/Cr:19/1.01, U/A with bacteria:1+ but without pyuria; CXR showed both lower lobes infiltration.
      • So, under impression of 1.) Sepsis, favor Covid-19 infection with secondary bacterial pneumonia; 2.) suspect colon cancer with liver metastases for one month; 3.) Severe microcytic Anemia, she is admitted to our isolation ward for further care on 20220712. - After admission, empirical antibiotic with Brosym, steroid agent with Decan injection were given for pneumonia treatment since 20220712. Urine culture showed mixed growth. Pending one set of blood culture and sputum culture. Antivirus agent with Remdesivir injection since 7/13-7/17 for treatment. We consulted Hospice for colon cancer terminal on 7/13. We consulted Oncologist for colon cancer terminal survey on 7/15. DNR was signed on 7/15. She is transfer to Oncologist ward for survey on 20220715.
      • At ONC ward, we had explained the current condition to family (third daughter-in-law).
      • CT of abdominal was performed on 20220427 at Cardinal Tien Hospital revealed 1) consider sigmoid colon malignancy, involving length is approximately 6.2cm, imaging staging favored T4bN1bM1b if pathological proven malignancy. 2) Multiple hepatic and splenic tumors, like metastases.
      • Colonscopy was arrange on 20220718 showed A huge ulcerative tumor with partial obstruction of the colon was noted at 35cm AAV, probable at SD junction, s/p biopsy. We need your expertise for evaluation, thanks.
    • A
      • O
        • Abdomen: soft, mild distended, no tenderness, no peritoneal sings
        • pass flatus(+)
        • diarrhea(+)
        • SOB(+)
      • A: S-colon cancer with multiple metastases of liver and spleen, stage IVb (incurable)
      • P:
        • 1. Diverting colostomy (under general anesthesia) may be considered if total obstruction symptoms/signs developing
        • 2. Surgical and anesthesia risk is very high due to very old age and terminal cancer stage and comorbidities
        • 3. We had discussed her disease condition to her family and she can understand
        • 4. Suggest hospice and palliative treatment
  • 2022-07-15 Hemato-Oncology
    • A
      • Impression:
        • 1. Suspect colon cancer? AAD (Against Advise Discharge) from Cardinal Tien Hospital
        • 2. DM, HTN under medical control
      • Suggestion:
        • 1. We had phone call her daughter-in-law and discuss with further care. They agree arrange colonscopy for tissue proof (for apply IC Cards for Severe Illness) after transfer to ordinary ward.
          • In addition, Daughter-in-law agreed to go to Cardinal Tien Hospital to apply for medical records and image CD after transfer to ordinary ward.
        • 2. Thanks for your consultation.

[assessment]

• Nasogastric tubes can be used to administer all oral medications in active prescriptions.
• The patient has applied for hospice care.
• F/S recorded low blood sugar levels
  • 2022-07-26 06:19 56 mg/dL
  • 2022-07-26 06:18 60 mg/dL
  • 2022-07-21 06:24 50 mg/dL
• A hypoglycemic event is more likely to occur in the early morning, and it should be observed if there is a difference in carbohydrate intake or consumption from the night before to the next day.

700301518

220726

• diagnosis
  • 67 y/o male, a pt of NSCLC at LLL wt lung to lung mets & liver, & adrenal mets & L neck LNs mets Dx in Dec 2021.
  • suffered from initial presentation of L neck LN enlargement at level II & III since Oct 2021.
  • This is a 67 year old man who has the history of liver cirrhosis, acute cholecystitis s/p cholecystectomy, old CVA with right hemiparesis, and non-small-cell lung cancer at left lower lung with lung to lung mets & liver, & adrenal mets & L neck LNs mets Dx in Dec 2021
• lab data
  • 2022-01-10 PD-L1 Immunostaining Result (28-8)
    • Labeled as: S21-18526
    • Tumor type: Head and neck cancer, squamous cell carcinoma
    • Tumor cell (TC) staining assessment: TC >= 50%
    • Percentage of 28-8 expressing tumor cells (%TC): 65%
  • 2021-12-30 PD-L1 Immunostaining Result (22C3)
    • Labeled as: S2021-18526
    • Tumor Proportion Score (TPS) assessment: TPS >= 50%
    • Tumor Proportion Score (TPS): 55%
• exam finding
  • 2022-07-25 CXR
    • S/P Port-A infusion catheter insertion.
    • Multiple nodules at bil. lungs.
    • Normal appearance of trachea and bil. main bronchus.
    • Atherosclerosis of the aorta.
    • S/P operation with retention of surgical clips.
    • Old frcture of bil. ribs.
    • Suggest clinical correlation.
  • 2022-07-04 CT - lung/mediastinum/pleura
    • Findings
      • Lungs:
        • significant inecrease in size of LLL anteromedial basal tumor (71mm in longest axial dimension) and increase in size and number of multiple nodules of variable sizes in both lungs as compared with CT on 2022/03/28
        • centrilobular emphysema in both upper lobes
      • Mediastinum and hila: enlarged LN at Rt paratracheal space, and subcarina
        • Vessels: moderate coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber. .
        • Heart: normal in size of cardiac chambers.
      • Pleura: minimal effusion.
      • Chest wall and visible lower neck: progression of enlarged left neck LAPs, level II-III-IV compared with CT on 2022/03/28
      • Visible abdominal contents: s/p cholecystectomy. pneumobilia in left lobe liver and increase in size and numbers of ill-defined heterogeneous tumors in liver and Rt adrenal tumor compared with CT on 2022/03/28.
        • unremarkable of the pancreas, and kidneys. bile ducts: dilatation of CBD and CHD. mild splenomegaly.
        • no enlarged lymph node.
      • Extensive atherosclerotic change of the abdominal aorta.
      • Visualized bones: extensive spondylosis.old fracture of many Lt ribs and Rt and Lt clavicles.
    • Impression:
      • LLL cancer T4N3M1c, in progression as compared with previous CT study on 2022/03/28
  • 2022-07-04 CXR + Lat. LT
    • S/P port-A implantation.
    • Primary lung cancer in LLL become smaller in size.
    • Few nodular opacity projecting in the left lower lung are noted. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Old fracture of bilateral clavicle and left ribs.
    • Spondylosis of the T-spine
  • 2022-06-06 SONO - abdomen
    • Diagnosis
      • poor echo window: please see discription
      • Liver tumor: (suspected HCC?)
      • Liver cirrhosis (incomplete exam of liver), splenomegaly
      • GB sac not seen
      • pancreas not shown
    • Suggestion
      • suggest further imaging study
  • 2022-05-03 KUB
    • s/p cholecystectomy
    • Unremarkable psoas shadows
    • Degenerative change of the lumbar spine
    • s/p right total hip replacement
  • 2022-05-03 CXR
    • Mass lesions in both lung fields
    • Bilateral clavicle and rib old fractures
  • 2022-05-03 ECG
    • Sinus tachycardia
  • 2022-05-03 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • No active bleeder nor coffee ground material was noted during this exam.
      • Suboptimal study due to food residual retention
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis
    • Suggestion
      • 2nd look endoscopy is warranted if active bleeding sign or persisted tarry stool.
  • 2022-03-28 CT - lung/mediastinum/pleura
    • Findings
      • 1. Lungs:
        • decrease in size of LLL anteromedial basal tumor (33 mm in longest axial dimension) and multiple nodules of variable sizes in both lungs, and resolution of LLL GGO as compared with CT on 2021/12/06.
        • centrilobular emphysema in both upper lobes
      • 2. Mediastinum: regression of enlarged LN at Rt paratracheal space.
      • 3. Hila: no enlarged LN.
      • 4. Vessels: moderate coronary arterial calcification Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta. Central pulmonary arteries: normal caliber.
      • 5. Heart: normal in size of cardiac chambers.
      • 6. Pleura: no effusion.
      • 7. Chest wall and visible lower neck: regression of enlarged left neck LAPs, level II-III-IV.
      • 8. Visible abdominal contents: s/p cholecystectomy. pneumobilia in left lobe liver and increase in size an ill-defined heterogeneous tumor in S6 (76x85 mm) and stationary of a 16 mm Rt adrenal tumor. unremarkable of the spleen, pancreas, and kidneys. bile ducts: dilatation of CBD and CHDno enlarged lymph node.
      • 9. Extensive atherosclerotic change of the abdominal aorta.
      • 10. Visualized bones: extensive spondylosis.old fracture of many Lt ribs and Rt and Lt clavicles.
    • Impression:
      • LLL cancer T4N3M1c, regression of primary LLL tumor and metastatiuc lung tumors, stationary of Rt adrenal tumor, and metastatic LAP at mediastinum and neck, but increase in size ofmetastatic hepatic tumor as compared with previous CT study on 2021/12/06
  • 2022-03-14 SONO - abdomen
    • Diagnosis
      • poor echo window: please see discription
      • Liver tumor: (suspected HCC?)
      • Liver cirrhosis (incomplete exam of liver), mild splenomegaly
      • GB sac not seen
    • Suggestion
      • suggest further imaging study
  • 2021-12-24 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • S2021-19387
        • Tumor type: squamous cell carcinoma
          
        • Tumor location: soft tissue, right neck
          
        • Testing assay: SP142 Assay (Ventana)
          
        • Testing platform: BenchMark XT
          
        • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
          Control slide result: Pass,
          Adequate tumor cells present (>=50 viable tumor cells): Yes,
          
      • Result:
        • 1. Tumor cell (TC) staining assessment:
             
          • 1. TC category: TC < 1%
               
        • 2. Tumor-infiltrating immune cell (IC) staining assessment:
             
          • 1. IC category: IC < 1%
               
      • Note:
        • 1. TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
             
        • 2. IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2021-12-13 Patho - lymphnode biopsy
    • DIAGNOSIS:
      • Soft tissue, left neck, sono-guide biopsy — squamous cell carcinoma, moderately differentiated, origin?
        
    • MICROSCOPIC DESCRIPTION:
      • Sections show solid sheets of hyperchromatic tumor cells infiltrating in a fibrotic stroma. No keratinization is seen.
      • The immunohistochemical stains reveal p40(+), TTF-1(-), Napsin A(-), and CD56(-). No lymphoid tissue is seen.
      • Please correlate with the clinical presentation and image study for tumor origin.
  • 2021-12-07 Whole body PET scan
    • 1. A prominent glucose hypermetabolic lesion in the lower lobe of left lung. Primary lung malignancy should be considered. Please correlate with other clinical findings for further evaluation.
    • 2. Glucose hypermetabolism in multiple left neck level II to V lymph nodes and in the right pulmonary hilar region, compatible with metastatic lymph nodes.
    • 3. Glucose hypermetabolism in multiple focal area in bilateral lung fields, in some focal areas in the liver and in some bones as mentioned above, suggesting multiple liver, lung and bone metastases.
    • 4. Mild glucose hypermetabolism in the right adrenal gland. The nature is to be determined (adrenal hyperplasia or adenoma? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2021-12-06 CT - lung/mediastinum/pleura
    • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T:T4(T_value), N:N3(N_value), M:M1c(M_value), STAGE:IVB
  • 2021-11-13 CT - neck
    • Multiple enlarged left neck LAPs, level II-III-IV.
    • Left carotid artery encasement by the LAPs were found.
    • No obvious nasopharynx, oropharynx, hypopharynx or larynx mass.
  • 2021-11-01 L-N aspiration
    • DIAGNOSIS:
      • Left neck mass— Carcinoma
        
    • MICROSCOPIC DESCRIPTION:
      • Smears show cohesive atypical tumor cells with nuclear hyperchromasia, pleomorphism and high N/C ratio.
  • 2021-10-29 SONO - head and neck soft tissue
    • Clinical impression/intent: left multiple neck mass (level 2-4)
    • Sonographic impression: left multiple neck mass with extra-capusular extension, suspected metastasis.
  • 2021-04-05 MRI - MR Cholangiography, MRCP
    • S/P cholecystectomy. A filling defect at distal CBD (1.4cm) with biliary dilatation suspected stone.
    • Splenomegaly.
    • Dilatation of p-duct (5.1mm).
  • 2021-03-15 CT - abdomen, pelvis
    • S/P cholecystectomy.
    • Suspected cholangitis and distal CBD stone.
  • 2021-01-09 Hip joints bilat.
    • S/P right THR without evidenced prothesis loosening.
  • 2021-01-09 CT - abdomen, pelvis
    • Suspected distal CBD stone (4mm). Mild dilatation of IHD (intrahepatic duct) suspected cholangitis. Liver cirrhosis with splenomegaly.
  • 2021-01-08 ECG
    • Sinus tachycardia
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2020-10-05 SONO - neurology
    • 1. Mild (to moderate) atheromatous lesions in R CCA bifurcation.
    • 2. Relatively smaller caliber with decreased flow in R cervical VA compared with L VA.
    • 3. Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • 4. Poor bilateral temporal windows for transcranial insonation.
    • 5. Suspicious mass lesion in left thyroid gland.
  • 2019-05-10 Cardiac ultrasound, M-mode Echo, Doppler color flow mapping
    • 1. Adequate LV systolic function with normal resting wall motion
    • 2. Septal hypertrophy; LV diastolic dysfunction, Gr 1
    • 3. Trivial MR and mild TR
    • 4. Preserved RV systolic function
  • 2019-05-09 Bronchodilator Test, Flow-volume curve
    • Moderate restrictive ventilatory impairment
    • Not significant bronchodilator reversibility
  • 2019-05-08 CT - abdomen
    • Distal CBD stone with biliary tree obstruction.
    • Liver cirrhosis.
  • 2019-05-08 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • Patent airway is found.
    • Senile fibrotic change is noted at lung fields.
  • 2018-05-28 Hip joints RT
    • S/p Total hip replacement over right side.
    • The alignment of the bony structure after procedure is satisfactory.
  • 2018-05-22 MRA - brain
    • Brain atrophy with multiple old lacunar brain infarcts.
    • Old hemorrhage in left thalamus. Abnormal signal intensity in bilateral middle cerebellar peduncles, nature to be determined.
  • 2018-05-21 Color transcranial Doppler, Dopscan, Carotid phonoangiograph (CPA)
    • 1. Mild to moderate atheromatous lesions in R CCA bifurcation; mild atheromatous lesions in L CCA bifurcation.
    • 2. Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • 3. Poor bilateraltemporal windows for transcranial insonation.
  • 2018-05-16 CT - brain
    • Brain atrophy and old infarcts.
• chemoimmunotherapy
  • 2022-06-20 - cisplatin 60mg/m2 1.5hr
  • 2022-05-30 - cisplatin 60mg/m2 1.5hr
  • 2022-05-09 - cisplatin 60mg/m2 1.5hr
  • 2022-04-11 - cisplatin 60mg/m2 1.5hr
  • 2022-03-21 - gemcitabine 1000mg/m2 30min
  • 2022-03-07 - gemcitabine 1000mg/m2 30min + cisplatin 60mg/m2 1.5hr
  • 2022-02-14 - gemcitabine 1000mg/m2 30min
  • 2022-02-07 - gemcitabine 1000mg/m2 30min + cisplatin 60mg/m2 1.5hr
  • 2022-01-17 - gemcitabine 1000mg/m2 30min
  • 2022-01-04 - gemcitabine 1000mg/m2 30min + cisplatin 50mg/m2 1.5hr

[assessment]

• Lab data 2022-07-26: Procalcitonin (PCT) 1.73ng/mL, CRP 21.88mg/dL
• The initial empiric therapy for fever and neutropenia in high-risk patients could be cefepime, imipenem/cilastatin, piperacillin/tazobactam, and ceftazidime. The administration of ceftazidime 2000mg Q8H IVD has been ongoing since 2022-07-26. Results of blood and urine cultures have not yet been released.
• If atypical bacteria are suspected, azithromycin, doxycycline, or fluoroquinolones might be an optional add-on. The use of fluconazole as a prophylactic measure might also be considered for anticipated mucositis.

701164228

220726

• diagnosis
  • 1: Endometroid carcinoma, FIGO grade 3, of the uterine endometrium, AJCC 8 th edition, Pathology stage: pT3aN0(cM0); stage IIIA; FIGO stage IIIA, s/p staging on 2022-02-07.
  • 2: Right breast Invasive carcinoma post breast conserving therapy, pT2N1a(sn)M0, stage IIB,
  • 3: Chronic viral hepatitis B without delta-agent
• exam finding
  • 2022-06-22 SONO - abdomen
    • Diagnosis
      • Fatty liver, marked
      • Liver cysts
      • Chronic kidney disease with renal calcifications
      • Left renal stone
      • (suboptimal echo window)
    • Suggestion
      • OPD follow-up
  • 2022-02-08 Patho - uterus (with or without SO) neoplastic
    • Pathologic Diagnosis
      • Uterus, endometrium, ATH — Endometroid carcinoma, FIGO grade 3
      • Fallopian tube, right, BSO — Involved by carcinoma
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND + PALND — Negative for malignancy (0/39)
      • AJCC 8 th edition, Pathology stage: pT3aN0; stage IIIA; FIGO stage IIIA; if cM0
    • Macroscopic Examination
      • Procedure: ATH + BSO + omentectomy + BPLND + para-aortic LN dissection
    • Microscopic Examination
      • Histologic Type: Endometroid carcinoma
      • Histologic Grade: FIGO grade 3
      • Adenomyosis: Not identified
      • Depth of Tumor Invasion: Tumor invading more than half of myometrium
      • Cervical Stromal Involvement: Not identified
      • Other Tissue/Organ Involvement: Tumor involving right fallopian tube
      • Peritoneal/Ascitic Fluid: Not submitted
      • Margins: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 1.5 cm
      • Lymphvascular Invasion: Present
      • Regional Lymph Nodes: All lymph nodes negative for tumor cells (0/39)
      • AdditionalPathologic Findings
        • Cervix: Chronic cervicitis with squamous metaplasia
        • Myometrium: Leiomyoma
        • Ovary, right: No remarkable change
        • Ovary, left: No remarkable change
        • Fallopian tube, left: Chronic salpingitis
        • Omentum: No remarkable change
  • 2022-02-08 Cytology - ascites
    • ASCITES: suspicious for malignancy
      
    • Smears show lymphoid cells, and few suspicious cells with elongated
  • 2022-01-17 MRI - pelvis
    • suspected endometrial malignancy with lymph nodes metastasis (paraaortic region).
      • right parametrial soft tissue tumors, parametrial lymph nodes metastasis or tumor seeding? cstage T3N2M0.
    • uterine tumors, suspected myomas.
    • suspected liver cysts.
  • 2022-01-06 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, TCR — Endometrioid adenocarcinoma
      
    • Microscopically, sections show endometrioid adenocarcinoma characterized by proliferation of neoplastic ells arranged in cribrinform to solid architecture and invasive growth pattern with tumor necrosis. The tumor shows eosinophilic cytoplasm, nuclear hyperchromasia, pleomoephism, loss of polarity, prominent nuleoli and mitoses.
      
    • Immunohistochemical stain reveals p16(patchy positive), p53(wild type), CK7(+), CK20(-) and vimentin(+).
  • 2021-12-31 Gynecologic ultrasonography
    • Uterine myoma
    • Uterine mass: 27x23mm, no blood flow
  • 2021-11-09 SONO - abdomen
    • Bil. liver cysts (up to 1.0cm).
  • 2021-11-09 SONO - breast
    • Right fibroadenomas
    • s/p right breast operation
    • benign
  • 2021-05-07 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20200316, no prominent change is noted in the lesions in the lower L-spines. Degenerative spine diseases may show such a picture.
    • Increased radiotracer uptake in maxilla and mandible, Dental lesions may show this picture.
    • Probably degenerative change in bilateral shoulders, sternoclavicular junctions, sacroiliac joints, knees, ankles and both feet.
    • No prominent bone abnormality was noted elsewhere.
  • 2021-03-16 Mammography
    • Post-op with breast tissue reduction in right breast.
    • Benign calcifications in bilateral breasts.
  • 2021-03-16 SONO - breast
    • Operation scar at right UOQ breast.
    • Probably right breast fibroadenomas, stationary.
  • 2021-03-02 Gynecologic ultrasonography
    • uterine myoma
  • 2020-12-08 SONO - breast
    • Operation scar at right UOQ breast.
    • Probably right breast fibroadenomas.
  • 2020-03-18 SONO - breast
    • Breast tissue reduction in right breast, could be due to post-op change.
    • Benign calcifications in bilateral breasts.
  • 2020-03-16 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20190114, the previously noted faint hot spots in bilateral rib cages had disappeared, indicating benign in nature.
    • Mildly and non-focally increased radiotracer uptake in lower L-spine, degenerative spine diseases may show such a picture.
    • Increased radiotracer uptake in maxilla and mandible, suggesting dental lesions.
    • Probably degenerative change in shoulders, sternoclavicular junctions, sacroiliac joints, knees, and ankles.
    • No definite evidence of osteoblastic skeletal metastasis by this bone scan.
  • 2019-02-12 Whole body PET scan
    • Mild glucose hypermetabolism in the right breast. The nature is to be determined (post-operative inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral shoulder joints, compatible with benign joint lesion such as arthritis.
    • Mildly increased FDG accumulation in the colon. Physiologic FDG accumulation is more likely.
  • 2019-01-22 Pathology Level VI
    • Pathologic diagnosis
      • Breast, right, partial mastectomy — Invasive carcinoma of no special type (90%) with focal mucinous carcinoma (10%)
        
      • Resection margin: Free of carcinoma
        
      • Lymph node, right axillary sentinel, lymphadenecomy — Metastatic carcinoma (1/1)
        
      • Pathology stage: pT2N1a(sn)(cMx); Anatomic stage IIB, Prognostic stage IB
    • Microscopic examination
      • Histologic grade (Nottingham histologic score): Grade I (score= 5)
        
      • Tumor necrosis: Present
        
      • Nodal status (Sentinel): Positive (1/1)
      • Treatment Effect: No presurgical neoadjuvant therapy received
        
      • Lymphovascular invasion: Absent
        
      • Perineural invasion: Absent
        
    • Immunohistochemical study (S2019-00163)
      • ER (Ab): Positive (90%)
      • PR (Ab): Positive (90%)
      • HER-2/Neu (Ab): Negative (score=0)
      • Ki-67: <5%
      • p53: <2%.
  • 2019-01-04 Surgical pathology Level IV
    • Breast, right, 10 o’clock/3cm, SONO guided core biopsy — Invasive carcinoma.
    • IHC: ER (+, 90%), PR: (+, 90%), Her2/neu: negative (score=0); Ki-67: <5%, p53: <2%.
  • 2019-01-03 SONO - breast
    • Highly suspicious of malignancy, with sonographic negative axillary LNs, suspected carcinoma, cT2N0.
    • BI-RADS: 5-Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken.
• consultation
  • 2022-02-26 Urology
    • Q
      • For on D-J catheterization.
      • This 51-year-old female with endometrial cancer  was admitted for staging surgery at 20220207. 
      • We need your evaluation of her condition for inserted D-J catheterization. Thanks for your help!
    • A
      • MRI showed lymph node and mild dialation of right renal pelvis.
      • We will stand by for this procedure
• surgical operation
  • 2022-02-07 Endometrial cancer - Staging surgery (ATH + BSO + lymph node dissection + infracolic omentectomy)        
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder, peritoneum due to tumor mass accupied .
    • Adnexa:
      • LOV: 3x2x2cm, capsule intact, smooth surface.
      • ROV: 3x3x3cm, capsule intact, smooth surface.
      • Fallopian tube: bilateral grossly normal
    • CDS: invisible due to tumor mass occupied
  • 2022-01-06 Transcervical resection polypectomy      
    • One endometrial polyp from low segemtn of uterus, with stalk from 5o’clock of direction
  • 2019-01-21 right breast cancer - BCT + SLND
• radiotherapy
  • 2022-03-09 ~ 2022-04-28 - 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.
  • 2019-08-27 ~ 2019-10-17 - 5000cGy/25 fractions of the right breast to right SCF, and 6000cGy/30 fractions of the right breast tumor bed (scar) area.
• chemoimmunotherapy
  • 2022-08-15 - paclitaxel 175mg/m2 360mg 3hr + carboplatin AUC 5 500mg 2hr
  • 2022-07-25 - paclitaxel 175mg/m2 360mg 3hr + carboplatin AUC 5 500mg 2hr
  • 2022-07-04 - paclitaxel 175mg/m2 360mg 3hr + carboplatin AUC 5 500mg 2hr
  • 2022-06-08 - paclitaxel 175mg/m2 360mg 3hr + carboplatin AUC 5 450mg 2hr
  • 2022-04-20 - paclitaxel 175mg/m2 360mg 3hr + carboplatin AUC 5 450mg 2hr
  • 2022-03-18 - paclitaxel 175mg/m2 330mg 3hr + carboplatin AUC 5 450mg 2hr
  • 2021-03-02 ~ 2021-05-18 - Medrone (medroxyprogesterone acetate) 5mg/tab 1# QD PO
  • 2019-08-13 ~ undergoing - Femara (letrozole) 2.5mg/tab 1# QD PO (Letrozole, or CGS 20267, is an oral non-steroidal type II aromatase inhibitor first described in the literature in 1990. It is a third generation aromatase inhibitor like exemestane and anastrozole, meaning it does not significantly affect cortisol, aldosterone, and thyroxine)
  • 2019-02-25 ~ 2019-08-05 - (pegylated liposomal) doxorubicin + cyclophosphamide

[note]

• Taxane derivatives: When administered as sequential infusions, taxane derivatives (docetaxel, paclitaxel) should be administered before the platinum derivatives (carboplatin, cisplatin) to limit myelosuppression and to enhance efficacy.

[assessment]

• RBCs were 2.75106/uL and HGBs were 7.8g/dL on 2022-07-25. 2U of LPRBC (Leukocyte-poor RBC) had been transfused on the night of 2022-07-25.

220609

[assessment]

• In this patient, endometrial cancer has been diagnosed following ATH + BSO + lymph node dissection + infracolic omentectomy on 2022-02-07. The patient is receiving treatment with paclitaxel + carboplatin from 2022-03-18. Before that, the right breast invasive carcinoma was treated with partial mastectomy on 2019-01-21, followed by doxorubicin + cyclophosphamide from 2019-02-25 to 2019-08-05, followed by letrozole from 2019-08-13.
• Lab data reported on 2022-06-08 indicated that liver and kidney functions, serum electrolytes, and blood cell counts were grossly normal.

220421

[objective]

• exam finding
  • 2022-02-08 Patho - uterus (with or without SO) neoplastic
    • Pathologic Diagnosis
      • Uterus, endometrium, ATH — Endometroid carcinoma, FIGO grade 3
      • Fallopian tube, right, BSO — Involved by carcinoma
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND + PALND — Negative for malignancy (0/39)
      • AJCC 8 th edition, Pathology stage: pT3aN0; stage IIIA; FIGO stage IIIA; if cM0
    • Macroscopic Examination
      • Procedure: ATH + BSO + omentectomy + BPLND + para-aortic LN dissection
    • Microscopic Examination
      • Histologic Type: Endometroid carcinoma
      • Histologic Grade: FIGO grade 3
      • Adenomyosis: Not identified
      • Depth of Tumor Invasion: Tumor invading more than half of myometrium
      • Cervical Stromal Involvement: Not identified
      • Other Tissue/Organ Involvement: Tumor involving right fallopian tube
      • Peritoneal/Ascitic Fluid: Not submitted
      • Margins: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 1.5 cm
      • Lymphvascular Invasion: Present
      • Regional Lymph Nodes: All lymph nodes negative for tumor cells (0/39)
      • AdditionalPathologic Findings
        • Cervix: Chronic cervicitis with squamous metaplasia
        • Myometrium: Leiomyoma
        • Ovary, right: No remarkable change
        • Ovary, left: No remarkable change
        • Fallopian tube, left: Chronic salpingitis
        • Omentum: No remarkable change
  • 2022-02-08 Cytology - ascites
    • ASCITES: suspicious for malignancy
      
    • Smears show lymphoid cells, and few suspicious cells with elongated
  • 2022-01-17 MRI - pelvis
    • suspected endometrial malignancy with lymph nodes metastasis (paraaortic region).
      • right parametrial soft tissue tumors, parametrial lymph nodes metastasis or tumor seeding? cstage T3N2M0.
    • uterine tumors, suspected myomas.
    • suspected liver cysts.
  • 2022-01-06 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, TCR — Endometrioid adenocarcinoma
      
    • Microscopically, sections show endometrioid adenocarcinoma characterized by proliferation of neoplastic ells arranged in cribrinform to solid architecture and invasive growth pattern with tumor necrosis. The tumor shows eosinophilic cytoplasm, nuclear hyperchromasia, pleomoephism, loss of polarity, prominent nuleoli and mitoses.
      
    • Immunohistochemical stain reveals p16(patchy positive), p53(wild type), CK7(+), CK20(-) and vimentin(+).
  • 2021-12-31 Gynecologic ultrasonography
    • Uterine myoma
    • Uterine mass: 27x23mm, no blood flow
  • 2021-11-09 SONO - abdomen
    • Bil. liver cysts (up to 1.0cm).
  • 2021-11-09 SONO - breast
    • Right fibroadenomas
    • s/p right breast operation
    • benign
  • 2021-05-07 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20200316, no prominent change is noted in the lesions in the lower L-spines. Degenerative spine diseases may show such a picture.
    • Increased radiotracer uptake in maxilla and mandible, Dental lesions may show this picture.
    • Probably degenerative change in bilateral shoulders, sternoclavicular junctions, sacroiliac joints, knees, ankles and both feet.
    • No prominent bone abnormality was noted elsewhere.
  • 2021-03-16 Mammography
    • Post-op with breast tissue reduction in right breast.
    • Benign calcifications in bilateral breasts.
  • 2021-03-16 SONO - breast
    • Operation scar at right UOQ breast.
    • Probably right breast fibroadenomas, stationary.
  • 2021-03-02 Gynecologic ultrasonography
    • uterine myoma
  • 2020-12-08 SONO - breast
    • Operation scar at right UOQ breast.
    • Probably right breast fibroadenomas.
  • 2020-03-18 SONO - breast
    • Breast tissue reduction in right breast, could be due to post-op change.
    • Benign calcifications in bilateral breasts.
  • 2020-03-16 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20190114, the previously noted faint hot spots in bilateral rib cages had disappeared, indicating benign in nature.
    • Mildly and non-focally increased radiotracer uptake in lower L-spine, degenerative spine diseases may show such a picture.
    • Increased radiotracer uptake in maxilla and mandible, suggesting dental lesions.
    • Probably degenerative change in shoulders, sternoclavicular junctions, sacroiliac joints, knees, and ankles.
    • No definite evidence of osteoblastic skeletal metastasis by this bone scan.
  • 2019-02-12 Whole body PET scan
    • Mild glucose hypermetabolism in the right breast. The nature is to be determined (post-operative inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral shoulder joints, compatible with benign joint lesion such as arthritis.
    • Mildly increased FDG accumulation in the colon. Physiologic FDG accumulation is more likely.
  • 2019-01-22 Pathology Level VI
    • Pathologic diagnosis
      • Breast, right, partial mastectomy — Invasive carcinoma of no special type (90%) with focal mucinous carcinoma (10%)
        
      • Resection margin: Free of carcinoma
        
      • Lymph node, right axillary sentinel, lymphadenecomy — Metastatic carcinoma (1/1)
        
      • Pathology stage: pT2N1a(sn)(cMx); Anatomic stage IIB, Prognostic stage IB
    • Microscopic examination
      • Histologic grade (Nottingham histologic score): Grade I (score= 5)
        
      • Tumor necrosis: Present
        
      • Nodal status (Sentinel): Positive (1/1)
      • Treatment Effect: No presurgical neoadjuvant therapy received
        
      • Lymphovascular invasion: Absent
        
      • Perineural invasion: Absent
        
    • Immunohistochemical study (S2019-00163)
      • ER (Ab): Positive (90%)
      • PR (Ab): Positive (90%)
      • HER-2/Neu (Ab): Negative (score=0)
      • Ki-67: <5%
      • p53: <2%.
  • 2019-01-04 Surgical pathology Level IV
    • Breast, right, 10 o’clock/3cm, SONO guided core biopsy — Invasive carcinoma.
    • IHC: ER (+, 90%), PR: (+, 90%), Her2/neu: negative (score=0); Ki-67: <5%, p53: <2%.
  • 2019-01-03 SONO - breast
    • Highly suspicious of malignancy, with sonographic negative axillary LNs, suspected carcinoma, cT2N0.
    • BI-RADS: 5-Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken.
• surgical operation
  • 2022-02-07 Endometrial cancer - Staging surgery (ATH + BSO + lymph node dissection + infracolic omentectomy)        
    • Supraumbilical midline vertical skin incision
    • Uterus: normal size, tense contact with bladder, peritoneum due to tumor mass accupied .
    • Adnexa:
      • LOV: 3x2x2cm, capsule intact, smooth surface.
      • ROV: 3x3x3cm, capsule intact, smooth surface.
      • Fallopian tube: bilateral grossly normal
    • CDS: invisible due to tumor mass occupied
  • 2022-01-06 Transcervical resection polypectomy      
    • One endometrial polyp from low segemtn of uterus, with stalk from 5o’clock of direction
  • 2019-01-21 right breast cancer - BCT + SLND
• radiotherapy
  • 2022-03-09 ~ ?? 4140cGy/23 fractions of the pelvic area
  • 2019-08-27 ~ 2019-10-17 - 5000cGy/25 fractions of the right breast to right SCF, and 6000cGy/30 fractions of the right breast tumor bed (scar) area
• chemoimmunotherapy
  • 2022-03-18 ~ undergoing - paclitaxel + carboplatin
  • 2021-03-02 ~ 2021-06-XX - Medrone (medroxyprogesterone acetate) 5mg/tab 1# QD PO
  • 2019-08-13 ~ undergoing - Femara (letrozole) 2.5mg/tab 1# QD PO
  • 2019-02-25 ~ 2019-08-05 - (pegylated liposomal) doxorubicin + cyclophosphamide

[assessment]

• This patient has been diagnosed with endometrial cancer s/p ATH + BSO + lymph node dissection + infracolic omentectomy on 2022-02-07 and is being treated with paclitaxel + carboplatin since 2022-03-18. Prior to that, right breast invasive carcinoma was treated with partial mastectomy on 2019-01-21, followed by doxorubicin + cyclophosphamide from 2019-02-25 to 2019-08-05, then letrozole since 2019-08-13.
• Lab data reported on 2022-04-20 showed that liver and kidney function, serum electrolytes, and blood cell counts were grossly normal.

700341500

220722

{colon cancer with liver mets}

[objective]

• lab data
  • Creatinine
    • 2022-07-21 1.62 mg/dL
    • 2022-07-06 1.59 mg/dL
    • 2022-06-12 1.85 mg/dL
    • 2022-05-27 1.84 mg/dL
    • 2022-04-30 1.67 mg/dL
    • 2022-04-22 1.55 mg/dL
    • 2022-03-30 1.66 mg/dL
    • 2022-03-17 1.46 mg/dL
    • 2022-03-01 1.81 mg/dL
    • 2022-02-25 1.90 mg/dL
    • 2022-02-22 1.68 mg/dL
    • 2022-02-10 1.25 mg/dL
    • 2022-02-07 1.30 mg/dL
    • 2022-01-20 1.31 mg/dL
    • 2022-01-15 1.55 mg/dL
    • 2022-01-06 1.51 mg/dL
    • 2021-12-20 1.35 mg/dL
• exam finding
  • 2022-06-29 SONO - abdomen
    • Chronic liver parenchymal disease
    • Hepatic tumors C/W metastatic liver tumors
  • 2022-05-27 CXR
    • S/P port-A implantation.
    • Borderline cardiomegaly
    • Bamboo spine is noted that is c/w ankylosing spondylitis.
  • 2022-05-02 CT - abdomen, pelvis
    • Findings
      • Several low density lesions are found at both lobes of liver up to 4.35cm in largest dimension. In comparison with CT dated on 2021-12-21, these lesions decreased in size
      • Filling defect at infrarenal aorta is found. r/o thrombus formnation. The lesion could also be found at previous CT.
      • Enlarged left adrenal gland is found. Metastasis is considered. In regression.
      • There is no evidence of paraarotic LAPs.
      • Mild thrinkage of the sigmoid colon mass is found.
      • The urinary bladder is well distended without soft tissue lesion.
      • No definite inguinal or pelvic sidewall LAP
      • Ankylosis of the thoracolumbar spine is found.
    • Imp:
      • Sigmoid colon cancer with liver and left adrenal mets, all of the tumor activity regressed and decreased in size.
      • Infra-renal aortic thrombus formation with stable size. suspected chronic thrombus formation. Suggest further treatment.
  • 2022-02-23 ECG
    • Normal sinus rhythm
    • Voltage criteria for left ventricular hypertrophy
    • Anteroseptal infarct, age undetermined
    • T wave abnormality, consider inferolateral ischemia
    • Abnormal ECG
  • 2022-02-23 2D transthoracic echocardiography
    • Dilated LA and LV
    • Septal hypertrophy
    • Poor LV systolic function
    • Adequate RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR, mild MR and TR
    • Hypokinesis of anteroseptal, anterior, apical and inferioposterior wall
  • 2022-02-22 ECG
    • Sinus tachycardia
    • Minimal voltage criteria for LVH, may be normal variant
    • Anterior infarct, age undetermined
    • T wave abnormality, consider lateral ischemia
  • 2022-02-22 Cardiac catheterization
    • In conclusion: Coronary artery disease, 1VD, m-LAD; Syntax score 9 s/p POBA and stenting with Boston SYNERGY Drug-eluting stent. 4.0 X 48 mm for proximal LAD to middle LAD.
    • Recommendation: Patient had take PPI and gastritis history, shift ticagrelor to clopiodgrel later.
  • 2021-12-23 Patho - colorectal polyp
    • A. Colon, transverse colon, s/p hot snare polypectomy (E) - Tubulovillous adenoma with low grade dysplasia.
    • B. Colon, 10cm to 20cm AAV, s/p biopsy (F) - Adenocarcinoma.
      • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
        
  • 2021-12-23 Colonoscopy
    • Colon polyp, transverse colon, s/p EMR and clipping.
    • Highly suspected colon cancer, 1-cm to 20cm AAV, s/p biopsy.
    • Colon polyps, s/p polypectomy and biopsy, at least four residue polyps not polypectomized.
  • 2021-12-21 CT - abdomen - liver, spleen, biliary duct, pancreas
    • Suspected rectosigmoid cancer with liver and left adrenal metastasis.
    • Small right lung nodule, suspected lung metastasis.
    • Right renal stones. Left middle ureteral stone with hydronephrosis.
  • 2021-12-17 Abdominal ultrasound
    • Parenchymal liver disease, suspected liver cirrhosis.
    • Hepatic tumors, HCC with portal vein invasion or metastatic tumor with vessel compression were suspected.
    • Left hydronephrosis, mild
    • Splenomegaly
• consultation
  • 2022-02-24 Rehabilitation
    • A
      • Assessment
        • ST elevation myocardial infarction, 1-vessel coronary artery disease, s/p balloon angioplasty and drug eluting stenting on 2022/02/22 -colon cancer
      • Plan
        • Rehabilitation programs: Bedside PT cardiopulmonary rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
        • May arrange PM&R OPD follow-up for further phase 2 cardiac rehabilitation program as needed
  • 2022-02-22 Cardiology
    • This 69 y/o male is a case of colon CA. He admitted due to chest pain. EKG ST elevation, anterior wall
    • bed side 2D anteroseptal, anterior and apex hypokinesia
    • Past history:
      • colon CA
    • impression
      • STEMI, onset <12 hours
    • Suggestion
      • Dual anti-PLT therapy (aspirin 3# po STAT and brilinta 2# po STAT; then spirin 1# po QD and brilinta 1# po QD) and anticoagulation (such as heparin 4000U stat)
      • We explain the indication of primary percutaneous coronary intervention in order to save life, but also potential risks of PCI including stroke around 1/1000.
      • Arrange admission to MICU
  • 2021-12-24 Colorectal Surgery
    • Q
      • for management of favor colon cancer with liver, lung and adrenal mets
      • This 68 y/o male due to Liver tumor, HCC with right portal vein invasion or metastatic tumor with vessel compression were suspected. He was admitted to our GI ward for management and further survey.
      • After admission, Colonscopy was done that showed Highly suspected colon cancer, 10cm to 20cm AAV, s/p biopsy.
      • Now, we will be pending pathology and need your management of favor colon cancer with liver, lung and adrenal mets. Thanks a lot!!!
    • A
      • I’ve visited this case. The patient was a case of colon cancer with multiple liver, lung, adrenal metastasis
      • O
        • Oral intake : well
        • Appetite: good
        • Stool passage: Normal
        • No obstruction sign
      • IMP：Colon cancer with multiple metastasis
      • Suggestion:
        • Consult Oncology for palliative chemotherapy + target therapy
        • Surgery will be reserved for obstruction for the patient
        • Thanks for your consultation
  • 2021-12-23 Urology
    • Q
      • Now, abdominal CT was done that showed Left middle ureteral stone with mild hydronephrosis.
    • A
      • Due to stone impaction with renal insufficiency, URSL with short term DBJ insertion (7 days) is indicated.
      • Treating stone may yield better renal function for chemotherapy in the future.
      • I will discuss with him after colonscopy
      • Adrenal tumor was seen. Metastasis is suspected.
      • Thanks for your consultation
• chemotherapy
  • 2022-01-20 ~ undergoing - bevacizumab 5mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 2800mg/m2 46hr (FOLFIRI plus bevacizumab)
  • 2022-01-20 - bevacizumab 5mg/kg 90min + irinotecan 160mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 2800mg/m2 46hr
  • 2022-01-06 - irinotecan 160mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 2800mg/m2 46hr

[assessment]

• 2022-07-21 Creatinine 1.62 mg/dL, 171 cm, 74 kg, 69 years old => CrCl 45 mL/min, eGFR 49 mL/min. There is no need to adjust doses in the active prescription.

220707

{colon cancer with liver mets}

[objective]

• lab data
  • Creatinine
    • 2022-07-06 1.59 mg/dL
    • 2022-06-12 1.85 mg/dL
    • 2022-05-27 1.84 mg/dL
    • 2022-04-30 1.67 mg/dL
    • 2022-04-22 1.55 mg/dL
    • 2022-03-30 1.66 mg/dL
    • 2022-03-17 1.46 mg/dL
    • 2022-03-01 1.81 mg/dL
    • 2022-02-25 1.90 mg/dL
    • 2022-02-22 1.68 mg/dL
    • 2022-02-10 1.25 mg/dL
    • 2022-02-07 1.30 mg/dL
    • 2022-01-20 1.31 mg/dL
    • 2022-01-15 1.55 mg/dL
    • 2022-01-06 1.51 mg/dL
    • 2021-12-20 1.35 mg/dL
• exam finding
  • 2022-06-29 SONO - abdomen
    • Chronic liver parenchymal disease
    • Hepatic tumors C/W metastatic liver tumors
  • 2022-05-27 CXR
    • S/P port-A implantation.
    • Borderline cardiomegaly
    • Bamboo spine is noted that is c/w ankylosing spondylitis.
  • 2022-05-02 CT - abdomen, pelvis
    • Findings
      • Several low density lesions are found at both lobes of liver up to 4.35cm in largest dimension. In comparison with CT dated on 2021-12-21, these lesions decreased in size
      • Filling defect at infrarenal aorta is found. r/o thrombus formnation. The lesion could also be found at previous CT.
      • Enlarged left adrenal gland is found. Metastasis is considered. In regression.
      • There is no evidence of paraarotic LAPs.
      • Mild thrinkage of the sigmoid colon mass is found.
      • The urinary bladder is well distended without soft tissue lesion.
      • No definite inguinal or pelvic sidewall LAP
      • Ankylosis of the thoracolumbar spine is found.
    • Imp:
      • Sigmoid colon cancer with liver and left adrenal mets, all of the tumor activity regressed and decreased in size.
      • Infra-renal aortic thrombus formation with stable size. suspected chronic thrombus formation. Suggest further treatment.
  • 2022-02-23 ECG
    • Normal sinus rhythm
    • Voltage criteria for left ventricular hypertrophy
    • Anteroseptal infarct, age undetermined
    • T wave abnormality, consider inferolateral ischemia
    • Abnormal ECG
  • 2022-02-23 2D transthoracic echocardiography
    • Dilated LA and LV
    • Septal hypertrophy
    • Poor LV systolic function
    • Adequate RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR, mild MR and TR
    • Hypokinesis of anteroseptal, anterior, apical and inferioposterior wall
  • 2022-02-22 ECG
    • Sinus tachycardia
    • Minimal voltage criteria for LVH, may be normal variant
    • Anterior infarct, age undetermined
    • T wave abnormality, consider lateral ischemia
  • 2022-02-22 Cardiac catheterization
    • In conclusion: Coronary artery disease, 1VD, m-LAD; Syntax score 9 s/p POBA and stenting with Boston SYNERGY Drug-eluting stent. 4.0 X 48 mm for proximal LAD to middle LAD.
    • Recommendation: Patient had take PPI and gastritis history, shift ticagrelor to clopiodgrel later.
  • 2021-12-23 Patho - colorectal polyp
    • A. Colon, transverse colon, s/p hot snare polypectomy (E) - Tubulovillous adenoma with low grade dysplasia.
    • B. Colon, 10cm to 20cm AAV, s/p biopsy (F) - Adenocarcinoma.
      • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
        
  • 2021-12-23 Colonoscopy
    • Colon polyp, transverse colon, s/p EMR and clipping.
    • Highly suspected colon cancer, 1-cm to 20cm AAV, s/p biopsy.
    • Colon polyps, s/p polypectomy and biopsy, at least four residue polyps not polypectomized.
  • 2021-12-21 CT - abdomen - liver, spleen, biliary duct, pancreas
    • Suspected rectosigmoid cancer with liver and left adrenal metastasis.
    • Small right lung nodule, suspected lung metastasis.
    • Right renal stones. Left middle ureteral stone with hydronephrosis.
  • 2021-12-17 Abdominal ultrasound
    • Parenchymal liver disease, suspected liver cirrhosis.
    • Hepatic tumors, HCC with portal vein invasion or metastatic tumor with vessel compression were suspected.
    • Left hydronephrosis, mild
    • Splenomegaly
• consultation
  • 2022-02-24 Rehabilitation
    • A
      • Assessment
        • ST elevation myocardial infarction, 1-vessel coronary artery disease, s/p balloon angioplasty and drug eluting stenting on 2022/02/22 -colon cancer
      • Plan
        • Rehabilitation programs: Bedside PT cardiopulmonary rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
        • May arrange PM&R OPD follow-up for further phase 2 cardiac rehabilitation program as needed
  • 2022-02-22 Cardiology
    • This 69 y/o male is a case of colon CA. He admitted due to chest pain. EKG ST elevation, anterior wall
    • bed side 2D anteroseptal, anterior and apex hypokinesia
    • Past history:
      • colon CA
    • impression
      • STEMI, onset <12 hours
    • Suggestion
      • Dual anti-PLT therapy (aspirin 3# po STAT and brilinta 2# po STAT; then spirin 1# po QD and brilinta 1# po QD) and anticoagulation (such as heparin 4000U stat)
      • We explain the indication of primary percutaneous coronary intervention in order to save life, but also potential risks of PCI including stroke around 1/1000.
      • Arrange admission to MICU
  • 2021-12-24 Colorectal Surgery
    • Q
      • for management of favor colon cancer with liver, lung and adrenal mets
      • This 68 y/o male due to Liver tumor, HCC with right portal vein invasion or metastatic tumor with vessel compression were suspected. He was admitted to our GI ward for management and further survey.
      • After admission, Colonscopy was done that showed Highly suspected colon cancer, 10cm to 20cm AAV, s/p biopsy.
      • Now, we will be pending pathology and need your management of favor colon cancer with liver, lung and adrenal mets. Thanks a lot!!!
    • A
      • I’ve visited this case. The patient was a case of colon cancer with multiple liver, lung, adrenal metastasis
      • O
        • Oral intake : well
        • Appetite: good
        • Stool passage: Normal
        • No obstruction sign
      • IMP：Colon cancer with multiple metastasis
      • Suggestion:
        • Consult Oncology for palliative chemotherapy + target therapy
        • Surgery will be reserved for obstruction for the patient
        • Thanks for your consultation
  • 2021-12-23 Urology
    • Q
      • Now, abdominal CT was done that showed Left middle ureteral stone with mild hydronephrosis.
    • A
      • Due to stone impaction with renal insufficiency, URSL with short term DBJ insertion (7 days) is indicated.
      • Treating stone may yield better renal function for chemotherapy in the future.
      • I will discuss with him after colonscopy
      • Adrenal tumor was seen. Metastasis is suspected.
      • Thanks for your consultation
• chemotherapy
  • 2022-01-06 ~ ongoing - FOLFIRI (plus bevacizumab since 2022-01-20)

[assessment]

• Following the administration of FOLFIRI plus bevacizumab since 2022-01-20, CT scan on 2022-05-02 revealed that all tumor activity had regressed and decreased in size.
• Under daily taking of aspirin and clopidogrel, an infra-renal aortic thrombus of stable size was also demonstrated on 2022-05-02 CT.
• TPR, BP signs during this hospitalizaion and lab data on 2022-07-06 were grossly normal except for creatinine 1.59 mg/dL. Chemotherapy should be able to proceed as scheduled.

220318

[assessment]

• As reported by the laboratory on 2022-03-17, the patient has normal liver function, but decreased renal function (creatinine 1.46 mg/dL), slightly low RBC (3.92*10^6/uL) and HGB (11.3 g/dL) readings.
• The patient is currently receiving FOLFIRI plus bevacizumab, and no reports of diarrhea were found in the nursing notes during this hospital stay.
• 5-FU has been associated with cardiac toxicity including myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of FU administration following development of cardiac toxicity.
  • reference:
    • https://www.uptodate.com/contents/image/print?imageKey=ONC%2F76300
    • https://www.uptodate.com/contents/fluoropyrimidine-associated-cardiotoxicity-incidence-clinical-manifestations-mechanisms-and-management
    • https://ro-journal.biomedcentral.com/articles/10.1186/1748-717X-7-212
    • https://www.frontiersin.org/articles/10.3389/fcvm.2021.713694/full

701084563

220722

{Small Lymphocytic Lymphoma}

[objective]

• lab data
  • BUN
    • 2022-07-21 BUN 60 mg/dL
      
    • 2022-07-13 BUN 41 mg/dL
      
    • 2022-07-08 BUN 56 mg/dL
      
    • 2022-07-06 BUN 56 mg/dL
      
    • 2022-07-04 BUN 52 mg/dL
      
    • 2022-06-27 BUN 32 mg/dL
      
    • 2022-06-22 BUN 24 mg/dL
      
    • 2022-06-10 BUN 19 mg/dL
      
    • 2022-06-01 BUN 18 mg/dL
      
  • Procalcitonin (PCT)
    • 2022-07-21 Procalcitonin(PCT) 4.53 ng/mL
      
    • 2022-07-13 Procalcitonin(PCT) 0.43 ng/mL
      
    • 2022-06-23 Procalcitonin(PCT) 0.82 ng/mL
      
    • 2022-06-01 Procalcitonin(PCT) 0.40 ng/mL
      
    • 2022-04-21 Procalcitonin(PCT) 1.76 ng/mL
      
  • 2022-03-22 BCR-abl mutation undetectable
  • 2022-03-16 bone marrow
    • FLT3-D835 mutation undetectable
    • FLT3/ITD mutation undetectable
    • NPM1 mutation undetectable
• exam finding
  • 2022-07-20 CXR
    • Ground glass opacities in bil. lungs.
  • 2022-07-14 Patho - paranasal biopsy
    • Nasal septum, left, biopsy — Necrotic tissues with candidiasis
    • Microscopically, it shows necrotic debris with granulation tissue, leukocytic infiltrate and presence of bacterial clumps and fungal hyphae. No viable tissue is seen.
  • 2022-07-14 Nasopharyngoscopy
    • Nasal lesions
  • 2022-07-13 Nasopharyngoscopy
    • Ulceration at L buccal, L retromolar trigone, L soft palate, blood clot with whitish
  • 2022-07-12 MRI - nasopharynx
    • Enlarged left posterior cervical and bil. supraclavicular LNs as indicated on axial fat sat T2WI when compared with 2021/09/08, 2021/03/23 MRI studies.
  • 2022-07-08, -07-04 CXR
    • Nodular opacities projecting in both lung are suspected. Please correlate with CT.
    • Right pleura effusion is noted.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2022-06-27 2D transthoracic echocardiography
    • 1. Dilated LA and LV; severely abnormal LV systolic function with global hypokinesia
    • 2. Minimal pericardiac effusion
    • 3. Moderate to severe MR, mild to moderate TR
    • 4. LV diastolic dysfunction, Gr 1
    • 5. Impaired RV systolic function
  • 2022-06-23 ECG
    • Sinus tachycardia
    • Nonspecific T wave abnormality
    • Poor wave progression V1~3
    • Abnormal ECG
  • 2022-03-08 Patho - lymph node region resection
    • Lymph node, right neck, excision - Small lymphocytic lymphoma
    • IHC: CD20(+), CD23(+), CD3(-), CD5(+) and CD10(-).
    • According to above histopathologic findings and past history, it is consistent with small lymphocytic lymphoma.
  • 2022-03-04 Whole body PET scan
    • Glucose hypermetabolism in bilateral axillary lymph nodes, bilateral supra and infraclavicular lymph nodes, bilateral neck lymph nodes and abdominal lymph nodes, suggesting recurrent lymphoma involving multiple lymph node regions on the both sides of the diaphragm (stage III).
    • Increased FDG accumulation in both kidneys, bilateral ureters and colon. Physiological FDG accumulation is more likely.
  • 2022-03-03 Patho - bone marrow biopsy
    • Bone marrow, iliac bone, biopsy - Small lymphocytic lymphoma / chronic lymphocytic leukemia
      
    • IHC: CD20(+), CD3(-), CD23(+), CD34(-), CD117(-), CD61 showed adequate megakaryocyte with focal mononucleation and hyposegmentation, MPO and CD71 showed marked hypoplasia of both myeloid and erythroid series.
  • 2021-12-21 SONO - abdomen
    • Two gallbladder polyp or sludge (2.2 mm).
      
    • A renal cyst measuring 1 cm in left lower pole is noted.
  • 2021-09-28 MRI - larynx
    • Small residual bil. supraclavicular LNs, seems stationary.
    • Markedly regression in other neck LNs found, stationary.
  • 2021-07-06 SONO - abdomen
    • Two gallbladder polyp or sludge (< 2 mm).
      
    • A renal cyst measuring 0.89 cm in left lower pole is noted.
  • 2021-03-23 MRI - larynx
    • Small residual bil. supraclavicular LNs, stationary.
    • Markedly regression in other neck LNs found, stationary.
  • 2020-12-29 SONO - abdomen
    • A gallbladder polyp 2.5 mm.
      
    • A renal cyst measuring 0.93 cm in left lower pole is noted.
  • 2020-10-06 MRI - larynx
    • Small residual bil. supraclavicular LNs.
    • Markedly regression in other neck found.
    • Chronic bil. paranasal sinusitis.
  • 2020-05-11 MRI - brain
    • Subacute ICH at left anterior frontal base. No evidence of brain metastasis.
  • 2020-05-06 CT -brain
    • localized SAH in the bilateral inferior frontal regions.
  • 2020-04-16 Patho - bone marrow biopsy
    • Bone marrow, biopsy - Compatible with B-cell lymphocytosis
    • B-cell proliferation in focal area, arranged in interstitial pattern, which immunohistochemistry shows CD3 and CD5: similar pattern, CD23: almost (-), CD20(+), Cyclin-D1(-), MPO(+) for myeloid series, CD71(+) for erythroid series, CD61(+) for megakaryocytes and CD117(+) for blast.. According to all above histopathologic findings, it is compatible with B-cell lymphocytosis due to lack aberrant expression.
  • 2020-04-08 Whole body PET scan
    • Glucose hypermetabolism in bilateral axillary lymph nodes, supraclavicular lymph nodes, and cervical lymph nodes, suggesting lymphoma with tumor recurrence in multiple lymph node regions.
      
    • Glucose hypermetabolism in the spleen and bilateral inguinal lymph nodes, the nature is to be determined. Please correlate with clinical findings and keep follow up to exclude the possibility of tumor recurrence in these regions.
    • B-cell lymphoma s/p treatment with tumor recurrence, rc-stage II, at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2020-03-27 Patho - lymphnode biopsy
    • Lymph node, right neck, excision - Small lymphocytic lymphoma
      
    • IHC: CD20(+), CD23(+, focal), CD3(-), CD5(+, focal), Bcl-2(+).
    • According to above histopathologic findings and past history, it is consistent with small lymphocytic lymphoma.
      
    • Reference: S2014-05750 Lymph node, neck, excisional biopsy - Chronic lymphocytic leukaemia / small lymphocytic lymphoma
  • 2020-03-19 MRI - larynx
    • lymphoma with extensive neck lymphadenopathy.
• consultation
  • 2022-07-13 ENT
    • Q
      • For chronic rhinosinusitis
      • This 64-year-old female has the medical history of congestive heart failure, and chronic lymphocytic leukemia, small lymphocytic lymphoma (CLL/SLL) diagnosed in 2014/04.
      • She was admitted for progressively enlarging bilateral axillary lymph node. She was orginally under Venetoclax treatment. However, the treatment was paused recently due to low WBC count.
      • Her current conditions are stable. However, she complained of headache (forehead headache), facial apin and facial fullness in these days. We have arranged nasopharynx MRI for her. Yet, no obvious discharge or foreign body was seen over bilateral maxillary sinuses. We need your help for further survey for chronic sinusitis! Thank you!
    • A
      • S
        • Facial pain, oral ulcer VAS 2~3 for 10+ days.
        • Previous epistaxis (+)
        • Hx of CLL/SLL
      • PE:
        • Nose: ulceration at L nasal septum
        • Scope: Ulceration at L buccal, L retromolar trigone and L soft palate, blood clot with whitish lesion on bil nasal septum and middle turbinate
      • Imp:
        • 1. Impending destruction of nasal septum, suspect CLL/SLL related
        • 2. Suspect fungal infection of nasal cavity, or previous epistaxis related
        • 3. Stomatitis, related to previous chemotherapy
      • Plan:
        • 1. ENT OPD f/u nasal condition for further local tx
        • 2. L nasal septal ulcerative tissue sent for pathology
        • 3. Oralog for oral ulcer
  • 2022-06-23 Cardiology
    • Q
      • This is a 64-year-old female with history of chronic lymphocytic leukemia, small lymphocytic lymphoma (CLL/SLL) diagnosed in 2014/04, Ann Arbor stage IV (BM involved), s/p R-CHOP x 2 (ceased in 2014-06, due to rapid progression), Bendamustin/Rituximab (BR) x 7 (finished in 2014-12, with CR).
      • Recurrent CLL/SLL at bil. axillary LNs, supraclavicular LNs, and cervical LNs was found, s/p BR Q3W x 5 (finished in Aug 2020-08).
      • Third time recurrent CLL/SLL confirmed in 2022/03 involving multiple lymph node regions at diaphragm stage III, with right neck lymph nodes biopsy confirmed SLL.
      • Thus, she underwent another session of chemotherapy with BR since 2022/03/21, C2 on 2022/04/25, C3 on 2022/06/01. After last cycle, the patient was noted to be pancytopenic with 11K of PLT, Hb 7.3, WBC 530 on the first revisit of hematology OPD. Blood transfusion with LRP 2U + LPRBC 1U were given and GCSF x 5 days was administered. The patient was then sent home with relatively stable condition. The patient also suffered from hemorrhoid, and went to LMD with medication use currently.
      • This time, the patient came to Dr. Wan’s OPD for help on 2022-06-22 with complaint of rapid progression of bilateral axillary lymph node swelling with heat and mild pain for 10 days. Mild dyspnea was also noted. The patient was thus referred to ER for emergent care. At ER, vital signs showed BT 37.6, BP 109/63mmHg; HR:134BPM; RR:20, with 94% spO2 under room air. Lab study found pancytopenia with Hb 5.9, PLT 6K WBC 6.86K with ANC 274. Emergent blood transfusion with LPRBC 4U + LRP 1U was given with dexamethasone and GCSF ST. The patient was then admitted to our ward for further evaluation and management.
      • After admission, neutropenic fever was noted. Abx of tapimycin was given. Due to CLL, rituximab, endoxan and prednisolon was given. High fever was noted in this morning with HR up to 150bpm. Bedside EKG showed sinus tachycardia without ST-T change. Troponin I was 1192.9 pg/ml. She only complained about mild dyspnea with fever and chillness. There was no typical chest pain. Follow-up EKG and troponin still showed sinus tachy with troponin upto 1495.9 pg/ml. We need your expertise for further evaluation and managment. Thanks!
      • Dx: CLL, neutropenic fever, UTI
      • For elevated troponin I from 1192.9 -> 1495.9
    • Q
      • S
        • This 64 y/o female patient is a case of CLL s/p C/T with pancytopenia. She was admitted for further treatment. PRBC 4U and PLT 3U were administered in the past 1 day. She complained of marked dyspnea today. Othropnea was also noticed. Elevated cardiac markers were detcted. Now we are consulted.
      • O
        • BP:119/76 mHg; HR:124
        • Consciousness: clear and acute ill looking
        • Chest: bilateral basal rales heard
        • Heart: RHB with tachycardia, grade 1~2/6 SM at LLSB
        • 20220623 EKG: sinus tachycardia with HR 135 BPM, nonspecific T wave abnormality
        • 20220622 sugar: 115, Cr: 0.51, AST/ALT: 26/42, CRP: 18.44, NTproBNP: 4105, hsTroponi-I: 1192 -> 1495
        • Hb:5.9 -> 8.4 -> 9.9
      • Impression:
        • 1. CLL s/p C/T with pancytopenia
        • 2. Acute pulmonary edema, suspected myocardial failure or fluid overload due to blood transfusion and large IV fluid administeration, or combination of these factors
        • 3. Suspected chemotherapy related cardiac toxicity with myocardial failure
      • Suggestion:
        • 1. Acute pulmaonry edema is prefered according to the physical examination. Please give IV lasix 1amp stat and 1amp Q12H. Arrange CXR stat.
        • 2. The patient has no past histyory of HTN, DM or smoking. She also denied past history of effort related angina. Acute MI with elevated cardiac markers is not likely. The elvated hsTroponin-I was possible due to demand ischemia (because of severe anemia), or myocardial failure due to chemotherapy. Please arrange echocardiography to evaluate LV function.
  • 2022-06-23 Family Medicine
    • Q
      • Due to progressed CLL, DNR was agreed by patient and family. We need your expertise for share care. Thanks!
    • A
      • 64 y/o lady CLL
      • DNR +
        
      • Our share care would follow up.
      • Thanks for consultation.
  • 2022-03-03 General and Gastrointestinal Surgery
    • Q
      • This time, she has nasal and gums ulcer with swelling at first and then multiple LNs enlarged over bilateral neck, supraclavicle and axillary in Chinese New Year and fatigue in recently days. She denied night sweat or BW loss. Due to leukocytosis and higher LDH, so she was admitted for management.
      • Due to swollen lymph nodes at right neck, so we need your help for lymphadenectomy and biopsy, thanks a lot!!
    • A
      • S: R’t neck lymph node excision is consulted.
      • O: vital signs: stable, no fever
        • PE: multiple enlarged lymph nodes over bilateral lateral neck
        • lab data: see chart
      • A: Chronic lymphocytic leukaemia / small lymphocytic lymphoma, suspect recurrence
      • P: I will right neck LN biopsy on 3/8
  • 2020-12-12 Neurology
    • Q
      • Patient’s mouth twisted to the right
    • A
      • O
        • NE E4V5M6
          
        • CNs: left peripheral facial palsy
        • MP: full
        • sensation: intact
        • FNF: no dysmetria
        • gait: steady
        • brain CT: no ICH
      • impression: left bell palsy
      • plan:
        • give prednisolone 1mg/kg QD, famotidine 1# QD for 4 days (till W2 OPD)
        • give kentamin 1# BID, and duratea ointment
        • neurology OPD follow-up on W2
  • 2020-05-08 ENT
    • Q
      • for severe dizziness & sudden onest of syncope on 5/6 night & 5/7 night about 10-20 sec
      • This 61-year-old female, a patinet of small B cell lymphoma S/P C/T. She was admitted for C/T with BR on 5/5-5/6 20. Sudden onest of vomiting & dizziness was developed on 5/6 20 afternoon at 18:15 pm. The brain CT (5/6 20) showed localized SAH in the bilateral inferior frontal regions. We need expertise to evaluate her condition thanks!
    • A
      • S: vertigo when postion change
      • O: dix-hallpike: left rotational nystagmus
      • A: suspected left BPPV
      • P:
        • left Epley (done)
        • symtpomatic treatment
        • ENT OPD f/u
        • please survey other cause of syncope
  • 2020-05-07 Neurosurgery
    • Q
      • For localized SAH in the bilateral inferior frontal regions evaluation
      • This 61-year-old female, a patinet of small B cell lymphoma S/P C/T. She was admitted for C/T with BR on 5/5-5/6 20. Sudden onest of vomiting & dizziness was developed on 5/6 20 afternoon at 18:15 pm. The brain CT (5/6 20) showed localized SAH in the bilateral inferior frontal regions.We need expertise to evaluate her condition. thanks!
    • A
      • S/O
        • 61 y/o female
        • Head trauma owing to an accidental fall last night. No loss of consciousness.
        • c/o headache and dizziness.
        • Consciousness clear.
        • Head CT scan: minimal anterior interhemispheric SAH.
      • A/P
        • Rx:
        • No neurosurgery is indicated.
        • Neuro monitoring and treatment for about 3 days.
        • Symptomatic treatment.
• surgical operation
  • 2022-03-08 Excision of r’t neck tumor
  • 2020-03-27 Excisional biopsy, right neck enlarged LAP
• chemoimmunotherapy
  • unknown - venetoclax
  • 2022-06-23 rituximab 375 mg/m2 10hr
  • 2022-06-02 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
  • 2022-04-25 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
  • 2022-03-21 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
  • 2022-03-18 ~ 2022-03-23 - hydroxyurea 500 mg BID
  • 2022-03-11 ~ 2022-03-18 - cyclophosphamide 50 mg BID
  • 2020-08-03 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
  • 2020-07-07 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
  • 2020-06-16 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
  • 2020-05-26 rituximab 375 mg/m2 10hr D1 + bendamustine 70 mg/m2 90 min D1-2
  • 2020-05-05 rituximab 375 mg/m2 10hr D1 + bendamustine 70 mg/m2 90 min D1-2
  • 2014-07 ~ -12 - rituximab + bendamustin (CR)
  • 2014-05 ~ -06 - R-CHOP, ceased due to rapid progression

[assessment]

• According to UpToDate, cardiovascular adverse reactions of rituximab are Cardiac disorder (5% to 29%), flushing (5% to 14%), hypertension (6% to 12%), peripheral edema (8% to 16%), and a cardiovascular adverse reaction of bendamustine is Peripheral edema (13%).
• It is recommended to have cardiac ultrasound routinely when the patient is undergoing treatment since she has a history of heart failure, abnormal ECG, and edema. The most recent 2D transthoracic echocardiography was done on 2022-06-27.

220721

[assessment]

• Tapimycin (piperacillin + tazobactam) is adequate for ground glass opacities in bil. lungs (2022-07-20 CXR). No dose adjustment is needed based on 2022-07-21 lab data.

220322

[assessment]

• For this patient with recurrent SLL, the r’t neck tumor was excised on 2022-03-08.
• The patient is receiving bendamustine and rituximab, the same regimen used from May to August of 2020.
• There were no detectable mutations in any of the following genes: BCR-abl (2022-03-22), FLT3-D835, FLT3/ITD, and NPM1 (2022-03-16).
• There is no del(17p), TP53 mutation status, CpG-stimulated karyotype or IGHV mutation status found in lab data.

700077356

220720

{left pyriform sinus cancer, cT2N2bMx, stage IVA, brain mets}

• exam finding
  • 2022-07-13 Electroencephalography, EEG
    • Findings
      • 1. the posterior background activities are at 10 Hz, symmetric and responsive to eye opening
      • 2. photic stimulation showed symmetric photo-driving response
      • 3. hyperventilation study was not done
    • EEG classification: normal
    • Interpretation: normal
  • 2022-07-12 Pure-tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 29 dB HL; LE 29 dB HL.
    • R’t normal to moderate SNHL.
    • L’t normal to moderately severe SNHL.
  • 2022-06-23 Patho - larynx biopsy
    • Left pyriform sinus medial wall, LMS for tumor mapping — Moderately differentiated squamous cell carcinoma
    • IHC stain — p16(-)
  • 2022-06-23 Whole body PET scan
    • 1. Glucose hypermetabolism in the left pyriform sinus, compatible with primary hypopharyngeal malignancy. Please correlate with other clinical findings for further evaluation.
    • 2. Glucose hypermetabolism in multiple left neck level IV and Vb lymph nodes, suggesting multiple ipsilateral lymph node metastases.
    • 3. Increased FDG accumulation/uptake in bilateral masseter muslces, both kidneys, bilateral ureters and colon. Physiological FDG accumulaion/uptake is more likely.
  • 2022-06-22 Frozen section
    • initial diagnosis: Pyriform sinus, left, frozen section — squamous cell carcinoma
  • 2022-06-22 SONO - abdomen
    • Diagnosis
      • Cirrhosis of liver with splenomegaly
      • Liver cyst
      • Portal hypertension
      • Chronic calcified pancreatitis with pancreatic duct dilatation
      • Subpleural consolidation of LLL with minimal pleural effusion
    • Suggestion
      • OPD follow-up
  • 2022-06-22 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Hypopharyneal tumor
      • Suspected Barett’s esophagus, C3M5
      • Reflux esophagitis LA grade A
      • Cervical inlet patches
      • Superficial gastritis
      • Suspected cascade stomach
    • Suggestion
      • Biopsy was NOT done due to anticoagulation.
  • 2022-06-16 Nasopharyngoscopy
    • Findings
      • bi nasal cavity and middle meatus clear; smooth nasopharynx; normal vocal function: granular tumor at left
      • pyriform sinus and left AE fold and left arytenoid
    • Summary:
      • left pyriform sinus and left supraglottis tumor, favor malignancy
  • 2022-05-30 MRI - nasopharynx
    • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage): T2N2bMx, stage IVA
  • 2021-03-11 MRI - nasopharynx
    • He had buccal cancer of left side 2013-10. abnormal mass-like fibrotic soft tissue overgrowth with ugly surface is noted at the left buccal mucosa.
    • IMP:
      • 1. focal mucosal thickening in the left upper and posterior buccogingival mucosa. Nature?
      • 2. prominent right oropharyngeal tonsil. Nature?
  • 2019-03-01 MRI - nasopharynx
    • Indication:
      • S: He is an oral cancer patient and received operations. He has poor liver function and lower bleeding control at this moment (waiting for liver transplantation).
      • O: Fungus infection at the left buccal mucosa is noted. leukoplakia on the left tongue border near #36 with mild ulceration is noted. surgical defect at the left buccal mucosa and tuberosity with fibrotic soft tissue overgrowth with ugly surface are present
      • A:
        • 1. SCC of left buccal mucosa (pT1N0M0) s∕p OP (2013-10)
        • 2. Trismus and fungus infection
      • P:
        • 1. BUN: normal
        • 2. arrange MRI with contrast to evaluate undermining tumor status
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • 1. Post operation change at left buccal region with abscence of subamandibular gland. No focal mass or nodule.
      • 2. Post left neck lymph nodes dissection .
      • 3. No evident abnormal enlarged lymph node in the visible neck.
      • 4. No abnormal enhancement in the tongue.
      • 5. A right maxillary retension cyst up to 1.7cm.
      • 6. No abnormal signal intensity of the mandible.
    • IMP:
      • post op change at left buccal region.
      • no recurrent tumor.
• consultation
  • 2022-07-12 Neurology
    • Q
      • This 46-year-old man patient is a case of Left piryform sinus cancer, cT2N2bM0, stage IVA. He was admited for prepare chemotherapy. Alcoholic cirrhosis of liver without ascites, child A with Encephalopathy on 2022/07/11 after admitted. He was to Taipei Mackay Hospital with brain CT on 2022/07/11 showed no brain metastasis.
      • Now, for evaluate Alcoholic cirrhosis of liver without ascites, child A with Encephalopathy examination and therapy. Thank you.
    • A
      • O
        • seizure as hypnopompic twitching of limbs
        • similar attack as alcohol withdrawal seizure before
        • NE: aware, fluent speech, normal cranial nerves, no obvious focal weakness
      • Impression:
        • 1. sleep related seizure or sleep related movement disorders
      • Suggest:
        • 1. EEG might be arranged
        • 2. Rivotril might be added as (0.5mg) 1-2# HS
        • 3. I would like to follow up this patient.
  • 2022-06-24 Oral and Maxillofacial Surgery
    • Q
      • This 46-year-old man has history of type 2 diabetes mellitus with medication control and alcoholic cirrhosis of liver without ascites, child A wait for liver transplantation. He had personal history of smoking, betel nut chewing and drink wine for over 15 years, quitted betel nut and drink 8 years ago. He had left buccal cancer, pT1N0M0, stage I, status post operation on 2013/10/07 at our hospital by OS Dr.Xia. He regular follow at Dr.Xia OPD.
      • This time, left pyriform sinus cancer, cT2N2bMx, stage IVA was diagnosed, induction chemotherapy was indicated. We request your consultation for dental evaluation.
    • A
      • Currently, no emergency treatment or prophylactic dental extraction is needed. Please arrange routine dental follow up after patient’s finished the cancer treatment .
  • 2022-06-23 Hemato-Oncology
    • Q
      • For induction chemotherapy for left pyriform sinus cancer, cT2N2bMx, stage IVA evaluation (Hx: DM, liver cirrhosis, child A)
      • Neck MRI followed on 2022/05/30 which revealed left pyriform sinus cancer, cT2N2bMx, stage IVA. He then was transferred to our ENT OPD. At OPD, scope showed granular tumor at left pyriform sinus and left AE fold. Several enlarged LN at left neck level IV and Vb, the largest one around 3cm at left Vb. Admission for laryngomicrosurgery biopsy and further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of left pyriform sinus cancer, the patient was admitted.
    • A
      • Impression:
        • 1. left pyriform sinus cancer, SCC, cT2N2bMx, stage IVA
        • 2. Diabetes mellitus
        • 3. Liver cirrhosis, child A
      • Suggestion:
        • 1. Induction chemotherapy is indicated. Thanks for your consultation. We will see the patient and discuss with patient.
        • 2. Please check anti Hbc
        • 3. Arrange port A insertion
• surgical operation
  • 2022-06-22
    • Surgery
      • Laryngomicrosurgery with esophagoscopy for tumor mapping
    • Finding
      • 1. Left pyriform sinus medial wall tumor
      • 2. Smooth mucosal over posterior pharyngeal wall, postcricoid region, and cervical esophagus
  • 2013-10-07
    • Surgery
      • 1. Wide excision of left buccal malignant lesion
      • 2. Extraction of teeth of #27,#28,#37 and #38
      • 3. Supraomohyoid neck dissection, left
      • 4. Skin graft at the left buccal mucosa (donnor side is left thigh)
      • 5. OBTURATOR BY USE OF Buccal stent fixation
    • Finding
      • 1. Unhealed ulcerative lesion at the left buccal mucsoa about 1.5 cm in diameter.
      • 2. the tooth attrition by #27 is noted.
      • 3. malposition of #27,#28,#37 and #38
• chemoimmunotherapy
  • 2022-07-20 - docetaxel 30mg/m2 1hr + cisplatin 30mg/m2 24hr + 5-Fu 1600mg/m2 48hr
  • 2022-07-14 - docetaxel 30mg/m2 1hr + cisplatin 30mg/m2 24hr + 5-Fu 1600mg/m2 48hr

[assessment]

• There are three oral hypoglycemic drugs - Forxiga (dapagliflozin 10mg), Amamet (glimepiride 2mg + metformin 500mg), Lodiglit (pioglitazone 15mg + metformin 850mg), as well as a long-acting insulin - Tujeo - used as the basal dose.
• F/S records and administered insulin units
  • Date QDAC basal QLAC basal
  • Unit mg/dL unit mg/dL unit
  • 2022-07-20 NA 16 - -
  • 2022-07-19 231 16 - -
  • 2022-07-18 254 16 - -
  • 2022-07-17 241 16 - -
  • 2022-07-16 193 16 - -
  • 2022-07-15 164 16 - -
  • 2022-07-14 189 16 - -
  • 2022-07-13 154 16 - -
  • 2022-07-12 237 - 176 16
• According to the patient, 2022-07-19, he was well-tolerated with last chemotherapy that had been started on 2022-07-14, with the exception of somewhat oral mucosal pain just developed. He also had good appetite during those post-therapy days, so he consumed more than usual and the serum glucose levels increased since 2022-07-17.
• The basal dose might be increased by 1 units if the glucose level still keeps above 200 mg/dL and his intake remains unchanged. In the event of hypoglycemia caused by a sulfonylurea - glimepiride, adjustment by only one unit should a precautionary measure.
• Newly developed oral candidiasis is treated with oral suspension Mycostatin (nystatin).
• The patient has alcoholic cirrhosis history with normal AST/ALT, bilirubin (total and direct) levels (2022-07-20), the doses of the chemotherapy regimen were adequate.

220712

[assessment]

• The self-carried items Cardiolol (propranolol) and warfarin should be indicated for cardiovascular conditions, the current panel does not provide a cardiovascular diagnosis or condition yet.
• Hx: type 2 DM. 2022-07-12 06:05 blood sugar level was 237 mg/dL. 2022-06-21 lab serum glucose AC 299 mg/dL.
  • Toujeo (insulin glargine) was prescribed by another hospital or clinic for this patient and could be considered to include it as a self-carried drug item for in-hospital use.
  • There are three oral hypoglycemic agents - Forxiga (dapagliflozin (SGLT2i) 10mg), Amamet (glimepiride (Sulfonylureas) 2mg + metformin 500mg), Lodiglit (pioglitazone (thiazolidinedione, TZD) 15mg + metformin 850mg) in active prescription.
    • If liver dysfunction becomes significant, please check for lactic acidosis. Liver disease is considered a risk factor for the development of lactic acidosis during metformin therapy.
    • Lodiglit contains pioglitazone. Pioglitazone should be use with caution if baseline liver tests are abnormal. If liver injury is suspected (eg, fatigue, jaundice, dark urine), please interrupt therapy, measure serum liver tests, and investigate possible etiologies.
  • HbA1c might be checked.
• Consideration of dose adjustment for patients with impaired liver function, possible regimen might be: gemcitabine/cisplatin, docetaxel/cisplatin/5-FU
  • 5-Fu. The following adjustments have been suggested:
    • Bilirubin >5 mg/dL: Avoid use (Floyd 2006).
    • Hepatic impairment (degree not specified): Administer <50% of dose, then increase if toxicity does not occur (Koren 1992).
  • Docetaxel
    • Hepatic impairment dosing adjustment specific for gastric or head and neck cancer:
      • AST/ALT >2.5 to <=5 times ULN and alkaline phosphatase <=2.5 times ULN: Administer 80% of dose.
      • AST/ALT >1.5 to <=5 times ULN and alkaline phosphatase >2.5 to <=5 times ULN: Administer 80% of dose.
      • AST/ALT >5 times ULN and /or alkaline phosphatase >5 times ULN: Discontinue docetaxel.
    • The following adjustments have also been used (Floyd 2006):
      • Transaminases 1.6 to 6 times ULN: Administer 75% of dose.
      • Transaminases >6 times ULN: Use clinical judgment.
  • Cisplatin
    • It undergoes nonenzymatic metabolism and predominantly renal elimination. Dosage adjustment is likely not necessary.
  • Gemcitabine
    • Serum bilirubin >1.6 mg/dL: Use initial dose of 800 mg/m2; may escalate if tolerated.

701003664

220720

{cervical cancer, adenocarcinoma, cT1bN1MB, FIGO stage IIIB}

• exam finding
  • 2022-07-14 KUB
    • S/P double J catheter insertion, left side urinary tract.
    • S/P clips projecting at right pelvis.
    • Ascites is noted. Please correlate with CT.
    • Segmental dilatation of bowel in the middle abdomen is noted. Please correlate with CT.
  • 2022-06-23 ECG
    • Sinus tachycardia
    • ST & T wave abnormality, consider inferior ischemia
    • ST & T wave abnormality, consider anterior ischemia
    • Abnormal ECG
  • 2022-06-23 KUB
    • S/P left side double J catheter insertion.
    • S/P operation with retention of surgical clips.
    • Presence of ileus.
  • 2022-06-10 2D transthoracic echocardiography
    • Adequate LV,RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild PR
  • 2022-06-03 CT - brain
    • No evidence of intracranial hemorrhage.
  • 2022-06-03 ECG
    • Normal sinus rhythm
    • ST & T wave abnormality, consider anterior ischemia
    • Prolonged QT
    • Abnormal ECG
  • 2022-05-18 ECG
    • Normal sinus rhythm
    • Nonspecific ST and T wave abnormality
  • 2022-05-17 SONO - abdomen
    • Diagnosis
      • 1. left abdominal wall mass, suspected tumor recurrence
      • 2. intestinal obstruction, DDx: carcinomatosis or adhesion
      • 3. right inguinal LAPs
    • Suggestion
      • refer to GYN
  • 2018-09-26 Gynecologic ultrasonography
    • suspected Rt corpus luteum cyst
  • 2018-09-23 CT - abdomen
    • Right hydronephrosis and hydroureter
    • Right distal ureter lesion; DDx: tumor invasion, post-RT change
    • Heterogeneous enhancing lesions in both lobes of liver. Suggest dynamic CT or sonography correlation.
  • 2018-04-04 Surgical pathology level V
    • clinical diagnosis
      • Mucous polyp of cervix; Subacute and chronic vaginitis;
    • pathological diagnosis
      • Uterus, cervic, LEEP conization
        • — Well to moderately differentiated adenocarcinoma
        • — carcinoma in situ
        • — margin inadequate (< or = 1mm of closest margin diatnce).
      • IHC satin — p16(+), CEA(focal+), vimentin (-)
    • microscopic description
      • It shows adenocarcinoma composed of prolieration of neoplastic glands lined by atypical cells and infiltrative growth pattern. The tumor shows hyperchromatic nuclei, plemorphism and promine tnucleoli. It also shows carcinoma in sit characterized by atypical cells replacing the fuul-thickness of the cervical epithelium with glandular involvement. The margin is inadequate (< or = 1mm of closest margin diatnce).
  • 2018-04-04 Surgical pathology level IV
    • clinical diagnosis
      • Mucous polyp of cervix; Subacute and chronic vaginitis;
    • pathological diagnosis
      • Uterus, endocervix, ECC — Mild glandular dysplasia
    • microscopic description
      • It shows endocervical mucosal tissue fragments with focal mild glandular dysplasia.
  • 2018-02-27 MRI - pelvis
    • Imaging Report Form for Cervical Carcinoma
    • 1. Soft tissue tumor in right cervical region (fornix), suspected cervical malignancy, cstage T1N0Mx.
    • 2. Prominent density in the uterine cavity, suggest further study.
    • 3. Uterine myoma.
  • 2018-02-14 Surgical pathology level IV
    • Screening for malignant neoplasms of cervix; Mucous polyp of cervix;
    • Diagnosis
      • Uterus, cervix, clinically R/O cervical cancer — Adenocarcinoma in situ (AIS), at least.
      • NOTE: Since invasive malignancy is suspected clinically, further work up is advised.
    • Microscopic description
      • Section shows pieces of adenocarcinoma in situ (AIS), at least, with papillary structures lined by epithelium demonatrsting elongated nuclei, occasional nuclear pleomorphism, and many mitoses. Occasional cribriform pattern glands are found.
• consultation
  • 2022-06-27 Chinese Medicine
    • Q
      • This 42-year-old woman patient is a case of Cervical cancer, adenocarcinoma, cT1bN1MB, FIGO stage IIIB,
        • s/p Robotic radical trachelectomy + pelvic lymphadectomy on 2018/04/23 at Far Eastern Memorial Hospital with pelvic recurrence and compression to lower part of right ureter and right ovary s/p Robotic pelvic adhesiolysis, pelvic mass biopsy, right salpingo-oophorectomy and left ovary suspension on 2018/11 at Far Eastern Memorial Hospital
        • s/p salvage CCRT with 6 cycles of chemotherapy with Cisplatin 40mg/m2 & pelvic radiotherapy (6000cGy/30fx) (2018/12~2019/02) at Far Eastern Memorial Hospital s/p radial trachelectomy and left ovarian transposition on 2019/05/31 at Far Eastern Memorial Hospital with left upper abdominal wall port site metastases,
        • s/p excision of abdomnal wall tumor on 2020/7/09, 2020/11/24, 2021/03/16 s/p systemic chemotherapy with 6 cycles of Cisplatin 50mg/m2 + Paclitaxel 175 mg/m2 + Bevacizumab 15mg/kg at Far Eastern Memorial Hospital (2021/03~?)
        • s/p left abdominal radiotherapy for the port-site metastatses x 10 times at Koo Foundation Sun Yat-Sen Cancer Center (2022/02~).
      • This time, ileus with nauseas with vomiting admitted for further treatment. Now, for evaluate Comprehensive protocol of integrated Chinese and western medicine (ICWM). Thank you.
    • A
      • past history
        • 2018/07/27 Uterine myoma
      • 2022-04 CT at KFSYSCC
        • Clinical History and Indications Metastatic Cervical adenocarcinoma:
          • 1. Larger of the lower abdominal wall lesion. R/I metastasis; and peritoneal / bowel wall invasion suspected. Right inguinal lymph node (8.6 mm), larger.
          • 2. Dilatation of small bowel, which may related to adhesion or peritoneal carcinomatosis.
      • 2022-06-27 lab data
        • S-GPT/ALT = 249 U/L;
        • S-GOT/AST = 112 U/L;
        • Albumin = 2.8 g/dL;
        • BUN = 20 mg/dL;
        • Bilirubin direct = 0.25 mg/dL;
        • eGFR = 90.07;
          
        • WBC = 1.52 *10^3/uL;
        • RBC = 3.68 *10^6/uL;
        • HGB = 10.0 g/dL;
        • PLT = 50 *10^3/uL;
          
        • Neutrophil = 65.0 %;
      • Plan
        • By using acupuncture to improve the symptom of intestinal obstruction
  • 2022-05-22 Hemato-Oncology
    • Q
      • This 42-year-old woman,G0P0, sex(+), with medical/surgical history of
        • 1. Cervical cancer, adenocarcinoma, cT1bN1MB, FIGO stage IIIB, - s/p Robotic radical trachelectomy + pelvic lymphadectomy on 2018/04/23 at FEMH
          • with pelvic recurrence and compression to lower part of right ureter and right ovary, s/p Robotic pelvic adhesiolysis, pelvic mass biopsy, right salpingo-oophorectomy and left ovary suspension on 2018/11 at FEMH
          • s/p salvage CCRT with 6 cycles of chemotherapy with Cisplatin 40mg/m2 & pelvic radiotherapy (6000cGy/30fx) (2018/12~2019/02) at FEMH
          • s/p radial trachelectomy and left ovarian transposition on 2019/05/31 at FEMH
          • with left upper abdominal wall port site metastases, s/p excision of abdomnal wall tumor on 2020/7/09, 2020/11/24, 2021/03/16
          • s/p systemic chemotherapy with 6 cycles of Cisplatin 50mg/m2 +Paclitaxel 175 mg/m2 + Bevacizumab 15mg/kg at FEMH (2021/03~?)
          • s/p left abdominal radiotherapy for the port-site metastatses x 10 times at KFSYSCC (2022/02~)
            
        • 2. Bilateral lower ureteral stricture with bilateral hydronephrosis,
          • s/p bilateral DBJ insertion since 2018/04
          • s/p left ureterolysis + right ureteroneocystostomy with psoas hitch and Boari flap on 2019/05/31
      • This time, abdominal discomfort (intermittent cramping pain) and body weight loss (8kg) were noted since 2022/03/26.
        • Abdominal CT scan showed
          • 1. Larger of the lower abdominal wall lesion. R/I metastasis; and peritoneal / bowel wall invasion suspected;
          • 2. Dilatation of small bowel, which may related to adhesion or peritoneal carcinomatosis.
        • Blood drawn on 2022/04/25 showed CA153 17.2, CA199 655.1 and CA125 137.3.
        • She visited to our GI hospital on 2022/05/17 where sonography showed
          • 1. Left abdominal wall mass, suspected tumor recurrence
          • 2.Intestinal obstruction, DDx: carcinomatosis or adhesion
          • 3.Right inguinal LAPs.
      • Under the impression of cervical adenocarcinoma suspected metastasis and recurrence, she was then referred to Prof. Huang and admission to our ward for further evaluation and management, we need your expertise for further evaluation and management.
        • s/p salvage CCRT with 6 cycles of chemotherapy with Cisplatin 40mg/m2 & pelvic radiotherapy (6000cGy/30fx) (2018/12~2019/02) at FEMH
        • s/p systemic chemotherapy with 6 cycles of Cisplatin 50mg/m2 +Paclitaxel 175 mg/m2 + Bevacizumab 15mg/kg at FEMH (2021/03~?)
    • A
      • Suggestion:
        • 1. For recurrent or metastasis cervical cancer, systemic chemotherapy is indicated. We will discuss with patient about further systemic chemotherapy.
        • 2. Thanks for your consultation. If there is any problem, please feel free to let us known.
• surgical operation
  • 2020-07-09, 2020-11-24, 2021-03-16
    • with left upper abdominal wall port site metastases, s/p excision of abdomnal wall tumor
  • 2019-05-31 at FEMH
    • radial trachelectomy and left ovarian transposition
    • left ureterolysis + right ureteroneocystostomy with psoas hitch and Boari flap
  • 2018-11-?? at FEMH
    • Robotic pelvic adhesiolysis, pelvic mass biopsy, right salpingo-oophorectomy and left ovary suspension
  • 2018-09-23
    • Diagnosis
      • Right hydronephrosis
    • PCS code
      • 28020C
    • Finding
      • Right lower ureter stricture 4cm proximal to ureteral orifice
      • External compression was clinically suspected
      • 6Fr 24cm DBJ was inserted
  • 2018-04-23 at FEMH
    • Robotic radical trachelectomy + pelvic lymphadectomy
  • 2018-04-04
    • Diagnosis
      • Mucous polyp of cervix
    • PCS code
      • 81031C
    • Finding
      • 1. Cervix:papillary lesion oner right external OS
      • 2. Three strips211, 111,0.5*0.5 cm strip of cervix were electrocauterized.
      • 3. Estimated blood loss:50ml
      • 4. Complication: nil
• radiotherapy
  • 2022-02 ~ ? at KFSYSCC
    • left abdominal radiotherapy for the port-site metastatses x 10 times
  • 2018-12 ~ 2019-02 at FEMH
    • salvage CCRT with 6 cycles of chemotherapy with Cisplatin 40mg/m2 & pelvic radiotherapy (6000cGy/30fx)
• chemoimmunotherapy
  • 2022-06-13, 2022-07-04 - topotecan 0.75mg/m2 30min D1-3 + cisplatin 25mg/m2 24hr D1-2
  • 2021-03 ~ ? at FEMH - 6 cycles of cisplatin 50mg/m2 + paclitaxel 175 mg/m2 + bevacizumab 15mg/kg
  • 2018-12 ~ 2019-02 at FEMH - 6 cycles of chemotherapy with cisplatin 40mg/m2 for CCRT
• chemotherapy regimen reference
  • Efficacy and Safety Evaluation of the Various Therapeutic Options in Locally Advanced Cervix Cancer: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials
    • https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0-S0360301618338185.pdf
  • Comparison of the efficacy among multiple chemotherapeutic interventions combined with radiation therapy for patients with cervix cancer after surgery: A network meta-analysis
    • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5564785/pdf/oncotarget-08-49515.pdf

[assessment]

• I visited the patient and her mother at approximately 16:45 on 2022-07-19.
• As compared with the experience at FEMH/KFSYSCC, the patient tolerates the current regimen well for less nausa and vomiting.
• The patient is concerned that the treatment will adversely affect her kidney function. According to the recent lab results, I told her that there is no problem with her kidney function.

220719

{BFluid - the amount of electrolyte can be added}

A supplement to my explanation after answering the nurse’s call this morning about the compatibility of B Fluid with KCl.

• Each 1000 mL BFluid solution contains (after mixing)
  • Electrolytes mEq/L, max amount to be added
    • Na+ 35 115
    • K+ 20 40
    • Ca++ 5 5
    • Mg++ 5 16
    • HPO4– 10 10
    • insulin 0 10~20 (IU)
• The addition of other drugs to BFluid is not recommended except for electrolytes and regular insulin.
• Within the limits of the amount, KCl is compatible with B Fluid. It contains 20mEq K+ in the prescribed 0.298% KCl 500mL.

701366805

220720

{High grade serous carcinoma FIGO stage IIIC, right ovarian cancer with peritoneal seeding s/p operation}

• lab data
  • CA125
    • 2022-04-22 401.9 U/mL
      
    • 2022-03-30 1091.2 U/mL
      
  • 2022-04-14
    • Anti-HBs 2.99 mIU/mL
      
    • Anti-HBc Nonreactive
      
    • Anti-HBc-Value 0.14 S/CO
      
    • Anti-HCV Nonreactive
      
    • Anti-HCV Value 0.15 S/CO
      
    • HBsAg Nonreactive
      
    • HBsAg (Value) 0.44 S/CO
      
  • 2022-03-31
    • Anti-HCV Nonreactive
      
    • Anti-HCV Value 0.16 S/CO
      
    • Anti-HBc Nonreactive
      
    • Anti-HBc-Value 0.13 S/CO
      
    • HBsAg Nonreactive
      
    • HBsAg (Value) 0.42 S/CO
• exam finding
  • 2022-05-10 Aspiration Cytology - LN
    • Left parotid tumor: Favor benign, pleomorphic adenoma
      
    • Two wet cellular smears show epithelial cells arranged in cord, nest or trabecular patterns and mononuclear cells in background resemble myoepithelial cells as well as chondromyxoid material in focal area. It maybe compatible with pleomorphic adenoma. Confirmatory biopsy is advised, if clinically indicated.
      
  • 2022-05-10 SONO - head and neck soft tissue
    • clinical impression/intent: right parotid tumor, previous cytology: atypia
    • sonographic impression: right parotid tumor
  • 2022-04-07 Patho - ovary (non-tumor)
    • Diagnosis
      • Ovary, right, oophorectomy — High grade serous carcinoma seeding on serosa
      • Fallopian tube, right, salpingectomy — High grade serous carcinoma seeding on serosa
      • F2022-00146:
        • Omentum, omentectomy — High grade serous carcinoma, metastatic (please see microdescription)
        • Ovary, left?, excision — Consistent with high grade serous carcinoma
    • Microscopic description
      • Sections show ovary and fallopian tube with high grade serous carcinoma seeding on serosa.
      • F2022-00146:
        • Sections show omentum with metastatic solid sheets and papillary tumor and psammoma bodies.
        • The cystic tumor reveals ovarian stroma with psammoma bodies. The lining epithelium is mostly denuded, and only scant tumor lining epithelial is seen.
        • The immunohistochemical stains reveal PAX(+), p53(aberrant expression +), WT-1(+), GATA3(-), Napsin A(-), PR(-), and Calretinin(-). The results are consistent with high grade serous carcinoma arising from ovary. Please correlate with the clinical presentation and image study.
        • Lymphovascular invasion is found. No fallopian tube is seen.
  • 2022-04-06 Body fluid cytology - ascites
    • Pathologic diagnosis: positive for malignancy
    • The smears show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2022-04-06 Frozen Resection
    • Preliminary diagnosis:
      • Pelvic mass, excision — Carcinoma, wait IHC for tumor origin
  • 2022-03-30 Gynecologic ultrasonography
    • Suspected rt adnexal mass: 124mm x 93mm, malignancy cannot be ruled out
    • Ascites (+)
  • 2022-03-25 CT - abdomen, pelvis
    • Findings:
      • There are lobulated enhancing soft tissue lesions in the omentum (omentum cake) and mesentery of the pelvis, and ascites that may be primary peritoneal serous carcinoma.
        • The differential diagnosis include ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB. Please correlate with CA125 and CT-guided biospy of the omentum lesion.
    • Impression:
      • Primary peritoneal serous carcinoma is highly suspected.
      • The differential diagnosis include ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB. Please correlate with CA125 and CT-guided biospy of the omentum lesion.
• consultation
  • 2022-03-31 Hemato-Oncology
    • A
      • Impression:
        • Primary peritoneal serous carcinoma is highly suspected.
        • The differential diagnosis including stomach cancer, ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB.
      • Suggestion:
        • Arrange PES to check UGI tract lesions, GYN ultrasound and CT-guided biospy of the omentum lesion
        • may check LDH, anti Hbc, HbsAg, Anti HCV
        • Thanks for your consultation, we wound like to follow up this case. If there is any problem, please feel free to let us known.
  • 2022-03-31 Obstetrics and Gynecology
    • A
      • Objective
        • The abdomen CT on 03/25 reported: There are lobulated enhancing soft tissue lesions in the omentum (omentum cake) and mesentery of the pelvis, and ascites that may be primary peritoneal serous carcinoma.
        • Lab data: CA125 1091.2 (0~35)
        • Echo: Right ovarian cystic mass 13 cm with solid part was noted, with small amount ascite, suspected ovarian cancer
      • Plan
        • please check CA199, CEA, Albumin, D-Dimer
        • check Esophagogastroduodenoscopy (EGD) and low gastrointestinal endoscopy
• surgical operation
  • 2022-04-06
    • Operation
      • Enterolysis
    • Finding
      • Multiple peritoneal seedings including tumor nodules in small bowel and mesentery
      • Adhesion of small bowel and large bowel
  • 2022-04-06
    • Surgery
      • Pelvic mass, peritoenal carcinomatosis?
      • Perineal cake
      • Operation:
        • RSO and omentectomy
    • Finding
      • Uterus: 4x3cm, grossly normal, with severe adhesion to pelvic wall
      • RAD: grossly normal,adhesion to pelvic wall and the mass
      • LAD: Severe adhesion to the mass
      • CDS: Severe adhesion/partial obliterated
      • During the procedure, omentum attached to the anterior wall of the pelvic cavity, adhesion lysis was performed before we entered the pelvic cavity. (due to perineal cake, severe adhesion was found during the procedure)
      • Residual tumor over colon and pelvic with size 1x1 cm.
      • Estimated blood loss: 1000 ml
      • Blood transfusion: 2 U
      • Complication: nil        
• chemoimmunotherapy
  • 2022-07-19 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr
  • 2022-06-27 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr
  • 2022-06-01 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr
  • 2022-05-04 - paclitaxel 160mg/m2 3hr + carboplatin 600mg 2hr

[note]

Ovarian Cancer Continue Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN Evidence Blocks, Version 1.2022 - January 18, 2022, p42,43

• Principles of Systemic Therapy
  • Primary Systemic Therapy Regimens - Epithelial Ovarian/Fallopian Tube/Primary Peritoneal
    • Primary Therapy for Stage I Disease
      • High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
        • Preferred Regimens
          • Paclitaxel/carboplatin q3weeks
        • Other Recommended Regimens
          • Carboplatin/liposomal doxorubicin
          • Docetaxel/carboplatin
        • Useful in Certain Circumstances
          • For carcinosarcoma:
            • Carboplatin/ifosfamide
            • Cisplatin/ifosfamide
            • Paclitaxel/ifosfamide (category 2B)
      • Mucinous carcinoma (stage IC)
        • Preferred Regimens
          • 5-FU/leucovorin/oxaliplatin
          • Capecitabine/oxaliplatin
          • Paclitaxel/carboplatin q3weeks
        • Other Recommended Regimens
          • Carboplatin/liposomal doxorubicin
          • Docetaxel/carboplatin
        • Useful in Certain Circumstances
          • None
      • Low-grade serous (stage IC)/Grade I endometrioid (stage IC)
        • Preferred Regimens
          • Paclitaxel/carboplatin q3weeks +- maintenance letrozole (category 2B) or other hormonal therapy (category 2B)
          • Hormone therapy (aromatase inhibitors: anastrozole, letrozole, exemestane) (category 2B)
        • Other Recommended Regimens
          • Carboplatin/liposomal doxorubicin
          • Docetaxel/carboplatin
          • Hormone therapy (leuprolide acetate, tamoxifen) (category 2B)
        • Useful in Certain Circumstances
          • None
    • Primary Therapy for Stage II-IV Disease
      • High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
        • Preferred Regimens
          • Paclitaxel/carboplatin q3weeks
          • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
        • Other Recommended Regimens
          • Paclitaxel weekly/carboplatin weekly
          • Docetaxel/carboplatin
          • Carboplatin/liposomal doxorubicin
          • Paclitaxel weekly/carboplatin q3weeks
        • Useful in Certain Circumstances
          • IP/IV paclitaxel/cisplatin (for optimally debulked stage II-III disease)
          • For carcinosarcoma:
            • Carboplatin/ifosfamide
            • Cisplatin/ifosfamide
            • Paclitaxel/ifosfamide (category 2B)
      • Mucinous carcinoma (stage IC)
        • Preferred Regimens
          • 5-FU/leucovorin/oxaliplatin +- bevacizumab
          • Capecitabine/oxaliplatin +- bevacizumab (category 2B for bevacizumab)
          • Paclitaxel/carboplatin q3weeks
          • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
        • Other Recommended Regimens
          • Paclitaxel weekly/carboplatin weekly
          • Docetaxel/carboplatin
          • Carboplatin/liposomal doxorubicin
          • Paclitaxel weekly/carboplatin q3weeks
        • Useful in Certain Circumstances
          • None
      • Low-grade serous/Grade I endometrioid
        • Preferred Regimens
          • Paclitaxel/carboplatin q3weeks +- maintenance letrozole (category 2B) or other hormonal therapy (category 2B)
          • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
          • Hormone therapy (aromatase inhibitors: anastrozole, letrozole, exemestane) (category 2B)
        • Other Recommended Regimens
          • Paclitaxel weekly/carboplatin weekly
          • Docetaxel/carboplatin
          • Carboplatin/liposomal doxorubicin
          • Paclitaxel weekly/carboplatin q3weeks
          • Hormone therapy (leuprolide acetate, tamoxifen) (category 2B)
        • Useful in Certain Circumstances
          • None
    • Primary Systemic Therapy Recommended Dosing
      • IV/IP Paclitaxel/cisplatin
        • Paclitaxel 135 mg/m2 IV continuous infusion Day 1;
        • Cisplatin 75-100 mg/m2 IP Day 2 after IV paclitaxel;
        • Paclitaxel 60 mg/m2 IP Day 8
        • Repeat every 21 days x 6 cycles
      • Paclitaxel/carboplatin q3weeks
        • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 5-6 IV Day 1
        • Repeat every 21 days x 3-6 cycles
      • Paclitaxel weekly/carboplatin q3week
        • Dose-dense paclitaxel 80 mg/m2 IV Days 1, 8, and 15 followed by carboplatin AUC 5-6 IV Day 1
        • Repeat every 21 days x 6 cycles
      • Paclitaxel weekly/carboplatin weekly
        • Paclitaxel 60 mg/m2 IV followed by carboplatin AUC 2 IV
          • Days 1, 8, and 15; repeat every 21 days x 6 cycles (18 weeks)
      • Docetaxel/carboplatin
        • Docetaxel 60-75 mg/m2 IV followed by carboplatinm AUC 5-6 IV Day 1
        • Repeat every 21 days x 3-6 cycles
      • Carboplatin/liposomal doxorubicin
        • Carboplatin AUC 5 IV + pegylated liposomal doxorubicin 30 mg/m2 IV
        • Repeat every 28 days for 3-6 cycles
      • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7)
        • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 5-6 IV, and bevacizumab 7.5 mg/kg IV Day 1
        • Repeat every 21 days x 5-6 cycles
        • Continue bevacizumab for up to 12 additional cycles
      • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (GOG-218)
        • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 6 IV Day 1. Repeat every 21 days x 6 cycles
        • Starting Day 1 of cycle 2, give bevacizumab 15 mg/kg IV every 21 days for up to 22 cycles
    • Primary Systemic Therapy Recommended Dosing for Elderly Patients (age >70 years) and/or Those with Comorbidities
      • Paclitaxel 135/carboplatin
        • Paclitaxel 135 mg/m2 IV + carboplatin AUC 5 IV given every 21 days x 3-6 cycles
      • Paclitaxel weekly/carboplatin weekly
        • Paclitaxel 60 mg/m2 IV over 1 hour followed by carboplatin AUC 2 IV over 30 minutes
        • Days 1, 8, and 15; repeat every 21 days x 6 cycles (18 weeks)

[assessment]

• Lab results 2022-07-19 indicated liver and kidney function, CBC, WBC DC, electrolytes were grossly normal. TPR, PB during this hospitalization is relatively stable.

220628

[assessment]

• No BRCA1/2 lab results were found. Patients with BRCA1/2-mutated clear cell carcinoma or carcinosarcoma may benefit from maintenance therapy with PARPi (poly ADP ribose polymerase inhibitor) if CR or PR is achieved after primary treatment with surgery and platinum-based first-line therapy

701381642

220720

{Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB, with malignant pleural effusion, bone and lung metastasis}

• exam finding
  • 2022-07-19 SONO - thorax
    • Echo diagnosis
      • Left thorax: organized pleural effusion
      • Right thorax: moderate amount, yellowish pleural effusion s/p insertion of 14 Fr. pig-tail catheter and fixed at 15cm.
  • 2022-07-16 CXR
    • Total white-out of left lung is noted that may be massive pleura effusion?
    • Right pleura effusion.
    • Several nodular opacity projecting in the right lung are noted that are c/w lung to lung metastases. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Metastasis in right 5th rib is suspected.
  • 2022-07-14 ECG
    • Sinus tachycardia
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-07-14 SONO - thorax
    • Symptoms: dyspnea improved
    • Indication: effusion, LUL
    • Clinical Diagnosis
      • Thymic cancer with persited left side pleural effusion, LUL consolidation with airbronchogram. localized pleural effusion, with LUL consolidation.
    • Procedure & Finding
      • The patient was in sitting upright posture while the chest echography was performed using 3.75-mHz convex probe.
      • Left-side of thorax
        • Pleura positive Pleura Line thin
        • Effusion: Echogenicity clear localized
        • Size 1-2-ICS, Left upper lung, fixed, with LUL consolidation, collapse.
        • Left lower back pleural thickening with fixed, organization of pleural effusion or parietal pleural involvement.
      • Right-side of thorax:
        • Pleura negative Pleura Line
    • Special Procedure: Nil
    • Echo diagnosis:
      • Left side:
        • Size 1-2-ICS, Left upper lung, fixed, with LUL consolidation, collapse.
        • Left lower back pleural thickening with fixed, organization of pleural effusion or parietal pleural involvement.
    • Removal of pig tail tube due to obstruction by debri.
    • Pig tail re-insertion was not safe because of a little pleural effuion only.
    • Suggestion:
      • CxR follow up 3-7 days. or chest echography if SOB develope again.
  • 2022-06-24 CXR
    • Patchy opacity projecting at left upper lung zone with lung volume decrease and air-bronchogram was noted. Please correlate with CT.
    • Several nodular opacity projecting in the right lung are noted that are c/w lung to lung metastases. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Left pleura effusion S/P pigtail catheter implantation.
    • S/P port-A implantation.
    • Metastasis in right 5th rib is suspected.
  • 2022-06-20 CXR
    • Patchy opacity projecting at left upper lung zone with lung volume decrease was noted. Please correlate with CT.
    • Several nodular opacity projecting in the right lung are noted that are c/w lung to lung metastases. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Left pleura effusion S/P pigtail catheter implantation.
    • S/P nasogastric tube insertion
    • S/P port-A implantation.
    • Metastasis in right 5th rib is suspected.
  • 2022-06-16 CXR
    • appropriately positioned gastric tube
    • Port-A catheter inserted into RA via right subclavian vein.
    • LUL lobar consolidaition with air-bronchogram
    • consolidation over Lt lower lung with enlarged hilum
    • nodular/patchy opacities in Rt lung in progression
    • enlarged cardiac silhoutte
    • Rt pleural effusion
    • Lt pleural effusion s/p pigtail drain placement
  • 2022-06-16 CXR
    • appropriately positioned gastric tube
    • approriately positioned endotracheal tube in place
    • Port-A catheter inserted into RA via right subclavian vein.
    • LUL lobar consolidaition with air-bronchogram
    • extensive consolidation over Lt lower lung with enlarged hilum
    • nodular/patchy opacities in Rt lung
    • enlarged cardiac silhoutte
    • Rt pleural effusion
    • Lt pleural effusion s/p pigtail drain placement
  • 2022-06-09 CXR
    • Port-A catheter inserted into RA via right subclavian vein.
    • LUL lobar consolidaition with air-bronchogram
    • extensive consolidation over Lt lower lung with enlarged hilum
    • nodular/patchy opacities in Rt lung
    • enlarged cardiac silhoutte
    • Rt pleural effusion
    • appropriately positioned gastric tube
    • approriately positioned endotracheal tube in place
    • regression Lt pleural effusion s/p pigtail drain placement
  • 2022-06-06 CXR
    • Port-A catheter inserted into RA via right subclavian vein.
    • LUL lobar consolidaition with air-bronchogram
    • extensive consolidation over Lt lower lunbg with enlarged hilum
    • numerous nodules/parchy opacities of variable sizes in Rt lung due to metastases
    • enlarged cardiac silhoutte
    • bilateral pleural effusions
    • appropriately positioned gastric tube
    • approriately positioned endotracheal tube in place
    • regression Lt pleural effusion s/p pigtail drain placement
  • 2022-06-02 SONO - chest
    • Clinical Diagnosis
      • Thymic cancer stage 4
      • Left side pleural effusion
    • Procedure & Finding
      • The patient was in supine posture while the chest echography was performed using 3.75-mHz convex probe.
        • Left-side of thorax
          • Pleura positive Pleura Line thin
          • Effusion: Echogenicity clear extending from the posterior to the anterior
          • Size 1-2-ICS
        • Right-side of thorax
    • Echo diagnosis:
      • Left side mild to moderate pleural effusion s/p pig-tail insertion, seroanguinous, drowsy
  • 2022-06-02 2D transthoracic echocardiography
    • Normal chamber size
    • Small pericardial effusion
    • Adequate LV and RV systolic function
    • AV sclerosis with mild AR, mild MR, TR and PR
    • No regional wall motion abnormalities
  • 2022-05-31 ECG
    • Sinus tachycardia
    • Nonspecific T wave abnormality
  • 2022-05-30 ECG
    • Sinus tachycardia
    • Low voltage QRS
    • Poor wave progression
    • Abnormal ECG
• consultation
  • 2022-06-16 Nephrology
    • Q
      • This 45y/o female was a case of Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB, with malignant pleural effusion, bone and lung metastasis. Regular in NTUH follow-up.
      • According to the statement of the patient families and ER medical record. She ever fever, suspected community-acquired pneumonia, status post Unasyn 3/29-4/8 under Augmentin. This time. she had suffered from palpitations, dyspnea, spiky fever and generalized malaise for 2 days, the symptoms became to worsen. Therefore she was sent to our ER.
      • At ER, spiky fever up to 38.1degree, Acetamol iv infusion and adequate fluid iv infusion were given. Elevation of breathing work and saturation around 80%, the patient refused invade procedule, NIPPV placement and steroid with solu-cortef 50mg iv injection. The chest films disclosed of bilateral pneumonia with massive plerual effusion, empiric antiboltic with Tapimycin was perscribed. Bordelrine blood pressure around SBP 95-99mmHg, Albumin 50ml IVD loading and fluid iv infusion for hydration.
      • Under the impression of sepsis and bilateral pneumonia with massive plerual effusion combine impending respiratory failure. She was admitted to our ICU for further observation and management.
      • Due to the very low creatinine level, electrolyte unbalance, short stature, we have check Aldosterone and PRA (plasma renin activity) according to the suggestion of endocrinologist and we need your expertise of further evaluation and management of the very low creatinine level, electrolyte unbalance, short stature. Thanks!
    • Q
      • Impression
        • Low creatinine due to low muscle mass, or cachexia related
        • Mg deficiency suspect nutritional deficiency related
      • Suggestion
        • Check 24h Cr
        • Nutrition supplement
      • Thank you very much for your consultation.
  • 2022-06-15 Metabolism and Endocrinology
    • c-peptide < 0.02 ng/mL
      
    • very poor beta cell function,
    • high risk for DKA and sugar unstable as same as DM type 1
    • please check Anti-GAD (GAD Ab, Glutamic Acid Decarboxylase Autoantibodies test), (self-paid item) to rule in DM type 1
    • re-on basal insulin with bolus insulin to control blood sugar
    • please check insulin Ab - –
    • very low Cr, electrolyte unbalance, short stature
    • glomerular hyperfiltration?
    • please check Aldosterone and PRA (plasma renin activity)
    • please Consult Nephrologist
    • may consult Pediatrics Dr. Tsai to rule out genetic disorder
    • please consult Oncologist
  • 2022-06-13 Gastroenterology
    • Q
      • We need your expertise for entecavir use before the chemotherapy use. Thanks!
    • A
      • Entecavir would be prescribed.
      • Indication: HbsAg(+) or HbsAg(-) while anti-Hbc(+) plus chemotherapy (1 wk before C/T unitl 6 mo after C/T)
  • 2022-06-09 Metabolism and Endocrinology
    • Q
      • Due to the poor control hyperglycemia condition, we need your expertise of further evaluation and management of medication control under insulin use. Thanks!
    • A
      • O:
        • BW: 43.2
        • Diet: NG, DM diet 1800 kcal/day
        • Medication in OPD: Metformin, Trajenta, NovoRapid, Toujeo
        • Medication during hospitalization: RI TIDAC, Toujeo, Metformin
        • Na: 132, K: 4.1
        • ALT: 7
        • BUN/Cr: 13/0.35 (eGFR: 213.07)
        • F/S (finger stick):
          • date 06-07 06-08 06-09
          • QDAC 277 357 281 -> RI 16u
          • QLAC 466 328 272 -> RI 16u
          • QNAC 240 393 91 -> Hold RI
          • HS 072 054 308
        • HbA1c: 6.5
        • Urine ACR: unavailable
        • OPH OPD: nil
      • A:
        • Type 2 DM, poor controlled
      • Suggestions:
        • 1. Avoid all OADs at this moment (DC Metformin during infection status)
        • 2. RI 14U QDAC (before first meal), 12U QLAC (before third meal), 10U QNAC (before fifth meal) with correction scales -> switch to apidra low dose before each feeding
          • F/S < 080，RI hold
          • F/S 081~090，RI -4U
          • F/S 091~100，RI -3U
          • F/S 101~110，RI -2U
          • F/S 111~120，RI -1U
          • F/S 201~250，RI +1U
          • F/S 251~300，RI +2U
          • F/S 301~350，RI +3U
          • F/S 351~400，RI +4U
          • F/S > 400，RI +5U
        • 3. Hold Toujeo temporarily
        • 4. Check urine ACR
        • 5. Contact us if needed. I’d like to follow up this patient. - –
      • low body weight 42-43 kg
      • sugar unstable under RI 12u tidac and basal insulin
        
      • Switch RI tidac to apidra before each feeding
      • Please call Dr. Hu QD or QOD to adjust insulin dosage if sugar poor control
      • Please check blood sugar and C-peptide to evaluate beta cell function
      • Fluoroquinolones may increase the risk of hypoglycemia, please closely monitor finger stick and hypoglycemia
      • consider switch Toujeo to Tresiba
        
  • 2022-06-03 Hemato-Oncology
    • Q
      • Due to Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB, with malignant pleural effusion, bone and lung metastasis. Regular in NTUH follow-up. Patient family stated that NTUH had thought to apply oral targeted drugs, need your evluation help and check targeted drugs, thanks a lot!!
    • A
      • Impression:
        • 1. Bilateral pneumonia with respiratory failure s/p endo with ventilation
        • 2. Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB, with malignant pleural effusion, bone and lung metastasis
      • Suggestion:
        • 1. Treat sepsis and respiratory failure as your expertise, best supportive care
        • 2. Have the patient family to bring medical records from NTUH
        • 3. Thanks for your consultation. If there is any problem, please feel free to let us known.
  • 2022-06-01 Infectious Diseases
    • Antibiotic therapy should be adjusted according to the results of in vitro sensitivity testing.
    • NO treatment for colonization. Do NOT use steroid.
    • Antimicrobiologic coverage with parental Finibax 500 mg q8h is recommended.
  • 2022-05-31 Family Medicine
    • Q
      • This consultation is for critically ill hospice care.
      • After admission, elevation of breathing work with paradoxical movement used and desaturation were found. We have informed prognosis and intubation indication with treatment programs to his hunsband, he understood and decided aggresive treatment. Due to these resasons, we sincerely need your expertise for critically ill hospice care. Thanks!
    • A
      • Patient has received intubation and just undergoes aggressive treatment.
      • We will arrange share care to F/U her prognosis.
      • We could arrange transfer if necessary.
      • Indication: Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB
• chemoimmunotherapy
  • 2022-06-13 ~ undergoing - cisplatin 20mg/m2 24hr + 5-Fu 2000mg/m2 24hr + leucovorin 200mg/m2 24hr (weekly)

[note]

• Thymomas and Thymic Carcinomas, NCCN EB, Version 2.2022 - May 4, 2022, p13
  • Principles of systemic therapy - first-line combination chemotherapy regimens
    • Thymoma
      • Preferred (Other Recommended for Thymic Carcinoma)
        • CAP1
          • Cisplatin 50 mg/m2 IV day 1
          • Doxorubicin 50 mg/m2 IV day 1
          • Cyclophosphamide 500 mg/m2 IV day 1
          • Administered every 3 weeks
      • Other Recommended for Thymic Carcinoma and Thymoma
        • CAP with prednisone
          • Cyclophosphamide 500 mg/m2 IV on day 1;
          • Doxorubicin, 20 mg/m2/day IV continuous infusion on days 1-3;
          • Cisplatin 30 mg/m2 days 1-3;
          • Prednisone 100 mg/day days 1-5;
          • Administered every 3 weeks
        • ADOC
          • Doxorubicin 40 mg/m2 IV day 1;
          • Cisplatin 50 mg/m2 IV day 1;
          • Vincristine 0.6 mg/m2 IV day 3;
          • Cyclophosphamide 700 mg/m2 IV day 4
          • Administered every 3 weeks
        • PE
          • Cisplatin 60 mg/m2 IV day 1;
          • Etoposide 120 mg/m2/day IV days 1-3;
          • Administered every 3 weeks
        • Etoposide/ifosfamide/cisplatin5
          • Etoposide 75 mg/m2 on days 1-4;
          • Ifosfamide 1.2 g/m2 on days 1-4;
          • Cisplatin 20 mg/m2 on days 1-4
          • Administered every 3 weeks
    • Thymic Carcinoma
      • Preferred (Other Recommended for Thymoma)
        • Carboplatin/paclitaxel
          • Carboplatin AUC 6
          • Paclitaxel 200 mg/m2
          • Administered every 3 weeks
  • Principles of systemic therapy - second-line chemotherapy regimens (subsequent therapy)
    • Thymoma
      • Other Recommended
        • Etoposide
        • Everolimus
        • 5-FU and leucovorin
        • Gemcitabine +- capecitabine
        • Ifosfamide
        • Octreotide (including LAR) +/- prednisone
        • Paclitaxel
        • Pemetrexed
    • Thymic Carcinoma
      • Other Recommended
        • Everolimus
        • 5-FU and leucovorin
        • Gemcitabine +- capecitabine
        • Lenvatinib
        • Paclitaxel
        • Pembrolizumab
        • Pemetrexed
        • Sunitinib
      • Useful in Certain Circumstances
        • Etoposide
        • Ifosfamide

[assessment]

• F/S records and administered insulin units
  • Date QDAC basal bolus QLAC bolus QNAC bolus
  • Unit mg/dL unit unit mg/dL unit mg/dL unit
  • 2022-07-20 184 12 7 - - - -
  • 2022-07-19 157 12 7 256 8 141 7
  • 2022-07-18 277 12 7 360 7 316 7
  • 2022-07-17 105 12 7 301 7 361 7
  • 2022-07-16 265 12 7 274 7 179 7
  • 2022-07-15 060 0 0 280 7 186 7 (QDPC 190 mg/dL, after taking sugar)
  • 2022-07-14 189 12 7 281 7 319 7
  • 2022-07-13 - - - - - 376 7
• According to the patient’s mother last evening, she had been feeling weaker these two days and had also reduced her calorie intake. In spite of the high blood sugar levels before lunch these days, there is no urgent need to adjust the insulin dose for her recent low intake at this time.

220718

[assessment]

• Insulins in active prescription
  • Apidra 100U/mL (insulin glulisine) 7 unit SC TIDAC
    • onset 5~15min, max 30~90min, duration 3~5hr
  • Tresiba FlexTouch 100U/mL (insulin degludec) 12 unit SC QDAC
    • onset 1hr, no apparent peak, duration >24hr
• F/S records
  • Date QDAC QLAC QNAC HS
  • 2022-07-18 277 360 - -
  • 2022-07-17 105 301 361 NA
  • 2022-07-16 265 274 179 NA
  • 2022-07-15 060 280 186 NA (QDPC 190, after taking sugar)
  • 2022-07-14 189 281 319 NA
  • 2022-07-13 NA NA 376 NA
• On 2022-07-15 morning before breakfast, hypoglycemia was observed, but it is unclear what transpired between 7/14 bedtime and the event.
• Last week I noted that the patient’s staple food was porridge, and her snack was bread, which are easy to raise blood sugar levels, and her each meal might not be taken in similar quantity, thus complicating blood sugar control.
• As there was a hypoglycemia event last week, the basal dose can be kept as usual, however, the F/S readings remain high these days. It is recommended that the QLAC bolus be increased by +2U, and the QNAC bolus by +1U.

220715

[assessment]

• There were no visual problems perceived by the patient when I visited her 09:10 2022-07-15. As there is no ophthalmology OPD record found, it would be recommended to consult Oph if diabetic retinopathy is suspected.

220714

[assessment]

• CNS depressants alprazolam, brotizolam, lorazepam, oxazolam were prescribed as HS co-administered, adverse/toxic effect might be enhanced.
• The half-life of each item (short to long): brotizolam (3.5 ~ 8 hr), oxazepam (5 ~ 15 hr), alprazoalm (6 ~ 12 hr), lorazepam (10 ~ 20 hr), it may be considered to remove drugs that have similar effect time.

700034769

220719

• lab data
  • Creatinine
    • 2022-07-19 1.80 mg/dL
    • 2022-07-11 2.25 mg/dL
    • 2022-07-05 2.31 mg/dL
    • 2022-06-28 2.04 mg/dL
    • 2022-06-13 2.31 mg/dL
    • 2022-05-28 2.23 mg/dL
    • 2022-05-17 2.29 mg/dL
    • 2022-05-05 2.47 mg/dL
    • 2022-05-03 2.40 mg/dL
    • 2022-04-29 2.94 mg/dL
    • 2022-04-28 2.11 mg/dL
    • 2022-04-25 1.90 mg/dL
    • 2022-04-17 1.70 mg/dL
    • 2022-04-15 2.03 mg/dL
    • 2022-03-29 1.84 mg/dL
    • 2022-03-21 2.16 mg/dL
    • 2022-03-17 1.99 mg/dL
    • 2022-03-16 1.77 mg/dL
    • 2022-03-15 1.95 mg/dL
    • 2022-03-01 1.68 mg/dL
    • 2022-02-21 1.73 mg/dL
    • 2022-02-15 1.78 mg/dL
    • 2022-02-07 1.30 mg/dL
    • 2022-01-24 1.40 mg/dL
    • 2022-01-17 1.38 mg/dL
    • 2022-01-14 1.45 mg/dL
    • 2022-01-11 1.35 mg/dL
    • 2022-01-03 1.11 mg/dL
    • 2021-12-28 1.41 mg/dL
    • 2021-12-21 1.41 mg/dL
    • 2021-12-16 1.52 mg/dL
    • 2021-12-14 1.36 mg/dL
    • 2021-12-06 1.11 mg/dL
    • 2021-11-26 1.07 mg/dL
    • 2021-10-05 1.44 mg/dL
    • 2021-09-07 1.22 mg/dL
    • 2021-07-13 1.25 mg/dL
    • 2021-03-23 1.13 mg/dL
    • 2021-01-26 1.07 mg/dL
    • 2020-10-06 1.18 mg/dL
    • 2020-09-04 1.20 mg/dL
  • BUN
    • 2022-07-19 44 mg/dL
    • 2022-07-11 31 mg/dL
    • 2022-06-28 38 mg/dL
    • 2022-05-28 34 mg/dL
    • 2022-05-05 28 mg/dL
    • 2022-05-03 33 mg/dL
    • 2022-04-29 46 mg/dL
    • 2022-04-28 32 mg/dL
    • 2022-04-25 43 mg/dL
    • 2022-04-17 28 mg/dL
    • 2022-04-15 35 mg/dL
    • 2022-03-16 34 mg/dL
    • 2022-02-21 27 mg/dL
    • 2022-02-07 20 mg/dL
    • 2022-01-24 23 mg/dL
    • 2022-01-03 25 mg/dL
    • 2021-12-28 36 mg/dL
    • 2021-12-06 23 mg/dL
    • 2021-11-26 19 mg/dL
• exam finding
  • 2022-06-20 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
  • 2022-05-28 CT - lung/mediastinum/pleura
    • Finding
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • Wedge shaped interstitial opacity over left upper lobe is found. The lesion is new. Recent inflammation is considered.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Left renal stone is found.
        • The spleen, liver, pancreas and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is stone at dependent portion of GB. GB stone(s) are noted.
    • Imp:
      • Gallstones.
      • No evidence of lymphadenopathy in the study.
      • Wedge shaped interstitial opacity over left upper lobe is found. The lesion is new. Recent inflammation is considered.
  • 2022-04-28 ECG
    • Left ventricular hypertrophy with QRS widening
  • 2022-02-24 Renal SONO (Nephrology)
    • Bilateral renal cysts, cortical and parapelvic ones.
  • 2022-02-16 CT - neck
    • no evidence of left neck nodular leions.
  • 2021-12-18 Renal SONO (Nephrology)
    • Parenchymal renal disease
    • Bilateral renal cysts
    • Left renal stone
  • 2021-11-29 Patho - bone marrow biopsy
    • Bone marrow, iliac crest, biopsy — Negative for malignancy
    • Microscopically, it shows 40% of marrow cellularity, with 3:2 of M:E ratio, presence of trilineage cellular component and occasional megakaryocytes.
      
    • Immunohistochemical stain reveals CD34(-), CD117(-), CD20(-), CD138(< 5%), MPO(+), CD71(+), Bcl-2(-) and Bcl-6(+).
  • 2021-12-01 2D transthoracic echocardiography
    • Heart size: Dilated LA, AoR
    • Thickening: IVS, LVPW
  • 2021-11-26 ECG
    • Normal sinus rhythm
    • Voltage criteria for left ventricular hypertrophy
    • Abnormal ECG
  • 2021-11-17 Whole body PET scan
    • Glucose hypermetabolism in the left neck lymph nodes and bilateral axillary lymph nodes comes to less evident compared with the previous study on 2017-08-18, indicating response to current therapy.
      
    • Glucose hypermetabolism in the left thyroid bed, the nature is to be determined (functioning nodule of thyroid, inflammatory process or other nature ?). Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive nodes or physiologic FDG uptake is more likely.
  • 2021-11-08 Patho - lymphnode biopsy
    • Lymph node, left neck, excisional biopsy— Diffuse large B-cell lymphoma, non-GCB (c-myc +)
      
    • Immunohistochemical stain profiles: CD23(focal+), CD20(+), CD10(-), Ki-67 index: 20%, Bcl-2(+), c-myc (+, >30%), MUM1(+), Bcl-6(+), cyclin D1(-), CD3 (immunoreactive at background T cell).
      
    • Reference: S2017-12983
  • 2021-11-02 Nasopharyngoscopy
    • Findings
      • smooth NPx, oropharynx, hypopharynx, no tumor found
    • Diagnosis
      • lymphoma s/p treatment
  • 2021-10-20 CT - lung/mediastinum/pleura
    • Findings - comparison made with previous CT dated on 2021/04/13
      • 1. Lungs: a 14 mm cyst at S10 of RLL, otherwise normal appearance of bilateral lungs.
      • 2. Mediastinum: no enlarged LN or mass.
      • 3. Hila: no enlarged LN.
      • 4. Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance..
      • 5. Heart: normal in size of cardiac chambers. midseptal hypertrophy of IVS.
      • 6. Pleura and pericardium: no effusion or thickening
      • 7. Chest wall and visible neck: multiple small lymph nodes in bilateral axillary regions and visible neck, stationary.
      • 8. Visible abdominal contents: a tiny Lt renal stone 2 mm. multiple small liver cysts up to 1.5 cm. many gall bladder stones. unremarkable of the spleen, adrenal glands, pancreas, and Rt kidney. no enlarged LN.
    • IMP:
      • no mass or enlarged lymphadenopathy in visible neck, mediastinum and axillary regions, and abdomen.
  • 2021-04-13 CT - lung/mediastinum/pleura
    • Findings - comparison made with previous CT dated on 2020/10/27
      • 1. Lungs: a 14 mm cyst at S10 of RLL, otherwise normal appearance of bilateral lungs.
      • 2. Mediastinum: no enlarged LN or mass.
      • 3. Hila: no LAP.
      • 4. Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • 5. Heart: normal in size of cardiac chambers. midseptal hypertrophy of IVS.
      • 6. Pleura and pericardium: no effusion or thickening
      • 7. Chest wall and visible neck: multiple small lymph nodes in bilateral axillary regions and posterior triangles of visible neck.
      • 8. Visible abdominal contents:
        • a tiny Lt renal stone 2 mm. multiple small liver cysts up to 1.5 cm. gall bladder stones.
        • unremarkable of the spleen, adrenal glands, pancreas, and Rt kidney.
        • no mass or lymphadenopathy in visible neck, mediastinum and axillary regions, and abdomen.
  • 2020-10-27 CT - lung/mediastinum/pleura
    • Findings - comparison: prior CT dated on 2019/01/17
      • 1. Lungs and large central airways: normal appearance of bilateral lungs.
      • 2. Mediastinum: no LAP or mass.
      • 3. Hila: no LAP.
      • 4. Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • 5. Heart: normal in size of cardiac chambers.
      • 6. Pleura, pericardium: no effusion or thickening
      • 7. Chest wall and neck: multiple small lymph nodes in bilateral axillary regions and posterior triangles of visible neck.
      • 8. Visible abdominal-pelvis contents:
        • a tiny Lt renal stone. multiple liver cysts up to 1.5cm
        • gall bladder stones.
        • unremarkable of the spleen, adrenal glands, pancreas, and Rt kidney. U-bladder and small and large bowels are grossly unremarkbale.
    • Impression:
      • no mass or LAP in visible, mediastinum and axillary regions.
  • 2020-06-10 CT - neck
    • multiple bilateral lymph nodes in the neck spaces.
  • 2019-11-14 SONO - abdomen
    • Diagnosis
      • Suspected chronic liver parenchyma disease(Please correlate with liver function)
      • Suspected liver cyst, left
      • Suspected GB stones
      • Pancreas not shown
      • Suboptimal examination of liver due to poor echo window
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Because of poor echo window, infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
  • 2019-05-20 SONO - abdomen
    • Parenchymal liver disease
    • GB stones
    • Liver cysts
    • Renal cyst, right side
    • Fatty infiltration of pancreas
  • 2019-01-17 CT - lung/pleura
    • Findings - comparison: prior CT on 2018/08/27
      • 1. Lungs and large airways: normal appearance of bilateral lungs. as compared with previous CT study.
      • 2. Mediastinum: no LAP or mass.
      • 3. Hila: no LAP.
      • 4. Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance..
      • 5. Heart: normal in size.
      • 6. Pleura: no effusion or thickening
      • 7. Chest wall and neck: no enlarged lymph nodes.
      • 8. Visible abdominal contents:
        • a tiny Lt renal stone. multiple liver cysts up to 1.5cm
        • gall bladder stones.
        • unremarkable of the spleen, adrenal glands, pancreas, and Rt kidney
        • bile ducts: No dilatation.
        • no enlarged lymphadenopathy.
      • 9. Visualized bones: unremarkable.
    • Impression:
      • no recurrent neck lymphadenopathy.
      • no lesion in mediastinum and axillary regions.
  • 2018-08-27 CT - lung/pleura
    • Impression:
      • Bilateral axillary non-specific lymph nodes
  • 2018-05-03 CT - lung/pleura
    • Impression:
      • 3mm calcified granuloma in basal segments of LLL.
      • No LAPs in neck, chest and abdomen. gallstones. a 2mm left renal stone.
  • 2018-01-03 CT - lung/pleura
    • Impression:
      • Nonspecific micronodules in LLL.
      • No LAPs in chest and abdomen. gallstones.
  • 2017-09-04 CXR
    • Borderline heart size enlargement.
    • Mild tortuosity of thoracic aorta. No mediastinal widening.
    • Presence of increased lung infiltrations.
  • 2017-08-19 SONO - abdomen
    • fatty liver, mild/ incomplete exam of liver
    • liver cysts
    • gallstones
    • gallbladder polyps, suspect adenomyomatosis of GB wall
  • 2017-08-18 ECG
    • Normal sinus rhythm
    • Left ventricular hypertrophy with QRS widening
    • Abnormal ECG
  • 2017-08-18 Whole body PET scan
    • Glucose hypermetabolism involving a confluent left neck level II-III lymph node, compatible with lymphoma.
    • Mild glucose hypermetabolism in bilateral axillary lymph nodes and glucose hypermetabolism in the left aspect of the nasopharynx. The nature is to be determined (inflammatory process? other nature?). Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in the right upper anterior chest wall in linear shape. Post-operative inflammation may show this picture.
    • Increased FDG uptake in bilateral neck muscles. Physiologic FDG uptake is more likely.
  • 2017-08-09 Surgical pathology Level IV
    • Lymph node, left neck, core needle biopsy —– Diffuse large B cell lymphoma.
    • IHC stains: CK(-), CD3 (-), CD20 (+), bcl-2 (+), bcl-6 (+), CD10 (+), cyclin D1 (-), CD23 (-), c-myc (+, 100%).
    • Histology type: B-cell neoplasms; Diffuse large B-cell lymphoma
• consultation
  • 2021-12-03 Cardiology
    • Q
      • The 69 y/o man recurrent lymphoma case, he has history of focal segmental glomerulosclerosis (UACR 783, Proteinuria 2+).
      • Due to SBP need keep < 130/80mmHg, his Exforge 5/160 1# bid, but can’t control, so we need your help for anti-hypertension drugs assassment. Thanks!
    • A
      • EKG showed NSR, LVH
      • Cardiac echo showed preserved LV function dilated LA Ao and LVH
      • please add doxaben 1 qd for BP control
      • If BP remained higher, indapamide 1 qd aslo can be administrated
  • 2021-12-02 Nephrology
    • Q
      • The 69 y/o man is a recurrent diffuse large B cell lymphoma case, he has past history of proteinuria and s/p biopsy at WanFang H (pathology report did not bring).
      • Due to urinalysis showed PRO 2+, so we need your help for management. Thanks!
    • A
      • Lab data:
        • U/A : clear yellow, SG: 1.013, PH: 5.5, Nit: -, Glu: -, Pro:2+, Ket :-, uro <1.5, Ob:- , RBC: 0-2, WBC: 0-5, bacteria:-
        • WBC: 5.9, Hb: 13.4, Plt: 176
        • BUN: 19,cre: 1.07, ALKP: 80, LDH: 194
        • Na: 140, K: 3.9, Albumin: 4.0, uric acid: 5.8
        • PE: edema-
        • Renal biopsy: FSGS (focal segmental glomerulosclerosis)
      • Impression:
        • Proteinuria caused by FSGS
      • Suggestion:
        • Check UACR
        • Keep Steroid 1mg/kg per day
        • DC ACEI
        • Esclate dose of ARB till BP control < 130/80mmHg
• surgical operation
  • 2022-05-02
    • Surgery
      • Double lumen catheter insertion (RIJV approach, 16cm)
    • Finding
      • Adequate size of RIJV
    • Procedure
      • Under LA, supine, disinfection and well drapped.
      • Under sonography guidance, puncture into RIJV then wiring into RA
      • tunnel through RIJV puncture site, dilator insertion    
      • insert D/L
      • check flow, Hemostasis
      • secure the cath.  
  • 2021-11-08
    • Surgery
      • Excision of left neck lymph nodes      
    • Finding
      • Several enlarged lymph nodes at left neck level V, size around 1~2cm, two of them was removed for pathology pathology and TB culture/PCR
      • The spinal acccessory nerve was exposed at the operative field and well preserved
    • Procedure
      • The patient was in supine position with neck hyperextended and turned to the right side. Skin was disinfected and draped as usual. Local anesthesia with Bosmin-rinsed Xylocaine was injected into the subcutaneous tissue around the enlarged lymph noded after marked with the pen. A horizontal incision parallel to the skin crease was made. The subcutaneous tissue was cut through. Several enlarged lymph nodes at left neck level V, size around 1~2cm, two of them was bluntly dissected from its surrounding tissue and removed for pathology and TB culture/PCR. No obvious adhesion was noted. The spinal acccessory nerve was exposed at the operative field and well preserved. After hemostasis, the wound was closed with 2 layers. The patient tolerated the procedure well.  
  • 2017-08-18
    • Diagnosis
      • Lymphoma
    • PCS
      • 47080B
    • Finding
      • We identify the cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative C-arm to check its position.
    • Procedure
      • Under loca lanethesia, 3cm incision was made over R’t subclavicular region, outer 1/3. Superficial fascia was opened and the cephalic vein was found from upper border of the pectoralis major muscle. The cephalic vein was dissected and then pulled out with 3-0 silks over proximal and distal portions respectively. The lumen was opened by a scissor and the catheter was inserted into proximal lumen for 16 cm in length. The silks were tied so that the catheter was fixed in the proximal lumen and the distal end was ligated. After hemostasis and testing the function of the port-A, wound was closed layer by layer.
• chemoimmunotherapy
  • 2022-04-19 - etoposide
  • 2021-12-08 ~ 2022-03-04 - R-DHAP (4 times)

==========

2022-07-19

• Creatinine dropped to 1.8 mg/dL and BUN rose to 44 mg/dL, it would appear that there has not been a obvious decline in renal function and that some dehydration might possibly be present. (the latter is diarrhea caused?)
  • Creatinine
    • 2022-07-19 1.80 mg/dL
    • 2022-07-11 2.25 mg/dL
    • 2022-07-05 2.31 mg/dL
    • 2022-06-28 2.04 mg/dL
    • 2022-06-13 2.31 mg/dL
    • 2022-05-28 2.23 mg/dL
    • 2022-05-17 2.29 mg/dL
    • 2022-05-05 2.47 mg/dL
    • 2022-05-03 2.40 mg/dL
  • BUN
    • 2022-07-19 44 mg/dL
    • 2022-07-11 31 mg/dL
    • 2022-06-28 38 mg/dL
    • 2022-05-28 34 mg/dL
    • 2022-05-05 28 mg/dL
    • 2022-05-03 33 mg/dL
• CrCl 35~40 mL/min, eGFR 38~45 mL/min/1.73m2, please check the following items in active prescription for patient’s clinical need
  • fluconazole
    • CrCl <=50 mL/minute: reduce normal dose by 50%.
  • levofloxacin
    • CrCl 20 to <50
      • If usual recommended dose is 500 mg every 24 hours: 500 mg initial dose, then 250 mg every 24 hours
      • If usual recommended dose is 750 mg every 24 hours: 750 mg every 48 hours
  • nystin
    • There are no dosage adjustments provided in the manufacturer’s labeling.
  • entecavir
    • CrCl 30 to <50 mL/minute: administer 50% of usual indication-specific dose daily. alternatively, administer the usual indication-specific dose every 48 hours.
  • pentoxifylline
    • CrCl >=30 mL/minute: there are no dosage adjustments provided in the manufacturer’s labeling. however, exposure to one of pentoxifylline’s the active metabolites (metabolite V) is increased with renal impairment; use with caution.
    • Aronoff 2007: CrCl 10-50 mL/minute: 400 mg every 12 to 24 hours

2022-07-12

[visiting]

• I visited the patient at approximately 13:10 2022-07-12.
• In spite of the upcoming transplant operation, the patient was still a bit nervous, which is believed to be a psychological reaction to the uncertainty of the future. In addition, he stated that he would actively cooperate with the doctor to receive treatment.
• The patient was also concerned about whether or not the renal function will be maintained in the future. My explanation to him was that our medication are adjusted in accordance with his renal function.
• No other medication-related questions raised by the patient.

2022-07-11

Dose adjustment recommendation for the scheduled PBSCT in this impaired renal function patient

• The patient was diagnosed with stage III CKD on 2021-12-18 at Nephrology OPD.
• The level of creatinine in his blood gradually increased between 2021Q4 and 2022Q1, and has remained slightly above 2 mg/dL since April 2022. Similar trends were observed in blood BUN.
• 2022-07-11 creatinine 2.25 mg/dL -> eGFR 29.1 ~ 35.2 mL/min/1.73m2, CrCl 28.1 ~ 34.0 mL/min
• As the patient has scheduled an autologous PBSCT for his NHL, let us go over the doses of items listed in the regimen:
  • BuCyE
    • busulfan
      • no dosage adjustments provided in the manufacturer’s labeling
    • cyclophosphamide
      • CrCl 10 to 29 mL/minute: administer 75% of normal dose
    • etoposide
      • CrCl 15 to 50 mL/minute: administer 75% of normal dose
  • premedication
    • phenytoin
      • primarily metabolized by the liver to inactive metabolites with <5% of active drug excreted unchanged in the urine
      • no dosage adjustment necessary for any degree of kidney dysfunction
    • fluconazole
      • CrCl <= 50 mL/minute: reduce dose by 50%
    • levofloxacin
      • CrCl 20 to <50: if usual recommended dose is 500 mg every 24 hours, 500 mg initial dose, then 250 mg every 24 hours
    • palonosetron
      • no dosage adjustment is necessary.
    • granisetron
      • no dosage adjustment necessary
    • betamethasone
      • no dosage adjustments provided in the manufacturer’s labeling
    • mannitol
      • contraindicated in severe renal impairment. Use caution in patients with underlying renal disease.
• The purchase order for busulfan has been sent and confirmed. In the event that a drug does not meet the schedule, the staff in the medicine storeroom will inform the updated status immediately.

701431525

220719

[assessment]

• Cardinal Tien Hospital provided a diagnosis of “epigastric pain” on 2022-06-11. In addition to functional dyspepsia, if there are known cardiac risk factors, symptoms suggestive of angina (e.g., shortness of breath, exertional symptoms) might be evaluated.
• This patient is admitted for bone marrow aspiration and biopsy.

700846672

220718

{T-cell lymphoma with bone invasion, stage IV}

• past history
  • Pneumonia and meningitis in ShuangHo Hospital
  • Unknown neurology problem in ShuangHo Hospital
  • Depression
  • GERD
  • Lung benign nodule s/p OP
  • Viral hepatitis B
  • Chronic obstructive pulmonary disease
  • Polymyositis with respiratory involvement, anti-SAE1 and anti-MDA5 Antibodies positive
• lab data
  • blood B2-Microglobulin (609-2366 ng/mL)
    • 2022-07-07 4691 ng/mL
    • 2022-06-11 2559 ng/mL
    • 2022-05-21 4000 ng/mL
    • 2022-04-02 3073 ng/mL
    • 2022-03-23 6077 ng/mL
    • 2022-02-21 2376 ng/mL
    • 2021-12-29 4427 ng/mL
  • Erythrocyte sedimentation rate, ESR (2-15 mm/hr)
    • 2021-12-28 55 mm/hr
    • 2021-09-27 72 mm/hr
    • 2021-09-08 56 mm/hr
    • 2021-09-02 60 mm/hr
    • 2021-04-05 38 mm/hr
    • 2021-01-25 42 mm/hr
    • 2021-01-05 34 mm/hr
    • 2020-12-09 55 mm/hr
• exam finding
  • 2022-06-22 CXR
    • Patchy opacity projecting at right lower lung zone was noted. Please correlate with CT.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura thickening?
    • Enlargement of cardiac silhouette.
  • 2022-05-10 2D transthoracic echocardiography (prior to doxorubicin)
    • Normal AV with no AR
    • Normal MV with mild MR
    • Concentric LVH
    • Preserved LV and RV systolic function
    • No PR, no TR, normal IVC size
  • 2022-04-16 KUB
    • Calcification in left pelvic cavity, could be due to granuloma.
    • Non-specific bowel gas pattern.
    • Clear margin of bilateral psoas muscles.
    • Lumbar spondylosis.
  • 2022-03-23 CT - abdomen, pelvis
    • Findings:
      • Prior CT identified lobulated soft tissue mass in RLL of the lung with calcifications component measuring 6 cm in the largest dimension is noted again, stable in size.
      • Fibrotic infiltrates in RUL of the lung show stationary.
      • Presence of small gallbladder stone.
      • Suspected liver cysts, up to 0.6cm in S4.
      • Tiny left renal stone.
      • There is no focal abnormality in the liver, biliary system, pancreas, spleen & right kidney.
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Prior CT identified lobulated soft tissue mass in RLL of the lung with calcifications component measuring 6 cm in the largest dimension is noted again, stable in size. please correlate with clinical condition.
  • 2021-12-07 CT - abdomen, pelvis
    • RLL tumor with right upper lung nodules, c/w lymphoma.
    • Lymph nodes in mediastinum and right hilar region, suspected lymphoma involvement.
    • GB stones.
    • RUL fibrotic infiltrates.
  • 2021-12-03 CXR
    • S/P port-A implantation.
    • S/P nasogastric tube insertion
    • S/P autosuture projecting at right upper lung.
    • Patchy opacity projecting at right lower lung zone was noted. Please correlate with CT.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura thickening?
  • 2021-12-02 Patho - bone marrow biopsy
    • Bone marrow, left buttock, biopsy — Positive for T-cell lymphoma
      
    • Microscopically, it shows bone marrow tissue with presence of aggregations and scattered T-cell type lymphomatous cells. The trilineage marrow components are not remarkable.
      
    • Immunohistochemical stain reveals CD3(+), CD20(-), CD136(< 5%), MPO(+), CD71(+), CD34(-) and CD117(-).
  • 2021-11-30 Whole body PET scan
    • A glucose hypermetabolic lesion in the posterior aspect of the lower lobe of right lung, compatible with lymphoma.
    • A glucose hypermetabolic lesion in the posterior aspect of the upper lobe of right lung and some glucose hypermetabolic lesions in the lower lobe of right lung and right pulmonary hilar region. Lymphoma should be watched out. Please correlate with other clinical findings for further evaluation.
    • Increased FDG uptake in the muslces in bilateral neck regions, proximal portions of bilateral upper arms, left anterior and posterior upper chest regions and bilateral lower pelvic regions. Physiological FDG uptake due to increased muscle tension or inflammation in these mucles may show this picture. Please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2021-11-29 CXR
    • RLL mass consolidation
    • Reticulonodular opacities in in both lungs due to bronchiolitis
  • 2021-11-22 Patho - pleural/pericardial biopsy
    • Lung, RLL, CT-guide biopsy — malignant T-cell lymphoma
    • Sections show alveolar lung tissue with diffuse infiltration of small lymphocytes and interstitial fibrosis.
    • The immunohistochemical stains reveal CK(-), CD3(+), CD20(-), CD43(+), CD10(-), CD56(-), Cyclin D1(-). The number of CD8 positive lymphocytes is more than CD4 positive lymphocytes. The results are in favor of malignant T-cell lymphoma. Please correlate with the clinical presentation and lab study.
  • 2021-11-18 Electroencephalography, EEG
    • Findings
      • there are continuous slowing at 3-4 Hz bilaterally
      • photic stimulation showed no photo-driving response
      • hyperventilation study was not done
    • EEG classification: abnormal significance II, bilaterally continuous slowing, 3-4 Hz.
    • Interpretation: this EEG study showed moderate diffuse encephalopathy
  • 2021-11-16 CT - lung/mediastinum/pleura
    • Comparison made with previous CT dated on 2021/08/19
      • Lungs:
        • In comparison with the previous study on the lesion is increasing in size
        • further increase in size a large RLL mass-like consolidation with air bronxhograms containing coarse staple line and progression of lobular areas of consolidation and centrilobular nodular and branching opacities (especially in LLL) in both lungs of as compared with previous CT study on 20210819.
        • extensive centrilobular emphysema subpleural paraseptal emphysema
      • Mediastinum: no enlarged LN or mass. old calcified LN in Rt visceral space, sequela of previous TB infection
      • Hila: no enlarged LN.
      • Vessels: mild coronary arterial calcification.
      • Aorta: normal caliber, atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: small Rt effusion.
      • Chest walleck: unremarkable.
      • Visible abdominal contents: no abnormal density in visible portion of liver, spleen, adrenal glands, pancreas, and kidney.
      • Visualized bones: marginal spurs of vertebrae.
    • Impression:
      • progressive increase in size a large RLL mass-like consolidation and bilateral lung infection (especially in LLL) as compared with previous CT study on 20210819.
  • 2021-08-19 CT - lung/mediastinum/pleura
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • s/p right upper lobe and right lower lobe op. Soft tissue like change at right lower lobe section area is found. In comparison with CT dated on 2021-04-24, the lesion decresed in size.
        • Patent airway is found.
        • Some tree in bud appearance at residual right lung is found.
        • One new nodlar lesion at right lower lobe up to 0.88cm in largest dimension. Recent inflammation is favored but follow up is suggested.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Suggest clinical correlation
    • Imp:
      • Post op. change of right upper lobe and right lower lobe
      • Tree in bud appearance at right lung, repeated inflammation is favored.
      • New nodular lesion at right lower lobe, suggest closely follow up.
  • 2021-07-24 CXR
    • Increased infiltration in right lung zone
    • Surgical stiches over right chest
    • Blunting of right CP angle
  • 2021-04-24 CT - lung/mediastinum/pleura
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • s/p op. over right upper lobe and right lower lobe
        • Some fibrotic change and tree in bud appearance at right upper lobem, right lower lobe is found.
        • Calcified coronary arteries is found.
        • Dense calcified lymph nodes are found in the mediastinum.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Suggest clinical correlation
    • Imp: post op. change at right upper lobe and right lower lobe
  • 2021-04-16 Abdominal Ultrasonography
    • Diagnosis
      • Fatty liver, mild
      • Liver cyst, small, S8
      • calcified spot of liver, S6
      • suspicious, GB stone
      • pancreatic tail masked by gas.
    • Suggestion
      • encourage exercise and diet adjustment.
  • 2020-12-30 Abdominal Ultrasonography
    • Diagnosis
      • Parenchymal liver disease, mild
      • Hepatic calcification, S6
      • Hepatic cyst, S4
      • GB polyp or stone (suboptimal study due to non-fasting status)
    • Suggestion
      • OPD follow-up
  • 2020-12-30 Brinchodilator Test
    • moderate restrictive impairment; non-significant bronchodilator response
  • 2020-10-21 MRI - brain
    • old insults in the bilateral basal ganglia.
  • 2020-10-20 MRI - c-spine
    • C3/4, C5/6 HIVDs.
    • No abnormal bony destruction.
    • No abnormal fluid collection.
• consultation
  • 2021-11-26 Hemato-Oncology
    • Q
      • This is a 64 year-old male patient presented to our emergency department due to fever. He has the following past medical history:
        • 1. HBV
        • 2. Peptic ulcer
        • 3. depression
        • 4. Polymyositis with respiratory involvement, anti-SAE1 and anti-MDA5 Antibodies positive
        • 5. Pneumonia, with respiratory failure
        • 6. COPD(2020/11/25)
        • 7. recurrent pneumonia with respiratory failure s/p prior intubation months ago
      • Apart from mild grade fever, his family members reported that he has excessive sputum. Physical examination showed positive rhonchi and tachypnea. Laboratory data did not reveal leukocytosis but U/A with mild sign of urinary tract infection with mild elevated CRP(2.90). CXR showed RML pneumonia.
      • Under the impression of recurrent pneumonia and prerenal AKI (suspected dehydration induced), he is admitted to our ward for treatment.
      • According to the CT image revealed progressive increase in size a large RLL mass-like consolidation and bilateral lung infection (especially in LLL) as compared with previous CT study on 2021/08/19. Arranged the CT guide biopsy, result malignant T-cell lymphoma. For maligant T-cell lymphoma, we are consulted.
    • A
      • Suggestion:
        • 1. Arrange PET for further work up
        • 2. Bone marrow aspiration and biopsy is indicated (suspected bone marrow involvement). We will discuss with patient and family.
        • 3. After image survey, Lumbar punture is indicated in this case. (suspected T cell lymphoma with CNS involvement). We will discuss with patient and family.
        • 4. Arrange 2D heart echo for future anthracycline base chemotherapy
        • 5. please complete baseline LDH, uric acid. (watch for tumor lysis after chmoetherapy), moreover, please check HbsAg, Anti-Hbs,Anti-Hbc, Anti-HCV
        • 6. Thanks for your consultation, we wound take over this case if you agree.
  • 2021-11-17 Radiation Oncology
    • Q
      • This time, we arranged the chest CT result progressive increase in size a large RLL mass-like consolidation and bilateral lung infection (especially in LLL) as compared with previous CT study on 2021/08/19. OPD medicines (Plavix) was hold since 2021/11/17 for prepare CT guide biopsy. We need your expertise and evaluate. Thanks!
    • A
      • This 64-year-old male patient is a case of RLL lung mass, suspected malignancy. CT-guided biopsy is indicated. Please check platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
  • 2021-11-16 Neurology
    • Q
      • Family complaint the patient conscious drowsy since 2021/11/14. We need your expertise and evaluate. Thanks!
    • A
      • O
        • Consciousness: GCS E3V1M5
        • Cranial nerve: pupil 2+/2+, VF intact, EOM: move freely; no facial palsy, on NG
        • Motor: >3/>3
        • sensory of limbs: symmetric
        • Chest CT: progressive increase in size a large RLL mass-like consolidation and bilateral lung infection (especially in LLL) as compared with previous CT study on 2021/08/19.
        • Lab: Cr: 0.86 => 3.42, CRP: 2.9
      • Impression:
        • Conscious disturbance due to infection, AKI and respiratory failure
        • Polymyositis with respiratory involvement, anti-SAE1 and anti-MDA5 Antibodies
      • Suggestion:
        • Please check CPK, Ca, Mg, P, TSH, Free T3, T4, Anti TPO and anti thyroglobulin Ab, 8AM Cortisol, ACTH, B12, Folic acid.
        • Arrange EEG
  • 2021-07-02 Infectious Disease
    • Q
      • This is a 63 year old man who was admitted to our hospital because of fever and dyspnea for several days. The patient had underlying polymyisitis, COPD and old CVA on regular OPD follow up at our hospital. Several days prior to admission to our hospital, the patient developed fever and dyspnea. He denied having diarrhea, change in the sense of smell or taste. On 2021/06/27, the patient was brought to our ER to seek medical attention.
      • Blood test showed elevated levels of CRP, lactate and WBC, while CXR revealed ground glass opacities in both lungs. Sputum culture on 2021/06/30 showed CRAP. In the following days, his fever off and on wihtout regression under the treatemtns of brosym.
      • Cr: 2.56 mg/dL
    • A
      • 1. Zavicefat for CRPA is indicated.
      • 2. Agree with your use of colimycin inhalation.
  • 2021-06-28 Infectious Disease
    • Q
      • Blood test showed elevated levels of CRP, lactate and WBC, while CXR revealed ground glass opacities in both lungs.
    • A
      • Antibiotics with brosym and cravit is suggested.
  • 2021-01-05 Rehabilitation
    • Q
      • In addition to unable to stand, we sincerely ask for your expert and ambulation training.
    • A
      • Premorbid status
        • Walk and BADL ID
      • Physical examination
        • Consciousness: E4V5M6
        • Cognition: mostly intact
        • Speech: mostly intact
        • Swallowing: oral feeding
        • Sphincter: continence
        • MP: UE: 5/5; hip and knee: 3/3; ankle: 0/0
        • Functional status: bed mobility under min A
        • BADL: feeding, grooming ID; others under mod-max A
      • Assessment
        • polymyositis with respiratory involvement with positive anti-SAE1 and anti-MDA5 antibodies
        • depression
        • GERD
        • COPD
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: improve lower extrimities endurance and muscle strength, improve transfer skills
        • Prescribe bilateral posterior AFO for him to prevent ankle contracture
  • 2020-10-23 Rehabilitation
    • Q: We need your help for arrange rehabilitation. Thank a lot!
    • A
      • 2020-10-01 NCV
        • mixed type sensorimotor polyneuropathy with bilateral lower cervical and lumbosacral radiculopathy.
      • Premorbid status
        • Unknown
      • Physical examination
        • Consciousness: E4VTM6
        • Cognition: could follow orders
        • Speech: tracheostomy
        • Swallowing: NG (+)
        • Sphincter: Foley (+), stool in diaper
        • MP: UE: 4/4, LE:2/2
        • Functional status: bed rest
        • BADL: needs max assistance
      • Assessment
        • generalized weakness especially at LEs, with difficulty weaning, suspect uncertain GBS (AMSAN), paraneoplastic polyneuropathy, critical illness polyneuropathy, inherited polyneuropathy, CIDP, MG
        • depression
        • Peptic ulcer
        • benign right lung nodule
      • Plans
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
  • 2020-10-16 Rheumatology and Immunology
    • Q
      • This 63 year old man had
        • 1. Pneumonia over bilateral (2020/09/03 Sp/C: CRPA)
        • 2. IHCA s/p CPCR s/p ET s/p extubation on 2020/09/11. Re-intubation on 2020/09/15; s/p Tr. on 2020/10/12
        • 3. Pulmonary TB s/p anti-TB agent since 2020/08/06
        • 4. Lower limbs weakness; suspected ALS or MG
      • 2020/10/02 Neurologist: generalized weakness with difficulty weaning, suspect uncertain GBS (AMSAN), paraneoplastic polyneuropathy, critical illness polyneuropathy, inherited polyneuropathy, CIDP, MG, Check autoantibodies SAE1 positive and MDA5 positive. He accepted pulse therapy medason 80mg Q8H*2day 2020/10/16-17. (Medason - methylprednisolone sodium succinate buffered 3%)
      • Due to Antibody-positive (SAE1) and anti-MDA5 antibodies positive consult evaluation. Thank you.
    • A
      • History review & physical examination were performed. Due to positive MDA5 & pulmonary fibrosis, inflammatory myopathy can’t be ruled out.
      • Suggestion:
        • 1. Treatment as current your expert’s management.
        • 2. Please check muscle enzyme, arrange EMG if no contraindication.
        • 3. Consider immunotherapy if no infectious contraindication.
        • 4. Please inform me again if there are any informative reports.
  • 2020-10-10 Anesthesiology
    • Q
      • for anesthesi evaluation
      • Hx: Depression, GERD
      • This is a 63 year-old male was admitted for impression of Pneumonia. Due to difficulted weaning of ventilator, CS was consulted and arrange tracheostomy on 2020/10/12 on call. We need your help for anesthesia evaluation.
    • A
      • Current problem:
        • 1. respiratory failure s/p ETT intubation, failure to weaning
        • 2. TB s/p medication use
        • 3. depression/ GERD
      • Plan:
        • 1. ASA: III
        • 2. Arrange GA with current ETT`
        • 3. please treat the patient’s current respiratory infection and TB under your expertise
        • 4. post-op ICU care
        • 5. inform the patient’s daughter about increasing risk of desaturation, hypotension, shock and bleeding during surgery
  • 2020-10-10 Thoracic Surgery
    • Q
      • In our hospital, PE showed right lung crackle sound. Lab data showed WBC 28140 with neutrophil 92%. Influenza screen was negative. CXR showed conslidation in the right lung field and mild blunting of right costophrenic angle. Under the impression of pneumonia with TB suspected, he is admitted for treatment and further evaluation.
      • After admission, he was treated with Brosym and TB medicins. Desaturation was noted on 2020/09/01, we changed the nasal canula to simple mask and saturation back to 94%. Blood culture was done too. CXR on 20200901 showed pneumonia progression, so we added Targocid. Sputum culture was collected on 20200902. Diamox (acetazolamide) 1# TID was added for 2 days on 20200902 due to metabolic akalosis. On 20200903 midnight, loss of consciousness with dyspnea was noted. Hypercapnic respiratory failure and septic shock was impressed. Assystole also occured, s/p CPCR for 1 min. Intubation was also done. And he was transfer to ICU for further care.
      • After transferred to ICU, he received inotropic agents, anti-TB agent with Akurit4 plus vit B6 since 20200806. However, fever developed was happened, discontinued Targocid (20200903~0910) and Mepem (20200903~0907), ex-change to Fortum (0907-0913) plus Colimycin IV(0907-0914) for sputum culture revealed CRPA. Adequate IV fluid for polyuria and albumin transfusion for hypoalbuminemia. Episode of persisted fever was also note and still S/C yiled CRPA, ex-change antibiotic to Mepem since 0913 was prescribed. Ventilator weaning then extubation on 20200911 under Mask full supply. But, weakness of cough reflex and elevation breathing work and desaturation were also note, re-intubation on 20200915 with ventilator supply. IV Colimycin since 20200916 was added for fever and S/C yiled CRPA, shifted to INHL on 20200922. Lower limbs weakness consider HIVD relate. Added Plavix for old CVA. RCC was consculted due to ventilator difficlut weaning and bedside rehabilitation, but hold scheduled due to fever and hematuria.
      • Arrange lower NCV study for persist lower limbes weakness,that report showed mixed type sensorimotor polyneuropathy with bilateral lower cervical and lumbosacral radiculopathy.
      • For difficult weaning ventilator ,so we need your help for tracheostomy evaluation. Thanks!
    • A
      • I will arrange tracheostomy for this patient after explained about risk and benefit next Monday. Thanks for your consultaiton.
  • 2020-10-02 Neurology
    • A
      • S
        • For persisted lower limb waeaknss and difficulty weaning, we were consulted for further evaluation.
        • According to the statment of his family, he complained of right chest/axillary pain (stabbing, intermittent with progressing frequency and intensity) over 10+ years. Before he was admited to ShuangHo Hospital this July, he complained of distal numbness with pain for a while. His wife mentioned of easily awakenend during sleep with limbs movment for 30 years, profuse sweating upon movmenet for many years were also menetioned. Weight loss about 20 kg within a year, with decreased appetite and altered taste. Denied urine retention, changed urine color, costipation, tachycardia, choking, dysarthria, tremor or other involuntary movements, travel or contact history.
          
        • From ShuangHo Hospital medical records, polyneuropathy was impressed with EMG myopathic findings. In addition, porphyria was highly suspected from positive finding in screening test and the result should be persuit.
        • 2020-10-01 NCV: mixed type sensorimotor polyneuropathy with bilateral lower cervical and lumbosacral radiculopathy.
      • O
        • Personal Hx:
          • denied toxic exposure history (contacted with acetone 20 years ago),
          • smoking (+, 1 PPD for 40 years)
          • alcohol 3-4 times per week/beer*10 bot, quit recently
          • denied family hx
        • NE: E4VTM6, cachexia, could answer by hand writing and gesture
        • EOM: free, no limitations
        • Nuchal rigidity : + (?)
        • CNS: noraml light reflex, symmetry CN5 sensations, normal pursuit and saccade, nystagmus (-), diplopia (-, intermittent as the patient stated)
        • Msucle atrophy and wasting
        • tone: soft and symmetric
          
        • power:
          • UE R/L: 3-4
          • LE R/L: Prox3Dis2/Prox3Dis2
        • DTR:
          • UE R/L: 2+/2+
          • LE R/L: -/-
        • Babinski: no response/no response
        • Sensation: bilateral lower limbs decreased with allodynia (?)
      • Impression: generalized weakness with difficulty weaning, suspect uncertain GBS (AMSAN), paraneoplastic polyneuropathy, critical illness polyneuropathy, inherited polyneuropathy, CIDP, MG
      • Suggestion:
        • check ACHR antibody to rule out MG and check Fabry disease serum check-up
        • persuit porphyria result
        • consider to repeat CSF study including self-paid exam including paraneoplastic autoantibiodies (the fee was about NT 30000)
        • consider to repeat tumor marker survey if CSF study repeated
        • Contact us if any questions and thank you for consultation.
  • 2020-09-24 Gastroenterology
    • A
      • Treat pneumonia
      • Survey the etiology elevated CA125 in “Male” patient (?)
      • Elective panendoscopy and colonoscopy after transfer to general ward under stable condition
  • 2020-09-18 Thoracic Medicine
    • Q
      • This time, due to ventilator diffcilut weaning, need your evaluation ventilator traning, thanks a lot!
    • A
      • After transfer to ICU, he received inotropic agents, antiTB agent with Akurit4 plus vit B6 since 20200806. However, fever developed, antibiotic with Targocid (teicoplanin) 9/3~9/10 and Mepem (meropenem) 9/3~9/7 shift to Fortum (ceftazidime) + colimcyin IV form (9/7~)for sputum culture revealed CRPA, blood transfusion for anemia. adequate IV fluid for polyuria and albumin transfusion for hypoalbuminemia. Ventilator weaning then extubation on 2020/09/11 under Mask full supply. But, weakness of cough reflex and elevation breathing work and desaturation were also note, re-intubation on 2020/09/15 with ventilator supply.
      • Transfer to RCC next week if bed available
  • 2020-09-03 Infectious Disease
    • Q
      • A 64 y/o male under the diagnosis of progressing pneumonia with septic shock + ARDS s/p ETT +MV and CPCR for 1 min despite under Targocid + Brosym. Long term hospitalization(transfered from ShuangHo Hospital), VAP first considered, but atypical pneumonia is also considered due to prolong disease course. Mepem + Cravit for septic shock and atypical coverage, thank you!
    • A
      • Consultation for Mepem antibiotic.
      • S/O
        • A 63-yeara-old suspect pulmonary TB male patient has severe both-lung pneumonia with pneumonia progression despite Brosym and anti-TB medications.
        • Persistent fever is noted during hospitalization, followed by respiratory failure and severe sepsis.
        • White count up to 29130 this early morning, with high CRP level 29.46 and hyperlactatemia.
        • Sputum culture shows normal flora only.
        • Brosym is replaced by Mepem, Cravit, and Targocid now.
      • Suggestion:
        • 1. Continue the present antibiotic regimen for one week first.
        • 2. Send sputum for TB-PCR and check serum fungal Aspergillus and Cryptococcal antigen titer.
• chemoimmunotherapy
  • 2022-05-10 ~ undergoing - CHOP (cylcophosphamide + doxorubicin + vincristine + prednisolone)
  • 2021-12-06 ~ 2022-03-22 - COP (cylcophosphamide + vincristine + prednisolone)
  • 2021-09-27 - Rituximab

[note]

• The disease should be subtype Peripheral T-cell lymphoma (PTCL), not otherwise specified (NOS)?

• T-Cell Lymphomas NCCN EB Version 2.2022 - March 7, 2022, p13

  • For PTCL-NOS histologies, preferred regimens (alphabetical order)
    • Brentuximab vedotin + CHP (cyclophosphamide, doxorubicin, and prednisone) for CD30+ histologies
    • CHOEP (cyclophosphamide, doxorubicin, vincristine, etoposide, prednisone)
    • CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone)
    • Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin)

• Restage after 3-4 cycles with PET/CT (preferred) or C/A/P CT scan with contrast

• Recommended Adult Immunization Schedule — United States, 2012 ( https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm )

  • Pneumococcal polysaccharide (PPSV) vaccination
    • Vaccinate all persons with the following indications:
      • age 65 years and older without a history of PPSV vaccination;
      • adults younger than 65 years with chronic lung disease (including chronic obstructive pulmonary disease, emphysema, and asthma); chronic cardiovascular diseases; diabetes mellitus; chronic liver disease (including cirrhosis); alcoholism; cochlear implants; cerebrospinal fluid leaks; immunocompromising conditions; and functional or anatomic asplenia (e.g., sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]);
      • residents of nursing homes or long-term care facilities; and
      • adults who smoke cigarettes.
    • Persons with asymptomatic or symptomatic HIV infection should be vaccinated as soon as possible after their diagnosis.
    • When cancer chemotherapy or other immunosuppressive therapy is being considered, the interval between vaccination and initiation of immunosuppressive therapy should be at least 2 weeks. Vaccination during chemotherapy or radiation therapy should be avoided.

[to be discussed]

• This patient has a history of COPD, polymyositis involving the respiratory system, would be more susceptible to respiratory infections. No Pneumococcal vaccination records found in HIS5. Locally available pneumococcal conjugate vaccines (PCV) and pneumococcal polysaccharide vaccines (PPV) are not live attenuated vaccines.
• As long as prior vaccination has not been received and there is no contraindication, vaccination could be an option when the disease is relatively stable. ( https://www.cdc.gov.tw/File/Get?q=66HT6AZdVjKmPmyJ9OclbE7fSUNF8o6T2nY3X4twcs645z0sPVYF-Bs9hyzud3ouyA0NF3_ytXiBg8vfMLUoeu1uOfFQUFxf9Ng_s1D2kkA2xEAnPozcYeqUsprymjFpcqOVZOxJeW8xojXUSe2bgA )

[assessment]

• Nexium (esomeprazole) must not be ground. Please open the capsure and pouring out the small granules and dissolved them in adequate drinking water prior to tube feeding.

220602

[assessment]

• The pathology reports (2021-11-22, 2021-12-02) did not specify CD30, ALK (anaplastic lymphoma kinase) or ALCL (anaplastic large cell lymphoma) subtype information.
• If CD30 is confirmed positive, brentuximab vedotin may prove beneficial.
• Past history of polymyositis has been linked to an increased incidence of cancer. reference:
  • Risk of Malignancy in Dermatomyositis and Polymyositis. https://pubmed.ncbi.nlm.nih.gov/27534779/
  • Cancer risk in dermatomyositis: a meta-analysis of cohort studies. https://pubmed.ncbi.nlm.nih.gov/25721032/
  • Polymyositis/dermatomyositis and malignancy risk: a metaanalysis study. https://pubmed.ncbi.nlm.nih.gov/25448790/
• Low HGB level (8.7 g/dL 2022-06-01) combined with underlying COPD might limit ventilation and/or oxygenation, please be aware of low oxygen symptoms.

701150775

220714

{pancreatic neck adenocarcinoma,cT1cNXM1, stageIV, with retroperitoneal spread status post Roux-en-Y hepatico-jejunostomy and cholecystectomy}

[objective]

• exam findings
  • 2022-03-30 CT - abdomen, pelvis
    • pancreatic neck cancer with vessel encasement and lymph nodes metastases show mild decreasing in size.
  • 2022-01-26 CT - abdomen, pelvis
    • pancreatic neck cancer with vessel encasement, lymph nodes metastases, and lung metastases.
  • 2022-01-06 Patho - F2022-00006
    • soft tissue, retroperitoneal, biopsy - metastatic adenocarcinoma, consistent with pancreas origin
    • section shows fibroadipose tissue and nerve bundles with metastatic adenocarcinoma. perineural invasion is seen.
    • IHC: CK7(+), CK20(-), and CK19(+).
    • the morphology and immunohistochemical stains are consistent with pancreas origin.
  • 2021-12-14 Patho -
  • 2021-12-03 Endoscopic Ultrasonography, EUS
    • pancreatic genu tumor s/p CH-EUS & EUS/FNB
    • lymphadenopathy, beside hepatic hilum
    • reflux esophagitis LA classification grade A
  • 2021-12-02 Ultrasound - abdomen
    • pancreastic head tumor with lymphadenopathy
    • GB sludge with distension
    • CBD dilatation
    • fatty liver, mild
  • 2021-11-30 MRI - pancreas
    • a faint enhancing tumor (1.2cm) at pancreatic body with distal p-duct dilatation.
    • some LNs around celiac trunk and proximal SMA.
    • dilatation of biliary tree suspected distal CBD lesion.
    • inhomogeneous intensity of pancreatic head.
  • 2021-11-25 CT - abdomen, pelvis
    • suspected pancreatic body cancer with distal pancreatic duct dilatation.
    • T4N1M0
• chemotherapy
  • 2022-01 ~ ongoing: FOLFIRINOX
    • FOL: folinic acid (leucovorin), a vitamin B derivative that enhances the effects of 5-fluorouracil (5-FU);
    • F: fluorouracil, a pyrimidine analog and antimetabolite which incorporates into the DNA molecule and stops DNA synthesis;
    • IRIN: irinotecan, a topoisomerase inhibitor, which prevents DNA from uncoiling and duplicating; and
    • OX: oxaliplatin, a platinum-based antineoplastic agent, which inhibits DNA repair and/or DNA synthesis.

[assessment]

• ALT (2022-07-13) was 117 U/L, the dose of irinotecan has been reduced to 150 mg/m2.

220420

[assessment]

• FOLFIRINOX is a chemotherapy regimen that is used to treat advanced pancreatic cancer. The patient is undergoing the regimen since Jan 2022.
• 2022-03-30 updated CT images showed a mild decrease in the size of the tumor, indicating that current treatment is working. However, CA-199 (137U/mL 2022-04-06) remained above the upper limit of normal, and should be noted.
• S-GPT/ALT elevated since late March (126U/L 2022-04-19), if bilirubin also elevates up to 1.5mg/dL, then the dosage of irinotecan should be lowered.
• Some targeted therapeutic agents might be an option if no contraindication
  • pembrolizumab for MSI-H or dMMR cases.
  • larotrectinib/entrectinib for NTRK gene fusion positive cases.

220215

[assessment]

• FOLFIRINOX is a chemotherapy regimen for treatment of advanced pancreatic cancer. the patient is on this regemen, which is made up of the following four drugs:
  • FOL: folinic acid (leucovorin), a vitamin B derivative that enhances the effects of 5-fluorouracil (5-FU);
  • F: fluorouracil, a pyrimidine analog and antimetabolite which incorporates into the DNA molecule and stops DNA synthesis;
  • IRIN: irinotecan, a topoisomerase inhibitor, which prevents DNA from uncoiling and duplicating; and
  • OX: oxaliplatin, a platinum-based antineoplastic agent, which inhibits DNA repair and/or DNA synthesis.
• some targeted therapeutic agents might be considered if no contraindication
  • pembrolizumab for MSI-H or dMMR cases.
  • larotrectinib/entrectinib for NTRK gene fusion positive cases.

701374548

220714

{DLBCL}

• lab data
  • 2022-05-24 HBsAg(核醫) Negative
    
  • 2022-05-24 HBsAg Value(核醫) 0.399
    
  • 2022-05-23 Anti-HBs 0.14 mIU/mL
    
  • 2022-05-23 Anti-HBc Nonreactive
    
  • 2022-05-23 Anti-HBc-Value 0.15 S/CO
    
  • 2022-05-23 Anti-HCV Nonreactive
    
  • 2022-05-23 Anti-HCV Value 0.06 S/CO
• exam finding
  • 2022-06-21 2D transthoracic echocardiography
    • 1. Normal LV systolic function with normal wall motion.
    • 2. Normal LV diastolic function.
    • 3. Normal RV systolic function.
    • 4. Typical mitral valve prolapse (bileaflet) with trivial MR; mild TR.
  • 2022-05-26 Whole body PET scan
    • 1. Glucose hypermetabolism in the right inferior buccal region, compatible with diffuse large B-cell lymphoma.
    • 2. Increased FDG accumulation in bilateral kidneys, probably physiological uptake of FDG.
         
    • 3. Diffuse large B-cell lymphoma, stage I (AJCC, 8th ed.), by this F-18 FDG PET scan.
  • 2022-05-24 Patho - bone marrow biopsy
    • Bone marrow, biopsy — No evidence of lymphoma involvement
    • The sections show normocellular marrow (35%). M/E ratio = 5:1. The myeloid cells show good maturation with mild neutrophilia. The megakaryocytes are normal in number and morphology. The erythoid precursors are not remarkable.
    • IHC, scattered small CD3+ T-cells and CD20+ B lymphocytes in interstitium and no lymphoid aggregates can be found. There is no evidence of lymphoma involvment in the sections examined. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2022-05-18 Patho - salivary gland biopsy
    • pathologic diagnosis
      • 1. Tumor, R’t buccal mucosa, excision — Diffuse large B-cell lymphoma
      • 2. Residual tumor, ditto — Diffuse large B-cell lymphoma and reactive lymph nodes
    • microscopic examination
      • Main tumor: diffuse large B-cell lymphoma shows medium to large atypical lymphoid cells with mitoses and occasional nucleoli.
        • Immunohistochemistry shows CD3(-), CD20(+), cyclin-D1(+, focal ), Bcl-2(+), CK(-), CD10(-), Bcl-6(+), C-MYC(-) and Ki-67: 80% for tumor.
        • According to all above histopathologic findings, it indicates a case of diffuse large B-cell lymphoma.
      • Residual tumor: one node showed diffuse large B-cell lymphoma as well as two reactive lymph nodes.
  • 2022-05-17 MRI - nasopharynx
    • Clinical information: suspected adenoma of right mandible.
    • Findings:
      • 1. One well-defined mass lesion (5.0cm in length) over right mandibular space, showing high-signal intensity on T2WI and homogeneous enhancement. Favor a soft tissue lesion. Suggest tissue proof.
      • 2. Normal appearance of both mastoid air-cells.
      • 3. Clear appearacne of all paranasal sinuses.
  • 2022-05-16 ECG
    • Normal sinus rhythm
    • Possible left atrial enlargement
  • 2022-05-16 CxR
    • No cardiomegaly
    • No active lung lesion
    • Normal bony contour
• consultation
  • 2022-05-23 Hemato-Oncology
    • Q
      • For evaluation and further management of diffuse large B-cell lymphoma
      • This is a 40-year-old female suffering from a painless mass over right lower face and was admitted on 2022/05/16 for surgical management.
      • According to her statement, she noted a painless mass at her right lower face about 6 months and the tumor was growing rapidly within past few months, she came to our OS OPD for help on 2022/04/26. Physical examination showed a mobile, painless lump at the right buccal-retromolar area, about 3.5 cm in size. No sensory change or numbness was complained by the patient. Under the impression of adenoma of right mandible, she underwent excision of oral tumor under general anesthesia on 2022/05/18. Post-operatively, mild sensory disturbance over right chin was reported by the patient. However, the pathological report showed diffuse large B-cell lymphoma of right mandible. Thus, we need your expertise for further evaluation and management. Thanks for your time.
    • A
      • Impression:
        • right buccal diffuse large B-cell lymphoma
      • Suggestion:
        • 1. Arrange PET scan for staging and port A insertion
        • 2. Please check HbsAg, Anti-Hbc, Anti-HCV, LDH
        • 3. We will arrange bone marros aspiration and biopsy on 2022/05/24
        • 4. After above was done, please arrange our hematology OPD
        • 5. Thanks for your consultation.
• chemoimmunotherapy
  • 2022-06-22 ~ undergoing - R-CHOP (Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)

[assessment]

• DLBCL stage I, PS 0, IPI score 0; lab data on 2022-07-13 and TPR, BP, SpO2 during this hospitalization were generally normal.
• R-CHOP treatment has been provided to the patient since 2022-06-22 without any known issue.

700948877

220711

{Left overain cacner, High grade serous carcinoma, with liver mrtastasis, s/p Debulking surgery}

• diagnosis
  • 1. Malignant neoplasm of left ovary
  • 2. Left overain cacner, High grade serous carcinoma, with liver mrtastasis, s/p Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy) on 2022/05/19, T3cN0M1b, FIGO Stage: IVB
  • 3. Chronic viral hepatitis B without delta-agent
• lab data
  • CA125
    • 2022-06-29 51.7 U/mL
      
    • 2022-05-28 281.5 U/mL
      
    • 2022-05-05 678.3 U/mL
• exam finding
  • 2022-06-29 SONO - abdomen
    • Liver tumor, S4 and S7, suspected hemangioma
    • GB stone
  • 2022-06-16 Pure tone audiometry, PTA
    • Reliability FAIR
    • Average RE 36 dB HL; LE 31 dB HL.
    • R’t normal to moderately severe SNHL.
    • L’t normal to moderate SNHL. - 2022-06-13 CXR
    • Blunted right costophrenic angle.
  • 2022-05-19 Patho - ovary (tumor)
    • Diagnosis:
      • A: Lymph node, right iliac, dissection — Negative for malignancy (0/4)
        • Soft tissue, right iliac, excision — Metastatic serous carcinoma
      • B: Lymph node, right obturator, dissection — Negative for malignancy (0/5)
      • C: Lymph node, left iliac, dissection — Negative for malignancy (0/4)
      • D: Uterus, corpus, total hysterectomy — Negative for malignancy — Leiomyoma
        • Uterus, cervix, total hysterectomy — Negative for malignancy
        • Uterus, endometrium, total hysterectomy — Negative for malignancy
      • E: Ovary, right, oophorectomy — Metastatic serous carcinoma seeding on serosa
        • Fallopian tube, right, salpingectomy — Metastatic serous carcinoma seeding on serosa
      • F: Ovary, left, oophorectomy — High grade serous carcinoma
        • Fallopian tube, left, salpingectomy — Serous tubal intraepithelial carcinoma
      • G: Peritoneum, excision — Metastatic serous carcinoma
      • H: Omentum, infracolic omentectomy — Metastatic serous carcinoma
        
      • AJCC 8th edition: pStage IIIC, pT3cN0(if cM0), FIGO Stage: IIIC
        • or pStage IVB, pT3cN0(if cM1b), FIGO Stage: IVB
    • Microscopic Description:
      • 1. Histologic Type:
        • Left ovary: High-grade serous carcinoma; The immunohistochemical stains reveal CK(+), PAX8(+), p53(aberrant expression (complete loss of expression)), WT-1(+), PR(-), and Napsin A(-).
        • Left fallopian tube: Serous tubal intraepithelial carcinoma (STIC) (0.2 x 0.1 mm)
      • 2. Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors): not available
           
      • 3. Implants (required for advanced stage serous/seromucinous borderline tumors only): not available
           
      • 4. Other Tissue/ Organ Involvement (select all that apply): bilateral ovaries and fallopian tubes, peritoneum, omentum, right iliac soft tissue
           
      • 5. Largest Extrapelvic Peritoneal Focus (required only if applicable): Macroscopic (greater than 2 cm)
      • 6. Peritoneal/Ascitic Fluid: N2022-01890: Negative for malignancy (normal/benign)
           
      • 7. Regional Lymph Nodes: right iliac: 0/4; right obturator: 0/5; left iliac: 0/4
      • 8. Additional Pathologic Findings: Leiomyomas are seen.
  • 2022-05-19 Patho - colorectal polyp
    • Colon, D-colon, s/p hot snare polypectomy — Tubulovillous adenoma with low grade dysplasia.
  • 2022-05-19 Patho - stomach biopsy
    • Stomach, low body, GC, s/p biopsy removal — Hyperplastic polyp
  • 2022-05-11 Gynecologic Ultrasonography
    • Pelvis mass: (1) 146x108mm, (2) 34.20mm
  • 2022-05-05 Gynecologic Ultrasonography
    • Multiple huge pelvic mass, the largest one is about 11.4x9.4cm without flow
  • 2022-05-04 CT - liver, spleen, biliary duct, pancreas
    • Findings:
      • 1. There is a well-defined lobulated heterogeneous mass in the uterine fossa, measuring 14.2 cm in size (the largest dimension), and non-visualization of the normal uterus.
        • Leiomyosarcoma of the uterus is highly suspected.
        • The differential diagnosis include ovarian cancer.
        • Please correlate with CA125.
      • 2. There is ascites and smudggy appearance of the omentum that may be carcinomatosis? Please correlate with ascites cytology.
      • 3. There are two well-defined poor enhancing masses measuring 3 cm in S7 and 1.4 cm in S8 of the liver capsule area with capsule defect that may be tumor seeding with indentation the liver capsule.
        • The differential diagnosis include liver metastases.
      • 4. There is are several enlarged nodes in para-aortic space that may be metastatic nodes.
      • 5. S/P Chest tube insertion, right.
        • Mild left side Pleura effusion is noted.
    • Impression:
      • 1. Leiomyosarcoma of the uterus is highly suspected.
        • The differential diagnosis include ovarian cancer.
        • Please correlate with CA125.
      • 2. Carcinomatosis is highly suspected.
        • Please correlate with ascites cytology.
      • 3. Tumor seeding in S7 & S8 of the liver capsule are suspected.
        • The differential diagnosis include liver metastases.
      • 4. Metastatic nodes in para-aortic space are suspected.
  • 2022-05-04 CXR
    • resolution of Rt pleural effusion s/p chest tube and pigtail drain placement
    • small Lt pleural effusion
  • 2022-05-03 SONO - abdomen
    • IMP: Gallbladder stones (0.74cm, 0.76cm, 0.70cm).
  • 2022-05-02 Patho - lung wedge biopsy
    • A: Pleura, right, excision — chronic inflammation
    • B: Pleura, right, cyst, excision — cyst with chronic inflammation
    • C: Lung, RLL, wedge resection — pleural fibrosis and chronic inflammation
  • 2022-05-02 CXR
    • signficiant regression of Rt pleural effusion s/p chest tube and pigtail drain placement
    • small Lt pleural effusion
  • 2022-05-01 CXR
    • progression of moderate Rt pleural effusion as compared with previous image
    • thoracic aortic arch calcified atheriosclerotic plaque
    • small Lt pleural effusion
  • 2022-04-22 CT - lung/mediastinum/pleura
    • Massive right pleural effusion and mild left pleural effusion with consolidation over right lower lobe and left lower lobe
    • Hepatic low density lesion.
  • 2022-04-13 CXR
    • regression of Rt pleural effusion as compared with previous image
    • Linear band subsegmental atelectasis at Lt lung base
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2022-04-06 Cell block cytology
    • pathologic diagnosis
      • Dense inflammation, reactive change
        
    • macroscopic examination
      • 50 cc red turbid right pleural effusion
    • microscopic examination
      • Immunocytochemistry shows TTF-1(-), Napsin-A(-), P40(-), CK7(-) and calretinin(-) for carcinoma.
  • 2022-04-06 CXR
    • moderate Rt pleural effusion
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • mild enlarged cardiac silhoutte
    • mild levoscoliosis of the spine
      
  • 2022-04-06 SONO - chest
    • pleural effusion, moderate to massive, right
    • consolidation, RLL
  • 2022-04-01 Bronchodilator test, BT
    • Moderate restrictive lung defect without significant reversibility
  • 2022-03-30 SONO - abdomen
    • parenchymal liver disease
    • liver hemangioma, S8
    • GB stone
    • pancreatic head masked by gas
    • ascites, minimal
    • pleural effusion, bilateral
  • 2022-03-22 Thyroid Ultrasound
    • Goiter
  • 2022-03-03 SONO - chest
    • pleural effusion, trivial amounts
    • high risk of pneumothorax during chest tapping
    • hold chest tapping procedure
  • 2022-03-02 CXR
    • Rt subpulmonary effusion or Linear band subsegmental atelectasis at lung base
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
    • mild levoscoliosis of the spine
      
  • 2021-09-29, 2021-03-01, 2020-08-03, 2020-02-23 SONO - abdomen
    • Diagnosis
      • GB stones
      • Hepatic tumor, suspect hemangioma, S8
      • Probable parenchymal liver disease
      • Suspect renal stones, right
    • Suggestion
      • Please follow sonography in 3-6 mon
      • Please check tumor, hepatitis markers and LFTs q3-6 mon
  • 2018-08-28 CT - abdomen
    • Small heaptic lesion at surface up to 1.9cm with marginal enhancement and filling in change is found. Hemangioma is considered.
  • 2019-07-29, 2019-01-28, 2018-07-30, 2018-01-10 SONO - abdomen
    • Parenchymal liver disease
    • Liver tumor, nature?
    • Fatty infiltration of pancreas
    • GB stones
  • 2017-06-26 SONO - abdomen
    • Diagnosis
      • suspect liver parenchyma disease, incomplete exam of liver
      • liver tumor suspected hemangioma
      • gallstones
  • 2017-01-09 SONO - abdomen
    • Suspected, Parenchymal liver disease
    • GB stone
    • Suspected, Parenchymal renal disease
• consultation
  • 2022-05-04 Obstetrics and Gynecology
    • Q
      • This 69 y/o woman with past hx of uterine myoma was admitted due to right pleural effusion. Three dimensional video-assisted thoracic surgery with right lower lung wedge resection, pleurodesis and pleural biopsy was done on 2022-05-02.
      • Urinary frequency was noted inrecent months. Body weight loss 5 kg was noted in 2 months. She denied abdominal pain, fullness, nor vaginal bleeding.
      • Abdominal CT on 2022-05-04 revealed a well-defined lobulated heterogeneous mass in the uterine fossa, measuring 14.2 cm in size (the largest dimension), and non-visualization of the normal uterus. Leiomyosarcoma of the uterus is highly suspected. The differential diagnosis include ovarian cancer.
      • Under the impression of suspected leiomyosarcoma of the uterus and ovarian cancer, we would like to consult you for evaluation.
    • A
      • S
        • 69 y/o, female, G4P3 (NSDx3)
        • Admitted on 2022/05/01 for VATS (Video-Assisted Thoracic Surgery)
        • Hx: s/p 3D VATS RLL wedge + pleurodesis + pleural biopsy on 2022/05/02
      • O
        • Abdominal CT on 5/4 revealed a well-defined lobulated heterogeneous mass in the uterine fossa
        • weight loss 5kg in 2months
        • WBC: 7510, Hb: 12.1
        • CT:
          • 1. Leiomyosarcoma of the uterus is highly suspected.
            • The differential diagnosis include ovarian cancer.
            • Please correlate with CA125.
          • 2. Carcinomatosis is highly suspected.
            • Please correlate with ascites cytology.
          • 3. Tumor seeding in S7 & S8 of the liver capsule are suspected.
            • The differential diagnosis include liver metastases.
          • 4. Metastatic nodes in para-aortic space are suspected.
        • sono: Multiple huge heterogenous pelvic mass, the largest is about 11.4x9.4cm without flow
        • CDS: no fluid
      • IMP:
        • Suspect uteine malignancy or ovarian cancer
      • P:
        • Please check CA125, CA199, CEA, SCC
        • OPD follow after 1 week
• surgical operation
  • 2022-05-19
    • Surgery
      • Diagnosis
        • Ovarian tumor suspected malignancy with intraperitoneal seeding and liver metastasis
      • Operation
        • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)     - Finding
      • Ovarian tumor, suspected malignancy.
      • Frozen: not performed
      • 1. Supraumbilical midline vertical skin incision
      • 2. Uterus: normal size, dense contact with bladder
      • 3. Adnexa:
        • LOV: 14x10cm, capsule intact, adhesion to bowels and posterior uterine wall; intraoperative rupture (+) with papillary contents and necrotic tissue.
        • ROV: 5x4 cm, capsule not intact,adhesion to bowels and posterior uterine wall; intraoperative rupture (+) with papillary contents
        • Fallopian tube: bilateral engorged
      • 4. CDS: invisible due to tumor mass occupied, totally obliterated
      • 5. Ascites: bloody, about 300 ml, cytology was performed
      • 6. Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
        • s/p dissection of right iliac LNs, right obturator LNs and left iliac LNs
      • 7. Omentum: infracolic omentectomy was done.
      • 8. Liver: miliary tumor seeding(+), bean sized over liver surface
        • Subdiaphragmatic surface: miliary tumor seeding(+), bean sized
      • 9. Appendix: not seen
      • 10. After the operation, suboptimal debulking surgery was achieved.
      • 11. Residual tumor: multiple tumor seeding over rectum, peritoneal wall s/p partial excision; suspected liver and subdiaphragmatic miliary tumor seeding
      • 12. Partial intestine bowels adhesion
      • 13. Due to the intestine was soaking in the ascites fluid, inflammation was noticed
      • Estimated blood loss: 1200ml (neovascular oozing)
      • Blood transfusion:s/p blood transfusion with pRBC 2u
      • Complication: none       
      • abdominal drainage tube x1 at right CDS
  • 2022-05-02
    • Surgery
      • 3D VATS RLL wedge + pleurodesis + pleural biopsy.
    • Finding
      • 1. One nodualr lesion was noted over RLL, suspected intrapulmonary LN. A mount of pleural effusion was also noted over right pleural cavity, about 1450mL.
      • 2. One 24 Fr. straight chest tube and 14 Fr. pig-tail was inserted via right 8th ICS.
• chemoimmunotherapy
  • 2022-06-17 paclitaxel + carboplatin + bevacizumab

701359667

220708

{Endometrium neuroendocrine carcinoma, pT2pN0M0, FIGO stage II s/p Staging surgery(ATH + BSO + omentectomy + LN dissection) on 2022/02/14}

[objective]

• exam finding
  • 2022-05-26 CT - abdomen, pelvis
    • Findings:
      • S/P hysterectomy.
      • Left renal stone (3mm).
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P hysterectomy.
      • No evidence of tumor recurrence.
  • 2022-03-07 Pure tone audiometry, PTA
    • Reliability FAIR
    • Average RE 43 dB HL; LE 111 dB HL.
    • R’t mild to moderately severe SNHL.
    • L’t moderately severe to profound mixed type HL.
  • 2022-02-14 Patho - uterus with or without SO non-neoplastic/prolapse
    • PATHOLOGIC DIAGNOSIS
      • Uterus, endometrium, total hysterectomy — Neuroendocrine carcinoma.
      • Uterus, myometrium, total hysterectomy — Neuroendocrine carcinoma. Invading > 1/2 thickness of the myometrium and 0.4 cm from serosal surface.
      • Uterus, cervix, total hysterectomy — Neuroendocrine carcinoma. Invading endocervix.
      • Ovaries and fallopian tubes, bilateral, BSO — Free
      • Lymph node, bilateral pelvic and para-aortic, dissection — Free
        
      • pT2 pN0 (if cM0) AJCC 8th edition Pathology FIGO stage: II, at least.
        
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: Staging surgery(ATH + BSO + omentectomy + LN dissection)
        
      • Specimens include: uterus, bilateral adnexae, bilateral pelvic and para-aortic lymph nodes.
    • MICROSCOPIC EXAMINATION
      • Histology type: Large cell neuroendocrine carcinoma
      • Histology grade: high grade.
      • Depth of invasion: invade > 1/2 thickness of the myometrial wall
        
      • Uterine Serosa Involvement - Not identified
      • Cervical Stromal Involvement - Present
      • Other Tissue/ Organ Involvement - Not identified
      • Bilateral, ovary: free
      • Bilateral, fallopian tube: free
      • Omentum: free
      • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
        • Ectocervical/Vaginal Cuff Margin: Free 2.5 cm away
    • Parametrial/Paracervical Margin: Free
      • Lymphovascular Invasion: Present
      • Regional Lymph Nodes: free
      • Ancillary Studies - S2022-02021: IHC stains: CD56 (+), Ki-67: 30-40%, p40 (-), WT-1 (-), vimentin (focal +), p16: <70%.
  • 2022-02-11 Whole body PET scan
    • A prominent glucose hypermetabolic lesion in the uterus, compatible with primary endometrial malignancy.
    • A small focal area of mildly increased FDG uptake in the right lateral aspect of the pelvic cavity. The nature is to be determined (a metastatic lymph node of low FDG uptake? other nature such as inflammation?). Please correlate with other imaging modalities for further evaluation.
    • Increased FDG accumulation in both kidneys, right ureter and intestine. Physiological FDG accumulation is more likely.
  • 2022-02-09 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, D&C — Neuroendocrine carcinoma.
    • IHC stains: CD56 (+), Ki-67: 30-40%, p40 (-), WT-1 (-), vimentin (focal +), p16: <70%.
    • Section show(s) piece(s) of markedly necrotic tissue with infiltration of sheets, nests, and trabeculae of round blue neoplastic cells demonstrating pleomorphic nuceli.
  • 2022-02-07 MRI - pelvis
    • Suspected endometrial malignancy, cstage T1bN2M0. IIIc.
    • Uterine myoma, in cervical region.
  • 2022-02-04 Gynecologic ultrasonography
    • Endometrial thickening (EM:43.8mm)
    • Uterine myoma
• lab data
  • 2022-02-26 Chromogranin A 52.1 ng/mL
    
  • 2022-02-24
    • Anti-HBs 9.49 mIU/mL
      
    • Anti-HBc Reactive
      
    • Anti-HBc-Value 4.50 S/CO
      
    • Anti-HCV Nonreactive
      
    • Anti-HCV Value 0.02 S/CO
      
    • HBsAg Nonreactive
      
    • HBsAg (Value) 0.35 S/CO
      
  • 2022-02-13
    • Blood type ABO B
      
    • RH(D) Positive
• surgical operation
  • 2022-02-14
    • Surgery
      • Diagnosis: endometrial malignancy, staging surgery. suspected endometrial malignancy, cstage T1bN2M0. III
      • Operation: Staging surgery (ATH + BSO + omentectomy + LN dissection)     - Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder, peritoneum dut to tumor mass accupied.
      • Adnexa:
        • LOV: 3x2x2cm, grossly normal
        • ROV: 2x2x2cm, grossly normal
        • Fallopian tube: bilateral grossly normal
        • CDS: mild adhesion
        • Ascites: 10 ml
        • Bilateralpelvic lymph nodes: normal(-), enlarged(-), indurated(+, right para aortic area)
        • Omentum: grossly normal
        • Liver: grossly normal and smooth
        • Appendix: not seen
        • After the operation, optimal debulking surgery was achieved.
        • Residue tumor: R0, No residual tissued left as we seen.
        • Estimated blood loss: 400ml
        • Blood transfusion: nil
        • Complication: nil
  • 2022-02-09
    • Surgery
      • Diagnosis: MRI reported suspect EM malignancy, cstage T1bN2M0
      • Operation: Diagnostic dilatation and curettage for pathology     - Finding
      • Uterus: anteversion/retroversion, sounding: 8 cm, dilatation to Hegar No. 9.
      • Some endometrial tissus was curetted from endometrial cavity.
      • Estimated blood loss: 3 ml , Blood transfusion: nil, Complication: nil.
• Radiotherapy
  • 2022-03-18 ~ - 4500cGy/25 fractions of the pelvic area.
• Chemoimmunotherapy
  • 2022-03-09 ~ undergoing - etoposide + cisplatin

[assessment]

• Estrogen receptor (ER) testing is recommended in the settings of stage III, stage IV, and recurrent disease.
• HER2 immunohistochemistry (IHC) testing is recommended for possible treatment of advanced-stage or recurrent serous endometrial carcinoma or carcinosarcoma.
• Consider HER2 IHC testing in TP53-aberrant endometrial carcinoma regarless of histotyping.
• Molecular analysis of endometrial carcinoma has identified four clinically significant molecular subgroups with differing clinical prognoses: POLE mutations, microsatellite instability-high (MSI-H), copy number low, and copy number high.
• Ancillary studies for POLE mutations, mismatch repair (MMR)/MSI, and aberrant p53 expression are encouraged to complement morphologic assessment of histologic tumor type.
• Universal testing of endometrial carcinomas for MMR proteins is recommended (MSI testing if results equivocal).
• Consider NTRK gene fusion testing for metastatic or recurrent endometrial carcinoma.

220503

[assessment]

• Estrogen receptor (ER) testing is recommended in the settings of stage III, stage IV, and recurrent disease.
• HER2 immunohistochemistry (IHC) testing is recommended for possible treatment of advanced-stage or recurrent serous endometrial carcinoma or carcinosarcoma.
• Consider HER2 IHC testing in TP53-aberrant endometrial carcinoma regarless of histotyping.
• Molecular analysis of endometrial carcinoma has identified four clinically significant molecular subgroups with differing clinical prognoses: POLE mutations, microsatellite instability-high (MSI-H), copy number low, and copy number high.
• Ancillary studies for POLE mutations, mismatch repair (MMR)/MSI, and aberrant p53 expression are encouraged to complement morphologic assessment of histologic tumor type.
• Universal testing of endometrial carcinomas for MMR proteins is recommended (MSI testing if results equivocal).
• Consider NTRK gene fusion testing for metastatic or recurrent endometrial carcinoma.

700900252

220701

{Pancreatic adenocarcinoma, T4N1M0, stageIII}

• lab data
  • Glucose (serum)
    • 2022-06-30 218 mg/dL
    • 2022-06-04 172 mg/dL
    • 2022-05-31 279 mg/dL
    • 2022-03-25 120 mg/dL
    • 2022-01-21 126 mg/dL
    • 2021-11-25 112 mg/dL
    • 2020-08-21 113 mg/dL
    • 2020-08-06 115 mg/dL
  • Mg (Magnesium) (1.9~2.7)
    • 2022-06-30 1.3 mg/dL
    • 2022-06-21 1.8 mg/dL
    • 2022-06-17 1.8 mg/dL
    • 2022-06-11 1.2 mg/dL
    • 2022-06-09 2.7 mg/dL
    • 2022-06-07 1.3 mg/dL
    • 2022-05-31 1.6 mg/dL
    • 2022-05-24 1.6 mg/dL
    • 2022-04-07 2.1 mg/dL
    • 2022-01-24 1.9 mg/dL
  • Albumin
    • 2022-06-30 3.2 g/dL
    • 2022-06-21 2.6 g/dL
    • 2022-06-17 2.5 g/dL
    • 2022-06-11 2.5 g/dL
    • 2022-06-07 2.6 g/dL
    • 2022-05-31 3.5 g/dL
    • 2022-05-24 3.3 g/dL
    • 2022-05-12 3.3 g/dL
    • 2022-04-28 4.3 g/dL
    • 2022-04-25 4.1 g/dL
    • 2022-04-19 3.5 g/dL
    • 2022-04-14 4.0 g/dL
    • 2022-04-07 3.7 g/dL
    • 2022-03-26 3.9 g/dL
    • 2022-01-24 3.2 g/dL
• exam finding
  • 2022-06-20 2D transthoracic echocardiography, TTE
    • Findings
      • Heart size: Dilated LA, AsAo (35 mm); (LA volume: 65 ml, LA volume index: 50 ml/m2)
      • Mitral E/A = 83 / 115 cm/s (E/A ratio = 0.72); Dec.time = 174 ms; Heart rate = 94 bpm
      • Septal MA e’/a’ = 5.4 / 12.2 cm/s; Septal E/e’ = 15.5 ;
      • Lateral MA e’/a’ = 8.8 / 18.4 cm/s; Lateral E/e’ = 9.5 ;
      • Calcified lestions: aortic root
      • IVC size 13 mm with inspiratory collapse >50%
    • Conclusion:
      • Indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis with mild AR; mild MR; mild TR; mild PR.
      • Dilated proximal ascending aorta (35mm); prominent aortic root calcification with protruding atheroma (7.5 mm of thickness).
      • No vegetation was found by TTE study.
  • 2022-06-15 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2022-06-13 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 36 dB HL // LE 36 dB HL
    • RE normal to moderately severe SNHL (sensorineural hearing loss)
    • LE normal to moderate SNHL (sensorineural hearing loss)
  • 2022-06-04 CXR
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-06-04 KUB
    • Degenerative joint disease of lumbar spine with marginal osteophytes.
  • 2022-06-04 ECG
    • Sinus tachycardia
  • 2022-05-09 Cholangiography
    • Cholangiography via PTCD catheter administration revealed:
      • S/P cholecystojejunostomy.
      • Obstruction of distal CBD.
      • Patency of the catheter.
  • 2022-04-19 Patho - pancreas biopsy
    • Diagnosis
      • Pancreas, biopsy — chronic inflammation and fibrosis
      • F2022-00175
        • FsA: Soft tissue, SMA root, biopsy — negative for malignancy
        • FsB: Pancreas, biopsy — chronic inflammation and fibrosis
          • Lymph node, site?, excision — metastatic adenocarcinoma (1/1)
    • Microscopic description
      • Section shows pancreatic tissue with infiltration of chronic inflammatory cell and fibrosis. No invasive tumor is found. The immunohistochemical stain of CK reveals no invasive tumor.
      • F2022-00175
        • FsA: Section shows fibroadipose tissue without malignancy. The immunohistochemical stain of CK reveals no invasive tumor.
        • FsB: Section shows a piece of pancreatic tissue and a lymph node. The pancreatic tissue reveals infiltration of chronic inflammatory cell and fibrosis. No invasive tumor is found. The immunohistochemical stain of CK reveals no invasive tumor. Metastatic adenocarcinoma is seen in the lymph node. The immunohistochemical stain of CK is positive.
  • 2022-04-18 Frozen section
    • Preliminary diagnosis:
      • FsA: Soft tissue, SMA root, biopsy — negative for malignancy
      • FsB: Pancreas, biopsy — in favor of reactive change
        • Lymph node, site?, excision — metastatic adenocarcinoma (1/1)
  • 2022-04-08 Percutaneous gall bladder drainage
    • Distention of the gallbladder (by CT images).
    • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the gallbladder smoothly.
  • 2022-04-06 2D transthoracic echocardiography, TTE
    • Findings
      • Heart size: Dilated LA; AsAo (33mm); (LA volume: 60 ml, LA volume index: 47 ml/m2)
      • Thickening: LVPW
      • Mitral E/A = 80 / 117 cm/s (E/A ratio = 0.68); Dec.time = 222 ms; Heart rate = 87 bpm
      • Septal MA e’/a’ = 5.4 / 9.3 cm/s; Septal E/e’ = 14.7 ;
      • Lateral MA e’/a’ = 8.3 / 16.9 cm/s; Lateral E/e’ = 9.6 ;
      • IVC size 12 mm with inspiratory collapse >50%
    • Conclusion:
      • Indeterminated LV filling pressure and impaired RV relaxation; moderately dilated LA.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis with trivial AR; trivial MR; trivial TR; mild PR.
      • Mildly dilated proximal ascending aorta (33mm).
  • 2022-03-31 Patho - pancreas biopsy
    • Tumor, pancreas, EUS FNA biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of blood, fibrin material, glandular or nest tumor cells with enlarged, hyperchromatic nuclei and nucleoli embedded in some fibrous stroma and focal mucin secretion, compatible with adenocarcinoma, moderately differentiated.
  • 2022-03-31 Fine needle aspiration biopsy - pancreas
    • Smears show clusters of papillary atypical hyperchromatic cells.
      
    • Malignancy is favored. Please correlate with the clinical presentation.
  • 2022-03-31 Endoscopic Ultrasonography, EUS
    • Using EUS-UCT 260 showed
      • 1.) dilatation of CBD up to 9.6mm filled with hyperechoic material
      • 2.) distented GB full of hyperechoic material.
      • 3.) a 22*20mm hypoechoic lesion at pancreatic head region
    • Diagnosis
      • Pancreatic head tumor with CBD obstruction, s/p EUS-FNA + ROSE
    • Suggestion
      • pursue pathological result
  • 2022-03-30 MRI - pancreas
    • Findings:
      • 1. There is an ill-defined homogeneous mass measuring 2 x 1.4 cm in the pancreatic head, causing bile duct, galbladder and pancreatic duct dilatation, and it showing hypointensity on T1WI and iso-intensity on both T2WI and DWI. During dynamic study, this tumor shows relative poor enhancement at arterial phase, portal-venous phase and delayed phase images.
        • Adenocarcinoma of the pancreatic head is highly suspected.
        • Please correlate with EUS.
      • There are symmetrical soft tissue lesions encompass the celiac trunk and superior mesenteric artery that may be metastases?
      • There are few enlarged nodes in hepatoduodenal ligament and aortocaval space.
      • Abdominal aorta shows atherosclerosis, ectasia 2.8 cm and mild intramural thrombus formation.
    • IMP:
      • Adenocarcinoma of the pancreatic head is highly suspected.
  • 2022-03-28 CT - abdomen
    • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage): T1cN1M0, stage IIB
  • 2022-03-25 CXR
    • Tortous aorta with calcification is noted.
  • 2022-03-25 SONO - abdomen
    • Diagnosis
      • Gallbladder stone and sludge
      • CBD dilatation
      • MPD dilatation
    • Suggestion
      • Please correlate with other image study
  • 2022-01-24 CT - abdomen
    • Fat stranding along celiac trunk, common hepatic artery, splenic artery and proximal SMA.
    • A vascular blush at right hepatic lobe.
  • 2021-12-24 Patho - colon biopsy
    • Colon, transverse, biopsy — tubular adenoma with low grade dysplasia
  • 2021-11-29 CTA - pelvis
    • History and indication: endometrial CA s/p ATH at VGH without F/U
    • S/P hysterectomy. No evidence of tumor recurrence.
  • 2021-11-29 SONO - abdomen
    • Diagnosis
      • Fatty liver, mild
      • Hepatic calcified lesion, S5
      • Slightly dilatation of MPD, body
    • Suggestion
      • Please correlate with other image study and clinical condition
• consultation
  • 2022-06-14 Infectious Disease
    • A
      • This is a case of pancreatic adenocarcinoma and neutropenic fever.
      • 2022/06/08 B/C: yeast-like.
      • Agree with your use of mycamine as antifungal treatment. Keep one anti-fungal agent is suggested.
      • Please f/u the final B/C results and adjust it according to the susceptibility.
      • Please check recheck B/C 3~5 days later.
  • 2022-04-28 Hemato-Oncology
    • Q
      • This 66-year-old woman has past history of
        • 1). Endometrial cancer s/p op and chemotherapy more than 20 years ago,
        • 2). hypertension,
        • 3). abdominal pain suspect with partial intestinal obstrucion related in 2014/11/14.
      • This time, she suffered from water diarrhea right after oral intake for 2+ months and fever with chills for 2 days. She was admitted to GI ward with the initial diagnosis of infectious gastroenteritis.
      • Abdominal MRI with MRCP was performed on 3/30 and revealed adenocarcinoma of the pancreatic head being highly suspected. EUS/FNAB on 3/31 and pathology revealed Adenocarcinoma. GS was consulted and the surgeon had well explain to families. PPN was added since 4/01. Follwed up abdomen echo revealed gall bladder distension, dilatation of CBD and bilateral IHD. PTGBD was done for bilitary tract obstruction drainage on 4/08. She was transferred to GS ward on 2022/04/14.
      • After transferred to GS ward, with stable condition after pancreatitis subsided, she was scheduled to receive Whipple’s operation. During operation, a >2cm pancreatic head tumor with SMA & SMV invasion and multiple enlarged LNs over SMA root were noted. Pancreatic tumor biopsy was done and the enlarged LN was harvested. The frozen section showed positive of malignancy of LN. After informing the family, GJ byass, cholecystojejunostomy were done instead.
      • The patient was currently with stable condition and would start full liquid diet today.
      • We needed your expertise for further management. Thank you!
    • A
      • Impression:
        • Pancreatic adenocarcinoma, T4N1M0, stageIII s/p 20220418 GJ byass, cholecystojejunostomy, excision of intraabdominal tumor
        • During operation, a >2cm pancreatic head tumor with SMA & SMV invasion and multiple enlarged LNs over SMA root were noted.
      • Suggestion:
        • For unresectable disease at surgery and local advanced disease, systemic therapy is indicated. We will discuss with patients later.
          • if good performance: FOLFIRINOX, or Gemcitabine + albumin-bound paclitaxel
          • if poor performance status, may consider gemcitabine alone or capecitabine.
      • If patient agrees, we take over this case.
  • 2022-04-01 General and Gastrointestinal Surgery
    • A
      • suggest:
        • please D/D ductal adenocarcinoma or NET
        • nutrition support with PPN or TPN for 1-2 weeks
        • check PFT and 2D echo
        • we will f/u this case
  • 2022-03-25 Psychosomatic medicine
    • Q
      • Anxiety was noted. So we need you evaluation and suggestion of this patient. Thank you very much
    • A
      • I. Psychiatric impression:
        • Anxiety state
        • Watery diarrhea, cause to be determined
        • suspected somatic symptom disorder
      • 2. Clinical course and presentation:
        • This 66 years old female had medical history of
          • 1). Endometrial cancer s/p op and chemotherapy more than 20 years ago,
          • 2). hypertension,
          • 3). abdominal pain suspect with partial intestinal obstrucion related in 2014/11/14.
        • This time, she suffered from persistent watery diarrhea since 4 months ago, and had detailed GI examination done at our hospital but in vain.
        • The patient claimed to have fair appetite, diarrhea after eating, fair sleep but notable distress feeling to her somatic symptoms.
        • Death thinking would occur but denied proper suicidal plans. Her body weight had decreased around 13 kg in recent 4 months.
        • According to the observation of the medical team, the patient often refrained from oral intake probably due to diarrhea.
        • She admitted to have fear of cancer relapse or some unknown medical disease despite reassurance by doctors.
        • She also claimed to be easily anxious, she was ever admitted to NTUH psy department for unknown psychiatric diagnosis, and lost follow-up.
        • She had been taking alprazolam from our GI department and told to have good response.
      • 3. Suggestion:
        • Sulpiride 1# HS
        • Alprazolam 1# PRNBID
        • Treat underlying reason for diarrhea, re-assurance of exam results
• surgical operation
  • 2022-04-18
    • Surgery
      • GJ byass
      • cholecystojejunostomy
      • excision of intraabdominal tumor, malignancy
    • Finding
      • pancreatic head tumor, >2cm
      • multiple enlarged LNs over group 15
      • SMA and SMV invasion
• chemoimmunotherapy
  • 2022-05-10 ~ undergoing - gemcitabine + cisplatin

[assessment]

• Hypomagnesimia (2022-06-30 1.3 mg/dL) could be caused by gastrointestinal loss (chemotherapy induced diarrhea, panceas disease) or renal loss (cisplatin, loop diuretic furosemide). Magnesium sulfate 10% 20mL IVD QD has been prescribed.
• The level of serum albumin was around 2.5 g/dL for most of June. BW 41 kg, BH 150 cm (2022-06-30); BMI 18.2 kg/m2, mild thinness. It is recommended to eat more to prevent malnutrition.
• It should be noted that blood sugar readings fluctuate at high levels even after insulin was administered.
• Both TPR and BP were stable during this hospital stay.

701358791

220630

• present illness
  • In the case of this 41-year-old female, she was diagnosed with endometrial adenocarcinoma IA Grade 2 and High grade endometrial stromal sarcoma (ESS), stage IIB post-hysterectomy at MacKay Memorial Hospital in 2021-08, where she was offered C/T & R/T for post-operative treatment, however, she hesitated and sought a second opinion at NTUH. The patient had a CT in 2021-10 at NTUH for tumor staging. However, she did not return to the clinic for the results.
• exam finding
  • 2022-06-28 CXR
    • S/P Port-A infusion catheter insertion.
    • Ground glass opacity in right lung.
  • 2022-06-13 Renal ultrasound (Nephrology)
    • 1. Normal right kidney except for a suspected AML, middle pole
    • 2. Left hydronephrosis
    • 3. Tumor compression of the left kidney
    • 4. PCN in the left renal pelvis
    • 5. Mass lesion in the pelvic region
  • 2022-06-04 CT - abdomen, pelvis
    • Recurrent endometrial cancer with LNs and lung metastases.
    • S/P bil. PCN.
    • Splenomegaly.
  • 2022-06-04 KUB + L-spine Lat
    • S/P bil. pig-tail catheters indwelling.
  • 2022-06-04 Electrocardiogram, ECG
    • Sinus tachycardia
  • 2022-05-24 KUB
    • S/P bil. pig-tail catheters indwelling.
  • 2022-05-06 PCN - pigtail revision
    • Obstruction of left PCN catheter.
    • Revision of the catheter smoothly.
  • 2022-05-06 KUB
    • The psoas shadow is clear.
    • Increased density in the abdominal cavity is found.
    • Stool impaction at the abdominal cavity is noted.
    • Scoliotic alignment of the lumbar spine is found.
    • Calcified dot(s) is found at left paravertebral region, ureter stone(s) is most likely.
  • 2022-04-28 KUB
    • 1. s/p pigtail insertion in the bilateral uper abdomen.
    • 2. increased density in the lower abdomen. Nature?
  • 2022-04-28 Electrocardiogram, ECG
    • Sinus tachycardia with Premature atrial complexes
    • Nonspecific ST abnormality
    • Abnormal ECG
  • 2022-04-12 Patho - lymphnode biopsy
    • Soft tissue, pelvis, left, CT guided biopsy — sarcoma, high grade.
    • IHC stains: vimentin (+), CD10 (-), CK (-), CK7 (-), CK20 (-).
    • Section shows cores of soft tissue with infiltration of epithelioid and spindle shaped neoplastic cells.
  • 2022-04-08 CT - abdomen, pelvis
    • Local recurrent endometrial sarcoma with lymph nodes and lung metastases is highly suspected.
  • 2022-04-08 Tc-99m MDP whole body bone scan
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral elbows, S-I joints, hips and knees. Benign joint lesions are more likely.
  • 2022-04-06 CT - abdomen
    • Ovarian cancer with lymph nodes metastases and lung metastais is highly suspected. Please correlate with CA125 and contrast-enhanced CT.
    • Splenomegaly is noted, nature? Please correlate with clinical condition.
  • 2022-04-06 Gynecologic ultrasonography
    • ATH
    • Bilateral kidney hydronephsis
    • Suspected pelvis mass > 30 cm
• consultation
  • 2022-06-28 Urology
    • Q
      • ER Examination: 3.
        • Medical device problems > acute peripheral severe pain (8-10)
        • The patient reported pain in the right waist and obstruction of the right renal drainage tube for 3 days
    • A
      • Ultrasound showed right hydronephrosis, combined with new left foot swelling and bilateral waist and back skin swelling, water moved to extravascular dehydration
      • The problem may not be solved by simply changing the tube, and there may be other factors to consider
      • A swelling on the left foot may indicate aggravation of the condition despite the patient’s pain and shortness of breath, and the patient hopes for active treatment
      • I will perform change Pigtail with c-arm+ contrast medium
      • Do blood test CXR for suspect infection and renal failure
  • 2022-05-27 Urology
    • Q
      • Bilateral hydronephrosis S/P Percutaneous Nephrostomy (PCN)
        • right Percutaneous Nephrostomy revision on 20220523.
        • left Percutaneous Nephrostomy revision on 20220506.
    • A
      • drainage function seems fine
      • no ecchymosis or leakage now
      • urine from right PCN is clear
      • there is no need of change Pigatail now
      • change of pigtail now may still be ainful
      • plan add morphine or other pain killer
  • 2022-04-19 Dermatology
    • Q
      • Newly erupted itchy skin rash at bilateral popliteal regions, elbows, axillary cavity, inguinal regions, metacarpophalangeal joints were noted for one day. So, we need your expertise on evaluation or some sugggestion. Thank you very much!
    • A
      • This patient suffered from multiple erytheamtous papules-plaques on bil legs after 2 dose BNT vaccine for months.
      • Imp: Vasculitis
      • Suggestion:
        • 1. Please check CBC/DC, ANA,TSH, C3/C4, ASLO, Anti-HBsAg, Anti-HCV
        • 2. Zaditen 1 / Bid
        • 3. Xyzal * 1 Hs
        • 4. SInpharderm * 1 tube/bid
        • 5. Topsym cream * 6 tubes/bid
      • Thanks!
  • 2022-04-13 Cardiology
    • Q
      • This 41y/o female was diagnosed with Endometrial endometrioid adenocarcinoma IA Grade 2 and High grade endometrial stromal sarcoma(ESS), stage IIB s/p hysterectomy in 2021/08 in MacKay Memorial Hospital.
      • This time was admitted to our Onco’s ward under impression of suspect local recurrent endometrial stromal sarcoma with lymphnode and lung metastasis and obstructive uropathy with UTI.
      • After admission, high blood pressure levels were found but the patient denied history of HTN. For suspect newly diagnosed HTN, we need your expertise for evaluation or some suggestion or OPD f/u. Thank you very much!
    • A
      • I was consulted for elevated hospitalized BP.
      • A
        • avg. 160-200 mmHg
        • EKG: LVH, sinus
        • Taking steroid, hydralazine now
      • Suggestion:
        • 1. Add amlodipine 1pc QD; keep hydralazine
        • 2. Pain/anxiety relief
        • 3. Treat underlying diseases
  • 2022-04-08 Urology
    • A
      • S
        • This time, the the patient had progressive low back pain, poor appetite with body weight loss (20Kg) in these 2-3 months.
      • O
        • Abdomen CT: pelvic mass with lymph nodes metastases and lung metastais; external compression/invasion to left ureter and bilateral hydronephrosis.
      • A
        • Bilateral ureteral catheterization +/- left pigtail insertion is indicated.
        • We’ve visited the patient and discussed with the patient about the further treatment plan.
        • Current treatment plan is not well established, pathology report of the pelvic mass is need.
      • P
        • Please contact us when pathology is done. Thank you.
        • Urine retention is noted from 2 CT scans. Foley insertion is recommended.
  • 2022-04-08 Rheumatology and Immunology
    • Q
      • For vasculitis-like skin rashes noted at the four limbs and APS not be excluded , we need your expertise on evaluation or some suggesion. Thank you very much!
    • A
      • Diffuse skin purpura over four limb for several months, no active joint pain, after vaccination?
      • O
        • Cr 0.89
        • ALT 6
        • CRP 8.97
        • urnie protein-, ob+
      • Suggestion
        • suspected r/o vasculitis, may check ANA, anti-SSA, SSB, SM/RNP, DSDNA, ANCA, anti-cardiolipin IG/IGM, B2glycoprotein 1, lupus anticoagulation, C3/C4
        • may keep prednisolone 1#bid.
  • 2022-04-06 Obstetrics and Gynecology
    • A
      • S
        • G0, SEX(-), TOCC(-)
        • PH: s/p hystectomy
        • Personal history:
          • Endometrial endometrioid adenocarcinoma IA Grade 2 =＞ s/p hysterectomy (2021/08 op at MacKay H)
          • High grade endometrial stromal sarcoma, ESS, IIB, s/p hysterectomy (2021/08 op at MacKay H, without CT/RT)
          • Vasculitis under medication of fexofenadine, prenisolone, and MgO
        • Family history: denied
      • O
        • CT:
          • Ovarian cancer with lymph nodes metastases and lung metastais is highly suspected.
          • Please correlate with CA125 and contrast-enhanced CT.
        • Lab data: Cre = 0.89, eGFR = 74
        • PE: no pitting edema, no swelling over bilateral legs.
        • Echo:
          • Pelvic mass > 30 cm, suspected ESS with bilateral hydronephrosis
      • Impression and plan:
        • 1. OPD follow up for suspect endometrial stromal sarcoma with lymph node and lung mets.
        • 2. Please check CA125, CA199, CEA
        • 3. Pain control
        • 4. please consult urology for bilateral hydronephrosis being noted.
• surigcal operation
  • 2022-04-13 Percutaneous Nephrostomy
  • 2022-04-12 Percutaneous Nephrostomy
• chemoimmunotherapy
  • 2022-04-20 ~ undergoing - paclitaxel + carboplatin

[assessment]

• There is severe pain a number of times after PCN, which could be caused by the renal drainage tube. Unbalanced drainage amount recorded, 2022-06-29 right PCN 900 and left PCN was 0. It may be worthwhile to investigate the underlying causal factors.
• Several months of sinus tachycardia have been observed, which could have been caused by hydralazine. In addition to acting as an antihypertensive, ivabradine may also lower heart rate, which might be worth considering.

220520

• present illness
  • In the case of this 41-year-old female, she was diagnosed with endometrial adenocarcinoma IA Grade 2 and High grade endometrial stromal sarcoma (ESS), stage IIB post-hysterectomy at MacKay Memorial Hospital in 2021-08, where she was offered C/T & R/T for post-operative treatment, however, she hesitated and sought a second opinion at NTUH. The patient had a CT in 2021-10 at NTUH for tumor staging. However, she did not return to the clinic for the results.
• exam finding
  • 2022-04-12 Patho - lymphnode biopsy
    • Soft tissue, pelvis, left, CT guided biopsy — sarcoma, high grade.
    • IHC stains: vimentin (+), CD10 (-), CK (-), CK7 (-), CK20 (-).
    • Section shows cores of soft tissue with infiltration of epithelioid and spindle shaped neoplastic cells.
  • 2022-04-08 CT - abdomen, pelvis
    • Local recurrent endometrial sarcoma with lymph nodes and lung metastases is highly suspected.
  • 2022-04-08 Tc-99m MDP whole body bone scan
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral elbows, S-I joints, hips and knees. Benign joint lesions are more likely.
  • 2022-04-06 CT - abdomen
    • Ovarian cancer with lymph nodes metastases and lung metastais is highly suspected. Please correlate with CA125 and contrast-enhanced CT.
    • Splenomegaly is noted, nature? Please correlate with clinical condition.
  • 2022-04-06 Gynecologic ultrasonography
    • ATH
    • Bilateral kidney hydronephsis
    • Suspected pelvis mass > 30 cm
• surigcal operation
  • 2022-04-13 Percutaneous Nephrostomy
  • 2022-04-12 Percutaneous Nephrostomy
• chemoimmunotherapy
  • 2022-04-20 ~ undergoing - paclitaxel + carboplatin

[assessment]

• The patient was diagnosed with high grade endometrial stromal sarcoma in August 2021 and has been treated with paclitaxel + carboplatin since April 2022.
• Lab data reported on 2022-05-19 showed grossly normal. No issue with active prescription.

701072376

220629

{cholangiocarcinoma, recurrenct, liver and lung mets, s/p colon cancer}

[objective]

• lab data
  • HGB
    • 2022-06-28 7.9 g/dL
    • 2022-06-09 8.0 g/dL
    • 2022-05-29 8.9 g/dL
    • 2022-05-13 8.3 g/dL
    • 2022-04-26 9.4 g/dL
    • 2022-04-25 8.9 g/dL
    • 2022-04-22 8.2 g/dL
    • 2022-04-07 9.3 g/dL
    • 2022-03-29 10.9 g/dL
    • 2022-03-22 11.1 g/dL
    • 2022-03-11 11.0 g/dL
    • 2022-02-23 12.6 g/dL
    • 2022-02-18 12.5 g/dL
    • 2021-12-17 13.8 g/dL
    • 2021-11-01 12.5 g/dL
    • 2021-03-20 14.1 g/dL
    • 2021-03-19 15.5 g/dL
  • Creatinine
    • 2022-06-28 1.91 mg/dL
    • 2022-06-21 1.79 mg/dL
    • 2022-06-09 1.43 mg/dL
    • 2022-05-29 1.79 mg/dL
    • 2022-05-13 1.68 mg/dL
    • 2022-04-25 1.24 mg/dL
    • 2022-04-22 2.17 mg/dL
    • 2022-04-07 1.62 mg/dL
    • 2022-03-29 1.44 mg/dL
    • 2022-03-22 1.29 mg/dL
    • 2022-03-11 1.36 mg/dL
    • 2022-02-23 1.23 mg/dL
    • 2022-02-18 1.13 mg/dL
    • 2022-01-20 1.04 mg/dL
    • 2021-12-17 1.41 mg/dL
    • 2021-11-03 1.11 mg/dL
    • 2021-11-01 1.40 mg/dL
    • 2021-09-16 1.17 mg/dL
    • 2021-08-16 1.40 mg/dL
    • 2021-03-19 2.11 mg/dL
    • 2021-03-02 1.30 mg/dL
    • 2020-12-08 1.27 mg/dL
    • 2020-09-15 1.40 mg/dL
    • 2020-03-25 1.30 mg/dL
    • 2020-02-21 1.30 mg/dL
• exam findings
  • 2022-06-09, 2022-05-29 Electrocardiogram, ECG
    • Sinus bradycardia with sinus arrhythmia
  • 2021-12-21 CT
    • S/P right lobectomy and cholecystectomy. S/P colostomy.
    • Multiple recurrent tumors in the liver and peritoneal seeding, lymph nodes metastasis, bilateral lung metastasis. (recurrent cholangiocarcinoma or colon malignancy?)
  • 2021-11-16 CT
    • recurrent cholangiocarcinoma in left hepatic lobe with lung and Rt cardiophenic angle LNs metastases. small airways disease in lungs too.
  • 2021-09-01 Myocrdial perfusion SPECT with persantin
    • Mildly improved myocardial perfusion to LV compared with the previous study on 2020-06-02, indicating resposne to current therapy.
    • There is still mild myocardial ischemia at the basal inferolateral wall and apical inferolateral wall (LCx territory) of LV. 3. No dilatation of LV is noted.
  • 2021-06-02 Myocrdial perfusion SPECT with persantin
    • Probably mild to moderate myocardial ischemia with possible a small portion of severe ischemia at the inferoapical wall and inferolateral wall and mild myocardial ischemia at the inferoseptal wall and posterior wall.
  • 2021-03-25 MRI - L-spine
    • mild spondylolisthesis at L5-S1
    • herniated discs in the L2/3, L3/4, and L4/5 discs.
  • 2019-05-21 CT
    • Recurrent cholangiocarcinoma or artifact 1.8 cm in S4 of the liver is suspected. Please correlate with AFP, CEA, and MRI.
  • 2018-08-07 SONO - Hepatobiliary
    • Post right hepatectomy. Poor defined gallbladder.
  • 2018-03-23 Surgical pathology Level V
    • Diagnosis: Liver, intrahepatic bile ducts, S5, right lobectomy - Cholangiocarcinoma
      • Pathologic Staging (AJCC): pT2N0(cMx); Stage II if cM0
    • Microscopic examination
      • Histologic Type: Cholangiocarcinoma
        
      • Histologic Grade: GIII (Poorly differentiated)
        
      • Tumor Growth Pattern: Mass-forming
        
      • Microscopic Tumor Extension: Tumor confined to hepatic parenchyma
        
      • Small Vessel Invasion (L): Present
        
      • Additional Pathologic Findings: Cirrhosis
        
      • Hepatitis: Chronic hepatitis B
        
      • Ishak Modified HAI Grading: Score = 4 (interphase hepatitis = 1/4, confluent necrosis = 0/6, focal necrosis = 1/4, portal inflammation = 2/4) (Corresponding Metavir A1, mild activity)
        
      • Ishak Staging: F6 (Corresponding Metavir F4, cirrhosis)
      • Fatty Change: Present (5%)
      • IHC for tumor cells: CK7(+), Hepa-1(-), Arginase(-)
  • 2018-02-23 Surgical pathology Level V
    • Diagnosis: Liver, c;inical histroy of colorectal adenocarcinoma, neele biopsy - Adenocarcinoma.
    • IHC:
      • CK7(+), CK20(-), CDX-2(-): dis-favor colorectal origin;
      • Hepatocyte(-), Arginase(-): dis-favor hepatocellular carcinoma.
      • CK19(+): favor cholangiocarcinoma.
  • 2018-01-19 CT
    • Irregular low density(around 2.4cm) in right lobe liver, suspected liver metastasis.
    • Post-op with colostomy in left abdomen.
  • 2017-07-12 Tc-99m MDP whole body bone scan
    • A new lesion in a middle C-spine in comparison with the previous study on 2013-07-17, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up.
    • Significantly increased radioactivity in the mandilbe, dental problems may show this picture.
    • Suspected benign lesions in the maxilla, bilateral sternoclavicular junctions, L-S junction, bilateral shoulders, bilateral knees, and bones/joints of right foot.
  • 2017-07-12 CT
    • Suspect small airway disease in lower lobes of lung.
    • Gallstones.
  • 2007-10-26 Patho
    • rectal adenocarcinoma pT2N1M0 s/p abdominal perineal resection.
• consultation
  • 2021-11-02 Thoracic Medicine
    • Q
      • This 70-year-old male patient had past history of:
        • 1. Smoking for about 40-50 years, has quit for 2 years.
        • 2. Rectal adenocarcinoma, pT2N1M0 s/p abdominal perineal resection on 2007/10/26.
        • 3. Hypertension for more then 10 years and diabetes for 5 years with medical control.
        • 4. Ileus for times since 2012/08/06.
        • 5. Right hip osteoarthritis s/p total hip replacement on 2013/12/25.
        • 6. Right knee osteoarthritis s/p TKR on 2018/01/25 at Chang Hua Hospital of MOHW
        • 7. Right cholangiocarcinoma, pT2N0M0; Stage II s/p right lobectomy + lymph node dissection + cholecystectomy on 2018/03/22.
      • He was under regular medical treatment in our CV, Neurology, Meta OPD in the recent years.
        
      • According to patients and his daughter, he complained of dyspnea after walking about 50 meters in the recent 1 years. The symptoms lasted for 5~10 minutes and subsided after rest. So, we arranged 2D transthoracic echocardiography on 2021/09/01, which showed EF 80%; 1. Septal and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.; 2. Normal LV and RV systolic function.; 3. Mild aortic valve sclerosis. Tl-201 stress myocardial perfusion scan on 2020/06/02, which showed: probably mild to moderate myocardial ischemia with possible a small portion of severe ischemia at the inferoapical wall and inferolateral wall and mild myocardial ischemia at the inferoseptal wall and posterior wall. We arrange CAG on 2021/11/02. Therefore, we need your expertise to evaluate his condition and make further comments. Thank you very much!
    • A
      • S
        • This 70 y.o male was a case of rectal adenocarcinoma, right cholangiocarcinoma and HTN. This time, he was admitted due to progressive dyspnea and suspected CAD. Now, we were consulted for further evaluation about possible lung disease.
        • Smoking: 1 ppd for 40-50 years and quit for 2 years
      • O
        • 2021-08-24 CXR: mild cardiomegaly, LLL retrocardiac opacity r/o consolidation or other etiology
        • 2021-10-19 PFT: FEF 25-75% <60%, suspected small airway disease with significant bronchodilator response
      • Suggestion:
        • 1. please follow up CXR, if LLL retrocardiac opacity still presented, Chest CT was indicaded
        • 2. please arrange Pulmonary provocation test for small airway disease (suspected underline asthma or airway hypersensitivity)
      • We will like to f/u this case if data complete
• surgical operations
  • 2021-03-23
    • Surgery: tumors excision
    • Finding: multiple granulomatous polyps formation around the colostomy
• chemotherapy regimen
  • 2022-04-07 - 5-FU + carboplatin + gemcitabine
  • 2022-02-23 ~ 2022-03-22 - 5-FU + cisplatin + gemcitabine

[assessment]

• 2022-06-28 RBC 2.3 *10^6/uL, HGB 7.9 g/dL, MCV 105.7 fL => could be macrocytic anemia. Kentamin (B1, B6, B12) has been prescribed.
• Gemcitabine could also induce macrocytosis. Gemcitabine related anemia incidence: 68%, grade 3 7%, grade 4 1%. This drug has been used since 2022-02-23. It could have accelerated the decline in HGB levels, however, there might also be other causal underlying conditions, as the decline has been documented since March 2021.
• There is an obvious downward trend of HGB with a monthly drop of -0.5 g/dL.
  • 2022-06-28 7.9 g/dL
  • 2022-06-09 8.0 g/dL
  • 2022-05-29 8.9 g/dL
  • 2022-05-13 8.3 g/dL
  • 2022-04-26 9.4 g/dL
  • 2022-04-25 8.9 g/dL
  • 2022-04-22 8.2 g/dL
  • 2022-04-07 9.3 g/dL
  • 2022-03-29 10.9 g/dL
  • 2022-03-22 11.1 g/dL
  • 2022-03-11 11.0 g/dL
  • 2022-02-23 12.6 g/dL
  • 2022-02-18 12.5 g/dL
  • 2021-12-17 13.8 g/dL
  • 2021-11-01 12.5 g/dL
  • 2021-03-20 14.1 g/dL
  • 2021-03-19 15.5 g/dL
• It is also possible for capecitabine-based regimens to cause anemia (72% to 80%, grades 3 or 4 <=3%)

220408

[assessment]

• The serum creatinine level rises from 1.04mg/dL (2022-01-04) to 1.62mg/dL (2022-04-07), which should be addressed.
• In the new regimen used during this hospital stay, cisplatin was substituted for carboplatin, which might mitigate renal toxicity.

220323

[assessment]

• Since late February 2022, the patient has been receiving 5-FU + cisplatin + gemcitabine. No issue with current medication.
• If a patient is not a candidate for a clinical trial or one is not available, and if S-1 is not available, gemcitabine plus cisplatin is recommended as a first-line regimen for patients with a good performance status. Another reasonable, possibly better tolerated option is gemcitabine plus oxaliplatin (GEMOX). Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) might also be considered.
  • reference: https://www.uptodate.com/contents/systemic-therapy-for-advanced-cholangiocarcinoma

701136097

220629

{right ovarian cancer, pT1c3N0 if cM0, FIGO IC3 s/p Op on 20200720}

• lab data
  • Mg (Magnesium)
    • 2022-06-28 1.5 mg/dL
      
    • 2022-06-01 1.7 mg/dL
      
    • 2022-04-26 1.5 mg/dL
      
    • 2022-03-29 1.8 mg/dL
      
    • 2022-03-07 1.9 mg/dL
• exam finding
  • 2022-04-08 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at RA
    • The lung fields are clear.
    • Clear bilateral costophrenic angle is noticed.
    • Patent airway is found.
  • 2022-04-08 Electrocardiogram
    • Normal sinus rhythm
    • ST & T wave abnormality, consider inferior ischemia
    • Abnormal ECG
  • 2022-03-09 Body Fluid Cytology - ascites
    • pathologic diagnosis
      • Before IP C/T: Atypia
        
    • macroscopic examination
      • 11 cc pink clear ascites
        
    • microscopic examination
      • The smears show some lymphocytes, reactive mesothelial cells and few atypical cells in necrotic debris show hyperchromatic nuclei and degenerative quality. Follow up
  • 2022-02-17 Electrocardiogram
    • Normal sinus rhythm
    • T wave abnormality, consider inferior ischemia
    • Abnormal ECG
  • 2022-01-04 Patho - ovary (tumor)
    • diagnosis
      • Peritoneal nodule, right, debulking surgery — High-grade serous carcinoma, seeding
        
      • Subdiaphramatic, right, debulking surgery — High-grade serous carcinoma, seeding
        
      • Omentum, debulking surgery — High-grade serous carcinoma, seeding
        
      • Transverse colon, debulking surgery — High-grade serous carcinoma, seeding
        
    • microscopic examination
      • The sections show serous carcinoma composed of irregular branching of neoplastic papillae lined by high-grade tumor cells with tumor necrosis and fibrous stroma. The tumor shows nclar hyperchromasia, pleomorphism, prominent nucleoli and mitotic activity.
        
      • Immunohistochemical stain reveals CK7(+), WT-1(+), CK20(-) and PAX-8(+).
  • 2021-12-31 Colonoscopy
    • Diagnosis
      • Poor colon preparation
      • Internal hemorrhoid
    • Suggestion
      • Repeat colonoscopy under good colon preparation if needed
    • Complication
      • No immediate complication
  • 2021-12-10 CT - lung/mediastinum/pleura
    • Imp: No evidence of pulmonary mets.
    • Liver metastasis. Statinoary.
    • Splenic hilar mets. Stable.
  • 2021-11-23 Mammography
    • Impression:
      • Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative. - annual screening.
  • 2021-11-18 CT - abdomen, pelvis
    • S/P hysterectomy.
    • Peritoneal seeding and liver metastases.
  • 2021-11-16 CXR
    • No active lung lesion.
    • Borderline cardiomegaly.
      
    • Thoracic spondylosis.
  • 2021-08-25 SONO - Abd for follow-up
    • A homogeneous hyperechoic nodule 0.9 cm in S6 of the liver is noted that may be hemangioma? Follow up is indicated.
    • A renal cyst measuring 0.76 cm in right upper pole is noted.
  • 2021-08-10 CT - abdomen, pelvis
    • Imp: s/p ATH and BSO. No evidence of recurrent/residual tumor in the current study.
  • 2021-02-23 CT - abdomen, pelvis
    • S/P hysterectomy and oophorectomy. Suggest follow up.
    • Renal cysts.
    • Right adrenal nodule, suspected adrenal adenoma.
  • 2020-07-20 Patho - uterus (with or without SO) neoplastic
    • Ovarian Fallopian tube Peritoneum Cancer Checklist (Based on AJCC 8th ed. and FIGO 2014)
      
    • pathologic diagnosis
      • Ovary, right, debulking surgery —- high-grade serous carcinoma
        
      • Ovary, left, debulking surgery —- high-grade serous carcinoma
        
      • Fallopian tube, right, debulking surgery —- high-grade serous carcinoma
        
      • Fallopian tube, left, debulking surgery —- high-grade serous carcinoma
        
      • Uterus, corpus, ebulking surgery —- intramural leiomyomas
        
      • Uterus, cervix, debulking surgery —- negative for malignancy
        
      • Omentume, debulking surgery —- negative for malignancy
        
      • Lymph node, left iliac, dissection — negative for malignancy (0/7)
        
      • Lymph node, left obturator, dissection — negative for malignancy (0/6)
        
      • Lymph node, right iliac, dissection — negative for malignancy (0/7)
        
      • Lymph node, right obturator, dissection — negative for malignancy (0/12)
        
      • Lymph node, left paraaortic, dissection — negative for malignancy (0/8)
        
      • Lymph node, left paraaortic, dissection — negative for malignancy (0/8)
        
    • pTNM stage: pT1c3N0(If cM0); FIGO IC3
      
    • microscopic examination 1. Histologic type: serous carcinoma
      • Histologic grade: high grade
        
      • Contralateral ovary involvement: present
        
      • Tumor side ovarian surface involvement: present
        
      • Contralateral ovary surface involvement: present
        
      • Right tube involvement: present
        
      • Left tube involvement: present
        
      • In situ adenocarcinoma in right and/or left fallopian tube: absent
        
      • Right adnexa soft tissue involvement: absent
        
      • Left adnexa soft tissue involvement: absent
        
      • Pelvic soft tissue involvement: absent
        
      • Uterine serosa involvement: absent
        
      • Omentum involvement: absent
        
      • Uterine Cervix involvement: absent
        
      • Endometrium involvement: absent
        
      • Myometrium involvement: absent
        
      • Appendix involvement: not received
        
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): N/A
        
      • Peritoneal/Ascitic Fluid - Malignant (positive for malignancy) (N20202-02181)
        
      • Regional Lymph Nodes: Negative for metastasis: (0/ 48)
        
      • Other organs or specimens involvement: absent
        
  • 2020-07-20 Body Fluid Cytology - ascites
    • pathologic diagnosis
      • Positive for malignancy
        
    • macroscopic examination
      • 33 cc red turbid ascites
        
    • microscopic examination
      • The smears show lymphocytes, mesothelial cells & many hyperchromatic atypical cell clusters, compatible with malignant tumor. Clinical correlation and confirmatory biopsy is advised.
  • 2020-07-20 Frozen section
    • Ovary, right, frozen section— malignant tumor
    • IHC stain — WT-1(+), CK7(+), CK20(-), vimentin(-)
  • 2020-07-17 CT - abdomen, pelvis
    • Findings
      • There is a well-defined lobulated soft tissue mass measuring 9.8 x 7.3 x 10 cm in right pelvis with suggestive mild fat and calcification component and it shows directly attached the uterus. Teratocarcinoma of right ovary is highly suspected. The differential diagnosis include serous carcinoma. Please correlate with clinical condition and MRI.
      • There is another soft tissue lesion 3.3 x 2.4 cm in left adnexa that may be left ovarian cyst or cystic tumor.
      • There are three Uterine myoma 3.5 cm, 3.2 cm, and 1 cm.
      • Ascites in abdomen and pelvis is noted. In addition, soft tissue lesions in the omentum is suspected that may be tumor seeding? Please correlate with ascites cytology.
      • A renal cyst measuring 1.3 cm in left upper pole is noted.
  • 2019-05-07 Surgical pathology Level IV
    • Uterus, cervix, biopsy — Mild dysplasia (CIN I)
    • Uterus, endocervix, ECC — Mild dysplasia (CIN I)
  • 2019-08-06 2Gynecologic ultrasonography
    • Uterine myoma
• surgical operation
  • 2022-01-03
    • Surgery
      • Right diaphragmatic tumor resection and repair
    • Finding
      • Table consultation.
      • Two tumors about 3.0cm x 2.0cm x1.0cm in size respectively over right diaphragm.
    • Procedure
      • Part of right diaphragm was resected by electrocautery. Lung injuury was prevented during dissection. The 2 tumors were removed together.
      • The diaphragmatic defect was closed by interrupted No.2 Silk. No more defected was detected by palpation.
  • 2020-07-20
    • Surgery
      • Cystoscopy and bilateral ureter catheter insertion
    • Finding
      • normal bladder mucosa
      • huge posterior indentation
      • no bladder tumor was seen
  • 2020-07-20
    • Surgery
      • Diagnosis
        • Right ovarian tumor suspected malignancy s/p debulking surgery.
      • Operation
        • Debulking surgery (ATH + BSO + Cytoreduction surgery + infracolic omentectomy + BPLND)     - Finding
      • Right ovarian tumor, suspected malignancy.
      • Frozen: malignancy
  • 2019-06-26
    • Dysplasia of cervix (uteri)
    • Finding
      • Uterus: Anteversion, 9 cm.
      • Scanty endocervical and some endometrial tissue were curetted out.
      • Estimated blood loss: 15 mL, Blood transfusion: nil, complication: nil.
    • Procedure: Fractional dilatation and curettage
      • Put the patient on lithotomy position.
      • Douching, skin disinfection and skin draping as usual.
      • Sounding: Anteversion, 9 cm.
      • Cervical dilatation to Hegar No. 7.
      • Curette endocervical canal and uterine cavity.
      • Pack the vagina with a piece of gauze
• chemoimmunotherapy
  • 2022-02-10 ~ undergoing - docetaxel + carboplatin + gentamicin (+ bevacizumab since 2022-03-08)
  • 2021-12-31 - liposome doxorubicin + carboplatin
  • 2020-09-12 ~ 2021-01-27 - paclitaxel + carboplatin

[note]

• Causes of magnesium depletion (2022-06-29 https://www.uptodate.com/contents/hypomagnesemia-causes-of-hypomagnesemia )
  • Gastrointestinal losses
    • Diarrhea, malabsorption and steatorrhea, and small bowel bypass surgery
    • Acute pancreatitis
    • Medications
      • PPIs
    • Genetic disorders
      • Intestinal hypomagnesemia with secondary hypocalcemia
  • Renal losses
    • Medications
      • Diuretics (loop and thiazide)
      • Antibiotics (aminoglycoside, amphotericin, pentamidine)
      • Calcineurin inhibitors
      • Cisplatin
      • Antibodies targeting epidermal growth factor (EGF) receptor (cetuximab, panitumumab, matuzumab)
    • Volume expansion
    • Uncontrolled diabetes mellitus
    • Alcoholism
    • Hypercalcemia
    • Acquired tubular dysfunction
      • Recovery from acute tubular necrosis
      • Postobstructive diuresis
      • Post-kidney transplantation
    • Genetic disorders
      • Bartter/Gitelman syndrome
      • Familial hypomagnesemia with hypercalciuria and nephrocalcinosis
      • Autosomal dominant isolated hypomagnesemia (Na-K-ATPase gamma subunit, Kv1.1 and cyclin M2 mutations)
      • Autosomal recessive isolated hypomagnesemia (EGF mutation)
      • Renal malformations and early-onset diabetes mellitus (HNF1-beta mutation)

[assessment]

• The serum magnesium level has declined over the past four months. The last dose of cisplatin was dated on 2022-04-27. In PharmaCloud, there are no records for loop diuretics, thiazide diuretics, or PPIs. Diarrhea, malabsorption or steatorrhea?
• Magnesium level time series
  • 2022-06-28 1.5 mg/dL
  • 2022-06-01 1.7 mg/dL
  • 2022-04-26 1.5 mg/dL
  • 2022-03-29 1.8 mg/dL
  • 2022-03-07 1.9 mg/dL
• The laboratory results on 2022-06-28 were considered acceptable for the continuation of the palliative chemotherapy.

220602

[assessment]

• This is a 59 y/o female with high-grade serous carcinoma accompanied by peritoneal seeding and liver mets underwent debulking surgery on 2020-07-20 and right diaphragmatic tumor resection on 2022-01-03.
• Her treatment regimens have included paclitaxel and carboplatin (2020-09 ~ 2021-01), liposome doxorubicin and carboplatin (2021-12) as well as the current regimen of docetaxel, carboplatin, and bevacizumab since the first quarter of 2022.
• The laboratory results on 2022-06-01 were considered acceptable for the continuation of the palliative chemotherapy. Lenograstim 250 mcg SC will be administered following chemotherapy on 2022-06-03.

701342752

220629

{intra-hepatic cholangiocarcinoma with lung and right adrenal mets}

• exam finding
  • 2022-06-29 ECG
    • Normal sinus rhythm
    • Possible Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-04-08 Cathay General Hospital Discharge Summary
    • intra-hepatic cholangiocarcinoma with lung and right adrenal mets, cT4N1M1, post Nivolumab, Gemcitabine and TS-1 cycle 6 with progression in lung mets, post PHDFL cycle 1
    • hepatitis B virus carrier. HTN. CKD.
  • 2022-04-01 CT - abdomen (Cathay General Hospital)
    • Related main clinical history: Large liver tumor s/p biopsy with adenocarcinoma diagnosed favored intrahepatic cholangiocarcinoma.
  • 2022-03-11 CT - chest (Cathay General Hospital)
    • multiple lung metastasis. s/p treatment follow up.
    • progression in number and size of bilateral lung nodules and bilateral lower pleural tickening.
    • findings:
      • Stationary upto nearly 14cm right hepatic poor contrast enhancing tumor invading right suprarenal region.
      • Multiple varying size upto nearly 3.5cm bilateral hepatic tumors.
      • Obliteration of right adrenal gland by right hepatic tumor invasion.
      • Peritoneum & mesentery: Mild increased ascites.
      • Lymph nodes: Stationary hepatic hilar, periceliac and aortocaval LAP.
    • impression:
      • Previous similar study on 2021/12/31.
      • Stationary upto n nearly 14cm right hepatic hypovascular tumor invading right suprarenal and adrenal gland.
      • Multiple varying size upto nearly 3.5cm bilateral hepatic tumors.
      • Mild increased ascites.
      • Stationary hepatic hilar, periceliac and aortocaval LAP.
  • 2021-12-31 Follow-up abdominal + pelvis CT and chest CT
    • liver tumor intra-abdominal and left supraclavicular fossa LN metastasis and bilateral lung metastasis.
    • mild ascites.
  • 2021-12-27 Patho - liver biopsy (Cathay general hospital)
    • Cholangiocarcinoma

[assessment]

• Tumour of the biliary tract with metastatic disease to the lungs and adrenals. Earlier this year, carboplatin and HDFL were administered and severe adverse effects were reported. There had been six cycles of Nivolumab, Gemcitabine, and TS-1 prior to that.
• Unresectable and metastatic biliary tract cancer is commonly treated with these regimens:
  • 5-fluorouracil + oxaliplatin
  • 5-fluorouracil + cisplatin
  • Capecitabine + cisplatin
  • Capecitabine + oxaliplatin
  • Gemcitabine + albumin-bound paclitaxel
  • Gemcitabine + capecitabine
  • Gemcitabine + oxaliplatin
  • Gemcitabine + cisplatin + albumin-bound paclitaxel
• In the discharge summary from Cathay general hospital, no info is found regarding what kind of severe adverse effects caused by carboplatin/HDFL. Gemcitabine as a single agent might be worth considering.
• It is possible to extend the options in the event that a particular gene pattern is approved:
  • NTRK gene fusion positive: entrectinib, larotrectinib
  • MSI-H/dMMR/TMB-H: pembrolizumab
  • FGFR2 fusion or rearrangements: pemigatinib, infigratinib
  • IDH1 mutation: ivosidenib
  • BRAF-V600E mutation: dabrafenib + trametinib

700520713

220628

• exam finding
  • 2022-06-27 CXR
    • General osteoporosis
    • Multilevel compression fracture of T-L spine
  • 2022-06-27 ECG
    • Sinus tachycardia
    • Left axis deviation
    • Inferior infarct, age undetermined
    • ST & T wave abnormality, consider lateral ischemia
    • Prolonged QT
  • 2022-06-14 CT - abdomen, pelvis
    • S/P gastrectomy.
    • No evidence of tumor recurrence.
  • 2022-05-24 SONO - abdomen
    • Normal sonographic study of the hepatobiliary system.
  • 2022-05-24 CXR
    • Patchy opacity projecting in the right upper medial lung or mediastinum shows stationary. Follow up is indicated.
      
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-04-12 CT - brain
    • Imp: Brain atrophy.
  • 2022-01-25 CT - abdomen, pelvis
    • S/P subtotal gastrectomy.
  • 2021-11-23 Bone densitometry - spine
    • Osteoporosis
  • 2021-11-09 T- L-spine AP + Lat.
    • Compression fracture of T7, T10, T12 and L4.
    • Atherosclerosis of the aorta.
  • 2021-07-20 Patho - stomach subtotal/total (tumor)
    • pathologic diagnosis
      • Stomach, anastomosis area, radical total gastrectomy —- Adenocarcinoma, poorly differentiated, s/p subtotal gastrectomy about 30 years ago
        
      • Small intestine, duodenum, radical total gastrectomy —- Adenocarcinoma, by direct invasion —- Neuroendocrine tumor,
      • G1 Soft tissue, anterior abdominal wall, excision —- Adenocarcinoma, by direct invasion
        
      • Omentum,radical total gastrectomy —- Negative for malignancy
        
      • Lymph node, lesser curvature, group 1, 3, 5, 7, 8, 9, 11p, 12a, dissection —- Adenocarcinoma, metastatic (2/14)
        
      • Lymph node, greater curvature, group 2, 4, 6, 14v, dissection —- Adenocarcinoma, metastatic (4/16)
        
      • AJCC 8 th edition pTNM Pathology stage:
        • Adenocarcinoma: pStage IIIB, pT4bN2 (if cM0)
          
        • Neuroendocrine tumor: pStage I, pT1N0 (if cM0)
    • microscopic examination
      • Histologic Type: Adenocarcinoma, Lauren classification of adenocarcinoma: Intestinal type
        
      • Histologic Grade : G3: Poorly differentiated, undifferentiated
        
      • Tumor Extension: Tumor invades adjacent structures/organs (specify) abdominal wall soft tissue
        
      • Lymphovascular Invasion: present
        
      • Perineural Invasion: present
        
      • Regional Lymph Nodes: lesser curvature: 2/14; greater curvature: 4/16
        
      • The immunohistochemical stains reveal CD56(+) and Synaptophysin(+). The Ki-67 is < 3%.
      • Intestinal metaplasia: present
        
      • Low-grade dysplasia: present
        
      • High-grade dysplasia: absent
        
      • Helicobacter pylori-type gastritis: absent
        
      • Autoimmune atrophic chronic gastritis: absent
        
      • Polyp(s): absent
  • 2021-06-30 CT - liver, spleen, biliary duct, pancreas
    • Findings:
      • S/P subtotal gastrectomy with suggestive BI anastomosis?please correlate with clinical history.
      • There is a lobulated wall thickening lesion in the stomach, beyond anastomosis area, that is compatible with adenocarcinoma. The fat plane between the gastric lesion, pancreatic body and abdominal wall shows obliteration that may be directly attached or invasion?
      • There are six enlarged nodes in the gastrohepatic ligament and adjacent omentum area that may be metastatic nodes.
    • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T4b(T_value) N:N2(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
  • 2021-05-13 Patho - stomach biopsy
    • Stomach, Remnant gastric cancer, s/p biopsy — Adenocarcinoma.
      
    • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
      
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
  • 2021-05-13 SONO - abdomen
    • Hepatic tumor prob. hemangioma
    • Susp. parenchymal liver disease
• consultation
  • 2021-07-13 Gastroenterology

[assessment]

• Lab data (2022-06-27) low K (2.3 mmol/L), high NT-proBNP (2561 pg/mL), high hs-Troponin I (561.5 pg/mL), high WBC (13.64 *10^3/uL) -> underlying cardiac conditions? following EKG indicated inferior infarct and lateral ischemia.
• pH 7.475, pCO2 22.8 mmHg, HCO3 16.4 mmol/L (2022-06-27) -> Hyperventilation to mitigate hypoperfusion of the heart?
• no issue with active prescription.

701378989

220627

• lab data
  • 2022-06-27 PD-L1 22C3 S22-9396
    • Tumor type: Lung cancer
    • 2022-06-27 Tumor Proportion Score (TPS): 60%
  • 2022-06-22 PD-L1 28-8 S22-9396
    • Tumor type: Lung cancer
    • Tumor Cell (TC) staining assessment: TC < 1%
    • Percentage of 28-8 expressing tumor cells (%TC): 0%
  • 2022-05-27
    • Protein, total 5.8 g/dL
      
    • Albumin 52.9 %
      
    • Alpha-1 5.2 %
      
    • Alpha-2 13.4 %
      
    • Beta 16.1 %
      
    • Gamma 12.4 %
      
    • M-peak Negative
      
    • A/G Ratio 1.10
      
    • IgG/A/M Kappa/Lambda No Paraprotein
  • 2022-05-26
    • B2-Microglobulin 3379 ng/mL
      
  • 2022-05-25
    • SCC 1.6 ng/mL
      
    • HBsAg Nonreactive
      
    • HBsAg (Value) 0.52 S/CO
      
    • Anti-HBc Reactive
      
    • Anti-HBc-Value 3.74 S/CO
      
    • Anti-HCV Nonreactive
      
    • Anti-HCV Value 0.16 S/CO
      
    • Anti-HBc IgM Nonreactive
      
    • Anti-HBc IgM Value 0.12 S/CO
• exam finding
  • 2022-06-24 CXR
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • Patchy opacity of the right lower lung zone was noted, which might be bronchogenic carcinoma. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • S/P pigtail catheter implantation at right CP angle.
    • Spondylosis of the T-spine
  • 2022-06-15 Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • S2022-9396
      • Tumor type: adenocarcinoma
      • Tumor location: lung
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>= 50 viable tumor cells): Yes,
    • Result:
      • 1. Tumor cell (TC) staining assessment: TC category: TC < 1%
      • 2. Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • 1. TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • 2. IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-06-15 Tc-99m MDP whole body bone scan
    • Highly suspected cancer with multiple bone metastases in the skull, both rib cages, sternum, some C-, T- and L-spine, sacrum, bilateral pelvic bones, and bilateral femoral trochanters.
    • Increased activity in the maxilla and bilateral shoulders, probably post-traumatic change or bone mets.
  • 2022-06-14 MRI - brain
    • Known a case of lung cancer. Numerous enhancing nodular lesions over both cerebral hemispheres and cerebellum and brainstem, compatible with metastases.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • Mild periventricular small vessel disease. NO acute ischemic infarct.
  • 2022-06-09 Patho - lung transbronchial biopsy
    • Lung, RML/RLL, bronchoscopic biopsy — adenocarcinoma, moderately differentiated
    • Sections show bronchial mucosa with invasive solid and acinar tumor cells in submucosa and lymphatic vessels.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(-), WT-1(-) and PAX8(-). The results are in favor of primary lung adenocarcinoma.
  • 2022-06-09 Body Fluid Cytology - bronchial washing
    • Smears show benign bronchial and squamous cells and clusters of atypical hyperchromatic and pleomorphic cells. Malignancy is favored. Please correlate with the clinical presentation.
  • 2022-05-27 CT - abdomen, pelvis
    • Findings:
      • There is a well-defined mild heterogeneous mass in RLL of the lung, measuring 9 cm in size (the largest dimension) that may be bronchogenic carcinoma with total obstruction of RLL bronchus and RLL collapse.
        • In addition, there are multiple small nodules in both lung that are c/w lung to lung metastases.
        • There are several enlarged nodes in the paratracheal space that may be metastastic nodes.
          
        • There is massive right side pleura effusion with lobulated thickening in the visceral pleura that may be pleura tumor seeding. Please correlate with pleura effusion cytology.
      • There is a poor enhancing lesion 5 mm in S8 of the liver that may be flow artifact or tumor?
      • There is minial wall thickening of right UPJ causing hydronephrosis and delayed contrast excretion of right kidney.
        • Please correlate with retrograde pyelography to R/O chronic UPJO or urothelial cell carcinoma.
      • There is a cystic lesion in right adnexa measuring 3.2 cm in size but no evidence of wall thickening or mural nodule.
        • Simple right ovarian cyst is highly suspected.
        • Please correlate with GYN. sonography.
        • In addition, There is a exophytic soft tissue mass measuring 4.4 cm in size protruding from right side uterus with central calcification that may be myoma.
      • There are diffuse bony metastases in the T-spine, L-spine and pelvis.
      • There are soft tissue lesions in the omentum that are c/w tumor seeding.
    • Impression:
      • Primary lung cancer in RLL with lung to lung metastases, right pleura metastases, diffuse bony metastases, and carcinomatosis is suspected.
        
      • Chronic UPJO or urothelial cell carcinoma at right UPJ causing obstructive uropathy is suspected. Please correlate with retrograde pyelography.
  • 2022-05-27 Gynecologic ultrasonography
    • IUD in situ
    • Multiple myomas
  • 2022-05-12 MRI - L-spine
    • Findings
      • Diffuse numerous lesions with T1-hypointensity and mild T2-hyperintensity involving both anterior and posterior elements of every vertebral body from C4 to S5 and iliac bones vivisble in these images, indicating bony metastases.
      • General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild to moderate spinal canal stenosis and bilateral mild to moderate neuroforaminal narrowing at L1-2-3-4-5-S1, esp L4-5.
      • Mild scoliosis of L-spine.
      • Dilatation of right renal calyces andproximal ureter, indicating obstructive uropathy.
      • A well-deifned cystic mass, about 37 mm, with T1-hypointensity and T2-hyperintensity in right aspect of pelvic cavity. R/O right ovarin cystic tumor.
      • Massive pleural effusion in right lung field with right lung collapse.
    • IMP:
      • Diffuse bony metastases involving vertebral column and bony pelvis as described.
      • Right hydronephrosis and hydroureter.
      • Suspected right ovarian cystic tumor (37 mm).
      • Right massive pleural effusion.
      • Suggest further evaluation.
  • 2022-05-12 Bone densitometry - spine
    • L-spines BMD (AP view) performed by DXA revealed:
      • AP L-spines, BMD of L1-4 0.711 gms/cm2, about 3.1 SD below the peak bone mass ( 68 %) and 0.1 SD above the mean of age-matched people ( 103 %).
    • IMP: osteoporosis
• consultation
  • 2022-06-20 Dermatology
    • A
      • This patient suffered from erytheamtous patches on vaginala area for days
      • Imp:
        • 1. Intetrigo
        • 2. Dyshidrotic dermatitis
      • Suggestion:
        • 1. Sinpharderm * 1 tube + topsym cream * 2 tubes/bid(feet)
        • 2. Zalain cream * 1 tubes/bid
  • 2022-06-16 Radiation Oncology
    • A
      • This 78-year-old woman case of Lung adenocarcinoma with brain and bone metastases, stage IV. Lower back pain developed. Whole body bonew scan on 2022/06/15 showed T-L spine bone metastasis.
      • Palliative RT is indicated. CT-simulation will be arranged on 2022-06-20. Plan to deliver 30 Gy/ 10 fx to the spine T11-L3. RT will start around 2022-06-21 or -06-22. Thank you very much.
  • 2022-06-08 Dermatology
    • A
      • This patient suffered from erytheamtous patches on vaginal area for months
      • Imp: Subacute dermatitis
      • Suggestion:
        • 1. Zalain cream * 2 tubes/bid
        • 2. Zaditen 1 */Bid
  • 2022-05-27 Urology
    • A
      • Right hydronephrosis + creatinine: normal
      • PCN was suggested if further C/T is indicated.
      • After discussed with the patient and families, they refused PCN.
      • Consult us again if they changed their mind.
  • 2022-05-27 Obstetrics and Gynecology
    • A
      • 78y/o, female, G3P3. Admitted due to diffuse bony metastases involving vertebral column and bony pelvis. Pleural effusion s/p tapping, cytology: Malignancy (+)
      • S:
        • Back pain for 1 year
        • The pain was diffuse to whole body and can not take care of herself in recent month
      • O:
        • Elevated tumor marker, CEA:941, CA153:405, CA125:364.8, CA199:358
        • Abdominal cT on 2022/05/27 showed right pleural effusion, rigth hydroneprosis, uterine myoma and R/O overain tumor.
        • Sono: uterus: AVf: 5.3x3.5cm, IUD in situ, EM:0.57
        • Uterine myoma about 4.6x3.7cm and 2.2x1.7cm
        • CDS: no fluid
      • IMP:
        • IUD in situ
        • Uterine myoma
      • P:
        • Tumor biopsy may be arranged after discussion with the family

{valganciclovir not for herpes}

• There is a diagnosis of an unspecified herpesvirus infection.
• Valganciclovir is a nucleoside analog group of antiviral medication that is used to treat cytomegalovirus (CMV) infections. It is not effective against herpes simplex virus (HSV) infection. ( https://www.sciencedirect.com/science/article/pii/B9780128012383994066 )
• Most patients with a first episode of genital HSV can be treated with oral therapy. IV acyclovir is typically reserved for the management of complicated infection (eg, central nervous system and disseminated disease). ( https://www.uptodate.com/contents/treatment-of-genital-herpes-simplex-virus-infection )
• The 2021 United States Centers for Disease Control and Prevention (CDC) guidelines recommend any of the following oral treatment options (doses based on normal renal function). Therapy should be administered for 7 to 10 days. However, on occasion, a patient may continue to have new lesions even after completing a 10-day course. When this happens, the course is typically extended by five to seven days.
  • Acyclovir: 400 mg three times daily
  • Famciclovir: 250 mg three times daily
  • Valacyclovir: 1000 mg twice daily
• All three agents appear to have similar efficacy for the treatment of a first episode of genital herpes, and the margins of safety and tolerability are excellent. Valacyclovir is generally administered since it is dosed less frequently than the others, although oral acyclovir may be preferred in certain settings as it can be less expensive.

700953139

220624

{pseudomyxoma peritonei}

• Lab data
  • CA-199
    • 2022-06-17 141.06 U/mL
    • 2022-06-02 171.303 U/mL
    • 2022-05-10 137.16 U/mL
    • 2022-04-22 128.052 U/mL
    • 2022-04-21 137.226 U/mL
    • 2022-03-25 195.97 U/mL
    • 2022-03-09 223.51 U/mL
    • 2022-02-18 225.74 U/mL
    • 2022-02-04 217.96 U/mL
    • 2021-12-07 223.03 U/mL
    • 2021-11-19 251.47 U/mL
    • 2021-11-09 180.081 U/mL
    • 2021-10-22 216.17 U/mL
    • 2021-10-05 185.36 U/mL
    • 2021-09-14 161.169 U/mL
    • 2021-07-23 138.66 U/mL
    • 2021-07-13 136.710 U/mL
    • 2021-04-20 197.23 U/mL
    • 2021-04-07 221.4 U/mL
    • 2021-03-26 182.849 U/mL
    • 2021-03-23 188.093 U/mL
    • 2021-03-08 187.400 U/mL
    • 2021-02-19 231.475 U/mL
    • 2021-02-04 222.5 U/mL
    • 2021-02-04 229.390 U/mL
    • 2021-01-15 195.585 U/mL
    • 2021-01-04 117.21 U/mL
    • 2020-12-31 183.1 U/mL
    • 2020-12-23 196.630 U/mL
    • 2020-12-23 204.470 U/mL
    • 2020-12-04 219.81 U/mL
    • 2020-11-25 232.83 U/mL
    • 2020-11-09 284.23 U/mL
    • 2020-10-02 273.88 U/mL
    • 2020-08-04 215.15 U/mL
  • CA-125
    • 2022-06-17 120.114 U/mL
    • 2022-06-02 61.224 U/mL
    • 2022-05-10 47.427 U/mL
    • 2022-04-19 38.267 U/mL
    • 2021-10-22 45.773 U/mL
    • 2021-10-05 49.708 U/mL
    • 2021-09-14 40.944 U/mL
    • 2021-07-23 38.211 U/mL
    • 2021-07-13 35.203 U/mL
    • 2021-04-20 31.553 U/mL
    • 2021-04-07 31.265 U/mL
    • 2021-03-23 29.899 U/mL
    • 2021-02-04 35.661 U/mL
    • 2020-10-06 113.319 U/mL
    • 2020-08-04 421.600 U/mL
• exam finding
  • 2022-06-16 Abdomen - standing (diaphragm)
    • Spondylosis with scoliosis of the L-spine with convex to right side.
    • Ascites is noted.
    • Wedge deformity at left lateral aspect of L2 and L3 vertebral body and right lateral aspect of L4 vertebral body are noted. Please correlate with clinical symptom and history.
    • Pseudomyxoma peritonei with multiple curvelinear calcification in the peritoneum.
  • 2022-04-15 CT - abdomen, pelvis
    • FINDINGS:
      • Prior CT (2022/01/11) identified carcinomatosis (pseudomyxoma peritonei) in peritoneal cavity and lesser sac with indentation defects at the liver capsule are noted again, stable in size that is compatible with stable disease.
      • Few small renal cysts on both kidney are noted.
      • Spondylosis with scoliosis of the L-spine with convex to right side. Disc space narrowing with marginal osteophyte formation and vacuum phenomenon from L2 to L5.
      • Bilateral mild Pleura effusion are noted.
    • IMP:
      • Carcinomatosis (pseudomyxoma peritonei) show stable disease.
  • 2022-03-08 Standing KUB
    • Curvelinear calcification in the whole abdomen is noted that is c/w pseudomyxoma peritonei.
    • Ascites is noted.
    • Compression fracture of L3, L4 and L5 vertebral body causing Spondylosis with scoliosis of the L-spine with convex to left side.
  • 2022-03-08 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Hypoinflation of both lung is noted.
    • Left hemi-diaphragm elevation is noted, which may be due to left lower lung volume decrease.
    • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2022-01-11 CT - abdomen, pelvis
    • findings
      • There are diffuse soft tissue tumores in the peritoneum with calcifications, suggesting peritoneal carcinomatosis. Stationary.
      • Left renal cyst, 1.8cm.
    • impression
      • Diffuse peritoneal carcinomatosis, stationary.
      • Left renal cyst.
      • Lumbar spine scoliosis.
  • 2021-10-09 CT - abdomen, pelvis
    • findings
      • Cystic lesions (n>30) with calcified wall inside abdominal cavity is found. In comparison with CT dated on 2021-07-06, the size and extension of the lesions are stationary.
      • Clear bilateral basal lungs is found.
      • Scoliotic alignment of the thoracolumbar spine is noted.
      • Degenerative change of the bony structure with marginal osteophyte formation is identified.
      • No evidence of liver tumor but the liver surface is compressed by calcified cystic lesions.
      • Tortous aorta with calcification is noted.
    • Imp:
      • Colon cancer with Cancerous carcinomatosis. Stationary.
  • 2021-07-06 CT - abdomen, pelvis
    • findings
      • There are diffuse soft tissue tumores in the peritoneum with calcifications, suggesting peritoneal carcinomatosis. Stationary.
      • Left renal cyst, 1.8cm.
      • Lumbar spine scoliosis.
    • Impression:
      • Diffuse peritoneal carcinomatosis, stationary.
      • Left renal cyst.
      • Lumbar spine scoliosis.
  • 2021-04-21 Patho - colon biopsy
    • Cecum, biopsy — Tubulovillous adenoma with low grade dysplasia and focal high grade dysplasia.
      
    • Section(s) show(s) fragment(s) of villous polypoid colonic mucosal tissue with proliferative finger-like mucinous glands lined by cells containing hyperchromatic, elongated nuclei with low grade dysplasia. There is focal high grade dysplasia.
  • 2021-04-20 Colonoscopy
    • Findings
      • 90cm to cecum, ulcerative lesion at cecum, biopsy
      • multiple external compression over S colon, and D colon
    • Diagnosis
      • ulcerative lesion primary tumro or secondary invasion are both consider
    • Suggestion
      • follow pathology
    • Complication
      • No immediate complication
  • 2021-04-16 CXR
    • S/P pacemaker.
    • No active lung lesion.
    • Borderline cardiomegaly.
    • Thoracolumbar spondylosis and scoliosis.
  • 2021-04-16 ECG
    • Sinus rhythm with Premature atrial complexes
    • Prolonged QT
    • Abnormal ECG
  • 2021-03-22 CT - abdomen, pelvis
    • Progression of peritoneal carcinomatosis.
  • 2021-01-17 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Hypoinflation of both lung is noted.
    • Left hemi-diaphragm elevation is noted, which may be due to left lower lung volume decrease.
    • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2020-12-11 CT - abdomen
    • Carcinomatosis (pseudomyxoma peritonei) show progressive disease.
  • 2020-08-21 Patho - soft tissue tumor, extensive resection
    • diagnosis
      • A. Labeled as “peritoneal carcinomatosis”, biopsy with frozen section (F2020-332FS) — mucnous adenocarcinoma. IHC stains: CK20 (+), pax-8 (-), GI origin is considered.
        
      • B. Labeled as “peritoneal carcinomatosis: omentum and small intstinal tumor”, biopsy (S2020-11921A) — mucinous adenocarcinoma
        
      • C. Labeled as “peritoneal carcinomatosis: right pelvic wall tumor”, biopsy (S2020-11921B) — mucinous adenocarcinoma.
        
    • microscopic description
      • Sections of F20-332FSA1-2, S20-11921A1-4 and B show mucnous adenocarcinoma.
      • IHC stains: CK20 (+), pax-8 (-), GI origin is considered.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+).
  • 2020-08-07 Colonoscopy
    • Findings
      • The scope reach the transverse colon near hepatic flexure under fair colon preparation; a large ulcerative tumor occupying almost whole colon lumen thus the scope could not be passed through: highly suspect colon cancer: biopsy was taken for six pieces.
      • diverticulosis: sigmoid colon
    • Diagnosis
      • transverse colon tumor(near hepatic flexure), suspect colon cancer, post biopsy (incomplete exam: insertion to transverse colon only because of tumor obstruction)
      • diverticulosis: sigmoid colon
    • Complication
      • No immediate complication
• surgical operation
  • 2020-08-19
    • Surgery
      • Bilateral DBJ insertion
    • Finding
      • Bilateral DBJ insertion, 6Fr 24cm DBJ, was performed smoothly
    • Procedure
      • Under ETGA
      • Lithotripsy position
      • Drapping and disinfection as usual
      • 6Fr 24cm DBJ was inserted smoothly
      • Patient stood the procedure well
  • 2020-08-19
    • Surgery
      • Diagnosis: Peritoneal carcinomatosis
      • Operation: exploratory laparotomy and tumor excision
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: atrophy, tense contact with bladder,
      • Adnexa:
        • LAD: not seen due to severe adhesion and tumor seeding
        • RAD: not seen due to severe adhesion and tumor seeding
      • CDS: invisible due to tumor mass occupied
      • Ascites: bloody , about 500 ml
      • Omentum: multiple hard, variablesized nodules
      • Liver: grossly normal & smooth
      • Appendix: not seen due to severe adhesion and tumor mass occupied
      • Multiple mucin-contained mass about 3~5 cm over intestine, peritonium and pelvic wall
      • Residue tumor: multiple tumors, maximal diameter about 5 cm, over intestine, colon and peritoneal wall
      • Note
        • Estimated blood loss:minimal
        • Blood transfusion:nil
        • Complication:nil
    • Procedure
      • Put the patient on the lithotomy position
      • Vaginal douching, on Foley, skin disinfection with beta-iodine, and skin draping.
      • Make midline vertical skin incision and open the abdominal wall layer by layer.
      • Serous ascites 20 ml, send for cytology
      • Apply auto-retractor and pack up the intestine.
      • Dissect the tumor and send for frozen section: mucinous adenocarcinoma
      • Consult CRS for futher evaluation
      • Insert a 15 J-P drain at the cul-de-sac.
      • Close the abdomen layer by layer.
      • Skin approximation with 4-0 Dexon. 
  • 2020-08-05
    • Surgery
      • Dilatation and curettage
    • Finding
      • Uterus: Anteversion, 5 cm.
      • Scanty endocervical and some endometrial tissue were curetted out.
      • A pollyp about 1.5x0.5cm at 1 o’clock was protuding from cervix.
      • Estimated blood loss: minimal, Blood transfusion: nil, complication: nil.
    • Procedure
      • Put the patient on lithotomy position.
      • Douching, skin disinfection and skin draping as usual.
      • Sounding: Anteversion, 5 cm.
      • Cervical dilatation to Hegar No. 8.
      • Curette endocervical canal and uterine cavity.
      • Polypectomy was perfomred.
      • Check bleeding.
• consultation
  • 2020-09-02 Family Medicine
    • Q
      • Colonscopy was performed on 2020/08/07 which revealed transverse colon tumor (near hepatic flexure), suspect colon cancer but biopsy showed tubular adenoma. CRS was consulted for exp.Lap with tissue proven and possible colostomy or ileostomy. Then she transfered to GYN ward on 2020/08/18 and underwent 1) Bilateral Double J insertion 2) exploratory laparotomy and tumor excision on 2020/08/19. Family refused colostomy or ileostomy. During the surgery, little tumor tissue was removed due to severe adhesion. Pathology on 2020/08/19 showed mucinous adenocarcinoma. IHC stains: CK20(+), pax-8 (-), GI origin is considered. Post operation then transfer to SICU for care on 2020/8/19-20. She still complained of abdominal fullness and vomiting. Owing to elevated D-dimer, Clexane was given. After evaluation by CRS Dr. Chen, repeated surgery for colostomy is not suggested due to poor prognosis. IPP and family meeting done on 2020/08/27 and she was transferred to oncology ward for further management. At ONC ward, consciousness clear and vital signs was stable. Abdominal fullness and pitting edema 4+ was noted. Keep liquid diet, smofkabiven and albumin infusion. Owing to terminal stage of mucinous adenocarcinoma of colon with peritoneal carcinomatosis metastasis, we need your expertise for hospice combined care, thanks.
    • A
      • Due to terminal stage of mucinous adenocarcinoma of colon with peritoneal carcinomatosis metastases, we were consulted for further evaluation.
      • When we visited, the patient lied on bed and her family stood by her. Her consciousness was clear and she asked that what time could she receive treatment. We will arrange hospice combined care first.
  • 2020-08-12 Colorectal Surgery
    • After admissoin, self paid of albumin with diuretics was given for right massive pleural effusion and ascites. Empirical antibiotics with Flumarin was given from 8/2 to 8/4, we shifted to Tapimycin from 8/4 due to still fever with chills and we repeat the blood culture. Owing to suspect ovarian or colon caner,series of examination were done. EGD showed Reflux esophagitis LA Classification grade A. PPI with Dexilant was given from 2020/8/4.
    • Reports:
      • Gynecologist was also consulted and D&C done on 2020/08/06 which endometrium curretage/biopsy showed endometrial polyp with few bland mucnous gland.
      • Bone scan on 2020/08/06 revealed No strong evidence of bone metastasis.
      • Colonscopy was performed on 2020/08/07 which revealed transverse colon tumor(near hepatic flexure), suspect colon cancer.Biospy on 2020/08/12 showed tubular adenoma.
      • Abdomen: soft, mild marked distended, palpable irregular masses(+), no peritoneal signs
      • Passage of little liquid stool
      • Tumor markers all elevated (CEA, CA19-9, CA12-5)
    • A: Peritoneal carcinomatosis with massive ascites and right pleural effusion, origin?
    • P:
      • Please consult RAD or CS for right pleural effusion drainage, and sent for cytology
      • Suggest echocardiography and pulmonary function test for pre-op evaluation
      • Exp.Lap with tissue proven and possible colostomy or ileostomy may be considered for further oncological treatment
      • We’ll follow this patient and arrange the operation next week
      • Please inform us if any problems
  • 2020-08-04 Obstetrics and Gynecology
    • Q
      • This 69 y/o woman is a case of HTN without medication control. She also denied any other systemic disease. According to this patient and her daughter, her poor appetite and B.W loss(>5 Kg) in recent 2 weeks. Associated symptoms with fever and BT up to 38.0 degree C, oligouria, SOB, abdomen fullness, vomit (epigastric juice) and minimal dark stool passage. She ever to GI OPD on 7/30 where MgO plus Gascon plus Morpide were given and abdomen echo/PES were perform. However, her SOB with abdomen fullness progress on 8/01. Then she was sent to our ER. TOCC(-)
      • At ER, her vital signs 100/18/37.2 and BP 150/75mmHg. Lab revealed no leukocytosis VBG no acidosis and U/A(-). Microcytic anemia (Hb:7.9 MCV/MCH:66.1/19.1), Alb 2.9 and CRP elevated 16.43 were noted. CxR revealed right pleural effusion and cardiomegaly. Abdomen CT was perfrom on 2020/08/01 which revealed suspected peritoneal carcinomatosis with massive ascites and pleural effusion. Suggest tissue study (ovary origin? appendix origin?). Chest tapping was perform and drainage 1000ml. Under the impression of ovarian cancer with massive ascites and pleural effusion. She was admitted for further management. After admission, we arranged the bone scan on 8/5 and pending for tumor marker data. We need your expertise for further treatment, thanks.
    • A
      • P3, menopaused
      • C.C: SOB with abdomen fullness for 2 weeks
      • O:
        • no vaginal bleeding, no lifting pain
        • Echo: Endometrial thickning with papillary mass like lesion, Bilateral adnexa mass. Cul-de-sac: with some ascites, abdominal mass, suspect omentum cake.
      • Imp:
        • endometrial thickning
        • pelvic mass with ascites, origin unknown
      • P:
        • arrange D&C on 2020/08/05
        • arrange colonsocpy
        • sent abdominal ascites and pleural effusion to cell block
• chemoimmunotherapy
  • 2022-06-06 ~ undergoing - FOLFIRI
  • 2022-03-17 ~ 2022-04-28 - FOLFIRI + ramucirumab (3 times)
  • 2021-09-02 ~ 2022-02-25 - FOLFIRI + bevacizumab (8 times)
  • 2021-08-13 - FOLFIRI
  • 2021-06-02 ~ 2021-07-30 - FOLFIRI + bevacizumab (4 times)
  • 2021-05-10 - FOLFIRI
  • 2020-11-23 ~ 2021-04-26 - FOLFIRI + bevacizumab (11 times)
  • 2020-09-07 ~ 2020-11-10 - FOLFIRI (6 times)

[assessment]

• Nowadays, cytoreductive surgery (CRS) associated with hyperthermic intraperitoneal chemotherapy (HIPEC) represents the only treatment with potential chances of cure and long-term disease control of patients affected by PMP.
• Exploratory laparotomy and tumor excision was performed on 2020-08-19, however the tumor adhesions were too serious, obscuring the surgical field and could not be removed completely. When surgery is not indicated due to comorbidities or for unresectable disease, systemic chemotherapy is considered, with the main aim to avoid progression and control symptoms. In general, a relatively unresponsiveness and chemoresistance of PMP cells to systemic chemotherapy is reported, due to their low proliferation rate and the uncertain drug availability in the mucinous microenvironment of tumor nodules. Moreover, tumor response is difficult to evaluate with standard radiological criteria, as PMP masses are mostly composed of mucin and it is unlikely to obtain a significant shrinkage even in case of full activity on tumoral cells. The results of systemic chemotherapy showed a response rate ranging between 8-20%, median OS between 26-56 months, and 1-year OS rate of 84-91. ( https://pubmed.ncbi.nlm.nih.gov/34885075/ )
• While CA-199 has remained relatively stationary in first half of 2022, CA-125 has trended upward in the last three months.
• Lab data
  • CA-199
    • 2022-06-17 141.060 U/mL
    • 2022-06-02 171.303 U/mL
    • 2022-05-10 137.160 U/mL
    • 2022-04-22 128.052 U/mL
    • 2022-04-21 137.226 U/mL
    • 2022-03-25 195.970 U/mL
    • 2022-03-09 223.510 U/mL
    • 2022-02-18 225.740 U/mL
    • 2022-02-04 217.960 U/mL
  • CA-125
    • 2022-06-17 120.114 U/mL
    • 2022-06-02 61.224 U/mL
    • 2022-05-10 47.427 U/mL
    • 2022-04-19 38.267 U/mL
• FOLFIRI has been used to treat the patient since September 2020 by IVD. In practice, chemotherapy can also be administered intraperitoneally in the PMP patients. Intraperitoneal administration of chemotherapy is designed to maximize the chemotherapeutic dose delivered to peritoneal tumor nodules while minimizing systemic toxicity. ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754301/ )

700022404

220623

{CNS DLBCL}

[objective]

• exam findings
  • 2022-06-22 MRI - brain
    • Findings
      • An intra-axial tumor, about 48 mm, with heterogeneous enhancement, diffuse restriction, central necrosis and perifocal white matter edema, involving right temporofrontal lobe, and causing mass effect (including effacement of right hemicerebral cortical sulci, compression and displacement of lateral ventricles and midline shift to left side).
        
      • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
      • S/P right frontotemporal craniotomy.
      • Diffuse mild luminal irregularity without obvious stenosis of major intracranial arteries in MRA study (including bilateral ICAs, MCAs, ACAs, PCAs and VAs and BA).
    • IMP: Right frontotemporal tumor with mass effect. Suspected recurrent lymphoma.
  • 2022-06-22 CT - brain
    • Findings
      • decreased intraventricular and extraventricular CSF spaces in the right supratentoral region.
      • a nodular lesion, about 52mm, in the right temporal lobe and right basal ganglion with moderate perifocal edema
      • unremarkable change in the skull base
    • IMP: an intra-axial tumor in the right temporal lobe and right basal ganglion.
  • 2022-03-29 MRI - brain: Right temporo-occipital enhancing tumors, regressed. Comparison: 2021/12/22 Brain CT, 2021/12/09 Brain MRI
  • 2022-03-28 CT - abdomen, pelvis: Right pulmonary hilar lymphadenopathy, stationary.
  • 2021-12-22 CT - Brain: Right temporoparietal tumors (lymphoma?) with progression mass effect as compare with CT study on 20211205, suggest clinical correlation.
  • 2021-12-09 MRI - Brain: Recurrent brain lymphoma. Old insults in left caudate head and splenium, stationary and mild general brain atrophy.
  • 2021-12-05 CT - Brain: Ill-defined heteregeneous lesions in right temporoparietal lobes. Brain metastasis or contusion hemorrhage, suggest clinical correlation. Focal hyperdensity along left frontal horn, suspected focal hematoma.
  • 2021-09-09 MRI - Brain: old insults in left caudate head and splenium, stationary as comapred with MRI on 20210609.
  • 2021-06-09 MRI - Brain: focal increased enhancement in the periventricular region of the right parietal lobe.
  • 2020-07-09 CT, MRI: showed no definite evidence of extra-crainial metastasis. (TMUH)
  • 2020-06-20 MRI: CNS lesion, then biopsy revealed DLBCL. (TMUH)
  • 2020H1 Initial presentation with blurred vision, especially, right eye, and personality change. (TMUH)
• lab data
  • Methotrexate (Toxic: 24hr > 10, 48hr > 1, 72h > 0.1, unit: umol/L)
    • 2022-04-30 <0.040
    • 2022-04-29 0.070
    • 2022-04-28 0.557
    • 2022-04-02 0.138
    • 2022-04-01 0.530
    • 2022-03-11 0.041
    • 2022-03-10 0.133
    • 2022-03-09 1.181
    • 2022-02-14 0.045
    • 2022-02-13 0.119
    • 2022-02-12 2.548
    • 2022-01-25 0.061
    • 2022-01-24 1.784
    • 2022-01-23 0.091
    • 2021-12-31 0.043
    • 2021-12-30 0.160
    • 2021-12-29 2.552
    • 2021-03-05 0.071
    • 2021-03-04 0.214
    • 2021-03-03 1.141
    • 2021-01-26 0.046
    • 2021-01-25 0.175
    • 2021-01-25 1.032
    • 2020-12-30 <0.040
    • 2020-12-29 0.058
    • 2020-12-28 1.379
    • 2020-12-28 0.218
    • 2020-12-02 <0.040
    • 2020-12-01 0.065
    • 2020-11-30 0.239
    • 2020-11-30 0.902
    • 2020-11-05 0.083
    • 2020-11-04 0.151
    • 2020-11-03 0.333
    • 2020-11-02 1.185
• consultation
  • 2022-01-03 Rehabilitation
    • Assessment
      • Diffuse large B-cell lymphoma with CNS invasion, stage IV s/p chemotherapy with MTR and chemotherapy with HD MTX, brain local recurrent
      • brain MRI 20211209: recurrent brain lymphoma and old insults in left caudate head and splenium, stationary and mild general brain atrophy.
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation programs
      • Goal: ambulation independent. transfer independent.
  • 2021-12-25 Neurosurgery
    • Q
      • This 68-year-old man patient is a case of Diffuse large B-cell lymphoma with CNS invasion, stage IV s/p chemotherapy with MTR and chemotherapy with HD MTX, brain local recurrent. Dizziness with nausea in 2021/12. Brain CT on 2021/12/05 showed 1) Ill-defined heteregeneous lesions in right temporoparietal lobes. Brain metastasis or contusion hemorrhage, suggest clinical correlation. 2) Focal hyperdensity along left frontal horn, suspected focal hematoma. 3) Brain atrophy. Brain MRI on 2021/12/09 showed recurrent brain lymphoma and old insults in left caudate head and splenium, stationary and mild general brain atrophy. Chest CT on 2021/12/11 showed no evidence of lymphadenopathy in the study, calcified coronary arteries is found and tiny nodule at Right lower lobe, stable. This time, for con’s drowsy with dizziness since yesterday. Therefore, he was snet to our ER and Brain CT on 2021/12/22 showed 1) Right temporoparietal tumors (lymphoma?) with progression mass effect as compare with CT study on 2021-12-05, suggest clinical correlation. 2) Brain atrophy. Now, for evaluate brain tumor operation. Thank you.
    • A
      • The 68 y/o male a patient with diffuse large B-cell lymphoma with CNS invasion, stage IV s/p chemotherapy with MTR and chemotherapy with HD MTX, brain local recurrent. We are consulted for surgical opinion.
      • We had well-explained risk and outcome to patient’s family. Surgical intervention is recommended if family agree and accept the risk and ouctome. (If Brain MRI with enhancement is not able to be done, please arrange CT with enhancement for navigation if possible for pre-operation evaluation)
  • 2020-10-30 Neurosurgery
    • This 67-year-old man patient is a case of Diffuse large B-cell lymphoma with CNS invasion, stage IV. This time, for right shoulder pain radiation to finger for weeks.
    • brain MRI favor post treatment change in corpus callosum and left inferior caudate head. band encephalomalacia in RT lateral occipital lobe. Mild cortical brain atrophy. no enhancing brain mass or nodule.
    • x-ray s/p C3-4 ACDF with lower cervical spondylosis
    • Plan: pain control, NS OPD follow-up
  • 2020-10-27 Ophthalmology
    • Q
      • This 67-year-old man patient is a case of CNS DLBCL, stage IVA. Crystal lymphoma invasion with bilateral blurred vision. Now, for bilateral eye evaluate and examnation. Thank you.
    • A
      • BV od for several months concurrent with CNS DLBCL
      • subjective VA stable compare to previous condition
      • patient refuse further work up for media opacity and cause of retina infiltrate od
      • BCVA: 0.2/0.6
      • IOP 16/16
      • Fd photo od: nasal and superior satellite retina infiltrate media mild blurred
• treatment
  • 2021-12 ~ ongoing - methotrexate + temozolomide
  • 2020-07 ~ 2021-03 - methotrexate + temozolomide + rituximab
• underlying diseases
  • DM and HTN are under medication management.

==========

2022-06-23

• The patient had vomiting, poor appetite, drowsiness, and incontinence during last two days. 2022-06-22 Updated images revealed an intra-axial tumor in the right temporal lobe and right basal ganglion that could be a recurrent lymphoma with decreased intraventricular and extraventricular CSF spaces in the right supratentoral region.
• Underlying health conditions are treated with corresponding drugs without issues.

2022-05-18

• MRI (2022-03-29) and CT (2022-03-28) images showed stable right hilar lymphadenopathy, and regressed tumors in the right temporo-occipital region, as compared to the images taken in Dec 2021. The current regimen appears to have some beneficial effects.
• According to lab records, methotrexate levels never reached toxicity levels. Lab data reported on 2022-05-09 indicated that liver and kidney function, CBC, WBC DC, electrolytes and b2 microglobulin were generally normal. The last item reinforced the aforementioned results of images.
• Urine glucose 2+ reported on 2022-05-17 (blood sugar data points since this hospitalization: 232, 203, 176). In patients with normal kidney function, significant glycosuria does not generally occur until the plasma glucose concentration exceeds 180 mg/dL (10 mmol/L). DM is an important factor affecting the prognosis of patients with DLBCL. Moreover, hyperglycemia during treatment is related to the poor prognosis of patients with DLBCL. (reference: https://pubmed.ncbi.nlm.nih.gov/33858047/ ) SGLT2 inhibitor might serve as an optional alternative agent of lowering blood sugar.

2022-03-28

• Recurrent DLBCL with brain mets, in progression (2021-12-22 CT).
• The patient got good response with methotrexate + temozolomide + rituximab during July 2020 to March 2021, and he is now on methotrexate + temozolomide since December 2021.
• No IHC or Karyotype or FISH results found in HIS5.
• The frequency of CNS involvement in systemic NHL varies depending at least partially upon the aggressiveness of the NHL subtype. Approximately 2 to 10 percent of patients with aggressive subtypes of systemic NHL (eg, DLBCL) will experience direct involvement of the CNS at some time during their course. The incidence is much higher in highly aggressive NHL (eg, Burkitt lymphoma/leukemia, lymphoblastic lymphoma) and lower in indolent NHL (eg, follicular lymphoma). Peripheral nervous system (PNS) involvement by lymphoma is rare.
• It is unknown whether the risk of CNS relapse has changed as initial treatment of these diseases has evolved. Several retrospective studies have suggested that the incidence may be lower among patients with B cell NHL treated with rituximab-containing therapy or etoposide-containing therapy. Other studies have found no difference in the incidence of CNS relapse in the pre- versus post-rituximab era.
  • https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-secondary-central-nervous-system-lymphoma
• Diffuse large B-cell lymphoma with secondary involvement of the central nervous system treated with R-IDARAM (rituximab 375 mg/m2 IV day 1; methotrexate 12.5 mg by intrathecal injection day 1; idarubicin 10 mg/m2/day IV days 1 and 2; dexamethasone 100 mg/day IV infusion over 12 h days 1-3; cytosine arabinoside 1000 mg/m2/day IV over 1 h days 1 and 2; and methotrexate 2000 mg/m2 IV over 2 h day 3.) and median follow-up for surviving patients was 49 months. At 2 years, estimated progression-free survival (PFS) was 39% and overall survival (OS) was 52%. Encouraging outcomes were reported in patients with new disease, with 5-year estimated PFS of 50% and OS 75%.
  • https://onlinelibrary.wiley.com/doi/full/10.1111/bjh.13867

2022-02-11

• brain DLBCL recurrence, in progression.
• the patient got good response with MTR when first introduced since 2020H2, he is now on the same regimen.
  • reference: “Therapy of primary CNS lymphoma: role of intensity, radiation, and novel agents” - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142584/pdf/bloodbook-2017-565.pdf
• autologous stem cell transplatation could be a worth trying alternative option if the patient younger.
  • reference: “The role of autologous stem cell transplantation in primary central nervous system lymphoma” - https://ashpublications.org/blood/article/127/13/1642/34766/The-role-of-autologous-stem-cell-transplantation
• if poor response proved under current regimen, then Ibrutinib might be an opt-in to the regimen.

2022-01-24

• blood sugar lab readings are above normal range under current mix of biguanide (metformin), DPP4i (sitagliptin) and sulfonylurea (glimepiride).
• if a rapid increase of blood sugar is found, then some regular insulin might be considered.

701277494

220623

[objective]

• exam finding
  • 2022-05-10 CT - abdomen, pelvis
    • S/P hysterectomy.
    • Left pneumothorax.
    • Much regression (1.6x5.0cm) of right liver margin metastases.
  • 2022-02-08 Patho - Liver biopsy needle/wedge
    • Liver, CT-guided biopsy - Consistent with metastatic endometroid carcinoma, poorly differentiated
      
    • IHC: ER (+), PR (focal +), Vimentin (+), and PAX8 (+).
  • 2022-01-29 CT - Lung, mediastinum, pleura
    • Liver surface meta and lung meta. The liver meta progressed.
    • There is no previous chest CT for comparison. the lung meta might be new.
  • 2022-01-11 CT - Liver, spleen, biliary duct, pancreas
    • S/P hysterectomy and oophorectomy.
    • Recurrent/peritoneal carcinomatosis in RUQ (subphrenic region with indentation of liver surface).
    • Subpleural nodule, 0.5cm in LLL.
  • 2021-12-20 MRI - Pelvis
    • S/P hysterectomy and oophorectomy.
    • Irregularity at liver surface (srs11 img11 and 18), carcinomatosis or artifact?
  • 2021-05-20 Patho - uterus neoplastic
    • pathologic diagnosis
      • Uterus, endometrium, staging surgery - Endometrioid carcinoma, grade 3
        
      • Uterus, myometrium, staging surgery - Involved by tumor ( > 1/2 thickness)
        
      • AJCC 8th edition Pathology stage: pT1bN0 (If cM0), FIGO IB, pStage IB
    • IHC: ER: positive (90%), PR: positive (90%), CK(+), vimentine(+), p63(+), Napsin A(-)
  • 2021-04-29 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, D&C - poorly differentiated carcinoma
    • ER(+), PR(+), p16(focal +), p63(focal +), and Vimentin(+).
  • 2021-04-23 MRI - Pelvis
    • suspected endometrial malignancy, if proven malignancy, cstage T1bN0M0.
• consultation
  • 2022-03-02 Urology
    • Q
      • The patient complaints frequent urination at night for 2weeks, so we need your help, thanks a lot!!
    • A
      • I have visit this patient and review the history. She compliant about nocturia for 3 weeks.
      • The possible etiologies including urinary tract infection, overactive bladder or nocturnal polyuria.
      • Please check U/A, U/C first and may treat UTI first as your expertise for at least one week if proved infection.
      • If there’s no evidence about UTI, Detrusitol 1# QD and Minirin 1# HS could be used for the other etiologies if no contraindications.
      • Uro. OPD follow up is indicated. Thanks for your consultation.
• surgical operation
  • 2021-05-20 ATH + BSO
    • Staging surgery for endometrial cancer.
    • Pathology and cytology pending.
    • Residual tumor: not seen residual tumor.
  • 2021-04-29
    • D&C, diagnostic and theraputic      
    • Endometrial hyperplasia 
• radiotherapy
  • 2021-06-18 ~ 2021-08-02: 4500cGy/25fx pelvic, 1200cGy/3fx vis IVRT to vaginal cuff mucosa surface.
• chemotherapy
  • 2021-03-01 ~ ongoing: paclitaxel + carboplatin
  • 2021-06-22 ~ 2021-07-27: cisplatin 6 cycles as part of CCRT.

[assessment]

• Following paclitaxel and carboplatin treatment since early March, the CT scan performed on 2022-05-10 showed significant regression of right liver margin metastases.
• Nocturia complained in late February is no longer in the list of problems.
• Blood glucose levels were 228 and 224 mg/dL since this hospitalization, and the patient might need to be followed up in order to check whether there is diabetes present.

220302

[assessment]

• disease progresses, liver mets has been proved s/p cisplatin-based CCRT (Jun ~ Jul 2021) s/p ATH + BSO (Apr ~ May 2021).
• the patient just starts receiving paclitaxel + carboplatin during this hospitalization.
• lenvatinib plus pembrolizumab showed promising antitumor activity in patients with advanced endometrial carcinoma who have experienced disease progression after prior systemic therapy, regardless of tumor MSI status.
  • source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7479759/

701343649

220621

• exam finding
  • 2022-05-04 CT - abdomen, pelvis
    • Post-operative change at LLL of the lung is suspected.
    • The differential diagnosis include residual metastasis.
  • 2022-03-16 Patho - lung total/lobe/segmental
    • Pathologic Diagnosis
      • Lung, left, upper lobe, lingula, segmentectomy — Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
      • Lung, left, lower lobe, wedge resection — Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
    • Microscopic Description
      • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobe
      • Histologic Type (select all that apply): Adenocarcinoma
      • IHC stains reveal CDX2(+) and TTF-1(-)
      • The morphology and immunohistochemical stains are consistent with metastatic colonic tumor.
        
      • Histologic Grade: G2: Moderately differentiated
      • Visceral Pleura Invasion: PL1
      • Lymphovascular Invasion (select all that apply): present
  • 2022-02-14 PET
    • Glucose hypermetabolism in the lower third of esophagus and soft tissue of RUQ of abdomen, probably s/p radiotherapy change.
      
    • Glucose hypermetabolism in the gastro-hepatic space, the nature is to be determined (metastatic lymph nodes or other nature?). Please correlate with other clinical findings for further evaluation.
      
    • Glucose hypermetabolism in the left upper and left lower lungs, compatible with cancer with lung metastases.
    • Increased FDG uptake in the uterus, probably physiological uptake of FDG or benign in nature. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
      
    • S-colon cancer s/p treatment, ycTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-01-28 CT - abdomen, pelvis
    • Lung metastases S/P C/T show partial response.
    • Liver metastasis S/P C/T shows complete response.
  • 2021-10-26 Abdominal Ultrasonography
    • Liver:
      • Suboptimal examination, the area near the diaphragm couldn’t be seen well. Smooth liver surface. No definite lesion could be seen.
    • Biliary system:
      • No gallbladder stone. No CBD dilatation.
  • 2021-10-25 Patho - colon segmental resection for tumor
    • Pathologic Diagnosis
      • Tumor, sigmoid colon, laparoscopic AR — Adenocarcinoma
        
      • Bilateral cutting ends, ditto — Free from tumor
        
      • Lymph nodes, mesocolic, dissection — Tumor metastasis (3/17), with extracapsular extension (2/3)
        
      • AJCC pathologic stage — pT4aN1bcM1a, stage IVA
        
    • Microscopic Examination
      • Histology: Adenocarcinoma
        
      • Histology Grade: G2, moderately differentiated
        
      • Depth of invasion: visceral peritoneum
        
      • Angiolymphatic invasion: present
        
      • Perineural invasion: present
        
      • Circumferential (radial) margin of rectosigmoid: Involved
        
      • Lymph node metastasis, mesocolic: positive (3/17)
        
      • Extranodal involvement: present (2/3)
        
      • Pathological TNM Stage: pT4aN1bcM1b, stage IVB
        
      • Additional pathologic findings: focal tumor necrosis
        
    • Immunohistochemistry
      • CDX-2(+), MLH1(+), PMS2(+), MSH2(+) and MSH6(+) for tumor
    • Addendum
      • Admission and OP note recorded a case of sigmoid cancer with liver and lung metastasis (cT3N0M1) according to serial examinations in Fu Jen Catholic University Hospital, but after examination and team discussion in our hospital, no definite lesion was seen in liver, so clinical M stage is modified from M1b (stage IVB) to M1a (stage IVA)
• surgical operation
  • 2022-03-16
    • Surgery
      • VATS, lingular segementectomy + LLL wedge resections + RLND
    • Finding
      • Metastatic nodule about 1.2cm in diameter, at lingula segement and LLL x2 s/p lingula segmentectomy + LLL wedge resections x 2
      • No malignant pleural effusion noted
      • Lymph nodes dissection over para-aortic, AP window, hilar and interlobar.
  • 2021-10-22
    • Surgery
      • Laparoscopic LAR        
    • Finding
      • Tumor at sigmoid colon cancer with liver, lung metastasis and obstruction, cT4N0M1b
      • Anastomosis is done
• chemoimmunotherapy
  • 2021-12-15 ~ undergoing - FOLFIRI + bevacizumab
  • 2021-11-09 ~ 2021-12-03 - FOLFIRI

[assessment]

• On the basis of the lab results reported on 2022-06-14, the patient is expected to be able to tolerate the current regimen as in the past.
• The TPR, BP, and SpO2 have remained stable since being hospitalized.

220602

[assessment]

• This patient was diagnosed with sigmoid cancer with lung mets following surgical operations on the colon (2021-10-22) and lung (2022-03-16). He is currently receiving Folfiri since 2021-11-09 (plus bevacizumab since 2021-12-15).
• CT on 2022-01-28 showed a partial response to lung mets, however, CT on 2022-05-04 showed possibly residual lung mets.
• The results of lab tests on 2022-05-26 indicated that liver and kidney function, electrolytes, and blood cell counts were grossly normal, which were considered acceptable to receive the regimen.
• No issue with active prescription.

220517

[assessment]

• This patient was diagnosed with sigmoid cancer with lung mets s/p surgical operations on the colon (on 2021-10-22) and lung (on 2022-03-16) and has been receiving FOLFIRI since 2021-11-09 (plus bevacizumab since 2021-12-15).
• CT on 2022-01-28 showed a partial response to lung mets, however CT on 2022-05-04 revealed a possible residural metastasis in the lungs.
• Lab data on 2022-05-10 showed that liver and kidney function, electrolytes, CBC and biomarkers were generally normal.
• No issue with active prescription.

701385445

220620

{alpha-fetoprotein-producing esophageal adenocarcinoma with liver metastasis, T4N2M1 stage IVB}

• lab data
  • Alkaline phosphatase (34~104)
    • 2022-06-20 300 U/L
    • 2022-06-17 208 U/L
  • LDH (140~271)
    • 2022-06-20 1087 U/L
    • 2022-06-17 838 U/L
  • S-GOT/AST (13~39)
    • 2022-06-20 95 U/L
    • 2022-06-17 45 U/L
    • 2022-06-13 24 U/L
    • 2022-06-09 16 U/L
    • 2022-06-06 20 U/L
    • 2022-06-01 31 U/L
    • 2022-05-29 32 U/L
    • 2022-05-12 48 U/L
  • S-GPT/ALT (<41)
    • 2022-06-20 51 U/L
    • 2022-06-17 15 U/L
    • 2022-06-13 9 U/L
    • 2022-06-09 8 U/L
    • 2022-06-06 13 U/L
    • 2022-06-01 17 U/L
    • 2022-05-29 22 U/L
    • 2022-05-12 54 U/L
  • Albumin (3.5~5.7)
    • 2022-06-20 2.5 g/dL
      
    • 2022-06-13 2.4 g/dL
      
    • 2022-06-09 2.5 g/dL
      
    • 2022-06-01 2.2 g/dL
      
    • 2022-05-29 2.3 g/dL
      
    • 2022-05-26 1.9 g/dL
      
  • Albumin % (54.0~60.3)
    • 2022-05-28 43.3 %
      
  • 2022-05-28
    • Zinc, Zn 417 ug/L
      
    • Protein, total 3.8 g/dL
      
    • Albumin 43.3 %
      
    • Alpha-1 4.7 %
      
    • Alpha-2 11.3 %
      
    • Beta 21.2 %
      
    • Gamma 19.5 %
      
    • M-peak Negative
      
    • A/G Ratio 0.8
      
  • 2022-05-27
    • Anti-ds DNA Antibody <0.5 IU/ml
    • Anti-ENA SS-A(Ro) 0.6 EliA U/ml
      
    • Anti-ENA SS-B(La) <0.3 EliA U/ml
      
  • 2022-05-23
    • Anti-HBs 49.32 mIU/mL
  • 2022-05-17
    • Anti-HBc Reactive 7.40 S/CO
      
    • AFP 14232.3 ng/mL
• exam finding
  • 2022-05-31 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Pleura effusion of right and left costal-phrenic angle
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2022-05-26 Visceral Angiography 2 vessels
    • Tumor enhancement at lower esophagus and stomach. No evidence of active bleeding.
  • 2022-05-26 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal tumor with surface friability, 30cm below the insicor extent to cardia
      • Superficial gastritis
      • Duodenal polyps, bulb
      • Duodenal subepithelial lesion, 2nd portion, suspected lymphatic cyst
    • Suggestion
      • If acitive bleeding, consider angiography for embolization and surgical intervention. Endoscopic treatment is NOT suitable for tumor bleeding. (Hemospray powder was not available in our hospitial)
  • 2022-05-19 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Compatible with AFP-producing carcinoma, poorly differentiated, metastatic
    • The sections show a picture compatible with metastatic AFP-producing carcinoma, poorly differentiated, composed of extensive and nearly total tumor necrosis, with a tiny solid nest of viable polygonal neoplastic cells.
    • IHC, tumor cells reveal: CK7(-), CK20(-), and AFP (scattered tumor cells +). Suggest clinic correlation.
  • 2022-05-19 2D transthoracic echocardiography
    • Dilated LA and aortic root
    • Thickening of IVS and LVPW
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • Calcified mitral annulus with mild to moderate MR, mild TR and PR
    • AV sclerosis with mild AR
    • No regional wall motion abnormalities
  • 2022-05-18 Patho - colon biopsy
    • Intestine, large, ascending colon, biopsy — hyperplastic polyp
    • Intestine, large, descending colon, biopsy — hyperplastic polyp
    • Intestine, large, sigmoid colon, biopsy — hyperplastic polyp
  • 2022-05-17 CT - liver, spleen, biliary duct, pancreas
    • Imaging Report Form for Esophageal Carcinoma
      • Large esophageal tumor with GE junction invasion, lymph nodes metastsais. Liver tumors, suspected liver metastasis. cstage T4N2M1.
      • Left pleural effusion. Bilateral basal lung atelectasis.
  • 2022-05-16 Abdominal Ultrasonography
    • Diagnosis
      • liver tumors: suspected HCC, or metastatic tumors
      • liver hyperechoic tumor, S1: suspected hemangioma
      • liver parenchymal disease
      • mild gallbladder wall thickening
    • Suggestion
      • 4 phase CT or dynamic MRI study
  • 2022-05-13 Patho - esophageal biopsy
    • Esophagus, middle to lower, biopsy — Poorly differentiated adenocarcinoma
    • Section shows pieces of solid sheets and glandular tumor cells infiltrating in fibrous tissue.
    • The immunohistochemical stains reveal CK(+), CK7(-), CK20(-), CK5/6(-), p40(-), CDX2(+), TTF-1(equivocal), Napsin A(-), CD56(-), and PSA(-). The results are in favor of poorly differentiated adenocarcinoma.
    • Addendum: The immunohistochemical stains reveal alpha-fetoprotein (focal +), Hepatocyte(equivocal), Arginase (-), and Her-2/neu (Ab): Negative (0). The results are in favor of gastric or esophageal primary tumor.
  • 2022-05-12 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal tumor, 30cm below the insicor extent to cardia, s/p biopsy
      • Superficial gastritis
      • Duodenal polyps, bulb
      • Duodenal subepithelial lesion, 2nd portion, suspected lymphatic cyst
    • Suggestion
      • Pursue biopsy result
• consultation
  • 2022-05-25 Radiation Oncology
    • Under the impression of Adenocarcinoma of M-L/3 esophagus, with liver metastases, cT4N2M1, with active tumor bleeding, palliative RT is indicated. CT-simulation will be arranged today. Plan to deliver 40 Gy/ 20 fx to the M-L/3 esophageal tumor.
  • 2022-05-25 Hemato-Oncology
    • Impression:
      • Alpha-fetoprotein producing esophageal adenocarcinoma with liver metastasis, T4N2M1 stage IVb
      • Anemia, subacute GI bleeding related
      • Fever, suspect transfusion reaction, mix with infection and tumor fever
      • Staphylococcus aureus bacteremia
      • Hypertension
    • Suggestion:
      • We wound like to take over this case if you agree
      • Consult radio-oncologist for CCRT
      • Arrange port A insertion
      • CCRT is indicated for esophagus cancer local tumor bleeding control and followed by palliative chemotherapy for metastasis disease
      • Add entecarvir for chemotherapy HBV flare up prophylaxis (Anti-Hbc positive)
      • LPRBC to keep Hb>=8, May consider give vena before blood transfusion (history of suspect transfusion reaction)
      • Check Ca for frequent blood transfusion
      • Pending anemia survey (Fe, TIBC, Ferrtin, folic acid, vitamin B12). May also check serum EP, TSH, Freee T4, ANA, C3, C4, Anti-dsDNA, RF, Anti-Ro/Anti-La)
      • Thanks for your consultation. If there is any problem, please feel free to let us known.
  • 2022-05-18 Infectious Disease
    • Q
      • Intermittent fever occur, 20220515 blood culture was showed Staphylococcus aureus (OSSA), we need your exerpance assessment the infcetion source and advice, thnak you~
    • A
      • Antibiotcs with stazilin 1g iv q8h is suggested for OSSA bacteremia.
      • Please arrange CV-echo.
      • F/u B/C 3 days later.
• radiotherapy
  • 2022-05-25 ~ undergoing - M-L/3 esophageal tumor 32 Gy/ 16 fx.
• chemoimmunotherapy
  • 2022-06-01 ~ undergoing - FOLFOX6

[memo]

• Pathology IHC results
  • Esophageal biopsy pathology (2022-05-13) IHC revealed CK(+), CK7(-), CK20(-), CK5/6(-), p40(-), CDX2(+), TTF-1(equivocal), Napsin A(-), CD56(-), PSA(-), alpha-fetoprotein(focal +), Hepatocyte(equivocal), Arginase(-), Her-2/neu(Ab): Negative(0).
  • Liver biopsy pathology (2022-05-19) IHC revealed CK7(-), CK20(-), and AFP (scattered tumor cells +).
• CK7−/CK20− could mean ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5923363/ )
  • Prostate adenocarcinoma
  • Renal (clear cells)
  • Hepatocellular carcinoma
  • Adrenocortical carcinoma
  • Non-seminoma germ cell tumours
  • Mesothelioma
  • Small cell lung carcinoma
  • Gastric adenocarcinoma
• Oesophagus: CDX2+/−, CEA+, CDH17+, MUC1−/+, MUC5AC−/+, SATB2−
• Liver: HepPar1+, CD10+, pCEA+, mCEA−, AFP+, Glypican-3+, Arginase-1+, CK19−

[assessment]

• This is a 57 y/o male was diagnosed with alpha-fetoprotein-producing esophageal adenocarcinoma with liver metastasis in May 2022, T4N2M1 stage IVB, and has been receiving CCRT with FOLFOX6 regimen since late May 2022.
• The liver enzyme levels have been rising for the last two weeks which should be addressed while daily Baraclude (entecavir) 0.5mg has been prescribed since a recent OPD visit on 2022-06-17.
  • S-GOT/AST (13~39)
    • 2022-06-20 95 U/L
    • 2022-06-17 45 U/L
    • 2022-06-13 24 U/L
    • 2022-06-09 16 U/L
  • S-GPT/ALT (<41)
    • 2022-06-20 51 U/L
    • 2022-06-17 15 U/L
    • 2022-06-13 9 U/L
    • 2022-06-09 8 U/L
  • ALT/AST ratio
    • 2022-06-20 1.86
    • 2022-06-17 3.00
    • 2022-06-13 2.66
    • 2022-06-09 2.00
• Hypoproteinemia, which is unlikely to be caused by proteinuria (2022-06-20 blood creatinine 0.57 mg/dL, eGFR 156.60) could be the result of malnutrition? or probably the result of impaired protein synthesis due to liver mets.
  • Albumin
    • 2022-06-20 2.5 g/dL
      
    • 2022-06-13 2.4 g/dL
      
    • 2022-06-09 2.5 g/dL
      
    • 2022-06-01 2.2 g/dL
      
    • 2022-05-29 2.3 g/dL
      
    • 2022-05-26 1.9 g/dL
      
• After correction for hypoalbuminemia, serum calcium falls within normal range (2.3 mmol/L). ( https://www.mdcalc.com/calcium-correction-hypoalbuminemia , based on unadjusted Ca 1.96 mmol/L, normal albumin 4 g/dL)

700983554

220617

• exam finding
  • 2022-06-15 CXR
    • Enlargement of right hilum.
  • 2022-06-15 EKG
    • Sinus tachycardia
  • 2022-02-24 SONO - neck (lymph node)
    • Sonography of neck revealed some LNs in bil. neck.
  • 2021-12-02 Patho - bone marrow biopsy
    • Bone marrow, iliac crest, biopsy — Compatible with acute myeloid leukemia with partial remission
      
    • The sections show hypercellular marrow (80%). The M/E ratio about 8:1 in CD71 immunostain. Both granulocytic and megakaryocytic proliferation with occasional small megakaryocytes are present. Clusters of MPO+ myeloid cells(30%) and CD68+ monocytes (15%) can be identified. Scattered CD34+ and/or CD117+ blasts,constitue 10% of marrow cells are evident. The finding is compatible with acute myeloid leukemia with partial remission. Suggest bone marrow smear evaluation and clinic correlation.
  • 2021-11-15 Patho - soft tissue nontumor/mass/lipoma/debridement
    • Skin, right groin, excisional biopsy — Acute leukemia involvement
      • Microscopically, it shows skin tissue with marked infiltration of leukemic tumor cells in the dermis with focal necrosis. The tumor cells show nuclear hyperchromasia, plemorphism, coarse chromatin, prominent nucleoli and high N/C ratio.
        
    • Skin, left groin, excisional biopsy — Acute leukemia involvement
      • Microscopically, it shows skin tissue with marked infiltration of leukemic tumor cells in the dermis. The tumor cells show nuclear hyperchromasia, plemorphism, coarse chromatin, prominent nucleoli and high N/C ratio.
        
    • Skin, left thigh, excisional biopsy — Acute leukemia involvement
      • Microscopically, it shows skin tissue with ulceration, focal necrosis, hemorrhage and dense infiltration of leukemic tumor cells.
        
      • Immunohistochemical stain reveals MPO(+), CD10(focal+), CD117&CD34(+, 25%), TdT(-), CD20(focal+, <5%), CK(-), CD3(+, 5%), CD138(+, <5%), Bcl-2(+), Bcl-6(+), cyclin d1(-).
  • 2021-09-14 EKG
    • Sinus tachycardia
  • 2021-09-13 2D Transthoracic Echocardiography
    • Dilated LA
  • 2021-09-01 CT - abdomen, pelvis
    • FINDINGS:
      • There is splenomegaly and the greatest anterior-posterior dimention measuring 14.7 cm.
      • There are multiple variable sized enlarged lymph nodes in gastrohepatic ligament, hepatoduodenal ligament, mesentery, and bilateral inguinal area. please correlate with clinical condition.
      • A hepatic cyst measuring 0.5 cm in S4 is suspected. Please correlate with sonography.
    • IMP:
      • Splenomegaly.
      • There are multiple variable sized enlarged lymph nodes in gastrohepatic ligament, hepatoduodenal ligament, mesentery, and bilateral inguinal area.
  • 2021-09-01 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — acute leukemia.
    • IHC stains: CD117: 30%; CD34: 30 %; MPO: 20-30%, LCA: 50-60%; CD10: <10% (of the nucleated cells). Please correlate with other laboratory results such as one marrow smear, hemogram, and flow cytometry.
      
    • Section shows piece(s) of bone marrow with 70% cellularity and M:E ratio of approximately 4:1. Three cell lineages are present with left shift of leukocytes, inculding many immature leukocytes, many lymphocytes, plasma cell and eosinophils. Megakaryocytes are adequate in number.
      
  • 2021-08-31 EKG
    • Sinus tachycardia
  • 2019-04-12 EKG
    • Sinus tachycardia
    • Rightward axis
    • Borderline ECG
• consultation
  • 2011-11-11 Plastic and Reconstructive Surgery
    • Q
      • This 41-year-old man has
        • Acute myeloblastic leukemia
        • AIDS under Atripla
        • Left dorsal foot cellulitis with ulcer and left medial thigh ulcer
        • Latent syphilis.
          
      • He is admitted to recieve target therapy for acute myeloblastic leukemia.
        • After admission, blood examination revealed WBC:303.62 10^3/uL, Hb: 4.9 g/dL, Plt: 96 10^3/uL, Band 2%, Neurophil: 0%, Blast: 87.0, and Uric acid: 9.2mg/dL.
          
        • Blood trasfusion with pack-RBC 4U and LPR 2U were given. Normal saline 1500ml and 1.5mg Rasburicase were administered to correct his uric acid.
        • Blood test today morning showed improvement and the treatment will be continued.
          
        • Bilateral inguinal masses 7x7cm were discovered. The masses are hard, round, elevated, and mildy pigmented. Tenderness was also noted.
      • Due to the bilateral inguinal masses, we would like to consult you for arranging I&D or other appropriate management for the patient. Thank you very much.
    • A
      • 41 y/o male patient
        • Right groin mass with partial necrosis
        • Left groin mass
        • Left thigh mass
      • A
        • underlying history: Acute myeloblastic leukemia, AIDS under Atripla, Latent syphilis.
        • I had visited the patient and explained to him and his father, the patient reported that these masses gradually enlarged within 1 month.
        • Those masses were hard, firm and non-movable without obvious infectoin sign.
        • The tumor border was ill-defined.
        • Partial necrosis of the tumor was suspected.
        • The possibility of malignant tumor was informed.
        • It’s not possible nor suitable for complete excision.
        • Tissue proof first is recommended
      • Plan
        • We will arrange biopsy of these 3 lesions and debridement of right groin area next Monday
  • 2021-09-02 Infectious Disease
    • Q
      • For advice on antibiotics for new onset of fever in an HIV patient with leukemia.
        • This is a 40 year old man who admitted to the hospital for the treatment of acute leukemia.
        • He had underlying HIV infection and was previously seen at your OPD. This time during hospitalization, he was found to have elevated levels of TPHA and RPR/VDRL titers.
        • On 20210902, his body temperature was elevated up to >38 C and elevated level of WBC but did not complain of any discomfort in particular.
      • Please kindly assist to evaluate the patient and advise us on the management of the condition. Thank you.
    • A
      • Assessment
        • 40-year-old HIV infection male patient, with loss of follow up with HAART (Highly Active Antiretroviral Therapy) for two years, now admitted due to acute leukemia.
        • No HIV viral load data is available, CD4 count up to 2905, leukemoid reaction related, white count high to 52800.
        • Besides HIV infection, he had received 3-dose penicillin injection in Jan 2018, and now syphilis RPR titer is high to 128.
        • Benzathin penicillin retreatment is necessary.
        • HAART with Atripla has been restarted since yesterday.
      • Suggestion
        • continue Atripla.
        • Benzathin penicillin injection with 2.4 million units IM once a week for 3 weeks.
        • Follow up RPR titer 3 months later.
  • 2021-08-31 General and Gastroenterological Surgery
    • Q
      • for on port-a
      • this is a 40-year-old male who has the history of human immunodeficiency virus and the INF follow-up, Atripla using since 2017 until 2019, due to the viral load <20, CD4:1046.
      • this time, he is admitted for ALL chemotherapy treatment, so we need your help for on port-a, think a lot!!
    • A
      • we will arrange port-A implantation this w4
• lab data
  • HIV 1 Viral Loads
    • 2022-04-15 83.2 copies/mL
    • 2022-01-17 30.1 copies/mL
    • 2021-09-08 29100 copies/mL
  • HIV-1 RNA
    • 2019-08-23 <20 copies/mL
    • 2019-02-01 <20 copies/mL
    • 2018-11-09 37 copies/mL
    • 2018-05-11 <20 copies/mL
    • 2018-02-09 191 copies/mL
  • HIV Ab EIA (enzyme immunoassay)
    • 2021-09-01 Reactive
    • 2018-01-03 Reactive
  • CD3+∕CD4+ Helper T
    • 2022-04-12 46.7 % 593 /uL
    • 2022-01-12 45.8 % 1195 /uL
      
    • 2021-09-01 32.9 % 2905 /uL
      
    • 2019-08-22 40.4 % 1345 /uL
      
    • 2019-01-30 38.0 % 1046 /uL
      
    • 2018-11-07 37.1 % 1161 /uL
      
    • 2018-05-09 35.5 % 980 /uL
      
    • 2018-02-07 32.9 % 880 /uL
      
  • CD3+∕CD8+ Suppressor T
    • 2022-04-12 44.5 % 565 /uL
      
    • 2022-01-12 44.4 % 1160 /uL
      
    • 2021-09-01 50.6 % 4459 /uL
      
    • 2019-08-22 37.9 % 1260 /uL
      
    • 2019-01-30 40.3 % 1108 /uL
      
    • 2018-11-07 40.8 % 1277 /uL
      
    • 2018-05-09 44.7 % 1233 /uL
      
    • 2018-02-07 48.9 % 1310 /uL
      
  • CD4/CD8 Ratio
    • 2022-04-12 1.0 Ratio
      
    • 2022-01-12 1.0 Ratio
      
    • 2021-09-01 0.7 Ratio
      
  • CD3 T Cells
    • 2022-04-12 92.3 %
    • 2022-01-12 91.6 %
    • 2021-09-01 79.4 %
    • 2019-08-22 80.5 %
    • 2019-01-30 80.4 %
    • 2018-11-07 79.2 %
    • 2018-05-09 83.2 %
    • 2018-02-07 84.5 %
  • CD19 B Cells
    • 2022-04-12 1.4 %
      
    • 2022-01-12 3.0 %
      
    • 2021-09-01 7.7 %
      
    • 2019-08-22 10.0 %
      
    • 2019-01-30 10.3 %
      
    • 2018-11-07 10.6 %
      
    • 2018-05-09 9.1 %
      
    • 2018-02-07 6.2 %
      
  • CD16+56 NK
    • 2021-09-01 8.9 %
  • CMV viral load assay
    • 2021-10-08 Target not deteceted IU/mL
      
    • 2021-09-06 Target not deteceted IU/mL
  • CMV IgG
    • 2021-09-01 Reactive 1,201.3 AU/mL
  • CMV IgM
    • 2021-09-01 Nonreactive 0.10 Index
      
  • TPHA (Treponema Pallidum Hemagglutination Assay)
    • 2022-04-12 Reactive 1: 5120
      
    • 2021-09-01 Reactive >1:20480
      
    • 2018-11-08 Reactive 1: 5120
      
    • 2018-05-21 Reactive 1: 5120
      
  • RPR/VDRL (Rapid Plasma Reagin / Veneral Disease Research Laboratory test)
    • 2022-04-12 Reactive 1: 64
      
    • 2021-09-01 Reactive 1:128
      
  • STS-RPR (Serological Test for Syphilis - Rapid Plasma Reagin)
    • 2018-11-07 Reactive 1: 4
      
    • 2018-05-21 Reactive 1: 4
      
    • 2018-01-03 Reactive 1:64
      
  • Procalcitonin (PCT)
    • 2022-06-15 1.29 ng/mL
    • 2022-03-23 0.64 ng/mL
    • 2021-11-15 0.65 ng/mL
    • 2021-11-12 0.52 ng/mL
    • 2021-10-07 0.40 ng/mL
    • 2021-10-04 0.37 ng/mL
    • 2021-09-27 0.64 ng/mL
    • 2021-09-20 0.60 ng/mL
    • 2021-09-06 0.39 ng/mL
    • 2021-09-01 0.26 ng/mL
  • CRP (C-reactive protein)
    • 2022-06-16 12.35 mg/dL
    • 2022-06-15 17.87 mg/dL
    • 2022-03-23 6.08 mg/dL
    • 2022-03-18 8.13 mg/dL
    • 2021-12-20 1.73 mg/dL
    • 2021-12-18 0.84 mg/dL
    • 2021-12-16 0.94 mg/dL
    • 2021-12-14 1.42 mg/dL
    • 2021-12-12 2.45 mg/dL
    • 2021-12-10 0.92 mg/dL
    • 2021-12-08 0.90 mg/dL
    • 2021-12-06 1.06 mg/dL
    • 2021-12-03 1.13 mg/dL
    • 2021-12-01 1.33 mg/dL
    • 2021-11-30 1.91 mg/dL
    • 2021-11-29 1.87 mg/dL
    • 2021-11-27 1.90 mg/dL
    • 2021-11-25 2.44 mg/dL
    • 2021-11-24 4.03 mg/dL
    • 2021-11-23 5.19 mg/dL
    • 2021-11-22 3.43 mg/dL
    • 2021-11-19 4.70 mg/dL
    • 2021-11-18 5.63 mg/dL
    • 2021-11-17 7.42 mg/dL
    • 2021-11-16 8.85 mg/dL
    • 2021-11-15 7.62 mg/dL
    • 2021-11-14 6.37 mg/dL
    • 2021-11-12 5.53 mg/dL
    • 2021-11-11 3.69 mg/dL
    • 2021-11-10 4.15 mg/dL
    • 2021-09-27 5.71 mg/dL
    • 2021-09-22 4.78 mg/dL
    • 2021-09-20 7.14 mg/dL
    • 2021-09-14 10.05 mg/dL
    • 2021-09-08 2.03 mg/dL
    • 2021-09-06 7.04 mg/dL
    • 2021-09-01 3.78 mg/dL
    • 2021-08-31 3.62 mg/dL
    • 2019-08-22 0.49 mg/dL
    • 2018-12-16 8.26 mg/dL
    • 2018-02-07 1.34 mg/dL
• chemoimmunotherapy
  • AML
    • 2022-06-16 azacitidine 75mg/m2 for 7 days
    • 2022-03-18 azacitidine 75mg/m2 for 7 days
    • 2021-11-22 azacitidine 75mg/m2 for 7 days
  • HIV
    • 2021-09-08 ~ ongoing - Atripla (efavirenz 600mg + emtricitabine 200mg + tenofovir 300mg) HS PO
    • 2018-01-10 ~ 2019-08 - Atripla (efavirenz 600mg + emtricitabine 200mg + tenofovir 300mg) HS PO

[assessment]

• Sinus tachycardia has been observed for over 12 months (EKG 2022-06-15, 2021-09-14, 2021-8-31, 2021-04-21).

700202562

220614

{multiple myeloma}

• exam finding
  • 2022-05-09 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Plasma cell myeloma
    • The specimen submitted consisted of one strip of bone marrow tissue measuring 2.1 x 0.3 x 0.3 cm in size, fixed in B-5 solution. Grossly, it was tan in color and bony hard in consistence. All embedded for sections after short decalcification.
    • The sections show a picture of plasma cell myeloma, composed of hypocellular marrow (45%) for her age. Interstitial distribution of plasma cells, comprised 10-20% nucleated cells in CD138 immunostain. The plasam cells also show lambda light chain restriction. M/E ratio about 1/4~5, hyperplasia of erythroid and hypoplasia of myeloid series, hyperplastic megakaryocytes with focal mononucleation and hyposegmentation and no increase of blast, which highlights by CD61, CD71, CD34, CD117 and MPO immunostains. Follow up.
  • 2021-12-30 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — myeloma.
    • IHC stains: CD117: <2%; CD34: <2 %; MPO: <5%, CD71: 10-20 %, CD138: 70-80%, and light chain of kappa and lambda show a predominant lambda sub-population. (of the nucleated cells).
      
    • Specimen submitted in formalin consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 1.6 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
      
    • Section shows piece(s) of bone marrow with 70% cellularity and M:E ratio of approximately 5:1. Three cell lineages are present with a predoimant plasmcytoid cells. Megakaryocytes are adequate in number.
• lab data
  • Hematopoietic Progenitor Cell (HPC) Ratio
    • 2022-05-31 0.20 %
      
    • 2022-05-30 0.33 %
      
  • CD45 + Total leukocyte
    • 2022-05-31 309430 /uL
    • 2022-05-31 55666 /uL
    • 2022-05-30 372040 /uL
  • CD34+ Count
    • 2022-05-31 4940 /uL
    • 2022-05-31 102 /uL
    • 2022-05-30 8140 /uL
  • %CD34+
    • 2022-05-31 1.60 %
      
    • 2022-05-31 0.18 %
    • 2022-05-30 2.19 %
  • WBC
    • 2022-05-31 62.43 *10^3/uL
      
    • 2022-05-31 65.69 *10^3/uL
      
    • 2022-05-30 56.24 *10^3/uL
      
    • 2022-05-30 54.79 *10^3/uL
      
    • 2022-05-29 21.76 *10^3/uL
      
    • 2022-05-28 4.57 *10^3/uL
      
    • 2022-05-26 3.07 *10^3/uL
      
    • 2022-05-25 7.57 *10^3/uL
      
    • 2022-05-23 21.61 *10^3/uL
      
    • 2022-05-19 7.44 *10^3/uL
      
    • 2022-04-22 18.42 *10^3/uL
      
    • 2022-04-15 10.56 *10^3/uL
      
    • 2022-04-01 12.93 *10^3/uL
      
    • 2022-03-25 8.36 *10^3/uL
      
    • 2022-03-11 9.42 *10^3/uL
      
    • 2022-03-04 6.47 *10^3/uL
      
    • 2022-02-18 12.45 *10^3/uL
      
    • 2022-02-11 4.78 *10^3/uL
      
    • 2021-12-22 5.68 *10^3/uL
      
  • HGB
    • 2022-05-31 9.9 g/dL
      
    • 2022-05-31 10.4 g/dL
      
    • 2022-05-30 10.2 g/dL
      
    • 2022-05-30 10.8 g/dL
      
    • 2022-05-29 11.6 g/dL
      
    • 2022-05-28 11.4 g/dL
      
    • 2022-05-26 10.8 g/dL
      
    • 2022-05-25 11.2 g/dL
      
    • 2022-05-23 12.4 g/dL
      
    • 2022-05-19 12.9 g/dL
      
    • 2022-04-22 11.3 g/dL
      
    • 2022-04-15 12.0 g/dL
      
    • 2022-04-01 11.2 g/dL
      
    • 2022-03-25 10.8 g/dL
      
    • 2022-03-11 10.2 g/dL
      
    • 2022-03-04 9.4 g/dL
      
    • 2022-02-18 9.0 g/dL
      
    • 2022-02-11 8.8 g/dL
      
    • 2021-12-22 8.7 g/dL
      
  • PLT
    • 2022-05-31 73 *10^3/uL
      
    • 2022-05-31 93 *10^3/uL
      
    • 2022-05-30 131 *10^3/uL
      
    • 2022-05-30 153 *10^3/uL
      
    • 2022-05-29 198 *10^3/uL
      
    • 2022-05-28 230 *10^3/uL
      
    • 2022-05-26 289 *10^3/uL
      
    • 2022-05-25 348 *10^3/uL
      
    • 2022-05-23 408 *10^3/uL
      
    • 2022-05-19 420 *10^3/uL
      
    • 2022-04-22 482 *10^3/uL
      
    • 2022-04-15 354 *10^3/uL
      
    • 2022-04-01 413 *10^3/uL
      
    • 2022-03-25 424 *10^3/uL
      
    • 2022-03-11 394 *10^3/uL
      
    • 2022-03-04 319 *10^3/uL
      
    • 2022-02-18 329 *10^3/uL
      
    • 2022-02-11 290 *10^3/uL
      
    • 2021-12-22 303 *10^3/uL
• chemoimmunotherapy
  • 2022-05-19 cyclophosphamide 2500mg/m2
  • 2022-02-11 ~ 2022-04-22 - bortezomib 1.3mg/m2 (day 4, day 7) (8 times) within VTD (bortezomib + thalidomide + dexamethasone)

700841543

220613

{gastric cancer with colon mets s/p subtotal gastrectomy and partial T-colectomy}

[subjective]

• 2020-08-03
  • fasting epigastric discomfort for 1-2 weeks
  • fullness(-), nausea(-)
• 2021-04-14
  • epigasrtalgia for for 2-3 months
  • mild response to strocain and h2 blocker from other hopsital but still discomfort
  • hunger pain (+) improving after intake

[objective]

• exam finding
  • 2022-06-11 CT - abdomen, pelvis
    • S/P gastric operation. Small bowel ileus with massive ascites.
    • Bil. liver cysts (up to 2.6cm).
  • 2022-05-09 Abdomen - standing (diaphragm)
    • Presence of ileus.
  • 2022-05-09 Abdominal Ultrasonography
    • suspected liver parenchymal disease
    • liver cysts
    • pancreas obscured
    • spleen obscured
    • ascites: moderate to large amount
  • 2022-04-22 CT - lung/mediastinum/pleura
    • s/p partial gastrectomy with massive ascites. Stationary.
    • regression of right lower lobe opacity, previous infection is favored.
  • 2022-04-14 CT - abdomen, pelvis
    • Gastric cancer s/p operation. Massive ascites. Small bowel ileus.
    • A patchy density (1.7mm) at RLL.
  • 2022-01-14 CT - abdomen, pelvis
    • s/p subtotal gastrectomy
    • there are several hepatic cysts in both lobes and the largest one 2.2 cm in size
  • 2021-10-07 CT - abdomen, pelvis
    • Gastric cancer s/p operation.
    • A nodule (3.7mm) at LUL.
  • 2021-10-05 CXR
    • Blurring of right heart border is noted.
  • 2021-06-21 Standing KUB; 2021-06-18 KUB
    • Small bowel obstruction is suspected. Please correlate with contrast enhanced CT.
    • S/P ileostomy? please correlate with clinical condition.
  • 2021-05-25 Small bowel series
    • Dilatation of proximal small bowel. Collapse of distal ileum and colon
    • The transmit time is less than 24 hours.
  • 2021-05-07 patho - stomach subtotal/total (tumor)
    • pathologic diagnosis
      • Stomach, subtotal gastrectomy — Poorly cohesive carcinoma (signet-ring cell carcinoma)
        
      • Lymph nodes, LN dissection — Metastatic carcinoma (3/32)
        
      • AJCC Pathologic staging — pT4aN2M1, stage IV
    • microscopic examination
      • Histologic type: Poorly cohesive carcinoma, signet-ring cell type (signet-ring cell carcinoma) (Lauren classification: diffuse type)
        
      • Histologic grade: Poorly differentiation (G3)
        
      • Depth of tumor invasion: Tumor invades the serosa
        
      • Margins: Free; Distance from closest margin: 3 mm (radial margin)
        
      • Perineural invasion: Present
        
      • Lymphovascular space invasion: Present
        
      • Regional lymph nodes: Metastatic carcinoma (3/32)
        
      • Extracapsular extension: Absent
        
      • Omentum: Free of tumor invasion
        
      • Additional pathologic findings: Metastatic carcinoma of T-colon (S2021-07224)
        
      • Pathologic Staging: pT4aN2M1; Stage IV
        
      • IHC (S2021-06134): HER2(-), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
        
  • 2021-05-07 patho - colon segmental resection for tumor
    • Transverse colon, partial resection — Poorly cohesive carcinoma (signet-ring cell carcinoma), metastatic
    • Histology Grade: Poorly differentiated
      
  • 2021-04-29 CT - whole abdomen, pelvis
    • imaging stage: T1aN0M0, stage I.
  • 2021-04-20 patho - stomach biopsy
    • greater curvature side of lower body - adenocarcinoma.
    • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
  • Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade B
      • Esophageal phlebectasia, lower esophagus
      • Gastric ulcer, GC, lower body, s/p Bx
      • Atrophic gastritis, antrum
    • Suggestion：
      • Pending Bx and CLO
      • PPI tx
• lab data
  • CA125
    • 2022-05-16 114.7 U/mL
    • 2022-04-25 95.9 U/mL
    • 2022-04-18 139.0 U/mL
    • 2022-03-14 157.8 U/mL
    • 2022-02-19 102.4 U/mL
    • 2022-01-11 31.0 U/mL
    • 2021-12-21 17.7 U/mL
    • 2021-11-16 19.9 U/mL
    • 2021-10-06 18.7 U/mL
    • 2021-09-06 31.5 U/mL
    • 2021-08-27 26.7 U/mL
    • 2021-07-27 34.5 U/mL
• consultation
  • 2021-06-23 Infectious disease
    • This 64-year-old man patient is a case of Gastric cancer with lymph nodes metastasis s/p subtotal gastrectomy with T-colectomy and D2+ lymph node dissection, pT4aN2M1, stage IV. Chemotherapy with FOLFOX (Oxalip 65mg/m2, LV 400mg/m2, 5FU 2400mg/m2) on 2021/06/16~2021/06/18. IP chemotherapy with 5FU(400mg/m2) + Gentamycin 40mg + Rolikan 40ml on 2021/06/16. Abdominal pain with Peritonitis with ascites/C showed Acinetobacter ursingii and Candida parapsilosis bacteria. Abdominal pain improving after antibiotic with Flumarin 1000mg iv q8h since 2021/06/18. Now, for evaluate antibiotic therapy for ascites/C showed Acinetobacter ursingii and Candida parapsilosis bacteria.
    • Antibiotics with tapimycin 4.5g iv q8h and diflucan 200mg iv qd is suggested.
• surgical operation
  • 2021-05-06 surgery
    • subtotal gastrectomy with LN 1,3,4,5,6,7,8,9,110,12a and 14v dissection
    • partial T-colectomy
    • IPCT with Mitomycin C 25mg/m2(42mg) for 2 hrs
• radiotherapy
  • 2021-10-25 ~ 2021-11-26 - completed RT to the preOP tumor bed and adjacent lymphatic drainage area: 45 Gy/ 25 fx
• chemotherapy
  • 2021-12-07 ~ 2022-03-15 - FOLFOX (6 times)
  • 2021-10-26 ~ 2021-11-23 - 5-Fu (4 times), CCRT
  • 2021-06-16 ~ 2021-10-07 - FOLFOX (6 times)
  • 2021-05-07 - 5-Fu 500mg/m2(839mg) day 1~5, leucovorin 34mg day 1, gentamicin
  • 2021-05-06 - mitomycin-C, gentamicin

[assessment]

• The patient presented to the emergency department (2022-06-11) with symptoms of severe upper abdominal pain (VAS 9, 3 days of on and off abdominal pain with yellow vomitus once per day). Small bowel obstruction has been listed as an active problem since his admission.
• Previously, small bowel obstruction was noted on KUB 2021-06 and Small Bowel Series 2021-05-25, which showed proximal small bowel dilatation and collapse of the distal ileum and colon.
• Proximal small bowel obstruction (duodenum, proximal jejunum) can cause severe nausea and vomiting; as a result, patients typically cease taking in food or liquids orally.
• Gaslan (dimethylpolysiloxane) 40mg TID PO and Mopride (mosapride citrate) 5mg TID PO have been prescribed since 2022-06-06.
• In the past few weeks, ascites and pitting edema have been observed; if the condition persists, some diurectics might be helpful.
• Heart rate 90 -> 120 on 2012-06-12, please keep monitoring the state of hemodynamics.
• All the oral drugs in active prescription can be administered with nasogastric tube.

210827

[assessment]

• recent lab data unremarkable, liver and kidney functions no abnormality, overall not bad.
• 2021-08-27 around 10:30 visiting the patient (accompanied by his wife)
  • he felt soreness/ache (not pain) in his left arm during the first 30min when premedication being administrated in last three hospitalization. rule out left arm compression or cruch caused symptom. cause remains unknown.
  • mild oral mucosa damage, some triamcinolone acetonide oral ointment (nincort or oralog, the former is available now) for local treatment might be of help.
  • mild diarrhea, not often, could be monitored with PRN antidiarrheal agent e.g. loperamide (2mg/cap is available now)

701350720

220613

• exam finding
  • 2022-05-27 MRI - brain
    • Finding
      • Mild increases in the size of the enhacning nodular lesions identified in previous MTI on 20220420.
      • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
      • No midline shift, nor mass effect.
      • Focal T1 and T2 hypintensity lesion in right temporal skull, r/o hemangioma. Stationary as compared with MRI on 20220304.
      • Mottled T2-hyperintensity in left pooly aerated mastoid, indicating mastoiditis.
    • IMP: Multiple brain metasases. Mild progression as comapred with MRI on 20220420.
  • 2022-05-26 CT - lung/mediastinum/pleura
    • Findings
      • Chest:
        • Soft tissue mass at left lower lobe up to 4.cm in largest dimension with attachment with left hemithorax is found.
        • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
        • Enlarged left thyroid up to 4.6cm in largest dimension. Stable.
        • There is bilateral pleural effusion.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered. In progression.
        • One fillling defect is found at right pulmonary trunk is found. Pulmonary embolism is considered.
      • Visible abdomen:
        • Low density lesions are found at both lobes of liver is found. In comparison with CT dated on 2022-03-03, the lesions are stationary.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Left lower lobe lung cancer with stationary size.
      • However, the bone meta and liver meta progressed.
      • Right pulmonary embolism is also noted. Suggest further treatment.
  • 2022-04-20 MRI - brain
    • Findings
      • No remarkable finding of cerebrospinal fluid spaces.
      • A total of 5 enhancing dots at subcortical region at bilateral frontal lobes, left parietal lobe, left occipital lobe and left basal ganglion. Multiple brain metasatses are considered.
      • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
      • No midline shift, nor mass effect.
      • Focal T1 and T2 hypintensity lesion in right temporal skull, r/o hemangioma. Stationary as compared with MRI on 20220304.
      • Mottled T2-hyperintensity in left pooly aerated mastoid, indicating mastoiditis.
    • IMP: Multiple brain metasases as described. Progressive change as comapred with MRI on 20220304.
  • 2022-04-14 CT - lung/mediastinum/pleura
    • Findings
      • Chest:
        • Nodular lesion at left thyroid up to 5.1cm in largest dimension is found. Stationary.
        • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
        • Lobulated mass at left lower lobe up to 3.1cm in largest dimension is found. In comparison with CT dated on 2022-03-03, the lesion regressed.
        • Spiculated nodule at left upper lobe up to 1.04cm is found. Stable.
        • No evidence of bilateral pleural effusion.
        • Small lymph nodes are found in the mediastinum.
        • Tiny nodular lesion at right lower lobe up to 0.2cm in largest dimension.
      • Visible abdomen:
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Nodular lesion at S7 of liver up to 0.8cm in largest dimension is found.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • LEFT LOWER LOBE mass with left upper lobe and right lower lobe lung meta and bone meta. In regression.
      • Left thyroid mass. 5.1cm
  • 2022-03-04 MRI - brain
    • Findings
      • No remarkable finding of cerebrospinal fluid spaces.
      • A small intra-axial enhancing dot at corticomedullary juction region of left anterior frontal lobe, much maller than that on 20220112 MRI.
      • A new enhancing dot at corticomedullary juction region of left posterior frontal lobe. suspected metastasis.
      • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
      • No midline shift, nor mass effect.
      • Focal T1 and T2 hypintensity lesion in right tmeporal skull, suspected hemangioma. Stationary as compared with MRI on 20210112.
      • No remarkable finding of bilateral orbital contents and optic nerves.
      • No remarkable finding of nasopharynx visible in these images.
      • Mottled T2-hyperintensity in left pooly aerated mastoid, indicating mastoiditis.
      • Diffuse mild mucosal thickening in bilateral paranasal sinsues, indicating chronic paranasal sinusitis.
    • IMP:
      • Regression of the metasattic lesion at left frontal lobe.
      • However, a suspicious metastatic lesion appears at left posterior frontal lobe.
  • 2022-03-03 CT - lung/mediastinum/pleura
    • Findings
      • Chest:
        • Thyroid nodule at left side up to 4.6cm in largest dimension.
        • S/p port-A placement with its tip at Superior vena cava.
        • Cavitatory lesion at left lower lobe up to 3.4cm in largest dimension. Reactive pleural effusion is found. In comparison with CT dated on 2022-01-13, the tumor regressed in size.
        • Diffuse Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Diffuse tiny nodules scattered at both lungs is found. Lung meta is considered. In regression.
        • One spluclated nodule at left upper lobe up to 9.5mm in largest dimension. stable.
        • Chains of lymph nodes are found at AP window and subcarinal region. Stationary.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Left lower lobe lung cancer with mediatinal lymphadenopathy, bilateral lung meta, bone meta.
      • The ovarall tumor extension and size are in regression.
      • Right Thyroid nodule. Suggest follow up.
  • 2022-02-25 MRI - T-spine
    • Findings
      • Numerous enhancing lesions involving every vertebral body of thoracic spine, causing vertebral body compression and spinal canal stenosis due to extensive soft tissue mass, most svere at T3-4 and T9-10 with cord compression and ill-defined intramedullary T2-hyperintensity.
      • Multiple metastatic lesions in bialetrla ribs.
      • A huge soft tissue tumor in left lower lung, with left pleural effusion.
      • Several T2-hyperintense lesions in right lobe of liver. D/D: metastases or cysts. -IMP:
      • C/W lung cancer with diffuse bony metastases in ribs and thoracic spine (with compressive myelopathy at T3-4 and T9-10 levels).
  • 2022-01-09 Tc-99m MDP whole body bone scan
    • Highly suspected multiple bone metastases in multiple C-, T- and L-spine, sacrum, sternum, bilateral rib cages, scapulae, and bilateral multiple pelvic bones.
  • 2022-01-13 CT - lung/mediastinum/pleura
    • Findings
      • Chest:
        • Soft tissue nodule at left lobe thyroid up to 5.3cm in largest dimension with tracheal deviation to right side is found. Stationary.
          
        • Lobulated nodule at left lower lobe up to 7.7cm in largest dimension is found. In comparison with CT dated on 2021-12-21, the lesion is slightly enlarged.
          
        • Mild left pleural effusion is found.
        • Spicualted nodule at left upper lobe up to 1.0cm in largest dimension is found. In regression.
        • Several tiny nodules at both lungs. Stationary in size and numbers.
        • Enlarged lymph nodes are found at AP window and paratracheal region.
      • Visible abdomen:
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • No definite inguinal or pelvic sidewall LAP
    • Imp:
      • LEFT LOWER LOBE lung cancer with bilateral lung meta, extensive bone meta.
      • The primary tumor enlarged slightly. The lung meta are statinary.
      • Mediastinal lymph nodes, in slighlty enlargement.
  • 2022-01-12 MRI - brain
    • A small intra-axial enhancing nodular lesion, about 5 mm, with mild perifocal edema in left frontal lobe, indicating metastasis.
  • 2021-12-28 CXR
    • A nodular opacity projecting in the left lower lung is noted that is c/w lung cancer. Please correlate with CT.
  • 2021-12-28 Patho - lung wedge biopsy
    • Lung, LLL, CT-guide biopsy—adenocarcinoma, moderately differentiated
      
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
  • 2021-12-27 MRI - L-spine
    • IMP: Bony metastasis involving L2, L4, L5 and S1 vertebral bodies and bilateral iliac wings. Mild lumbar spondylosis.
  • 2021-12-21 CT - lung/mediastinum/pleura
    • Imaging Report Form for Lung Carcinoma
    • Impression (Imaging stage): T4N2M1c, stage IVB
  • 2021-12-26 CXR
    • an oval-shaped mass over LLL, high possibly of a malignant lesion, suggest do CT study
    • Displacement of the tracheal axis to right at thoracic inlet and
    • superior mediastinum probably due to enlarged thyroid gland or
    • lymph node enlargement
• lab data
  • PD-L1
    • 2022-01-06
      • Pathologic Report for PD-L1 (SP142) Assay (Ventana) S2021-19566
        • Tumor type: Adenocarcinoma
          
        • Tumor location: Lung
          
        • Testing assay: SP142 Assay (Ventana)
          
        • Testing platform: BenchMark XT
          
        • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
          
        • Control slide result: Pass,
          
        • Adequate tumor cells present (>=50 viable tumor cells): Yes,
      • Result:
        • Tumor cell (TC) staining assessment: TC category: TC < 1%
          
        • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
          
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
          
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• consultation
  • 2021-12-28 Orthopedics
    • Q
      • for suspected lumbar nerve compression evaluation.
      • This is a 60 year-old male, who denied having any history. He complaimts low back pain with radiation to right thigh after trauma 6 Ms ago, and limping gait, he came to our Ortho OPD follow-up, then he received the L-spine MRI on 2021/12/27. However, he was admitted for LLL lung cancer T4N2M1c stage IVB, intrathoracic goiter evaluation. So we need your help for suspected lumbar nerve compression evaluation.
    • A
      • The MRI revealed bony metastasis involving L2, L4, L5 and S1 vertebral bodies and bilateral iliac wings. No nerve compression was noticed at present.
      • Suggestion:
        • Tx of lung ca as your specialty
        • Consult radiooncologist for possible radiotherapy, if indicated.
• chemoimmunotherapy
  • 2022-01-26 ~ undergoing - carboplatin + pemetrexed + BGB-A317 tislelizumab + BGB-A1217 ociperlimab (BGB trial)

701376921

220613

• exam finding
  • 2022-05-26 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Metastatic adenocarcinoma, consistent with colonic primary
    • The specimen submitted consists of three strips of yellow gray soft tissue, labeled liver, measuring up to 0.4 x 0.1 x 0.1 cm. All for section.
    • The secvtions show metastastic adenocarcinoma, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction.
    • IHC, tumor cells reveal: CK7(-), CK20(+), and CDX2(+). The finding is consistent with colonic primary.
  • 2022-05-23 Abdominal Ultrasonography
    • Diagnosis
      • Liver tumors, S4-S5-S8 and S6, suspected hepatocellular carcinoma
      • Hepatic tumor encasing right portal vein
      • Suspect left partial hepatectomy
      • Suspect gallbladder adenomyomatosis
      • Gall stone
      • Splenomegaly
    • Suggestion
      • Please correlate with other image for hepatic tumor survey
      • Follow liver function test and AFP
• consultation
  • 2022-05-24 Gastroenterology
    • Q
      • The 61 y/o woman has S-colon adenocaricnoma with liver and lung metastases s/p treatment in ShuangHo Hospital. She transfered to our OPD for secondary opinion. Due to liver function impairmenet, so we need your help for management.
      • O
        • GOT 33 -> 113
        • GPT 17 -> 153.
        • Abd echo was done on 20220523, report showed one huge hyperechoic lesion with hypoechoic rim, at least 13.16x12.71cm in size, was noted at S4, S5 and S8. One 4.44cm hyperechoic lesion was noted at S6, Hepatic lobe S2 and S3 was invisible.
    • A
      • 61F, a case of S-colon adenocaricnoma with liver and lung metastases s/p treatment in ShuangHo Hospital
      • S
        • Conscious clear
    • O
      • @Abdominal echo (20220523)
        • Liver tumors, S4-S5-S8 and S6, suspected hepatocellular carcinoma
        • Hepatic tumor encasing right portal vein
        • Suspect left partial hepatectomy
        • Suspect gallbladder adenomyomatosis
        • Gall stone
        • Splenomegaly
      • @LAB
        • AST: 33 (5/3) -> 99 (5/19) -> 113 (5/24)
          
        • ALT: 17 (5/3) -> 102 (5/19) -> 153 (5/24)
          
        • Bilirubin total: 0.57 (5/20)
          
        • Bilirubin direct: 0.18 (5/20)
          
        • Albumin: 3.5 (5/20)
          
        • Creatinine: 0.73 (5/19)
          
        • Alkaline phosphatase: 365 (5/19)
          
        • CA-199: 242.62
          
        • CEA: 183.415
    • A:
      • Abnormal liver function, suspect hepatic tumor related
    • P:
      • Check Anti HAV IgM, HBsAg, anti-Hbs Ab, anti-Hbc Ab, Anti HCV Ab to exclude viral hepatitis
      • Check HBeAg, Anti HBe Ab, HBV DNA
      • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
      • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication
      • Silymarin 1#~2# TID (GOT and GPT >= 2X ULN covered by NHI)
      • If patient had symptoms of abdominal fullness, may arrange abdominal echo for ascites evaluation (consider ascites tapping if available)
• chemoimmunotherapy
  • 2022-05-27 ~ undergoing - FOLFIRI + ramucirumab

700148929

220610

{high grade B-cell lymphoma}

[objective]

• exam finding
  • 2022-06-09 Nasopharyngoscopy
    • Infiltrative soft tissue lesion involving R Meckel’s cave, superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also foramen ovale, along the course of trigeminal nerve. Suspect Tolosa-Hung syndrome, lymphoma or sarcoidosis.
    • Brain atrophy and leukoaraiosis.
  • 2022-06-02 Nerve Conduction Velocity (NCV), Electromyography (EMG)
    • Findings
      • MNCV: no recordable response in left peroneal nerve and left ulnar nerve; decreased CMAPs amplitude of left median, right peroneal and bilateral tibial nerves; slow motor conduction velocity of left median, left peroneal and right ulnar nerve across elbow
      • SNCV: no recordable response in left ulnar and sural nerves; delayed SNAPs onset latency and decreased amplitude of right sural nerve; slow sensory conduction velocity of right ulnar and sural nerves
      • F-wave: no recordable response of left ulnar and peroneal nerves; delayed responses of left median, right peroneal and right tibial nerves
      • H-reflex: no recordable response of left lower limb; delayed response of right lower limb
    • Conclusion
      • This NCV study suggested left lower cervical and bilateral lumbosacral radiculopathy (worse in the left), left median axonal neuropathy, right ulnar neuropathy across elbow and right ulnar neuropathy.
      • Please correlate with clinical features.
  • 2022-05-27 MRA - brain
    • Findings
      • brain atrophy with prominent sulci, fissures and dilated ventricles.
      • multiple nonspecific hyperintense patches in T2WI at bilateral periventricular white matter, leukoaraiosis is considered.
      • no abnormal bright up on DWI to suggest recent infarct.
      • increased soft tissue with abnormal enhancement involving right Meckel’s cave, with extension to superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also to foramen ovale, along the course of trigeminal nerve. This is not obviously seen in previous MRI on 20220221. Possible etiology may include: inflammatory (Tolosa-Hunt syndrome), tumor (lymphoma, less likely: trigeminal neuroma, meningioma), or sarcoidosis.
      • TOF MRA shows patent and unremarkable intracranial arteries.
    • Impression
      • Infiltrative soft tissue lesion involving right Meckel’s cave, superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also foramen ovale, along the course of trigeminal nerve. Suspect Tolosa-Hung syndrome, lymphoma or sarcoidosis.
      • Brain atrophy and leukoaraiosis.
  • 2022-04-18 Nerve Conduction Velocity (NCV), Electromyography (EMG)
    • Findings
      • The facial NCV and blink reflex study showed:
        • Facial NCV (ENOG) : 0% R/L amplitude ratio
        • Absent signal in right facial nerve.
      • Absent ipsilateral R1 by right trigeminal nerve stimulation
      • Absent ipsilateral R2 & Absent contralateral R2 by right trigeminal nerve stimulation.
    • Conclusion
      • These findings suggest right facial neuropathy.
      • Advise clinical correlation.
  • 2022-04-13 Patho - interveterbral disc
    • Bone and joint, vertebra, cervical 3-4, 4-5 ,5-6 , anterior cervical discectomy — Confirmed
    • Specimen submitted in formalin consists of multiple pieces of tan, irregular tissue with the largest piece measuring 1.5 x 1 x 0.5 cm. Representative tissue for section in one cassette after decalcification.
    • Section shows pieces of bone, degenerated ligament, and cartilage.
  • 2022-04-09 CT - brain
    • Brain atrophy.
    • No evidence of ICH, SAH or SDH.
    • No evidence of space occupying lesion in the brain parenchyma is found.
  • 2022-02-21 MRA - brain
    • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
  • 2022-01-28 CT - lung/mediastinum/pleura
    • Minimal left breast soft tissue at lower part, in regression.
    • LEFT LOWER LOBE nodule. Stable, old insult is favored.
  • 2021-12-10 MRI - c-spine
    • Degenerative spinal and disc disease.
    • Herniated disc at posterior central C3-4 level, causing moderate adjacent spinal cord compression.
    • Mild C4-5, C5-6, C6-7 spinal cord compression.
    • Bilateral C4-5, C5-6, C6-7 neuroforaminal narrowing.
  • 2021-10-12 CT - abdomen, pelvis
    • Residual nodule at left breast, residual tumor activity is considered.
      
    • No evidence of lymphadenopathy other than left breast.
  • 2021-06-19 CT - lung/mediastinum/pleura
    • Lymphoma s/p C/T with C/T
    • Regression of bilateral breast mass with residual mass at left breast and no visible lymphadenopathy in the current study.
  • 2021-04-07 Whole body PET scan
    • Glucose hypermetabolism in the left nasal cavity, bilateral breasts, and left lobe of the liver, probably lymphoma with involvement of multiple extralymphatic organs.
      
    • Glucose hypermetabolism in the right maxilla, bilateral femurs, tibiae, and left fibia, probably lymphoma with involvement of the bone marrows.
      
    • Increased FDG accumlation in bilateral renal pelvis and colon, probably physiological uptake of FDG.
    • Lymphoma, stage IV (AJCC 8th ed.), by this F-18 FDG PET/CT scan.
  • 2021-03-24 Patho - breast biospy
    • diagnosis
      • Breast, right, core biopsy — high grade B-cell lymphoma
      • Breast, left, core biopsy — high grade B-cell lymphoma
    • Section shows cores of breast tissue with diffusely infiltration of large lymphoid cells.
    • IHC: CD20(+), CD3(-), CD10(+), BCL2(+), BCL6(+), MUM1(+), cMYC(-), CD5(-), and CD30(-). The Ki-67 is about 80%.
    • The results are in favor of high grade B-cell lymphoma.
  • 2021-03-16 CT - lung/mediastinum/pleura
    • two lt lung nodules up to 6 mm, stationary, favor intrapulmonary LNs.
    • regression of Rt inguinal LNs as compare with CT study on 20201027.
    • post treatment change with calcification in anterior mediastinum.
    • bilateral breast masses.
  • 2020-10-27 CT - abdomen, pelvis
    • S/P hysterectomy.
    • Stationary right inguinal lymph nodes.
    • Liver cysts.
  • 2020-06-29 CT - abdomen, pelvis
    • S/P hysterectomy.
    • Some LNs (up to 6mm) at bil. inguinal regions.
  • 2020-04-30 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy - Hypocellularity and free from lymphoma involvement
      
    • Sections show 5-20 % cellularity. The M/E ratio is about 1/1 - 2/3. Megakaryocytes are found about 0-1/HPF. No increase of blasts is noted. There are no granulomas,foreign malignant cells, nor aggregation of atypical lymphocytes.
  • 2020-02-18 CT - abdomen, pelvis
    • S/P hysterectomy.
    • Stationary right inguinal lymph nodes as compare with CT study on 20180802.
    • Liver cysts.
  • 2019-10-11 Surgical pathology Level IV
    • In-hospital
      • pathologic diagnosis - Breast, right, excision - Follicular lymphoma
      • Histology type: B-cell neoplasms, Follicular lymphoma
      • Follicular lymphoma - grading: 2, predominantly diffuse pattern
      • IHC: CK(-), CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), CD5(-), CD21(-), CyclinD1(-), SOX11(-), and cMYC(-)
    • Dr. KungChao Chang
      • Breast, right, excision: Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)
      • Sections show breast parenchyma diffusely replaced by small to medium-sized lymphoid tumor cells with slightly irregular nuclei, inconspicuous nucleoli and focally abundant pale cytoplasm. Lymphoepithelial lesions are present, highlighted by cytokeratin immunostain.
      • Immunohistochemically, these cells are positive for CD20, CD79a, bcl-2 and MNDA (focal) but negative for CD3, CD5, CD10, cyclin D1, SOX11, IRTA1, HGAL, LMO2, CD21 and c-MYC. Bcl-6 is focally positive for some cells, probably tumor cells. The Ki-67 proliferative index is around 40%. The lymphoepithelial lesions are evident but many cells infiltrating ductal epithelium are negative for CD20 or CD79a but focally positive for MNDA. The CD10-positive cells are mainly stromal cells (fibroblasts) not lymphocytes.
  • 2019-10-28 SONO - breast
    • Post-op scar in right breast.
    • Right breast tumor, suspected fibroadenoma.
    • Left breast nodule with central hyperechoic, suspected intramammary lymph node, suggest following up.
  • 2019-10-09 Whole body PET scan
    • Glucose hypermetabolic lesion in the right breast, suggesting lymphoma involving a single extralymphatic organ in the absence of any lymph node involvement.
    • Mild glucose hypermetabolic lesions in bilateral palatine tonsils, probably chronic inflammation/infection process.
      
    • Mild glucose hypermetabolic lesions in the colon, probably physiological uptake of FDG.
    • Lymphoma, c-stage IE (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2018-08-02 CT - abdomen
    • S/P operation. No evidence of tumor recurrence.
    • Liver cysts (up to 1.2cm). Grade 3 fatty liver.
• consultation
  • 2022-06-09 Radiation Oncology
    • Q
      • For evaluating and possible image-guided tissue proof
      • The 68 year old woman had Hypothyroidism under medical, Sleep disorder, Diffuse large B-cell lymphoma with multiple extralymphatic involvement over supra and infradiaphramatic region, Lugano stage IV, Herniated disc at posterior central C3-4 level, Autoimmune disease not eleswhere classified under rheumatology regular outpatient follow-up.
      • She complaint of neck pain and left ulnar area soreness, pain and numbness for for a month, left grips weakness and opponents weakness (left 4,5 fingers claw hand), ulnar side. And severe left ulnar area pain,soreness and numbness. Medical treatment and physical therapy was ineffective at all.
      • She visited our neurosurgery clinic, follow NCV study suggested left lower cervical radiculopathy, left median mild axonal neuropathy and left ulnar neuropathy across elbow post left cubital tunnel syndrome for neurolysis/cubital tunnel closure and anterior transposition on 2022/01/06.
      • She has left limbs weakness and numbness were noted and left drop foot. No evidence of spinal metastasis lesion from MRI in WanFang Hospital on 2022/03/21, but suspect compression fracture at T7. NCV and CMG were done, report showed mononeuritis multiplex.
      • Bone scan showed degnerative change of T8, T10 and L3 is first cinsidered on 2022/03/25. Right facial palsy, drooling, and mildly slurred speech was noted on 2022/04/07 morning on awakening. The neurologist suggested arranging a brain CT with contrast, which did not reveal any ICH, SAH, or SDH, and no space-occupying lesion in the brain parenchyma was found. The neurosurgeon suggested surgical intervention due to a previous C-spine MRI showing C4-5 herniated intervertebral disc  disease with spinal canal stenosis.
      • After discussion and the fullexplanation with the patient and her son, she decided to undergo anterior cervical discectomy for C3-4, C4-5, and C5-6 and anterior spinal fusion on 2022/04/12. She still felt right facial numbness. Arrange blink test, facial nerve stimulation and showed these findings suggest right facial neuropathy.
      • Brain MRA on 2022-05-27 revealed Infiltrative soft tissue lesion involving right Meckel’s cave, superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also foramen ovale, along the course of trigeminal nerve. Suspect Tolosa-Hung syndrome, lymphoma or sarcoidosis. Brain atrophy and leukoaraiosis.
      • Nasopharyngoscopy on 2022-06-09 showed Infiltrative soft tissue lesion involving R Meckel’s cave, superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also foramen ovale, along the course of trigeminal nerve. Suspect Tolosa-Hung syndrome, lymphoma or sarcoidosis. Brain atrophy and leukoaraiosis.
      • Under the impression of Diffuse large B-cell lymphoma with multiple extralymphatic involvement over supra and infradiaphramatic region, Lugano stage IV, PS:0, suspect relapse in brain .
  • 2022-04-14 Rehabilitation
    • A
      • Objective
        • imaging studies
          • 20220221 brain MRA
            • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
          • 20220409 brain CT
            • Brain atrophy.
            • No evidence of ICH, SAH or SDH.
            • No evidence of space occupying lesion in the brain parenchyma is found.
          • 20220413 c spine x ray
            • Post disectomy and disc grafting C3/4/5/6.
        • physical examination
          • 20220414 14:09 T/P/R: 36.0℃ / 89bpm / 17bpm BP:152/81mmHg
          • height: 154.0 Body weight: 56.3 BMI:23.7 Consciousness: E4V5M6
          • right facial palsy, suspected peripheral type
          • Cognition: oriented could follow orders
          • Speech: no aphasia, no dysarthira
          • Swallowing: NG (-). no dysphagia.
          • drooling on right side. right face numbness + hypoethesia
          • no choking
          • Sphincter: Foley (-), stool continence
          • MP: RUE 5 / RLE 5 / LUE 4+ / LLE 4
          • Functional status: needs min assistance in transfer
          • BADL: needs min assistance
      • Assessment
        • C3-6 herniated intervertebral disc with spinal stenosis post anterior cervical discectomy for C3-4, C4-5, and C5-6 and anterior spinal fusion on 2022/04/12
        • facial numbness, suspected peripheral facial palsy
        • pending blink reflex
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: improve ADL ability, improve lower limb endurance
  • 2022-04-08 Neurology
    • Q
      • The 69 y/o woman has endometrium cancer and diffuse large B-cell lymphoma with multiple extralymphatic involvement over supra and infradiaphramatic region, Lugano stage IV. This time, she has left limbs weakness, numbness, painful sensation and unsteady gait for months on WanFang Hospital and Taipei Medical University Hospital treatment. She was brought to ED for left leg severe pain on 4/5. We need your help for management.
    • A
      • S
        • This is a 68 year old woman had aHx of
          • Diffuse large B-cell lymphoma with multiple extralymphatic involvement over supra and infradiaphramatic region, Lugano stage IV, s/p C/T (doxorubicin? liposomal doxorubicin? epirubicin?) and R/T (until 2022-03 for left breast)
          • Cervical cancer endometrium carcinoma s/p radical hysterectomy on 2002?08/03?
          • Hypothyroidism under medication
          • Herniated disc at posterior central C3-4 level
          • Left cubital tunnel syndrome for neurolysis/cubital tunnel closure and anterior transposition on 2022/01/06
          • Autoimmune disease not eleswhere classified under rheumatology regular OPD follow-up
        • She suffered from subacute progressive left arm numbness since 2 months ago during R/T; leg pain (burning sensation) and numbness since 1 month ago. Bilateral bottuck numbness, urine retention, constipation, annus less sensation when using toilet paper since 0.5 month ago. Right facial palsy, drooling, and mild slurred speech was noted on 2022047 morning on awakening.
      • O
        • NE
          • GCS: E4V5M6
          • VF: intact
          • pupil 3/3 t/t
          • EOM: free
          • right facial palsy, central or peripheral
          • right V1-3 hypoesthesia
          • hearing: left hearing loss (baseline)
          • mild dysarthria
          • tongue in the mid
          • motor
            • 5/P5D3
            • 5/P4D1
          • Left
            • shoulder rotation, arm abduction, elbow flexion, elbow extension, wrist extension:5
            • finger extension, finger flexion: 4
            • finger abduction, finger adduction: 3
            • thumb abduction: 4
            • left interosseous muscle atrophy
            • claw hand
          • hip flexion, hip adduction, knee extension: 4
          • hip abduction, hip extension: 3
          • foot dorsiflexion, plantarflexion inversion, eversion: 1
          • extension of toes: 2
        • sensory:
          • hypoesthesia over
            • right face, right head over
            • bilateral medial antebrachial cutaneous and left ulnar
            • bilateral buttoack and left below knee, left femoral cutaneous
        • brain MRA (20220222): Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
        • MRI: C4-5 HIVD
      • A
        • impression: mononeuropathy multiplex; Bell’s palsy
      • P
        • suggestion:
          • arrange NCV and EMG
          • arrange blink test, facial nerve stimulation test
          • arrange brain CT with contrast
          • give prednisolone 5mg 11# per day (devide to 3 times), then decrease 2# per day since day 6
  • 2021-04-22 Infectious Disease
    • Q
      • The 68 year old woman is a case of diffuse large B-cell lymphoma with multiple extralymphatic involvement over supra and infradiaphramatic region, Lugano stage IV,PS:0
      • She received C1 R-CHOP (Adriamycin shift to self paid of Lipo-dox) was administered on 2021/04/08 ~ 2021/04/09.
      • This time, she suffered dysuria for about 2 days and frequency and urgency also suffered swelling nose for about 1 day with headache. She then had fever for about 2 days.
      • At ER, hemogram showed neutropenia with ANC 362, elevated CRP. CXR was clear. Water view’s mild obliteration of the right maxillary sinus.
      • Empiric antibiotics with Cefepime was given for neutropenic fever
      • We need your expertise for antibiotics used, thanks
    • A
      • Consultation for neutropenic fever.
      • 68-year-old B-cell lymphoma female patient, who received recent chemotherapy, has neutropenic fever now.
      • White count 630 with ANC only 362 yesterday.
      • There is rhinitis symptoms, and Water’s view shows suspect right maxillary sinusitis.
      • CxR film shows clear lungs, that no urinalysis data available for interpretation.
      • Patient is receiving cefepime now, which would be appropriated for her.
      • Suggestion:
        • Check urinalysis and send urine for culture.
        • Continue Cefepime.
        • Consult ENT specialist for scope examination.
        • Check blood culture report.
• surgical operation
  • 2022-01-06 Left cubital tunnel syndrome for neurolysis/ cubital tunnel closure and anterior transposition
    • Left ulnar area numbness/ grips muscular atropy and weakness/ claw hand.
    • Prominent left epicondyl of humerus. Severe adhesion around ulnar nerve both at para-epicondyl area, including proxiaml cutibal tunnel are/ cubital tunnel inside and distal area to FCU area.
  • 2002-08-03 radical hysterectomy at NTUH
• chemoimmunotherapy
  • 2021-04-08 ~ 2021-09-08 - R-CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone plus rituximab)
  • 2020-01-20 ~ 2020-03-11 - R-COP (cyclophosphamide, vincristine, prednisone plus rituximab)

[assessment]

• Brain MRA (2022-05-27) revealed:
  • Infiltrative soft tissue lesion involving right Meckel’s cave, superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also foramen ovale, along the course of trigeminal nerve. Suspect Tolosa-Hung syndrome, lymphoma or sarcoidosis.
  • Brain atrophy and leukoaraiosis.
• The above described infiltrative soft tissue lesion at trigeminal nerve course is consistent with the finding of NCV (2022-04-18). DLBCL with CNS involved?
• There is no cure or specific treatment for vanishing white matter (leukoarailsis) so far.
• Neurological symptoms might be prioritized?
• HR > 100, potential hypoperfusion?
• No issue with active prescription.

220406

[assessment]

• The patient underwent R-COP from 2020-01 to 2020-03 after pathologically proving follicular lymphoma in October 2019, then received R-CHOP from 2021-04 to 2021-09 after pathologically proving high grade B-cell lymphoma in March 2021.
• There would be an increased risk of CNS involvement for patients with double-hit or triple-hit high-grade b-cell lymphomas (in this case, cMYC(-), BCL2(+), BCL6(+)), but CNS involvement was not proven by brain MRA on 2022-02-21.
• While the standard of care is not established, the following induction regimens have been reported:
  • RCHOP (used in 2021)  - DA-EPOCH-R  - Potentially toxic regimens; performance status and comorbidities should be considered
    • R-HyperCVAD (rituximab, cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with high-dose methotrexate and cytarabine)
    • R-CODOX-M/R-IVAC (rituximab-cyclophosphamide, vincristine, doxorubicin with methotrexate/ifosfamide, etoposide, and cytarabine)
• Laboratory results reported on 2022-03-29 indicated normal liver and kidney function, along with slightly lower CBC readings.

700622927

220608

{cyclosporine-A TDM}

• The level of serum cyclosporine-A gradually increases (normal range 100~400 ng/mL), please monitor for potential adverse reactions such as post-transplant diabetes mellitus, drug-induced gingival overgrowth, drug-induced thrombotic microangiopathy, neurotoxicity. (Recent laboratory data do not indicate liver toxicity, nephrotoxicity, hyperkalemia, or hypertension.)
  • 2022-06-06 307.0
  • 2022-06-02 287.9
  • 2022-04-09 165.8

220504

{Minutes of the Interprofessional Practice Meeting and Family Meeting}

• This was the second meeting held on 2022-05-04 at 10:00 in the ward, the first meeting being held on 2022-03-30. The patient’s son participated in the meeting via a smart phone.
• Dr. Kao explained the treatment schedule to the patient family, as well as the prognosis and possible risks.
• The patient asked questions about her small amount of bleeding from the catheter needle wound and the soybean-based meals in the hospital. These questions got immediate feedback, as she understood that willpower is an indispensable element of treatment for the disease.

220330

{Interprofessional Practice Meeting and Family Meeting following up}

• This meeting was held on 2022-03-30 at 9:00 in the ward, the patient was present, as was her son.
• Dr. Kao explained the treatment plan of the disease to the patient family, as well as the prognosis and possible risks, and interprofessional practice team members were present for inquiries.
• For the transplant will need relatively rare used drugs, the pharmacy should prepare in advance to ensure that the drugs are readily available and Dr. Kao will provide an updated version of conditioning agent schedule.

701009623

220606

{follicular lymphoma}

• exam finding
  • 2022-06-02 CT - abdomen, pelvis
    • With and without contrast enhancement CT of abdomen shows:
      • Distended stomach and proximal small bowel.
      • Unremarkable chagne of the liver, spleen, pancreas, and kidneys.
      • Peritoneal stranding at low abdomen. Wall thickening and increased enhancement of terminal ileum.
      • Surgical clips and stiches over abdomen.
      • No bony destructive lesion on these images.
      • Penetrating atherosclerotic ulcer at abdominal aorta, infrarenal segment.
    • Impression
      • Gastric and proximal small bowel distension
      • Terminal ileum thickening and peritoneal stranding, due to lymphoma?
      • Suggest small bowel series to r/o obstruction if progression of bowel distension
  • 2022-06-01 Abdominal Ultrasonography
    • c/w, Ileus
    • Liver cyst, small, S7
  • 2022-05-31 Standing KUB
    • Presence of ileus.
    • S/P operation with retention of surgical clips.
    • Intact bony structure(s).
  • 2021-09-18 CT - abdomen, pelvis
    • Infrarenal AAA (2.1cm) with mural thrombus and ulceration.
• consultation
  • 2022-06-03 General and Gastroenterological Surgery
    • Q
      • Patient admit to Cardinal Tien hospital on for operation for malignant lyphoma on 20210730, Brain MRA on 20210731 showed left MCA, PCA infarction with hemorrahge transformation. S/P HBO (Hyperbaric Oxygen Therapy) for 10 sessions, under rehab program .
      • NG(-), Foley(-)
      • Palpitations, epigastric pain with nausea, crampy sensation and shaking chills for 3 days. TOCC(-). No known allergy.
      • 2022/04/11@TMUH Abd CT:
        • Penetrating aortic ulcer (PAU) noted at infrarenal aorta, no obvious interval change.
        • Post op chage of small bowel. Some prominent LNs at mesentery, no interval change.
      • 2022/06/01 Abd SONO
        • dilated A-colon and D-colon was noted.
        • Diagnosis:
          • c/w, Ileus
          • Liver cyst, small, S7
      • 2021/09/18 CT Abd:
        • Infrarenal AAA (2.1cm) with mural thrombus and ulceration.
    • A
      • 67 y/o male small bowel lymphoma s/p segmental resection
      • bloating and abdominal pain but subside
      • PE: soft, no tenderness
      • CT: Terminal ileum thickening and peritoneal stranding, due to lymphoma?
      • P: suggest admission and further evaluation
  • 2021-09-24 Hemato-Oncology
    • Q
      • This is a 66-year-old man with history of:
        • Mesentric tumor in small bowel, s/p exploratory laparotomy with tumor excision and resection of jejunum for about 160cm on 2021-07-30, pathology report: malignant lymphoma
        • Small bowel syndrome
        • Abdominal aorta aneurysm, measuring 2.1cm
        • Pulmonary hypertension
        • Atrial fibrillation with right bundle branch block
        • Anemia, suspected chromic inflammation of GI tract
          
      • He had found one big mass at lower middle abdomen for one month. He went to GI department in Cardinal Tien Hospital on 2021-07-16. Abdominal echo revealed left intra-abdominal tumor, 10.2x8.8cm. Abdominal CT was arranged on 2021-07-19 and showed (1) suspected tumor, 8.9x8.8x6.3cm, in small intestine with retroperitoneal lymphadenopathy; (2) abdominal aorta aneurysm and focal dissection. Exploratory laparotomy with excision of intraabdominal tumor and resection of jejunum about 160cm was performed on 2021-07-30. Pathalogy report of operation finding revealed a follicular lymphoma, grade 2, in the mesentry, measuring 11x10x6.5cm, immunoreactive for CD20, bcl-2 and CD10 and non-reactive for CD3, CD5, CD21, CD23 and cyclin D1. After operation, acute onset of conscious disturbance with right limbs weakness was noted in 2021-07-31 early morning. Brain MRA on 2021-07-31 revealed recent infarction in the left middle cerebral artery (MCA) and posterior cerebral artery (PCA) territory with suspicious hemorrhagic transformation at the left temporal area and basal ganglia. Cardiac ultrasound on 2021-08-02 showed LVEF: 75.7% and moderate pulmonary hypertension. Whole body PET scan on 2021-08-11 showed suspicious inflammatory change in right lower lobe of lung and no evidence of abnormal FDG uptake throughout whole body region elsewhere. His consciousness was alert and E4VAM6.
      • With impression of left MCA and PCA infarction with hemorrhagic transformation on 2021/07/31 with right hemiplegia, dysphagia and aphasia, he was transferred to our PM&R ward on 2021/09/15 for further rehabilitation treatment.
      • We need your expertise for evaluation of follicular lymphoma s/p tumor excision.
      • Pathology report in Cardinal Tiem Hospital
        • Gross Description
          • The specimen submitted consisted of 2 parts. Part(A) was a segment of small intestine measuring 102 cm in length and up to 3 cm in diameter, fixed in formalin.
          • Grossly, the small intestine showed unremarkable. There was a tumor measuring 11 x 10 x 6.5 cm in the mesentery. Part(B) was a piece of soft tissue labelled mesentery lymph nodes, measuring 9 x 4 x 2 cm in size and 30 gm in weight. Representative sections were taken.
        • Microscopic description
          • Microscopically, sections of the mesentery tumor and mesentery lymph nodes show numerous variably sized, back to back neoplastic follicles. Most have absent or attenuated mantle zones. Occasional larger admixed centroblasts are seen.
          • The tumor cells are immunoreactive for CD20, bcl-2 and CD10, and non-reactive for CD3, CD5, CD21, CD23 and cyclin D1. The morphological and immunohistochemical features are compatible with follicular lymphoma, grade 2. Sections of jejunum and both cut ends show chronic inflammatory cell infiltration in the mucosa.
    • A
      • Paitent examined and Chart reviewed. A case of intestinal lymphoma is noted. I am consulted for further evaluation and management.
      • My suggestions:
        • Please complete staging work, e.g., Chest/Abd/Pelvis CT, PET-CT, bone marrow study. All is covered by National Health Insurance.
        • Please check lab: Anti-HCV, Anti-HBs Ab, Anti-HBc Ab, HBs Ag, LDH, Beta2-microglobulin.
        • Already discussed with patient and family.
        • Any problem, please let me know.
  • 2021-09-22 Cardiac Surgery
    • Q
      • After admission, follow-up abdominal CT with/without contrast for abdominal aortic aneurysm was performed on 20210918 and showed one infrarenal AAA (2.1cm) with mural thrombus and ulceration. His systolic blood pressure was around 140 mmHg and sometimes above 150mmHg recently. We need your expertise for evaluation of abdominal aortic aneurysm and target of blood pressure control. Thank you so much!
    • Q
      • Thanks for consultation.
      • CTA showed a small, if it can be diagnosed as, AAA. The diamter is 21mm. Blood pressure is well controled.
      • There is no current indication for surgical intervention. Conservative treatment with aggressive BP control is recommended. OPD f/u is recommended.

[assessment]

• This patient was diagnosed with follicular lymphoma based on pathology results from Cardinal Tien Hospital and has undergone exploratory laparotomy with excision of intraabdominal tumor as well as resection of about 160cm of jejunum on 2021-07-30 at that hospital during the third quarter of 2021. Is it possible that the staging workup has not been completed, or that the records collected at Cardinal Tien Hospital have not been totally transferred?
• First line therapy for follicular lymphoma grade 1 or 2 could be the following regimens:
  • Bendamustined + obinutuzumabe or rituximab
  • CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) + obinutuzumabe or rituximab
  • CVP (cyclophosphamide, vincristine, prednisone) + obinutuzumabe or rituximab
  • Lenalidomide + rituximab
• CT 2021-09-18 revealed an infrarenal abdominal aortic aneurysm (2.1cm) with mural thrombi and ulceration, while CT 2022-06-01 demonstrated a penetrating atherosclerotic ulcer at the abdominal aorta, infrarenal segment. In the TPR records since this hospital stay, SBP fluctuates between 135 and 180 mmHg, BP might not be considered well controlled, and this patient has no cardiac medicine or cardiac surgery follow up records since 2021-09, perhaps some consultation might be appropriate.
• In this case, the patient has a history of atrial fibrillation and right bundle branch block. However, only antihypertensive medication Sevikar is prescribed now.
• All the oral drugs in active prescription can be administered with nasogastric tube.

701391119

220601

{steroid conversion}

An approximate corticosteroid dosing conversion

• Approximately 4mg of dexamethasone is equivalent to 4mg of betamethasone.
• The current dose of betamethasone 4g IVD Q8H may be switched to Limeson (dexamethasone 4mg/tab) 1# PO Q8H.

701364241

220531

• exam finding
  • 2022-03-15 Patho - pancreas biopsy
    • Labeled as “pancreatic head”, incision biopsy — adenocarcinoma.
    • Section shows 1 piece of pancreatic tissue with irreular shaped adenocarcinoma.
    • IHC stains: CK19 (+), CA-199 (equivocal), CK7 (+), CK20 (-). The pattern in conjunction with elevated levels of serum lipase and CA-19-9 is compatible with pancteatic origin.
  • 2022-03-08 MRI - pancreas
    • Suspected a tumor (1.8cm) at pancreatic head with biliary tree and p-duct dilatation.
  • 2022-03-07 Endoscopic Ultrasound, EUS
    • Diagnosis
      • Pancreatic head tumor with CBD invasion, highly suspected pancreatic cancer
      • Dilated biliary tree
    • Suggestion
      • Correlate with other imaging
      • Consult surgeon for indication of operation
  • 2022-03-07 Abdominal Ultrasonography
    • Diagnosis
      • Suspicious pancreatic head tumor
      • Dilated biliary tree
      • Distended GB with sludge
      • Dilated MPD
    • Suggestion
      • Correlate with other imaging
  • 2022-03-03 CT - abdomen, pelvis
    • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage): T1cN0M0, stage IA
• consultation
  • 2022-03-23 Hemato-Oncology
    • Q
      • for chemotherapy
      • This 48 y/o male was a case of pancreatic head cancer with obstructive s/p PTCD on 3/9. Further operation was performed on 3/14. Operation finding showed pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion dilated CBD up to 1.8cm multiple LN enlarge at duodenal ligament and paraaorta. So Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy was done. After operation with well oral intake and condition become stable, we need you help for further chemotherapy for this patient.
    • A
      • This 48 y/o male was a case of pancreatic head CA wt obstructive s/p PTCD on 3/9. Op was performed on 3/14 22. Op finding showed pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion dilated CBD up to 1.8cm multiple LN enlarge at duodenal ligament and paraaorta. Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy was done.
      • Palliative or pre-neoadjuvant C/T is to be proposed.
      • Image study:
        • Pancreas MRI (3/8 22):
          • Findings
            • Suspected a tumor (1.8cm) at pancreatic head with biliary tree and p-duct dilatation.
            • Distention of gallbladder.
            • No ascites, nor enlarged lymph node.
            • No abnormal intensity in bilateral basal lungs.
          • IMP: Suspected a tumor (1.8cm) at pancreatic head with biliary tree and p-duct dilatation.
        • Abd CT (3/3 22):
          • Findings
            • Wall thickening of distal CBD with biliary tree and p-duct dilatation.
            • Distention of gallbladder.
            • Patency of portal vein.
            • No ascites, nor enlarged lymph node.
            • No abnormal density at bilateral basal lungs.
          • IMP: Wall thickening of distal CBD with biliary tree and p-duct dilatation suspected tumor.
      • Dx: R/I local advanced pancreatic CA, stage, unamenable to resection.
      • Medical advice:
        • It will be possible to be cured only in the patient whose pancreatic cancer is amenable to total surgical resection ( R0 resection ). The pacnreatic tumor of this pt seeems to be unresectable.
          
        • Pancreatic CA divided into 2 main kinds of carcinoma, one is adenocarcinoma, another is neuroendocrine tumor. Both should be subject to complete resection for cure.
        • But the two kinds of cancer have totally different Tx pattern. For unresectable pancreatic adenocarcinoma, the first treatment of choice is palliative C/T wt FOLFIRINOX or Gemcitabine-based C/T. As for unresectable neuroendocrine tumors, the first treatment of choice may be targeted therapy wt Sutent (sunitinib).
        • If pancreatic tumor is not subjected to resection, biopsy of pancreatic tumor may be indicated for definitive Dx. Tx will be arranged according to accurate pathologic Dx.
        • If pancreatic adenocarcinoma is proved, pre-Op neoadjuvant C/T wt FOLFIRINOX or CCRT (concurrent chemoradiation therapy) over pancreatic tumor may be first priority of Tx for this pt to make pancreatic tumor shrink & may render Op feasible.
          • Post-CCRT, abd CT will be done to evaluate Op feasibility.
          • Palliative C/T regimens for local advanced pancreatic CA or metastatic Dz may be:
            • FOLFIRINOX ( self-paid ) ( preferred )
            • Gemcitabine + albumin-bound paclitaxel
            • Gemcitabine + erlotinib ( at mets dz )
            • Gemcitabine-based combination C/T
            • Gemcitabine alone
            • Capecitabine or continous infusion 5-FU.
            • TS-1 ( Phase III Clinical Study (GEST) of TS-1 in pt wt local advanced & metastatic pancreatic CA, reported at JCO 2013 March. ) ( not included at NCCN guideline recommendation )
              
          • Recent data showed FOLFIRINOX offered better survival benefit than Gemcitabine-based C/T.
      • If pancreatic neuroendocrine tumor (pNET) is proved, pNET (or NET) can be classified as local, regional, or advanced dz. Treatment goal should be curative where possible, with the use of pharmacological Tx as necessary.
        • If complete resection wt curative-intent can be achieved for the pNET pt without evidence of residual dz, adjuvant C/T for post-Op NET pt is not necessary. 
        • No adjuvant C/T is suggested. C/T is only considered if recurrence is proved.
      • As for the pt wt unresctable local advanced or metastatic NET, variable target therapy drugs are available:
        • mTOR inhibitor everolimus ( Afinitor, 5mg / #, 2# QD)
        • tyrosine kinase inhibitor sunitinib ( Sutent).
        • VEGF inhibitor Bevacizumab (Avastin).
  • 2022-03-23 Radiation Oncology
    • Q
      • for CCRT
      • This 48 y/o male was a case of pancreatic head cancer with obstructive s/p PTCD on 3/9. Further operation was performed on 3/14. Operation finding showed pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion dilated CBD up to 1.8cm multiple LN enlarge at duodenal ligament and paraaorta. So Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy was done. After operation with well oral intake and condition become stable, we need you help for further CCRT for this patient. Thanks for your time!!
    • A
      • Subjective:
        • History: This 48 y/o male was a case of pancreatic head cancer with obstructive jaundice s/p PTCD on 2022/3/09. BW loss of 7-8 kg in 3 months is noted. Further operation was performed on 3/14. Operation finding showed pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion, dilated CBD up to 1.8cm, multiple enlarged LAPs at duodenal ligament and paraaortic region. Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy was done. After operation, he can tolerate soft diet now.
          • Previous RT: denied.
          • Other disease: denied.
          • Family history: denied.
        • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
        • Single. Caregiver: his brother (also single). Job: nil. No economic stress.
        • Language: Mandarin. Taiwanese.
        • Religion: Nil.
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2022/3/23: No SCF LAPs. Minimal icteric sclera. 43.8 kg (51 kg before).
        • Pathology, 2022/03/15: Labeled as ‘pancreatic head’, incision biopsy — adenocarcinoma. IHC stains: CK19 (+), CA-199 (equivocal), CK7 (+), CK20 (-). The pattern in conjunction with elevated levels of serum lipase and CA-19-9 is compatible with pancreatic origin.
        • Images:
          • CT, 2022/3/03: Wall thickening of distal CBD with biliary tree and p-duct dilatation suspected tumor.
          • MRI, 2022/3/08: Suspected a tumor (1.8cm) at pancreatic head with biliary tree and p-duct dilatation. No enlarged regional LNs. No ascites. No liver metastasis.
        • LAB, 2022/3/07: CEA 4.80; CA199, 1471.32.
      • Diagnosis:
        • Pancreatic head cancer, adenocarcinoma, with PV encasement > 270 degree and partial SMA invasion, dilated CBD up to 1.8cm (obstructive jaundice), multiple enlarged LAPs at duodenal ligament and paraaortic region, cT4N1M0, stage III, s/p PTCD on 2022/3/09, s/p Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy on 2022/3/14; ECOG =1.
      • Plan:
        • CCRT to pancreatic head tumor and LAPs for 5000cGy/25 fx is suggested for tumor control & down staging. Aggressive nutritional support is suggested due to BW loss of 7-8 kg in 3 months. CT simulation is arranged on March 29, 08:30 am. Treatment will be started on March 31 if his surgical wound heals well. Diet education and tolerable exercise is suggested.
  • 2022-03-09 Radiological Diagnosis
    • Q
      • Reason: for biliary tract drainage
      • This 48-year-old male with anxiety had regular taken medication from local psychiatric clinic. Abdomen MRI revealed Suspected a tumor (1.8cm) at pancreatic head with biliary tree and p-duct dilatation. We sincerely need your expertise for his further evaluation and arrangement of biliary tract drainage.
    • A
      • According to the clinical condition and imaging findings, PTCD is indicated.
  • 2022-03-08 General and Gastroenterological Surgery
    • Q
      • Reason: for pancreatic head tumor
      • This 48-year-old male with anxiety had regular taken medication from local psychiatric clinic. This time, he was admitted for obstructive jaundice. Abdomen CT revealed wall thickening of distal CBD with biliary tree and p-duct dilatation suspected tumor. EUS revealed pancreatic head tumor with CBD invasion, highly suspected pancreatic cancer, and dilated biliary tree. MRI would be arranged on 2022/03/08 12:00. We sincerely need your expertise for his further evaluation and management.
    • A
      • S
        • According to the patient, he had weight loss of 7kg recently, postprandial diarrhea and poor appetite.
      • O
        • Lab data on 2022-03-07
          • CA199 1471.32 U/mL
            
          • Bilirubin total 16.82 mg/dL
            
          • Bilirubin direct 8.63 mg/dL
            
          • S-GOT/AST 137 U/L
            
          • S-GPT/ALT 292 U/L
            
          • Alkaline phosphatase 427 U/L
            
          • r-GT 708 U/L
            
        • Abdomen CT: Wall thickening of distal CBD with biliary tree and p-duct dilatation suspected tumor.
        • EUS: Pancreatic head tumor with CBD invasion
      • Impression: pancreatic head tumor, dilated biliary tree
      • Suggestions:
        • PTGBD insertion first due to hyperbilirubinemia.
        • Adequate nutrition due to weight loss.
        • Pending IgG4 and MRI report.
        • We will evaluate the need of surgery after the tests.
      • We would like to follow up this patient, feel free to contact us.
• VS note
  • 2022-04-11
    • Local advanced pancreatic head tumor with partial SMA invasion & dilated CBD & multiple LN enlarge at duodenal ligament & paraaorta s/p Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy on 3/14 22 & s/p PTCD on 3/9 22.
    • XRT started on 4/6 22.
    • #1 pre-Op neoadjuvant CCRT with 5-FU (200mg/m2) IVF 24 hr plus R/T on 4/11 22. .
    • encourage pt to eat more food.
    • Stable vital sign. MBD today.
  • 2022-04-08
    • admitted for #1 CCRT with 5-FU (200mg/m2) on 4/8 22 due to pancreatic head CA wt obstructive s/p PTCD on 3/9 22, s/p Op on 3/14 22. Op finding showing local advanced dz wt pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion dilated CBD up to 1.8cm & multiple LN enlarge at duodenal ligament and paraaorta. Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy.
• surgical operation
  • 2022-03-14
    • Surgery
      • Roux-en-Y hepaticojejunostomy
      • GJ anastomosis
      • cholecystectomy
    • Finding
      • pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion
      • dilated CBD up to 1.8cm
      • multiple LN enlarge at duodenal ligament and paraaorta
• radiotherapy
  • 2022-04-06 ~ 2022-05-10 - CCRT to pancreatic head tumor and LAPs for 5000cGy/25 fx
• chemoimmunotherapy
  • 2022-05-30 ~ undergoing - FOLFIRINOX
  • 2022-04-11 ~ 2022-05-09 - 5-Fu (CCRT)

[assessment]

• Pancreatic head cancer has been diagnosed (CT 2022-03-03) and proven to be adenocarcinoma (pathology 2022-03-15).
• CCRT was provided to the patient starting in early April and continuing through early May 2022, following the starting of FOLFIRINOX since this hospital stay.
• Lab data on 2022-05-30 showed grossly normal except for elevated AST/ALT, however the administration of regimen should not likely to be affected.
• TPR remains stable during this hospitalization. No issue with active prescription.

700898650

220530

{potential drug interactions}

• all the oral drugs in active prescription can be administered with nasogastric tube.
• some potential drug interactions should be addressed:
  • cation exchange resin - antacid
    • Calicum polystyrene sulfonate (CPS) removes potassium by exchanging calcium ions for potassium ions in the intestine before the resin is excreted from the body.
    • The combined use of calcium carbonate (500mg PO TID) and kalimate (calcium polystyrene sulfonate, 4gm PO TID) might result in metabolic alkalosis and/or loss of efficacy of the cation exchange resin.
    • Cation exchange resins such as CPS binds magnesium and calcium ions, and may thereby prevent binding and neutralizing of bicarbonate ions in the small intestine. Additionally, this binding might attenuate the therapeutic effects of the exchange resin. Prescribing information for CPS highlights this risk of alkalosis with cation-donating antacids, but does not give specific recommendations for action.
    • To minimize this interaction, consider: a) separating the doses of calcium polystyrene sulfonate and calcium carbonate by 2 or more hours; b) administering CPS rectally; or c) choosing an alternative acid reducing agent (e.g. H2-antagonist). Monitor for metabolic alkalosis and attenuation of CPS effects if concomitant therapy cannot be avoided.
  • CNS depressants
    • The concomitant use of two or more drugs (clonazapam 0.5mg BID and fexofenadine 60mg BID) that have the potential to depress CNS function (either as a therapeutic intention or a side effect) is often clinically appropriate. However, it is important to recognize that the risk of unwanted effects may increase with such use.
    • Consider the duration of CNS depressant use and each patient’s response (particularly tolerance to CNS depressant effects) when selecting additional agents and their doses. Dose reductions of one or both CNS depressant agents may be necessary. Monitor for additive CNS-depressant effects whenever two or more CNS depressants are concomitantly used.
    • Advise patients to avoid any unprescribed, illicit, or recreational use of other CNS depressants.
  • CNS depressant - metaclopramide
    • Metoclopramide might enhance the CNS depressant effect of CNS Depressants.
    • Metoclopramide prescribing information states that metoclopramide might impair the mental and/or physical abilities required for the performance of hazardous tasks such as operating machinery or driving a motor vehicle. Concomitant use of central nervous system (CNS) depressants or drugs associated with EPS may increase this effect (eg, alcohol, sedatives, hypnotics, opiates, anxiolytics).
    • Please monitor patients for increased CNS depressant effects (eg, somnolence, drowsiness) if metoclopramide is combined with CNS depressants.

701390387

220526

{tachycardia}

• underlying condition
  • visually impairment
  • dementia
• exam finding
  • 2022-05-25 CT - abdomen, pelvis
    • There is a well-defined poor enhancing lesion measuring 1.2 x 1 cm in the spleen. Please correlate with sonography and MRI.
    • There are few small ground-glass opacity on RLL of the lung that may be inflammatory process. please correlate with clinical condition and chest CT.
    • Compression fracture of T12 vertebral body. please correlate with clinical condition, old film, or MRI.
  • 2022-05-25 Chest PA
    • Ground glass opacity in right lung.
    • Normal appearance of trachea and bil. main bronchus.
    • Normal size of heart.
    • Intact bony structure(s).
  • 2022-05-25 Electrocardiography
    • Atrial fibrillation with rapid ventricular response
    • Nonspecific ST abnormality
• lab data
  • 2022-05-25
    • CRP 20.77 mg/dL
    • WBC 11.17 *10^3/uL
    • Neutrophil 82.9 %
    • urine Bacteria 3+
    • urine Sediment-WBC >=100
    • urine Leukocyte esterase 3+
  • 2022-05-17
    • Covid-19 confirmed

[assessment]

• Tachycardia remains evident (over 120 on 0222-05-26 morning) even under prescribed bisoprolol, with a faster breathing rate (22/min on 0222-05-25 morning) and without a high blood pressure (93/60 on 0222-05-26 04:42, this patient has HTN history). An analysis of blood gas might provide some insight into the underlying condition (sequelae of hypoventilation caused by Covid-19)?
• Lab results on 2022-05-25 revealed CRP 20.77 mg/dL, WBC 11.17 *10^3/uL, Neutrophil 82.9 %, urine Bacteria 3+, Sediment-WBC >=100, Leukocyte esterase 3+
• Bacterial infection is treated with Brosym (cefoperazone + sulbactam) 4g Q12H IVD since 2022-05-25. There is currently no culture outcome available.
• No issue with current medication. Please monitor the effects of ABX.

700588193

220525

• exam finding
  • 2022-06-01 CT - abdomen, pelvis
    • Findings:
      • There are multiple well-defined variable-sized thin wall cysts on both lung that is c/w lymphangiomyomatosis. In addition, mild right side Pleura effusion is noted.
      • There are three fatty masses on both hepatic lobes and the largest one measuring 1.8 cm in S4 that may be lipomas or angiomyolipomas.
      • Right kidney shows enlarged in size and multiple angiomyolipomas. S/P left nephrectomy? All of these findings are c/w tuberous sclerosis after correlate with prior MRI of brain.
      • S/P hysterectomy. There is ascites, multiple soft tissue lesions in the omentum and pelvis that is c/w carcinomatosis.
      • There are multiple osteoblastic change in the ribs, T-and L-spine vertebral body, sacrum, and bilateral ilium that are c/w bony metastases. In addition, There are multple enlarged nodes in para-aortic space and para-cava space that are c/w Multiple LNs metastases.
      • The urinary bladder shows small size (passive compression by the omentum tumor) and S/P suprapubic cystostomy.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, and spleen.
        
      • There is no bowel wall thickening, and no bowel obstruction.
        
      • The abdominal aorta and IVC are grossly unremarkable.
        
    • Impression:
      • Carcinomatosis, bone metastases, and Multiple LNs metastases in para-aortic space and para-cava space are noted.
  • 2022-05-30 KUB
    • Fecal material store in the colon.
    • Relative Increase soft tissue density projecting at right middle abdomen and left paracolic gutter space is suspected. Please correlate with sonography and CT.
    • S/P drainage catheter insertion from right pelvis and the tip projecting at the midline lower pelvis.
    • There are several osteoblastic lesions in the sacrum and bilateral ilium that may be bony metastases?
  • 2022-05-24 EKG
    • Normal sinus rhythm
    • T wave abnormality, consider inferior ischemia
    • Prolonged QT
  • 2022-04-19 Patho - uterus with or without SO non-neoplastic/prolapse
    • Uterus Endometrial Cancer Checklist
      
    • Diagnosis:
      • Uterus, endometrium, total hysterectomy — Large cell neuroendocrine carcinoma with focal small cell neuroendocrine carcinoma
        
      • Uterus, myometrium, total hysterectomy — Large cell neuroendocrine carcinoma with focal small cell neuroendocrine carcinoma, by direct invasion
        
      • Uterus, cervix, total hysterectomy — Large cell neuroendocrine carcinoma with focal small cell neuroendocrine carcinoma, by direct invasion
        
      • Ovary, right, oophorectomy — Neuroendocrine carcinoma, metastatic
      • Ovary, left, oophorectomy — Negative for malignancy
      • Fallopian tube, bilateral, salpingectomy — Negative for malignancy
      • Lymph node, left iliac, dissection — Neuroendocrine carcinoma, metastatic (2/5)
      • Lymph node, left obturator, dissection — Neuroendocrine carcinoma, metastatic (1/6)
      • Lymph node, right iliac, dissection — Negative for malignancy (0/3)
      • Lymph node, right obturator, dissection — Neuroendocrine carcinoma, metastatic (3/10)
      • Lymph node, left para-aortic, dissection — Negative for malignancy (0/1)
      • Lymph node, right para-aortic, dissection — Neuroendocrine carcinoma, metastatic (1/2)
      • Omentum, omentectomy — Neuroendocrine carcinoma, metastatic
      • Urinary bladder, partial cystectomy — The sections of urinary bladder show tumor invasion in muscular propria. The resection margin is involved by tumor.
      • AJCC 8th edition Pathology stage: pStage IVB, pT3bN2aM1; FIGO Stage: IVB
    • Microscopic Description:
      • Histologic Type: Large cell neuroendocrine carcinoma with focal small cell neuroendocrine carcinoma.
      • The immunohistochemical stains reveal CK(-), EMA(-), CD56(+), Synaptophysin(+), Chromogranin A(+), CD10(-), Cyclin D1(-), SMA(-), Desmin(-), h-Caldesmon(focal +), CD99(focal +), Melan A(-), a-inhibin(-).
      • Histologic Grade: Not available
        • FIGO Grading System applies to endometrioid carcinomas only. Serous, clear cell, transitional, small cell and large cell neuroendocrine carcinomas, undifferentiated/dedifferentiated carcinomas, and carcinosarcomas are generally considered to be high grade and it is not recommended to assign a histologic grade to these tumor types.)
      • Myometrial Invasion: present (whole thickness)
      • Uterine Serosa Involvement: Present
        
      • Cervical Stromal Involvement: Present
        
      • Other Tissue/ Organ Involvement: Right ovary, Parametrium, side not specified, Omentum
      • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
        • Ectocervical/Vaginal Cuff Margin: Free
          
        • Parametrial/Paracervical Margin: Not Free
      • Lymphovascular Invasion: Present
      • Regional Lymph Nodes: left iliac: 2/5; left obturator: 1/6; right iliac: 0/3; right obturator: 3/10; left para-aortic: 0/1; right para-aortic: 1/2
        
      • Additional Pathologic Findings: Metastatic tumors, measuring up to 0.1 x 0.1 cm, are seen in omentum.
  • 2022-04-19 Ascites
    • Diagnosis: Positive for malignancy
    • Microscopic description: Many small clusters of neoplastic cells present.
  • 2022-04-19 Frozen section
    • Preliminary diagnosis: Uterus, corpus, biopsy — malignant tumor (round blue cell tumor), wait immunohistochemical stains for final diagnosis
  • 2022-04-07 Gynecologic ultrasonography
    • Pelvis mass suspected uterine myoma degeneration (uterine pain), sized 9.57X8.34 cm
  • 2022-02-16 Peripheral Vascular Test: AV fistula
    • Access type:AV fistula
    • Site:left forearm
    • Clinical problem:maturation evaluation
    • Age of vascular access: 6 weeks
    • Result: S/P left radiocephalic AV fistula, VF at inflow radial artery (diameter 3.5mm) 313-403 ml/min, inflow anastomotic diameter 8.2mm(wide patent), juxta-anastomotic cephalic vein diameter 4.8 - 4.6 - 3.3 mm, proposed A-puncture site cephalic vein diameter 5.5mm (depth 3.1mm), continuous forearm cephalic vein, proposed elbow V-puncture site cephalic vein diameter 5.5mm (depth 3.2mm), cubital vein 6.6mm, patent cubitocephalic vein with upperarm cephalic vein diameter 6.8mm and PS 42 cm/s, discontinuity between cubital and upper arm basilic vein, continuous flow pattern over draining cephalosubclavian vein indicating no overt outflow obstruction
    • Recommendation
      • Borderline maturation of left radiocephalic AV fistula, may start to use as dialysis access sited
      • Keep on gripping exercise
    • Suggestion: Clinical follow up
  • 2021-12-23 2D transthoracic echocardiography
    • Dilated LA and LV; Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy
    • Minimal pericardiac effusion
    • Mild MR, moderate TR
    • Mild pulmonary hypertension
    • Preserved RV systolic function
  • 2021-11-25 MRA - brain
    • Findings
      • Multiple subcortical T2- and FLAIR-hyperintensities in bilateral cerebral hemispheres. suspected cortical tubers,
      • Multiple nodualr lesions along walls of lateral ventricles.
    • IMP: Tuberous sclerosis.
  • 2021-10-22 SONO Renal
    • Left kidney, absent s/p nephrectomy.
    • Right multiple renal tumors, c/w angiomyolipomas.
    • Liver tumor, ( 1.3cm) , suspected hemangioma.
• lab data
  • 2022-06-06 Urine Culture - micturition
    • Trichosporon asahii - colony count > 100,000 CFU/cc
  • 2022-05-28 Urine Culture - catheterization
    • Staphylococcus aureus - colony count 2,000 CFU/cc
    • Antibiotic SIR MIC(mcg/mL)
      • Oxacillin S 0.5
      • Penicillin R >=0.5
      • Vancomycin S 1
      • Linezolid S 2
      • Tetracycline S <=1
      • Moxifloxacin S <=0.25
      • Trimethoprim/Sulfamethoxazo S <=10
      • Gentamicin S <=0.5
      • Ciprofloxacin S <=0.5
      • Tigecycline S <=0.12
  • 2022-04-21 VRE Culture - anal swab
    • No VRE
  • 2022-04-21 CRE Culture - anal swab
    • No CRE
• surgical operation
  • 2022-04-18
    • Surgery
      • Diagnosis: Uterine malignancy with severe abdominal wall adhesion and bladder invansion
      • Frozen section: Uterus, corpus, biopsy — malignant tumor (round blue cell tumor), wait immunohistochemical stains for final diagnosis
      • Operation:
        • Debulking surgery
        • Adhesiolysis     - Finding
      • Uterus: Multiple papillary lesion over the uterine surface and invansive to the posterior bladder wall
      • Frozen section: Uterus, corpus, biopsy — malignant tumor (round blue cell tumor), wait immunohistochemical stains for final diagnosis
      • Bilateral adnexa: grossly normal
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • CDS: moderate bloody ascites, about 500 ml, sent for cytology
      • Severe adhesion between omentum and abdominal peritoneum, s/p adhesiolysis
      • Severe adhesion between posterior bladder wall and uterus, and malignant invasion of the uterus to bladder, s/p partial cystectomy by urologic surgeon.
      • Omentum: multiple hard, variablesized nodules (5~20 mm in diameter) infracolic omentectomy was done.
      • Liver: grossly normal & smooth
      • Appendix: grossly normal
  • 2022-04-18
    • Surgery: partial cystectomy
    • Finding: uterus tumor with bladder invasion over dome and posterior wall
  • 2022-01-13
    • Surgery
      • Long-term hemodialysis catheter implantation via right IJV
      • Intraoperative sonography
    • Finding
      • Sonographic localization of right IJV
      • C-arm fluoroscopic confirmation of catheter tip
      • Free blood withdrawal of A/V routes
  • 2021-12-23
    • Surgery
      • Left radiocephalic AV fistula creation
      • Intraoperative sonography
    • Finding
      • Moderate-sized cephalic vein with continuity to elbow, small radial artery
      • S/P left AV fistula, thrill(++)

[assessment]

• Micturition urine culture (2022-06-06) found Trichosporon asahii colony count > 100,000 CFU/cc which is treated with teicoplanin currently.
• Vomit OB 3+ (2022-06-06) which is being treated with pantoprazole.
• RBC 2.84 *10^6/uL, HGB 7.5 g/dL (2022-06-06), anemia is treated with Recormon epoetin beta 5000 unit SC QW5, LPRBC is also prepared.

700526699

220524

700526699

{drug identification}

Total 14 drugs for identification.

The 10 identified items has been shown as following while the other 4 items still remain unknown:

• Musco (ambroxol hydrochloride 30mg)
• Viartril-S (glucosamine sulfate, polycrystalline 314mg)
• Madopar (levodopa 100mg, benserazide 25mg)
• MgO (magnesium oxide 250mg)
• Merislon (betahistine 6mg)
• Evoxac (cevimeline 30mg)
• Clopid (clopidogrel hydrogen sulphate 97.875mg)
• Rivotril (clonazepam 2mg)
• Xanax (alprazolam 0.25mg)
• Solaxin (chlorzoxazone 200mg)

These drugs will be sent back to ward by the in-hospital porter.

701240441

220523

{upper GI bleeding}

• exam finding
  • 2022-05-22 CT - abdoemn, pelvis
    • Without contrast Abdomen CT showed unremarkable change in the organs
  • 2022-05-04 CT - abdomen, pelvis
    • . Please correlate with gastroscopy.
    • Adenomas in bilateral adrenal gland.
  • 2022-05-04 Electrocardiography
    • Normal sinus rhythm
    • Left ventricular hypertrophy with repolarization abnormality
    • Prolonged QT
  • 2022-05-04 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • No active bleeder nor coffee ground material was noted during this exam.
      • Suboptimal study due to patient’s inability to tolerate the procedure
      • Reflux esophagitis LA Classification grade B
      • Ulcerative mucosa, lower esophagus
      • Superficial gastritis
    • Suggestion：
      • Suggest repeat endoscopy for esophageal ulcer biopsy and detailed examination later
  • 2021-05-14 Abdominal Ultrasonography
    • Diagnosis
      • Negative finding
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
• Lab data
  • 2022-05-22
    • gastric juice Clarity Turbid
    • gastric juice Color Brown
    • gastric juice OB 3+
    • Bilirubin total 1.09mg/dL
    • WBC DC 94%
    • CRP 1.3mg/dL
    • K 2.7mmol/L
    • serum Glucose 154mg/dL
    • WBC 11.1*10^3/uL
  • 2021-05-13 ( Hepatitis B FAQ https://www.immunize.org/catg.d/p4090.pdf )
    • HBsAg Reactive 4431.01
    • Anti-HBc Reactive, 7.6
    • Anti-HBs 0
    • Anti-HCV Nonreactive, 0.05

[assessment]

• TPR, BP were all within normal limits during this hospitalization, however, gastric juice OB 3+, slightly elevated Bilirubin total, WBC, WBC DC, CRP and serum Glucose were recorded on 2022-05-23.
• EGD was performed on 2022-05-04 and no active bleeding was observed (in a suboptimal condition). There might be a need for a re-endoscopy. CT on 2022-05-04 showed sliding hiatus hernia. Patients with documented pathologic acid reflux who have complete or partial response to proton pump inhibitors (PPIs) are good candidates for one of the antireflux procedures. The choice of procedure depends on whether a clinically significant hiatal hernia is present. ( https://www.uptodate.com/contents/hiatus-hernia )
• Presently, the patient is rehydrated, receiving appropriate dose of PPI, and receiving potassium gluconate for his low potassium level accordingly. All the oral drugs in active prescription can be administered with nasogasric tube. No issue with current medication.

700340565

220520

{small bowel ileus}

[assessment]

• This patient is diagnosed with small bowel ileus and had past history of colon cancer in situ s/p OP, inguinal hernia s/p OP.
• Small bowel obstruction can be functional or mechanical, the latter is caused by intraluminal or extraluminal mechanical compression. In developed countries, adhesion is the most common cause, followed by hernias, malignancies, and various other infectious and inflammatory disorders.
• TPR 36.2/63/18, BP 122/52 (2022-05-20 05:35), WBC 7.37*10^3/uL, Neutrophil 93.1%, CRP 1.75mg/dL (2022-05-19)
• Currently, no fever, tachycardia, hypotension, or altered mental state have been observed. If any of these systemic signs develop, additional laboratory testing may include: Arterial blood gas, serum lactate, blood culture, and procalcitonin.
• The basic plain radiographic examination should include an upright chest film and upright and supine abdominal films, abdomen - standing (diaphragm) has been scheduled on 2022-05-20. CT of the abdomen could also be helpful, however, due to the low renal function, contrast might be contraindicated.
• The patient is currently rehydrated and using laxatives to stimulate the intestinal lining. His underlying diseases (AF, HTN, CKD) are treated with corresponding self-carried drugs.
• No issue with active prescription.

700900778

220520

• exam finding
  • 2022-05-04 CT - abdomen, pelvis
    • Recurrent HCCs in left hepatic lobe S/P treatment show stable disease.
  • 2022-02-15 CT - abdomen, pelvis
    • Progression of HCCs and portal venous thrombosis. Progression.
  • 2022-01-24 CT - lung/mediastinum/pleura
    • no abnormality in both lungs or central airways for the cause of hemoptysis.
  • 2022-01-11 CT - liver, spleen, biliary duct, pancreas
    • Recurrent HCCs and portal venous thrombosis. Progression.
  • 2022-01-05 Abdominal Ultrasonography
    • Diagnosis
      • Cirrhosis of liver
      • Liver tumor, S3, S6, suspicious newly lesion
      • liver tumor, S4, suspicious HCC post TACE or RFA effect, suspected viable tumor
    • Suggestion
      • arrange liver dynamic CT
  • 2021-07-30 CT - abdomen
    • Recurrent HCC 7.17 x 4.61 cm in S3/4 liver is suspected.
    • The differential diagnosis include cholangiocarcioma.
    • Please correlate with tumor marker, MRI, or biopsy.
  • 2021-07-28 Abdominal Ultrasonography
    • Diagnosis
      • HCC post segment 6, 7, 8, segmental hepatectomy
      • HCC post RFA with viable HCC s/p TACE
      • Liver cirrhosis
      • Liver cyst
      • GB sludge?
      • Fatty liver, mild
      • Fatty pancreas
    • Suggestion
      • Please correlate with other image studies
      • Please arrange CT or MRI
  • 2021-06-18 MRI = liver, spleen
    • Recurrent HCC 2.8 x 2.3 cm in S2/3 liver is highly suspected.
  • 2021-03-24 CT - abdomen
    • Recurrent HCC 2.2 cm in S3 liver is highly suspected.
    • The differential diagnosis include cholangiocarcioma.
    • Please correlate with tumor marker and MRI.
  • 2021-01-11 MRI - liver, spleen
    • HCC s/p RFA without viable tumor.
  • 2020-10-21 MRI - liver, spleen
    • HCC in S4 S/P RFA shows complete response.
  • 2020-06-20 CT - abdomen
    • HCC s/p RFA and Op. No evidence of recurrent HCC in the study
    • Calcified coronary arteries is found.
  • 2020-05-05 CT - abdomen
    • Post-op at right lobe liver, developed washout nodule, 1.17cm in S8/4 region, r/o recurrent HCC.
    • Liver cyst.
    • Ascending colon diverticula.
  • 2019-11-05 CT - abdomen
    • Post-op at right lobe liver, focal low density along the surgical margin, regression.
    • Liver cyst.
    • Ascending colon diverticula.
  • 2019-05-14 CT - abdomen
    • S/P surgical resection S5/6/7 and part of S3 of the liver.
    • There is no evidence of tumor recurrence.
    • A hepatic cyst 2.1 cm in S3.
  • 2019-03-26 Surgical pathology Level V
    • pathologic diagnosis
      • Liver, S3, partial hepatectomy — Hepatocellular carcinoma, recurrent
        
      • Pathologic Staging (AJCC): Stage II at least (rpT2Nx(cMx))
    • microscopic examination
      • Histologic Type: Hepatocellular carcinoma
        
      • Histologic Grade: GIII (Poorly differentiated)
        
      • Cytological grade: Ⅲ
        
      • Tumor necrosis: Absent
        
      • Inflammatory cell infiltration: Moderate
        
      • Tumor capsule: Encapsulated with focal infiltrative border
        
      • Satellite nodule: Absent
        
      • Venous (Large Vessel) Invasion: Absent
        
      • Portal Vein Thrombosis: (-)；Capsular vein invasion: (-)
        
      • Perineural Invasion: Not identified
        
      • Bile duct Invasion: Absent
        
      • Pathologic Staging (rpTNM): Stage II at least (rpT2Nx(cMx))
        
      • Margins
        • Parenchymal Margin: Uninvolved by invasive carcinoma, 0.5 cm from closest margin
          
        • Hepatic capsule: Uninvolved by invasive carcinoma
          
      • Additional Pathologic Findings: Focal fatty change in tumor cells and large cell dysplasia
      • Hepatitis: Hepatitis B
        
      • Ishak Modified HAI Grading: Score=4 (interphase hepatitis=1/4, confluent necrosis=0/6, focal necrosis=1/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
        
      • Ishak Staging: F4 (Corresponding Metavir F3, septal fibrosis)
      • Fatty Change: Present (10%)
        
  • 2019-03-26 Surgical pathology Level V
    • pathologic diagnosis
      • Liver, S7, partial hepatectomy — Hepatocellular carcinoma, recurrent
        
      • Pathologic Staging (AJCC): Stage II at least (rpT2Nx(cMx))
    • microscopic examination
      • Histologic Type: Hepatocellular carcinoma
        
      • Histologic Grade: GIII (Poorly differentiated)
        
      • Cytological grade: Ⅲ
        
      • Tumor necrosis: Mild
        
      • Inflammatory cell infiltration: Moderate
        
      • Tumor capsule: Encapsulated with focal infiltrative border
        
      • Satellite nodule: Absent
        
      • Venous (Large Vessel) Invasion: Absent
        
      • Portal Vein Thrombosis: (-)；Capsular vein invasion: (+)
        
      • Perineural Invasion: Not identified
        
      • Bile duct Invasion: Absent
        
      • Pathologic Staging (rpTNM): Stage II at least (rpT2Nx(cMx))
        
      • Margins
        • Parenchymal Margin: Uninvolved by invasive carcinoma, 0.8 cm from closest margin
          
        • Hepatic capsule: Uninvolved by invasive carcinoma
          
      • Additional Pathologic Findings: Fatty change in tumor cells and Large cell dysplasia
      • Hepatitis: Hepatitis B
        
      • Ishak Modified HAI Grading: Score=4 (interphase hepatitis=1/4, confluent necrosis=0/6, focal necrosis=1/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
        
      • Ishak Staging: F4 (Corresponding Metavir F3, septal fibrosis)
        
      • Fatty Change: Present (10%)
        
  • 2019-03-22 Visceral Angiography 2 vessels
    • IMP: Bil. liver tumors suspected recurrent HCCs
  • 2019-03-08 MRI - abdomen
    • Hepatoma measuring 2.1 cm in S3 of the liver is first impressed.
      
    • Please correlate with clinical condition and AFP.
      
    • According to AJCC staging system,8th edition, CT staging of HCC:T1N0Mx
  • 2018-06-19 CT - abdomen
    • HCC, s/p segmental hepatectomy
    • No evidence of local recurrence
  • 2018-01-11 Surgical pathology Level V
    • pathologic diagnosis
      • Liver, segment 6, 7, 8, segmental hepatectomy — Hepatocellular carcinoma
        
      • Pathologic Staging (AJCC): Stage II (pT2Nx(cMx)
  • 2018-01-05 Visceral Angiography 2 vessels
    • Right liver tumor suspected HCC as described. Another small perfusion defect (5mm) at right hepatic lobe.
  • 2017-12-13 CT - abdomen
    • Imaging Report Form for Hepatocellular Carcinoma
      • A poor enhancing tumor (4.6cm) in S7 of liver suspected hypovascular HCC.
      • Hepatocellular carcinoma (T1N0Mx, radiology staging: stage I)
• surgical operation
  • 2021-05-14 Radiofrequency ablation
    • Course: By sono-guided, RFA probe (COVUDIEN Cool-tip ACT 2030, 17 Fr) was inserted into the S4/5 tumor with whiteout appearance. (stop after 2 pauses)
    • Time:
      • 1st (inf part) 5:56, Power (Max100- Min60); Impedance (Max100- Min65); cool time 4:32, temp: 76C
      • 2nd (sup part) 4:32, Power (Max 90- Min60); Impedance (Max95- Min65); cool time 3:08, temp: 75C
    • Findings: HCC post RFA
  • 2020-05-29 Radiofrequency ablation
    • Course: By sono-guided, RFA probe (COVUDIEN Cool-tip ACT 2020, 17 Fr) was inserted into the S4/8 tumor with whiteout appearance. (stop after 1 pause)
    • Time: total 6:11; Power (Max80- Min60); Impedance (Max125- Min85)
    • Findings: HCC post RFA
  • 2019-03-25 Partial hepatectomy
    • Finding
      • rcurrent S3 tumor 2.0 x 1.2 x 1.2 cm
      • S7 tumor 2.5 x 2.0 x 2.0 cm
      • mild fibrosis
  • 2018-01-10 Segemental hepatectomy-three segement
    • Finding
      • 4.2 x 3.5 x 3.0 cm hepatic tumor at S6-7-8
      • small nodule at S6 suspected FNH or small HCC
• chemoimmunotherapy
  • 2022-03-11 ~ undergoing - FOLFOX
  • 2022-01-25 - atezolizumab + bevacizumab
  • 2021-05-12 ~ 2021-08-16 - nivolumab
  • 2019-04-23 ~ 2019-07-02 - sorafenib

[assessment]

• Under the current regimen, the recurrent HCC in the left hepatic lobe was stable on a recent CT (20202-05-04).
• No issue with active prescription.

701000332

220518

{Vulvar Cancer}

[exam findings]

• 2023-05-11 CXR

  • Ground glass opacities in bil. lungs.

• 2023-05-02 CXR

  • Rt subpulmonary effusion
  • patchy bilateral areas of consolidation and ground-glass opacities as well as reticular opacities over both lungs
  • Osteoblastic metastasis in spine and ribs

• 2023-04-26 MRA - brain

  • Clinical information: Multiple lung metastases from carcinoma of the vulva, s/p excision, s/p simple vulvectomy, rcT1b(cN0)M1, stage IVB
  • Findings:
    • Scattered numerous enhancing nodular lesions over whole cerebrum and cerebellum. The largest one (2.6cm) over left cerebellar lobe. Favor metastases.
    • Multifocal peritumoral edema over cerebral hemispheres and left cerebellar lobe.
    • MR angiography of the brain shows normal intracranial vessel including circle of willis.

• 2023-04-07 CT - abdomen

  • Indication and History
    • Vulvar ca with lung and bone met status
    • Skull palpable mass (20201002) which grew up for 6 months -> improved after RT and chemo (20210105)
    • asks for follow up myoma due to she feels vulvar discomfort of rt vulvar tumor.
  • Findings:
    • There is IHDs dilatation and an ill-defined equivocal poor enhancing lesion 1 cm in S2 of the liver. Please correlate with MRI.
    • There are multiple osteoblastic change of the T-spine and L-spine that are c/w osteoblastic bony metastases.
    • Right side Pleura effusion
    • The gallbladder shows small contracted.
  • Impression:
    • There is IHDs dilatation and an ill-defined equivocal poor enhancing lesion 1 cm in S2 of the liver. Please correlate with MRI.
    • There are multiple osteoblastic change of the T-spine and L-spine that are c/w osteoblastic bony metastases.

• 2023-02-24 Tc-99m MDP bone scan with SPECT

  • The Tc-99m MDP bone scan with SPECT 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the skull, both rib cages, multiple C-, T- and L-spines, sternum, left sternocalvicular junction, left S-I joint and left femoral shaft, in whole body survey.
  • IMPRESSION: In comparison with the previous study on 2021/08/09, some new bone lesions are noted and most of the previous bone lesions are more evident, indicating multiple bone metastases in progression.

• 2023-02-22 Skull PA + Lat.

  • Several small nodular defects in the skull are suspected. please correlate with clinical condition or CT.

• 2023-02-02 SONO - chest

  • pleural effusion, but only trivial amounts
  • right side.

• 2023-01-31 Mammography

  • Screening digital mammography of both breasts with MLO and CC views:
    • Old mammographic study: 2021-01-15 (BIRADS 1)
    • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
  • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative. - annual screening.

• 2022-12-29 CT - abdomen

  • History and indication: Multiple lung metastases from carcinoma of the vulva, s/p excision, s/p simple vulvectomy, rcT1b(cN0)M1, stage IVB
  • With and without-contrast CT of abdomen-pelvis revealed:
    • S/P operation.
    • Multiple bony metastases.
    • A patchy density (3.2cm) at RUL. Right pleural effusion.
    • Retroversion of uterus. A tumor (3.0cm) at uterus.
  • Impression:
    • S/P operation.
    • Multiple bony metastases.
    • A patchy density (3.2cm) at RUL. Right pleural effusion.

• 2023-03-19, -03-10, -02-05, -01-15, 2022-10-28, -10-25, -09-27, -09-22, -08-22, -06-24 CXR

  • S/P metalic autosuture projecting at right upper lung zone.
  • Few nodular opacity projecting in right lung are suspected. Please correlate with CT.
  • Right diaphragmatic tenting is noted, which may be due to lung volume decrease of RUL.
  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • Osteoblastic change of right upper ribs are suspected that are compatible with bony metastases after correlate with CT.

• 2022-09-06 CT - abdomen

  • Clinical vulva cancer.
  • Sclerotic densities in the bones, suspected bone metastasis.
  • Uterine tumor, suspected uterine myoma.
  • Regression of left lobe liver hypodense lesions.
  • Bilateral pleural effusion, more prominent at right side.
  • Consolidations in right lower lung.
  • Fibrotic infiltrates in RUL.

• 2022-08-16 Gynecologic ultrasonography

  • LT adnexae: free
  • Uterine myoma

• 2022-07-05 Laryngoscopy

  • Findings
    • bi nasopharynx smooth, hypopharynx smooth mucosa, normal vocal function, right vocal cord anterior part edema,
  • Conclusion
    • chronic corditis
    • no evidence of vocal palsy

• 2022-06-16 Neurosonology

  • Normal vessel wall in bilateral extracranial carotid arteries.
  • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
  • Poor left temporal windows for transcranial insonation.

• 2022-06-16 Brainstem Auditory Evoked Potentials, BAEP

  • Findings
    • Normal absolute and inter-peak interval latencies of brainstem auditory evoked potentials from both ear.
  • Conclusion
    • Normal BAEP.

• 2022-06-15 MRI - brain

  • mild dilated intraventricular and extraventricular CSF spaces
  • punctate white matter gliosis in the bilateral frontal, parietal and parietal lobes; old lacunar infarction in the pons.
  • unremarkable change in the skull base
  • no abnormal brain parenchymal enhancement.

• 2022-06-02 CT - lung/mediastinum/pleura

  • Finding
    • Chest
      • Septal infiltration and peribronchovascular bundle infiltration is found at residual lung fields. In comparison with CT dated on 2022-02-23, the lesion is stationary.
      • Bilateral hilar and mediastinal lymphadenopathy is found.
      • Patent airway is found.
      • S/p port-A placement with its tip at Superior vena cava.
      • Right pleural effusion is found.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Visible abdomen:
      • Increased intestinal gas is found.
      • Low density lesion at left lobe liver is found, causing left IHD focal dilatation. Stable.
      • The spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
  • Imp: Compatible with bilateral lung mets, liver and bone meta with stationary tumor extension.

• 2022-05-24 Gynecologic ultrasonography

  • Uterine myoma

• 2022-04-08 Chest XR

  • S/P port-A implantation.
  • S/P metalic autosuture projecting at right upper lung zone.
  • Few nodular opacity projecting in right lung are suspected. Please correlate with CT.
  • Fibrosis at right upper lung is noted. Please correlate with clinical history and CT.
  • Right diaphragmatic tenting and right hilum elevation is noted, which may be due to lung volume decrease of RUL.
  • Osteoblastic change of right upper ribs are suspected that are compatible with bony metastases after correlate with CT.

• 2022-03-14 Laryngoscopy

  • subacute corditis, improved with vocal cord fibrotic change
  • no evidence of vocal palsy

• 2022-03-11 Chest XR

  • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?

• 2022-03-01 Gynecologic ultrasonography

  • Uterine myoma

• 2022-02-23 CT - lung/mediastinum/pleura

  • Multiple lung metastases from carcinoma of the vulva, s/p excision, s/p simple vulvectomy, rcT1b(cN0)M1, stage IVB
  • comparison made with previous CT dated on 2021/11/06
    • Lungs
      • stationary of metastatic nodules and septal and peribronchovascular interstial thickening in both lungs (most severe at RUL and LLL)
      • stationary of metastatic lymphadenopathy in Rt precarinal space and both hila
    • Vessels:
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch.
      • Central pulmonary arteries: normal caliber.
    • Heart: normal in size of cardiac chambers.
    • Pleura: bilateral pleural effusions and scattered Rt upper pleural thickening.
    • Chest wall: small LNs in left supraclavicular fossa
    • Visible abdominal contents:
      • several poorly enhanced areas in peripheral S6 and left lobe of liver, stable.
      • normal appearance of gallbladder.
        
      • unremarkable of the spleen, adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no onvious ascites.
    • Visualized bones: blastic metastatic change in multiple vertebrae, sternum, and ribs, stable.
  • Impression:
    • stationary metastatic lung, liver, bony lesions, and LAPs in mediastinum and hila, as compared with CT dated on 2021/11/06

• 2022-01-17 Laryngoscopy

  • acute corditis, maybe related to previous Foster use
  • no evidence of vocal palsy

• 2022-01-03 Laryngoscopy

  • acute corditis, maybe related to previous Foster use or chemotherapy
  • no evidence of vocal palsy

• 2021-11-06 CT - lung/mediastinum/pleura

  • Compatible with vulva cancer with left lower lobe lung meta. In progression.
  • Mediastinal lymphadenopathy, stable
  • Liver and adrenal meta. In progression.
  • Bone meta. stationary.

• 2021-10-26 Bronchodilator test

  • FVC: 50%, FEV1: 44%, FEV1/FVC: 72%.
  • negative bronchodilator test.

• 2021-08-09 Tc-99m MDP whole body bone scan

  • The Tc-99m MDP bone scan with SPECT 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the left parietal region of the skull, both rib cages, multiple C-, T- and L-spine, sternum, left sternocalvicular junction, upper portion of left S-I joint and left femoral shaft, in whole body survey.
  • Impression: In comparison with the previous study on 2021/04/09, all lesions are old and show less evident, indicating multiple bone metastases with partial response to current therapy.

• 2021-07-19 CT - lung/mediastinum/pleura

  • regression metastatic lung lesions and LAPs in mediastinum and hila, but progression of bony metastasis compared with Ct on 2021/04/15.

• 2021-04-09 Patho

  • Skin, left post-auricular, excision - poorly differentiated carcinoma, metastatic.
  • IHC: ER positive (strong, >95%), PR: positive (moderate, 90%), CK20(-), P40(-), CEA(+).

• 2021-02-25 Patho

  • scalp metastatic cancer nodule
  • IHC: CD56(-), GATA-3(+), mamoglobin(focal +). The pattern is the same as those of S2019-15699/S2019-15746.

• 2021-01-29 MRA - Brain

  • A newly developed left cerebellar metastasis.
  • Marked regression of the left parietal skull and scalp metastasis.
  • Brain atrophy and leukoaraiosis.

• 2021-01-13 CT

  • metastasis 1.2cm in S2 liver is suspected.
  • there are three soft tissue nodules in left diaphragm.

• 2020-10-28 Tc-99m MDP whole body bone scan

  • Suspected Ca with multiple bone mets in the left parietal region of the skull, both rib cages, some T- and L-spine, and left femoral shaft, M/3.
  • Suspected benign lesions in C-spine, maxilla, mandible, bilateral sternocalvicular nctions, shoulders, elbows, knees, and right foot.

• 2020-10-21 CT

  • newly developed T3 vertebral metastasis.

• 2020-07-06 MRI - Brain

  • Left parietal scalp, skull metastasis with intracranial extension.

• 2020-07-03 CT

  • post operative change at right upper lobe with pleural thickening, in progression.
  • recurrent pleural meta is favored.

• 2019-09-18 Patho

  • Lung, right, upper, middle, lower lobe, wedge resection - poorly differentiated carcinoma, metastatic.
  • Histologic Type: carcinoma, The morphology is consistent with S2017-19644.
  • IHC: GATA3(+), Mammaglobin A(focal +), ER(+, 100%), PR(+, 20%), HER-2/Neu(Ab): Negative (1+), PAX8(-), p63(-), Uroplakin II(-), CK5/6(-), Chromogranin A(-), CD56(-), and TTF-1(-). The Ki-67 is about 40%. The results are most compatible with breast origin.

• 2019-09-05 CT: multiple lung nodules, favor metastatic lesions.

• 2019-06-03 CT: uterine myoma is suspected.

• 2017-12-13 CT: a 3.0cm tumor at uterus.

• 2017-11-28 Patho

  • Right vulva, excision biopsy - Carcinoma, margin positive.
  • IHC: GATA-3(+), GCDFP-15(-), CK7(+), CK20(-), p40(-), p16(focal +), HMB-45(-).

[consultation]

• 2023-05-15 Family Medicine
  • Q
    • The 64 y/o woman has vulva cancer with mulitple lung and brain mets /p chemotherapy and under RT. Due to con’s disturbance with V/S unstable, so we need your help for hospice care. Thanks!
  • A
    • 64-year-old female, DM, HTN, dyslipidemia
      • Vulva cancer with mulitple lung and brain metastasis s/p chemotherapy, under radiotherapy
      • This time suffer from alteration of consciousness
      • Consciousness E3V3M5, ECOG 4
      • Advance Care Planning Document” or “Advance Directive.” (+)
      • We will arrange hospice combine care and follow up her condition
      • Consider hospice ward if families agreed with palliative treatment
      • Thanks for your consultation.
• 2023-04-26 Radiation Oncology
  • A
    • A: Carcinoma of the vulva, right aspect, s/p excision, with positive margin, s/p simple vulvectomy, stage pT1b(cN0M0), s/p radiotherapy, with lung metastastases, s/p operation (thoracoscopic segmentectomy of lung, thorecoscopic excision of mediastinal tumor, thoracoscopic wedge or partial resection of the Lung), and s/p chemotherapy, with left parietal scalp and skull metastasis, s/p chemotherapy and radiotherapy, and status during chemotherapy, with multiple brain metastases.
    • P: Radiotherapy is indicated for this patient with the following indicators: multiple brain metastases.
      • Goal: palliation
      • Treatment target and volume: metastatic brain lesions
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 2400cGy/12 fractions of the metastatic brain lesions
      • The patient already received radiotherapy before. The treatment modality and the possible effects of re-irradiation were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0930, 2023-05-03.
• 2023-04-24 Neurology
  • Q
    • She was admitted for chemotherapy on 4/24,but according to family, she began to repetitively chew with her mouth and slurred speech was noted for one week, suspect parkinson’s disease.
    • We need your expertise for further management, thanks
  • A
    • repeated praying in the morning 1 week ago, vertigo in these days
    • NE: aware, fluent speech, chewing of mouth, suspect right visual hemineglect, left side weakness and dysmetria
      • with equivocal left Babinski signs
    • Impression:
      • suspect recurrent brain metastasis and encephalopathy
    • Suggest:
      • brain MRA with contrast might be arranged
      • I would like to follow up this patient. Thank you for your consultation.
• 2022-06-13 Neurology
  • Q
    • The 63 y/o woman has Multiple lung metastases from carcinoma of the vulva, s/p excision, s/p simple vulvectomy, rcT1b(cN0)M1, stage IVB. She has dizziness progress in recently days. Anemia, but no SOB or tachycardia condition, so we need your help for dizziness management. Thanks!
  • A
    • This is a 63 y/o woman with history of vulvar carcinoma with multiple lung metastases and cerebellar metastasis, s/p excision, s/p simple vulvectomy, rcT1b(cN0)M1, stage IVB. She complained positional dizziness and vertigo sensation while lying down for one week. Anemia was also noted. Piracetam and betahistin were prescibed since 20220610. She felt better after taking betahistin. She denied focal weakness, unsteady gait, falling, nausea, vomiting, headache, tinnitus, and hearing impairment.
    • NE
      • GCS: E4V5M6
        -VF: no hemianopia -light reflex: 3/3 +/+ -EOM: free and full -no facial palsy
        -Muscle power:
        -RUE/LUE: 5/5 -RLE/LLE: 5/5 -Babinki: plantar/plantar -Sensory: intact and symmetric -FNF: np dysmetria -HKS: no dysmetria -Gait: narrow base, steady -Tandem gait: no falling.
    • Exam
      • 2021/01/29 brain MRI: left cerebellar metastasis
      • 2022/06/12 Hb:8.9
    • Assessment
      • central vertigo, suspected brain metastasis, suspected VBI (Vertebrobasilar insufficiency)
    • Suggestion
      • arrange brain MRI with/without contrast to r/o new brain metastasis.
      • arrange carotid-duplex, BAEP.
      • Keep current Nilasen 1 tab BID.
• 2022-01-25 Oral and Maxillofacial Surgery
  • Q
    • The 63 y/o woman has Multiple lung metastases from carcinoma of the vulva, s/p excision, s/p simple vulvectomy ,rcT1b(cN0)M1,stage IVB. She received chemotherapy on 1/25-1/27.
    • Due to complicated extraction of tooth 24, we need your help for removed stitches on 1/27.
  • A
    • We had removed stitches of oral cavity were done.
    • Education home care.
• 2021-04-29 Neurosurgery
  • Q
    • For suspect radiculopathy due to bone metastasis of spine
    • A case of vulvar carcinoma with lung, liver and bone metastases in progression
    • This 62 y/o woman with DM, cerebral vascular calcification, left breast benign neoplam s/p excision, right vulvar carcinoma s/p vulvectomy on 2018/01/15. She also received chemtherapy, immunotherapy Opdivo. However, the disease still progressed. CT in March showing mediastinal LN, lung, liver and bone metastases in progression. This time, She was admitted for salvage treatment.
    • Right shoulder and arm pain was complained. Bone scan on 2021/04/09 revealed increased activity in the left parietal region of the skull, both rib cages, multiple C-, T- and L-spine, sternum, left sternocalvicular junction, upper portion of left S-I joint and left femoral shaft in whole body survey.
    • Due to bone mets of spine noted, we need your expertise for whether there’s rediculopathy due to bone meta of spine and further management suggestion.
  • A
    • We areconsulted due to bone metastasis (spine).
    • Suggest conservative treatment (medication) first.
    • Surgical intervention is not recommended at present.
    • C-spine MRI with may be arranged if the sign of radiculomyelopathy worsening.
• 2020-11-20 Oral and Maxillofacial Surgery
  • A
    • Due to we need do the XGEVA, so we need your help for management.
  • Q
    • This is a 62 female suffer from tooth pain over lower left jaw for a while.
    • S: She complain tooth pain when drinking water.
      
    • O: 45: cervical abrasion without pulp exposed, EPT(+), Cold test(+), lingering pain(?)(patient can not distingulish), percussion(-), palpation(-) probing WNL.
    • A: tooth 45 pulpitis
    • P:
      • Take dental Pano film and physical examination for evaluation.
      • Explain the finding and treatment plan to the patient.
      • Suggest desensitization toothpast first
      • OPD for 45 OD or endodontic treatment if irriversable pulpitis occur. Do not need to extraction at this moment.

[surgical operation]

• 2021-04-08 Excision of left post-auricular tumor
• 2021-02-25 Excision of scalp tumor
• 2018-01-15 Vulvectomy
• 2017-11-28 Excision of right upper vulvar major

[chemoimmunotherapy]

• 2023-03-20 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-02-22 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-02-06 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2023-01-15 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

  • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

• 2022-12-26 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

• 2022-11-25 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

• 2022-11-04 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

• 2022-10-13 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

• 2022-09-27 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

• 2022-09-05 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3850mg 46hr

• 2022-08-22 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

• 2022-07-29 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

• 2022-07-13 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

• 2022-06-28 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

• 2022-06-15 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3790mg 46hr

• 2022-05-30 - irinotecan liposome 70mg/m2 90mg 1.5hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr

• 2022-05-06 - irinotecan liposome 70mg/m2 90mg 1.5hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr

• XXXX

• 2021-12-27 ~ undergoing - Onivyde (irinotecan liposome) + FL

• 2021-04-28 ~ 2021-12-03 - FOLFOX + Bevacizumab

• 2020-11-24 ~ 2021-04-06 - Nivolumab

• 2020-10-02 -

• 2020-07-23 ~ 2020-09-25 - Cisplatin + Vinorelbine, Vinorelbine, take turns alternately

• 2019-10 ~ 2019-12 - Cisplatin + Paclitaxel

==========

2022-09-28

[assessment]

• The blood sugar level was 76 mg/dL on 2022-09-28 06:05; Glimet (glimepiride plus metformin) might be held temperately. Please follow up on the new serum glucose readings.

2022-06-13

[assessment]

• CT 2022-06-02 showed the bilaterial lung mets was stationary.

2022-05-30

[assessment]

• Compared to the previous CT images, which were taken on 2021-11-06, the last CT images on 2022-02-23 revealed metastatic lung, liver, bones, and a LAP in the mediastinum and hilar region were stationary. It is possible that a new CT scan will be necessary.
• Since 2020-04-10, almost every CXR has shown fibrosis in the right upper lung. If lung fibrosis becomes a concern, nintedanib or pirfenidone are likely to provide some relief.
• The blood sugar recorded was 142 mg/dL (2022-05-30 06:54, HbA1c 6.8% 2022-05-24) while on Galvus Met (vildagliptin + metformin) and Glimet (glimepiride + metformin). In the event of a spike observed, some insulin may be beneficial.

2022-03-17

[assessment]

• In contrast to previous CT images on 2021-11-06, CT images updated on 2022-02-23 showed stationary metastatic lung, liver, bones, and LAPs in the mediastinum and hilar region.
• Lab tests reported on 2022-03-16 indicated no abnormalities in liver and kidney function, but low WBC, RBC, and HGB levels were observed, which should be monitored as usual in patients undergoing chemotherapy
• According to the blood sugar level as of 2022-03-17, the level is slightly low, which should be noted and monitored if anti-DM drugs need to be adjusted.

701385762

220517

• initial presentation
  • 2022-05-12 Emergency
    • abd pain for 1 week, poor appetitie for 3 days
    • lower leg edema 3+
    • bloody stool passage once months ago
    • denied abd Op hx
    • BW: 65 kg -> 40+ kg in half a year
    • Single. This patient lives in the north, and her family lives in the south
• exam finding
  • 2022-05-16 Gynecologic ultrasonography
    • Asites(+)
    • IMP: Pelvis mass:145x88mm with blood flow.
  • 2022-05-12 Chest PA erect view
    • Faint aveolar opacity over left lower lobe is found.
    • Another opacity over right lower lobe is found.
    • Patent airway is found.
    • Normal heart size.
  • 2022-05-12 CT - abdomen, pelvis
    • Abdominal CT with and without enhancement revealed:
      • Solid soft tissue necrotic mass at pelvis probably originates from left ovary is found up to 10.59cm in largest dimension. Ovarian cancer is favored.
      • Massive ascites with free air at pelvic cavity, suspected peritonitis.
      • Several low density heterogeneous tumors are found at both lobes of liver up to 8.6cm at S5/6 of liver.
      • Bilateral mild pleural effusion is found.
      • Thrombus formation at INFERIOR VENA CAVA is found. Please exclude the possibility of pulmonary embolism if there is dyspnea.
    • IMp:
      • Huge pelvic mass with liver necrotic tumors, ovarian cancer with liver meta is most likely.
      • Massive ascites with air pockets, suspected peritonitis.
      • INFERIOR VENA CAVA thrombus formation.
• lab data
  • Blood K (potassium)
    • 2022-05-17 2.4 mmol/L
  • D-dimer
    • 2022-05-17 2420.90 ng/mL(FEU)
  • Gastric Juice OB
    • 2022-05-16 3+
  • Blood WBC
    • 2022-05-12 23.11 *10^3/uL
    • 2022-05-14 27.18 *10^3/uL
  • WBC DC (differential count) Neutrophil
    • 2022-05-17 98%
    • 2022-05-14 99%
  • Blood CRP
    • 2022-05-12 14.09 mg/dL
  • Blood Albumin
    • 2022-05-17 2.3 g/dL
    • 2022-05-12 1.9 g/dL
  • Blood Total Protein
    • 2022-05-17 4.8 g/dL
  • Urine Bacteria
    • 2022-05-12 3+
  • Blood CEA
    • 2022-05-14 54.77 ng/mL
  • Blood CA125
    • 2022-05-14 100.58 U/mL
  • Blood CA199
    • 2022-05-14 100.58 U/mL
• consultation
  • 2022-05-16 Gynecology and Obstetrics
    • Suggestion and plan:
      • Compatible with CT report, pelvic mass 15x8 cm, with ascites.
      • Please check d-dimer, aFP, LDH.
      • Please arrange panendoscopy and colonscopy.
      • Ascites cell block
      • If these data are available, contact us
  • 2022-05-12 Colorectal Surgery
    • Assessment
      • huge heterogeneous tumor in the pelvis with marked ascites, diffuse carcinomatosis and liver metastases, colon origin or GYN cancer is considered
    • Plan
      • We had well explained her terminal cancer disease to the patient and her friend (family?) and they can understand.
      • Due to diffuse carcinomatosis and liver metastases, her disease is unresectable and incurable, and has been in very terminal stage, we suggested palliative treatment and hospice consultation.
      • We would like to follow this patient.

[assessment]

• The presence of a large heterogeneous tumor in the pelvis, with ascites, diffuse carcinomatosis, and liver metastases from the colon or gynecological origin could be considered (2022-05-12 CT abd, 2022-05-16 SONO Gyn). Further investigation is needed, working up now.
• Heart rate roughly maintained at more than 100 beats per minute (from TPR records), this tendency of tachycardia might be caused by inferior vena cava thrombosis (2022-05-12 CT) decreased preload, decreased cardiac output, and leads to increased frequency.
• The active prescription rehydrates, adjusts electrolytes, and supplements albumin with no problems.
• Urine bacteria 3+ (2022-05-12) is treated with Brosym (cefoperazone, sulbactam) since 2022-05-13, body temperature never reached 37 degrees these days.
• No issue with current medication.

700350760

220513

• diagnosis
  • gastrointestinal hemorrhage
  • hypo-osmolality and hyponatremia
  • hypovolemic shock
  • acute posthemorrhagic anemia
• exam finding
  • 2022-05-10 Chest PA erect view
    • Presence of ileus.
    • Ground glass opacity in right lung.
    • Normal appearance of trachea and bil. main bronchus.
    • Atherosclerosis of the aorta.
  • 2022-05-09 Abdominal Ultrasonography
    • Suspected bladder wall thickening
    • Prostate hypertrophy
    • Stool impaction
    • Ascites, small
    • Pleural effusion, bilateral
    • Pericardial effusion
    • Parenchymal renal disease and renal cysts, both
  • 2022-05-06 Esophagogastroduodenoscopy (EGD)
    • Incomplete study due to much coffee ground material and looping
    • Reflux esophagitis LA Classification grade B
    • Superficial gastritis
    • Deformed antrum
    • Suggestion: 2nd look endoscopy is warranted only if ACITVE BLEEDING sign or PERSISTED Tarry stool.

[assessment]

Harnalidge (tamsulosin) 0.4mg PO QDAC should be replaced with Urief (silodosin) 8mg PO QD as a preferred alternative.

700376437

220513

• exam finding
  • 2022-05-09 CT - abdomen, pelvis
    • Multiple HCCs with peritoneal seeding, LNs/ lung/ bony metastases and massive ascites.
  • 2022-05-09 KUB
    • Diffuse hepatomegaly with poor defination of both kidneys, spleen, and psoas shadows, and inferiorly displaced bowel loops
    • Abdominal ascites
  • 2022-05-09 Chest PA erect view
    • Numerous nodules of variable sizes throughout both lungs due to metastases.
    • Normal heart size
    • Costophrenic angles are preserved
    • Diffuse hepatomegaly
  • 2022-04-25 Paracentesis
    • Procedure
      • Ascites tapping
    • Course
      • After echo localization, local anesthesia was performed at RLQ and 2200ml serosanguinous ascites was drained out with 18Fr catheter.
    • Findings
      • Massive clear ascites was noted.
    • Complication
      • No immediate complication
  • 2022-04-23 Chest PA erect view
    • There are multiple nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
  • 2022-04-18 KUB
    • Ascites and hepatomegaly is noted.
  • 2022-04-14 CT - abdomen, pelvis
    • Progression of bil. HCCs with PVT, peritoenal seeding, LNs, spine, lung metastases. Massive ascites.
  • 2022-04-14 Paracentesis
    • Procedure
      • Ascites tapping
    • Course
      • After echo localization, local anesthesia was performed at RLQ and 2200ml serosanguinous ascites was drained out with 18Fr catheter.
    • Findings
      • Massive clear ascites was noted.
    • Complication
      • No immediate complication
  • 2022-03-22 Paracentesis
    • Procedure
      • Ascites tapping
    • Course
      • 18G needle was inserted at RLQ under echo guided insertion.
    • Findings
      • 2000ml clear yellowish ascites was drained. 75ml was sent to lab exam
    • Complication
      • No immediate complication
  • 2022-03-18 CT - CTA, chest
    • D-dimer 3280 suspected pulmonary embolism
    • Imp:
      • Huge HCC at right lobe liver with previous rupture, PV thrombosis and left lobe tumor, lung mets.
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • Massive ascites and bilateral mild pleural effusion.
  • 2022-03-17 Chest PA/AP view
    • There are multiple nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-03-16 Paracentesis
    • Ascites tapping 3000mL
  • 2022-02-15 CT - liver, spleen, biliary duct, pancreas
    • Impression:
      • Huge HCCs with portal veins invasion, newly developed left lobe HCCs.
      • Peritoneal carcinomatosis, T-spine metastasis, diffuse lung metastasis. Disease in progression.
  • 2022-03-14 KUB
    • Ascites is noted.
  • 2022-01-21 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the lower T-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2021-11-20 CT - abdomen, pelvis
    • Huge hepatic tumors (up to 29cm) at S4-5-6-7-8 with right portal vein thrombosis and hemoperitoneum. No evidence of active bleeding.
    • Multiple lung metastases.
  • 2021-10-12 Visceral Angiography 2 vessels
    • DSA of celiac trunk and SMA via right common femoral artery puncture revealed:
      • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
      • Thrombosis of right portal vein.
      • Hypervascular tumors at S4 and right hepatic lobe c/w HCCs. No evidence of active bleeding.
      • No procedure-related complication during the whole procedure. Remain the arterial sheath (4 Fr) at right inguinal region. Thanks for your further care.
    • IMP: Bil. HCCs with right portal vein thrombosis as described.
  • 2021-10-12 CT - CTA, abdomen
    • History and indication: abdominal pain
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • CTA of abdomen revealed:
      • Huge hepatic tumors (up to 26cm) at S4-5-6-7-8 with right portal vein thrombosis and rupture causing hemoperitoneum.
      • Multiple lung metastases.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Normal appearance of gallbladder.
      • Intact bony structures.
      • No enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
    • Imaging Report Form for Hepatocellular Carcinoma
      • Impression (Imaging stage): T4N0M1, stage IVB
  • 2021-10-12 Abdominal Ultrasonography
    • Hepatic tumor, multiple, probably metastatic tumor
    • Ascites
• consultation
  • 2022-05-10 Family Medicine
    • Q
      • For Hospice care.
      • A 46-year old man patient is a case of liver cell carcinoma with lung and bone metastasis. admitted to ICU for AKI with GI bleeding.
      • Nasal cannula support.
      • Current problem: Con’s clear, the family and the patient prefer palliative care. We need your specialist to evaluate and Hospice. Thanks.
    • A
      • After discussion, I decided to arrange hospice combine care for him first. Our nurse will contact the family.
      • Indication: liver cell carcinoma with lung and bone metastases
      • Plan: hospice combined care
  • 2022-05-09 Nephrology
    • Geneal weakness, dsypnea, poor appetite, coffee ground vomitus and tarry stool passage note for about 1 wk
    • Vital signs: BP 115/65mmHg, PR 101/min, RR 20/min, SPO2 98%
    • Lab data
      • BUN: 22 -> 130
      • Cre: 1.03 -> 9.17
      • Na: 129, K: 6.2
      • T bil: 9.74, GOT: 121, GPT: 88, Albumin: 3.4
      • PH: 7.245, PCO2: 34.2, HCO3: 14.5, BE: -12.3
      • CXR: numerous nodules of variable sizes throughout both lungs due to metastases
      • EKG: sinus tachycardia
    • Impression:
      • Acute kidney injury stage 3 suspect prerenal or postrenal
      • HCC with lung metastases, supsect short survival period
    • Suggestion:
      • On foley and record urine output
        • First medical treatment for hyperkalemia and metabolic acidosis
        • Follow up ABG, electrolyte (ABG: Artery Blood Gas)
        • Check Abdomen CT to rule out other obstructive uropathy
        • If progressive refractory metabolic acidosis, hyperkalemia, fluid overload and anuria, we will arrange RRT if patient and family agree (RRT: Rapid Response Team)
        • Patient refuse HD and prefer medical treatment first when we explain the condtion to him in ER
        • Consider hospice care if patinet prefer DNR
  • 2022-03-18 Cardiology
    • Q
      • The 46 y/o man has hepatocellular carcinoma with right portal vein thrombosis and lung metastasis, cT4N0M1, stage IVB, BCLC: C, child score: A, under Kyetruda and Nexavar treatment. Due to SOB and elevated d-dimer level, the CTA was done and report showed huge HCC at right lobe liver with previous rupture, PV thrombosis and left lobe tumor, lung mets. We need your help for thrombosis assessment. Thanks!
    • A
      • We were consutled for HCC associated PVT.
      • CT finding on 20220318 showed
        • Huge HCC at right lobe liver with previous rupture, PV thrombosis and left lobe tumor, lung meta.
        • No evidence of pulmonary embolism nor aortic dissection is found.
        • Massive ascites and bilateral mild pleural effusion.
      • Suggestion
        • Liver cirrhosis with portal vein thrombosis easy occured in late‐stage liver cirrhosis; it is very poor prognosis. anticoagulation with warfarin maybe some benefit and also increasing fatal risks, including bleeding, tumor bleeding. Maybe you could discuss with GI man.
        • There is no specific endovascular intervention for malignancy and cirrhosis related portal vein thrombosis.
  • 2021-11-23 General Gastroenterological Surgery
    • Q
      • For management of HCC
      • This 46-year-old man has past medical history of chronic hepatitis B, Liver cirrhosis; HCC with lung metastasis, rupture, s/p emergent TAE, portal vein thrombosis. Stage T4N0M1: IVb, BCLC stage C; undergoing R/T. F/U in GS and R/T OPD; undergoing 1st immunotherapy with Nivolumab 100mg (By GS surgeon).
      • This time, due to he suffered from shortness of breath, poor intake and tarry stool for 2 days. He was brought to our ER for help. Under the impression of: 1) GI bleeding, favor variceal or PUD bleeding both considered related; 2) HCC with lung metastasis. he was admitted to our ward for further treatment.
      • After admission, NPO with IV fluid supplement and high dose PPI pump was used. Glyperssin 1amp Iv Q6H was used to correct favor EV, GV bleeding. Explained this condition to himself (including do EGD for further survey) but he refused. There was no tarry/bloody stool nor vomiting coffee ground found after medical treatment. Try clear liquid diet since 20211122 by himself request. Last time follow up hemogram on 20211123 revealed Hb:8.1 g/dL. Now, due to he request consulted GS Dr. Chen visited. We need your further survey and management of HCC.
    • A
      • huge HCC over right lobe with lung metastasis
      • liver cirrhosis, child A
      • under R/T and nivolumab Tx now
      • we will take over this case
  • 2021-10-21 Gastroenterology
    • Q
      • This 46 years old male a case of rupture HCC with lung metastasis cT4N0M1, stage IVB s/p angiography (no active bleeding) on 20211012. Hepatitis survey revealed HBsAg: reactive, Anti-HBc: reactive, Anti-HBs: nonreactive, Anti-HCV(-), HBV DNA is pending. We need your expertise for HBV treatment.
    • A
      • 46M
      • PHx: denied
      • PI: rupture HCC with lung metastasis cT4N0M1, stage IVB s/p angiography (no active bleeding)
      • Plan
        • For immunotherapy, may prescribe self-paid baraclude 0.5mg QD (prescribe 1mg to peel half can save money)
        • NHI does not cover
        • GI OPD follow up
  • 2021-10-20 Radiation Oncology
    • Assessment: HCC, stage cT4N0M1, with lung meatstases.
    • Plan: Radiotherapy is indicated for this patient with the following indicators: Huge hepatic tumors (up to 26cm) with mild dyspnea
    • Goal: palliation
    • Treatment target and volume: hepatic tumor
    • Technique: VMAT/IGRT
    • Preliminary planning dose: 5000cGy/20 fractions
    • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and would like to receive radiotherapy. The treatment planning of radiotherapy will be started at 2PM, 2021-10-25.
  • 2021-10-12 General Gastroenterological Surgery
    • Q
      • After feeling something rupure on his RUQ on 20211008, he started severe diffused abdominal, diarrhea, urinary frequency/dysurea, nausea sensation, easily dyspnea and dizziness.
      • Left leg numbness aggressive in recently.
      • BW loss 10 kg in 1/2 yr.
      • 20211006 AFP: 22898, HBV-Ag: (+)
      • 20211012 Abdomen echo:
        • Hepatic tumor, multiple, probably metastatic tumor
        • Ascites
      • Past history: Left leg trauma s/p surgery
      • Allergy: nil
      • TOCC: (-)
    • A
      • emergent TAE
      • admit to ICU

[assessment]

• This patient has advanced HCC with lung mets, AKI, indicating poor prognosis. Paracentesis has been performed several times in recent months for ascites tapping. Hospice combined care has been arranged this week.
• Low RBC and HGB readings (2.66 * 10^6/uL, 8.4 g/dL 2022-05-13) might be caused by GI bleeding, 2022-05-11 vein blood gas PO2 64mmHg, O2 saturation 89%. Ventilation becomes more important when oxygenation is low.
• Hyperphosphatemia and hypocalcemia might result from renal dysfunction. 2022-05-13 blood ammonia 100 umol/L, BUN 120 mg/dL. If the patient does not wish to undergo hemodialysis, lactulose or lactitol might alleviate hyperammonemia.

701264039

220513

{mediastinum small cell carcinoma with pericardial effusion with SVC syndrome, stage IV}

[objective]

• exam finding
  • 2022-03-11 CT - lung/mediastinum/pleura
    • suspected IPF (idiopathic pulmonary fibrosis)
    • Extensive mediasitinal lymphadenopathy, in regression with mild SUPERIOR VENA CAVA compression.
  • 2022-01-19 Chest PA/AP view
    • S/P median sternotomy with metalic wires fixation.
    • Patchy opacity projecting at right suprahilum and Diffuse miliary lesions on both lung are notd.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette
  • 2021-12-08 Patho - soft tissue biopsy
    • diagnosis
      • Mediastinum, biopsy - Small cell carcinoma
      • Thymus, thymectomy - Involution
      • Lymph node, regional, thymectomy - Negative for malignancy (0/2)
    • IHC: CD56(+), chromogranin(+), CK(+), LCA(-) and TTF-1(-).
  • 2021-12-07 Cell block
    • suspect small cell carcinoma
    • smears and cell block show small clusters of malignant tumor cells with inconspicuous nuclei, high N/C ratio, scanty cytoplasm, pleomorphism, hyperchromasia and nuclear molding.
      • reference: S2021-18038
  • 2021-12-03 CT - chest
    • T4N3M0, stage IIIC
      • T4: Tumor > 7cm or tumor of any size invading one or more of the following: diaphragm , mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, separate tumor nodule(s) in a different lobe of the ipsilateral lung.
      • N3: Contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s).
      • M0: No distal metastasis (in this study)
• surgical operation
  • 2021-12-07
    • surgery
      • partial pericardiectomy
      • thymectomy
      • mediatinal tumor biopsy
    • finding
      • Some masses at mediastinum with mass effect to SVC.
      • Pericardial effusion.
      • Bil. lung fibrosis.
• chemotherapy
  • 2021-12-10 ~ undergoing: etoposide + cisplatin
  • 2021-04-07 ~ undergoing: nintedanib (for interstitial lung diseases)

[assessment]

• No updated image since last hospitalization. Last CT on 2022-03-11 showed suspected IPF and mediastinal lymphadenopathy, the latter was in regression under recent regimen [etoposide + cispaltin].
• Patients with extensive-stage small cell lung cancer are generally treated with chemotherapy and immunotherapy. Extensive-stage disease is not considered to be curable, and the goals of treatment are to relieve symptoms caused by the cancer and to prolong life.
• People who respond well to chemotherapy may be given radiation therapy to the brain to prevent the development of brain metastases, and may also receive radiation therapy to the chest. Radiation therapy may also be used to treat other areas of the body to relieve symptoms caused by the spread of cancer. As this patient also has pulmonary fibrosis, treatment outcomes for patients with lung cancer and IPF were generally poor, and exacerbations resulting from treatment were frequent. (source: https://www.nature.com/articles/s41598-021-87747-1 )
• In order to determine whether radiotherapy is feasible, there is a published article that states that patients with lung cancer associated with ILD have a poor prognosis. They are at high risk of severe and even fatal radiation pneumonitis. Careful patient selection is necessary, appropriate high-risk consenting and strict lung dose-volume constraints should be used, if these patients are to be treated with thoracic radiotherapy (reference: Is Thoracic Radiotherapy an Absolute Contraindication for Treatment of Lung Cancer Patients With Interstitial Lung Disease? A Systematic Review https://pubmed.ncbi.nlm.nih.gov/35168842/ )
• 2022-05-12 vein blood gas PO2 23mmHg, O2 saturation 36%. When oxygenation is low, ventilation becomes more important. Under 100% O2 mask, the patient’s respiratory rate remains at approximately 18 ~ 22 per minute so far during this hospital stay.
• NT-proBNP was found to be 521 ng/mL and CKMB was 7.0 ng/mL on 2022-05-11, suggesting possible myocardial injury. Could myocardial injury be the result of low oxygenation? The blood pressure (105/62 2022-05-13 04:28) currently under antihypertensive agent (amlodipine + valsartan) was “too normal” in readings with somewhat tachycarida (> 100 pulse/min) even when CRP was 4.39 mg/dL and WBC was 13.45 103/uL. The coronary perfusion should be monitored if it is always adequate.

220401

[assessment]

• This patient presented with stage IV mediastinum small cell carcinoma, recent CT scan taken on 2022-03-11 showed extensive mediastinal lymphadenopathy, in regression with mild superior vena cava compression.
• The goals of management for malignant SVC syndrome are to alleviate symptoms and treat the underlying disease. Treatment of the underlying cause depends on the type of cancer, the extent of disease, and the overall prognosis, which is closely linked to histology and whether or not prior therapy has been administered.
• The patient has been receiving [nintedanib] since April 2021 then [etoposide + cispaltin] have been added since mid December 2021 s/p [partial pericardiectomy and thymectomy] early December 2021. According to the aforementioned CT examination results, the current treatment should still be effective.
• Laboratory data indicate slight low serum magnesium levels for months since the end of 2021. This might be related to the administration of cisplatin. MgO tablets are currently being administered.

220311

[objective]

• exam finding
  • 2021-12-08 Patho - soft tissue biopsy
    • diagnosis
      • Mediastinum, biopsy - Small cell carcinoma
      • Thymus, thymectomy - Involution
      • Lymph node, regional, thymectomy - Negative for malignancy (0/2)
    • IHC: CD56(+), chromogranin(+), CK(+), LCA(-) and TTF-1(-).
  • 2021-12-07 Cell block
    • suspect small cell carcinoma
    • smears and cell block show small clusters of malignant tumor cells with inconspicuous nuclei, high N/C ratio, scanty cytoplasm, pleomorphism, hyperchromasia and nuclear molding.
      • reference: S2021-18038
  • 2021-12-03 CT - chest
    • T4N3M0, stage IIIC
      • T4: Tumor > 7cm or tumor of any size invading one or more of the following: diaphragm , mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, separate tumor nodule(s) in a different lobe of the ipsilateral lung.
      • N3: Contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s).
      • M0: No distal metastasis (in this study)
• chemotherapy
  • 2021-12-10 ~ ongoing: etoposide + cisplatin
• medication
  • 2021-04-07 ~ ongoing: nintedanib

[assessment]

• It is common for patients with SCLC to have extensive stage of the disease. Unlike limited-stage cancers, extensive-stage cancers are not recommended to be treated with high radiation doses intended to cure the disease.
• T4N3Mo, stage IIIC, was shown in the CT images of 2021-12-03, which is classified as a limited but not extensive stage using VA system in NCCN guidelines.
• Using individual patient data from four randomized studies, meta-analysis has been conducted to compare cisplatin-based versus carboplatin-based regimens for patients with SCLC. Among the 663 patients included in this meta-analysis, 32% had a limited-stage disease and 68% had an extensive-stage disease. As a result, no significant difference was observed in response rate (67% vs. 66%), progression-free survival (PFS) (5.5 vs. 5.3 months), or overall survival (9.6 vs. 9.4 months) in patients treated with cisplatin-containing versus carboplatin-containing regimens, indicating equivalent efficacy in patients with SCLC.
  • reference: https://pubmed.ncbi.nlm.nih.gov/22473169/
• Trilaciclib or G-CSF may be used as prophylactic options to reduce the incidence of chemotherapy-induced myelosuppression in patients receiving platinum/etoposide (might plus immunocheckpoint inhibitor if applicable) containing regimens or topotecan containing regimens.
• Electrolyte disorders including hyponatremia, hypokalemia and hypomagnesemia might be associated with administration of cisplatin or carboplatin. Lab readings for Na, K, and Mg in the past few months have been low. Monitoring is needed.
  • reference: https://www.frontiersin.org/articles/10.3389/fonc.2020.00779/full

700936145

220511

• exam finding
  • 2022-05-09 KUB
    • Degeneration of bony structures.
    • Stool retention in bowl.
  • 2022-05-09 Chest PA erect view: Essential negative findings
  • 2022-05-04 CT - abdomen, pelvis: Unremarkable
  • 2022-05-04 KUB: Unremarkable
  • 2022-05-04 Chest PA erect view
    • Lung markings: focal increased density in the left middle lung field. Please f/u.
• 2022-05-10 admission
  • cheif complaint
    • This 59 year-old male has the histories of 1) DM; 2) Hypertension; 3) Hyperlipidemia; 4) HBV.
    • This time, he suffered from palpitations, epigastric pain with nausea, crampy sensation and shaking chills for 3 days. The epigastralgia was persistent but no radiation. There was no fever, no cold sweating, diarrhea or constipation accompanied. He denied alcohol drinking recently, hematemesis or tarry stool passage and no tea-color urine found. He visited our ER for help. At ER, vital sign was BT:36.6C, BP:141/88mmHg, PR:103/min, RR:18/min, SpO2 96% under room air. Con’s: E4V5M6. PE revealed tenderness over epigastric area. Lab data revealed leukocytosis (25.73 *10^3/uL) with elevation of CRP level (8.44 mg/dL), impaired liver function (ALT/AST 263/222 IU/L) and hyperbilirubinemia (total Bil 4.53 mg/dl), prominent elevation of lipase level (870 U/L).
    • Under the impression of acute pancreatitis, he was admitted to our GI ward for further evaluation and management.
  • past history
    • DM
    • HTN
    • Hyperlipidemia
    • HBV
    • Denied other admission or operation history. 
  • family history
    • Family history is unremarkable.
    • There is no family history of cancer, hypertension, mental diseases or asthma.
    • No members of the family with diabetes.

[assessment]

• Vital signs (TPR 36.8/70/16, BP 122/71, SpO2 95%, 2022-05-11 04:45) were stable during this hosptial stay so far.
• Active prescription
  • Fluid replacement with 0.9% NaCl, lactated ringers (Ca 2.19 mmol/L 2022-05-11), nako no.5
  • Pain management with Tramadol
  • Symptom mitigation with serine protease inhibitor gabexate mesilate
  • Use silymarin as a hepatoprotectant
  • Brosym (cefoperazone + sulbactam) for possible infection.
  • High blood sugar level treated with human insulin
  • Diovan (valsartan) for underlying hypertension
• Up to 20 percent of patients with acute pancreatitis develop an extrapancreatic infection (eg, bloodstream infections, pneumonia, and urinary tract infections). When an infection is suspected, antibiotics should be started while the source of the infection is being determined. However, if cultures are negative and no source of infection is identified, antibiotics should be discontinued. Culture order might be considered.
• No issue with current medication

701050716

220511

• exam finding
  • 2022-05-10 Chest PA/AP view
    • Blunted right costophrenic angle.
    • S/P Port-A infusion catheter insertion.
    • Atherosclerosis of the aorta.
  • 2022-04-25 PD-L1 Immunostaining
    • Tumor Cell (TC) staining assessment < 1%
  • 2022-04-08 KUB
    • S/P double J catheter insertion in place, left side.
    • Lumbar spondylosis.
    • Calcification in the pelvic cavity, could be due to phlebolith.
  • 2022-04-07 Renal ultrasound
    • Impression
      • Mild hydronephrosis, left kidney.
      • Mass lesion in the urinary bladder, suspected Bladder tumor, suspected bladder blood clot.
      • Suspected dislocation of left double-J catheter
    • Suggestion
      • Follow up KUB to detect the location of double-J catheter.
      • Cystscopic study is recommended.
  • 2022-04-06 ECG
    • Atrial fibrillation
    • Left axis deviation
    • Incomplete right bundle branch block
    • Poor wave progression V1~3
    • Possible Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-04-05 Chest PA erect view
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Tortuosity of thoracic aorta
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Patchy consolidation of the right lower lung is suspected.
    • please correlate with clinical condition or CT.
  • 2022-03-03 KUB
    • S/P double J catheter insertion in place, left side.
    • Lumbar spondylosis.
    • Calcification in the pelvic cavity, could be due to phlebolith.
  • 2022-03-02 Patho - urinary bladder TUR
    • Pathologic diagnosis
      • Urianry bladder, “tumor”, TURBT — Invasive urothelial carcinoma, high-grade
    • Microscopic examination
      • Histologic type: Urothelial carcinoma, invasive
      • Histologic grade: High-grade
      • Tumor configuration: Nodular
      • Muscularis propria: Present
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades muscularis propria
  • 2022-03-01 ECG
    • Sinus rhythm with Premature ventricular complexes
    • Inferior infarct, age undetermined
  • 2022-02-23 CT - lung/mediastinum/pleura
    • atherosclerosis of aorta with ascending aorta dilatation 4.5 cm in caliber.
    • moderate 2V-CSD. small pericardial effusion.
    • subsegmental atelectasis of RML.
    • substantial subpleural paraseptal emphysema at anterior LUL.
  • 2022-02-11 CT - abdomen, pelvis
    • UCC of the urinary bladder with left UVJ invasion causing obstructive uropathy.
  • 2022-02-10 Chest PA erect view
    • Port-A catheter inserted into SVC via left subclavian vein.
    • Blunting of right costophrenic angle due to pleural effusion
    • moderate enlarged cardiac silhoutte may be due to dilated cardiac chambers (LAD and LVD) and prominent cardiophrenic angle mediastinal fat pad
    • patch at right inferior paracardiac lung region, could be atelectasis of RML
  • 2021-12-30 CXR
    • S/P Port-A infusion catheter insertion.
    • Right pleural effusion. Ground glass opacity in RLL.
    • Atherosclerosis of the aorta.
    • Suggest clinical correlation.
  • 2021-11-20 CT - abdomen, pelvis (ShuangHo Hospital)
    • Urinary bladder cancer s/p treatment, still thickening of urinary bladder wall.
    • Lt hydroureteronephrosis.
    • Loculated fluid or urinary diverticulum at left pelvic region.
    • Consolidation over right basal lung with pleural effusion. Ubsegmental atelectasis over left basal lung.
  • 2021-09-27 Pathology (SH2119345, ShuangHo Hospital)
    • Urinary bladder, TUR-BT, urothelial carcinoma, nested variant.
    • Urinary bladder, labeled as “tumor base, TUR-BT” urothelial carcinoma.
    • Some muscle tissue invaded by the carcinoma is seen.
  • 2021-09-17 CT - abdomen (ShuangHo Hospital)
    • Enhancing soft tissue (5.8cm) at left posterior urinary bladder wall with hyperdense collection in the urinary bladder.
    • Left severe hydroureteronephrosis noted, suspect UVJ invasion. C/W urinary bladder cancer causing hematuria, suspect UVJ invasion. (UVJ: ureterovesical junction)
  • 2020-08-13 Exercise Electrocardiogram
    • Resting ECG: Normal sinus rhythm
    • Exercise: Nonspecific ST change
    • Conclusion
      • negative for myocardial ischemia
      • isolated VPCs at the exam
• consultation
  • 2022-01-04 Thoracic Medicine
    • Q
      • Cigarette smoking for more than 50 years, quitted this September after diagnosis of bladder cancer, hypertension for 20 years and DM, hyperlipidemia, gastric ulcer. Due to pneumonia and he was discharged from MICU at ShuangHo Hospital in 2021-12. He mentioned productive cough, mild chest discomfort, easy shortness of breath while fast walking, walking stairs about 2-3 floors, lower limbs edema after discharge. In our service, he also has cough with pneumonia under antibiotic treatment. The lung function test showed small airway obstruction, resulting in low lung volume with significant response to bronchodilator, so we need your help for COPD?
    • A
      • Assessment
        • bladder cancer on CCRT by ShuangHo
        • PN with parapneumonic pleural effuison, acute respiratory failure, 110-12, tx at ShuangHo - with residual RML abscess and lung consoidation, residual pleural effuison
        • COPD, under sipolto by ShuangHo, ex-smoking, PFT showed both restriction and airway obstruction.
      • Suggestion:
        • Due to the CXR had no interval change since 2021-12-04, and pt did not have toxic sign clinically, only f/u was suggested
        • Add spiolto 2 puff QD for him.
        • Check TB sputum X 3 days
        • OPD F/U
• surgical operation
  • 2022-03-02
    • Surgery
      • TURBT and left URS exam        
    • Finding
      • Diffuse thickening of urinary bladder wall at left lateral wall    
      • U/O was identified after TURBT; incomplete URS exam, no tumor, no stone was found until the level of upper ureter
  • 2021-09 TURBT, transurethral resectionof bladder tumor, ShuangHo Hospital
• radiotherapy
  • 2021-10-12 ~ 2021-11-19 - 4500cGy/25 fractions of the whole bladder and 5040cGy/28 fractions of the bladder tumor.
• chemoimmunotherapy
  • 2021-10-12 ~ 2021-11-19 - 5Fu + cisplatin, 3 times, CCRT, ShuangHo Hospital.

[assessment]

• CXR (2022-05-10) revealed blunted right costophrenic angle and atherosclerosis of the aorta. Lab data (2022-05-10) showed generally normal results.
• Respiratory symptoms are well-managed with self-carried drugs in active prescription.
• PD-L1 tumor cell < 1% (2022-04-25), the effectiveness of pembrolizumab, nivolumab or avelumab might not be very great.
• The genetic alteration of FGFR3/FGFR2 has not been confirmed, so it is unclear whether erdafitinib should be considered.
• Regimen for treatment of the cacner could be
  • Gemcitabine and cisplatin followed by avelumab maintenance therapy, or
  • DDMVAC (dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin) with growth factor support followed by avelumab maintenance therapy
• No issue with current medication.

700152280

220510

[objective]

• exam finding
  • 2022-03-23 Patho - lumph node region resection
    • pathologic diagnosis
      • Endometrium, uterus, frozen and LSC staging surgery — Endometrioid carcinoma, grade 3
      • Myometrium, uterus, ditto — Tumor invasion, greater than half thickness
      • Cervix, uterus, ditto — Free from tumor, atrophy with Nabothian cysts
      • Left ovary, ditto — Free from tumor, corpus albicans
      • Left fallopian tube, ditto — Free from tumor, paratubal cysts
      • Right ovary, ditto — Free from tumor, corpus albicans
      • Right fallopian tube: free from tumor, paratubal cysts
      • Lymph node, left iliac, dissection — Free from tumor metastasis (0/12)
      • Lymph node, left oburator, ditto — Tumor metastasis (1/19)
      • Lymph node, right iliac, ditto — Free from tumor metastasis (0/11)
      • Lymph node, right oburator, ditto — Tumor metastasis (1/16)
      • Parametrium, bilateral — Free from tumor
      • AJCC Pathologic stage — pT1bN1a, if cM0, stage IIIC1 / FIGO stage IIIC1
    • macroscopic examination
      • Operation Procedure: frozen section and LSC staging surgery (TAH, BSO and BPLND)
      • Specimens include: Uterus, bilateral ovaries, fallopian tubes and pelvic LNs
      • Tumor site: endometrium
      • Tumor size: 4.2 x 3.7 cm
      • The myometrium: up to 1.3 cm in thickness
      • The cervix : mucoid cyst
      • Adnexa (bilateral): bilateral ovaries and bilateral tubes are not invaded by tumor
      • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs and right obturator LNs
      • Representative sections as follows: [Reference: F2022-00124 FS: endometrial mass, A1: R’t ovary + F-tube, A2: L’t ovary + F-tube, A3-A5: uterus from fundus to cervix, A6-A8: tumor + serosa(ink), A9: tumor + endocervix, A10: cervix, A11: R’t parametrium, A12: L’t parametrium]
        • A1-A2: left iliac LNs;
        • B1-B2: left obturator LNs;
        • C1-C3: right iliac LNs;
        • D1-D2: right obturator LNs.
    • microscopic examination
      • Histology type: Endometrioid carcinoma
      • Histology grade: Grade 3
      • Depth of invasion: greater than half thickness of myometrium, less than 0.1 cm away from serosa
      • Lymphovascular invasion: present
      • The cervical stroma involvement:: absent
      • Resection margins of the cervix: Free, 2.8 cm away from tumor
      • Additional pathologic findings: focal tumor necrosis
      • Lymph nodes:
        • left iliac LNs: free from tumor metastasis (0/12)
        • left oburator LNs: tumor metastasis (1/19) without extracapsular extension (0/1)
        • right iliac LNs: free from tumor metastasis (0/11)
        • right oburator LNs: tumor metastasis (1/16) without extracapsular extension (0/1)
      • Immunohistochemistry: WT-1(-), CK(+), ER(-), PR(-) and vimentin(+. focal) for tumor
  • 2022-02-23 Frozen section
    • Mass, endometrial cavity, frozen section — Adenocarcinoma
  • 2022-03-20 CT - abdomen, pelvis
    • A mass lesion (4.6cm) in uterus.
    • Left liver cyst (6.5mm).
  • 2022-03-20 Gynecologic ultrasonography
    • A 54 x 42 mm mass with flow was noted in endometrial cavity, submucosal myoma with degeneration or endometrial malignancy need to be ruled out
    • Bilateral adnexae: free
  • 2021-11-16 CT - lung/mediastinum/pleura
    • Lungs:
      • areas of patchy expiratory air-trapping in both lower lobes, indicating small airways disease.
      • an ill-defined ground glass nodule at posterobasal segment of LLL (about 7 mm in largest axial dimension) as compared with previous CT study.
    • Impression:
      • LLL-S10 ill-defined GGO 7 mm, suggest f/u LDCT at 12 months later. (GGO: ground glass opacity; LDCT: low dose CT)
      • small airways disease in both lower lobes of lungs.
  • 2021-11-02 SONO - breast
    • Bilateral breasts fibroadenomas. Suggest follow up.
    • BI-RADS category 2, Benign finding.
• surgical operation
  • 2022-03-23
    • Diagnosis:
      • Endometrial cancer (Frozen section: Adenocarcinoma)
      • Intra-abdominal adhesions (right site, surgical history: s/p appendectomy)
    • Operation:
      • Laparoscopic gynecologic oncology staging surgery (LAVH + BSO + bilateral pelvic lymphectomy)
    • Finding
      • Uterus: normal size, smooth surface, papillary mass in uterus cavity
      • Bilateral adnexa: grossly normal
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • CDS: free
      • Adhesion over right abdominal wall
  • 2018-11-06 Intracapsular (extracapsular) lens extractionunder microscope + IOL insertion
• lab data
  • 2022-04-08
    • HBsAg negative, value 0.384
    • Anti-HCV negative, value 0.0336
    • Anti-HBc positive, value 0.00706
    • Anti-HBs positive, value 34
• chemoimmunotherapy
  • 2022-04-19 ~ undergoing - paclitaxel + carboplatin

[assessment]

• For this post-operative endometrial cancer patient, the current regimen is preferred, and the patient was able to tolerate the regimen during last hospitalization.
• Laboratory results on 2022-05-09 indicated that liver and kidney function, CBC and electrolytes were generally normal.
• Baraclude (entecavir 0.5mg) QDAC is used for the management of heptatitis virus B.

700140236

220509

[objective]

• exam finding
  • 2022-05-07 Chest PA/AP view
    • Increased infiltration over RLL. May be active infection.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-05-07 MRA - brain
    • Patchy area of acute ischemic infarct over right anterior MCA territory. (MCA: Middle Cerebral Artery)
    • Also focal acute ischemic cortical infarcts over both superior frontal and parietal lobes and right occipital lobe.
    • Multifocal areas of old infarction over left PICA territory, left PCA territory and left cerebral hemispheres. (PICA: Posterior Inferior Cerebellar Artery; PCA: Posterior Cerebral Artery)
    • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
  • 2022-05-07 CT - brain
    • Focal area of faint hypodense change over right frontal lobe, may be recent ischemia. Multifocal areas of old ischemic infarcts over left PICA territory, left PCA territory and left cerebral hemispheres. One old lacuna infarct within right putamen. There is no intracranial hemorrhage seen.
    • The posterior structures including the brain stem, cerebellum and CP angles look normal. However, the beam-hardening artifact over the skull base may hamper the film reading.
    • Please take notice that non-enhanced CT scan is limited in the detection of acute ischemic infarction (particularly within the first 6 hours), small vascular lesion, neoplasm, infectious/toxic/metabolic disease. Recommend correlate with clinical condition.
• consultation
  • 2022-05-07 Neurology
    • This 79 y/o woman has a history of arrhythmia, old stroke with left limbs ataxia, lung adenocarcinoma s/p and suspicious lung abscess. She had had anticoagulant before but discontinued medication since last year. She was able to walk slowly and could live alone with ADLs independently. Today her son visited her at around 11am and found her slow speech and left limbs weakness. Therefore she was sent to our ER for help. According to the patient’s and family’s statement, the patient could talk normally on the phone last night and this morning she had breakfast between 8:30-9:00. For acute ischemic stroke, I was consulted.
    • NE
      • E4V5M6 slowly speech,
      • left hemineglect and hemianopia
      • right gaze deviation
      • left facial palsy
    • MP
      • upper >4/3
      • lower >4/3
    • sensation: intact
    • FNF: left dysmetria
    • brain CT: right MCA territory equivocal hypodense lesion, left cerebellar/occipital region old insult
    • impression: right MCA large infarct
    • suggestion:
      • do MRA/MRI stat and consider EVT accordingly (EVT: endovascular thrombectomy)
      • give aspirin 1# stat and IV Ns 40ml/hr
      • neurology ward admission
    • Brain MRI: right frontal infarct, patent large vessel
• progress note
  • Problem: Acute infarcts in right frontal lobe, onset on 2022/05/07
  • Assessment: Dysarthria and left side weakness
  • Plan:
    • Keep closely monitor neurological signs and vital signs Q4H ~ Q6H
    • Keep adequate IV hydration with normal saline at 40ml/hr
    • Keep antiplatelets agents: Bokey 1# QD
    • H2 block or PPI after acute stroke stage
    • Stroke etiology survey: Arrange sugar, lipid, carotid duplex, ABI, cardiosonography, 24 holter if need
    • Explained to the patient and family about current condition and managment

[assessment]

• Acute ischemic infarction in the right anterior MCA territory occurred on 2022-05-07 in the morning. GCS remained at E4V4M5 during this hospitalization so far. Lab data 2022-05-07 showed slightly elevated CRP 1.22 mg/dL, WBC 12.22 *10^3/uL, Neutrophil 88%, and CXR revealed increased infiltration over RLL, body temperature was no more than 37 degree Celsius.
• No issue with blood sugar (115 mg/dL 2022-05-08 17:43, 129 mg/dL 2022-05-09 06:17).
• A tendency toward tachycardia (111 pulse/min 2022-05-09 04:14) might indicate hypoperfusion in the infarcted area, however, blood pressure has been kept at a very “normal” level (131/72), there might be no need of administration of beta-blocker yet at this moment.

700580399

220509

[objective]

• exam finding
  • 2022-05-02 MRI - brain
    • MRA shows patency of the major vessels of the Willis circle, bilateral ICAs and vertebrobasilar trunk.
    • Imp: Abnormal signal intensity change (with water movement restriction) on caudate nucleus, posterior corpus callosum and possible bil. medial temporal lobes (uncus), cause?
      
  • 2022-04-29 Electroencephalography
    • Abnormal, marked continuous diffuse cortical dysfunction in bilateral hemsiphere
  • 2022-04-28 CT - brain
    • IMP: No evidence of intracranial hemorrhage.
• consultation
  • 2022-05-05 Mental Health
    • Q
      • This is a 47 y/o female who had HX of depression for 10+ years ago, but poor medication compliance. (Medication as Estazolam, Trazodone and Alprazolam).
      • This time, she was admmited to our MICU for the impression of 1) encephalopathy favor hypoglycemia and suicide (BZD over dose).
      • Now, consciou became E4M5V1 (with eyes contect but can not obey) and irritable, we need your expirence for evaluation!
    • A
      • Psychiatric impression:
        • suspected delirium, mixed level of activity
        • suspected neurocognitive disorder due to another medical condition (unknown time duration of concious loss when sending to hospital)
      • Clinical course:
        • This is a 47 y/o female, with history of depression, taking Estazolam, Trazodone, Alprazolam.
        • She was sent to ER on 20220428, coma, found in bedroom by family. Lab data showed hypoglycemia, BZD positive in urine, not sure if she has drug overdose. She was then admitted to ICU, intubation in 20220429, extubation 20220505 morning. We are consulted for conscious disturbance and irritable.
        • MSE: Confusional in conscious, mental muddy and perplexity features. kempt, lying on the bed, not agitated, with O2 mask and NG tube. She has fair eye-contact, intermittently smiling, quit, seems like unable to understand instruction well. She couldn’t express, most of the time she stares when being asked question, only occasionally making sounds with hoarsening voice, incomprehensible. According to caregiver, she becomes more agitated and irritable at night, and physical restraint was applied last night. Unable to follow order to eye-tracing, or moving specific limb. Unable to answer her name, age.
      • Suggestion:
        • Please stablize medical condition as your expertise and monitor mental condition.
        • Psychiatric medication is not essential under current condition. Psychiatric evalutaion will be provided if the patient become more clear.

[assessment]

• During this hospitalization, the blood sugar levels were greater than 100 mg/dL, except for the first measurement of 86 mg/dL on the TPR panel. Hyperglycemia might be reclassified as an inactive item on the problem list.
• GCS E4V2-3M5 2022-05-09 08:27, alprazolam 0.5mg was administrated. If the patient’s mental status becomes clear, then a mental health consultation may be considered.
• There are drugs prescribed to treat underlying conditions, as well as supportive care provided. No issue with current medication.

700522990

220506

[objective]

• exam finding
  • 2022-05-05 Abdominal Ultrasonography
    • Periampullary tumor, causing CBD/MPD obstruction, close to or invaded to IVC, with PTCD in situ
    • C/W cholangitis change, lower CBD
    • C/W A-colon cancer, with luminal stricture but no evidence of obstruction
    • Pancreatic cystic lesions, head-body, suspected IPMN
    • GB polyps
    • Hepatic cyst, left lobe
    • Renal cyst, LK
  • 2022-05-04 CT - abdomen, pelvis
    • suspected colon cancer
    • suspected pancreatic head or ampulla vater cancer.
  • 2022-05-04 CT - brain
    • no acute intracranial hemorrhage
• lab data
  • Bilirubin total
    • 2022-05-06 9.97 mg/dL
    • 2022-05-04 16.82
  • S-GPT/ALT
    • 2022-05-06 55 U/L
    • 2022-05-04 67
  • S-GOT/AST
    • 2022-05-04 113 U/L
  • RBC
    • 2022-05-06 3.61 *10^6/uL
    • 2022-05-04 3.92
  • HGB
    • 2022-05-06 7.9 g/dL
    • 2022-05-04 8.7
• surgical operation
  • 2022-05-05 PTCD drainage

[assessment]

• 2022-05-06 04:45 vital signs TPR 35.9/68/16, BP 132/64 were relatively stable, low energy consumption. This patient has been diagnosed with primary hypertension, her tissue perfusion might be less than usual. No antihypertensive agents are prescribed currently.
• The abdominal ultrasonography performed on 2022-05-05 showed periampullary tumors causing CBD/MPD obstruction and A-colon tumor with luminal stricture, which might need further evaluation to determine if they should/could be resected.
• After PTCD drainage on 2022-05-05, bilirubin total decreased to 9 mg/dL (2022-05-06) from 16 mg/dL (2022-05-04).
• RBC decreased to 3.61 (2022-05-06) from 3.92 (2022-05-04), HGB decreased to 7.9 (2022-05-06) from 8.7 (2022-05-04). ABO, Rh typing, antibody screening have been performed on 2022-05-06.
• There are no records of drug allergies in the database. There are no issues with the current medication.

701254197

220506

[objective]

• exam finding
  • 2022-03-04 SONO chest
    • right side minimal amount of pleural effusion, 600cc serosangious fluid was drained out for symptom relief.
  • 2022-03-03 Chest PA erect view
    • Atherosclerotic change of aortic arch
    • Pleura effusion of right costal-phrenic angle
    • Few nodular opacity projecting in the both lung are suspected. Please correlate with CT.
  • 2022-02-25 CT - abdomen, pelvis
    • FINDINGS:
      • Prior CT identified an ill-defined mild heterogeneous enhancing mass in left hepatic lobe is noted again, increasing in size that is c/w cholangiocarcinoma S/P C/T with progressive disease.
      • Prior CT identified several metastatic lymph nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space and para-cava space are noted again, mild increasing in size that is c/w progressive disease.
      • Prior CT identified several small metastasis on both lung are noted again, mild increasing in size.
      • Prior CT identified mild right side Pleura effusion is noted again, increasing in volume.
      • Ascites in the abdomen and pelvis is noted.
      • Prior CT identified tumor seeding in bilateral ovary (more severe on right side) are noted again, stable in size.
      • Segmental sigmoid colon shows enhancement and thickening that may be tumor seeding in left ovary with sigmoid invasion? Please correlate with colonoscopy.
      • S/P colostomy at left transverse colon.
      • S/P R/T device implantation in the vagina is suspected? please correlate with clinical history.
      • Compression fracture of T12 vertebral body.
    • IMP:
      • Cholangiocarcinoma at Lt lobe liver shows progressive disease.
  • 2021-11-26 Patho - liver biopsy needle/wedge
    • pathologic diagnosis
      • Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with cholangiocarcinoma
      • IHC shows: CK7(+), CK20(few tumor cells+), and Hepatocyte(-).
  • 2021-11-24 CT - abdomen, pelvis
    • Cholangiocarcinoma at left lobe liver shows mild increasing size.
  • 2021-08-11 CT - abdomen, pelvis
    • Cholangiocarcinoma at left lobe liver shows mild increasing size.
    • Lobulated metastatic tumor in right ovary shows mild increasing in size. please correlate with clinical condition.
  • 2021-06-06 CT - abdomen, pelvis
    • Lobulated metastatic tumor in right ovary shows mild increasing in size. please correlate with clinical condition.
    • Segmental sigmoid colon shows enhancement and thickening that may be normal variation or tumor? Please correlate with colonoscopy.
  • 2021-04-13 CT - abdomen, pelvis
    • Stationary of left lobe cholangiocarcinoma and lymph nodes metastasis.
    • Stationary peritoneal carcinomatosis.
    • Suspected right ovarian metastasis, stationary.
    • Colon diverticulosis.
    • Multiple lung nodules, suspected lung metastasis.
  • 2021-03-31 CT - abdomen, pelvis
    • Cholangiocarcinoma at left lobe liver with metastasis in right ovary, metastatic lymph nodes in gastrohepatic ligament, hepatoduodenal ligament, and para-aortic space, and lung metastases show stable disease.
  • 2020-12-24 CT - abdomen, pelvis
    • Imaging Report Form for Cholangiocarcinoma: T2N2M1, stage IV
  • 2020-03-05 Pathology at TMUH
    • colonoscopy biopsy - showing adenocarcinoma (CK7+, CDX2-, P40-, CD20-, ER-, PR-, PA8X-)
• surgical operation
  • 2020-02-20 T-colostomy and intra-abdominal tumor excision
• lab data
  • CEA
    • 2022-04-20 4.42 ng/mL
      
    • 2022-03-29 5.37
    • 2022-03-09 5.56
    • 2022-02-11 6.65
    • 2021-11-23 18.18
    • 2021-10-26 19.05
    • 2021-09-24 15.90
    • 2021-08-17 14.77
    • 2021-07-20 14.81
    • 2021-06-22 14.92
    • 2021-05-24 12.44
    • 2021-04-13 9.68
    • 2021-03-17 9.98
    • 2021-02-17 9.07
    • 2021-01-20 8.42
    • 2020-12-23 8.64
    • 2020-11-10 10.77
    • 2020-10-14 9.25
  • CA125
    • 2022-04-20 350.9 U/mL
      
    • 2022-03-29 386.6
    • 2022-03-09 329.8
    • 2020-12-23 26.8
    • 2020-11-10 26.2
    • 2020-10-14 26.7
  • CA199
    • 2022-04-20 120.56 U/mL
      
    • 2022-03-29 113.47
    • 2022-03-09 119.88
    • 2022-02-11 130.83
    • 2021-11-23 237.10
    • 2021-10-26 195.89
    • 2021-09-24 154.07
    • 2021-08-17 125.27
    • 2021-07-20 92.50
    • 2021-06-22 89.58
    • 2021-05-24 72.72
    • 2021-04-13 73.86
    • 2021-03-17 72.85
    • 2021-02-17 56.65
    • 2021-01-20 51.93
    • 2020-12-23 46.93
    • 2020-11-10 55.32
    • 2020-10-14 51.87
• radiotherapy
  • 2021-12-01 ~ 2022-01-04 RT to the ovarian metastases: 50 Gy/ 25 fx completed
• chemoimmunotherapy
  • 2022-03-03 ~ undergoing - gemcitabine + carboplatin
  • 2021-08-23 ~ 2021-11-11 - FOLFOX (5-Fu + oxaliplatin)
  • 2021-06-22 ~ 2021-08-17 - PXL-249145 (CAL056 mesylate 20mg/tab) 2# QDAC PO
  • 2021-05-25 ~ 2021-05-26 - PXL-249145 (CAL056 mesylate 20mg/tab) 2# QDAC PO
  • 2021-04-27 ~ 2021-05-11 - PXL-249145 (CAL056 mesylate 20mg/tab) 2# QDAC PO
  • 2020-08-28 ~ 2021-03-16 - Gemcitabine 1000 mg/m2 and Carboplatin AUC 2 on 2020-08-28, -09-11, -09-24, -10-08, -10-20, -11-03, -11-11, -11-30, -12-09, -12-25, -12-31, 2021-01-13, -01-20, -02-03, -02-17, -02-24, -03-09, -03-16.
    • The cisplatin was shifted to carboplatin due to elevated level of creatinine upto 1.5 (eGFR down to 37 mL/min/1.73 m2) on 2020-08-27.
    • Best response: SD.
    • Discontinuation: PD in liver. (PD date:2020-12-24)
  • 2020-03-17 ~ 2020-08-13 - Gemcitabine 1000 mg/m2 and Cisplatin 30 mg/m2 on 2020-03-17, 03-24, 04-07, 04-14, 04-28, 05-05, 05-19, 05-26, 06-09, 06-17, 07-02, 07-09, 08-03, 08-13.
    • Best response: SD.
    • Discontinuation: The creatinine level was increased during regular lab test. (PD date: nil)

[assessment]

• This patient diagnosed with cholangiocarcinoma (in early 2020) has previously undergone T-colostomy and intra-abdominal tumor excision (2020-02), [gemcitabine + cisplatin] (2020-03 ~ 2020-08), [gemcitabine + carboplatin] (2020-08 ~ 2021-03), CAL056 (2021-04 ~ 2021-08), FOLLFOX (2021-08 ~ 2021-11), RT (2021-12 ~ 2022-01), and is now on [gemcitabine + carboplatin] (2022-03 ~ undergoing).
• Following consecutive CT scans conducted over the past 12 months, the disease appeared to be mildly advancing unidirectionally.
• Both RBC and HGB have rebounced (3.72 (2022-05-06) <- 3.12 (2022-05-04), 10.3 (2022-05-06) <- 8.6 (2022-05-04), respectively). In the blood lab, sodium (134 mmol/L), potassium (3.2 mmol/L), and magnesium (1.3 mg/dL) levels were low (2022-05-04). MgSO4 10% 20mL IVD QD has been prescribed.

701345193

220506

{ovarian clear cell carcinoma stage IA}

[objective]

• exam finding
  • 2022-03-17 Gynecologic ultrasonography
    • No obvious uterine or ovarian lesion
  • 2021-12-06 Patho
    • debulking surgery
      • total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + bilateral pelvic lymphnode dissection
    • Diagnosis
      • Ovary, right, oophorectomy - clear cell carcinoma; AJCC 8th edition: pStage IA, pT1aN0(if cM0); FIGO stage: IA
        
      • Ovary,left, oophorectomy - Endometrioma
        
      • Histologic Type: Clear cell carcinoma
      • IHC: Napsin A(focal +), PAX8(+), WT-1(-), p53(wild type), and PR(-).
        
      • Histologic Grade: Clear cell carcinoma is not graded.
        
  • 2021-11-03 CT
    • Cystic adenocarcinoma of the left ovary is suspected.
      
    • Small ground-glass opacity 3.5 mm in LLL of the lung, nature?
    • The differential diagnoses include primary lung cancer, metastasis, or benign lesion?
• lab data
  • S-GPT/ALT
    • 2022-05-05 71 U/L
    • 2022-04-28 47 U/L
    • 2022-04-21 66 U/L
    • 2022-04-06 58 U/L
    • 2022-03-24 29 U/L
    • 2022-03-09 38 U/L
    • 2022-02-24 33 U/L
    • 2022-02-15 38 U/L
    • 2022-01-25 26 U/L
    • 2022-01-13 34 U/L
    • 2021-12-23 39 U/L
    • 2021-12-01 17 U/L
• surgical operation
  • 2021-12-03 debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + Bilateral Pelvic Lymphnode Dissection) + enterolysis
• chemotherapy
  • 2022-01-04 ~ undergoing - paclitaxel + carboplatin

[assessment]

• S-GPT/ALT has been elevated above the normal range since April 2022
  • 2022-05-05 71 U/L
  • 2022-04-28 47 U/L
  • 2022-04-21 66 U/L
  • 2022-04-06 58 U/L
  • 2022-03-24 29 U/L
  • 2022-03-09 38 U/L
  • 2022-02-24 33 U/L
  • 2022-02-15 38 U/L
  • 2022-01-25 26 U/L
• The infusion of 3-hour infusion paclitaxel in the current regimen might have to be adjusted to 135 mg/m2 if ransaminases less than 10 times ULN and bilirubin levels are 1.26 to 2 times ULN.

220412

[assessment]

• For this ovarian clear cell carcinoma stage IA patient, IV platinum-based therapy could serve as preferred first-line treatment, specifically speaking paclitaxel + carboplatin Q3W, this is just the treatment the patient receiving now, as from early Jan 2022.
• The patient tolerates the current regimen well according to nursing notes. Alternatively, albumin-bound paclitaxel may be considered if the patient experiences hypersensitivity to paclitaxel.
• Three months after the debulking surgery on 2021-12-03, a gynecologic ultrasonography on 2022-03-17 found no evidence of uterine or ovarian lesions. So far, so good.

220126

{ovarian clear cell carcinoma stage IA}

[objective]

• 2021-12-06 Patho
  • debulking surgery
    • total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + bilateral pelvic lymphnode dissection - ROV - 20x18cm: multiple (13-14#) solid mass, 2cm for each, with 1700c.c brown fluid in cyst
  • Diagnosis
    • Ovary, right, oophorectomy - clear cell carcinoma; AJCC 8th edition: pStage IA, pT1aN0(if cM0); FIGO stage: IA
      
    • Ovary,left, oophorectomy - Endometrioma
      
    • Histologic Type: Clear cell carcinoma
    • IHC: Napsin A(focal +), PAX8(+), WT-1(-), p53(wild type), and PR(-).
      
    • Histologic Grade: Clear cell carcinoma is not graded.
      
• 2021-11-03 CT
  • Cystic adenocarcinoma of the left ovary is suspected.
    
  • Small ground-glass opacity 3.5 mm in LLL of the lung, nature?
  • The differential diagnoses include primary lung cancer, metastasis, or benign lesion?

[assessment]

• for this ovarian clear cell carcinoma stage IA patient, IV platinum-based therapy could serve as preferred first-line treatment, specifically speaking Paclitaxel + Carboplatin Q3W, this is just the treatment the patient receiving now, as from early Jan 2022.
• if patient experienced a hypersensitivity reaction to paclitaxel, then albumin-bound paclitaxel might be considered as an alternative.
• no apparent intolerence observed during this hospitalization.
• no issue found in active medication.

701374584

220506

[objective]

• exam finding
  • 2022-05-05 CT - abdomen, pelvis
    • Massive ascites.
    • Swelling of pancreas.
    • General subcutaneous edema.
  • 2022-05-05 KUB
    • Some calcifications in pelvic cavity.
    • Presence of ileus.
    • Intact bony structure(s).
  • 2022-05-05 Chest PA erect view
    • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage.

[assessment]

• Items in active problem list were treated with corresponding agents
  • metabolic acidosis - sodium bicarbonate
  • hyperkalemia - calcium polystyrene sulfonate
  • hypertension - nifedipine, clonide, doxazosin, carvedilol
  • type II diabetes - linagliptin, repaglinide
• Beta-blockers can potentially increase blood glucose concentrations and antagonize the action of oral hypoglycemic drugs, however the odds are greater for selective beta blockers than for carvedilol. reference: https://cardiab.biomedcentral.com/articles/10.1186/s12933-019-0967-1
• There are no records of drug allergies in the database. There are no issues with the current medication.

701096428

220505

[objective]

• exam finding
  • 2022-04-11 CT - abdomen, pelvis
    • Indication: Right ovarian cancer, pT2bN0; stage IIB; FIGO stage IIB post Debulking surgery s/p C/T with BEP recurrence s/p Debulking surgery on 2021/10/25
    • Abdominal CT with and without enhancement revealed:
      • s/p ATH and BSO.
      • Soft tissue mass at right pelvic floor up to 3.44*1.65cm in largest dimension. In comparison with CT dated on 2021-10-04, the lesion regressed.
      • s/p drainage tube placement at pelvis is found.
      • Wall thickening of the urinary bladder is found.
      • One cystic change at splenic tip up to 0.6cm in largest dimension is found. Stable. Simple cyst is considered.
      • Calcified coronary arteries is found.
      • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
      • Suggest clinical correlation
    • IMp:
      • Right ovarian cancer s/p BSO and ATH with recurrence s/p dubulking surgery. Residual soft tissue mass at right pelvis side wall. In regression.
      • Wall thickening of the urinary bladder, post op. change? Ovarian seeding at bladder out-layer? Suggest closely follow up.
  • 2022-02-18 Chest PA erect view
    • Atherosclerotic change of aortic arch
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2021-10-26 Patho - soft tissue tumor, extenstive resection
    • S2021-14976:
      • Soft tissue, pelvic, excision — consistent with recurrent malignant ovarian sex cord tumor
        
    • F2021-420:
      • Soft tissue, pelvic, excision — consistent with recurrent malignant ovarian sex cord tumor
        
  • 2021-10-25 Frozen section
    • Preliminary diagnosis:
      • Soft tissue, pelvic, biopsy — consistent with recurrent malignant tumor
        
  • 2021-10-12 Whole body PET scan
    • An inhomogenous glucose hypermetabolic lesion in the right posterior lower pelvic cavity. A recurrent tumor should be considered.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammatory process may show this picture.
    • Increased FDG uptake in bilateral masseter muslces and increased FDG accumulation in the colon, rectum, both kidneys and bilateral ureters. Physiological FDG uptake/accumulation is more likely.
  • 2021-10-04 CT - abdomen, pelvis
    • S/P hysterectomy. A soft tissue lesion (3.6x5.4cm) at right pelvic cavity with some cystic component suspected tumor recurrence.
  • 2021-08-16 Patho - soft tissue debridment
    • Skin and soft tissue, left anterior thigh., fasciectomy — Necrosis and acute inflammation.
  • 2021-08-13 CT - left femur
    • Abscess formation at left anterior thigh (vastus medialis muscle)and iliopsoas muscle
    • Cellulitis of left thigh
    • Post-OP change of pelvis with a mass lesion in right perirectal region.
  • 2021-05-20 Patho - soft tissue tumor, extensive resection
    • pathologic diagnosis
      • Ovary right, debulking surgery — Compatible with malignant ovarian sex cord tumor
      • Lymph nodes, pelvic, bilateral, BPLND — Negative for malignancy
      • Soft tissue, pelvic, debulking surgery — Metastatic tumor
      • AJCC 8 th edition, Pathology stage: pT2bN0; stage IIB; FIGO stage IIB
    • microscopic examination
      • Histologic Type: Compatible with malignant ovarian sex cord tumor
        
      • Histologic grade: High grade
        
      • Regional Lymph Nodes: All lymph nodes negative for tumor cells
        • number of lymph node examined: 4 (left iliac), 1 (left obturator), 4 (right iliac), 1 (right obturator)
          
      • Pathologic Stage
        • Primary Tumor: pT2b (tumor extension and/or implants on other pelvic tissues)
        • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
        • Distant Metastasis: Not applicable
      • Specimen labled “pelvic tumor”: Compatible with malignant ovarian sex cord tumor with pelvic seeding
      • IHC: WT1(+), CAM 5.2(+), CK(-), Inhibin(-), CD117(focally weakly+), DOG1(-), Desmin(-), Smooth mucle actin(-), CD34(-), S100(-), MDM2(-), STAT6(-)
        
  • 2021-05-19 Frozen section
    • Ovary right, frozen section — Favor malignant (pleomorphic epitheloid tumor cells with necrosis), tumor nature wait for paraffin section
  • 2021-05-13 Gynecologic ultrasonography
    • suspected pelvis mass > 25cm, malignancy can not be ruled out
• surgical operation
  • 2021-10-25
    • operation
      • Excision of pelvic cancer
      • HIPEC
      • IOUS
      • Tenckhoff insertion     - finding
      • s/p midline incision
      • Adhesion of small bowel was encountered.
      • IOUS: a recurrent ovarian cancer in the pelvic cavity adjacent to rectum
      • Pathologic report of frozen section: malignancy
      • HIPEC regimen: Lipodox 30mg/m^2 + Carboplatin AUC 5
      • Drain: 15 Fr Blake drain x 1 in the pelvic cavity
      • Tenckhoff catheter from RLQ
  • 2021-10-25
    • surgery
      • Debulking surgery + adhesiolysis     - finding
      • Supraumbilical midline vertical skin incision
      • Uterus: s/p hysterectomy
      • Adnexa: s/p Bilateral Salpingo-oophorectomy
      • CDS: adhesion with intestines
      • Moderate adhesion between omentum, small & large intestines and CDS
      • A 5x4 cm mass at right pelvic cavity with cystic component, beside the rectum.
      • s/p bilateral cystoscopic catheterization insertion before the operation
  • 2021-08-13
    • surgery
      • Deep debridement + fasciectomy + primary closure
    • finding
      • An abscess with necrotizing fasciitis and gas gangrene is found about 10*20cm in size over the left anterior thigh.
  • 2021-05-19
    • operation
      • enterolysis
      • excision of intraabdominal tumor
    • finding
      • s/p hystectomy
      • a bulky tumor mass in pelvic cavity with adhesion to small bowel and rectum
      • several bleeders in pelvic wall
  • 2021-05-19
    • surgery
      • Pelvic tumor, suspect malignancy
      • Frozen: sarcoma
      • Debulking surgery (tumor excision + pelvic lymph nodes dissection+ Cytoreduction surgery + infracolic omentectomy )        
    • finding
      • Supraumbilical midline vertical skin incision
      • Uterus: s/p hysterectomy
      • Adnexa: pelvic tumor 10*10 cm, invasion to posterior pelvic wall, intra-op rupture(+)
      • CDS: invisible due to tumor mass occupied
      • Ascites: bloody , about 500 ml
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: normal appearance, infracolic omentectomy was done.
      • Liver: grossly normal & smooth
      • Appendix: grossly normal.
      • After the operation, suboptimal debulking surgery was achieved.
      • Residue tumor: multiple tumors, maximal diameter more than 1 cm, over rectum and peritonealwall and bladder base
• chemotherapy
  • 2022-05-05 - paclitaxel + cisplatin
  • 2022-04-19 - paclitaxel
  • 2022-04-12 - paclitaxel + cisplatin
  • 2022-03-16 - paclitaxel
  • 2022-03-09 - paclitaxel + cisplatin
  • 2022-02-16 - paclitaxel
  • 2022-02-08 - paclitaxel + cisplatin
  • 2022-01-13 - paclitaxel
  • 2022-01-05 - paclitaxel + cisplatin
  • 2021-12-24 - paclitaxel
  • 2021-12-16 - paclitaxel + cisplatin
  • 2021-11-22 - paclitaxel + cisplatin
  • 2021-10-23 - liposome doxorubicin + carboplatin
  • 2021-09-22 - bleomycin
  • 2021-09-13 - bleomycin + etoposide + cisplatin
  • 2021-07-14 - bleomycin + etoposide + cisplatin
  • 2021-07-01 - bleomycin
  • 2021-06-24 - bleomycin
  • 2021-06-17 - bleomycin + etoposide + cisplatin (BEP)

[assessment]

• The CT (2022-04-11) showed a residual soft tissue mass over the right pelvis side wall in regression, as well as a thickening of the bladder wall. At least a partial response was achieved by the current regimen [paclitaxel + cisplatin] so far.
• The blood concentrations of cations have remained relatively low in recent months. Mg 1.4 mg/dL, K 3.8 mmol/L, Na 134 mmol/L (2022-05-03), Ca 2.01 mmol/L (2022-04-18). Following administration of magnesium sulfate injections, Mg rebounded to 2.0 mg/dL on 2022-05-05.
• Poor control of blood sugar levels. A record of 422 mg/dL was obtained 2022-05-05 07:33, one hour after 8 units of insulin actrapid were administered. No HbA1c data found in recent 3 months.
• The last “acute embolism and thrombosis of unspecified deep veins of lower extremity” was diagnosed in cardiology OPD on 2021-11-19. There is no cardiology follow-up record since then, so it is unclear if the thrombosis risk remains for the purpose of determining the need for edoxaban.

220408

[assessment]

• Systemic therapy regimens for patients with recurrent advanced sex cord stromal tumors might include paclitaxel + carboplatin, EP (etoposide + cisplatin), or BEP (bleomycin + etoposide + cisplatin). The patient had received BEP from June to September 2021 and has been receiving paclitaxel + cisplatin since November 2021.
• The last three consecutive analyses of body fluid cytology (ascites, on 2022-02-18, 2022-03-14, 2022-03-18) after debulking surgery with HIPEC (2021-10-25) did not reveal granuloma or malignancy. Regarding the cancer, so far, not bad.
• Low serum magnesium level (1.6mg/dL on 2022-04-06) has been managed with prescribed magesium sulfate injection, however, high blood sugar reading (359mg/dL at 17:23 on 2022-04-07) should be monitored closely to determine whether a hypoglycemic agent is needed.

701113992

220504

[objective]

• diagnosis
  • Esophagus cancer (Squamous cell carcinoma) with right middle lobe lung metastasis, cT4bN2M1, stage IVB, s/p Tr and jejunostomy on 2022-02-18
• exam finding
  • 2022-05-03 Chest PA/AP view
    • Ground glass opacity in RUL.
  • 2022-04-18 Abdominal Ultrasonography
    • liver parenchyma disease (incomplete exam of liver)
    • bilateral renal cysts
    • pancreas obscured
    • left pleural effusion
  • 2022-04-06 Chest PA/AP view
    • S/P tracheostomy
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
    • Blunting of bilateral costal-phrenic angle is noted, which may be due to pleura effusion?
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • Otherwise, there is no significant abnormality of the chest. (Note that ground-glass lesion, small nodule or retrocardiac lesion might be missed on plain chest radiography.)
  • 2022-03-26 MRI - brain
    • Without- and with-contrast multiplanar cerebral MRI (including axial and coronal T1W FLAIR, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) and cerebral TOF MRA reveal:
      • General enlargement of cistern spaces and cortical sulci, indicating general brain atrophy.
      • Dilatation of ventricles, periventricular T2-hyperintense caps and flattening corpus callosum, indicating hydrocephalus.
      • Diffuse T2-hyperintensities in periventricular deep white matters, indicating leukoaraiosis.
      • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
      • No midline shift, nor space-occupying lesion.
      • No remarkable finding of skull base and bony structures.
      • No remarkable finding of bilateral orbital contents and optic nerves.
      • No remarkable finding of nasopharynx visible in these images.
      • Diffuse luminal irregularity with mild segmental stenosis of major intracranial arteries in MRA study (including bilateral ICAs, MCAs, ACAs, PCAs and VAs and BA).
    • IMP:
      • General brain atrophy.
      • Hydrocephalus.
      • Leukoaraiosis.
      • Intracranial artherosclerosis.
  • 2022-03-24 ENT hearing test
    • Tymp:
      • R’t type A; L’t type Ad.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR TO POOR
      • Average RE 63 dB HL; LE 65 dB HL.
      • Bil moderate to profound mixed type HL.
  • 2022-03-23 Nasopharyngoscopy
    • Rt. side tympanic membrane was in pattern of post tympanoplasty
    • Lt. side atrophic scar
  • 2022-03-16 Tc-99m MDP whole body bone scan
    • Increased radioactivity in the sternum, the nature is to be determined (post-traumatic change or other nature?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in the right rib cage, some lower C-, upper T- and L2-5 spines, bilateral sternoclavicular junctions, shoulders, right S-I joint, and knees.
  • 2022-02-16 Patho - esophageal biopsy
    • Esophageal tumor, 20-25 cm below incisors, biopsy — Squamous cell carcinoma
    • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated of the esophageal tumor tissue characterized by solid tumor cell nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrate in the stroma with focal necrosis.
    • Immunohistochemical stains of CK(+); P16(-), P63(+) and P53 (+, scant) for tumor.
  • 2022-02-15 CT - lung/mediastinum/pleura
    • advanced lower cervical esophageal cancer or Cervithorocic junction esophageal cancer with extensive adjacent structures involvement and regional LNs metastases d/d includes large conglomerated metastatic LAP.
    • LLL pneumonia and RML metatasis of lung.
  • 2022-02-15 Esophagogastroduodenoscopy
    • Diagnosis：
      • Highly suspect esophageal cancer, 20-25cm below the incisor, s/p biopsy
      • Esophageal stenosis, 20cm below the incisor
      • Gastric subepithelial lesion, fundus
      • Superficial gastritis
    • Suggestion：
      • Pursue pathology result
  • 2022-02-15 Bronchoscopy
    • Bronchoscopic diagnosis:
      • Upper airway external compression over upper trachea
      • left lower lobe bronchus: sputum impaction s/p bronchoscopic sunction
  • 2022-02-14 Esophagogastroduodenoscopy
    • Esophagus：
      • Luminal stenosis with acute angle was noted at 20cm below the incisor, suspect external compression. The endoscopy could not pass through it.
    • Diagnosis：
      • Esophageal stenosis, 20cm below the incisor, suspect external compression by left neck mass
    • Suggestion：
      • arrange CT: neck ~ chest
      • If EGD was indicated, slim-caliber scope is needed
  • 2017-05-25 Pelvis - THR
    • Marked disk space narrowing with spurs formation at L3-L4, L4-L5 levels due to spondylosis
• consultation
  • 2022-04-14 Rehabilitation
    • Dx: Cervithorocic junction esophageal cancer with extensive adjacent structures involvement and regional LNs metastases d/d includes large conglomerated metastatic LAP. LLL pneumonia and RML metatasis of lung
    • swallowign evaluation
      • no drooling
      • no choking with 3cc water
      • tongue ROM: intact
      • tongue muscle power : fair
      • delayed reflex (prolonged oral holding)
      • hyoid bone elevation: fair.
      • foreign body sensation during swallowing
      • no dyspnea upon examination
    • Plan
      • arrange swallowing training
      • consider arrnage PMR Dr. Wu’s OPD follow up for further OPD swallowing trainign program. Maybe arrange VFSS in the future
  • 2022-03-28 Dermatology
    • Q
      • For skin rash & icthing at back
    • A
      • This patient suffered frpm erythematous papules-patches on trunk for days.
      • Imp: Subacute dermatities
      • Suggestion:
        • Sinphardema 1 tubes, bid
        • Topsym cream 5 tubes, bid
        • Zaditen 1, bid
  • 2022-03-23 ENT
    • Q
      • For right ear tinnitus
      • This 85-year-old man, a patient of Eso cancer with Lns mets S/P Tr & J-tube inserted. He was admitted for CCRT. He complained of right ear tinnitus for 2 days. We need expertise to evaluate his condition thanks!
    • A
      • Local finding via scope:
        • Rt. side tympanic membrane was in pattern of post tympanoplasty
        • Lt. side atrophic scar
      • The tinnitus may be due to chemotherapy
      • We’ll arrange PTA exam this afternoon, thanks for your consultation.
  • 2022-03-09 Rehabilitation
    • Assessment
      • respiratory failure s/p intubation
      • advanced lower cervical esophageal cancer or Cervithorocic junction esophageal cancer with extensive adjacent structures involvement and regional LNs metastases
        
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation programs
      • W5 starts with standing balance training. caregiver transfer skills training. next W1 ambulation trianing.
    • Goal
      • Recondition, improve endurance and muscle strength
  • 2022-02-17 General and Gastroenterological Surgery.
    • Q
      • This time, he was admitted to MICU for treatment of hypercapnea respiratory failure post intubation with ventilator since 20220214. After admission, NG tube insert was done but failure. Dut to long term NPO status, so we need your help for TPN nutrition supply, thanks !
    • A
      • obj?
        • A case of esophageal cancer with obstruction who request nutrition support.
        • General appearance: ill looking
        • GI tract: Dysphagia (+), Abd pain (-), Abd distension (-), Nausea (-), Vomiting (-), Diarrhea (-), Poor appetite (+), Poor digestion (-), BW loss (-) , stool (+), Bowel sound (+)
          
        • Feeding: NPO (NG tube insert failure)
        • Allergy: NKA
        • Nutrition assessment: BH 172cm, BW 57.8kg, IBW 65kg, 89% IBW, BMI 19.5, BEE (calculated based on IBW) 1246kcal, TEE 1943kcal
        • Lab data: Alb 2.9, BUN 26, Cr 0.58, Na 133, K 3.6, BS 100
        • According to the patient’s present conditions, parenteral nutrition will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
      • PN suggestion:
        • F/U preAlb. ALP. rGT. T/D Bil GOT GPT TG
        • DC Bfluid 1000ml QD
        • SMOFkabiven central 1477ml QD, 61.5ml/hr
        • Lyo-Povigent 4ml/QD (add in TPN) (if out of stock, then use B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
        • Addaven 10ml/QD (add in TPN)
        • Total fluid 30-40ml/kg/day (2000-2500ml/day)
        • Feeding gastrostomy or feeding jejunostomy ASAP
      • PN monitor items
        • Check BW QW5 and record I/O Q8H
        • Check one touch Q6H for 2days, if stable QD check
        • Please control BS < 200 mg/dl with RI sliding scale
        • QW1 check CBC/DC
        • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
        • if TPN not sufficient, use YF5 or D10W instead.
      • postscript
        • 20220218 op, on feeding gastrostomy or feeding jejunostomy
        • 20220218 Sent to OR DC TPN, post-op PPN supply and try EN as soon as possible.
  • 2022-02-16 Radiation Oncology
    • Assessment
      • Suspicious advanced lower cervical esophageal cancer or cervithorocic junction esophageal cancer with extensive adjacent structures involvement and regional LNs metastases.
    • Plan
      • Radiotherapy can be considered for this patient if positive pathology report available and his condition stable (including respiration such as if s/p tracheostomy). Further discussion in tumor board (20220218).
  • 2022-02-16 Thoracic Surgery
    • Q
      • For tumor excision and tracheostomy
      • This 85-year-old male who had past history of: 1) BPH; 2) Thyroid cancer with squsamous cell carcinoma (Cheng Hsin general hospital in 20211126 report).
      • According to the description of the patient’s family and medical record. He suffered from poor appetite and general weakness since 2021-12, he went to VGHTPE and left neck neoplasm was noted by CT. Panendoscopy showed one protruding ulcerative lesion with luminal narrowing and easily contact bleeding was noted at 20 to 21 cm of incisor. The ordinary scope could not pass through the stenosis and we then shifted to nasoendoscope. Biopsy was done on 20220110 and pending biopsy result.
      • This time, progressive shortness of breath and fever intermittently since 20220210, he was sent to our ER for help. At ER, his consciousness clear, marked dyspnea with desaturation, stridor and left decreased breath sound were noted. ABG analysis showed CO2 retension (PaCO2: 61.8 -> 85.8 mmHg). Emergency intubation with ventilator was done. He was admitted to MICU for treatment of 1) hypercapnea post intubation with ventilator; 2) Suspect esophageal cancer survey.
      • After admission, keep on ventilator support. EGD was done which showed Esophageal stenosis, 20cm below the incisor, suspect external compression by left neck mass. Chest CT showed advanced lower cervical esophageal cancer or Cervithorocic junction esophageal cancer with extensive adjacent structures involvement and regional LNs metastases d/d includes large conglomerated metastatic LAP. LLL pneumonia and RML metatasis of lung. So we need your help for tumor excision and tracheostomy evaluation, thanks!
    • A
      • I have visited the patient and reviwed the images. If his family agree treatment, I will arrange tracheostomy, port-A and feeding jejunostomy. Thanks for your consultation!!
  • 2022-02-14 Anesthesiology
    • Q
      • For difficult intubation
        • This 85 y/o male patient had history of suspect esophageal cancer.
        • This time, he was admitted to MICU for hypercapnea with respiratory failure post intubation with ventilator. After admisison to MICU, irritable and dyspnea, stridor were noted. so we change endotracheal tube but difficult intubation, so we need your help, thanks!
    • A
      • We were consulted for emergent intubation.
      • A #6.5 ETT was placed via McGrath and fiber-scope fixed at 25cm.
      • Bil. breathing sounds were noticed equally.
      • SpO2 was 99-100% after the procedure.
      • Please f/u CXR.
• surgical operation
  • 2022-02-18 tracheostomy + port-A + jejunostomy
    • 7.0mm ID, 120mm length bivona tracheal tube in place
    • 8Fr. polysite port-A via right cephalic vein
    • 18 Fr. jejunosotmy tube

[assessment]

• The patient is an elderly male suffering from esophageal cancer (squamous cell carcinoma) with RML lung mets following tracheostomy and jejunostomy (Op on 2022-02-18).
• The advanced age could necessitate shared decision-making prior to cancer-specific treatment, taking into account the patient’s overall life expectancy. Alternatively, the following regimen in combination with RT might also be considered:
  • Paclitaxel + carboplatin
  • Fluorouracil + oxaliplatin
  • Fluorouracil + cisplatin
• The S-GPT/ALT level was normal in early 2022-04, rose above 50 U/L on 2022-04-11 and reached 113 U/L on 2022-05-03. No hepatitis virus lab data were found. During that period, no medications other than herbal medicine were prescribed according to in-hospital records. Access to NHI-PharmaCloud is not authorized. Further study might be needed.
• There could be a decrease in ventilation efficiency due to lung mets, making oxygenation more important. Lab data showed RBC 3.62*10^3/uL and HGB 10.8g/dL on 2022-05-03, both below normal limits. There might be a need for monitoring.
• Pneumonia at RUL is treated with Tapimycin 4.5g IVD Q6H currently.

700167626

220503

• There is only one item remaining on the list of current active problems: fever with UTI since 2022-04-29.
• Escherichia coli 33000 CFU/cc were found in urine culture, and Staphylococcus epidermidis were found in blood culture.
• Following administration of Flumarin (flomoxef) 1000mg IVD Q12H since 2022-04-29, the patient’s temperature became stable on 2022-05-02 afternoon, and no higher than 37 degrees Celsus observed so far.
• Underlying diseases are managed with corresponding medicine.

701186882

220503

[objective]

• This 43 years old female patient has the history of: 1) Chronic kidney disease for 10 years; 2) Ulcerative colitis with medical treatment for 20 years; 3) Fourth degree hemorrhoids status post hemorrhoidectomy on 20210623; 4) Left arteriovenous fistula on 20220124.

• diagnosis

  • chronic kidney disease, stage 5
  • anemia, unspecified
  • ulcerative colitis without complications
  • fever, unspecified

• exam finding

  • 2022-05-02 Abdominal Ultrasonography
    • Parenchymal renal disease
    • Renal cyst, right
    • Gallbladder sludge
    • Minimal ascites
  • 2022-03-08 Abdominal Ultrasonography
    • Parenchymal renal disease
  • 2021-11-19 Renal ultrasound
    • Chronic renal parenchymal disease, advanced degree
  • 2021-06-23 Patho - hemorrhoids
    • Anus, hemorrhoidectomy — hemorrhoid
    • Microscopically, it shows dilatation of venous plexus with congestion.

• lab data

  • 2022-03-11
    • HSV 1 IgG positive
    • HSV 1 IgG Value 53.6 RU/mL
    • HSV 2 IgG negative
    • HSV 2 IgG Value < 0.50
    • HSV 1 IgM negative
    • HSV 1 IgM Value 0.05
    • HSV 2 IgM negative
    • HSV 2 IgM Value 0.08
  • 2022-03-10
    • EB VCA IgA positive
    • EB VCA IgA Value 1.9
    • EB VCA IgG positive
    • EB VCA IgG Value 8.6
    • Toxoplasma IgG negative IU/mL
    • Toxoplasma IgG Value 0.2 IU/mL
      
    • Toxoplasma IgM negative
    • Toxoplasma IgM-index 0.05
    • HLA A 11
      
    • HLA A 24
      
    • HLA B 60
      
    • HLA B 61
      
    • HLA C 9
      
    • HLA C 10
      
  • 2022-03-09
    • EB VCA IgM negative
    • EB VCA IgM Value 0.0
      
    • VZV IgM negative
    • VZV IgM Value 0.1
    • CMV_IgG Reactive
      
    • CMV_IgG Value 937.1 AU/mL
      
    • CMV IgM Nonreactive
      
    • CMV IgM Value 0.19 Index
      
  • 2022-03-08
    • VZV IgG positive
    • VZV-G Value 3.1
  • 2022-02-22
    • Thyroglobulin 12.95 ng/mL
      
  • 2022-02-21
    • RPR/VDRL Nonreactive
      
    • RH(D) Positive
      
    • Blood type ABO O
      
    • HBsAg Nonreactive
      
    • HBsAg (Value) 0.28 S/CO
    • Anti-HBc Nonreactive
      
    • Anti-HBc-Value 0.14 S/CO
    • Anti-HCV Nonreactive
      
    • Anti-HCV Value 0.08 S/CO
      
    • Anti HTLV I/II Nonreactive
      
    • Anti HTLV I/II Value 0.06 S/CO
      
    • HIV Ab-EIA Nonreactive
      
    • Anti-HIV Value 0.05 S/CO
      
    • Anti-HBe S/CO
      
    • Anti-HBe Nonreactive
      
    • Anti-HBe Ratio 1.56 S/CO
      
    • Anti-HBs 376.18 mIU/mL
      
    • HBeAg(EIA) S/CO
      
    • HBeAg Nonreactive
      
    • HBeAg(Value) 0.362 S/CO
      
    • RF <10 IU/mL
      
    • CA125 14.8 U/mL
      
    • CA153 7.7 U/mL
      
    • CA199 34.20 U/mL
      
    • CEA 3.62 ng/mL
      
    • AFP 2.1 ng/mL
      
  • 2020-05-14
    • ANA Negative
      
  • 2020-05-13
    • Zinc,Zn 621 ug/L
      
  • 2020-05-11
    • Anti-ENA SS-A(Ro) 0.4 EliA U/ml
      
    • Anti-ENA SS-B(La) 0.4 EliA U/ml
      
    • TPHA <1:80
      
  • 2020-05-08
    • RPR/VDRL Nonreactive
      
    • Ferritin 105.3 ng/mL
      
    • T3 0.88 ng/dL
      
    • TSH 1.373 uIU/mL
      
    • Free-T4 0.80 ng/dL
      
    • Ferritin 110.1 ng/mL

• surgical operation

  • 2022-01-24 Creation of LT wrist AVF        
    • Left Radial Artery: Calcification(-), Diameter(2.3)mm
    • Cephalic Vein: Stenosis(-), Fibrosis(-),Transpostion(-),Diameter(3.0)mm
    • Anastomosis of Left Radial artery & cephalic vein with 7-0 prolene.   
  • 2021-06-23 Hemorrhoidectomy        
    • Prolasped hemorrhoids at 3,7,11 o’clock        
    • Easy bleeding, Naldebain

[assessment]

This patient has CKD stage 5 adminitted on 2022-04-29

CKD stage 5, high Creatinine, high BUN, high phosphorus, low calcium, low bicarbonate normal CRP and WBC AV shunt

701361784

220429

[objective]

• exam finding
  • 2022-03-27 Chest
    • Lung markings: emphysematous change in the bilateral lung fields
  • 2022-03-26
    • Fecal material store in the colon.
    • Spondylosis of the L-spine is noted.
  • 2022-03-26 Femur LT
    • Left femoral intersubtrochanteric fracture, s/p ORIF
  • 2022-03-14 Chest
    • Atherosclerosis of the aorta.
  • 2022-03-08 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, spleen, stomach and bones/bone marrow (stage IV).
  • 2022-03-07 Bone densitometry - hip
    • Right hip, BMD is 0.537 gms/cm2, about 2.8 SD below the peak bone mass (63%) and 0.3 SD below the mean of age-matched people (95%).
    • Osteoporosis
  • 2022-02-25 Patho - lymphnode biopsy
    • pathologic diagnosis
      • Left subhepatic lesion, CT-guide biopsy — High grade B cell lymphoma, favor diffuse large B-cell lymphoma
        
    • microscopic examination
      • Histology type: high grade B cell lymphoma shows medium to large atypical lymphoid cells with nucleoli, frequent apoptosis and focal tumor necrosis.
      • Immunohistochemistry: CK(-), CD3(-), CD20(+), Bcl-2(-), CD30(-), CD10(+), Bcl-6(+), C-MYC(+, 80%), cyclin-D1(-) and Ki-67:>90% for tumor. According to all above histopathologic findings, it is in favor of diffuse large B-cell lymphoma, and Burkitt’s lymphoma is less likely, but can not be entirely excluded due to limited specimen.
  • 2022-02-18 MRI - liver, spleen (non-contrast)
    • Non-contrast MRI has limitation in diagnosis of solid organ pathology, bowel loop lesion, and vascular system abnormality. We recommend contrast enhanced MRI if patient’s renal function can tolerate Gd-DTPA injection.
      • There are several lobulated soft tissue masses in the hepatic hilum, gastrohepatic ligament, hepatoduodenal ligament, aortocaval space, and right perirenal space. In addition, One enlarged node measuring 1.9 x 1.4 cm in right supradiaphram cardiac-phrenic space is noted. Three soft tissue masses in the omentum are noted. Malignant lymphoma is highly suspected.
      • There is a well-defined heterogeneous mass measuring 5 x 3.2 cm in the submucosal layer of the gastric body that may be lymphoma. Please correlate with gastroscopy.
      • There is edematous wall thickening and distension of the gallbladder, and mild dilatations of IHDs and CHD. Please correlate with clinical condition.
      • Both kidney show small size and thin renal parenchyma that are compatible with chronic renal disease. Please correlate with renal function.
      • Mild ascites is noted.
      • Mild right side pleura effusion is noted.
      • There is no focal abnormality in the pancreas and spleen.
      • The abdominal aorta and IVC are grossly unremarkable.
        
    • Malignant lymphoma is highly suspected. Please correlate with biopsy and serum LDH level.
• lab data
  • 2022-02-17
    • Anti-HBc reactive, 4.57 S/CO
    • Anti-HCV nonreactive, 0.10 S/CO
    • HBsAg nonreactive, 0.34 S/CO
• consultation
  • 2022-04-19 cardiology
    • Q
      • For hypertension poor control
      • This 72-year-old female, a pt of double-hit DLBCL at troperitoneal fossa, Lugano stage IV Dx in Feb 2022 S/P C/T. She was admitted for chemotherapy. Owing to high blood perssure was noted (195/91 mmHg) and anti-hypertensive agent was given but still poor control. We need expertise to evaluate her condition thanks!
    • A
      • This is a 72 years old lady who was admitted for Diffuse large B cell lymphoma under R-DA-EPOCH therapy. We were consulted for poor control BP
      • Current medication
        • concor 5mg 1# qd
        • hyzaar 1# qd
      • exam
        • BP: 195/91 (most of the day: SBP>160)
        • HR: 80
        • EKG: LVH pattern
        • CXR: normal heart size
        • Cr 2.0
        • UA 10.5;
      • Impression
        • Hypertensive cardiovascular disease with poor cpntrol; suspected C/T induced.
      • Suggestion
        • May add sevikar 1# qd; regular use of apresoline if SBP still >160 mmHg.
        • DC hyzare due to significant hyperuricemia.
        • Check chemotherapy side effect (whether using tyrosine kinase inhibitor? VEGF inhibitor?), and change regimen if feasible.
  • 2022-02-25 cardiology
    • S: abdominal pain
    • O:
      • Labs
        • Cr: 1.75 -> 2.43 -> 1.2
        • CRP: 4
        • Na/K: 136/4.2
      • Cardiac echo: EF: 70%
        • Normal LV systolic function with normal wall motion.
        • Hypertrophic cardiomyopathy without outflow tract obstruction; LV diastolic dysfunction Gr 1.
      • Current BP medications
        • PO concor and po hyzaar
    • Impression:
      • Hypertensive cardiovascular disease, without acute hypertensive crisis
      • Hypertrophic cardiomyopathy without outflow tract obstruction
      • Suspected cholangiocarcinoma or suspected lymphoma
    • Suggestion:
      • Adequate pain control if patient is in pain due to fracture or abdominal pain.
      • Add norvasc 1# qd - bid.
      • to keep concor 5 mg qd
  • 2022-02-23 radiological diagnosis
    • According to the clinical condition and imaging findings, biopsy is indicated.
  • 2022-02-16 surgery
    • a huge tumor near liver hilum, liver origin? pancreatic origin? or lymphoma
      • admission for tumor survey
      • check MRI and tumor markers after admission
      • check HBsAg, anti-HCV, anti-HBs, anti-HBc
• chemotherapy
  • 2022-03-15 ~ undergoing - R-DA-EPOCH, Dose-adjusted EPOCH-R,
    • etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, plus rituximab
      • https://www.uptodate.com/contents/image?imageKey=ONC%2F88411
      • drugs
        • Rituximab, 375 mg/m2 IV, Day 0 or 1
        • Etoposide, 50 mg/m2 per day IV, Days 1 to 4 (96 hours)
        • Doxorubicin, 10 mg/m2 per day IV, Days 1 to 4 (96 hours)
        • Vincristine, 0.4 mg/m2 per day IV (dose not capped), Days 1 to 4 (96 hours)
        • Cyclophosphamide, 750 mg/m2 IV, Day 5
        • Prednisone, 60 mg/m2 orally twice daily, Administer first dose 30 minutes prior to chemotherapy on day 1., Days 1 to 5
        • Granulocyte colony stimulating factor (G-CSF), Start day 6
    • Pretreatment considerations:
      • Hydration
        • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day) and void frequently to reduce risk of hemorrhagic cystitis.
      • Emesis risk
        • MODERATE.
      • Prophylaxis for infusion reactions
        • Premedicate with acetaminophen and diphenhydramine, with or without an H2 receptor blocker, 30 minutes prior to at least the first and second infusions of rituximab.
      • Vesicant/irritant properties
        • Doxorubicin and vincristine are vesicants; avoid extravasation. Etoposide is an irritant.
      • Infection prophylaxis
        • Primary prophylaxis with hematopoietic growth factors is an essential component of this regimen. Regular or pegylated G-CSF may be used according to center policy. In addition, due to the risk of developing Pneumocystis jiroveci pneumonia and other opportunistic infections, consider the use of antimicrobial prophylaxis.
      • Dose adjustment for baseline liver or renal dysfunction
        • Adjustment of initial cyclophosphamide, doxorubicin, etoposide, and vincristine doses may be needed for preexisting liver dysfunction. In addition, dose adjustment of etoposide and cyclophosphamide may be required for renal dysfunction.
      • Hepatitis screening
        • Patients should be screened for hepatitis B and C prior to starting rituximab, and, if positive, considered for antiviral prophylaxis.
      • Cardiac screening
        • Doxorubicin is associated with cardiomyopathy, the incidence of which is related to cumulative dose. Assess baseline LVEF prior to initiation of therapy. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation, those with recent myocardial infarction, severe myocardial dysfunction, severe arrhythmia, or previous therapy with high cumulative doses of doxorubicin or any other anthracyclines.
      • CNS prophylaxis
        • The need for CNS prophylaxis is determined based upon the aggressiveness of the tumor reflected in the histology, organ involvement, and presence or absence of high risk features.
      • HIV screening
        • Patients should be screened for HIV prior to starting therapy. Consider reducing the initial dose of cyclophosphamide to 187 mg/m2 if CD4 <100/microL at diagnosis.
      • Neurotoxicity
        • Vincristine may cause constipation, and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine.
    • Monitoring parameters:
      • CBC with differential and platelet count twice weekly during treatment.
      • Assess basic metabolic panel (creatinine and electrolytes) and liver function prior to each subsequent treatment cycle.
      • Monitor cumulative doxorubicin dose. Reassess LVEF periodically during dose-adjusted EPOCH-R therapy, as clinically indicated.
      • Carriers of hepatitis B or C should be monitored for clinical and laboratory signs of active infection during and following completion of therapy. Rituximab should be discontinued if reactivation occurs.

[assessment]

• SBP 190~140 (most times > 150), DBP 65~90, HR no less than 100 pulse per minite since 2022-04-28 this hospitalization so far, under Concor (bisoprolol 5mg, QD), Sevikar (amlodipine 5mg + olmesartan 20mg, QD) prescribed as self-carried drugs since 2022-04-29. Chemotherapy has not yet been administered for now in this hospital stay.
• WBC 310/uL, Neutrophil 18%, CRP 5.24 mg/dL, RBC 2.610^6/uL, HGB 8.0g/dL, PLT 4310^3/uL, normal urine exam results on 2022-04-28, body temperature 39.3 degree Celsius at 07:41 2022-04-29.
• Primary prophylaxis with hematopoietic growth factors should be a component of the R-DA-EPOCH regimen. Chemotherapy induced cytopenia is managed with Granocyte (lenograstim 250mcg, QD). Elevations of CRP occur in association with acute and chronic inflammation due to a range of causes, including infectious diseases and noninfectious inflammatory disorders. Elevated CRP with fever is managed with Tapimycin (piperacillin 2g + tazobactam 0.25g, Q8H). Due to the risk of developing Pneumocystis jiroveci pneumonia and other opportunistic infections, the use of antimicrobial prophylaxis might be necessary. reference: https://pubmed.ncbi.nlm.nih.gov/11929754/
• Doxorubicin is associated with cardiomyopathy, the incidence of which is related to cumulative dose. The baseline LVEF prior to chemotherapy initiation on 2022-02-22 was 70%, this does not suggest a dose alteration.
• The patient was screened for hepatitis B and C prior to starting rituximab and is now receiving Vemlidy (tenofovir alafenamide 25mg QDCC) for her HBV infection.

220418

[assessment]

• Pathology on 2022-02-25 revealed that C-MYC(+, 80%), BCL-2(-), BCL-6(+), high-grade B-cell lymphoma (HGBL) with translocations of MYC and BCL6, also known as double-hit lymphoma, is frequently associated with poor prognostic factors, including elevated LDH, bone marrow and central nervous system involvement, and high IPI score.
• PET on 2022-03-08 indiated involvement of multiple lymph nodes on both sides of the diaphragm, spleen, stomach and bones/bone marrow, stage IV.
• DA-EPOCH-R has been in use since 2022-03-15, the LDH has decreased to 181 U/L (2022-04-15, WNL) from its peak of 1364 U/L (2022-03-16), which might hint an improvement, and no evidence of CNS involvement has yet been confirmed.
• Vincristine may cause constipation, and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine. Metoclopramide and sennoside have been prescribed.
• Hypomagnesemia (1.4 mg/dL 2022-04-18) is treated with MgSO4 10% 20mL IVD QD currently.

700126665

220427

{synchronous double (breast and colon) primary tumors s/p MRM s/p hemicolectomy}

[objective]

• exam findings
  • 2022-03-16 CT - abdomen, pelvis
    • Liver metastases S/P C/T show progressive disease.
    • Mechanical small bowel obstruction is noted. However, the transition zone is hard to identify. The differential diagnosis include tumor seeding or adhesion.
    • A soft tissue nodule 5 mm in LUQ omentum is noted that may be tumor seeding. Ascites in right subphrenic space and Morison pouch.
  • 2022-02-08 ultrasound - abdomen
    • Hepatic tumor, nature to be determinated
    • Hepatic cyst, GB stone
  • 2022-01-20 esophagogastroduodenoscopy
    • suspected gastric intestinal metaplasia, antrum and low body, s/p biopsy at antrum, GC
  • 2021-11-30 CT - ABD
    • Post-op at the colon and small bowel loops.
    • RLQ peritoneal soft tissue tumors, suspected carcinomatosis.
    • Newly developed liver tumors, suspected liver metastasis.
    • Liver and renal cysts.
  • 2021-08-03 patho - small intestine resection for tumor
    • mucinous adenocarcinoma, colonic origin
    • IHC: CK7(-), CK20(+), CDX2(+) and GATA-3(-), colonic origin
  • 2021-07-27 whole body PET scan
    • two glucose hypermetabolic lesions in the liver, some glucose hypermetabolic lesions in the abdominal cavity and a glucose hypermetabolic lesion in the umbilicus. metastatic lesions should be considered first.
  • 2021-01-20 patho - colon segmental resection for tumor
    • tumor, transverse colon, SILS left hemicolectomy - mucinous adenocarcinoma - pT3N0 (if cM0), stage IIA
  • 2021-01-19 patho - breast mastectomy with regional lymph nodes
    • breast, right, modified radical mastectomy - invasive carcinoma. grade 2.
    • lymph node, right axilla, lymphadenecomy - metastatic carcinoma.
    • pathology stage: pT2 pN2 (if cM0); anatomic stage: IIIA, pathology prognostic stage: IIIA
  • 2021-01-12 patho - colorectal polyp
    • adenocarcinoma. IHC stain: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
  • 2020-12-28 patho - lymphnode biopsy
    • axilla, right, core biopsy - invasive carcinoma.
    • IHC stains: CK (+).
  • 2020-12-28 patho - breast biopsy (no margin)
    • invasive carcinoma, no special type.
    • IHC stains: ER (+, strong intensity, 95%), PR(-), Her2/neu: negative (score=0), Ki-67(<2%).
• consultation
  • 2021-01-18 Rehabilitation
    • Imp
      • Right breast invasive carcinoma with axillary metastasis
      • Lymphoma 30+ yrs ago
      • T-colon cancer found in 2020/12
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation and home program education
      • Goal: Functional ability ID, maintain ROM, prevent post-OP complications
• surgical operations
  • 2021-08-02 surgical operation
    • local excision abdominal wall tumor + small bowel resection with anastomosis
  • 2021-01-19 surgical operation
    • right breast MRM (modified radical mastectomy)
    • SILS (single incision laparoscopic surgery) left hemicolectomy + laparoscopic adhesionolysis
• radiotherapy
  • 2021-07-15 ~ -07-30
    • 2400cGy/12 fractions (6 MV photon) to rt chestwall and SCF lymph nodes
• chemo regimen
  • 2022-03-18 ~ undergoing - FOLFOX
  • 2021-11-16 ~ 2022-03-02 - FOLFIRI
  • 2021-08-20, -11-03
    • 5-Fu (fluorouracil) + Covorin (leucovorin)
  • 2021-04-28, -05-19, -05-26
    • Nolbaxol (docetaxel)
  • 2021-02-02, -02-24, -03-17, -04-08
    • Lipo-Dox (liposome doxorubicin) + Endoxan (cyclophosphamide)

[assessment]

• The patient admitted to receive FOLFOX treatment, the current regimen being used since 2022-03-18.
• No images have been updated since last hospitalization. The lab data reported on 2022-04-25 showed slightly elevated levels of BUN (43 mg/dL), creatinine (1.32 mg/dL), bilirubin total (1.26 mg/dL) and decreased level of potassium (3.2 mmol/L); these results should not affect the chemotherapy procedure.
• TPR 36/106/17, BP 105/59 recorded at 19:50 2022-04-26. Insufficient blood pressure caused a faster pulse?
• Drugs prescribed in the OPD have been put as self-carried items in the list of active medications.

220412

[assessment]

• A patient with synchronous double primary cancers s/p surgery; systemic therapy was initially focused on breast cancer from 2021-02 to 2021-05, and then refocused on colon cancer from 2021-08 based on clinical judgment.
• The CEA and CA199 levels have been trending upward from 43ng/mL and 59U/mL (2021-12-13) to 130ng/mL and 83U/mL (2022-04-07) respectively. Abdominal CT on 2022-03-16 showed progression of liver mets and possible peritoneal seeding.
• As a result of the disease being resistant to FOLFIRI, the regimen has switched to FOLFOX since 2022-03-18.
• Sundowning-like behaviors were observed during last hospital stay (2022-03-12 ~ 2022-03-31). According to nursing notes, these behaviors did not occur since this admission.
• Lab data reported on 2022-04-06 showed normal liver and kidney function and no obvious abnormalities with CBC and WBC readings.

220315

• Lab data reported on 2022-03-15 showed stool OB 3+, stool glutamate dehydrogenase (GDH) positive, Clostridium difficile toxin A/B negative.
• Colonization with nontoxinogenic strains also affords protection. This observation suggests that the initial colonizing strain may occupy a microbial niche in the large intestine that is protective against superinfection with a new toxin-producing C. difficile strain
• The antibiotics most frequently implicated in predisposition to C. difficile infection (CDI) include fluoroquinolones, clindamycin, penicillins, and cephalosporins.

220225

• no updated exam findings as of last hospitalization (2022-02-10).
• new lab data showed lower serum potassium 3.2mmol/L (reported on 2022-02-22) is treated with 0.298% KCl in NaCl 500mL IVD QD.
• neutrophil is just above 1500/uL (WBC 2910/uL, Neutrophil 58%, 2022-02-22) should be regularly monitored.

220210

{synchronous double (breast and colon) primary tumors s/p MRM s/p hemicolectomy}

[objective]

• exam findings
  • 2022-02-08 ultrasound - abd
    • Hepatic tumor, nature to be determinated
    • Hepatic cyst, GB stone
  • 2022-01-20 esophagogastroduodenoscopy
    • suspected gastric intestinal metaplasia, antrum and low body, s/p biopsy at antrum, GC
  • 2021-11-30 CT - ABD
    • Post-op at the colon and small bowel loops.
    • RLQ peritoneal soft tissue tumors, suspected carcinomatosis.
    • Newly developed liver tumors, suspected liver metastasis.
    • Liver and renal cysts.
  • 2021-08-03 patho - small intestine resection for tumor
    • mucinous adenocarcinoma, colonic origin
    • IHC: CK7(-), CK20(+), CDX2(+) and GATA-3(-), colonic origin
  • 2021-07-27 whole body PET scan
    • two glucose hypermetabolic lesions in the liver, some glucose hypermetabolic lesions in the abdominal cavity and a glucose hypermetabolic lesion in the umbilicus. metastatic lesions should be considered first.
  • 2021-01-20 patho - colon segmental resection for tumor
    • tumor, transverse colon, SILS left hemicolectomy - mucinous adenocarcinoma - pT3N0 (if cM0), stage IIA
  • 2021-01-19 patho - breast mastectomy with regional lymph nodes
    • breast, right, modified radical mastectomy - invasive carcinoma. grade 2.
    • lymph node, right axilla, lymphadenecomy - metastatic carcinoma.
    • pathology stage: pT2 pN2 (if cM0); anatomic stage: IIIA, pathology prognostic stage: IIIA
  • 2021-01-12 patho - colorectal polyp
    • adenocarcinoma. IHC stain: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
  • 2020-12-28 patho - lymphnode biopsy
    • axilla, right, core biopsy - invasive carcinoma.
    • IHC stains: CK (+).
  • 2020-12-28 patho - breast biopsy (no margin)
    • invasive carcinoma, no special type.
    • IHC stains: ER (+, strong intensity, 95%), PR(-), Her2/neu: negative (score=0), Ki-67(<2%).
• surgical operations
  • 2021-08-02 surgical operation
    • local excision abdominal wall tumor + small bowel resection with anastomosis
  • 2021-01-19 surgical operation
    • right breast MRM (modified radical mastectomy)
    • SILS (single incision laparoscopic surgery) left hemicolectomy + laparoscopic adhesionolysis
• radiotherapy
  • 2021-07-15 ~ -07-30
    • 2400cGy/12 fractions (6 MV photon) to rt chestwall and SCF lymph nodes
• chemo regimen
  • 2021-11-16 ~ ongoing FOLFIRI
  • 2021-08-20, -11-03
    • 5-Fu (fluorouracil) + Covorin (leucovorin)
  • 2021-04-28, -05-19, -05-26
    • Nolbaxol (docetaxel)
  • 2021-02-02, -02-24, -03-17, -04-08
    • Lipo-Dox (liposome doxorubicin) + Endoxan (cyclophosphamide)

[assessment]

• synchronous double primary cancers s/p surgical operation
  • systemic therapy had been focused on breast cancer from 2021-02 to 2021-05, then refocused on colon cancer since 2021-08 based on clinical judgement.
  • time serial CEA readings trend up slowly from 2021-07-27 25.48ng/mL to 2022-02-07 66.56ng/mL during last half year.
  • newly found liver tumor could be another metastatic lesion.
• drugs approved by FDA for both breast cancer and colon cancer include: 5-FU, capecitabine, pembrolizumab.
  • polyp patho showed pMMR, pembrolizumab might not be indicated.
  • bevacizumab might be considered if no contraindication.
• EGFR overexpression (up-regulation or amplification) or mutation is usually associated with progression and resistance of epithelial tumors.
  • reference: Wang Z. ErbB receptors and cancer. Methods Mol Biol. (2017)1652:3-35. doi:10.1007/978-1-4939-7219-7_1
  • cetuximab or panitumumab might be considered if no contraindication.
• liver and kidney functions showed no abnormality based on ALT, AST, and creatinine reported on 2022-02-07.
  • introduction of irinotecan should not likely to be restricted.
• no drug allergy recorded in database, no issue found in current medication.

210908

{synchronous double (breast and colon) primary tumors s/p MRM s/p hemicolectomy}

[history]

• lymphoma at appendix s/p C/T 30+ years ago at Taipei City Hospital RenAi Branch

[definite diagnosis, disease extent]

• 2020-12-28 patho - breast biopsy (no margin)
  • diagnosis
    • invasive carcinoma, no special type.
    • IHC stains: ER (+, strong intensity, 95%), PR(-), Her2/neu: negative (score=0), Ki-67(<2%).
  • microscopic description
    • fragments of breast tissue with irregular neoplastic ducts infiltration.
• 2020-12-28 patho - lymphnode biopsy
  • diagnosis
    • axilla, right, core biopsy - invasive carcinoma.
    • IHC stains: CK (+).
  • microscopic description
    • soft tissue with necrotic neoplastic ducts infiltration.
• 2021-01-12 patho - colorectal polyp
  • diagnosis
    • adenocarcinoma.
    • IHC stain: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • microscopic description
    • colonic tissue with invasive irregular neoplastic glands.
• 2021-01-19 patho - breast mastectomy with regional lymph nodes
  • pathologic diagnosis
    • breast, right, modified radical mastectomy - invasive carcinoma. grade 2.
    • lymph node, right axilla, lymphadenecomy - metastatic carcinoma.
    • pathology stage: pT2 pN2 (if cM0); anatomic stage: IIIA, pathology prognostic stage: IIIA
  • microscopic examination
    • histologic type: invasive carcinoma with approximtely 20-25% mucinous component
    • histologic grade (Nottingham histologic score): grade II (score 6,7)
• 2021-01-20 patho - colon segmental resection for tumor
  • pathologic diagnosis
    • tumor, transverse colon, SILS left hemicolectomy - mucinous adenocarcinoma
    • AJCC pathologic stage - pT3N0 (if cM0), stage IIA
  • microscopic examination
    • histology: mucinous adenocarcinoma
    • histology grade: G2, moderately differentiated
    • depth of invasion: pericolonic fat
    • angiolymphatic invasion: present
• 2021-07-27 whole body PET scan
  • two glucose hypermetabolic lesions in the liver, some glucose hypermetabolic lesions in the abdominal cavity and a glucose hypermetabolic lesion in the umbilicus. metastatic lesions should be considered first.
• 2021-08-03 patho - small intestine resection for tumor
  • pathologic diagnosis
    • tumor, under umbilicus, excision with small bowel resection - mucinous adenocarcinoma, colonic origin
    • small intestine, segmental resection - tumor invasion to subserosal fat
    • skin, umbilicus, excision - tumor invasion
    • hard nodule, small intestine, segmental resection - submucosal hematoma
    • lymph node, dissection - free from tumor metastasis (0/1)
  • microscopic examination
    • histology: mucinous adenocarcinoma. After discussing with surgeon, it is compatible with carcinomatosis
    • histology Grade: G2: moderately differentiated
    • depth of invasion: umbilical skin and subserosal fat of small bowel
    • angiolymphatic invasion: present
    • perineural invasion: present
    • pathological TNM Stage: compatible with carcinomatosis
    • IHC: CK7(-), CK20(+), CDX2(+) and GATA-3(-), colonic origin

[treatment]

• 2021-01-19 surgical operation
  • right breast MRM (modified radical mastectomy)
  • SILS (single incision laparoscopic surgery) left hemicolectomy + laparoscopic adhesionolysis
• 2021-02-02, -02-24, -03-17, -04-08 chemotherapy
  • Lipo-Dox (liposome doxorubicin) + Endoxan (cyclophosphamide)
• 2021-04-28, -05-19, -05-26 chemotherapy
  • Nolbaxol (docetaxel)
• 2021-07-15 ~ -07-30 radiotherapy
  • 2400cGy/12 fractions (6 MV photon) to rt chestwall and SCF lymph nodes
• 2021-08-02 surgical operation
  • local excision abdominal wall tumor + small bowel resection with anastomosis
• 2021-08-20, -09-06 chemotherapy
  • 5-Fu (fluorouracil) + Covorin (leucovorin)
  • irinotecan and bevacizumab are supposed to be added

[assessment]

• synchronous double primary cancers s/p surgical operation
  • systemic therapy had been focused on breast cancer from 2021-02 to 2021-05, refocused on colon cancer since 2021-08 based on clinical judgement.
• drugs approved by FDA for both breast cancer and colon cancer include: 5-FU, capecitabine, pembrolizumab.
  • polyp patho showed pMMR, pembrolizumab might not be indicated.
• liver and kidney functions showed no obvious abnormality based on ALT, AST, and creatinine reported on 2021-09-02.
  • introduction of irinotecan should not likely to be restricted because of hepatic dysfunction.

700529746

220426

• 2022-04-25 Chest PA/AP view
  • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • S/P coronary artery stent implantation.
  • Spondylosis of the T-spine
  • Compression fracture of L1 vertebral body S/P cement vertebroplasty.
• 2022-04-22 Chest PA/AP view
  • S/P operation.
  • S/P Port-A infusion catheter insertion.
  • S/P VP.
  • Patch density at bil. lungs.
• 2022-04-18 MRI - upper abdomen
  • S/P operation.
  • Multiple LNs, lung and liver metastases.
  • Bil. pleural effusion.
• 2022-04-18 Chest PA + Lat. LT
  • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
  • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • S/P coronary artery stent implantation.
  • Spondylosis of the T-spine
  • Compression fracture of L1 vertebral body S/P cement vertebroplasty.
• 2022-04-01 Tc-99m MDP whole body bone scan
  • Increased activity in the lower C-spine, lower T- and upper L-spines and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
  • Increased activity in the maxilla and mandible. Dental problem may show this picture.
  • Increased activity in the right shoulder, bilateral hips and right knee, compatible with benign joint lesions.
• 2022-03-31 Patho - lung transbronchial biopsy
  • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated, consistent with metastatic colonic origin
  • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma and proliferating along the alveolar wall with focal tumor necrosis.
  • The immunohistochemical stains reveal TTF-1(-) and CDX2(+). The results are consistent with metastatic colonic adenocarcinoma. Please correlate with the clinical presentation and image study.
• 2022-03-31 Chest PA/AP view
  • no pneumothorax s/p transthoracic needle biopsy of RML nodule.
• 2022-03-31 Whole body PET scan
  • Multiple glucose hypermetabolic lesions in bilateral lungs. Multiple lung metastases should be considered first. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • Some glucose hypermetabolic lesions in the right and left lobes of the liver. Liver metastases should be watched out.
  • Glucose hypermetabolism in bilateral pulmonary hilar and multiple mediastinal lymph nodes and in multiple abdominal lymph nodes, compatible with metastatic lymph nodes.
  • Prominent glucose hypermetabolism in a focal area in the right lobe of the thyroid gland. The nature is to be determined (thyroid malignancy? other nature?). Please also correlate with other clinical findings for further evaluation.
  • Glucose hypermetabolism in a focal area in the right parotid gland and in a focal area in the left parotid gland. The nature is to be determined (some kind of parotid lesions? metastases? other nature).
  • Mild glucose hypermetabolism in some left lower neck lymph nodes and glucose hypermetabolism in the left shoulder. Inflammation is more likely.
• 2022-03-31 MRI - brain
  • General brain atrophy. An old infarct in right corona radiata.
  • No evidence of brain metastases based on this non-contrast MRI.
• 2022-03-21 CT - lung/mediastinum/pleura
  • multiple nodules in both lungs, favors metastatic tumors
  • suspect combined lung edema, pleural effusion, and LAD and LVD of heart. extensive 3V-CAD.
• 2022-03-17 Chest PA erect view
  • Cardiomegaly and tortuosity of the thoracic aorta.
  • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
  • Degenerative joint disease of T-spine with marginal osteophytes.
  • S/P internal fixation of C-spine.
• 2021-11-01 Chest PA erect view
  • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
  • Atherosclerotic change of aortic arch
  • Enlargement of cardiac silhouette.
  • S/P coronary artery stent implantation.
  • Spondylosis of the T-spine
  • Compression fracture of L1 vertebral body S/P cement vertebroplasty.
• 2021-10-27 Patho - colorectal polyp
  • Colon, anastomotic site, s/p biopsy.(A) — Tubular adenoma with low grade dysplasia
  • Colon, T-colon, s/p biopsy.(B) — Hyperplastic polyp
  • Colon, D-colon, s/p biopsy.(C) — Hyperplastic polyp
  • Colon, S-colon, 20 cm from AV, s/p hot snare polypectomy and S-colon, 18 cm from AV, s/p cold snare polypectomy (D) — Tubulovillous adenomas with low grade dysplasia.
• 2020-11-20 Myocardial perfusion SPECT with persantin
  • Probably moderate myocardial ischemia with possible a small portion of severe ischemia at the apex and anterior wall and mild to moderate myocardial ischemia at the anterolateral wall.
  • Mild reverse redistribution of radioactivity to the basal inferolateral wall, either normal variant or myocardial ischemia may show this picture.
• 2020-09-26 MRA - brain
  • Moderate stenosis in the bilateral cavernous ICAs, esp, left side. Please correlate with cerebral angiography.
• 2020-06-03 Patho - colon segmental resection for tumor
  • Pathologic diagnosis
    • Large intestine, hepatic flexure colon, SILS right hemicolectomy — Adenocarcinoma, moderately differentiated
      
    • Resection margins: free
      
    • Lymph node, mesocolic, dissection — metastatic adenocarcinoma (7/16)
      
    • Lymph node, IMA / SMA, dissection — N/A.
      
    • Pathology stage: pT3N2b(If cM0); pStage IIIC
      
  • Microscopic examination
    • Histology: Adenocarcinoma
      
    • Histology Grade: moderately differentiated
      
    • Depth of invasion: pericolorectal tissue
      
    • Angiolymphatic invasion: Present.
      
    • Perineural invasion: Not identified.
      
    • Discontinuous extramural tumor extension: Not identified.
    • Circumferential (radial) margin of rectum: Uninvolved
      
    • Lymph node metastasis, mesocolic: Positive (7/ 16)
      
    • Lymph node metastasis,, IMA / SMA: N/A.
      
    • Extranodal involvement: Present.
      
    • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
      • Primary Tumor (pT) pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        
      • Regional Lymph Nodes (pN) pN2b: Seven or more regional lymph nodes are positive
        
      • Distant Metastasis (pM) pMX
        
    • Type of polyp in which invasive carcinoma arose: Not identified
      
    • Additional pathologic findings: None identified.
      
    • TNM descriptors: N/A.
      
    • Tumor regression grading S/P CCRT: N/A.
• 2020-06-02 CT - abdomen, pelvis
  • Imaging stage: T3N2M0, stage IIIB
• 2020-06-02 Patho - colon biopsy
  • Colon, hepatic flexure, biopsy — Adenocarcinoma.
  • IHC stains: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
    
  • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
• 2020-06-02 Patho - colorectal polyp
  • Colon, transverse, polypectomy — Tubular adenoma with low grade dysplasia
• 2020-02-07 Paho - intradermal nevus
  • Skin, excision biopsy — Basal cell carcinoma, solid type, 0.1 cm away from the closest (side and deep) margin.
  • IHC stains: adipophilic(-), EMA(-), Ber-EP4(+).
• 2019-11-04 MRA - brain
  • Diffuse arteriosclerosis with multi-focal stenoses.
  • Brain atrophy.
• 2019-04-17 CPA - carotid phonoangiograph
  • Sonographic diagnosis
    • Multi-focal mild stenosis in bil BIF, bil ICA, right ECA; mild atheromatous lesions in right SCA, right CCA.
    • Normal extracranial carotid, vertebral, and right intracranial basal cerebral arterial flows; severe stenotic flow in right ICA, bil ECA, left SCA; mild to moderate stenotic flow in right PCA and right ECA.
    • Poor temporal windows for left transcranial insonation.
    • Normal bilateral ophthalmic arterial flows.
    • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
• 2018-12-21 KUB
  • Osteoporosis, mild scoliosis and spondylosis of L-spine. S/P VP at T12. S/P TPS and disc prosthesis at L3-4-5. Mottled bowel gas pattern.
• 2018-10-17 CPA - carotid phonoangiograph
  • Sonographic diagnosis
    • Severe stenosis with severe stenotic flow in right proximal ICA; moderate to severe stenosis with mildly increased flow velocity in left proximal ECA; moderate stenosis in right distal CCA and right BIF; multi-focal mild stenosis in right proximal & mid CCA, left distal CCA, left BIF and left proximal ICA; moderate atheromatous lesions in left mid CCA.
    • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows; severe stenotic flow in right proximal ICA and BA; mild stenotic flow in left ECA and right intracranial VA; smaller caliber and decreased flow in right cervical VA, indicated hypoplasia.
    • Poor temporal windows for bilateral transcranial insonation.
    • Normal bilateral ophthalmic arterial flows.
    • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
• 2018-09-03 CT - brain
  • No brain lesion.
  • Intracranial ICAs and VAs atherosclerosis.
  • Age-appropriate cerebral atrophy.
• 2018-06-27 Upper GI panendoscopy
  • Erosive esophagitis (La Gr A-) 　　- Hiatal hernia
• 2018-06-20 Myocardial perfusion SPECT with persantin
  • Probably (1) moderate myocardial ischemia in the apex and anterior wall (LAD territory) and (2) mild myocardial ischemia in the basal lateral wall (LCx-M territory) of the left ventricle.
  • No post-stress dilatation of the left ventricle.
• 2017-03-24 Upper GI panendoscopy
  • gastric shallow ulcers and erosions, antrum
• consultation
  • 2021-10-21 Gastroenterology
    • PI
      • ADHF, with pulmonary edema, s/p ETT+MV 10/08-10/14
    • S
      • still tarry stool today
    • O
      • E4V5M6
      • Hb: 11.7->8.6->9.2
      • EGD: no active bleeder
    • A
      • Black with dark green stool, suspected LGIB
    • P
      • Arrange colonscopy on 10/23 AM if the patient and family understand the risk of CFS (organ perforation… etc)
      • Add transamine
        
  • 2021-10-18 Rehabilitation
    • Q
      • For CHF of cardiopulmonary muscle endurance training and muscle strengthening exercise.
      • 2021/10/08 heart echo showed: EF = 21.1%; Dilated LA; Poor LV systolic function, generalized hypokinesis, especiaaly IVS; Concentric LV hypertrophy, Impaired LV relaxation; Moderate MR.
        
      • This 76 year old female had a past history of
        • NSTEMI, s/p stent placement at ShuangHo Hospital 202109 under Bokey + Blingta
        • 3-V-D s/p PTCA and Rota, 2 stents over RCA on 20161019
        • Pneumonia
        • Chronic kidney disease stage 4
        • Hypertension
        • T2DM control with Humalog Mix25 38u BID
        • Anemia, gastric OB 3+, UGIB cannot be ruled out
        • Colon Ca, pT3N2bM0, stage IIIC s/p laparoscopic right colectomy on 20200603
        • C4-5-6-7 HIVD s/p op in 201310 and L3-4-5 s/p op in 20130529.
        • PUD hx
      • According to her husband, she experienced dyspnea for last weeks. The symptoms persisted and progressed despite of OPD follow up. Thus she came to our ED for help. At ER, CXR revealed bilateral pulomonary inflitration, suggesting acute pulmonary edema. Breathing pattern was swallow and fast. Intubation was performed after informed consent. Under the impression of acute decompensated heart failure with pulmonary edema, she was admitted into ICU for further medical care. After admitted to MICU, 2D echo was done and showed Dilated LA, Poor LV systolic function, generalized hypokinesis, especiaaly IVS, Concentric LV hypertrophy, Impaired LV relaxation, Moderate MR. EF was 21% under Simpson method. Lasix 40mg Q12H was given and much urine output and BW loss were noted. Empirical Abx with rocephine was also prescribed since 20211008. Mexiletine and Ivabradine was given. Due to no active bleeding sign, oral diet was resumed and PPI was shifted to oral. However, acute on CKD was noted on 20211012, suspected pre-renal AKI. Lasix was tapered off, minimal IV hydration with 500cc NS QD was given. The ventilator was tapered smoothly. T-piece was tried on 20211013. On 20211014, extubation was done and BIPAP support was given. The patient weaning off BIPAP soon after 1 day. She also tolerated oral diet well. F/u CXR and lab were both improved with residual left consolidation. No fever was noted thus Ceftriaxone was discontinued after 1 wk. Under stable condtion, she was transfered to ward on 20211018.
    • A
      • Rehabilitation programs: Bedside PT cardiopulmonary rehabilitation programs
      • Goal: recondition, improve endurance and muscle strength
      • May arrange PM&R OPD follow-up for further phase 2 cardiac rehabilitation program as needed
  • 2021-10-08 Cardiology
    • BILATERAL pulmonary edema noted s/p intuvbation. With her creatine 3.2, no obvious progression compared her last creatinine study.
    • Received cath at nearby hostpital for LAD. No obvious lower limb swelling this time.
    • Last echoc was performd at 202012 with preserved LV function, thus, the pulmonary edema cause would multi-factorial, pending on admission to MICU by ER doctor.
  • 2020-12-16 Nephrology
    • Q
      • Reason: for CKD stage 4 assessment
      • This is a 75 years old lady who has CAD s/p stent, DM for 20+ years, Ca colon s/p op in June 2020.
      • Patient was admitted for planned CAG on 20191216, However, we noted patient had renal anemia, (Hb : 8.6 with eGFR < 15) (Stool OB: negative Oct 2020). currently using plavix, progressive renal function impairment.
      • We arranged Ca,P, iPTH, Iron profile, Ferritin, renal echo, urine analysis and proteinuria screening
      • WE consult you for assessment of EPO SC usage and CKD managment with your superior profession.
    • A
      • Impression
        • CKD stage 4, suspect DM nepropathy relatd
        • CAD s/p stent
        • DM
        • Ca colon s/p op on June 2020.
      • Suggestion
        • Stage 4 cannot use EPO
        • Nephrology OPD follow up was suggested
        • Treat the underlying diseases as your expertise
        • Avoid nephrotoxc agents
• surgical operation
  • 2020-06-03 SILS right hemicolectomy 
  • 2020-02-07 skin excision
    • a flesh color papule with hyperpigmented dots on nose for years -> suspected BCC
• chemoimmunotherapy
  • 2022-04-25 ~ undergoing - FOLFIRI

[assessment]

• This DM related CKD stage 4 patient has advanced colon cancer with lung mets s/p left hemicolectomy on 2020-06-03. She has been receiving FOLFIRI as from this hospitalization.
• Lab data on 2022-04-25 showed BUN 70mg/dL, urine creatinine 3.95mg/dL, eGFR 11.71, HGB 9.0 g/dL, serum uric acid 8.8 mg/dL. Hyperuricemia is managed with Feburic (febuxostat) 40mg PO QD currently.
• There are no irinotecan dosage adjustments provided in the manufacturer’s labeling (has not been studied) for kidney impairment, please use with caution and monitor closely. Use of irinotecan in patients with dialysis is not recommended by the manufacturer; however, literature suggests reducing weekly dose from 125 mg/m2 to 50 mg/m2 and administer after hemodialysis or on nondialysis days. Irinotecan is associated with early and late diarrhea, both of which may be severe (atropine has been subscribed as a pre-/co-treatment in the regimen). In the event the patient develops diarrhea, supportive care (e.g. fluid and electrolyte replacement, loperamide, antibiotics, etc.) should be provided as needed.
• The patient has two stents for her coronary artery disease. Cardiotoxicity observed with 5-FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of 5-FU administration following development of cardiac toxicity, and the drug should be discontinued. She is also taking Plavix (clopidogrel) for her stents, for bevacizumab has the potential to cause hypertension, hemorrhage, and thromboembolism, so the patient should be closely monitored if bevacizumab is also administered.
• Erythropoietin 5000U weekly could be considered as an additional item if no contraindiction, until the reading backs to 11 g/dL.

700886156

220425

[objective]

• exam finding
  • 2022-04-02 ECG
    • Atrial fibrillation with rapid ventricular response
    • ST & T wave abnormality, consider lateral ischemia
  • 2022-03-30 CT - lung/mediastinum/pleura
    • recurrent esophageal cancer with spinal metastasis, in progresion.
    • post op change in RML and RUL.
    • small amount of pleural effusion, exudative, in regression.
    • dendritic change or old fibrosis at LLL and lingula
  • 2021-12-23 Chest PA erect view
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Pleura effusion of right and left costal-phrenic angle
    • S/P posterior instrumentation fixation at T-spine
  • 2021-12-22 SONO - chest
    • Pleural effusion, moderate, left
    • Atelectasis, RML, RLL and RUL
  • 2021-12-15 CT
    • Hemangioma or Metastasis 1.1 cm in S2/4 is highly suspected.
  • 2021-10-29 Patho - Interveterbral disc
    • T6 pathologic fx
    • Bone and joint, vertebra, T6 body, corpectomy - Neuroendocrine carcinoma.
    • IHC: CK (+, intermediate intensity), S-100 protein (+), CK7 (-), CK20 (-), CD117 (-), CD56 (+, intermediate intensity), p40 (-), TTF-1 (-). Ki-67: 20%.
  • 2021-10-23 MRI - T-spine
    • T5-6-7 metastases with thecal sac and spinal cord compression.
  • 2021-10-19 CT
    • recurrent esophageal cancer with spinal metastasis.
    • post op change in RML and RUL.
    • small amount of pleural effusion, exudative, in progression, and nonspecific inflammation or fibrosis in left lower lung, stationary.
  • 2021-04-20 CT
    • post op change in RML and RUL.
    • small amount of Rt pleura, exudative, post op change? and nonspecific inflammation or fibrosis in left lower lung, stationary.
  • 2021-01-19 CT
    • post op change in RML and RUL.
    • small amount of Rt pleura, exudative, post op change? and nonspecific inflammation or fibrosis in left lower lung.
  • 2020-09-29 Patho - Lung wedge biopsy
    • Lung, RML, VATS pneumolysis+ RML wedge - necrotizing granuloma
    • IHC: CK7(-), TTF-1(+ at pneumocytes), Ki-67: <10%.
  • 2020-09-28 Frozen section
    • Lung, RML, frozen section - Necrosis with focal atypia (reactive change or AAH?)
  • 2020-09-03 CT
    • s/p esophagectomy with gastric tube reconstruction.
    • Tiny nodular lesion at right middle lobe, suspected lung meta.
  • 2020-06-02 CT
    • new RML nodules, favor metastatic lesions.
    • residual small amount of Rt pleura and nonspecific inflammation in left lower lung.
  • 2019-07-09 CT
    • Pleura effusion, stationary and increased volume of pericardial effusion.
    • post op change in RLL and nonspecific inflammation in left lower lung, stationary.
    • No abnormal soft-tissue mass or LAP in the mediastinum.
  • 2018-03-29 Whole body PET scan
    • In comparison with the previous study on 2017-04-17, the glucose hypermetabolic lesion between the descending aorta and the thoracic spine is more prominent. Recurrent malignancy should be considered.
    • Glucose hypermetabolism in the right supraclavicular fossa. The nature is to be determined (metastatic lesion? other nature?).
    • Glucose hypermetabolism in both lobes of the thyroid gland and left cricoarytenoid area. The nature is to be determined (inflammation? other nature?).
  • 2017-03-27 Surgical pathology Level V
    • Lung, RLL, wedge resection - Squamous cell carcinoma x 3, poorly differentiate (G3), metastatic
      
    • IHC:
      • the large tumor reveal CK5/6(+), p40(weak +), p63(+), and TTF-1(-).
        
      • the 2 small tumors reveal p40(+), CD56(-), and TTF-1(-).
  • 2017-03-15 CT
    • Indication: Esophageal cancer, M/3, squamous cell carcinoma, cT2N2M0, with Rt paratracheal and subcarinal LAP metastasis, Rt vocal cord paralysis, s/p PortA on 2016-01-15, s/p CCRT since 2016-01-21 to 2016-03-03 s/p esophagectomy & LN dissection on 2016-04-23, ypT3N0 (cM0) with involved circumferential (adventitial) margin s/p fistulectomy on 2016-06-17.
    • s/p esophagectomy and gastric tube reconstruction.
    • A RLL nodule, recurrent tumor in lung?
    • Inflammation in LLL-basal segments.
• surgical operation
  • 2021-10-28
    • Surgery
      • Esophagal cancer with T5-6-7 spinal metastasis; tumor excision and ant/ post fixation; Modified LECA approach
    • Finding
      • Esophageal tumor s/p previous op.
      • T5-6-7 metastastic tumor with T6 pathologic fracture/ epidural circumferential cord compression, more at anterolateral area;
      • Circumferential epidural tumor 3x3x3cm caused severe cord compression;
  • 2020-09-28
    • Surgery
      • VATS pneumolysis + RML wedge
    • Finding
      • severe intra-pleura cavity adhesion due to previous RLL wedge for esophagus SCC metastasis
      • one nodule about 1cm with caseating granuloma and calcification was found in RML
      • Estimated blood loss: 150mL.
      • one 20 Fr. straight chest tubes were inserted via right 7th ICS. 
  • 2019-07-29
    • Diagnosis
      • Pericardial effusion
    • PCS code
      • 68049B
    • Finding
      • Moderate serosangious pericardial effusion was noted about 300mL.
      • One 14 Fr. pig-tail was inserted via left 7th ICS.
  • 2017-03-27
    • Diagnosis
      • RLL lung nodule
    • PCS code
      • 67051B
    • Finding
      • One firm nodular lesion was noted over RLL, size about 1.5cm in diameter.
      • One 28 Fr. straight chest tube was inserted via right 8th ICS.
• radiotherapy
  • 2018-04-12 ~ 2018-05-07: 4500cGy/18 fractions (15 MV photon) to para-T6 tumor (part of CCRT)
• chemotherapy
  • 2022-04-22 - PFL (cisplatin + 5-Fu + leucovorin)
  • 2021-12-16 ~ 2022-03-29 - cisplatin + etoposide
• consultation
  • 2021-12-21 Thoracic Medicine
    • Q
      • This 74-yrear-old man patient is a case of Esophageal cancer, M/3, squamous cell carcinoma, cT2N2M0, with Rt paratracheal and subcarinal LAP metastasis, Rt vocal cord paralysis, s/p PortA on 20160115, s/p CCRT since 20160121 to 20160303 s/p esophagectomy & LN dissection on 20160423, ypT3N0 (cM0) with involved circumferential (adventitial) margin s/p fistulectomy on 20160621 with lung metastasis s/p resection on 201703 s/p adjuvant C/T, last on 20180108 with 2nd mediastinum relapse in 201803 s/p salvage RT on 20180507.
      • Pericardial effusion s/p Thoracoscopic Pericardial Window and Pneumonolysis, extrapleural.
    • A
      • I was consulted wheezing and suspected COPD of the patient
      • objective
        • PFT in 2017: normal screening, no further data
        • CXR cardiomegaly and left PE
        • Fibroreticular infiltration in right lung field
        • Mediastinum widening
        • Diffuse pleural thickening was found bilaterally, especially on right
      • assessment
        • recurrent esophageal ca with multiple mets
        • suspected COPD
        • restrictive lung ventilatory defect was suspected for bilateral irregularly thickened pleurae
      • plan
        • keep current bronchodilator nebulization
        • inform high risk of acute respiratory failure, plan of further tx?
        • sputum AFS/TB cultures x 3 days
        • chest echo for left pleural effusion if dyspnea
  • 2021-11-03 ENT
    • Q: Current problem:
      • Tinnitus since 2021-10-29.
      • Post-op wound suspected CSF leakage. Remove drain on 2021-10-30.
        
      • We will give AcetaZOLAMAX 250 mg/tab (AcetaZOLAMIDE) and Diphenidol S.C 25mg/tab use.
      • We need your expertise for further management.
    • A
      • L>R pulsatile tinnitus for 3 days.
      • PE:
        • Ear drum: bil intact, L ear drum atrophic scar
        • EAC: clean
        • Bedside scope: smooth NPx, OPx, HPx
      • Tymp:
        • R’t type A; L’t type A with round peak.
      • ART: Bil absent.
      • PTA:
        • Average RE 49 dB HL; LE 79 dB HL.
        • R’t normal to severe SNHL.
        • L’t moderately severe to profound mixed type HL.
      • Suggestion:
        • keep current Betahistine 1# BID
        • ENT OPD follow up for PTA and hearing aid evaluation
  • 2021-11-01 Rehabilitation
    • Q
      • This 73-year-old patient has past history of
        • 1. Coronary artery disease,
        • 2. Hypertension,
        • 3. Enlarged prostate with lower urinary tract symptoms,
        • 4. Gout,
        • 5. Middle third esophageal squamous cell carcinoma with lung metastasis pathology stage: Stage IV, pT3N0M1 s/p CCRT,
        • 6. Hypothyroidism,
        • 7. AF,
        • 8. Hyperlipidemia,
        • 9. Right middle lobe lung nodule status post-video-assisted thoracic surgery pneumolysin and right middle lung wedge resection on 2020-09-28.
             
      • He was a regular follow-up at our OPD. This time, he suffered from left leg clumsiness and weakness for two weeks. Mild lower chest pain. He was being referred from Oncology OPD. T-spine MRI with/without contrast showed T5-6-7 metastases with thecal sac and spinal cord compression. After discussing with the patient and his family surgical risk. He was admitted for surgical intervention. Esophagal cancer with T5-6-7 spinal metastasis post tumor excision and posterior fixation on 20211028. Post-operative course was uneventful. His discomfort was relieved a lot.
      • Current problem:
        • Chest pain improve.
        • He complaint still left leg clumsiness and weakness.
        • Muscle power: Upper limbs: Rt 5 Lt 5; Lower limbs: Rt 5 Lt 4-5
        • Gait: unstable gait. Need use a walker to walk.
      • We need your expertise for physical therapy.
    • A
      • MP:
        • upper limbs 5/5
        • lower limbs
        • Quadriceps R/L 5/4
        • Knee extensors R/L 5/4
        • Ankle dorsiflexors R/L 4/4
        • Ankle plantar flexors R/L 4/4
        • toe extensors 4/4
        • BADL: max A
        • ambulation: now walker with min A
      • Plan
        • Rehabilitation programs: GYM PT + OT rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength

[assessment]

• After receiving etoposide + cisplatin since December 2021, the patient’s chemotherapy regimen has been changed to 5-FU + cisplatin since this hospitalization following 2022-03-30 CT evidence of progression. The new regimen is generally tolerated by the patient.
• A variety of underlying diseases such as coronary artery disease, hypertension, enlarged prostate, lower urinary tract symptoms, gout, hypothyroidism, AF, and hyperlipidemia are currently treated with appropriate medications.
• Lab data on 2022-04-20, liver and kidney functions, serum electrolytes and blood cell counts were grossly normal, except decreased WBC level of 2780/uL (neutrophil 58%) which should be noted.

220330

[assessment]

• No updated images for this patient since last hospital stay. Lab data reported on 2022-03-29 indicated that the CBC readings were below normal ranges and CEA (6.02 ng/mL), SCC (1.7 ng/mL) were above normal ranges.
• EP (etoposide + cisplatin) has been administered since December 2021 for his neuroendocrine carcinoma, and the patient has no intolerance during this hospitalization according to nursing note.
• Pembrolizumab can be considered for patients with dMMR/MSI-H or advanced tumor mutational burdenhigh (TMB-H) tumors that have progressed following prior treatment and have no satisfactory alternative treatment options.
• In the event hypothyroidism remains a diagnosis (no updated lab data found since 2022), then levothyroxine (Eltroxin) might be considered.

220302

[assessment]

• EP (etoposide + cisplatin) is applied since Dec 2021 and the patient tolerates the treatment during this hospitalization.
• if somatostatin receptor (SSR) is proved positive, then octreotide or lanreotide might be an optional add-on.

700973989

220422

{esophageal squamous cell carcinoma with liver and lung mets}

[objective]

• exam finding
  • 2022-04-20 SONO - chest
    • left side moderate hemothroax, s/p chest tapping 600 ml bloody effusion for study and s/s relief
    • right side moderate pleural effusion, s/p chest tapping 350 ml for study
  • 2022-04-13 Chest PA (erect) view
    • A poorly defined huge mass over over medial RUL and midlung zone with multiple nodular opacities in both lungs, due to metastases
    • Bilateral pleural effusions
    • Superior mediastinal widening due to lymph node enlargement,
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Otherwise, there is no significant abnormality of the chest. (Note that ground-glass lesion, small nodule or retrocardiac lesion might be missed on plain chest radiography.)
  • 2022-04-11 Tc-99m MDP whole body bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, some T-and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, right femoral trochanters, and right knee.
  • 2022-04-08 Patho - lung transbronchial biopsy
    • Lung, right, CT-guide biopsy — squamous cell carcinoma, please correlate with the clinical presentation and image study to differentiate primary or metastatic tumor
    • Sections show solid sheets of hyperchromatic tumor cells infiltrating in a fibrotic stroma. Focal keratinization is seen.
    • The immunohistochemical stains reveal p40(+), and TTF-1(-). Please correlate with the clinical presentation and image study to differentiate primary or metastatic tumor.
  • 2022-04-07 MRI - brain
    • No obvious intracranial lesion.
    • Large patchy area of encephalomalacia over left PCA territory.
    • Also small areas of old infarction over right frontal lobe, right medial occipital lobe, bilateral cerebellar lobe.
    • Mild periventricular small vessel disease. NO acute ischemic infarct.
  • 2022-04-06 Cell block
    • Suggestive of malignancy
      
    • The smears and cell block show lymphocytes, reactive mesothelial cells and a few atypical cell nests, which immunocytochemistry shows TTF-1(-), Napsin-A(-) and P40(+, scant) for atypical cells, suggestive of malignancy. According to cytomorphologic finding, it is compatible with metastatic squamous cell carcinoma. Please refer to S2022-05907 and clinical correlation for tumor origin.
  • 2022-04-02 CT - chest
    • Imaging stage: T4aN3M1, stage IVB
  • 2022-04-01 Pathology - esophageal biopsy
    • Esophageal tumor, 27 and 40 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated characterized by solid tumor nests with enlarged, hyperchromatic and pleomorphic nuclei infiltratde in the stroma with focal keratin formation and some necrotic debris.
  • 2022-03-31 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA A
    • Highly suspected esophageal cancer, 27-40cm, s/p biopsy
    • Superficial gastritis
• consultation
  • 2022-04-21 family medicine
    • Q:
      • The 66-year-old male has history of Type II Diabetes mellitus and Hypertension under Chang Gung OPD follow up and esophageal cancer with lung and liver meta. He suffer from short of breath for one day. He came to our ER for help on 20220402. Under the impression of esphogeal cancer, jejunostomy performed on 20220414 and intubated ETT at the same day. The patient prefer palliative care, so extubated on 20220418. However, tachypnea with short of breath were noted, NIPPV supportive.
      • Current problem: We need Hospice care and take over the patient for palliative care.
    • A:
      • 66y/o gentleman just dx advanced esophageal cancer
      • Dyspnea s/p intubation now with BIPAP
      • DNR +
      • ECOG 4
      • Would put p’t on Hospice ward list.
      • Our share care would follow up.
  • 2022-04-20 Thoracic Medicine
    • Q:
      • The 66-year-old male has history of Type II Diabetes mellitus and Hypertension under Chang Gung OPD follow up and esophageal cancer with lung and liver meta. He suffer from short of breath for one day. He came to our ER for help on 20220402. Under the impression of esphogeal cancer, jejunostomy performed on 20220414 and intubated ETT at the same day. The patient prefer palliative care, so extubated on 20220418. However, tachypnea with short of breath were noted, NIPPV supportive.
      • Current problem: We need your specialist to arrange pleural drainage.
    • A:
      • A case of heavy smoking with COPD, admitted due to esophageal cancer s/p palliative feeding jejunostomy.
      • Bed-side chest echo had been done and showed right side serosanguous exudative PE and left side hemothorax, s/p chest tapping with left side 350ml and right side 600ml.
      • Suggestion:
        • Left side chest tube drainage for hemothorax.
        • Add foster 2puff BID, spiriva 2puff HS.
        • F/U prn.
  • 2022-04-18 Infectious Disease
    • Q:
      • Esophgeal Ca with lung metastasis s/p Feeding jejunostomy
      • Developed high fever suspected pneumonia
    • A:
      • Antibiotic therapy should be adjusted according to the results of in vitro sensitivity testing.
      • NO treatment for colonization. Do NOT use steroid.
  • 2022-04-09 Hemato-Oncology
    • Impression:
      • Esophageal cancer with liver and lung metastasis
      • Type II Diabetes mellitus
      • Hypertension
      • Old CVA
    • Suggestion:
      • We will discuss with patient about further treatment after complete work up
      • Please check AntiHbc, SCC
      • May consult chest surgeon for port A insertion and involve in this case.
      • Consult GI to involve in this case (esophagus stent? or gastrostomy?)
      • Consult RT for CCRT
  • 2022-04-06 Radiological Diagnosis
    • Q: for chest CT guiding biopsy of lung mass, sinecrely need your professional evaluation
    • Q:
      • This 66-year-old patient is a case of bilateral lung nodules, suspected metastasis or primary lung cancer.
      • CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.

[assessment]

• This patient, who suffers from esophageal squamous cell carcinoma with liver and lung metastases, has been placed on the hospice waiting list on 2022-04-21.

701198481

220422

[objective]

• exam finding
  • 2022-04-01 Abdomen - Standing(Diaphragm)
    • Fecal material store in the colon.
    • Ascites is suspected. Please correlate with sonography.
  • 2022-03-22 Abdomen - Standing(Diaphragm)
    • Air-fluid level in the bowel at the upper abdomen is noted that may be bowel obstruction? Please correlate with contrast enhanced CT.
    • Fecal material store in the colon.
    • Ascites is suspected.
  • 2022-03-09 Abdomen - Standing(Diaphragm)
    • Fecal material store in the colon.
    • Ascites is suspected. Please correlate with sonography.
  • 2022-03-07 Abdomen - Standing(Diaphragm)
    • Multiple segment of small intestine show air-fluid level that are c/w bowel obstruction.
    • Ascites is suspected. Please correlate with sonography.
  • 2022-03-04 CT - abdomen, pelvis
    • Carcinomatosis induce mechanical bowel obstruction is suspected.
  • 2022-03-04 KUB
    • Increased intestinal gas is found.
    • Stool impaction at the abdominal cavity is noted.
  • 2021-11-23 CT - abdomen, pelvis
    • Stationary of pancreatic tail low density lesion.
    • More prominent soft tissue density in RLQ, suspected carcinomatosis.
    • Stationary of bilateral lung nodules, suspected lung metastasis.
  • 2021-11-09 Tc-99m MDP bone scan
    • In comparison with the previous study on 20210120, no prominent change is noted, suggesting no strong evidence of bone metastasis.
    • Suspected benign lesions in the maxilla, middle T-spines, lower L-spines, sacrum, bilateral sacroiliac joints, shoulders, sternoclavicular junctions, hips, and knees,
  • 2021-09-21 CT - abdomen, pelvis
    • Small bowel ileus, suspected adhesion.
    • Relative increased density in RLQ, suspected carcinomatosis.
    • Stationary of pancreatic lesion.
    • Left lower lung nodule, suspected lung metastasis.
  • 2021-07-13 Abdomen - Standing(Diaphragm)
    • Fecal material store in the colon.
  • 2021-07-12 CT - abdomen, pelvis
    • Stationar condition of pancreatic cancer and peritoneal carcinomatosis as compared with previous CT study on 20210511.
  • 2021-05-11 CT - abdomen, pelvis
    • Dilated pancreatic duct at tail portion. The pancreatic condition is stationary.
    • No evidence of mestastatic lesion in the study.
  • 2021-04-18 Abdomen - Standing(Diaphragm)
    • Fecal material store in the colon.
  • 2021-03-02 CT - abdomen, pelvis
    • Suspected rupture appendicitis.
    • Suspected abscess in the pelvic cavity.
  • 2021-01-20 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in middle T-spine, lower L-spine, sacrum, sacroiliac joints, shoulders, sternoclavicular junctions, hips, and knees.
  • 2021-01-19 CT - abdomen, pelvis
    • Non-visualization of the pancrreatic tumor. Either current therpay is effective or the diagnostic method should be further investigated.
  • 2020-12-14 Abdomen - Standing(Diaphragm)
    • Transitional vertebra of L5-S1, left side.
  • 2020-10-12 CT - abdomen, pelvis
    • Stationar condition of pancreatic cancer and peritoneal carcinomatosis as compared with previous CT study on 20200706.
  • 2020-07-20 Tc-99m MDP bone scan
    • Mildly and non-focally increased radiotracer uptake in middle T-spine, lower L-spine, and sacrum that had been less evident in comparison with the previous study on 20200204, degenerative spine diseases may show such a picture.
    • Probably degenerative joint lesions in shoulders, sternoclavicular junctions, sacroiliac joints, hips, and knees.
    • No definite evidence of osteoblastic skeletal metastasis by this bone scan.
  • 2020-07-06 CT - liver, spleen, biliary duct, pancreas
    • Much regression of pancreatic cancer and peritoneal carcinomatosis.
  • 2020-04-07 CT - abdomen, pelvis
    • Pancreatic malignancy s/p treatment.
    • Regression of peritoneal carcinomatosis.
  • 2020-02-04 Tc-99m MDP bone scan with SPECT
    • Increased activity in the lower C-spine and lower L-spine. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the bilateral shoulders, bilateral sternoclavicular junctions, hips, knees, ankles and both feet, compatible with benign joint lesion.
  • 2020-01-02 CT - abdomen
    • Pancreatic carcinoma imaging stage: T1cN1M1, Stage IV
    • Other findings: mild repression of primary tumor and peritoneal seeding
  • 2019-09 Pathology - omentum (at VGHTPE)
    • pancreatic adenocarcinoma, metastatic, cT4N1M1
    • CK7(+), CK20(-).
• lab data
  • CEA
    • 2022-04-19 8.36 ng/mL
    • 2022-04-08 8.734
    • 2022-04-06 8.86
    • 2022-03-23 5.451
    • 2022-02-22 10.47
    • 2022-02-08 8.176
    • 2022-01-19 5.384
    • 2022-01-03 6.370
    • 2021-12-21 5.508
    • 2021-11-25 7.414
    • 2021-04-28 2.419
    • 2021-04-20 2.64
    • 2021-03-04 1.607
    • 2021-01-14 1.155
    • 2020-12-09 1.343
    • 2020-12-08 1.11
    • 2020-11-06 1.757
    • 2020-10-02 1.591
    • 2020-08-28 1.875
    • 2020-08-04 0.749
    • 2020-04-13 1.86
    • 2020-02-27 2.766
    • 2019-12-31 3.478
    • 2019-11-05 2.995
    • 2019-10-16 2.789
  • CA199
    • 2022-04-19 10566.2 U/mL
    • 2022-04-08 10638
    • 2022-04-06 5603.49
    • 2022-03-23 10346.6
    • 2022-02-22 9232.6
    • 2022-02-08 8534.6
    • 2022-01-19 8673.8
    • 2022-01-03 9546
    • 2021-12-21 8695.7
    • 2021-12-17 3930.36
    • 2021-12-03 11539.95
    • 2021-11-25 11030.5
    • 2021-11-09 16219.4
    • 2021-10-13 12661
    • 2021-09-17 5472.1
    • 2021-09-07 6671.4
    • 2021-08-06 3643.3
    • 2021-07-23 4275.3
    • 2021-07-09 2841.0
    • 2021-06-25 3306.2
    • 2021-06-18 3287.4
    • 2021-06-08 3073.35
    • 2021-05-25 3015.7
    • 2021-05-12 3141.6
    • 2021-04-28 2667.2
    • 2021-04-20 1630.65
    • 2021-04-01 1143.5
    • 2021-03-19 701.39
    • 2021-03-04 354.060
    • 2021-02-24 335.25
    • 2021-01-15 177.130
    • 2021-01-14 169.370
    • 2020-12-16 110.182
    • 2020-12-08 156.614
    • 2020-11-06 71.735
    • 2020-10-02 38.132
    • 2020-08-28 23.155
    • 2020-08-11 21.897
    • 2020-07-31 20.589
    • 2020-07-20 19.681
    • 2020-06-24 23.338
    • 2020-05-29 29.415
    • 2020-04-30 64.378
    • 2020-04-13 68.09
    • 2020-04-08 145.41
    • 2020-02-27 493.18
    • 2020-02-04 678.54
    • 2019-12-31 1127.2
    • 2019-12-03 1981.5
    • 2019-11-14 3700
    • 2019-11-05 4329.2
    • 2019-10-18 8888.3
• chemoimmunotherapy
  • 2022-04-15 - gemcitabine
  • 2022-04-07 - carboplatin + gencitabine
  • 2021-09-29 ~ 2022-03-21 - FOLFIRI?
  • 2020-09-14 - FOLF (irinotecan to be plused)
  • 2020-02-13 - 2021-09-07 - gemcitabine + nal-paclitaxel
  • 2020-02-06 - gemcitabine
  • 2019-10-21 ~ 2020-01-20 - FOLFIRINOX (experienced oxaliplatin-allergic shock 2020-01)
  • 2019-10-07 - oxalip 150 mg iv q2wk plus TS-1 60 mg 3tab bid and folic acid 2tab bid

[assessment]

• Initially diagnosed with pancreatic carcinoma (T1cN1M1, Stage IV) in September 2019, followed by FOLFIRINOX between 2019-10 and 2020-01; following oxaliplatin allergy, the regimen changed to gemcitabine + nal-paclitaxel until 2021-09; following lung metastases, the regimen changed to 5-Fu + irinotecan until 2022-03; following carcinomatosis-induced mechanical bowel obstruction, the regimen changed to carboplatin + gencitabine since 2022-04.
• The patient experienced severe back pain on 2022-04-20 night and was taken to the Emergency Department. Morphine 5mg IVD PRNQ4H is prescribed to treat the pain.
• Lab readings on 2022-04-21 were CRP 7.53mg/dL, urine bacteria 3+, urine OB 2+, urine sediment RBC 6-9/HPF, urine sediment WBC 50-99/HPF. Body temperature did not exceed 37.5 degrees during this hospital stay for now. The blood culture has been ordered, but the results are not yet available. Empirical antibiotics ceftriaxone 2000mg IVD QD are being used since 2022-04-22.
• Vemlidy (tenofovir alafenamide) is used to treat underlying positive HBsAg.

            

700466967

220421

[objective]

• exam finding
  • 2022-04-14 MRI - brain
    • A left posterior cerebellar tumor, consistent with metastasis.
  • 2022-04-14 CT - brain
    • One mass lesion (2.8cm in size) over left cerebellar lobe with perifocal edema. Compatible with a metastasis.
      
    • Mild dilatation of ventricles.
    • The posterior structures including the brain stem, cerebellum and CP angles look normal.
  • 2022-04-14 Patho - lung transbronchial biopsy
    • Lung, right, CT-guide biopsy — consistent with metastatic choriocarcinoma
    • Section shows alveolar tissue with infiltration of large pleomorphic tumor cells and tumor necrosis.
    • The immunohistochemical stains reveal CK7(+), CK20(-), beta-hCG(+), GATA-3(+), TTF-1(-), OCT3(-), PLAP(-), and SALL4(equivocal). The results are consistent with metastatic choriocarcinoma. Please correlate with the clinical presentaiton and lab study.
  • 2022-04-12 CT - chest
    • bilateral lung metastatic tumors.
    • two hepatic hemangiomas up to 35 mm.
  • 2022-04-08 MRA - brain
    • Left cerebellar metastasis.
  • 2022-04-08 CT - brain
    • Probably left cerebellar metastasis.
  • 2021-12-20 Chest PA/AP view
    • a large consolidation with lobulated contour over Rt lower lobe, in regression as compared with previous chest image
    • near complete resolution of the LLL small nodule post transthoracic needle biopsy
  • 2021-12-14 Chest PA/AP view
  • diffuse consolidation in Rt lower lobe stationary as compared with previous chest image
  • a nodular opacity (well-defined) over LLL
  • 2021-12-14 Patho - lung transbronchial biopsy
    • Lung, LLL, CT-guide biopsy — Scant atypical cells present
      
    • Sections show alveolar lung tissue with interstitial fibrosis and scant atypical cells in fibrous stroma.
    • The immunohistochemical stains reveal CK(+), p40(-), TTF-1(-), Napsin A(-), CD56(-), SALL4(-), and OCT4(-). Please correlate with the clinical presentation and lab study. Further examination is suggested.
  • 2021-12-07 SONO - chest
    • lung consolidation, suspected abscess
  • 2021-12-06 Chest PA (erect) view
    • Radiopacity in right middle and lower lung zone, suspected mass or loculated pleural lesion
• lab data
  • 2022-04-12
    • LDH 776 U/L
      
    • beta-HCG >265200 mIU/mL
      
    • AFP 207.4 ng/mL
• consultation
  • 2022-04-12 hemato-oncology
    • This 22-year-old male patient had past history of
      • Testis cancer status post operation at Tri-Service General Hospital for 2 years ago.
      • Pneumonia and lung abscess in 2021-12 at Taipei Tzu Chi Hospital
      • RLL and LLL solid nodules, suspected lung metastases on 20211229 at Tri-Service General Hospital.
        
    • This time, he suffered from headache and dizzness for one week. He was brough to our emergency room for help. Arrival at our emergency room, initial consciousness remained E4M6V5. Labortory data showed normal range of WBC, but elevated CRP (11.60mg/dl). Brain CT was done, which showed a 2.2cm heterogeneous hyperdense nodule at left cerebellum, associated with vasogenic edema. Brain metastasis is first considered. Brain MRI was performed, which revealed a 2.2cm rim-enhancing nodule at left cerebellum, associated with vasogenic edema. Brain metastasis is first considered. Multiple nodular and mass over bilateral lung were found. Consulted Neurosurgeon was done cause by suspected brain metastases of left cerebellum. He then admitted to SICU for neurological condition monitoring and further management on 2022-04-08. After SICU, he remained conscious during ICU stay. Under anti-swelling agent as Mannitol and Medason were used. PPI for ulcer prevention. Anticonvulsant agent as Keppra was given. He will arrange lung CT this afternoon.
      • Tumor marker: B-HCG: >265200, AFP:207.4, LDH:?
      • Chest CT: pending
      • Brain CT: left cerebellar metastasis.
      • Brain MRI: left cerebellar metastasis.
    • Impression:
      • Suspect recurrent nonseminal germ cell tumor with lung and brain metastasis
    • Suggestion:
      • Pending chest CT report, check LDH
      • Arrange CT guide biopsy for suspect lung metastasis
      • If proof recurrent non seminoma germ cell tumor, arrange port A insertion
      • Arrange pulmonary function test: FRC + DLCO
      • Wait for CT-guided biopsy of lung tumor that will be done on 4/14 22. If recurrent germ cell tumor wt lung mets & L cerebellar mets is Dx, palliative C/T will be started soon.
      • Germ cell tumor may be well responsive to palliative C/T wt BEP.
      • As for L cerebellar mets tumor, may consult radiation oncologist for R/T evaluation.
      • may check AFP, b-HCG as well.
  • 2022-04-08 Neurosurgery
    • Q:
      • cough with blood-tinged sputum for 2 weeks
      • headache with dizziness after waking up for one week
      • no fever, no sore throat or runny nose, no SOB, no chest pain
      • PMH: testis cancer s/p op, Rt lung cyst
      • allergy: denied
    • A:
      • A case of 22 y/o male; Testis cancer s/p; Headache/dizziness progressed for 1+ week;
      • A brain CT showed a 2.2cm heterogeneous hyperdense nodule at left cerebellum, associated with vasogenic edema. Brain metastasis is first considered.
      • A brain MRI with Gd showed a 2.2cm rim-enhancing nodule at left cerebellum, associated with vasogenic edema. Brain metastasis is first considered.
      • P: ICU care; mannitol/ steroid; Tumor excision indicated;
  • 2021-12-13 Radiological Diagnosis
    • Q: 22 year old male with past history of prostate cancer s/p OP 2 years ago admitted this time due to RLL pneumonia (suspected abscess) and treated with Brosym, Colistin, and Targocid. CT also showed an 1.3 cm nodule over left lower lungs. Thus, we needed your expertise for CT-giuded biopsy for left lower lung nodule.
    • A: This 22-year-old patient is a case of LLL nodule, r/o malignancy. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.

[assessment]

• Not sure if orchiectomy has been performed.
• Bleomycin + Etoposide + Cisplatin might be indicated.
• Additionally, opioids may be a viable option for this patients with moderate to severe pain. (reference: https://www.ncbi.nlm.nih.gov/books/NBK554435/ )
• Besides analgesics, non-pharmacological interventions that can control pain over a longer period of time might also be considered. The following interventions are available to treat cancer pain (not exhaustive, reference: https://pubmed.ncbi.nlm.nih.gov/31140913/):
  • Epidural and selective nerve root block
  • Radiofrequency ablation and cryoablation
  • Vertebral augmentation
  • Intrathecal drug delivery
  • Spinal cord stimulation
  • Dorsal root ganglion stimulation

700803304

220420

{ovarian cancer}

• history
  • Right ovarian cancer status post suboptimal debulking surgery (right salpingo-oophorectomy (RSO) + bilateral pelvic lymphadenectomy + cytoreductive surgery + infracolic omentectomy + Appendectomy) and hyperthermic intra-peritoneal chemotherapy on 2021-11-01.
  • Uterine myoma and left ovarian cyst s/p ATH + LSO
  • Type 2 diabetes mellitus with unspecified complications
• exam finding
  • 2022-01-21 SONO - abdomen
    • Fatty liver, moderate
    • GB adenomatosis
  • 2021-11-21 CT
    • Focal small bowel ileus.
    • Colonic diverticula.
  • 2021-11-02 Patho - ovary (tumor)
    • Pathologic diagnosis
      • Ovarian tumor, right, frozen + debulking surgery - Carcinosarcoma and endometriosis
      • Pelvic tumor, debulking surgery - Tumor present
      • AJCC Pathologic staging: pT2bN0, if cM0, stage IIB
      • IHC
        • Carcinoma component: CK(+)
          
        • Sarcoma component: vimentin(+), CK(-), WT-1(-), ER(-), SMA(-), myogenin(-), CDK4(-), beta-HCG(-), CD10(+) and cyclin-D1(+, focal), CD31(+, focal)
          
        • Lymphovascular space invasion: present
          
  • 2021-10-27 CT - whole abdomen, pelvis
    • Right ovarian malignant tumor with carcinomatosis is highly suspected. Please correlate with CA125 and ascites cytology.
    • Right side obstructive uropathy is noted.
    • Several small lymph nodes in para-aortic and para-cava space.
• surgical operation
  • 2021-11-01
    • HIPEC
    • Excision of intraabdominal tumor
    • Omentectomy
    • Appendectomy
    • Tenckhoff tube insertion
      
    • Right ovarian tumor, Frozen section: malignancy, type to be determined
    • status post Laparoscopic Assisted Vaginal Hysterectomy(LAVH) + Left Salpingo-oophorectomy (LSO)
• chemotherapy
  • 2021-12 ~ ongoing: paclitaxel + carboplatin
  • 2021-10-30: Liposome doxorubicin + carboplatin

[assessment]

• The patient was diagnosed with ovarian cancer following suboptimal debulking surgery on 2021-11-01, and has been treated with paclitaxel + carboplatin since December 2021.
• The findings in the lab on 2022-04-20 were generally typical.
• Readings of blood sugar in the ward fluctuated up to 430 mg/dL at 06:12 on 2022-04-21, which should be addressed (self-carried metformin has been prescribed on the active medication list). Additional insulin might be considered if blood sugar levels remain unruly.

220323

[comment]

• At present, the patient is receiving platin-based chemotherapy without intolerance during this hospital stay; no apparent abnormalities were found in laboratory results reported on 2022-03-22.
• Blood sugar readings tested in the ward fluctuated up to 211 mg/dL at 06:30 on 2022-03-23, which should be addressed (self-carried metformin has been prescribed in active medication list).

220302

[comment]

• the patient is currently receiving platin-based chemotherapy without intolerance.
• most recent HbA1c recorded 7.3% on 2021-10-27, blood sugar tested 328mg/dL at 06:48 on 2022-03-02, metformin prescribed at Metab & Endoc OPD might be considered if needed.

700127501

220419

{tube feeding}

• All oral PPIs should not be ground.
• PPIs are easily protonated and therefore unstable at acid pH. In gastric juice, this would result in inactivation before absorption. This is why some PPIs are enteric coated. Following absorption, they partition by ionic trapping into the acidic environment of the parietal cell cytoplasm, where the unstable sulphonamide/sulphenic acid species that result from protonation form irreversible disulphide bonds with cysteine residues in the proton pump.
• Pariet FC (rabeprazole 20mg/tab) is film-coated and not intended for tube feeding. It could be replaced with Takepron (lansoprazole 30mg/tab), Nexium (esomeprazole 40mg/tab) or Dexilant (Dexlansoprazole 60mg/cap), with opening the capsule and pouring out the small granules into drinking water prior to tube feeding.

220418

[objective]

• exam finding
  • 2022-03-30 Esophagogastroduodenoscopy
    • Diagnosis:
      • Reflux esophagitis LA grade A
      • Superficial gastritis
      • Gastric erosions, body, GC
      • Doudenal ulcers with duodenitis, bulb to 3rd portion
      • Incomplete study of esophagus due to residual food
    • Suggestion:
      • Pursue CLO test result
  • 2022-03-27 Sacrum & coccyx
    • mild spondylolisthesis at L5-S1
    • moderate decreased L5/S1 joint space
  • 2022-03-27 L-spine Lat
    • loss of the natural curvature of the spine
    • mild spondylolisthesis at L5-S1
    • severe decreased disc space in the L5/S1 disc
    • unremarkable change in the paravertebral region
    • compression racture at T11 vertebral body
  • 2022-03-27 CT - abdomen, pelvis
    • suspected duodenal perforation
  • 2022-02-16 CT - lung/mediastinum/pleura
    • breast cancer with hematogeneous and lymphatic metastases in both lungs, and spine metastasis, and bilateral pleural effusions, in progression as compared with previous CT on 20210921.
    • suspect associated with infection or drug toxicity in the lungs.
  • 2022-02-15 Chest
    • S/P port-A implantation.
    • Multiple nodular opacity projecting in the both lung are noted that may be metastases. Please correlate with CT.
    • Presence of old fracture(s) at the bil. ribs and right clavicle are noted that may be bony metastases? Please correlate with CT.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura thickening or effusion?
    • Atherosclerotic change of aortic arch
  • 2021-09-21 CT - chest
    • S/P right breast operation. Bil. lung metastases.
    • Suspected metastases at T10.
  • 2021-09-10 Chest
    • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
    • Multiple ill-defined nodules of variable sizes and reticular abndormality throughout in both lungs due to metastases.
    • A large increased opacity shadow over lateral Rt hemithorax, extrapulmonary lesion
    • Absence of medial half of Rt clavicle and focal bone defects at Rt humeral head
    • Old fracture of many Lt ribs
    • Osteoblastic metastasis in spine
  • 2021-08-16 KUB
    • Fecal material store in the colon.
  • 2021-05-21 CT - lung/mediastinum/pleura
    • S/P mastectomy at right side.
    • Diffuse lung meta, stationary.
    • Right humoral head bony invasion. Stable.
    • Bone mets at lumbar spine
  • 2021-02-06 CT - lung/mediastinum/pleura
    • Compatible with breast cancer lung meta, stationary in lung mets.
    • Bone mets at right clavicle. stable.
  • 2020-12-14 Pathology - bronchus biopsy
    • Diagnosis
      • Lung, side?, CT-guide biopsy — metastatic breast carcinoma of no special type
        
    • Microscopic Description
      • Section shows cores of alveolar lung tissue with irregular neoplastic glands infiltration.
      • IHC: GATA3(+) and TTF-1(-). The results are consistent with metastatic breast carcinoma of no special type.
    • Immunohistochemical Study
      • ER (Ab): Positive(95%, strong)
        
      • PR (Ab): Negative
        
      • Her-2/neu (Ab): Negative (1+)
        
      • Ki-67: 20%
  • 2020-10-23 CT - lung/mediastinum/pleura
    • Breast cancer with bilatral lung mets and right clavicle mets.
  • 2020-10-15 CT - brain
    • Mild brain atrophy and intracranial atherosclerotic disease
  • 2020-09-14 ABR, Auditory brainstem evoked response
    • R’t 60 dB nHL
    • L’t 55 dB nHL
  • 2020-03-13 CT - lung/mediastinum/pleura
    • Diffuse lung mets and bone mets. In progression.
  • 2019-07-17 CT - lung/mediastinum/pleura
    • Breast cancer with lung metastasis with fibrosis, slightly in progression.
  • 2018-01-30 CT - lung/mediastinum/pleura
    • Breast cancer with lung metastasis, stationary.
  • 2017-10-25 CT - lung/mediastinum/pleura
    • Lung metastasis still present.
  • 2017-03-23 SONO - breast
    • A small right breast calcification.
    • Post OP with Edema at right axillary region.
    • Small left breast nodules and cysts.
    • BI-RADS: 2, Benign findings
  • 2017-03-21 CT - lung/mediastinum/pleura
    • D/D lung edema and/or pulmonary lymphagitic carcinomatosis.
    • LVD of heart.
    • Rt shoulder and arm post treatment change or edema.
  • 2017-02-17 Tc-99m MDP whole body bone scan
    • Increased activity in the lower C-spine and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Increased activity in the right shoulder, left sternoclavicular junction, right elbow, right wrist, bilateral knees and right foot. Either benign joint lesion such as arthritis or post-traumatic change may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • No prominent bone abnormality was noted elsewhere.
  • 2008-07-14 CT
    • bilateral multiple pulmonary metastasis
    • pT2N2M1, stage IV
  • 2008-06 Pathology
    • Infiltrating ductal carcinoma, grade II with pectoralis major muscle invasion
    • IHC: ER(+) 5% score 1, PR(+) 20% score 1, Her2(-)
• surgical operation
  • 2008-06-16 MRM at Taipei City Hospital FuYou Branch
• chemotherapy
  • 2022-03-15 ~ undergoing - ribociclib
  • 2020-12-25 ~ undergoing - exemestane
  • 2017-02-03 ~ 2020-12-18 - letrozole
  • 2008-07-10 ~ 2008-09-16 doxorubicin + cyclophosphamide; (then docetaxel, letrozole, vinorelbine?)

[assessment]

• This patient was diagnosed with breast cancer (ER+ PR- HER2-, 2020-12-14 pathology, s/p MRM) with lung and spine mets in progress (2022-02-16 CT) and was treated with exemestane since 2020-12-25, and with ribociclib since 2022-03-15.
• The current regimen (aromatase inhibitor and CDK4/6 inhibitor) is a treatment of choice for HR+ HER2- postmenopausal recurrent or stage IV breast cancer.
• All the listed underlying health conditions have been managed with corresponding drugs. As TPR readings remain relatively stable, blood sugar readings fluctuate at a higher range, which should be addressed.
• Kisqali (ribociclib) prescribed at 2022-04-15 OPD has been filled to 2022-04-29. Severe, life-threatening, and/or fatal interstitial lung disease (ILD) and/or pneumonitis may occur with ribociclib (and other cyclin-dependent kinase inhibitors). Symptoms of ILD/pneumonitis may include hypoxia, cough, dyspnea, or interstitial infiltrates on radiologic exam. (exclude infectious, neoplastic, and other causes for pulmonary toxicity.) Kisqali (ribociclib) is currently suspended.

700379547

220419

{Recurrent hepatocellular carcinoma with Lung and C-spine, T-spine and L-spine metastasis cT2N0M1 stage IV}

[objective]

• exam finding
  • 2022-04-01 KUB
    • S/P operation with retention of surgical clips.
    • Stool retention in the bowel.
    • Degeneration and spondylosis of L-S spine.
  • 2022-03-18 CT - abdomen, pelvis
    • Multiple bony metastases on the T-and L-spine, and bilateral ilium show progressive disease.
    • Compression fracture of L5 vertebral body is noted.
    • Right lower Lung metastases show progressive disease.
  • 2022-02-25 Patho - omentum biopsy
    • diagnosis
      • Tissue, site unspecified, CT-guide biopsy — hepatocellular carcinoma
      • Microscopically, it shows hepatocellular carcinoma composed of neoplatic cells with hyperchromatic nuclei, fine granular cytoplasm, arranged in trabecular pattern with greater than 3 cell thick cords.
        
      • IHC: CK7(-), CK19(-), arginase(+), CD10(-), and hepatocytes(+).
  • 2022-02-25 Tc-99m MDP whole body bone scan
    • The scintigraphic findings suggest multiple bone metastases.
  • 2022-02-18 MRI - upper abdomen
    • Multiple HCCs at left hepatic lobe are noted.
    • Multiple bony metastases on the T-and L-spine are suspected.
    • Lung metastasis 1.1 cm at RLL is noted.
  • 2022-01-11 CT - liver, spleen, biliary duct, pancreas
    • Post-op at right lobe liver.
    • Diffuse HCCs, progression.
    • Lung and bone metastasis.
    • Suspected left renal cysts, up to 2.1cm.
  • 2021-12-15 CT - liver, spleen, biliary duct, pancreas
    • Multiple HCCs at left hepatic lobe are suspected.
    • Lung metastasis 1.1 cm at RLL is highly suspected.
  • 2021-10-14 CT - liver, spleen, biliary duct, pancreas
    • S/P liver operation. Several recurrent HCCs (0.3-0.9) at remnant liver.
    • A nodule (9mm) at RLL r/o metastases.
    • Liver cirrhosis with portal hypertension and splenomegaly.
  • 2021-09-01 CT - liver, spleen, biliary duct, pancreas
    • Two viable HCCs 1.1 cm in S2 and 0.7 cm in S4 are suspected.
    • Two recurrent HCCs 0.6 cm and 0.5 cm in S4 are suspected.
    • Cirrhosis of the liver with portal hypertension.
  • 2021-07-21 CT - liver, spleen, biliary duct, pancreas
    • Two recurrent HCCs 1.8 cm in S2 and 0.7 cm in S4 are highly suspected. Please correlate with AFP.
    • Cirrhosis of the liver with portal hypertension.
  • 2021-06-02 CT - liver, spleen, biliary duct, pancreas
    • Two recurrent HCCs 1.6 cm in S2 and 0.7 cm in S4/8 are highly suspected. Please correlate with AFP.
    • Prior CT identified HCC in S4/8 of the liver S/P TACE on 20210513 shows complete response.
    • Cirrhosis of the liver with portal hypertension.
  • 2021-05-19 Abdominal Ultrasonography
    • Liver tumors, suspected recurrent HCCs
    • Liver cirrhosis with mild splenomegaly
    • Liver lesions, spspect tumor scars or regeneration nodules
    • Invisible GB
  • 2021-05-06 CT - liver, spleen, biliary duct, pancreas
    • S/P liver operation. Two recurrent HCCs (1.1cm, 1.3cm, srs3, img13, 15) at S2 and right liver margin.
    • A nodule (6mm) at RLL r/o metastases.
    • Liver cirrhosis with portal hypertension and splenomegaly.
  • 2021-02-25 Patho - liver partial resection
    • Pathologic diagnosis
      • Liver, S6-7, segmentectomy — Hepatocellular carcinoma, recurrent
        
      • Pathologic Staging: rpT2Nx(cM0), Stage II at least
  • 2021-02-03 MRI - liver, spleen
    • Imaging stage: T2N0M0, stage II
  • 2020-11-03 CT - liver, spleen, biliary duct, pancreas
    • S/P RFA and S/P cholecystectomy.
    • Post-op at left lobe liver with focal enhancement at S4 around the surgical region, probably vascular shunting. Suggest clinical correlation and follow up study.
    • Renal cysts.
    • Minimal ascites in the pelvic cavity.
  • 2020-09-21 CT - abdomen, pelvis
    • Long segmental wall edema of esophagus and duodenum. Distention of stomach.
    • S/P liver operation and cholecystectomy. Liver cirrhosis.
  • 2020-08-17 MRI - liver, spleen
    • Liver cirrhosis with portal hypertension and splenomegaly. HCC s/p operation and RFA without tumor recurrence.
  • 2020-06-17 CT - liver, spleen, biliary duct, pancreas
    • Liver cirrhosis with HCC at S6 s/p RFA. No evidence of local recurrence is found.
  • 2020-03-16 CT - liver, spleen, biliary duct, pancreas
    • HCCs s/p operation, TACE and RFA. Residual and recurrent HCCs (3-8mm) at right hepatic lobes.
  • 2020-02-04 Embolization (TAE) - abdomen
    • HCCs at RIGHT hepatic lobe s/p TACE.
  • 2019-11-28 MRI - liver, spleen
    • Liver cirrhosis.
    • HCC at S6 s/p RFA with recurrent tumor adjacent to the lesion. Suggest further treatment.
  • 2019-09-18 CT - liver, spleen, biliary duct
    • Liver cirrhosis with HCC s/p RFA and TACE, no evidence of local recurrence in the study.
  • 2019-07-03 CT - liver, spleen, biliary duct
    • Liver cirrhosis.
    • HCC s/p op. and RFA with suspected tumor recurrence at S7. Malignant liver neoplasm, primary;
  • 2019-05-20 Surgical pathology Level V
    • Liver, sono-guided biopsy — Consistent with hepatocellular carcinoma and liver cirrhosis
    • The sections show a picture liver cirrhosis, composed of regenerative nodules separated by broad fibrous bands. Scant atypical cells arranged in thin trabecular pattern can be found.
    • IHC: Glutamine synthetase(+), HSP70(+), glypican-3(+) and CK7(-). The IHC finding is consistent with hepatocellular carcinoma.
  • 2019-03-12 CT - liver, spleen, biliary duct
    • S/P operation. A recurrent HCC (9mm) in S6 of liver.
    • Liver cirrhosis with portal hypertension and splenomegaly.
  • 2018-09-07 Surgical pathology Level V
    • pathologic diagnosis
      • Liver, S5, partial hepatectomy — Hepatocellular carcinoma
        
      • Liver, S6, partial hepatectomy — Combined hepatocellular-cholangiocarcinoma
        
      • Specimen labeled “surface tumor”, frozen section — Regenerative nodule
        
      • Pathologic Staging: ypT2Nx(cM0), Stage II at least
    • microscopic examination
      • Diagnosis: Hepatocellular carcinoma(S5) and combined hepatocellular-cholangiocarcinoma(S6)
      • Histologic Grade: G2 (Moderately differentiated, both tumors)
      • Tumor Extension: Tumor confined withing liver (both tumors)
      • Pathologic Stage Classification
        • Primary Tumor (pT): ypT2 (multiple tumors, none >5 cm)
          
        • Regional Lymph Nodes (pN): ypNx (No lymph nodes submitted)
          
        • Distant Metastasis (pM): Not applicable
          
      • Additional Pathologic Findings: Chronic hepatitis C
      • Ishak modified staging of fibrosis: Cirrhosis (F6)
        
      • IHC: Cholangiocarcinoma component reveals CK7(+), Hepa1(-), Arginase-1(-)
  • 2017-07-10 MRI - liver, spleen
    • HCC s/p RFA. A poor enhancing nodule (1.5cm) in S6 of liver without interval change.
    • Liver cirrhosis with regenerative nodules, portal hypertension and splenomegaly.
  • 2017-02-16 CT - liver, spleen, biliary duct
    • HCC s/p RFA. Liver cirrhosis with splenomegaly.
• lab data
  • 2021-08-13 PIVIKA-II 62.36 mAU/mL (normal < 40)
• surgical operation
  • 2021-12-17 Embolization (TAE) - abdomen for tumor
    • HCCs at both hepatic lobes s/p TACE.
  • 2021-11-03 Embolization (TAE) - abdomen for tumor
    • HCCs at both hepatic lobes s/p TACE.
  • 2021-09-02 Embolization (TAE) - abdomen for tumor
    • HCCs at both hepatic lobes s/p TACE.
  • 2021-07-22 Embolization (TAE) - abdomen for tumor
    • HCCs at both hepatic lobes s/p TACE.
  • 2021-06-21 Embolization (TAE) - abdomen for tumor
    • HCCs at both hepatic lobes s/p TACE.
  • 2021-05-13 Embolization (TAE) - abdomen for tumor
    • HCCs at both hepatic lobes s/p TACE.
  • 2021-02-24
    • surgery - laparoscope assist right posterior segmntectomy S6-7
    • finding - two hepatic tumors at S7 and scaring at S6 and S6 postresected scarring
  • 2020-05-29 RFA, Radiofrequency ablation - HCC
  • 2020-05-06 PEIT, Sonography guided percutaneous ethanol injection
  • 2019-08-23 Embolization (TAE) - abdomen
    • HCCs at RIGHT hepatic lobe s/p TACE.
  • 2018-09-06 Partial Hepatectomy
• chemoimmunotherapy
  • 2020-05-05 ~ 2022-01-10 - nivolumab
  • 2020-04-01 ~ 2021-03-19 - lenvatinib

[assessment]

• This patient underwent partial hepatectomy on 2018-09-06, PEIT on 2020-05-06, RFA on 2020-05-29, 7 times of TACE between 2019-08-23 and 2021-12-17, and Lenvatinib from 2020-04-01 to 2021-03-19 as well as Nivolumab from 2020-05-05 to 2022-01-10. The patient’s disease has progressed based on 2022-03-18 CT.
• Historically, traditional chemotherapy agents have not shown great efficacy in the treatment of HCC when used in advanced stage of disease, in particular in case of progression after locoregional therapy. FOLFOX is listed in NCCN HCC guideline as a category 2B regimen. In the event of MSI-H/dMMR being proven, dostarlimab-gxly might be tried (also category 2B).

701361740

220415

{Acute myeloid leukemia}

[objective]

• exam finding
  • 2022-03-22 Patho - bone marrow biopsy
    • Bone marrow, iliac bone, biopsy — Acute myeloid leukemia
    • Microscopically, the sections show a picture of acute myeloid leukemia, no remission, composed of hypocellular marrow for her age (20-30%). The blasts are small-sized with round nuclei, and small amount of cytoplasm, 70-80% of nucleated cells.
    • Immunohistochemistry shows CD34(+), CD117(+) and MPO(-) for blast, CD61(+, megakaryocytes) and CD71(+, erythroid series) revealed hypoplasia of megakaryocyte and erythroid series.
  • 2022-02-22 Abdominal Ultrasonography
    • Indication: pancytopenia
    • Diagnosis: possible liver lesion or false lesion, S5/8
  • 2022-02-21 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with acute myeloid leukemia
    • The sections show normocellular marrow (35%). The marrow space is partially replaced by a population of medium-sized immature cells with oval nucleus and high N/C ratio, constitue 50% of marrow cells.
    • IHC, the immture cells reveal: CD34(+), CD117(+), TdT(rare+), CD3(-), CD20(-), CD79a(-). The finding is compatible with acute myeloid leukemia. Suggest bone marrow smear study and flow cytometry evaluation.
• lab data
  • 2022-03-11
    • HLA A-high 11:01
    • HLA B-high 39:01
    • HLA C-high 07:02
    • HLA DRB1
      • HLA DQ-high 04:02, 06:01
      • HLA DQ-high 04:10, 08:03
  • 2022-03-04
    • FLT3/ITD mutation undetectable
    • NPM1 mutation undetectable
  • 2022-03-03 Aspiration
    • CD2 NA
    • CD3 1.53
    • CD4 NA
    • CD5 0.25
    • CD7 0.15
    • CD8 NA
    • CD10 0.82
    • CD11b 59.4
    • CD13 76.3
    • CD14 0.13
    • CD15 NA
    • CD16 0.9
    • CD19 19.16
    • CD19/kappa NA
    • CD19/Lambda NA
    • CD20 0.23
    • CD23 NA
    • CD25 NA
    • CD33 87.26
    • CD34 98
    • CD38 NA
    • CD56 0.15
    • CD103 NA
    • CD117 0.04
    • CD138 NA
    • FMC7 NA
    • HLA-DR 99.76
    • MPO NA
    • TdT NA
• chemotherapy
  • 2022-03-04 ~ undergoing - idarubicin + cytarabine, 3 + 7

[assessment]

• The patient almost 60 was recently diagnosed with AML and has been receiving idarubicin and cytarabine (3 + 7) since 2022-03-04.
• For patients with AML, FLT3/ITD marks poor survival in younger (<60 years) but not in older (60-74 years) and NPM1 mutation marks good survival in older, but not younger. reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7094014/
• The patient’s lab results of FLT3/ITD and NPM1 were undetectable (2022-03-04), not revealing much direction in terms of risk stratification.
• Neutropenic fever and HBV are treated with corresponding ABX and entecavir, respectively. No issue with current medication.

220323

{Quinolones-Antacids Interactions}

[objective]

• Drugs listed in current medication
  • Cravit (levofloxacin 500mg/tab) 1.5 tab PO QDAC
  • Strocain (oxethazaine, polymigel i.e. aluminum hydroxide + calcium carbonate + magnesium carbonate) 5mg/tab 1 tab PO TIDAC

[assessment]

• Antacids may decrease the absorption of quinolones in the setting of oral administration of quinolones.
  • Antacids interacting members: Almagate, Aluminum Hydroxide, Calcium Carbonate, Diomagnite, Magaldrate, Magnesium Carbonate, Magnesium Hydroxide, Magnesium Trisilicate, Potassium Bicarbonate
    • Exception: Sodium Bicarbonate
  • Quinolones interacting members: Ciprofloxacin (Systemic), Delafloxacin, Enoxacin, Gemifloxacin, Levofloxacin (Systemic), Lomefloxacin, Moxifloxacin (Systemic), Nalidixic Acid, Norfloxacin, Ofloxacin (Systemic), Pefloxacin, Pipemidic Acid, Sparfloxacin, Zabofloxacin
    • Exception: Levofloxacin (Oral Inhalation)

[suggestion]

• Either administration of Cravit 30 minutes before Strocain or lowering of Strocain to QLAC + QNAC is recommended.

701328847

220413

{Interprofessional Practice Meeting and Family Meeting}

• The postponed meeting rescheduled at 10:30 2022-04-13 in the ward, the patient was present, as was her son.
• Dr. Kao explained the treatment plan of the disease to the patient family, as well as the prognosis and possible risks, and interprofessional practice team members were present for inquiries.

220412

{mesna administration}

• mesna administration via ntravenous route
  • dilute with D5W, NS, LR, D5-0.2%NaCl, D5-0.33%NaCl, or D5-0.45%NaCl to a final concentration of 20 mg/mL
  • following initial puncture of multidose vial, use within 8 days
  • following dilution, store at 25 degrees C and use within 24 hours
  • do not mix with epirubicin, cyclophosphamide, cisplatin, carboplatin, or nitrogen mustard
  • if mixed with ifosfamide in the same IV bag, do not exceed a final ifosfamide concentration of 50 mg/mL
• the patient is 50kgw, scheduled dose is 12mg/kg, 600mg should be dissolved in at least 30mL aforementioned solvent, injection 30 min is recommended.

220411

[objective]

• diagnosis
  • Mantle cell lymphoma involving in bilateral neck lymph nodes, supraclavicular lymph nodes, mediastinal and bilateral pulmonary hilar lymph nodes and some bilateral axillary lymph nodes and the soft tissue in the right buttock, bone marrow(+), PS:0, Lugano stage IV, MIPI 6.7, high risk, HCT-CI score:0 (low risk, non-relapse mortality 14% at 2years)
• exam finding
  • 2022-03-18 CT - lung/mediastinum/pleura
    • Mild splenomegaly
    • No evidence of lymphadenopathy in the study.
    • Dilated aortic root.
  • 2022-02-08 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Consistent with myelodysplastic syndrome
    • Sections show 30-50 % cellularity with marked decreased erythroid cells. Atypical small and hypolobated megakaryocytes are found about 3-8/HPF. Some megakaryocytes are positive for CD34. The CD34 and CD117 show no increased blasts. The immunohistochemical stain of Hemoglobin A show scant residual erythroid cells. The immunohistochemical stains of CD3 and CD20 show some CD3-positive lymphocytes without CD20-positive lymphocytes.
    • The morphology is consistent with myelodysplastic syndrome.
  • 2022-01-13 MRA - brain
    • Cerebral white matter FLAIR-hyperintensitie. Suspected demyelineation process due to ischemia or chemotherapy.
  • 2021-12-17 CT - lung/mediastinum/pleura
    • No evidence of lymphadenopathy in the study but borderline splenomegaly is noted.
  • 2021-09-16 Patho - bone marrow biopsy
    • diagnosis
      • Bone marrow, iliac, clinically: newly diagnosed in China with first time chemotherapy), biopsy — Mantle cell lymphoma.
      • IHC: CD3(-), CD20(+), bcl-2(+), bcl-6(-), Cyclin-D1(focal +).
        
    • microscopic description
      • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There are multiple minute aggregates of small atypical lymphoid cells.
  • 2021-09-07 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma of low to median FDG uptake involving multiple lymph nodes on the same side of the diaphragm as mentioned above (stage II).
    • Mildly increased FDG uptake in a focal area in the soft tissue in the right buttock. The nature is to be determined (inflammation? other nature?).
    • Increased FDG accumulation in both kidneys and left ureter. Physiological FDG accumulation is more likely.
  • 2021-09-07 CT - neck
    • Multiple enlarged bil. neck LNs, esp. at right posterior cervical space, supraclavicular fossa and axilla.
• chemoimmunotherapy
  • 2022-02-15 - ESHAP (etoposide, methylprednisolone, cytarabine, cisplatin)
  • 2022-02-14 - rituximab
  • 2021-12-28 - R-DHAP
    • R - rituximab (also called Mabthera), a type of targeted cancer drug called a monoclonal antibody
    • DH - dexamethasone, which is a steroid
    • A - cytarabine (also known as Ara C), a chemotherapy drug
    • P - cisplatin, a chemotherapy drug
  • 2021-12-01 - R-CHOP, rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride (doxorubicin hydrochloride), vincristine (Oncovin) and prednisone
  • 2021-11-08 - R-DHAP
  • 2021-09-16, -10-12 - R-CHOP
  • 2021-08-04 - R-CHOP (in mainland China)
• consultation
  • 2022-01-12 Neurology
    • Assessment
      • Peripheral vertigo, suspected platinum based chemotherapy related
    • Suggestion
      • Arrange BAEP, Intracranial and carotid doppler ultrasound, check BP at lying, sitting and standing with 3 minutes interval each position.
      • Use diphenidol and meclizine routinely.
      • MRA brain with/without contrast may be arranged if new neurological deficit occured.

[assessment]

• The arranged IPP meeting (TP1110411001) has been postponed until further notice.
• There is no TP53 mutation lab data found.
• The patient has been treated with RCHOP, alternating RCHOP/RDHAP, R-ESHAP during Aug 2021 to Feb 2022.
• The results of two consecutive bone marrow biopsies revealed mantle cell lymphoma (2021-09-16) and myelodysplastic syndrome (2022-02-08). High-dose therapy (HDT) and autologous stem cell rescue (ASCR) might be indicated. There will be a patient family meeting to discuss ASCR in the near future.
• During this hospital stay, phenytoin was prescribed to prevent intravenous busulfan induced seizures in recipients of hematopoietic cell transplantation. Phenytoin is primarily metabolized by the liver to inactive metabolites with <5% of active drug excreted unchanged in the urine, making routine dose adjustments for kidney dysfunction unnecessary. Lab results reported on 2022-04-11 indicated slight elevations of ALT (44 U/L, normal < 41) and creatinine (1.4 mg/dL, normal < 1.3), which did not require adjusting the pheytoin dose.

220111

[objective]

Creatinine lab data: - 2022-01-10 1.25mg/dL - 2022-01-07 1.43mg/dL - 2022-01-03 0.93mg/dL

[assessment]

• serum creatinine elevates slightly above normal range during ABX administration.

[suggestion]

• no immediate dose adjustment needed for now, keep monitoring renal function as regular to check the trend.

700306021

220412

[objective]

• exam finding
  • 2022-03-14 Patho - pancreas biopsy
    • Labeled as pancreatic head, EUS fine needle biopsy - adenocarcinoma.
    • Section shows core of tissue with irregular neoplastic glands and markedly desmoplastic stroma.
    • IHC stains: CK19(+), CA19-9(+), CD56(-), p40(-).
  • 2022-03-14 Fine needle aspiration cytology - pancreas
    • Pancreatic head tumor: adenocarcinoma
  • 2022-03-11 Endoscopic Retrograde CholangioPancreatography, ERCP
    • Pancreatic head tumor with CBD invasion, s/p TPS, s/p ERBD
    • Marked dilatation of biliary tree
    • Inadvertent performance of partial pancreatography
  • 2022-03-11 Endoscopic ultrasonography
    • Diagnosis
      • Pancreatic head tumor, s/p EUS/FNB
      • Tumor invasion of CBD with marked biliary dilatation
      • Gastric shallow ulcers and erosions, antrum
      • Hiatal hernia
    • Suggestion
      • Pursue pathology and cytology result
      • Give PPI after the procedure
  • 2022-03-10 MRI - pancreas
    • Pancreatic head cancer (3.3cm) with common hepatic artery, SMA, SMV, proximal main portal vein, CBD, p-duct. duodenal invasion and LNs metastases (T4N1M0, stage III).
  • 2022-03-10 Echocardiography
    • Dilated LA, LV
  • 2022-03-08 MRI - pancreas
    • In favor of pancreatic head tumor with SMA, SMV, portal vein, distal CBD, p-duct and duodenal invasion. Some LNs at hepatic hilar region.
  • 2022-03-07 Endoscopic ultrasonography
    • Pancreatic tumor with cystic components, head, probable pancreatic cancer
    • MPD dilatation
    • CBD dilatation and sludge
    • Distended GB with sludge
    • Esophageal erosion, lower esophagus
  • 2022-03-07 Abdominal sonography
    • Pancreatic head tumor, suspected cancer
    • Bilateral IHD and CBD dilatation
    • Distented gallbladder
  • 2022-03-05 CT - liver, spleen, biliary duct, pancreas
    • Soft tissue mass at uncinate process of the pancreas with obliteration of the CBD up to 2.09cm is found, causing IHDs and CBD dilatation. Pancreatic cancer is suspected. The SMV is attached by the tumor.
  • 2020-07-06 MRA - brain
    • T2 hyperintensities in bilaetral white matter and periventricular region, suspected chronic ischemic or other demyelinating white matter change.
    • Brain atrophy.
• consultation
  • 2022-03-08 Gastroenterology & General Surgery
    • Impression
      • Pancreatic head tumor, IHDs and CBD dilatation
    • Suggestions:
      • Insert PTCD/endo stent first due to hyperbilirubinemia.
      • Check blood sugar HbA1c, glucose AC/PC.
      • Arrange cardiopulmonary function tests such as cardiac echo and lung function test due to old age.
      • We will evaluate the need of the operation after her hyperbilirubinemia subsided.
• radiotherapy
  • 2022-03-29 ~ 2022-04-11 - 720cGy/4 fractions (15 MV photon) to pancreatic head tumor and lymphatics
  • Neoadjuvant C/T and R/T for 5040cGy/28 fractions is sugested for downstage and tumor control.
• chemotherapy
  • 2022-03-28 ~ undergoing - FOLFIRINOX, pre-Op neoadjuvant C/T
    • oxaliplatin 50mg/m2 2hr
    • irinotecan 90mg/m2 2hr
    • leucovorin 400mg/m2
    • 5-Fu 2000mg/m2 46hr

[reference]

• FOLFOXIRI vs FOLFIRINOX as first-line chemotherapy in patients with advanced pancreatic cancer: A population-based cohort study. https://dx.doi.org/10.4251/wjgo.v12.i3.332
  • FOLFIRINOX was administered according to the standard schedule validated by the PRODIGE 4/ACCORD 11 study. This regimen consisted of a combination of oxaliplatin (85 mg/m2, over 2 h), followed by leucovorin (400 mg/m2, over 2 h), with the addition through a Y-connector, after 30 min, of irinotecan (180 mg/m2, over 90 min), followed by 5-FU (400 mg/m2) by intravenous bolus, on Day 1. Then, a continuous intravenous infusion of 5-FU (2400 mg/m2) was administered over 46 h starting on Day 1.
    • oxaliplatin 85mg/m2 2hr
    • leucovorin 400mg/m2 2hr
    • irinotecan 180mg/m2 90min
    • 5-FU 400mg/m2 IV bolus
    • 5-FU 2400mg/m2 46h
  • FOLFOXIRI consisted of the same molecules with a reduced dose of irinotecan and no bolus 5-FU, according to the GONO regimen used in metastatic colorectal cancer: Irinotecan (165 mg/m2, over 1 h), followed by oxaliplatin (85 mg/m2) and leucovorin (200 mg/m2) concomitantly over 2 h through a Y‐connector, on Day 1; and followed by a continuous intravenous infusion of 5-FU (3200 mg/m2) over 48 h starting on Day 1.
    • irinotecan 165mg/m2 1hr
    • oxaliplatin 85mg/m2
    • leucovorin 200mg/m2 2hr
    • 5-FU 3200mg/m2 48hr

[assessment]

• There is a case of pancreatic head cancer with common hepatic artery, superior mesenteric artery, superior mesenteric vein, proximal main portal vein, CBD, pancreatic duct, duodenal invasion and lymph node metastases (2022-03-10 MRI).
• If jaundice is present, placement of a self-expanding metal stent is recommended, preferably via ERCP. ERBD was performed via ERCP on 2022-03-11. Bilirubin total decreased from its peak of 13.75mg/dL on 2022-03-07 to 1.86mg/dL on 2022-04-11.
• The patient has been given 720cGy/4 fractions (15 MV photon) to treat the pancreatic head tumor and lymphatics (2022-03-29 to 2022-04-11) and has been receiving neoadjuvant FOLFIRINOX to downstage the tumor since 2022-03-28.
• Tumor/somatic gene profiling is recommended for patients with locally advanced/metastatic disease who are candidates for anti-cancer therapy to identify uncommon mutations. Consider specifically testing for actionable somatic findings including, but not limited to: fusions (ALK, NRG1, NTRK, ROS1), mutations (BRAF, BRCA1/2, HER2, KRAS, PALB2), and mismatch repair (MMR) deficiency (detected by tumor IHC, PCR, or NGS). Testing on tumor tissue is preferred; however, cell-free DNA testing can be considered if tumor tissue testing is not feasible.
• The laboratory results reported on 2022-04-11 showed normal ALT and creatinine readings as well as lower WBC (2930/uL, Neutrophil 58%), which should not affect the chemotherapy treatment in this hospital stay.
• No drug allergy records found in database, no issue with current medication.

700026574

220411

{Left renal cell carcinoma with metastatic mediastinal lymphadenopathies and suspecious RUL lung metastasis, liver and bone metastases s/p chemotherapy and radiotherapy}

[objective]

• exam finding
  • 2022-04-10 Pelvis THR & Rt Hip Lat; KUB & L-spine
    • Lucent lesions in L5, S1, right acetabulum.
  • 2022-04-10 CT - abdomen
    • Bony metastases.
    • Dilatation of A- and T-colon.
    • Collapse of gallbladder with small stones (2-3mm). Small CBD stones (2-3mm).
  • 2022-04-10 Chest
    • Presence of ileus.
    • Fracture of right ribs with union.
    • Ground glass opacity in right lung.
  • 2022-04-01 Chest
    • Several nodular opacity projecting in the right upper lung are suspected. Please correlate with CT.
    • Left hemi-diaphragm elevation was noted that is compatible with bronchiectasis with collapse after correlate with CT.
    • Atherosclerotic change of aortic arch.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura thickening.
  • 2022-02-23 Tc-99m MDP bone scan with SPECT
    • In comparison with the previous study on 20200911, some new bone lesions in both rib cages are noted, suggesting multiple bone metastases in progression. However, several previous bone lesions in multiple T- and L-spine, sternum, right humeral head, and right iliac bone become less evident, indicating partial respopnse to current therapy.
    • Suspected benign lesions at bilateral knees.
  • 2022-02-22 CT - abdomen, pelvis
    • Bone meta at left rib, L5 and right acetabulum, Suggest further treatment.
  • 2022-02-21 KUB
    • Fracture of right acetabulum is suspected.
  • 2020-09-11 Tc-99m MDP bone scan
    • In comparison with the previous study on 20200407, some new bone lesions are noted and some of the previous bone lesions are more evident, suggesting multiple bone metastases in progression.
    • No prominent change is noted in the lower C-spine and right sternoclavicular junction. Degenerative change may show this picture.
  • 2020-04-22 Chest
    • A nodular opacity projecting in the ventral aspect of RUL of the lung is suspected that is compatible with metastasis after correlate with chest CT.
    • Band-like atelectasis in RLL and LUL of the lung.
    • Patchy opacity projecting at the left lower medial lung zone and Left hemi-diaphragm elevation was noted that is compatible with bronchiectasis with collapse after correlate with CT.
    • Atherosclerotic change of aortic arch.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura thickening.
  • 2020-04-07 Tc-99m MDP bone scan
    • Prominently increased activity in the L5 spine, sternum and right iliac bone. Bone metastases should be considered. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the lower C-spine, some middle and lower T-spines, right sternoclavicular junction and right humeral head. Either degenerative change or bone metastases may show this picture. Please keep follow-up for further evaluation.
    • Some hot and faint spots in bilateral rib cages and mildly increased activity in the lesser trochanter of right femur. The nature is to be determined (post-traumatic change? bone metastasis? other nature?).
  • 2020-03-18 MRI - L-spine
    • tumors in the L5 and right iliac bone.
  • 2019-12-13 CT - lung/pleura, chest and upper abdomen
    • Compatible with RCC lung meta and mediastinal lymph nodes, stable.
  • 2019-09-11 CT - lung/pleura, chest and upper abdomen
    • no mediastinal LAP and no lung nodule on this F/U study.
    • stationary atelectatic basal segments with air-bronchograms of the LLL.
  • 2019-06-06 CT - lung/pleura, chest and upper abdomen
    • no mediastinal LAP and no lung nodule on this F/U study.
    • stationary atelectatic basal segments with air-bronchograms of the LLL.
  • 2019-03-06 CT - chest and upper abdomen
    • RCC with resolution of left lung and mediastinal LNs metastasis as compared with previous CT study.
  • 2018-11-21 CT - chest and upper abdomen
    • RCC with left lung and mediastinal LNs metastasis, further in regression as compared with previous CT study.
  • 2018-08-23 CT - chest and upper abdomen
    • RCC with lung and mediastinal LNs metastasis, further in regression as compared with previous CT study.
  • 2018-05-09 CT - chest and upper abdomen
    • RCC with lung and mediastinal LNs metastasis, in regression compared with previous CT study.
  • 2018-02-13 CT - chest and upper abdomen
    • Metastatic mediastinal and left hilar LAPs and Lt Main bronchus with left lung atelectasis.
  • 2017-10-14 Renal Echo
    • Absence of left kidney with hypertrophy of right side kidney
    • History of RCC s/p left side nephrectomy
  • 2017-10-11 CT - chest and upper abdomen
    • suspected endobronchial CA in left main bronchus with obstructive pneumonitis.
  • 2017-08-03 MRI - kidney, adrenals
    • S/P left nephrectomy with residual minimal fatty infiltrates in left renal fossa.
    • GB stones.
  • 2017-05-06 CT - abdomen
    • S/P left nephrectomy with fluid density in left renal fossa, seroma, abscess or hematoma?
      
    • Thickening/edema of small bowel loops around surgical region.
  • 2017-03-24 CT - abdomen
    • Left renal tumor, suspected RCC, suspicious renal venous branch invasion. Cstage T3N0Mx.
  • 2017-03-22 Renal Echo
    • Left renal tumor was noted at Taipei CGMH
• radiotherapy
  • 2022-03-02 ~ 2022-03-15 - 3000cGy/10 fractions (IMRT) to Rt iliac bone, palliative
  • 2020-03-27 ~ 2020-04-06 - 3000cGy/10 fractions (6 MV photon) to L5, & 3000cGy/10 fractions to Rt hip
  • 2018-08-16 ~ 2018-08-31 - 3600cGy/12 fractions (6 MV photon) to Rt humeral head
• chemoimmunotherapy
  • 2022-03-17 ~ 2022-04-11 - everolimus
  • 2022-03-17 - denosumab
  • 2022-02-19 ~ 2022-02-26 - axitinib
  • 2018-03-02 ~ 2020-06-17 - axitinib
  • tried oral sunitinib, axitinib (Cheng Hsin General Hospital)

[assessment]

• The patient was diagnosed with RCC with metastatic mediastinal LAPs, suspected RUL lung metastases, liver and bone metastases and is currently enrolled in hospice combined care (since 2022-03-11).
• He is now taking everolimus (since 2022-03-17 s/p axitinib) and has tried denosumab to prevent pathological spontaneous fractures, as well as opioid analgesics to relieve pain.
• Serum calcium 1.55mmol/L (normal 2.2 ~ 2.65) and magnesium 1.8mg/dL (normal 1.9 ~ 2.7) reported on 2022-04-10. In patients with hypomagnesemia, hypocalcemia is difficult to correct without first normalizing the serum magnesium concentration. The patient’s serum magnesium was just slight below normal range and currently treated with oral magnesium oxide and calcium carbonate without issues.
• Urine bacteria (1+) were reported on 2022-04-10; since everolimus is also an immunosuppressive agent, some ABX might be considered to prevent an infection from worsening.

220318

{RCC with multiple bone metastases}

[objective]

• exam finding
  • 2022-02-23 Tc-99m MDP whole body bone scan with SPECT
    • In comparison with the previous study on 20200911, some new bone lesions in both rib cages are noted, suggesting multiple bone metastases in progression. However, several previous bone lesions in multiple T- and L-spine, sternum, right humeral head, and right iliac bone become less evident, indicating partial respopnse to current therapy.
    • Suspected benign lesions at bilateral knees.
  • 2022-02-22 CT - whole abdomen, pelvis
    • Bone mets at left rib, L5 and right acetabulum, suggest further treatment.
  • 2022-02-19 KUB + L-spine Lat
    • L5 compression fracture
    • suspected an osteolytic lesion with bone destruction at right pelvis.
  • 2020-09-10 Chest PA
    • Band-like atelectasis in RLL of the lung is suspected. Please correlate with CT.
    • Left hemi-diaphragm elevation was noted that is compatible with bronchiectasis with collapse after correlate with CT.
    • Atherosclerotic change of aortic arch.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura thickening.
  • 2020-09-11 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20200407, some new bone lesions are noted and some of the previous bone lesions are more evident, suggesting multiple bone metastases in progression.
  • 2020-04-07 Tc-99m MDP whole body bone scan
    • Prominently increased activity in the L5 spine, sternum and right iliac bone. Bone metastases should be considered. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the lower C-spine, some middle and lower T-spines, right sternoclavicular junction and right humeral head. Either degenerative change or bone metastases may show this picture. Please keep follow-up for further evaluation.
    • Some hot and faint spots in bilateral rib cages and mildly increased activity in the lesser trochanter of right femur. The nature is to be determined (post-traumatic change? bone metastasis? other nature?).
  • 2020-03-18 MRI - L-spine
    • Tumors in the L5 and right iliac bone.
  • 2019-12-13 CT - lung/pleura
    • Compatible with RCC lung meta and mediastinal lymph nodes, stable.
  • 2019-09-11 CT - lung/pleura
    • No mediastinal LAP and no lung nodule on this F/U study.
    • Stationary atelectatic basal segments with air-bronchograms of the LLL.
  • 2019-03-06 CT - lung/pleura
    • RCC with resolution of left lung and mediastinal LNs metastasis as compared with previous CT study.
  • 2018-11-21 CT - lung/pleura
    • RCC with left lung and mediastinal LNs metastasis, further in regression as compared with previous CT study.
  • 2018-08-23 CT - lung/pleura
    • RCC with lung and mediastinal LNs metastasis, further in regression as compared with previous CT study.
  • 2018-05-09 CT - lung/pleura
    • RCC with lung and mediastinal LNs metastasis, in regression compared with previous CT study.
  • 2018-02-13 CT - lung/pleura
    • Metastatic mediastinal and left hilar LAPs and Lt Main bronchus with left lung atelectasis.
  • 2017-10-11 CT - lung/pleura
    • suspected endobronchial CA in left main bronchus with obstructive pneumonitis.
  • 2017-08-03 MRI - kidney, adrenals
    • S/P left nephrectomy with residual minimal fatty infiltrates in left renal fossa.
    • GB stones.
  • 2017-05-06 CT - whole abdomen
    • S/P left nephrectomy with fluid density in left renal fossa, seroma, abscess or hematoma?
      
    • Thickening/edema of small bowel loops around surgical region.
  • 2017-03-24 CT - whole abdomen
    • Imaging Report Form for Renal Cell Carcinoma
    • Left renal tumor, suspected RCC, suspicious renal venous branch invasion. Cstage T3N0Mx.
• surgical operation
  • 2017-08-14 Left inguinal hernia
• radiotherapy
  • 2022-03-02 ~ 2022-03-15 - 3000cGy/8~10fx to Rt iliac bone
  • 2020-03-27 ~ 2020-04-06 - 3000cGy/10fx (6 MV photon) to L5, 3000cGy/10fx to Rt hip
  • 2018-08-16 ~ 2018-08-31 - 3600cGy/12fx (6 MV photon) to Rt humeral head
• chemotherapy
  • 2022-02-19 ~ 2022-02-26 axitinib
  • 2018-03-02 ~ 2020-05-20 axitinib
  • 2018-02-03 ~ 2020-01-17 sunitinib

[assessment]

• The RCC patient with multiple bone metastases in progression (2022-02-23 CT), has been treated with axitinib and sunitinib.
• If the conditions are covered by the national health insurance or a commercial insurance, or the patient is financially able to afford the medication, immunotherapy might also be considered as an add-on treatment.
• Some regimens in which drug used in immunotherapy can be found, including but not limited to:
  • axitinib + pembrolizumab
  • cabozantinib + nivolumab
  • lenvatinib + pembrolizumab
  • ipilimumab + pembrolizumab
• Hospice care is being considered by the patient and his family.
• Caregivers have an urgent problem of controlling pain for patients at home that needs to be resolved. Besides analgesics, non-pharmacological interventions that can control pain over a longer period of time might also be considered.
• The following interventions are available to treat metastatic bone cancer pain (not exhaustive, reference: https://pubmed.ncbi.nlm.nih.gov/31140913/):
  • Epidural and selective nerve root block
  • Radiofrequency ablation and cryoablation
  • Vertebral augmentation
  • Intrathecal drug delivery
  • Spinal cord stimulation
  • Dorsal root ganglion stimulation

700815802

220411

{Recurrence nasopharyngeal carcinoma with skull base destruction and cranial nerve (V2, VI) invasion , liver metastasis and multiple lung metastases in progression.yT4N2M1,stageIVB}

[objective]

• exam finding
  • 2022-03-24 Chest
    • Borderline cardiomegaly
    • Increased lung markings on both lower lung are noted.
    • Hypoinflation of both lung is noted.
  • 2022-02-19 CT - liver, spleen, biliary duct, pancreas
    • Progression of liver metastases.
    • Multiple lung metastases.
  • 2021-10-19 MRI - nasopharynx
    • NPC, s/p R/T with abnormal residual enhancing soft-tissue at Rt skull base, pterygopalatine fissure and clivus, stationary.
    • Chronic bilateral mastoiditis and paranasal sinusitis, stationary.
  • 2021-09-25 CT - abdomen, pelvis
    • Liver metastasis with tumors regression (partial remission)
  • 2021-06-16 CT - liver, spleen, biliary duct, pancreas
    • Multiple metastases on both hepatic lobes show stable disease or progressive disease.
  • 2021-04-28 Nasopharyngoscopy
    • bulging tumor over NP, subside
    • NPC s/p CCRT with recur
  • 2021-04-22 SONO - abdomen
    • liver tumors, bil. propable metastases
    • suspected liver cyst, right
    • suspected right renal cyst
  • 2021-02-26 CT - abdomen, pelvis
    • Multiple metastases on both hepatic lobes show stable disease.
  • 2021-02-08 MRI - nasopharynx
    • C/W NPC s/p treatment with residual abnormal signal intensity at skull base, stationary as compared with MRI on 2020817.
  • 2021-02-01 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20200213, increased radiotracer uptake in skull base had been slightly less evident, probably indicating post-treatment inflammatory change. Please correlate with other imaging modalities to exclude the possibility of malignant local bone invasion.
    • Mildly and non-focally increased radiotracer uptake in lower L-spine and sacrum, degenerative spine diseases may show such a picture.
    • Some faint hot areas in maxilla and mandible, dental lesions may show such a picture.
    • Probably degenerative joint lesions in shoulders, sternoclavicular junctions, manubriosternal joint, sacroiliac joints, and hips.
    • No definite evidence of distant osteoblastic skeletal metastasis by this bone scan.
  • 2021-01-05 GI bleeding embolization
    • Duodenal hemorrhage s/p TAE.
  • 2021-01-04 Esophagogastroduodenoscopy
    • Diagnosis
      • Reflux esophagitis LA classification grade A
      • Incomplete study of stomach and doudenum
      • Duodenal ulcers, 2nd portion, s/p hemostasis with injection, APC & hemoclipping
    • Suggestion
      • Transfer to ICU for intensive care and monitor
      • NPO with high dose PPI for at least 3 days
      • Angiography is suggested if active bleeding develops
  • 2020-11-17 CT - abdomen, pelvis
    • Liver metastsis, regression.
    • Liver cysts.
    • Right renal cyst.
  • 2020-10-12 Nasopharyngoscopy
    • bulging tumor over NP, subside
    • npc s/p ccrt with mets
  • 2020-09-22 Patho - colon biopsy
    • Rectum, biopsy - Nonspecific proctitis with superficial ulcer
  • 2020-09-18 Patho - stomach biopsy
    • Stomach, antrum, PW & LC side, biopsy - ulcer. No H.pylori present
  • 2020-08-17 MRI - nasopharynx
    • NPC, s/p R/T with abnormal residual enhancing soft-tissue at Rt skull base, pterygopalatine fissure and clivus, stationary.
    • Chronic bilateral mastoiditis and paranasal sinusitis.
  • 2020-08-12 CT - liver, spleen, biliary duct, pancreas
    • Multiple metastases on both hepatic lobes.
  • 2020-08-04 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Metastatic non-keratinizing squamous carcinoma, consistent with nasopharynx primary
    • The secvtions show non-keratinizing squamous cell carcinoma, composed of nests of poorly differentiated neoplastic cells in fibrous stroma.
    • IHC, tumor cells reveal: CK7(-), CK20(-), p40 (+) and Hepa-1(weakly +). The finding is consistent with metastatic nasopharyngeal carcinoma.
  • 2020-07-29 CT - CTA, chest
    • no acute pulmonary embolism.
    • multiple HCC in both lobes.
  • 2020-05-07 SONO - abdomen
    • fatty liver, mild
    • liver tumors, bil. propable metastases
    • suspected liver cyst, left
    • suspected fatty infiltration of pancreas
    • suspected right renal cyst
    • s/p cholecystectomy
  • 2020-03-26 MRI - nasopharynx
    • NPC, s/p R/T with abnormal enhancing soft-tissue at Rt skull base, pterygopalatine fissure, and clivus still visible, stationaryas compared with MRI 2019/11/26
    • Chronic mastoiditis and otitis media.
    • Thyroid goiter.
  • 2020-02-24 Nasopharyngoscopy
    • npc s/p ccrt with recur
  • 2020-02-13 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20180613, the hot spot in the skull base is less evident. Please correlate with other imaging modalities for further evaluation.
    • The previous hot spot in the suerolateral aspect of the left orbital area of the skull is less evident and the previous rib lesions disappeared, probably more benign in nature.
    • Suspected benign lesions in bilateral sternoclavicular junctions, shoulders, knees, and feet.
  • 2020-02-10 CT - abdomen
    • No interval change of liver lesions.
    • Right renal cyst (2.4cm).
  • 2019-11-26 MRI - Nasopharynx
    • NPC, s/p R/T with abnormal enhancing soft-tissue at Rt skull base, pterygopalatine fissure and clivus, stationary.
    • Chronic bilateral mastoiditis.
  • 2019-10-18 CT - abdomen
    • Indication: NPC with liver Metastasis in S5 s/p RFA, for follow up
    • Impression: Prior CT identified metastasis in S5 S/P RFA shows complete response.
  • 2019-07-23 Echo for liver, gall bladder, pancreas, spleen
    • Hepatic tumor, probably metastatic tumor (S5-6)
    • Hepatic tumor, probably post RFA change (S8, according hx and CT)
    • Hepatic cyst
    • Postcholecystectomy
  • 2019-07-15 CT - abdomen
    • Liver tumors s/p RFA. suspected residual tumor in S6 of liver.
  • 2019-06-03 MRI - nasopharynx
    • Indication:
      • NPC, with skull base destruction and cranial nerve (V2, VI) invasion, cT4N2M0. s/p CCRT and adjuvant RT.
    • Impression:
      • NPC, s/p R/T with abnormal enhancing soft-tissue at Rt skull base, pterygopalatine fissure and clivus, stationary.
      • Chronic Right mastoiditis.
  • 2019-05-21 Surgical pathology Level V
    • Liver, needle biopsy — Metastatic undifferentiated carcinoma.
  • 2019-05-21 SONO guide biopsy
    • Metastasis in S5 of the liver is suspected.
  • 2019-04-23 Echo for liver, gall bladder, pancreas, spleen
    • Diagnosis
      • Hepatic tumor, probably metastaic tumor
      • GB stone, multiple
      • Splenomegaly, mild
    • Suggestion
      • refer to medical ONC for further evaluation and treatment
  • 2019-04-11 CT - abdomen
    • A faint enhancing lesion (2.1cm, srs501, img19) in S5 of liver.
  • 2019-02-27 Whole body PET scan
    • No significantly increased FDG uptake in bilateral N-P regions and skull base was noted, indicating response to current therapy.
    • Glucose hypermetabolism in the left lobe of the thyroid gland, the nature is to be determined (functioning nodule, benign or malignant neoplasm, or others ?), suggesting biopsy for further investigation.
    • Glucose hypermetabolism in the right lobe of the liver and in a nodular lesion in the RLQ of abdomen, the nature is also to be determined (benign or malignancy/metastasis ?).
  • 2019-02-19 MRI - nasopharynx
    • NPC, s/p R/T with post R/T change abnormal enhancing soft-tissue at Rt skull base, pterygopalatine fissure and clivus, stationary.
      
    • Chronic Right mastoiditis.
  • 2018-12-11 SONO - abdomen
    • Fatty liver, mild
    • Liver cyst, left lobe
    • Gall stone
    • Renal cyst, left kidney
    • Splenomegaly
  • 2018-11-13 MRI - nasopharynx
    • NPC, s/p R/T with post R/T change abnormal enhancing soft-tissue at Rt pterygopalatine fissure and clivus, suggest F/U.
    • Right mastoiditis.
  • 2018-06-13 Tc-99m MDP whole body bone scan
    • A hot spot at the skull base, NPC with local bone involvement should be considered, suggesting F-18 FDG PET/CT scan for further investigation.
    • Three hot spots in the right 8th to 10th ribs, respectively, the nature is to be determined (post-traumatic change or other nature?). Please follow up bone scan in 3 months.
    • Suspected benign lesions in the left rib cage, bilateral sternoclavicular junctions, shoulders, knees, and feet.
  • 2018-06-12 MRI - nasopharynx
    • NPC T4N2Mx
    • Right mastoiditis.
  • 2018-05-28 Surgical pathology Level IV
    • Nasopahrynx, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
    • IHC stain: CK (+).
• lab data
  • EBV
    • 2021-03-01 1236copies/mL (normal < 120)
    • 2019-11-11 <120
    • 2019-02-02 252
    • 2018-09-17 <120
• surgical operation
  • 2021-01-07
    • Surgery
      • duodenal ulcer suture ligation
      • trucal vagotomy wth pyloroplasty
    • Finding
      • active duodenal 2nd portion ulcer bleeding
      • chronic DU with bulb deformity
• radiotherapy
  • 2018-07-13 ~ 2018-08-23 - completed RT to the bil. neck lymphatic drainage area: 50 Gy/ 25 fx. The NP tumor and LAPs: 70 Gy/ 35 fx.
• chemotherapy
  • 2022-03-04 ~ undergoing - 5-Fu + Leucovorin
  • 2021-07-09 ~ 2021-12-03 - Doxorubicin
  • 2021-05-11 ~ 2021-06-07 - 5-Fu + Leucovorin
  • 2020-08-27 ~ 2020-12-22 - 5-Fu + Leucovorin

[assessment]

• This is a patient with non-keratinizing nasopharyngeal carcinoma (2018-05-28 pathology).
• According to medical images during the last 12 months (2021-04 and 2022-04), the primary lesions (s/p CCRT, now on FL) are generally stable, however, liver metastases (s/p RFA) appear to have developed.
• Nivolumab might be an optional alternative for nonkeratinizing NPC that has previously been treated.

700174551

220408

{rectal cancer with liver mets s/p LAR and liver partial resection}

[objective]

• exam finding

  • 2022-04-06 Abdominal sonography
    • post cholecystectomy
    • parenchymal liver disease
  • 2022-03-08 CT - abdomen, pelvis
    • Rectal cancer s/p operation. Wall thickening of proximal A-colon.
    • Mild regression of liver metastases.
  • 2021-12-08 CT - abdomen, pelvis
    • Metastasis 1.5 cm in S7 of the liver is highly suspected.
  • 2021-08-27 Patho - liver partial resection
    • pathologic diagnosis
      • Liver, S2-3, segmental hepatectomy — Metastatic rectal adenocarcinoma
        
      • Liver, S5, segmental hepatectomy — Metastatic rectal adenocarcinoma
        
      • Liver, S8, segmental hepatectomy — All specimen taken for section and no metastatic carcinoma present
        
      • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
    • microscopic examination
      • Diagnosis: Metastatic rectal adenoarcinoma x3
        
      • Histologic grade: Moderately differentiated
        
      • Tumor growth pattern: Infiltrating
        
      • Tumor pseudocapsule: Present
        
      • Tumor necrosis: Present (50%)
        
      • Parenchymal margin: Uninvolved by carcinoma
        
      • Distance of invasive carcinoma from closest margins: 0.4 cm (S5)
        
      • Vascular invasion: Not identified
        
      • Perineural invasion: Not identified
        
      • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
        
      • Non-neoplastic liver parenchyma: Perivenular congestion, regeneration of hepatocytes, mild lymphocytic portal inflammation, and mild fatty change (10%)
  • 2021-06-15 CT - abdomen, pelvis
    • rectal cancer s/p LAR and autosuture with liver mets.
    • the liver mets regressed.
  • 2021-02-18 Patho - colon segmental resection for tumor
    • pathologic diagnosis
      • Large intestine, rectum, robotic-assisted low anterior resection —- Adenocarcinoma, moderately differentiated
        
      • Lymph node, mesocolic, dissection —- Adenocarcinoma, metastatic (1/21)
        
      • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1a(if cM0), or pStage IVA, pT3N1a(if cM1a), Please correlate with the clinical presentation and image study
    • microscopic examination
      • Histology: adenocarcinoma
      • Histology Grade: moderately differentiated
        
      • Depth of invasion: mesocolic soft tissue
        
      • Angiolymphatic invasion: Present.
        
      • Perineural invasion: Present.
        
      • Discontinuous extramural tumor extension: Not identified.
        
      • Circumferential (radial) margin of rectum: Uninvolved, 16 mm from the margin
      • Lymph node metastasis, mesocolic: 1/21
        
      • Lymph node metastasis, IMA / SMA: not received
        
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          
        • Regional Lymph Nodes (pN): pN1a: One regional lymph node is positive
          
        • Distant Metastasis (pM): if cM0 or cM1a(CT finding)
          
      • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
        
      • S2021-02016 IHC: EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
        
  • 2021-02-08 CT - abdomen, pelvis
    • Imaging stage: T2N1bM1a stage IVA
  • 2021-02-05 Patho - colorectal polyp
    • Large intestine, rectum, 10 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
      
    • IHC: EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
      
  • 2021-02-04 Colonoscopy
    • A mass was noted in the rectum, size 3cm, 10cm from anal verge, suspected malignancy.
  • 2020-09-01 Renal echo
    • parenchymal renal disease

• lab data

  • 2021-03-08 NRAS/KRAS mutation not detected

• surgical operation

  • 2021-08-26
    • surgery
      • S2-3 resection
      • S8 and S5 partial resection
      • LC
    • finding
      • S2-3 two hypoechoic tumor + 1.5cm in diameter suspected hypoechoic tumor 1.2cm at S8
      • superifcal small tumor at S5 near GB
      • echo didn’t find any tumor at right posterior segment
  • 2021-02-17
    • surgery
      • Robotic-assisted low anterior resection        
    • finding
      • Rectal cancer 43.52 cm at 10 cm from AV

• chemoimmunotherapy

  • 2021-04-27 ~ undergoing - FOLFIRI + bevacizumab
  • 2021-03-12 ~ 2021-04-12 - FOLFIRI

[assessment]

• The patient with rectal cancer and liver mets has received FOLFIRI since 2021-03-12 (plus bevacizumab since 2021-04-27) s/p LAR (2021-02-17) and liver partial resection (2021-08-26).
• Available molecular review results include: pMMR, EGFR(+), NRAS/KRAS WT; no BRAF, HER2, NTRK results found.
• Recent surveillance detected suspected mets in S7 (CT, 2021-12-08) and proximal A-colon wall thickening (CT, 2022-03-08), CEA fluctuates within a narrow range of 10 to 13 ng/mL since November 2021.
• There is still some progression of the disease (albeit at a slower rate?)

700598345

220407

{Acute myeloblastic leukemia, not having achieved remission}

[objective]

• exam finding
  • 2022-03-24 Patho - bone marrow biopsy
    • Bone marrow, iliac, (AML, S/P induction C/T and consolidation C/T x 2), biopsy - Normal cellularity.
    • IHC: CD117: <1 %; CD34: <1 %; MPO: 20-30%, CD61: 5-10%; CD71: 70-75% (of the nucleated cells).
    • Section shows piece(s) of bone marrow with 40% cellularity and M:E ratio of approximately 1:3. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2022-03-09 CT - lung/mediastinum/pleura
    • pulmonary infection or leukemic infiltration in both lungs.
  • 2021-12-14 Patho - bone marrow biopsy
    • Bone marrow, iliac bone, biopsy - Hypocellularity and no increase of blast
    • Hypocellularity for her age, 5-10%
    • Marked hypoplasia of all three lineages
      
    • No obviously increase of blast
  • 2021-11-29 Patho - bone marrow biopsy
    • Bone marrow, iliac bone, biopsy - Compatible with acute myeloid leukemia
    • Microscopically, the sections show a picture of acute myeloid leukemia, composed of hypercellular marrow (70-80%) with proliferative blasts about 30% of nucleated cells, which immunohistochemistry shows CD34(+), CD117(+) and MPO(+). Besides, hypoplasia of erythroid series and megakaryocytes highlights by CD61(+, megakaryocytes) and CD71(+, erythroid series) is also noted. Clinical and bone marrow smear correlation is advised.
• lab data
  • 2022-03-18 P.jiroveci DNA-Sp undetectable
  • 2021-12-09 FLT3-D835 mutation undetectable
  • 2021-12-02 Aspiration
    • CD2 NA
    • CD3 0.39
    • CD4 NA
    • CD5 0.14
    • CD7 61.64
    • CD8 NA
    • CD10 1.15
    • CD11b 2.5
    • CD13 77.23
    • CD14 5.23
    • CD15 NA
    • CD16 2.28
    • CD19 1.14
    • CD19/kappa NA
    • CD19/Lambda NA
    • CD20 NA
    • CD23 NA
    • CD25 NA
    • CD33 99.86
    • CD34 92.71
    • CD38 NA
    • CD56 0.05
    • CD103 NA
    • CD117 83.82
    • CD138 NA
    • FMC7 NA
    • HLA-DR 95.7
    • MPO NA
    • TdT NA
• chemotherapy
  • 2022-01-07 ~ undergoing - cytarabine (high dose Ara-C, HiDAc, 300mg/m2 IVD 3h Q12H D1,3,5 total 5 doses or 200mg/m2 3h Q12H D1-4 total 8 doses) + daunorubicin (45mg/m2 IV D1-3)
  • 2021-12-02 - idarubicin (45-80mg/m2 d1-3) + cytarabine (100-200mg/m2 d1-7)
• consultation
  • 2021-12-02 Dr. YaoRen Xu
    • Q
      • This 40 year-old female patient who has history of childhood epilepsy under medication was admitted via the OPD due to leukocytosis with anemia and thrombocytopenia. The PB smear showed increase blast cells (40-60%). Acute leukemia is considered. She was admitted for bone marrow biopsy and AML was confirmed. We will start chemotherapy with regimen of Idarubicin + Cytarabine - 3 + 7 days.
      • She is unmarried, G0P0 and no GYN history. For prevention of excessive bleeding, we need to halt her menstrual cycle.
    • A
      • consider to halt menstrual cycle due to thrombocytopenia
      • no active GYN problems
      • Danazol 200ml 1# BID PO may be considered, no more than 6 months, can be administered during chemotherapy course.

[assessment]

• The patient with AML (2021-11-29 bone marrow biopsy pathology) without the FLT3-D835 mutation (2021-12-09 undetectable) was treated with high dose cytarabine + daunorubicin starting on 2022-01-07, following idarubicin + cytarabine (3+7) in December 2021.
• The last two consecutive bone marrow biopsy pathology (2021-12-14 and 2022-03-24) showed no obviously increase of blast and normal cellularity. So far, so good.
• There were no other obvious abnormalities found except an elevated level of uric acid of 7.6 mg/dL reported on 2022-04-06, which might be controlled with febuxostat or benzbromarone.

220311

{compatibility}

The combination of calcium gluconate, magnesium sulfate, and potassium chloride in 0.9% sodium chloride normal saline is compatible.

220110

Lab data reported on 2022-01-10 - RBC 3.44*10^6/uL - HGB 9.4g/dL

Danol (Danazol) androgen is prescribed to pause menses to maintain RBC, HGB levels in the setting of chemotherapy.

700728977

220407

{rectal cancer cT2N1bM0 stage IIIA}

[subjective]

• 2021-07-12 having anal fresh bleeding on and off prior to visiting OPD.
• family history: two younger brothers died because of colon cancer.

[objective]

• exam finding
  • 2021-11-04 Patho - colon segmental resection for tumor
    • Large intestine, rectum, low anterior resection —- No residual viable tumor, s/p neoadjuvant CCRT
      
    • Resection margins: free
      
    • Lymph node, mesocolic, dissection - Negative for malignancy (0/17)
    • Lymph node, IMA / SMA, dissection - Not received
    • AJCC 8th edition Pathology stage: ypT0N0(if cM0)
  • 2021-10-20 Patho - colon biopsy
    • Large intestine, rectum, biopsy - non-specific colitis with fibrosis
  • 2021-10-19 CT - abdomen, pelvis
    • Compatible with rectal cancer s/p CCRT with swelling of the sigmoid colon.
  • 2021-07-20 CT - lung/mediastinum/pleura
    • combined emphysema and pulmonary fibrosis.
    • old RUL TB change.
  • 2021-07-16 Patho - colorectal polyp
    • Rectum, 8 cm from anal verge, biopsy — Adenocarcinoma
      
    • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
      
  • 2021-07-15 CT - abdomen, pelvis
    • for colorectal carcinoma T2N1bM0 IIIA
  • 2021-07-15 Colonoscopy
    • suspected rectal malignancy, 8cm from anal verge, s/p biopsy
    • diverticula, sigmoid colon, with lumen narrowing
    • mixed hemorrhoid
  • 2020-11-24 CT - brain
    • Brain atrophy
    • Atherosclerosis of vertebral arteries
• surgical operation
  • 2021-11-03
    • Low anterior resection
      • Adenocarcinoma of rectum, cT2N1bM0, Stage IIIA s/p neoadjuvant CCRT
      • Anastomosis by CDH 29#, TISSEL 4ml covered on anastomosis site
      • TA contour for low anterior resection
      • Protective ileostomy was created on RLQ area
• radiotherapy
  • 2021-07-28 ~ 2021-09-07 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions (15MV photon) of the rectal tumor area. (pre-op CCRT)
• chemotherapy
  • 2021-12-14 ~ undergoing - FOLFOX
  • 2021-08-03 - 5-Fu + leucovorin (pre-op CCRT)

[assessment]

• The patient was diagnosed with T2N1bM0 stage IIIA rectal cancer and had LAR in Nov 2021 following pre-op CCRT during the 3rd quarter of that year; he is currently undergoing adjuvant FOLFOX regimen since Dec 2021.
• A colon segmental resection pathology on 2021-11-04 revealed no residual viable tumor and evaluated the disease as ypT0N0 (if cM0).
• As of 2022-03-29, the laboratory data showed normal liver and kidney function as well as slightly lower blood cell counts, which should not affect the chemotherapy course.
• HBV is managed with Baraclude (entecavir) currently.

210805

{rectal cancer}

[initial presentation]

• 2021-07-12 having anal fresh bleeding on and off prior to visiting OPD.
• family history: two younger brothers died because of colon cancer.

[definite diagnosis]

• 2021-07-15 colonoscopy:
  • suspected rectal malignancy, 8cm from anal verge.
  • diverticula, sigmoid colon, with lumen narrowing.
  • mixed hemorrhoid
• 2021-07-16 patho - colorectal polyp
  • adenocarcinoma
  • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+)

[disease extent]

• 2021-07-15 CT - whole adbomen, pelvis:
  • imaging stage: cT2N1bM0, IIIA

[treatment & plan]

• pre-Op CCRT then Op
  • radio
    • 4500cGy/25frac for pelvic
      • 900cGy/5frac from 2021-08-04 to 2021-08-06
    • 5040cGy/28frac for rectal tumor bed
  • chemo
    • 5-Fu + leucovorin from 2021-08-04

[effect & side effect]

• CCRT just started, to wait and see.
• adjuvant chemo with cetuximab/panitumumab (EGFR+) might be indicated after resection operation.
  • no RAS, BRAF, or other immune checkpoint biomarkers tested found in charts yet.

[ongoing problem]

• HBV
  • 2021-07-23 lab data
    • Anti-HBc Reactive
    • Anti-HBs 31.38mIU/mL
  • medication
    • baraclude (entecavir 0.5mg) QDAC
• combined pulmonary fibrosis and emphysema
  • 2021-07-20 CT lung/mediastinum/pleura found

[assessment]

• CCRT just kicked off and HBV is managed by entecavir, no medication issue observed.

700713215

220406

{hepatic failure, cirrhosis of liver, hepatorenal syndrome, esophageal varices, gastric varices, ascites, type 2 diabetes ellitus, hyperlipidemia, anemia}

• All the oral drugs can be administered with nasogastric tube.
• For the patient with hepatorenal syndrome, albumin (lower serum reading 2.8 g/dL reported on 2022-04-06) might be an option to combine with terlipressin (currently prescribed).

700733699

220406

[objective]

• diagnosis
  • liver cell carcinoma
  • recurrence hepatocellular carcinoma with lung and bone metastasis, stage IV
  • hepatitis B virus related liver cirrhosis, child A
  • essential (primary) hepertension
  • type 2 diabetes mellitus without complications
• exam finding
  • 2022-03-07 CT - liver, spleen, biliary duct, pancreas
    • HCC s/p right hepatic lobectomy and RFA at S2, S3 and S4.
    • Bilateral Lung meta, stationary.
    • Bone meta. Suggest bone scan study.
  • 2021-11-24 CT - liver, spleen, biliary duct, pancreas
    • Cholangiocarcinoma at S3 liver is highly suspected.
    • The differential diagnosis include metastasis (colon cancer?) and atypical HCC. Please correlate with tumor marker and MRI. Biopsy is indicated.
    • Two metastases in S3 are suspected.
  • 2021-11-23 Tc-99m MDP whole body bone scan with SPECT
    • In comparison with the previous study on 20210720, some of the previous bone lesions are a little more evident, suggesting multiple bone metastases in a little more progression.
    • Suspected benign lesions in bilateral shoulders.
• chemmoimmunotherapy
  • 2020-03 ~ undergoing - lenvatinib
  • 2020-01-17 ~ 2020-12-22 - nivolumab
  • 2019-09 ~ 2019-12 - sorafenib

[assessment]

• This patient with advanced HCC (lung and bone mets) has been treated with sorafenib (Sept to Dec in 2019), Nivolumab (in 2020) and Lenvatinib (since March 2020), he refuses to be resuscitated and has been referred to the hospice ward waiting list.

700769250

220331

{ovary cancer s/p oophrocystectomy}

[objective]

• exam finding
  • 2022-02-15 Patho - uterus
    • pathologic diagnosis
      • Ovary, right, debulking surgery (s/p oophorcystectomy) - No residual tumor
      • Ovary, left, debulking surgery - Negative for malignancy
      • Fallopian tube, bilateral, debulking surgery - Negative for malignancy
      • Uterus, corpus,debulking surgery - Adenocarcinoma, seeding
      • Uterus, cervix, debulking surgery - Negative for malignancy
      • Omentume, debulking surgery- - Peritonitis
      • Labeled “utreosaroligment” - Negative for malignancy
      • Labeled “rectum” - Negative for malignancy
      • Labeled “right abdominal wall” - Negative for malignancy
      • AJCC 8th edition Pathology stage: pT2aNO(if cM0); FIGO IIA; AJCC stage IIA
    • microscopic examination
      • Histologic type: Adenocarcinoma, mixed endometrioid type and mucinous type
      • Histologic grade: grade 1
        
      • IHC: CK(+), Calretinin(focal+), CD68(+), PAX8(-); Reference: S2022-01793
  • 2022-02-11 CT - pelvis
    • An enlarged nodes in left pelvic side wall measuring 2.3 cm in size is noted.
  • 2022-02-04 Patho - ovary biopsy, wedge resection
    • Diagnosis:
      • Ovary, right, laparoscopic oophorocystectomy —- Adenocarcinoma, mixed endometrioid type and mucinous type, grade 1
        • IHC stains: WT( focal +), PAX-8 (-), p53 (wild type), Napsin-A (-), ER (-), PR (-).
        • pT1c2 pNx (if cM0); FIGO stage: IC2, at least.
    • Gross description:
      • Tumor Site: Right ovary
      • Ovarian Surface Involvement - Absent
      • Fallopian Tube Surface Involvement - no tissue submitted.
    • Microscopic Description:
      • Histologic Type: Mixed epithelial carcinoma: endometrioid grade 1 (60%) and mucinous grade 1 (40%).
      • Histologic Grade - WHO Grading System-G1: Well differentiated
      • IHC: WT( focal +), PAX-8 (-), p53 (wild type), Napsin-A (-), ER (-), PR (-).
  • 2022-01-31 CT - abdomen, pelvis
    • A lobulated right adnexal mass (9.0x6.8x10.2cm). Suspect TOA, ovarian torsion, or ovarian cystic tumor.
• surgical operation
  • 2022-02-14
    • Excision of abdominal wall tumor
    • Excision of greater omentum and rectal serosa tumor
    • IOUS (intraoperative ultrasound)
  • 2022-01-31
    • ROV teratoma with rupture
    • pelvic adhesion
    • Laparoscopic oophorocystectomy + pelvic adhesionlysis       
• chemotherapy
  • 2022-03-09, -03-30 - paclitaxel + carboplatin
• underlying disease
  • chronic viral hepatitis B without delta-agent

[assessment]

• This patient was diagnosed with ovarian adenocarcinoma, mixed endometrioid and mucinous type in early 2022 s/p oophrcystectomy (2022-01-31) and excision of abdominal wall tumor and greater omentum and rectal serosa tumor (2022-02-14).
• paclitaxel + carboplatin is a preferred regimen for both endometrioid and mucinous ovarian cancers, and the patient has been receiving this regimen since 2022-03-09.
• According to CBC results on 2022-03-29, there was a slight decrease in readings, not expected to affect chemotherapy.
• HBV is managed with Baraclude (entecavir). No issue with current medication.

701208485

220331

{pancreatic cancer T4N1M0 stage III}

[objective]

• exam finding
  • 2022-01-24 ERCP (Endoscopic Retrograde CholangioPancreatography)
    • biliary obstruction s/p SEMS
    • chronic cholangitis
  • 2022-01-14 CT - liver, spleen, biliary duct, pancreas
    • There is filling defects at left lobe portal vein that is c/w thrombosis and the etiology may be thrombophlebitis.
    • Adenocarcinoma of the pancreatic head-body with portal vein, splenic vein, and celiac trunk encasement is suspected.
  • 2022-01-12 Patho - pancreas biopsy
    • Pancreas, head, EUSFNB — adenocarcinoma, moderately differentiated
      
    • Section shows pancreas tissue with infiltration of neoplastic glands in fibrous stroma.
    • IHC: CK(+)
  • 2022-01-10 ERCP (Endoscopic Retrograde CholangioPancreatography)
    • biliary obstruction s/p brushing cytology & plastic stent placement
    • chronic cholangitis
    • reflux esophagitis
• chemotherapy
  • 2022-02-10 ~ undergoing - FOLFIRINOX + pembrolizumab

[assessment]

• Pancreatic adenocarcinoma with or without BRCA1/2 or PALB2 mutations, FOLFIRINOX is preferred; this patient has been receiving this regimen since 2022-02-10.
• Results of liver and kidney function tests reported on 2022-03-30 were normal, CBC readings were slightly lower, the latter should not be likely to affect treatment in this hospital stay.
• No issue with current medication.

700814298

220330

[objective]

• diagnosis
  • Pancreatic cancer, T3N1M1 (M1 diagnosed by CT), stage IV, tail, status post endoscopic ultrasound-guided fine-needle biopsy on 2021-10-07
• exam finding
  • 2022-03-21 CT - abdomen, pelvis
    • Pancreatic cancer with liver mets and adrenal mets. In progression.
    • Paraaortic lymphadenopathy, stable
    • Diffuse lung consoliations. Nature to be determined.
    • Air pockets inside the urinary bladder, suspected emphysematous cystitis.
  • 2022-01-07 CT - brain
    • Old lacunar infarcts.
    • Encephalomalacic change in left temporal lobe.
    • Brain atrophy.
  • 2021-12-07 CT - abdomen, pelvis
    • Pancreatic tail cancer with liver mets. The primary tumor is decreased in size but the liver mets progressed.
    • Paraaortic lymphadenopathy, in regression.
    • LEFT LOWER LOBE consolidation.
  • 2021-10-07 Patho - pancreas biopsy
    • Pancreas, EUS-FNB - adenocarcinoma, moderately differentiated
      
    • Sections show pancreas with neoplastic glandular cells infiltrating in fibrous stroma.
  • 2021-10-07 Needle aspiration cytology
    • Smears show necrotic debris and clusters of atypical, hyperchromatic cells. Malignancy is favored.
  • 2021-10-04 CT - abdomen, pelvis
    • suspected pancreas CA with splenic vessels and stomach invasions
    • Liver and para-aortic lymph node metastases
  • 2018-07-23 MRA - brain
    • recent ischemic of left MCA territory due to severe stenosis in distal M1 an M2 of left MCA.
    • Brain atrophy. Multiple lacunar infarcts, deep cerebral hemisphere and cerebellum.
    • Bilateral subcortical and periventricular white matter change (leukoaraiosis).
  • 2018-07-20 CT - brain
    • Brain atrophy and lacunar infarcts.
• chemotherapy
  • 2021-10-26 ~ undergoing - gemcitabine + nab-paclitaxel
• past history
  • Gout arthritis for 40+ years
  • CVA with right side hemiparesis and motor aphasia since 2018-07

[assessment]

• Patient presents with stage IV T3N1M1 pancreatic cancer with paraaortic LAP, liver mets, and adrenal mets.
• Fusions (ALK, NRG1, NTRK, ROS1), mutations (BRAF, BRCA1/2, HER2, KRAS, PALB2), and MMR status were not found in HIS5.
• FOLFIRINOX or gemcitabine + nab-paclitaxel would be preferred regimens. The patient has been receiving the latter since late October 2021.
• This patient has just been arranged for hospice combined care on 2022-03-29.
• No issue with current medication.

700799013

220329

[objective]

• exam finding
  • 2022-02-25 CT - lung/mediastinum/pleura
    • Consolidation over both lungs. Pneumonia is favored.
    • Bilateral pleural effusion
  • 2022-01-11 Patho - omentum biopsy
    • Tissue, labeled LUQ omentum, CT-guide biopsy - adenocarcinoma, seeding
      
    • IHC: CDX-2(+), CK7(-), CK20(-). The tumor is compatible with GI tract origin.
      
    • Microscopically, it shows adenocarcinoma composed of irregular neoplastic glands with infiltrative growth pattern, tumor necrosis and stromal fibrosis. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
      
  • 2021-11-24 CT - abdomen, pelvis
    • One Metastasis in LUQ omentum S/P C/T show partial response.
    • Two metastases in RLQ mesentery, and left lower pelvis (with urinary bladder invasion) S/P C/T show stable disease.
  • 2021-08-13 CT - abdomen, pelvis
    • Three Metastases 3.6 x 2.6 cm in the LUQ omentum area, 1.3 x 0.7 cm in RLQ mesentery, and 3.2 cm in left lower pelvis (with urinary bladder invasion) are noted.
    • Intrapulmonary lymph node in LLL of the lung is suspected and it shows stable in size and feature as compared with prior CT.
  • 2021-04-28 Whole body PET scan
    • Glucose-hypermetabolism in the soft tissue in the LUQ of abdomen, lower pelvis, and RLQ of abdomen, probably tumor recurrence.
      
    • Glucose-hypermetabolic lesions in the right shoulder and right elbow, probably post-traumatic change.
      
    • Increased FDG uptake in bilateral pulmonary hilar region, probably reactive nodes or physiological uptake of FDG.
    • Colon cancer s/p treatment with tumor recurrence, rcTxNxM1c, stage IVC (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2021-04-20 CT - abdomen, pelvis
    • Some infiltration at right anterior abdominal wall is found, regional inflammation is considered
    • No evidence of soft tissue mass at pancreas.
  • 2021-01-18 CT - abdomen, pelvis
    • R-S colon cancer s/p operation. Some LNs at mediastinum and bil. inguinal regions.
    • Stationary condition and lung nodules.
  • 2021-11-19 Patho - colon segmental resection for tumor
    • diagnosis
      • Tumor, rectosigmoid, left hemicolectomy — Residual mucinous adenocarcinoma
        
      • Bilateral cutting ends, ditto — Free of tumor invasion
        
      • Lymph node, mesocolic, dissection — Free of tumor metastasis (0/18) with acellular mucin deposit (7/18)
        
      • Pelvic lesion, frozen section — Acellular mucin, compatible with tumor regression
        
      • AJCC pathologic stage — ypT3N0 (if cM0), stage IIA
  • 2020-10-05 CT - abdomen, pelvis
    • S-colon cancer as described (mild regression). T4bN2bM1a (IVa).
  • 2020-07-02 CT - abdomen, pelvis
    • S-colon cancer T4bN2bM1a (IVa).
  • 2020-06-30 Patho - colon biopsy
    • Sigmoid colon, 20 cm from anal verge, biopsy — Adenocarcinoma
    • IHC: EGFR(+), MLH1(-), PMS2(-), MSH2(+), and MSH6(+).
      
    • Comment: The tumor cells show loss of expression of the mismatch repair proteins MLH1 and PMS2. This pattern is likely to be sporadic (MLH1 promoter hypermethylation), although it is possible due to Lynch or related syndromes.
  • 2020-06-30 Patho - colorectal polyp
    • Rectum, 10 cm from anal verge, polypectomy — Adenocarcinoma in high-grade tubulovillous adenoma
      
    • The sections show adeocarcinoma in tubulovillous adenoma, composed of rectal mucosal tissue with atypical glands lined by pseudostratified, high-grade dysplastic columnar cells, in tubular, cribriform and villous arrangement. Focal desmoplastic stromal reaction is present.
• surgical operation
  • 2021-03-11 Closure of T-loop colostomy
  • 2020-11-18 Exp. Lap with sigmoidectomy
  • 2020-07-06 T-loop colostomy
• radiotherapy
  • 2020-07-22 ~ 2020-08-31 - 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the tumor bed area.
• chemotherapy
  • 2021-06-11 ~ 2022-02-23 - FOLFOX + bevacizumab
  • 2020-07-16 ~ 2021-05-24 - FOLFIRI

701342376

220329

[objective]

• exam finding
  • 2022-03-28 Colonoscopy
    • colon diverticulum, cecum, ascending colon
  • 2022-03-08 CT - abdomen, pelvis
    • S/P gastrectomy, splenectomy and pancreas operation. Fat stranding of upper peritoneal cavity.
  • 2021-10-28 Patho - small intestine resction (not tumor)
    • Small intestine, distal ileum, segmental resection - Consistent with Meckel diverticulum
      
    • Sections show ileal tissue with a diverticulum lined by gastric mucosal tissue. The morphology is consistent with Meckel diverticulum.
      
  • 2021-10-28 Patho - stomach subtotal/total (tumor)
    • pathologic diagnosis
      • Stomach, lesser curvature, total gastrectomy - Adenocarcinoma, moderately differentiated
      • Esophagus, total gastrectomy - Adenocarcinoma, by direct invasion with negative resection margin
      • Duodenum, total gastrectomy - Negative for malignancy
        
      • Liver, left lateral segment, segmentectomy - Negative for malignancy - Acute suppurative inflammation
        
      • Pancreas, distal, distal pancreatectomy - Negative for malignancy
      • Spleen, splenectomy - Negative for malignancy
        
      • Omentum, omentectomy - Negative for malignancy
        
      • Liver, caudate lobe, specimen B, resection - Negative for malignancy - Acute suppurative inflammation
        
      • Proximal esophagus, specimen C, resection - Negative for malignancy
        
      • Margin: free
        
      • Lymph node, lesser curvature, dissection - Negative for malignancy (0/8)
        
      • Lymph node, greater curvature, dissection - Negative for malignancy (0/14)
        
      • Lymph node, peri-pancreatic, dissection - Negative for malignancy (0/12)
        
      • AJCC 8th edition pT4aN0 (if cM0) pStage IIB,
        
      • F2021-423: Esophagus, resection margin, excision - Negative for malignancy
        
    • microscopic examnation
      • Histologic Type: Lauren classification of adenocarcinoma: Intestinal (tubular) type; The immunohistochemical stain Her-2/neu (Ab) is negative.
      • Histologic Grade: G2: Moderately differentiated
        
      • Tumor Extension: Tumor invades esophagus, the serosa (visceral peritoneum) and attached to the liver and pancreas capsule. No direct invasion in the liver and pancreas parenchyma is found. The subserosal liver parenchyma reveals acute suppurative inflammation. The immunohistocehmical stain of CK reveals no invasive tumor. The spleen, duodenum and omentum are free of tumor.
        
      • Additional Pathologic Findings
        • Intestinal metaplasia: absent
          
        • Low-grade dysplasia: absent
          
        • High-grade dysplasia: present
          
        • Helicobacter pylori-type gastritis
          
        • Autoimmune atrophic chronic gastritis: absent
          
        • Polyp(s): absent
• surgical operation
  • 2021-10-27
    • Total gastrectomy with D2+ LN dissection
      • En-block left lateral segmentectomy with caudate loberesection with distal pancreatectomy with splenectomy
    • Distalsmallbowel segmental resection with anastomsois
• radiotherapy
  • 2021-12-02 ~ 2021-12-06 - 540cGy/3 fractions (15 MV photon) to anastomosis and regional lymphatics
• chemotherapy
  • 2022-01-24, -02-07, -02-22, -03-09, -03-28 - FOLFOX
  • 2021-12-08, -12-13, -12-20, -12-27, 2022-01-03 - 5-FU

[assessment]

• gastric cancer pT4aN0 cM0 stage IIB s/p gastrectomy with D2+ LN dissection (2021-10-27) followed by post-Op CCRT (5-FU, early Dec 2021 to early Jan 2022) and adjuvant chemotherapy (FOLFOX, since late Jan 2022).
• tumor pathology (2021-10-28) showed Her-2/neu (Ab) negative. no MSI/MMR, PD-L1 results found in HIS5
• patients who have undergone primary D2 lymph node dissection are preferred to receive [capecitabine + oxaliplatin] and [fluorouracil + oxaliplatin], the latter is what the patient is getting now.
• no adverse reaction found in nursing note for now during this hospital stay. no issue with current medication.

700070771

220325

[objective]

• exam finding
  • 2022-02-12 CT - abdomen, pelvis
    • S/P liver and colon operation. No evidence of tumor recurrence.
  • 2022-02-07 SONO - abdomen
    • Post-op at right lobe liver. Calcified spot in the liver.
      
    • Right renal cyst.
    • Left renal stone.
  • 2011-11-04 CT - abdomen, pelvis
    • S/P liver and colon operation. Some fluid and air collection at right subphrenic region. Bil. pleural effusion with adjacent lung collapse.
  • 2021-10-29 Patho - liver partial resection
    • Liver, S6-7, segmental hepatectomy — Metastatic adenocarcinoma, consistent with colonic primary
      
    • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
  • 2021-09-22 CT - abdomen, pelvis
    • S/P right hemicolectomy. There is no evidence of tumor recurrence.
    • Two metastasis in S7 and S4 S/P C/T show partial response.
    • A newly-developed metastasis or flow artifact 0.5 cm in S6 liver is suspected.
  • 2021-05-20 NRAS/KRAS, BRAF not detected
  • 2021-05-17 MRI - liver, spleen
    • Two poor enhancing tumors (0.4cm, 2.6cm) in S8 of liver suspected metastases.
  • 2021-04-28 Patho - colon segmental resection for tumor
    • Pathologic diagnosis
      • Tumor, ascending colon, SILS R’t hemicolectomy — Adenocarcinoma
      • Resection margins, bilateral, ditto — Free from tumor invasion
      • Lymph node, mesocolic, dissection — Free from tumor metastasis (0/23)
        
      • Appendix, excision — Fecalith and free from tumor
        
      • AJCC pathologic stage — pT3N0, cM1a, compatible with stage IVA
    • Microscopic examination
      • Histology: adenocarcinoma
        
      • Histology Grade: G2: moderately differentiated
        
      • Depth of invasion: pericolonic fat
        
      • Angiolymphatic invasion: Present
        
      • Perineural invasion: Present
        
      • Discontinuous extramural tumor extension: NOT present
        
      • Circumferential (radial) margin of rectosigmoid: NOT involved
        
      • Lymph node metastasis, mesocolic: free from tumor metastasis (0/23)
        
      • Lymph node metastasis, IMA / SMA: N/A
        
      • Extranodal involvement: N/A
        
      • Pathological TNM Stage: pT3N0, but cM1a (liver meta), compatible with stage IVA
        
      • Type of polyp in which invasive carcinoma arose: N/A
        
      • Additional pathologic findings: focal necrosis and abscess
        
      • TNM descriptors: N/A
        
      • Tumor regression grading S/P CCRT: N/A
        
  • 2021-04-22 Whole body PET scan
    • Glucose hypermetabolism in the proxinal portion of the ascending colon and some adjacent lymph nodes, compatible with primary colon malignancy with some adjacent lymph node metastases.
    • A glucose hypermetabolic lesion in the segment 7 of the liver. A metastatic lesion may show this picture.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammatory process may show this picture.
  • 2021-04-19 CT - abdomen, pelvis
    • T3N2aM1a, stage IVA
  • 2021-04-16 Patho - colorectal polyp
    • Colon, ascending, biopsy — Adenocarcinoma.
    • IHC: EGFR(focal +); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
• surgical operation
  • 2021-10-28 laparoscope S6-7 resection
    • solid tumor at S7
    • suspected small nodule at S6.
  • 2021-04-28 SILS Right-hemicolectomy
    • Adenocarcinoma of ascending colon, cT3N2aM1a (liver mets) stage IVa
    • Huge tumor with tissue edema suspecting as T4 lesion.
• chemoimmunotherapy
  • 2021-06 ~ ongoing - FOLFIRI plus bevacizumab since
• initial presentation
  • unintentional body weight loss 6 kgs in half year before diagnosed with cancer.
  • exertional dyspnea and intermittent right abdomen pain were noted without bowel habit change.
  • iOFBT(+)
• underlying disease
  • type 2 diabetes
  • chronic hepatitis B

[assessment]

• Patient with colon cancer with liver mets after SILS right hemicolectomy (2021-04-28) and liver S6/S7 resection (2021-10-28) is receiving FOLFIRI plus bevacizumab since June 2021. Recent CT (2022-02-12) and SONO (2022-02-07) have revealed no signs of recurrence.
• Lab results reported on 2022-03-15 indicated no abnormality in liver or kidney functions, but a slight pancytopenia was detected. The lower blood counts should not affect the application of chemoimmunotherapy during this hospital stay.
• Chronic hepatitis B and type 2 diabetes are managed with corresponding drugs.
• No issue with current medication.

700464889

220325

{hypopharyngeal and supraglottic cancer, cT4bN2b cM0, stage IV with recurrent lung mets, progression of mets pulmonary lesions and mediastinal/hilar LAP}

[objective]

• exam finding
  • 2022-03-10 Laryngoscopy
    • right hypopharyngeal cancer s/p induction chemotherapy + CCRT in 2016
    • lung mets proved in 2018-11, no local recurrence found according to PE and fiber
  • 2022-02-15 CT - lung/mediastinum/pleura
    • progression of metastatic pulmonary lesions and distant metastatic LAP as compared with previous CT on 20210823.
  • 2022-01-06 Laryngoscopy
    • right hypopharyngeal cancer s/p induction chemotherapy + CCRT in 2016
    • lung mets proved in 2018-11, no local recurrence found according to PE and fiber
  • 2021-11-30 Nasopharyngoscopy
    • saliva cumulation at hypopharynx and rt. piriform sinus
  • 2021-10-07 Laryngoscopy
    • right hypopharyngeal cancer s/p induction chemotherapy + CCRT in 2016
  • 2021-08-23 CT - lung/mediastinum/pleura
    • progression of metastatic pulmonary lesions and mediastinal and hilar LAP as compared with previous CT on 20210216.
  • 2021-05-14 MRI - Larynx
    • Post-treatment change at hypopharynx and larynx, without evidence of recurrence. Less edema as compared with previous MRI on 20181107.
  • 2021-05-11 SONO - abdomen
    • Few gallstones and the size < 1.15 cm.
      
    • Two renal cyst 2.37 cm in left lower pole and 0.91 cm in right middle pole are noted.
  • 2021-02-16 CT - lung/mediastinum/pleura
    • stationary of metastatic pulmonary lesions and progression of mediastinal and hilar LAP as compared with previous CT on 20200827.
  • 2020-11-17 SONO - abdomen
    • Few gallstones and the size < 0.68 cm.
      
    • Two renal cyst 1.57 cm in left lower pole and 1 cm in right middle pole are noted.
  • 2020-08-27 CT - lung/mediastinum/pleura
    • right upper lobe, left lingula lobe and right lower lobe lung mets, stable.
  • 2020-06-02 SONO - abdomen
    • Few gallstones and the size < 0.68 cm.
      
    • A renal cyst measuring 1.38 cm in left lower pole is noted.
  • 2020-03-10 CT -lung/mediastinum/pleura
    • metastatic tumors in bilateral lungs and medastinal and hilar lymphadenopathy, stationary as compared with previous CT study on 20191216.
  • 2019-12-16 CT
    • metastatic tumors in bilateral lungs and medastinal and hilar lymphadenopathy, in regression as compared with previous CT study on 20190916.
  • 2019-09-16 CT
    • metastatic tumors in bilateral lungs and medastinal and hilar lymphadenopathy, in regression as compared with previous CT study on 20190717.
  • 2019-07-17 CT
    • diffsue lung metastatic lesions and mediastinal lymphadenopathy, stable.
  • 2019-06-22 CT
    • metastatic tumors at bilateral lungs and medastinal and hilar lymphadenopathy, in progression as compared with previous CT study.
  • 2019-04-19 CT
    • pulmonary necrotic metastatic tumors at bilateral lungs and medastinal lymphadenopathy, in progression.
  • 2019-01-25 CT
    • compatible with hypopharyngeal cancer with lung mets. in regression.
  • 2018-11-07 MRI - Larynx
    • Post-RT changes at hypopharynx and larynx, without evidence of recurrence. Stationary as compared with MRI on 20180524.
  • 2018-11-07 Surgical pathology Level IV
    • Malignant hypopharynx neoplasm, pyriform sinus
    • Lung, side?, needle biopsy - squamous cell carcinoma, moderately differentiated, origin?
    • IHC: p40(+), TTF-1(focal weak positive), and CD56(focal weak positive). The results are in favor of squamous cell carcinoma.
    • Please correlate with the clinical presentation to differentiate primary or metastatic tumor.
  • 2018-11-06 Surgical pathology Level IV
    • Malignant hypopharynx neoplasm, pyriform sinus
    • Lung, side?, bronchoscopic biopsy - squamous cell carcinoma, moderately differentiated, origin?
    • IHC: p40(+), TTF-1(focal weak positive), and CD56(focal weak positive). The results are in favor of squamous cell carcinoma.
    • Please correlate with the clinical presentation to differentiate primary or metastatic tumor.
  • 2018-10-30 CT
    • hypopharynx cancer s/p RT s/p CT with lung and mediastinal-hilum LNs metastasis.
  • 2018-05-24 MRI - nasopharynx
    • Post R/T and C/T change in right pyriform sinus and adjacent hypopharynx, stationary.
  • 2017-11-28 MRI - nasopharynx
    • Post R/T and C/T change in right pyriform sinus and adjacent hypopharynx, seems stationary.
  • 2017-05-26 MRI - larynx
    • Right hypopharynx CA, post CT and R/T, stationary in size of abnormal soft-tissue combined more prominent post R/T change as compared with MRI on 20161121.
  • No earlier data available before 2017.
• Chemoimmunotherapy
  • 2022-02-23, -03-24 - 5-FU + cisplatin + gemcitabine + nivolumab
  • 2021-09-10, -10-04, -11-01, -11-30, -12-27, 2022-01-17 - 5-FU + cisplatin + docetaxel + cetuximab

[assessment]

• On CT images taken from the second half of 2019 through 2020, metastatic lesions in bilateral lungs, mediastinal and hilar lymphadenopathy remained stationary. However, on 2021-02-16 CT images, progression of mediastinal and hilar LAP was observed, then on 2021-08-23 and 2022-02-15 CT images, metastatic pulmonary lesions and distant metastatic LAP were observed.
• From September 2021 to January 2022, the patient was treated with chemoimmunotherapy comprising 5-FU + cisplatin + docetaxel + cetuximab, followed by 5-FU + cisplatin + gemcitabine + nivolumab from February 2022 onwards.
• The new regimen has been administered to the patient for the second time during this hospitalization, and it will take time for the responses to be confirmed.
• The patient’s low serum magnesium reading on 2022-03-24 was treated with MgSO4 IVD QD.

700542356

220325

• Patient was transferred from Cardinal Tien Hospital with a diagnosis of suspected MDS and urinary tract infection. Our emergency room did not note any obvious signs of discomfort, such as fever, chills, chest pain, dyspnea, or abdominal pain.
• The following laboratory results were obtained on 2022-02-24: CRP 4.84 mg/dL, serum glucose 454 mg/dL, WBC 1040/uL, HGB 7.4 g/dL, PLT 3000/uL, NT-proBNP 5006 pg/mL, urine OB 3+, urine bacteria 1+, APTT 38 sec.
• The blood culture result is not out yet. Symptomatic treatment is being provided to the patient currently. No issue is identified with the current medication.

700372070

220322

[assessment]

• The last medical image update occurred on 28 January 2022. Treatment with Fluorouracil + Carboplatin + Paclitaxel has been ongoing since October 2021.
• Serum glucose(AC) remained above normal (128mg/dL 2022-03-09), however HbA1C reading went down to 7.5% (2022-03-09) from 8.0% (2021-12-06), which is a positive sign.
• More than one year of below normal serum magnesium and above normal serum creatinine.
• Cisplatin and, to a much lesser extent, carboplatin therapy, is associated with hypomagnesemia, more so than any other electrolyte deficiency. Hypomagnesemia affects 40%~90% of patients on cisplatin; in contrast, 10% of patients treated with carboplatin or oxaliplatin experience hypomagnesemia. Platinum-induced hypomagnesemia can persist for up to 6 years after cessation of treatment and is primarily attributed to renal Mg wasting.
  • reference: https://kidney360.asnjournals.org/content/kidney360/2/1/154.full.pdf
• It is possible to treat hypomagnesemia without acute symptoms with oral Mg supplementation and by eliminating medications that may be contributing to the hypomagnesemia, however, the latter may not be the optimal option during chemotherapy. MgO is presently in active medication for the patient.

220210

• exam findings
  • 2022-01-28 CT
    • suspected lower third esophageal wall thickening. stable.
  • 2021-09-24 CT
    • borderline wall thickening at lower third esophagus is found.
  • 2021-09-24 Esophagogastroduodenoscopy
    • gastric intestinal metaplasia, antrum
  • 2021-09-09 Patho
    • Diagnosis
      • Lung, left lower lobe, history of hypopharyngeal and eosphaeal carcinomas, s/p CT and RT, now VATS lobectomy (S2021-12142A) with biopsy for forzen section (F2021-348FS) - squamous cell carcinomas x2, favor metastatic.
      • IHC: CK5/6(+), p40(+), Napsin-A(-), TTF-1(-), CD56(-).
        
      • pM1 pStage: IVC.
        
    • Microscopic Description
      • Tumor Focality - Separate tumor nodules of same histopathologic type in same lobe
      • Histologic Type - Invasive squamous cell carcinoma, keratinizing
      • Histologic Grade - G2: Moderately differentiated
      • Spread Through Air Spaces (STAS) - Present
      • Visceral Pleura Invasion - Not identified
      • Lymphovascular Invasion - Present
        
  • 2021-08-02 Whole body PET scan
    • The lesions of glucose hypermetabolism in the right cervical lymph nodes are old and show much less prominent compared with the previous study on 2020-09-21, indicating recurrent tumor with partial response to current therapy.
    • Glucose hypermetabolism in the mediastinal lymph nodes and bilateral pulmonary hilar lymph nodes, probably reactive nodes. Please keep follow up to exclude the possibility of distant lymph node metastasis in these regions.
    • Glucose hypermetabolism in the left lower lung, probably another primary or secondary lung cancer, suggesting biopsy for further investigation.
    • Probably inflammatory change at the left shoulder joint.
    • Recerrent hypopharyngeal cancer s/p treatment with partial response to current therapy; another primary or secondary lung cancer in the left lower lung (if proved), by this F-18-FDG PET/CT scan.
  • 2021-07-22 MRI - Larynx
    • focal increased soft tissue in the right hypopharynx. Please f/u.
    • focal enhancement in the right maxillary bone, surrounding the tooth
  • 2021-07-05 CT
    • minimal emphysema in LUL and RUL.
    • new solid nodule in LLL, primary tumor or metastasis, suggest f/u.
  • 2020-10-02 Patho - Lymph node region resection
    • pStage: rpTXN3b (cM0); rp Stage IVB (2020-10-16 ENT tumor board consensus)
      
  • 2020-09-21 Whole body PET scan
    • Glucose hypermetabolism in a right level IV cervical lymph node, suggesting malignant involvement in an ipsilateral regional lymph node.
    • Mild to moderate glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change from locoregional inflammation may be considered. Please keep follow up, however, to exclude the possibility of distant lymph node metastasis in these regions.
    • Mild glucose hypermetabolism in left lower cervical lymph nodes and mediastinal lymph nodes, reactive change in response to locoregional inflammation may show such a picture.
    • Right hypopharyngeal cancer s/p CCRT with tumor recurrence, rcTxN1M0, r-stage III at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2020-09-10 MRI - Larynx
    • an enlarged lymph node in the right lower carotid space.
  • 2020-03-10 MRI - Larynx
    • thick soft tissue, tight space, suspected residual/recurrent tumor in right pyriform sinus.
  • 2019-12-09 MRI - Nasopharynx
    • residual tumor at right pyriform sinus. no enlarged lymph node. s/p operation at left tongue and neck.
  • 2019-07-04 CT - Mediastinum
    • Recurrent tongue base tumor at right pyriform sinus, in regression as compared with previous PET/CT.
    • No evidence of tumor recurrence along the course of the esophagus.
  • 2019-06-17 Whole body PET scan
    • A glucose hypermetabolic mass in right supraglottic region, compatible with the primary lesion of laryngeal cancer.
    • Glucose hypermetabolism in the right level II and III cervical lymph nodes, suggesting malignant involvement in multiple ipsilateral regional lymph nodes.
    • Supraglottic laryngeal cancer, cTxN2bM0, stage IVA (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2019-06-14 MRI - Larynx
    • Right hypopharynx CA, T4aN2bMx stage IVA
  • 2019-06-13 Patho
    • Labeled as “right supraglottic tumor”, biopsy - Squamous cell carcinoma, moderately differentiated.
    • IHC stains: p40(+), p16(-, 0%).
  • 2017-08-02 Patho
    • Diagnosis
      • Paralysis of vocal cords or larynx, bilateral, partial; Malignant tongue neoplasm, tip and lateral; Inflammatory conditions, abscess, osteitis, osteomyelitis, periostitis, sequestrum of jaw bone; Acute gingivitis; Atrophy of salivary gland;
      • Esophagus, upper, 20cm and 30cm from incisor, biopsy - Squamous cell carcinoma.
• Radiotherapy
  • 2020-11-06 ~ 2020-12-02
    • 3600cGy/18 fractions of the recurrent nodal with extranodal extension area.
  • 2019-09-17 ~ 2019-11-06
    • 5000cGy/25 fractions (6MV photon) of the primary hypopharyngeal to supraglottic tumor, right neck involved nodal, bilateral neck,
    • 7000cGy/35 fractions of the reduced hypopharyngeal to supraglottic tumor, right neck involved nodal area.
  • 2017-08-16 ~ 2017-09-22
    • 4500cGy/25 fractions (15MV photon) of the esophageal tumor, tract, to regional lymphatic nodal,
    • 5040cGy/28 fractions of the esophageal tumor area.
• Chemotherapy
  • 2021-10 ~ ongoing Fluorouracil + Carboplatin + Paclitaxel
  • 2021-01 ~ 2021-06 Fluorouracil + Cisplatin + Docetaxel
  • 2020-11 ~ 2020-12 Carboplatin (CCRT)

701204933

220322

[objective]

• exam finding
  • 2022-01-14 CT - whole abdomen, pelvis
    • S/P right hemicolectomy. There is no evidence of tumor recurrence.
  • 2021-12-31 Abdomen Ultrasound
    • chronic liver parenchymal disease
    • suspect GB polyp
    • cholecystopathy
    • suspect tiny stones, left kidney
  • 2021-08-26 Patho - colon segmental resection for tumor
    • Large intestine, ascending colon, laparoscopic right hemicolectomy - Adenocarcinoma, moderately differentiated
    • Lymph node, mesocolic, dissection - metastatic carcinoma
      
    • pT3 pN2a (if cM0) Pathology stage: IIIB.
      
    • Histologic Type - Adenocarcinoma
      
    • Histologic Grade - G2 Moderately differentiated
      
    • Tumor Extension-Tumor invades through the muscularis propria into pericolorectal tissue with no involvement of visceral peritoneum serosal surface.
      
    • Lymphovascular Invasion: Present
      
    • Regional Lymph Nodes - Number of Lymph Nodes Involved/Examined: 4/15 with extranodal extension.
      
    • Ancillary Studies - The result of biopsy specimen: S2021-09938
      
    • IHC: EGFR(+), PMS2(+), MLH-1(+), MSH-2(+), MSH-6(+)
  • 2021-08-16 CT - whole abdomen, pelvis
    • Imaging stage: T3N1bM0, stage IIIB
  • 2021-08-03 Patho - colon biopsy
    • Intestine, large, hepatic flexure colon, biopsy - adenocarcinoma
      
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • 2021-08-03 Colonoscopy
    • suspect colon cancer, hepatic flexure, s/p biopsy
    • internal hemorrhoid
  • 2021-01-31 CT - whole abdomen, pelvis
    • suspected acute pancreatitis, suggest clinical lab data correlation.
    • small gallbladder stone. collapsed gallbladder with wall thickening, suspected chronic cholecystitis.
    • left renal stone without obstruction.
    • relative thickening renal pelvis wall, right side.
• surgical operation
  • 2021-08-25 SILS Right-hemicolectomy - Proximal T-colon tumor
• chemotherapy
  • 2021-10-12 ~ ongoing - FOLFOX

[assessment]

• The survival benefit of adding oxaliplatin to adjuvant fluoropyrimidines in patients with resected stage III colon cancer has been shown in multiple randomized trials, and benefit appears to be evident across diverse practice settings and patient subgroups.
  • reference: https://www.uptodate.com/contents/adjuvant-therapy-for-resected-stage-iii-node-positive-colon-cancer
• After undergoing right hemicolectomy on 2021-08-25, the patient has been treated with FOLFOX regimen since mid-October 2021. There is no evidence of peripheral neuropathy mentioned in nursing notes or medical records in 2022.

701355468

220322

{Malignant neoplasm of rectosigmoid junction, stage cT3N0M0, stage IIA}

[objective]

• radiotherapy
  • 2022-01-17 ~ 2022-03-07 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.

[assessment]

• On 2022-01-11, the cancer multidisciplinary meeting recommended pre-operative CCRT for this patient.
• The patient has been undergoing CCRT treatment since mid-January 2022, and has started the FOLFOX regimen during this hospital stay.
• There were no extreme anomalies in the laboratory data reported on 2022-03-17, 18, 21.
• In nursing notes, adverse events of grade 0 have been recorded at 11:55 on 2022-03-22.
• No issue with current medication.

220222

{Malignant neoplasm of rectosigmoid junction, stage cT3N0M0, stage IIA}

[objective]

• exam findings
  • 2022-01-07 Patho - colorectal polyp
    • Intestine, large, rectum, 8 cm from anal verge, biopsy - Adenocarcinoma
      
    • IHC: EGFR(+), PMS2(+), MLH-1(+), MSH-2(+), MSH-6(+)
      
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
      
  • 2022-01-06 Colonoscopy
    • Diagnosis: Rectal cancer s/p biopsy
    • Suggestion: CCRT then Op
• treatment plan
  • preOp CCRT
• radiotherapy
  • 2022-01-17 ~ - 3060cGy/17 fractions (15 MV photon) of the pelvic area.
• chemotherapy
  • 2022-01-18, -01-24, -02-21 - FL (biweekly 5-Fu + Lv)

[assessment]

• this 78-year-old male diagnosed with malignant neoplasm of rectosigmoid junction in early Jan 2022 is on pre-Op CCRT since mid-Jan.
• lab data reported on 2022-02-16 showed no dysfunction of liver and kidney, and slightly lower blood counts.
• hypertension, gout and HBV are under treatment of corresponding self-carried drugs
  • bisoprolol, valsartan
  • febuxostat
  • entecavir
• no issue with current medication.

701312127

220321

[objective]

• exam finding
  • 2022-03-07 Chest PA/AP view
    • Normal heart size.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Faint aveolar opacity over RIGHT LOWER LOBE is found.
    • Right pleural effusion is found.
  • 2022-02-21 CT - abdomen, pelvis
    • Mild progression of lymphoma.
    • Right pleural effusion with adjacent lung collapse. Some nodules at bil. lungs.
  • 2022-02-09 Chest PA (Erect) view
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of bilateral costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-01-10 CT - abdomen, pelvis
    • Follicular lymphoma S/P C/T show partial response.
  • 2021-10-08 Chest AP
    • S/P port-A implantation.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2021-10-05 Ga-67 Whole body inflammation scan with SPECT
    • Increased radiotracer uptake in bilateral lungs, bilateral pulmonary hilar regions, left mediastinum, stenum, spines, and S-I joints, the nature is to be determined (lymphoma involving regions, inflammation or other nature ?).
    • Increased radiotracer accumulation in the colon, probably physiological radiotracer accumulation.
    • No prominent abnormal focal radiotracer uptake is noted elsewhere.
  • 2021-10-01 CT - whole abdomen, pelvis
    • Follicular lymphoma S/P C/T show partial response.
  • 2021-07-19 Patho - bone marrow biopsy
    • Bone marrow, biopsy - B-cell lymphoma involvement
      
    • Microscopically, it shows positive for B-cell lymphoma composed of foci of lymphoid aggregation with follicular architecture.
    • IHC: CD20(+), Bcl-2(+), CD10(+), MPO(+), Bcl-6(+, at germinal center), CD71(focal+), CD117(-), CD34(-).
      
  • 2021-07-16 Chest PA (Erect) view
    • S/P port-A implantation.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Increased lung markings on both lower lung are noted.
  • 2021-07-16 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, spleen and sacrum (stage IV).
    • Mildly and diffusely increased FDG uptake in the bone marow of the skeleton. The nature is to be determined (lymphoma? bone marrow hyperplasia?).
  • 2021-07-12 Patho - lymphnode biopsy
    • Lymph node, right axillary, sono guide biopsy - Follicular lymphoma, grade 2
      
    • Histology type: B-cell neoplasms, Follicular lymphoma, grade 2
      
    • IHC: CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), Cyclin D1(-), CD56(-), and CK(-).
  • 2021-07-09 CT - CTA, chest
    • Diffuse enlarged lymph nodes, suspected lymphoma.
    • Bilateral pleural effusion with lung collapse.
    • GB stone.
    • Ascites.
• Chemotherapy
  • 2022-03-18 - bendamustine + obinutuzumab
  • 2022-02-09 - rituximab
  • 2021-11-17 - R-CHOP (Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)
  • 2021-10-27 - R-CHOP
  • 2021-09-22 - R-CHOP
  • 2021-09-01 - R-CHOP
  • 2021-08-03 - R-CHOP
  • 2021-07-19 - R-CHOP
    • R-CHOP Regimen - An immunochemotherapy regimen consisting of rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride (doxorubicin hydrochloride), vincristine (Oncovin) and prednisone used to treat both indolent and aggressive forms of non-Hodgkin lymphoma.
      • Regimen - cycle length 21 days.
        • Rituximab
          • 375 mg/m2 IV
          • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. For subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count >=5000/microL.
          • Day 1
        • Cyclophosphamide
          • 750 mg/m2 IV
          • Dilute in 250 mL NS or D5W and administer over 30 minutes.
          • Day 1
        • Doxorubicin
          • 50 mg/m2 IV
          • Dilute in 50 mL NS or D5W and administer over three to five minutes.
          • Day 1
        • Vincristine
          • 1.4 mg/m2 IV (max dose 2 mg)
          • Dilute in 50 mL NS or D5W and administer over 15 to 20 minutes.
          • Day 1
        • Prednisone
          • 100 mg orally
          • Administer 30 minutes prior to chemotherapy on day 1, then every 24 hours on days 2 to 5.
          • Days 1 to 5
      • Pretreatment considerations:
        • Hydration
          • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day) and void frequently to reduce risk of hemorrhagic cystitis.
        • Emesis risk
          • MODERATE (30 to 90% risk of emesis).
        • Prophylaxis for infusion reactions
          • Premedicate with acetaminophen and diphenhydramine, with or without an H2 blocker, 30 minutes prior to at least the first and second infusions of rituximab.
        • Vesicant/irritant properties
          • Doxorubicin and vincristine are vesicants; avoid extravasation.
        • Infection prophylaxis
          • The risk of febrile neutropenia with this regimen is 10 to 20%; primary prophylaxis with hematopoietic growth factors should be considered on an individual basis, particularly for high-risk patients such as those with preexisting neutropenia, advanced disease, poor performance status, or patients age 65 years or older.
        • Dose adjustment for baseline liver or renal dysfunction
          • Adjustment of initial cyclophosphamide, doxorubicin, and vincristine doses may be needed for preexisting liver dysfunction. In addition, dose adjustment of cyclophosphamide may be required for renal dysfunction.
        • Hepatitis screening
          • Patients should be screened for hepatitis B and C virus prior to starting rituximab, and if positive, considered for antiviral prophylaxis.
        • Cardiac screening
          • LVEF should be evaluated prior to initiation of therapy. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation. Infusion times and schedule may be adjusted to decrease the risk of cardiotoxicity in individuals at high risk for its development.
        • Neurotoxicity
          • Vincristine may cause constipation, and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine.
      • Monitoring parameters:
        • CBC with differential and platelet count weekly during treatment.
        • Assess basic metabolic panel (creatinine and electrolytes) and liver function prior to each subsequent treatment cycle.
        • LVEF should be evaluated periodically based on LVEF at initiation of therapy and cumulative dose of doxorubicin.
        • Carriers of hepatitis B or C should be monitored for clinical and laboratory signs of active infection during and following completion of therapy. Rituximab should be discontinued if reactivation occurs.
      • Suggested dose modifications for toxicity:
        • Myelotoxicity
          • Treatment should be delayed until ANC is >1500/microL and platelet count is >100,000/microL. If a patient develops grade 4 (ANC <500/microL) neutropenia or febrile neutropenia with any cycle, G-CSF support is added to the regimen for subsequent cycles. If grade 4 neutropenia or febrile neutropenia occurs despite G-CSF support, or if the patient develops grade 3 (25,000 to 50,000/microL) or 4 (<25,000/microL) thrombocytopenia with any cycle, the doses of cyclophosphamide and doxorubicin should be decreased by 50% for subsequent cycles.
        • Neuropathy
          • Dose adjustment of vincristine may be necessary if the severity of neuropathy persists or worsens. No specific guidelines are available for dose adjustments.

[assessment]

• A patient with stage II, III, or IV FL is usually not cured by conventional treatment. Remissions can be achieved, but relapses are not uncommon. The treatment is intended to relieve symptoms, reverse cytopenias, and improve the quality of life. Despite not being curative, a modern therapy that incorporates anti-CD20 antibodies can prolong survival. The goal of modern chemoimmunotherapy regimens is usually to achieve a complete response, however, a significant minority of patients treated with these regimens will only show a partial response. Additional therapy (e.g., maintenance) may result in complete recovery in some of these patients. As well, for this group as a whole, some interventions, such as maintenance therapy and obinutuzumab, prolong progression-free survival but do not improve overall survival.
  • reference: https://www.uptodate.com/contents/initial-treatment-of-stage-ii-to-iv-follicular-lymphoma
• During the period of Mid-July 2021 through Mid-November 2021, this patient received R-CHOP, then had rituximab prescribed on 2022-02-09. CT images taken on 2021-10-01 and 2022-01-10 indicated partial response, however CT images taken on 2022-02-21 showed mild progression.
• During this hospitalization, the patient begins receiving his new chemoimmunotherapy regimen of bendamustine plus obinutuzumab without issue.
• Underlying diseases include HTN and DM (admission diagnosis), drugs for the latter have not been prescribed as active medication and no updated blood sugar lab readings found within these 3 months.

700980179

220318

{Peripheral T-Cell Lymphoma, PTCL, relapsed}

[objective]

• exam finding
  • 2022-01-26 CT - neck
    • Necrotic tumor at right neck, much smaller in size and less enhancement as compared with CT scan on 20211228.
  • 2021-12-28 CT - neck
    • Probably abscess with deep neck infection at right upper neck. Differential diagnosis suspected necrotic tumor mass with infection.
  • 2021-11-25 Whole body PET scan
    • Increased FDG uptake in bilateral tonsils and a right upper neck lymph node, compatible with residual lymphoma. In comparison with the previous study on 20210107, the FDG avid lesions in bilateral tonsils and a right upper neck lymph node are less evident. Other previous lesions in the nasopharynx and other bilateral neck lymph nodes disappeared.
      
    • Increased FDG uptake in the stomach. Inflammation is more likely.
    • No prominent change is noted in the mild FDG avid lesions in some mediastinal lymph nodes, right pulmonary hilar lymph nodes and left adrenal gland, possibly more benign in nature.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
  • 2021-11-24 Patho - bone marrow biopsy
    • Bone marrow, biopsy - No evidence of T-cell lymphoma involvement
    • The sections show normocellular marrow (35%). M/E ratio = 4:1. The erythroid precursors are not remarkable. The myeloid cells show good maturation. The megakaryocytes are normal in number with few small megakatyocytes. No lymphoid aggregates can be found. There is no evidence of T-cell lymphoma involvement in CD20, CD3, CD4 and CD8 immunostains. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2021-11-10 Patho - tonsil biopsy
    • Diagnosis
      • Tonsil, left, tumor excision — Peripheral T-cell lymphoma
        
      • Tonsil, right, tumor excision — Peripheral T-cell lymphoma
    • Histologic type: Peripheral T-cell lymphoma
    • Immunophenotyping: CD3(+), CD20(-), CD4(+), CD8(focal+), and CD30(focal+)
  • 2021-11-09 Frozen section
    • Tonsil, left, frozen section — Atypical lymphoid cell infiltration, compatible with lymphoma involvement.
  • 2021-11-03 CT - neck
    • C/W residual oropharyngeal lesions, mild regression as compared with CT scna on 20210106.
  • 2021-01-07 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple bilateral neck lymph nodes.
    • Milldy increased FDG uptake in some mediastinal lymph nodes and right pulmonary hilar lymph nodes. Inflammation is more likely.
    • Milldy increased FDG uptake in the left adrenal gland. The nature is to be determined (benign tumor? other nature?).
    • Increased FDG accumulation in both kidneys and right ureter. Physiological FDG accumulation may show this picture.
  • 2021-01-06 CT - neck
    • Bilateral tonsillar lesions and bilateral neck LAPs. R/O lymphoma (stage II).
  • 2020-12-28 Patho - tonsil biopsy
    • Tonsil, right, biopsy —- Malignant T-cell lymphoma
    • Histology type: T-cell neoplasms, in favor of Peripheral T-cell lymphoma
      
    • Immunohistochemical stain profiles: CD3(+), CD4(+), CD8(-), CD56(-), Granzyme B(-), CD30(+), ALK(-), and CK(-).
      
    • Fungal hyphe is seen in necrotic debris. The PAS special stain is positive.
  • 2020-12-26 Nasopharyngoscopy
    • Ulcerative lesion over right tonsil upper pole and right palatopharyngeal arch
• chemotherapy
  • 2021-12-10 ~ ongoing Folotyn (pralatrexate)
  • 2021-01-11 ~ 2021-05-13 CHOP (cyclophosphamide, doxorubicin hydrochloride (hydroxydaunorubicin), vincristine sulfate (Oncovin), and prednisone)

[assessment]

• Pralatrexate is indicated to treat relapsed PTCL. The patient is taking pralatrexate currently since early December 2021, and CT scans (2022-01-26 versus 2021-12-28) demonstrated improvements.
• Hepatotoxicity and LFT abnormalities have been observed with pralatrexate use. Persistent abnormalities may indicate hepatotoxicity. In the period 2021-12-01 to now, S-GPT/ALT readings have ranged from 15U/L to 403U/L, with 77U/L being reported on 2022-03-17.
• Package insert revealed 30% of patients treated with pralatrexate experienced edema, which should be addressed.

701148578

220318

{Nasopharyngenl Carcinoma - NPC, non-keratinizing carcinoma}

[objective]

• radiotherapy
  • 2022-02 ~ ?? CCRT?
• chemotherapy
  • 2022-02-14 ~ ongoing - 5-FU + carboplatin
  • 2021-11-29 ~ 2022-01-10 - carboplatin (weekly)

[assessment]

• Nivolumab could be added optionally to the treatment regimen for patients suffering from recurrent or metastatic non-keratinizing disease.
  • reference: https://pubmed.ncbi.nlm.nih.gov/29584545/

220215

[objective]

• Exam findings
  • 2021-11-24 PET
    • Glucose hypermetabolic lesions in the post. aspect of nasal septum, nasal cavity, and part of left NP region, compatible with recurrent tumor of NPC.
      
    • Glucose hypermetabolic lesions in bilateral mediastinal lymph nodes and bilateral pulmonary hilar lymph nodes, probably reactive nodes.
    • Glucose hypermetabolic lesion in the right femoral shaft, the nature is to be determined (post-traumatic change, benign or even another primary malignant neoplasm of bone, or other nautre?), suggesting further investigation.
      
    • NPC s/p treatment with tumor recurrence, rcTxN0M0, by this F-18 FDG PET scan.
  • 2021-11-01 Patho - Larynx biopsy
    • Nasopahrynx, biopsy - Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
    • IHC: CK(+), EBER(+).
  • 2021-11-01 MRI - Nasopharynx
    • A soft tissue tumor, about 27 mm x 22 mm x 24 mm, with relatively homogeneous mild T1- and T2-hyperintensity and faint enhancement involving posterior aspect of nasal septum, posterior nostril, florr of sphenoid sinus and part of left nasopharyngeal wall.
    • Diffuse fluid accumulation in bilateral sphenoid sinuses.
  • 2020-11-02 MRI - Nasopharynx
    • Markedly regressed bil. neck LNs.
  • 2020-04-22 MRI - Nasopharynx
    • C/W NPC T4N2Mx, Stage IVA. Progressive change as compared with MRI on 2019-12-04.
  • 2019-12-05 PET
    • The FDG PET findings are compatible with nasopharyngeal malignancy with invasion to the skull base and possible intracranial extension.
    • Glucose hypermetabolism in bilateral retropharyngeal lymph nodes and multiple right neck level II to III and left neck level II lymph nodes, compatible with metastatic lymph nodes.
    • Mild glucose hypermetabolism in the lesser trochanter of right femur. The nature is to be determined (post-traumatic change? other nature?).
  • 2019-12-04 MRI - Nasopharynx
    • Bilateral NPC, at least T4N2Mx, stage IVA.
• Radiotherapy
  • 2020-05 ~ 2020-06:
    • 6090cGy/29 fractions (6 MV photon) to NPX tumor and bilateral neck LAPs (incomplete).
    • 2020-06-22 RT side effect evaluation: radiation mucositis, grade 2; pharyngitis, grade 2; dermatitis, grade 2; N/V, grade 1; esophagitis, grade 1; xerostomia, grade 2.
• Chemotherapy
  • 2020-11 ~ ongoing: carboplatin + fluorouracil
  • 2019-12 ~ 2020-06: cisplatin, 2020-04-21 + UFT

701240249

220315

[objective]

• exam finding
  • 2022-03-02 Patho - bone marrow biopsy
    • pathologic diagnosis
      • Bone marrow, biopsy - acute myeloid leukemia
    • microscopic examination
      • Microscopically, the sections show a picture of acute myeloid leukemia, composed of hypercellular marrow (>90%). The marrow space is almost completely replaced by blasts.
    • Immunohistochemistry: CD34(+, 60%), CD117(+, 60%), MPO(+, 10%), CD61(+, megakaryocytes) and CD71(+, erythroid series).
  • 2022-02-25 CT - lung/mediastinum/pleura
    • Right middle lobe and right lower lobe subsegmental consolidation.
  • 2022-01-12 Patho - bone marrow biopsy
    • pancytopenia
      
    • Bone marrow, iliac, biopsy - Normal cellular marrow.
    • IHC stains: CD117: <2%; CD34: <2 %; MPO: 10%, CD61: <2 %; CD71: 20%, CD138: 5% (of the nucleated cells). Kappa and lambda light chains: no predominant monoclonal sub-population.
      
    • Section shows piece(s) of bone marrow with 50 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no metastatic malignancy present.

701272755

220315

[subjective]

• 2021-03-04 cough for several months, CT scan at ShuangHo Hospital showed a necrotic mass at anterosuperior mediastinum, suspected malignant thymoma.

[objective]

• exam finding
  • 2022-03-11 CT - brain
    • multiple brain metastases.
  • 2022-02-17 CT - lung/mediastinum/pleura
    • s/p thymectomy with recurrent soft tissue at anterior mediastinum and lymph nodes at subcarina region. stationary as compred with previous CT.
  • 2021-1-17 Patho - soft tissue nontumor/mass/lipoma/debridement
    • subcutanoeus nodule over right back
    • diagnosis - soft tissue, back, excisional biopsy - Metastatic thymoma - Margin free
    • IHC: P40(+), CK5/6(+), CD5(focal+).
  • 2021-11-04 CT - lung/mediastinum/pleura
    • Residual low density lesion at anterior mediatinum, in regression.
    • Some lymph nodes are found at paracaval region. Stable.
    • The pleural effusion is not visualized in the current study.
  • 2021-09-08 Patho - soft tissue nontumor/mass/lipoma/debridement
    • Diagnosis - Skin and soft tissue, previous right chest tube wound, excisional biopsy - metastatic thymoma
      
    • IHC: CK5/6(+), p40(+), CD5(-), and CD117(-). The results are consistent with metastatic thymoma. The deep resection margin is involved by tumor.
  • 2021-08-03 CT - lung/mediastinum/pleura
    • recurrent or residual mediastinal invasive thymoma with mediastinal LAP and bilateral pleural effusions suspected mediastinal abscess.
  • 2021-04-13 Patho - meiastinum mass
    • anterior mediastinal tumor with pericardial and LUL invasion
    • Thymus, excision - Invasive thymoma, poorly differentiated, AJCC 8th edition: pStage IIIA, pT3N0 (if cM0), at least
      • The peripheral resection margin is involved
        
    • Lung, LUL, wedge resection - Invasive thymoma, by direct invasion, with negative resection margin.
    • IHC CK5/6(+), p63(+), CD117(-), CD5(-), TTF-1(-), GATA3(-) and CD56(-).
  • 2021-03-18 Patho - thymus tumor
    • Mediastinal tumor
    • Diagnosis: Thymus, CT-guide needle biopsy - in favor of invasive thymoma
    • IHC: CK5/6(+), p63(+), TTF-1(-), Naspin A(-), CD56(-), Calretinin(-), PAX8(-), and CD117(-). The results are in favor of invasive thymoma, but metastatic squamous cell carcinoma or urothelial carcinoma can not be excluded.
• surgical operation
  • 2021-09-08
    • Surgery: Removal of granuloma
    • Finding: Erythematous granuloma over previous right chest tube wound. suspected stitches-related and tumor seeding.
  • 2021-04-12
    • Surgery: Radical left side pericardiectomy with tumor mobilization and excision.
    • Finding: A huge, stiff anterior mediastinal mass tightly adhered to ASAo/MPA and extended to left anterior chest wall. We meticulously divided the InV and LIJV and tumor debulking from surroundings.
• radiotherapy
  • 2021-05-14 ~ 2021-07-05: 4500cGy/25 fractions of the thymic tumor, and 6480cGy/36 frcations of the reduced thymic tumor area.
• chemotherapy
  • 2022-01-06 vincristine + cyclophosphamide
  • 2022-01-05 cisplatin + doxorubicin
  • 2021-12-01 vincristine + cyclophosphamide
  • 2021-11-29 cisplatin + doxorubicin
  • 2021-10-20 vincristine + cyclophosphamide
  • 2021-10-18 cisplatin + doxorubicin
  • 2021-09-20 vincristine + cyclophosphamide
  • 2021-09-20 cisplatin + doxorubicin
  • 2021-08-11 vincristine + cyclophosphamide
  • 2021-08-09 cisplatin + doxorubicin
  • 2021-07-13 vincristine + cyclophosphamide
  • 2021-07-13 cisplatin + doxorubicin
  • 2021-05-15 ~ 2021-06-29: cisplatin (part of CCRT)

700309329

220309

{rt breast ca (TNBC), cT2N0M0 stage IB}

• exam finding
  • 2020-11 recurrence
• surgical operation
  • 2018-10 at WanFang Hospital
• chemotherapy
  • ongoing oral vinorelbine
  • 2021-05 ~ 2021-10 Eribulin / Xeloda
  • 2021-02 ~ 2021-04: Taxol + Gem
  • 2020-12 ~ 2021-01 EP x 3
  • 2018-18 ~ ?: post-Op adjuvant CAP
  • 2018-07 ~ 2018-09 pre-Op neoadjuvant TAC x 3
  • 2018-05 ~ 2018-06 pre-Op neoadjuvant C/T x CEF x 3
• shared decision making
  • 2022-03-01
    • effective Tx option had been tried and failed. hospice care had been recommended at WanFang Hospital.

[assessment]

• Use of preoperative systemic therapy may provide important prognostic information based on response to therapy. Achieving a pathologic complete response (pCR) to neoadjuvant therapy is associated with favorable disease-free and OS in early-stage breast cancer. The correlation between pathologic response and long-term outcomes in patients with early-stage breast cancer is strongest for patients with triple-negative breast cancer.
  • references:
    • Liedtke C, Mazouni C, Hess KR, et al. Response to neoadjuvant therapy and long-term survival in patients with triple-negative breast cancer. J Clin Oncol 2008;26:1275-1281. https://www.ncbi.nlm.nih.gov/pubmed/18250347.
    • Cortazar P, Zhang L, Untch M, et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. Lancet 2014;384:164-172. http://www.ncbi.nlm.nih.gov/pubmed/24529560.
    • von Minckwitz G, Untch M, Blohmer JU, et al. Definition and impact of pathologic complete response on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes. J Clin Oncol 2012;30:1796-1804. https://www.ncbi.nlm.nih.gov/pubmed/22508812.
• Different subsequent chemotherapy regimen did not yield satisfactory results for this patient.
• Biomarkers such as BRCA1/2, PIK3CA, PD-L1, NTRK, MSI-H/dMMR, or TMB-H not found in the system, or targeted drugs may provide an alternative approach.

700835850

220304

[subjective]

• 2021-12 the patient noted vaginal bleeding and coital pain after sexual intercourse, and post-voiding vaginal bleeding developed afterwards.

[objective]

• exam finding
  • 2022-01-25 Patho - uterus neoplastic
    • pathologic diagnosis
      • Tumor, uterine endocervix, radical hysterectomy - Carcinosarcoma
      • Tumor, uterine fundus, ditto - Serous carcinoma, high grade
      • Myometrium, ditto - Tumor invasion, less than half thickness
      • Parametria, bilateral, ditto - Free from tumor, two reactive lymph nodes at R’t parametrium
    • AJCC pathological stage
      • endometrial cancer - pT1aN0, if cM0, stage IA
      • cervical cancer - pT1b1N0, if cM0, stage IB1 / FIGO stage IA1
    • Microscopic examination
      • Tumor 1
        • Tumor location: Fundus
        • Myometrium involvement: involved, less than 0.2 cm in depth
        • Tumor type: high grade serous carcinoma
        • Histologic grade: high grade
        • Immunohistochemistry: P16(+), P53(+), WT-1(+, focal), ER(+, focal) and PR(+, focal)
      • Tumor 2
        • Tumor location: Between low body and endocervix
        • Corpus involvement: involved, focal
        • Tumor type: homologous type carcinosarcoma
        • Histologic grade: high grade
        • Depth of invasion: less than 0.1 cm, <1/2 cervical wall
        • Immunohistochemistry:
          • carcinoma component: P16(+), P53(+), WT-1(+, focal), CK(+), vimentin(-), CD10(-)
          • Sarcoma component: vimentin(+), CD10(+, focal), WT-1(+, focal), P16(+), P53(+), CK(-)
  • 2022-01-11 MRI - pelvis
    • Clinical cervical polypectomy, carcinosarcoma. No evidence of advanced lesion.
    • Soft tissue in the uterine cavity (fundus and lower body), suspected polyps or endometrial tumors, suggest further study.
  • 2022-01-03 Patho - cervix/endometrial polyp
    • pathologic diagnosis
      • Uterus, cervix, polypectomy - Carcinosarcoma
    • microscopic examination
      • The sections show carcinosarcoma, composed of a adenocarcinomatous component admixed with a high-grade sarcomatous component.
• surgical operation
  • 2022-01-24 radical hysterectomy
• radiotherapy
  • 2022-02-18 ~ 4500cGy/25 fractions of the pelvis, and 1200cGy/3 fractions by IVRT to vaginal cuff mucosa surface.
• chemotherapy
  • 2022-03-03 ~ ongoing: cisplatin

[assessment]

• Surgical findings without nodes, margins and parametrium infiltrations, s/p radical hysterectomy (2022-01-24), pelvic EBRT and concurrent platinum-containing chemotherapy were recommended for stage IB1 cervical cancer.
• concurrent platinum-containing chemotherapy with EBRT utilizes cisplatin as a single agent. currently, the patient is being hospitalized to receive her first chemotherapy dose. in case of cisplatin intolerance, carboplatin may be used instead.
• regular cytology can be considered for detection of lower genital tract dysplasia and for immunocompromised patients, although its value in detection of recurrent cervical cancer is limited.

700267431

220303

{Compatibility for both Tapimycin and KCl in Suntose}

• tapimycin in suntose: compatible
• potassium chloride in suntose: compatible
• both tapimycin and KCl in suntose: no compatibility data availabe yet, not recommended.

700334023

220303

{Panceratic carcinoma, cT1N1M1 (left neck subclavicle mets), stage IV}

[objective]

• exam finding
  • 2022-01-17 CT - lung/mediastinum/pleura
    • distal pancreatic cancer with regression of neck LNs metastases but progression of retroperitoneal para-aortic LNs metastases, new left adrenal metastasis, and resolution cystic component at pancreatic tail as compared with previous chest, neck, and abdominal CT exams.
    • favor hepatic cysts, cannot totally rule out small metastatic lesions, stationary
  • 2021-10-11 CT - neck
    • multiple left low neck and supraclavicular fossa LAPs.
  • 2021-09-20 CT - liver, spleen, biliary duct, pancreas
    • A soft tissue nodule (2.5cm) at LUQ.
    • Enlarged LNs at paraaortic region.
  • 2021-06-12 CT - whole abdomen, pelvis
    • metastatic paraaortic lymph nodes with partial response.
    • atrophy of pancreatic tail with dilated P-duct.
    • suspected liver cysts.
  • 2021-03-05 Patho - lymphnode biopsy
    • tissue, intraabdominal lymph node, biopsy - poorly differentiated carcinoma
    • IHC: CK7(+), CDX-2(+), CK(+), CK20(-).
  • 2021-03-05 Cytology
    • positive for malignancy
      
    • smears show clusters of atypical tumor cells with nuclear hyperchromasia, pleomorphism and high N/C ratio.
  • 2021-03-04 Whole body PET scan
    • Glucose hypermetabolism in the hypopharynx. The nature is to be determined (inflammation/infection? malignancy?).
    • A glucose hypermetabolic in the left upper abdomen just between the stomach and spleen. Malignancy (colon malignancy?) in this region should be watched out. However, no prominent abnormal focal FDG uptake was noted in the pancreas.
    • Glucose hypermetabolism in multiple left neck level V and left supraclavicular lymph nodes, a mediastinal A-P window lymph node and multiple abdominal paraaortic and right plevic lymph nodes, compatible with multiple metastatic lymph nodes.
    • Mild glucose hypermetabolism in the stomach, some mediastinal right paratracheal lymph nodes, right pulmonary hilar lymph nodes and a left axillary lymph node. Inflammatory process is more likely.
  • 2021-02-22 Patho - soft tissue
    • Lymph node, left neck, excision - metastatic carcinoma, poorly differentiated consistent with gastrointestinal or pancreatobiliary origin
    • IHC: CK7(focal +), CK20(-), CDX2(+), CK5/6(-), TTF-1(-), CD56(-), and GATA3(-).
  • 2021-02-18 CT - lung/mediastinum/pleura
    • Atrophy of the pancreatic tail with dilated distal pancreatic duct is found. suspected IPMT, suggest EUS/ERCP.
    • Lymphadenopathy at left thoracic inlet and paraaortic region.
• surgical operation
  • 2021-02-22 Excision - a 1.5x2x2 cm soft tumor over L’t supraclavicle region.
• chemotherapy
  • 2022-02 ~ ongoing: 5-Fu + leucovorin + irinotecan liposome, Q2W
  • 2021-04 ~ 2022-01: gemcitabine + nal-paclitaxel, Q2W
  • 2021-03: gemcitabine

[assessment]

• Most recent CT images (2022-01-17) showed regression of neck LNs metastases, progression of retroperitoneal para-aortic LNs metastases, new left adrenal metastasis. Each metastasis has its own ups and downs. In general, the disease is still advancing.
• FOLFIRINOX or modified FOLFIRINOX should be limited to those with ECOG 0-1.
• Gemcitabine + albumin-bound paclitaxel is reasonable for patients with ECOG 0-2. (Apr 2021 to Jan 2022)
• 5-FU + leucovorin + liposomal irinotecan is a reasonable subsequent therapy option for patients with ECOG 0-2. (since Feb 2022)
• Sympathomimetics for glaucoma prescribed by ophthalmology OPD might be added as a self-carried item into current medication.

701252496

220302

[objective]

• exam finding
  • 2022-03-01 CT
    • bilateral lung, mediastinal and supraclavicular LNs, chest wall, pleural, bony, and liver metastases, in progression as compared with CT on 2022-01-19.
    • multiple numerous nodules of variable sizes throughout in both lungs due to metastasis.
  • 2022-01-19 CT
    • bilateral lung, mediastinal and supraclavicular LNs, chest wall, pleural, and liver metastases, in progression as compared with CT on 2021-11-09.
    • multiple numerous nodules of variable sizes throughout in both lungs due to metastasis.
  • 2021-12-20 Pelvis & Bilat. Hip Lat
    • osteolytic bony lesion in left lower sacrum and right pubic bone are suspected.
  • 2021-12-01 Hearing test
    • bil. moderately severe to profound HL.
  • 2021-11-09 CT
    • bilateral lung, mediastinal LNs, chest wall, and liver metastases, in progression as compared with CT on 2021-09-06.
  • 2021-09-06 CT
    • bilateral lung, mediastinal LNs, chest wall, and liver metastases, in progression as compared with CT on 2021-07-02.
  • 2021-07-02 CT
    • esophageal cancer s/p esophagectomy and gastric tube reconstruction. No regional recurrence is found.
    • bilateral lung meta with enlarged size is found.
    • s/p jejunal stomy.
  • 2021-03-24 Patho - soft tissue biopsy / simple excision (non lipoma)
    • skin, infra-gluteal fold, right, excision - metastatic adenosquamous carcinoma, compatible with esophageal primary
  • 2021-03-16 CT
    • favor bilateral lung and mediastinal LNs metastases and bronchiolitis or endobronchial spreadinf nodules, and residal posterior wall thickening at M/3 of esophages
  • 2021-02-01 Patho - soft tissue biopsy / simple excision (non lipoma)
    • skin, scalp, incisional biopsy - compatible with metastatic adenosquamous carcinoma from esophagus
      
    • IHC: CK7(+), CK5/6(+), and p63(focal +).
  • 2021-01-19 Patho - esophagus subtotal/total resection
    • Esophagus, middle third, VATS esophagectomy - Adenosquamous carcinoima, poorly differentiated, s/p CCRT
      
    • Soft tissue, peri-gastric, specimen 1, dissection - Adenosquamous carcinoima, metastatic (1/10)
      
    • Lymph node, group 5, dissection - Adenosquamous carcinoima, metastatic (1/2)
      
    • Pathology stage:
      • ypStage IIIB, ypT3N1(if cM0)
      • if brain metastasis is proofed, ypStage IVB, ypT3N1(if cM1)
  • 2021-01-06 Whole body PET scan
    • The glucose hypermetabolic lesions in the middle portion of the esophagus, in mediastinal lymph nodes, and in bilateral pulmonary hilar lymph nodes come to less evident compared with the previous study on 2020-10-16, compatible with esophageal malignancy s/p treatment.
      
    • However, glucose hypermetabolic lesions in the left lower lung and right lower lung become more prominent, suggesting lung metastases.
  • 2021-01-05 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2020-10-13, the lesion in the region about left 3rd costovertebral junction is new. The nature is to be determined (post-traumatic change? other nature?).
    • No prominent change is noted in other bone lesions, possibly more benign in nature.
  • 2021-01-05 MRI - Brain
    • A small enhancing nodule in right caudate nucleus head. Seems slightly increase in size (4.7 mm), suggest follow up.
    • Brain atrophy.
  • 2021-01-04 CT
    • M/3 thoracic esophageal cancer, significant regression of a sessile like intralumal mass in posterior wall as compared with CT on 2020-09-30.
    • no regional LAP. inflammation or infection in RLL and LLL of lungs.
  • 2020-10-23 MRI - Spectroscopy
    • An enhancing lesion (3 mm) in right caudate nucleus. Metastasis is first considered until proved otherwise.
  • 2020-10-16 Whole body PET scan
    • A glucose hypermetabolic lesion involving the middle portion of the esophagus, compatible with primary esophageal malignancy. Besides, there were two small focal areas of glucose hypermetabolism in the lower portion of the esophagus. Esophageal malignancy involving these two small focal areas should be considered.
    • Glucose hypermetabolism in multiple bilateral supraclavicular lymph nodes and multiple mediastinal lymph nodes (more than 7 lymph nodes), in bilateral pulmonary hilar lymph nodes and in two upper abdominal lymph nodes. Metastatic lymph nodes may show this picture.
    • Some small glucose hypermetabolic lesions in bilateral lung fields. Lung metastases should be watched out.
  • 2020-10-15 Patho - Esophageal biopsy
    • Esophagus, 34, 37-38 cm below incisors, biopsy - Squamous cell carcinoma, poorly differentiated
      
  • 2020-10-15 MRI - Brain
    • A metastatic lesion (3 mm) in right caudate nucleus. Left lateral nasopharyngeal mucosal thickening.
  • 2020-09-30 CT
    • Esophageal Carcinoma
    • Imaging stage: T2N1M0, stage IIIA
  • 2020-09-28 Patho - Esophageal biopsy
    • Esophagus, middle third, 25-30 cm below incisor, biopsy - Squamous cell carcinoma, poorly differentiated
  • 2020-09-28 Esophagogastroduodenoscopy, EGD
    • Suspect esophageal cancer, middle third, 25-30 cm below incisor s/p biopsy x 3
• surgical operation
  • 2021-01-18 VATS + esophagectomy + laparoscopy gastric tube reconstruction
• radiotherapy
  • 2021-02-22 ~ 2021-03-05 18Gy/6fx to the whole brain The .
    • whole brain: 18Gy/6fx
    • rt caudate nucleus metastatic tumor: 30Gy/10fx
    • scalp boost: 9Gy/3fx (4MeV electron)
  • 2020-11-02 ~ 2020-12-11 50.4Gy/28fx to the esophagus, Rt hilar LAPs, and adjacent lymphatic drainage area (part of preOp neoadjuvant CCRT)
• chemotherapy
  • 2021-12 ~ ongoing: 5-Fu + cisplatin + paclitaxel
  • 2021-07 ~ 2021-11: FOLFIRI
  • 2021-03 ~ 2021-07: 5-Fu + cisplatin + docetaxel
  • 2020-11 ~ 2020-12: 5-Fu + cisplatin (PF, part of preOp neoadjuvant CCRT)

[assessment]

• for recurrent, metastatic esophageal squamous cell carcinoma with general weakness and fatigue, if ECOG score <= 2 or Karnofsky score >= 60%, then microsatellite and PD-L1 testing might be performed for those previously not done, to expand the subsequent choice like nivolumab or pembrolizumab.
• if NTRK gene fusion positive proved, entrectinib or larotrectinib could also serve as an optional choice.

210517

{tube feeding}

the oral drugs in active medication including: - keto (ketorolac 10mg) - neurontin (gabapentin 100mg) - tramacet (tramadol 37.5mg, acetaminophen 325mg)

all the above drugs can be grinded and administrated via NG tube

700867682

220301

[objective]

• diagnosis
  • 2022-01-26 dischargenote
    • Recurrent hepatocellular carcinoma, rypT3N0(cM0), Stage IIIA; status post 3rd Transarterial chemoembolization on 2022-01-25, BCLC: B, ECOG:1
    • Liver cirrhosis with moderate splenomegaly, child score: A
    • Hypertension
    • Type 2 diabetes mellitus without complications
    • Enlarged prostate without lower urinary tract symptoms
• exam finding
  • 2022-02-25 MRI - L-spine
    • multiple bone tumors
    • herniated discs in the L2/3, L3/4 and L4/5 discs
    • mild spondylolisthesis at L4-5
  • 2022-01-17 MRI - Liver, Spleen
    • HCC s/p operation. Liver cirrhosis with splenomegaly. Multiple recurrent HCCs (up to 2.0cm) in liver.
  • 2021-11-19 CT - ABD
    • Four newly-developed HCCs or pseudolesions in S8 and S2 are suspected? Please correlate with MRI.
    • Viable HCC in S7 of the liver is suspected. Please correlate with MRI.
  • 2021-09-09 MRI
    • HCC at right lobe liver up to 6.6cm with several satellite smaller lesions at right lobe.
    • Lymphadenopathy at retroperitonum, paraaoritc and hepatic hilar region.
  • 2021-08-25 CT - ABD
    • HCC 6.8 x 4.6 cm in S7 of the liver is suspected. Please correlate with AFP and MRI to evaluate the tumor margin.
    • Two Recurrent HCCs 1.4 cm in S7 and 1.1 cm in S6 of the liver are suspected. The differential diagnosis include dysplastic nodules. Please correlate with MRI.
    • HCC or flow artifact 1.6 cm in S5 liver is suspected.
  • 2021-08-16 SONO - ABD
    • HCC status post S5 segmenectomy and cholecystectomy
    • Fatty liver, moderate
    • Liver cirrhosis with moderate splenomegaly
    • Fatty pancreas
    • Left renal stone
  • 2021-07-28 SONO - Kidney
    • Bilateral chronic change with large sized kidney suspect diabetic nephropahty
    • Left renal stone
  • 2020-04-17 SONO = Kidney
    • Left moderate hydronephrosis
  • 2019-03-11 Surgical pathology Level V
    • Pathologic diagnosis
      • Liver, S5, partial hepatectomy - Hepatocellular carcinoma
        
      • Pathologic Staging: pT1bNx(cMx); Stage IB at least
    • Microscopic examination
      • Histologic type: Hepatocellular carcinoma, predominantly clear cell
        
      • Histologic Grade: G3 (Poorly differentiated)
        
      • Cytological grade: Grade III
        
      • Tumor necrosis: Present (10%)
        
      • Inflammatory cell infiltration: Moderate
        
      • Tumor capsule: Partially ncapsulated with infiltrative border
        
      • Satellite nodule: Absent
        
      • Bile duct Invasion: Absent
        
      • Hepatitis: Non-B, non-C
        
      • Ishak Modified HAI Grading: Score=3 (interphase hepatitis=0/4, confluent necrosis=0/6, focal necrosis=1/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
        
      • Ishak Staging: F6 (Corresponding Metavir F4, cirrhosis)
        
      • Fatty Change: Marked (70%)
  • 2019-02-26 Visceral Angiography 2 vessels
    • Right hepatic tumor suspected HCC
  • 2019-02-26 Echo for liver, gall bladder, pancreas, spleen
    • Fatty liver , severe
    • Liver tumor, S5, suspicious HCC
    • Renal stone, left
    • Accessory spleen
  • 2019-01-30 SONO - ABD
    • Bilateral parenchymal renal disease.
    • Left mild hydronephrosis.
    • Left renal stones.
    • Liver tumor.
• Lab data
  • AFP
    • 2022-01-17 103 ng/mL
    • 2021-10-26 19
    • 2021-08-16 20
    • 2019-02-26 2
  • S-GPT/ALT
    • 2022-01-26 92 U/L
    • 2022-01-17 35
    • 2021-12-07 28
    • 2021-12-01 62
    • 2021-10-26 22
    • 2021-09-24 43
  • S-GOT/AST
    • 2022-02-27 97 U/L
    • 2022-01-26 279
    • 2022-01-17 112
    • 2021-12-01 87
    • 2021-10-26 26
    • 2021-09-24 53
    • 2021-09-22 36
• Embolization
  • 2022-01-25 Embolization (TAE) - ABD for tumor
    • HCCs at both hepatic lobes s/p TACE.
  • 2021-11-30 Embolization (TAE) - ABD for tumor
    • HCCs at RIGHT hepatic lobe s/p TACE.
  • 2021-09-23 Embolization (TAE) - ABD for tumor
    • HCCs at RIGHT hepatic lobe s/p TACE.
• Radiotherapy
  • 2021-10-05 ~ 2021-11-08: 5000cGy/25 fractions (15 MV photon) to hepatic hilum & paraaortic LAPs.
• Medication
  • 2021-01 ~ ongoing: lenvatinib 10mg QD
  • 2021-10-12, -10-26, -11-30: nivolumab 100, 100, 40mg, respectively
    
  • 2021-09 ~ 2022-01: sorafenib 200mg BIDAC

[assessment]

• Recurrent HCC progressed, bone mets observed by MRI on 2022-02-25 s/p 3 times of TAE in 2021-09, 2021-11, 2022-01, s/p nivolumab (Oct, Nov 2021), sorafenib (Sep 2021 ~ Jan 2022) and lenvatinib (since Jan 2022).
• Neither pembrolizumab nor atezolizumab used in advanced HCC setting are covered by the most updated NHI policy (2022-02-23 version). However atezolizumab/bevacizumab for Child-Pugh Class A patients is recommended as a preferred regimen by NCCN (2021 version 5).
• First-line nivolumab treatment did not significantly improve overall survival compared with sorafenib, but clinical activity and a favourable safety profile were observed in patients with advanced hepatocellular carcinoma. Thus, nivolumab might be considered a therapeutic option for patients in whom tyrosine kinase inhibitors and antiangiogenic drugs are contraindicated or have substantial risks.
  • source: https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(21)00604-5/fulltext
• There are limited data supporting the use of FOLFOX, and use of chemotherapy in the context of a clinical trial is preferred.
  • source: https://pubmed.ncbi.nlm.nih.gov/23980077/
• If NTRK gene fusion is positive, then larotrectinib or entrectinib might be opt-in as subsequent line use.
• Lenvatinib was non-inferior to sorafenib in overall survival in advanced hepatocellular carcinoma. This drug is prescirbed as part of current medication.
  • source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30207-1/fulltext
  • source: https://pubmed.ncbi.nlm.nih.gov/30993651/
• In addition to dermatologic adverse effects, since lenvatinib could increase the possibility of hypertension (45% to 73%; severe hypertension 3%; UpToDate) which is a underlying disease the patient has, a closer blood pressure monitoring might be needed.

700962200

220301

{myelodysplastic syndrome}

[objective]

• exam finding
  • 2022-02-16 Patho - bone marrow biopsy
    • Diagnosis - Bone marrow, biopsy - Compatible with myelodysplastic syndrome
    • IHC:
      • MPO: positive for myeloid series
      • CD71: positive for erythroid series
      • CD61: positive for megakaryocytes
      • CD117: positive for blast
      • CD34: positive for blast
    • Microscopically, the sections show pictures as follows:
      • Cellularity 30-40%
      • M/E ratio about 1/2, left shift maturation of both myeloid and erythroid series
      • Megakaryocyte proliferation, 30% with dysplastic change. Immunohistochemistry of CD34(+) and CD61(+)
      • Blast cells about 5%
      • According to all above histopathologic findings and clinical presentation, it is compatible with myelodysplastic syndrome.
  • 2021-09-27 Patho - bone marrow biopsy
    • Bone marrow, buttock, biopsy - Hypocellularity
    • IHC:
      • MPO: positive for myeloid series
        
      • CD71: positive for erythroid series
        
      • CD61: positive for megakaryocytes
        
      • CD117: positive for blast
        
      • CD34: positive for blast
        
    • Microscopic examination
      • Hypocellularity for her age, 5-10%
      • M/E ratio about 1/3, hypoplasia of myeloid series and hyperplasia of erythroid series
      • Megakaryocyte proliferation, 20-30% with interstitial or paratrabecular distribution
      • No obviously increase of blast (5%)
        
      • According to all above histopathologic findings and clinical history, the differential diagnosis includes myelodysplastic syndrome (MDS) or therapy-associated reactive change.
  • 2020-09-04, -08-14 CT
    • S/P hysterectomy.
    • Hepatosplenomegaly, nature?
  • 2019-10-17 Tc-99m MDP whole body bone scan
    • Increased activity in the middle T-spines and L4-5 spines. Degenerative change may show this picture.
    • Increased activity in the maxilla. The nature is to be determined (dental problem? other nature?).
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?).
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, elbows, knees and right ankle. Benign joint lesion is more likely.
  • 2016-05-17 Pathology
    • Uterus, endometrium, staging surgery - carcinosarcoma, Grade 3
    • pTNM: pT1bNO(cM0) , FIGO stage: IB.
    • Uterus, myometrium, staging surgery - involved by carcinosarcoma (> 1/2 thickness) - adenomyosis.
  • 2016-05-06 MRI
    • Endometrial tumor, suspected malignancy, cstage T1aN0Mx.
• surgical operation
  • 2016-05-10 laparoscopic gynecology staging surgery (LAVH + BSO + BPLND + omentectomy); laparoscopic adhesionolysis.
• radiotherapy
  • 2016-06-16 ~ 2016-08-01: 4500cGy/25fx (15MV photon) of the pelvic, and 900cGy/3fx via IVRT to vaginal cuff mucosa surface area.
• chemotherapy
  • 2016-06-01, -06-23, -08-10, -09-06, -11-14.

[assessment]

• Allogeneic hematopoietic cell transplantation (HCT) is the treatment with the highest potential to cure MDS. However, because of advanced age, comorbid conditions, lack of adequately matched donors, and/or patient preferences, only a small subset of patients with MDS are candidates for allogeneic HCT. HLA typing should be performed if hematopoietic cell transplant (HCT) approach is not ruled out.
• For most patients with MDS, the goals of care are to lessen symptoms, improve the quality of life, and prolong survival, while minimizing treatment-related toxicity. IPSS/IPSS-R could be applied to categorize prognostic risk group.
• If del(5q) is confirmed, then lenalidomide might be considered for IPSS low/intermediate MDS.
• lab data uric acid 11.8, eGFR 30.11 reported on 2022-02-28, allopurinol (50 mg daily) or febuxostat (no dosage adjustment necessary) might be considered if no contraindication.

701049704

220301

[objective]

• underlying disease
  • ESRD and dependence on renal dialysis (QW135)
• exam finding
  • 2021-12-23 CT
    • Right hilar lung meta, in regression.
    • Mediasitnal lymphadenopathy, regressed.
    • s/p left nephrectomy.
  • 2021-09-24 CT
    • Bladder ca. with right pulmonary hilar meta, causing right lung partial collapse and bilatral pleural effusion. The tumor is stationary in size and extension.
  • 2021-08-13 CT
    • Lung metastases show decreasing in size.
  • 2021-04-21 bronchoscopy
    • right main residual endobronchial tumors s/p electrocautery.
    • RUL and right intermediate bronchus endobronchial tumors, cannot be approached.
  • 2021-04-21 patho - bronchus biopsy
    • sections show solid sheets of hyperchromatic tumor cells in a fibrotic stroma. keratinization is focally seen.
    • IHC: CK5/6(+), p63(+), GATA3(+), TTF-1(-), and CD56(-). the results are consistent with metastatic urothelial carcinoma.
  • 2021-04-16 bronchoscopy
    • autofluorescence: abnormal mucosa over right main bronchus
    • right main bronchus: total occlusion by tomor s/p biopsy for 1 specimen with mild bloody oozing s/p epinephrin 0.5 amp local spray
    • EBUS: endobronchial tumor over right main bronchus.
  • 2021-03-25 chest PA (erect) view
    • extensive opacification and volume reduce and nodular opacities over Rt lung, in progression associated Rt pleural effusion as compared with previous image
    • obliteration of Rt main bronchus
    • small nodular opacities over left lung
  • 2021-02-19 CT - lung/mediastinum/pleura
    • right middle lobe lung cancer with right lower lobe lung mets is suspected.
  • 2020-10-29 chest AP
    • extensive consolidation in Rt upper lobe and extensive ground glass opacity over Rt mid and lower lung zones
  • 2020-10-16 patho - urinary bladder TUR
    • histologic type: papillary urothelial carcinoma, invasive, with marked squamous differentiation
    • histologic grade: high-grade
    • tumor configuration: papillary
    • mascularis propria: present
    • microscopic tumor extension: tumor invades subepithelial connective tissue
    • VENTANA PD-L1 (SP142) assay for urothelial carcinoma: PD-L1 expression <5% IC
  • 2020-08-17 patho - urethra biopsy
    • urothelial carcinoma, low-grade.
    • muscularis propria not present.
• surgical operation
  • 2020-01-16 Transurethral Resection of Bladder Tumor, TURBT
• radiotherapy
  • 2021-10: 60Gy/30fx to the Rt hilar mets.
• chemotherapy
  • 2021-11: VAC(vinblastin 3mg/m2, doxorubicin 22.5mg/m2, carboplatin 50mg)
  • 2021-05 ~ 2021-09: gemcitabine + carboplatin
  • 2020-11 ~ 2020-12: doxorubicin (intravesical)

[assessment]

• hypotenstion 80/40 around 2022-03-01 01:00 ~ 02:00 was mitigated to 110/55 at 08:20 later the same day.
• HGB 8.2 g/dL reported on 2022-02-28, EPO 5000U weekly could be considered if no contraindiction, until the reading backs to 11 g/dL.

210831

{lowering BP gently}

visiting the patient at around 16:45 on 2021-08-30, he did not complain of discomfort or unwellness these days, however he shared his experience of dizziness and fainting when SBP below 160mmHg since years ago. lowering blood pressure should be in a gentle way.

210830

{Low HGB, HTN, ESRD}

[objective]

• 2021-08-25
  • epoetin beta 5000 unit SC administered (QW3)
• lab data
  • RBC 2.84(8/30), 2.51(8/26), 2.28(8/24)
  • HGB 8.6 (8/30), 7.8 (8/26), 7.0 (8/24)
  • Na 135mmol/L(8/24)
• blood pressure around 200/90 for half week
• current medication including:
  • captopril 25mg PO BID
  • nicorandil 5mg PO HS
  • amlodipine 5mg PO QW2467

[assessment]

• Low HGB
  • EPO worked, RBC and HGB increased gradually, still some gap to normal range.
• hypertenstion
  • drugs act as antihypertensive agents:
    • captopril (angiotensin converting enzyme inhibitor)
    • nicorandil (guanylyl cyclase stimulator; K channel activator)
    • amlodipine (Ca channel blocker)
  • for an ESRD patient, diurectics might not be indicated
  • sodium had fallen to the lower margin of normal range, no need to restrict Na intake.
  • interdialytic BP of <140/80 mmHg could be set an the target
    • there were argues on beta-blockers application to NSTEMI patient, source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5721004/
    • increase dialysis time: the length or frequency of sessions is often effective in reducing target dry weight.

[suggestion]

• keep routine CBC monitoring as usual.
• increase dialysis time might be considered if blood pressure remains high too long.

210826

{bladder cancer with lung mets}

[definite diagnosis]

• 2020-08-17 patho - urethra biopsy
  • urothelial carcinoma, low-grade.
    
  • muscularis propria not present.
    
• 2020-10-16 patho - urinary bladder TUR
  • histologic type: papillary urothelial carcinoma, invasive, with marked squamous differentiation
    
  • histologic grade: high-grade
  • tumor configuration: papillary
    
  • mascularis propria: present
    
  • lymphovascular invasion: not identified
    
  • microscopic tumor extension: tumor invades subepithelial connective tissue
    
  • VENTANA PD-L1 (SP142) assay for urothelial carcinoma: PD-L1 expression <5% IC
    
• 2020-10-29 chest AP
  • extensive consolidation in Rt upper lobe and extensive ground glass opacity over Rt mid and lower lung zones
• 2021-02-19 CT - lung/mediastinum/pleura
  • imp: right middle lobe lung cancer with right lower lobe lung mets is suspected.
• 2021-03-25 chest PA (erect) view
  • extensive opacification and volume reduce and nodular opacities over Rt lung, in progression associated Rt pleural effusion as compared with previous image
  • obliteration of Rt main bronchus
  • small nodular opacities over left lung
• 2021-04-16 bronchoscopy
  • autofluorescence: abnormal mucosa over right main bronchus
  • right main bronchus: total occlusion by tomor s/p biopsy for 1 specimen with mild bloody oozing s/p epinephrin 0.5 amp local spray
  • EBUS: endobronchial tumor over right main bronchus.
• 2021-04-21 patho - bronchus biopsy
  • sections show solid sheets of hyperchromatic tumor cells in a fibrotic stroma. keratinization is focally seen.
  • IHC stains CK5/6(+), p63(+), GATA3(+), TTF-1(-), and CD56(-). the results are consistent with metastatic urothelial carcinoma.
• 2021-04-22 bronchoscopy
  • right main residual endobronchial tumors s/p electrocautery.
  • RUL and right intermediate bronchus endobronchial tumors, cannot be approached.

[treatment]

• 2020-11-24, -12-01, -12-08: doxorubicin
• 2020-12-15: cisplatin
• 2020-12-22, -12-29: doxorubicin
• 2021-05-11 up to now: doxorubicin + carboplatin, palliative

[assessment]

• this is an ESRD patient on hemodialysis with multiple comorbidities.
• chemo drug dosing - source: https://pubmed.ncbi.nlm.nih.gov/30942181/
  • doxorubicin:
    • hemodialysis: consider administering 75% of the original dose.
  • carboplatin:
    • hemodialysis: carboplatin dose (mg) = target AUC x 25; administer on a nondialysis day, hemodialysis should occur between 12 to 24 hours after carboplatin dose.
• hypochromemia
  • HGB 7.8g/dL reported on 2021-08-26 remains low for now.
  • epoetin beta 5000 unit SC QW3 prescribed since 2021-08-24.
• not received chemo yet since this hospitalization.

[suggestion]

• drugs prescribed for NSTEMI found in PharmCloud, refilled items listed as following, might be set as patient-carried ones into active medication if no contraindication…
  • famotidine 20mg QD
  • clopidogrel 75mg QD
  • aspirin 100mg QD
  • amiodarone QD
  • nitroglycerin ASORDER
  • nicorandil 5mg HS
  • amlodipine 5mg ASORDER
  • atorvastatin 20mg QD

700105459

220223

{SCC of tongue, cT4N1M0, s/p total glossectomy, right mandibular osteotomy, right marginal mandibulectomy, selective neck dissection, wide excision of malignant left lower gum SCC and marginal mandibulectomy, teeth extraction of #46, tracheotomy and free flap reconstruction}

[objective]

• exam findings
  • 2022-02-10 CT - Lung/Mediastinum/Pleura
    • Impression: Bilateral lung meta, in progression.
    • S/p tracheal tube placement with its tip in place.
    • S/P NG tube placement.
  • 2021-10-25 Chect PA (Erect) view
    • Few nodular opacity projecting in the right upper and left lower lung is noted.
  • 2021-10-22 CT - Lung/Mediastinum/Pleura
    • Right upper lobe and left lower lobe lung meta.
    • Recurrent lymphadenopathy at right level II and level III and left parapharyngeal space.
  • 2021-10-19 CT - Neck
    • Status post tracheostomy.
    • Postoperative change in the oral cavity and neck, and post-irradiation change.
    • Suspect tumor recurrence or infection at left parapharyngeal space involving medial pterygoid muscle.
    • Necrotic nodal recurrence at right level II and left level III.
    • RUL nodule (2.1cm), suspect lung metastasis.
  • 2021-10-18 LN aspiration
    • Left neck mass: Positive for malignancy
      • Two wet smears show multiple dysplastic sqaumous cell clusters, compatible with metastatic squamous cell carcinoma.
  • 2021-08-16 Patho - oral cancer (wide excision + lymph node)
    • pathologic diagnosis
      • Tongue, total glossectomy - Moderately differentiated squamous cell carcinoma
      • Oral cavity, right retromolar region, right marginal mandibulectomy - Moderately differentiated squamous cell carcinoma
      • Oral cavity, left mandible region, wide excision - Severe dysplasia with ulcer
      • Pathology stage: pT4a(m)N0(if cM0); AJCC stage IVA
  • 2021-08-03 PET
    • Glucose hypermetabolism in the left aspect of the tonge with invasion to the mouth floor and left aspect of soft palate, compatible with malignancy involving these regions.
    • Glucose hypermetabolism in the some left neck level II, left submandibular and left level IV lymph nodes, compatible with metastatic lymph nodes.
    • Mild glucose hypermetabolism in some right neck level II and right submandibular lymph nodes. The nature is to be determined (inflammatory process? other nature?).
    • Glucose hypermetabolism in a focal area in the right aspect of mandible. The nature is to be determined (dental problem? other nature?).
    • Glucose hypermetabolism in the right shoulder and in the right pulmonary hilar region, compatible with inflammatory process.
  • 2021-08-02 Patho - Gingival/oral mucosa biopsy
    • Labeled as “left lateral tongue”, biopsy - squamous cell carcinoma.
    • IHC: P16(-, 0%); p40(+).
• lab data
  • SCC
    • 2022-02-08 5.7ng/mL
    • 2021-08-04 6.1
    • 2021-08-03 5.8
• surgical operation
  • 2021-08-13
    • Total glossectomy
    • R mandibular osteotomy
    • R marginal mandibulectomy
    • Selective neck dissection
    • Wide excision of malignant L lower gum SCC+ marginal mandibulectomy
    • Extraction of #46 (at anterior margin of skip L lower gum SCC)
    • Tracheotomy
    • Free left anterolateral thigh flap resurfacing to the intra-oral defect
    • Open reduction of mandible and internal fixation with reconstruction plates
• radiotherapy
  • 2021-10-04 ~ 2021-11-22: bil. neck 50Gy/25fx. The tongue preOP tumor site: 66Gy/33fx. The gross LAPs: 70Gy/35fx
• chemotherapy
  • 2022-02-03 ~ ongoing: 5-Fu + cisplatin + cetuximab, biweekly
  • 2021-10-27 ~ 2021-11-22: cisplatin weekly

700509991

220215

{gastric cancer, stage IIA, extra-capsular spread (ECS) positive}

[objective]

• exam findings
  • 2021-12-24 Patho - stomach subtotal/total (tumor)
    • Diagnosis - Tumor, stomach, subtotal gastrectomy - Adenocarcinoma
    • AJCC Pathologic staging - pT2N1, if cM0, stage IIA
  • 2021-12-20 Patho - stomach biopsy
    • Diagnosis
      • Stomach, antrum GC side, s/p biopsy (A) - Adenocarcinoma.
        • IHC: Her2/neu: negative (score=1+).
      • Stomach, prepyloric antrum, s/p biopsy (B) - low grade dysplasia.
  • 2021-12-18 CT - abdomen, gastric filling with water
    • Gastric carcinoma
      • T2N1M0, stage IIA
• surgical operation
  • 2021-12-23 radical subtotal gastrectomy with D2 lymph nodes dissection.
• treatment
  • post-Op adjuvant CCRT with 5-FU 24 hr QD x 5 per wk x 6 plus R/T on 2022-02-14.

[assessment]

• several targeted therapeutic agents, trastuzumab, pembrolizumab/nivolumab, and entrectinib/larotrectinib have been approved by the FDA for use in gastric cancer.
  • trastuzumab is based on testing for HER2 overexpression.
  • pembrolizumab/nivolumab are based on testing for MSI by PCR or NGS/MMR by IHC, PD-L1 immunohistochemical expression, or high tumor mutational burden (TMB) by NGS.
  • FDA granted approval for the use of select TRK inhibitors for NTRK gene fusion-positive solid tumors.
• when limited tissue is available for testing, or the patient is unable to undergo a traditional biopsy, sequential testing of single biomarkers or use of limited molecular diagnostic panels may quickly exhaust the sample. in these scenarios, comprehensive genomic profiling via a validated NGS assay performed in a CLIA-approved laboratory may be used for the identification of HER2 amplification, MSI status, MMR deficiency, TMB, and NTRK gene fusions. the use of IHC/ISH/targeted PCR should be considered first followed by additional NGS testing as appropriate.
• no drug allergy recorded in database, no issue found with current medication.

700926086

220215

[objective]

• Exam findings
  • 2022-02-11 CT
    • Prior CT identified few small LNs at para-aortic space and bil. inguinal regions show stationary.
  • 2021-11-08 MRI
    • Cervical spondylosis with diffuse spinal canal stenosis, cord compression and neuroforaminal narrowing, esp C3-4 with compressive myelopathy.
  • 2021-10-29 PET
    • Lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm and bone marrow may show this picture (stage IV).
    • Increased FDG uptake in the soft tissues around bilateral hips. Inflammation is more likely.
  • 2021-10-20 Patho - bone marrow biopsy
    • Diagnosis
      • Bone marrow, iliac, biopsy — Lymphoma, B cell type
      • IHC:
        • CD3 and CD20: a predominant small sized B lymphoid cells subpopulation;
        • CD138: 50%;
        • kappa and lambda: approximately 2:1.
        • bcl-2 (+, 90%) bcl-6 (-) (of the nucleated cells).
        • Serum immunoglobin levels show evelated both IgG and IgM levels.
        • KI-67: marked variation from areas to areas ranging 5% to 60% and averaing 20% to 25%.
    • Microscopic
      • Section shows piece(s) of bone marrow with 100 % cellularity a mixed small lymphocytes subpopulation and plasmacytoid cell subpupulation.
      • The bone marrow findings in conjunction with serum immunoglbulin levels is suggestive of B cell lymphoma, small B cell type, or lymphoplasmacytoid cell type. Probably a polyclonal Waldemstrom-like lymphoma.
  • 2021-07-24 CT
    • Minimal opacity over B6 (superior segment) of right lower lobe, right middle lobe, and left upper lobe is found.
    • Small lymph nodes at bilateral axillary, supraclavicular and abdominal paraaortic region.
  • 2020-10-23 MRA - Brain
    • Mild general brain atrophy. Subcortiacl arteriosclerotic encephalopathy.
  • 2020-10-05 Clinical Dementia Rating (CDR)
    • Score 1
  • 2020-09-19 CT
    • Small LNs at retroperitoneum, bil. axillary and bil. inguinal regions.
  • 2020-09-01 Patho - bone marrow biopsy
    • Diagnosis
      • Bone marrow, iliac, biopsy - Proliferation of lymphoplasmacytic cells.
      • IHC:
        • CD20 (80-90%);
        • CD138 (weak intensity, approximately 50%);
        • kappa and lambda: no predominant subpopulation.
        • CD3: <10%. (of the nucleated cells).
      • The possibility of lymphoplasmycitc lymphoma/ Waldenström macroglobulinemia (WM) cannot be excluded.
    • Microscopic
      • Section shows one piece of bone marrow with 90% cellularity and M:E ratio of approximately 5:1.
      • Three cell lineages are present with a predominant of leukocytes.
• Chemotherapy
  • 2021-11-16 ~ up to now: R-CVP (rituximab, cyclophosphamide, vincristine, prednisone)

[assessment]

• the most updated NCCN clinical practice guidelines for B-Cell Lymphomas (evidence blocks, version 5.2021 - Sep 22, 2021) suggests small cell testing panel: CD5, CD10, CD21, CD23, cyclin D1, BCL2, BCL6, Ki-67, CD11c, CD25, CD103 for differential diagnosis. not all items found in patho records.
• lab data reported on 2022-02-14 revealed no abnormality of liver and kidney functions.
• CT on 2022-02-11 showed stable LNs at para-aortic space and bil. inguinal regions.
• involved-site RT (ISRT) might not be indicated for the stage IV disease.
• the patient is on R-CVP regimen which is recommend in the guidelines. R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) might be an alternative.
• no drug allergy recorded in database. no issue with current medication.

701349358

220215

[objective]

• exam findings
  • 2021-12-02 Patho - stomach subtotal/total (tumor)
    • stomach, antrum, subtotal gastrectomy - signet-ring cell carcinoma
    • small intestine, duodenum, subtotal gastrectomy - signet-ring cell carcinoma, by direct invasion
    • omentum, omentectomy - negative for malignancy
    • lymph node - signet-ring cell carcinoma, metastatic
    • pT2N3b(if cM0), pStage IIIB
    • gross configuration: for advanced carcinoma (Borrmann classification): Type III
      • ulcerated with poorly defined infiltrative margins
    • histologic type: adenocarcinoma, Lauren classification of adenocarcinoma: diffuse type
    • histologic grade: G3 - poorly differentiated, undifferentiated
    • tumor extension: tumor invades the muscularis propria
    • lymphovascular Invasion, perineural invasion, intestinal metaplasia, high-grade dysplasia, polyps: absent
  • 2021-11-30 Patho - stomach biopsy
    • stomach, antrum, biopsy — signet-ring cell carcinoma
      
    • IHC: CK(+), Her-2/neu (Ab)(-).
      
  • 2021-11-30 Esophagogastroduodenoscopy
    • highly suspected gastric cancer, antrum, Borrmann type 3, sp biopsy
  • 2021-11-29 CT - abdomen gastric filling with water
    • T2N2M0, stage IIA
• radiotherapy
  • 2022-02 Adjuvant RT to anastomosis and regional lymphatics for 4500cGy/25fx is suggested for locoregional control.
• chemotherapy
  • 2022-02-14 starts 5-FU

700276060

220209

{Thalidomide/Dexamethasone Interaction}

Dexamethasone might enhance the dermatologic adverse effect and/or thrombogenic effect of Thalidomide.

Consider using venous thromboembolism prophylaxis in patients with multiple myeloma who are receiving both thalidomide and dexamethasone, particularly if the patient is newly diagnosed or has other risk factors for thromboembolism. Low-molecular-weight heparin or warfarin (at INR of 2.0-3.0) have been proposed as reasonable prophylactic agents. Regarding the potential dermatologic interaction between thalidomide and dexamethasone, monitor for any evidence of dermatologic events, particularly maculopapular or erythematous rash. If evident, discontinuation of drug therapy or dosage reduction may be required.

701023219

220208

• Lab findings
  • MRI - nasopharynx
    • Right NPC with neck LAPs. T2N3M0 stage IVA.
  • 2021-08-04 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharyngeal carcinoma, non-keratinizing and poorly differentiated
    • IHC: CK(+).
  • 2021-08-04 Nasopharyngoscopy
    • rt np tumor.
  • 2021-07-29 Patho - lymphnode biopsy
    • Labeled as “right neck”, biopsy - Lymph node with round blue cell tumor, metastatic.
    • IHC: CK(+), poorly differentiated carcinoma. EBV(-), p16(-).
    • Please check nasopharynx, oropharynx, supra- and sub-glottis first.
• Surgical operation
  • 2021-08-17 removing an enlarged lymph node over right posterior neck.
• Regimen
  • 2021-11 ~ ongoing Cisplatin + Fluorouracil
  • 2021-08 ~ 2021-10 Cetuximab
• Radiotherapy
  • 2021-08-20 ~ 2021-10-11
    • 5000cGy/25 fractions of the nasopharyngeal to bilateral neck,
    • 6000cGy/30 fractions of the nasopharyngeal tumor and involved nodal,
    • 7000cGy/35 fractions of the reduced nasopharyngeal tumor and involved nodal lesions.

700731496

220128

{possible drug interaction: Dasatinib / Histamine H2 Receptor Antagonists}

[objective]

• current medication includes:
  • Sprycel (Dasatinib 50mg) 1# PO QD
  • Ulstop (Famotidine 20mg) 1# PO BID

[assessment]

• Histamine H2 Receptor Antagonists might decrease the absorption of Dasatinib.
• Coadministration of H2RAs and Dasatinib may reduce dasatinib concentrations and efficacy.
• Dasatinib prescribing information states histamine H2 receptor antagonists (H2RAs) should not be coadministered with dasatinib due to the risk of reduced dasatinib concentrations and efficacy. Given the longer-term acid suppression achieved with H2-antagonist or proton pump inhibitor therapy, the manufacturer suggests the use of antacids (with 2-hour dose separation) if acid-reducing therapy is required.
• The likely mechanism for this apparent interaction is impaired absorption of dasatinib, which does appear to display pH-sensitive solubility, due to the increase in gastric pH caused by a H2-receptor antagonist.
• references:
  • Takahashi N, Miura M, Niioka T, Sawada K. Influence of H2-receptor antagonists and proton pump inhibitors on dasatinib pharmacokinetics in Japanese leukemia patients. Cancer Chemother Pharmacol. 2012;69(4):999-1004.
    • https://pubmed.ncbi.nlm.nih.gov/22147077/
  • Sprycel (dasatinib) [prescribing information]. Princeton, NJ: Bristol-Myers Squibb Company; September 2016.
  • Eley T, Luo FR, Agrawal S, et al. Phase I study of the effect of gastric acid pH modulators on the bioavailability of oral dasatinib in healthy subjects. J Clin Pharmacol. 2009;49(6):700-709.
    • https://pubmed.ncbi.nlm.nih.gov/19395585/
  • Matsuoka A, Takahashi N, Miura M, et al. H2-receptor antagonist influences dasatinib pharmacokinetics in a patient with Philadelphia-positive acute lymphoblastic leukemia. Cancer Chemother Pharmacol. 2012;70(2):351-352.
    • https://pubmed.ncbi.nlm.nih.gov/22678358/
  • Koutake Y, Taniguch J, Yasumori N, et al. Influence of proton pump inhibitors and H2-receptor antagonists on the efficacy and safety of dasatinib in chronic myeloid leukemia patients. Int J Hematol. 2020;111(6):826-832.
    • https://pubmed.ncbi.nlm.nih.gov/32152877/

[suggestion]

• Antacids should be taken 2 hours before or after dasatinib administration if acid-reducing therapy is needed.

701032519

220127

{marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)}

[objective]

• Exams
  • 2022-01-11 Whole body PET scan
    • Mild glucose hypermetabolism in some focal areas in bilateral lung fields. Residual lymphoma should be considered. However, in comparison with the previous study on 2021/08/19, the previous glucose hypermetabolic lesions in bilateral lung fields are either less evident or disappeared.
      
    • Glucose hypermetabolism in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation is more likely.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-01-04 CT - Lung/Mediastinum/Pleura
    • post op change in LUL
    • regression nodular lesions of both lungs as compared with CT on 2021/8/18.
  • 2021-08-20 Patho
    • Bone marrow, iliac, biopsy - Negative for malignancy
      
    • Microscopically, it shows 15% of cellularity, prsence of trilineage cellular component and some megakaryocytes.
    • IHC: CD20(-), CD34(-), CD117(-), CD3(-), CD138(-), MPO(+), CD71(+).
  • 2021-08-19 Whole body PET scan
    • Glucose hypermetabolism in multiple focal areas in bilateral lung fields, compatible with lymphoma.
    • Glucose hypermetabolism in some mediastinal lymph nodes. The nature is to be determined (inflammation? other nature?).
    • Increased FDG accumulation in the left neck muscle, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2021-08-18 CT - ABD - whole abdomen, pelvis
    • Lymphoma s/p treatment show partial response.
  • 2021-07-26 Patho
    • Lung, right upper lobe, CT-guide biopsy - Extranodal marginal zone lymphoma of MALT type with amyloidosis
    • The immunohistochemical analysis shows that these cells are positive for CD20, bcl-2, and CD43, and negative for CD3, BCL6, and CD23. CD138 highlights increased plasma cells, but kappa and lambda are inconclusive. CD68 is positive for the foreign-body giant cells. CK highlights lymphoepithelial lesions.
      
    • Taken together, extranodal marginal zone lymphoma of MALT type with amyloidosis is considered.
      
  • 2020-10-13 Patho
    • Lung, RUL, CT-guide biopsy - interstitial fibrosis and lymphoplasma cells infiltration
      
    • The immunohistochemical stains of CD3, CD20, CD138, and Ki-67 show mixed lymphoid and plasma cells population with lymphoid follicles.
    • The immunohistochemical stain of CK reveals no invasive tumor. No amyloid deposition is seen.
• Surgery
  • 2019-12-30
    • One nodular lesion was noted over left apex of LUL, another one nodule was noted over LUL, size about 0.8cm and 1.5 cm.
    • Frozen section: benign lesion.
• Regimen
  • 2021-08 ~ ongoing R-CVP (R-COP)
    • Rituximab 375mg/m2 IV D1
    • Cyclophosphamide 750mg/m2 IV D1
    • Vincristine 1.4mg/m2 IV D1
    • Prednisone 40mg/m2 PO D1-5
    • repeat every 21 days for a max of 8 cycles

[assessment]

• This 80-year-old male patient was diagosed with extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) 2021 summer, being receiving R-CVP since 2021-08 and partial response was seen in early Jan 2022 based on CT and PET images.
• R-CHOP, R-CVP (which is being usd now), Bendamustine + Rituximab, are candidate regimen as first-line therapy. no issue with current regimen.
• Consolidation with rituximab 375mg/m2 one dose every 8~12wk for up to 24 mo could be an optional extended therapy for future consideration.

220110

COPD is listed as one of the diagnoses (but not in current problem list) in this hospitalization, however no corresponding medication prescribed yet.

Some bronchodilators such as beta agonists, antimuscarinic agents, or methylxanthines might be considered later after other acute symptoms mitigated.

700506064

220126

[objective]

• Lab findings
  • 2021-11-09 Patho
    • Diagnosis
      • Ovary, bilateral, debulking surgery - Residual high grade serous carcinoma
      • Fallopian tube, bilateral, ditto - High grade serous carcinoma
      • Endometrium, uterus, ditto - Free from tumor, endometrial polyp
      • Myometrium, uterus, ditto - Tumor invasion, focal
      • Tumor on bladder, ditto - Tumor present
        
      • Tumor on rectum, ditto - Tumor present
        
      • Lymph node, L’t iliac artery, dissection - Tumor metastasis (1/4) without extracapsular extension (0/1)
      • Lymph node, R’t iliac artery, ditto - Tumor metastasis (1/3) without extracapsular extension (0/1)
      • Lymph node, R’t obturator nerve, ditto - Tumor metastasis (1/6) without extracapsular extension (0/1)
      • AJCC Pathologic staging: ypT3cN1a, if cM0; stage IIIC
        
    • Microscopic Exam
      • Histologic type: high-grade serous carcinoma (refer to S2021-05715)
      • Histologic grade: high grade
      • Contralateral ovary involvement: present
        
      • Tumor side ovarian surface involvement: present
        
      • Contralateral ovary involvement: present
        
      • Right tube involvement: present
        
      • Left tube involvement: present
        
      • Right adnexa soft tissue involvement: present
        
      • Left adnexa soft tissue involvement: present
        
      • Uterine serosa involvement: present
        
      • Endometrium involvement: absent, endometrial polyp
        
      • Myometrium involvement: present, focal
        
      • Lymph nodes metastasis: tumor metastasis (3/19) without extracapsular extension (0/3) in total number
      • Lymphovascular space invasion: present
        
      • Tumor on bladder: high grade serous carcinoma with necrosis and microcalcification
      • Tumor on rectum: high grade serous carcinoma with necrosis and microcalcification
  • 2021-04-15 Patho
    • Diagnosis
      • Peritoneum, debulking -Metastatic serous carcinoma, compatible with fallopian tube or ovarian origin - Microscopic Exam
      • The sections show metastatic serous carcinoma, high grade, compatible with fallopian tube or ovarian origin, composed of nests of pleomorphic neoplastic cells with numerous mitotic figures, arranged in solid and papillary patterns. Scattered psammoma bodies and tumor necrosis are noted.
      • IHC: ER(+), WT1(+), PAX8 (+), p53(+ with aberrant expression).
        
  • 2021-04-14 Ascites
    • Smears show clusters of pleomorphic tumor cells. Malignancy is favored.
  • 2021-04-14 Frozen Section
    • Peritoneal tumor, frozen section - Malignant, favor serous carcinoma.
• Treatments
  • 2021-05 ~ 2021-09 - Paclitaxel + Carboplatin
  • 2021-09 ~ 2021-10 - Paclitaxel
  • 2021-11 ~ 2021-11 - Liposome Doxorubicin + Carboplatin
  • 2021-12 ~ ongoing - Paclitaxel + Carboplatin

[assessment]

• Paclitaxel + Carboplatin is preferred as an primary systemic therapy regimen for high-grade serous stage II-IV disease.
• Albumin-bound paclitaxel could be substituted for patients experiencing a hypersensitivity reaction to paclitaxel.
• Bevacizumab (or its biosimilar) might be an optional component to the aforementioned regimen.
• for elderly patients and/or those with comorbidities and/or intolerence, the following adjustment might be considered.
  • paclitaxel 60mg/m2 IV over 1 hour followed by carboplatin AUC 2 IV over 30 minutes
  • days 1, 8, 15; repeat every 21 days
• no issue found in active medication.

700560024

220125

{marginal zone lymphomas}

[objective]

• lab findings
  • 2021-09-14 CT - Lung/Mediastinum/Pleura
    • Impression: lymphadenopathy in the axillary and abdominal regions, involving both sides of diaphgrams.
  • 2021-09-07 Patho - lymphnode biopsy
    • Lymph node, axillary, left, biopsy - Small B-cell lymphoma, compatible with marginal zone lymphoma.
      • Immunophenotyping: CK(-), CD3(-), CD20(+), CD5(-), CD23(+), CD43(-), CD10(-/+), Cycline D1(-).
  • 2020-11-20 Patho
    • Stomach, antrum, PW, biopsy - Suspicious lymphoid infiltrate, probably extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) with Helicobacter pylori infection.
      • IHC, the small lymphoid cells: CD3(-), CD20(+), BCL2(+), CD5(-), CD10(-), and CD43(-).
    • Stomach, low body, GC side, biopsy - Suspicious lymphoid infiltrate, probably extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) with Helicobacter pylori infection.
      • IHC, the small lymphoid cells: CD3(-), CD20(+), BCL2(+), CD5(-), CD10(-), and CD43(-).
• treatment
  • 2021-10 ~ ongoing - R-CHOP

[assessment]

• first-line therapy regimens for marginal zone lymphomas could be:
  • CHOP(cyclophosphamide, doxorubicin, vincristine, prednisone) + Rituximab
  • CVP(cyclophosphamide, vincristine, prednisone) + Rituximab
  • Bendamustine + Rituximab
• the patient is receiving R-CHOP without much intolerance.
• no issue with current medication.

700149178

220124

This 92-year-old woman diagnosed by NTUH in 2021 Dec wtih advanced ascending colon cancer with lung, paraaortic LN, peritoneal carcinomatosis, cT4aN2bM1c, stage IVC.

Take into account of the patient’s age, intensive therapy might not be most appropriate, a vanilla regimen like FOLFOX could be a candidate for systematic treatment.

KRAS, NRAS, BRAF, HER2, MSI/MMR, NTRK fusion, dihydropyrimidine dehydrogenase test might be ordered optionally if related data from NTHU is not anticipated.

700191057

220124

{lung cancer with bone and brain metastasis}

[lab data]

• PD-L1(28-8) 2021-04-08 TC < 1%
• ROS1 2021-03-24 not detected
• PD-L1(22C3) 2021-03-22 TPS < 1%
• EGFR 2021-03-19 G719X not detected
• EGFR 2021-03-19 Exon19 deletion not detected
• EGFR 2021-03-19 S768I not detected
• EGFR 2021-03-19 T790M not detected
• EGFR 2021-03-19 Exon20 insertion not detected
• EGFR 2021-03-19 L858R not detected
• EGFR 2021-03-19 L861Q not detected
• ALK IHC 2021-03-18 negative

[exam findings] (not completed)

• 2023-05-04 MRI - brain
  • Known a case of lung cancer with brain metastasis. As compared with prior MRI (2023/03/08), disseminated leptomeningeal metastasis of whole cerebrum. Metastatic lesions over cerebellum and both temporal lobes are in worse condition.
  • Severe paranasal sinusitis.
  • Left mastoiditis.
• 2023-05-02 CXR
  • Atherosclerotic change of aortic arch
  • Diffuse Bony metastases.
• 2023-03-14 MRI - C-spine
  • Several mass lesions within C4, C5, C6 and T1 vertebral bodies, compatible with metastases.
  • No actual disk protrusion or cord compression.
  • The cervical spinal cord shows normal size and signal intensity without evidence of compressive edema, ischemia or myelomalacia. There is no extrinsic compresson of the cord.
  • The neural foramina of the cervical spine are patent. No impingement is seen.
• 2023-03-09 CT - chest
  • Indication: Lung cancer with bone and brain mets
  • Chest CT with and without IV contrast ehnancement shows:
    • s/p left upper lobe op.
    • Minimal atelectatic change at bilateral lower lobes is found.
    • S/p port-A placement with its tip at Superior vena cava
    • Non-specific lymph nodes are found at bilateral paratracheal region.
    • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • s/p cholecystectomy.
  • Imp:
    • s/p left upper lobe op.
    • Diffuse bone meta.
    • Non-specific lymph nodes at bilateral paratracheal region.
• 2023-03-08 MRI - brain
  • r/o leptomeningeal metastasis in the bilateral posterior cranial fossa.
• 2023-03-01 Tc-99m MDP bone scan
  • In comparison with the previous study on 2022-12-05, all of above-mentioned bone lesions are old and show stationary or less evident, and no new lesion of increased tracer uptake is noted in this study, indicating metastatic bone disease with partial response to current therapy.

[immunochemotherapy]

• 2022-01-21 ~ ongoing
  • Nivolumab + Ipilimumab + Pemetrexed + Carboplatin
    • Nivolumab 3mg/kg D1 Q3W
    • Ipilimumab 1mg/kg D1 Q6W
    • Pemetrexed 500mg/m2 D1 Q3W*2cycles
    • Carboplatin AUC 5~6 D1 Q3W*2cycles
• 2021-10-22 ~ 2022-01-04
  • Nivolumab + Ipilimumab
    • Nivolumab 3mg/kg D1 Q3W
    • Ipilimumab 1mg/kg D1 Q6W
• 2021-03-25 ~ 2021-10-21
  • Gefitinib 250mg QD

[consultation]

• 2021-02-17 Hemato-Oncology
  • Q
    • for suspect multiple myeloma, metastases
    • This 49-year-old female was Dx (1) Leukocytosis, suspect intra abdominal infection (2) Suspect multiple myeloma, metastases (3) Hypertension (4) Fracture of 7th ribs in 2020-12. This time, she was admission because bilateral lower leg edema for two days. She complained for lower back pain while mobile and right back sorenss for 3 months and subside while lying down. She has suffered from fracture of left 7th rib and right little toe pain and local redness. According to the patient, she has visited Ortho OPD and Rheumatology OPD for the recurrent multiple joint pain. She came to our ER. CT image revealed retroversion of uterus with tumors (up to 6.3cm) suspected myomas and Multiple osteolytic lesions at bony structures. DDX: multiple myeloma, metastases. Please evaluation her condition by your expertise. Thank you very much.
  • A
    • Patient examined and Chart reviewed. A case of multiple bony destruction is noted. I am consulted for the possible etiolgy.
    • My suggestions:
      • Complete CT scan work-up e.g., Chest CT, to rule out CEA-elevated lung cancer or CEA/CA153-elevated breast cancer
      • Please survey breast conditin, using breast sono and/or mammography to rule out CEA/CA153-elevated breast cancer
      • Please check Protein EP/IFE, kappa/lambda chain to rule out myelopma or light chain disease
      • Please perform EGD and colonoscopy to rule out CEA-elevated GI cancer
      • If no clue from the afroementioned examinations, bone marrow biopsy is mandatory.

==========

2022-01-24

• pembrolizumab is approved for NSCLC with PD-L1 expression levels ≥ 1%, it is not the case here.
• for NSCLC with no specific mutations, if progression on PD-1/PD-L1 inh, using a PD-1/PD-L1 inh might not be recommended.
• there is no issue found in current medication.

700974194

220124

{drug identification}

requesting drug identification for 6 items.

the 4 identified items has been shown as following while the other 2 items still remain unknown: - Megajohn - megestrol 160mg - Kentamin - thiamine 50mg, pyridoxine 50mg, cyanocobalamin 500mcg - Romicon-A - lysozyme 20mg, dextromethorphan 20mg, cresolsulfonate 90mg - Olmetec - olmesartan medoxomil 20mg

these drugs will be sent back to ward by an in-hospital porter.

701358139

220124

[objective]

This is a patient diagnosed by TSGH with poorly differential gastric adenocarcinoma with carcinomatosis and metastatic lymphadenopathy and bone metastasis, cT4aN3aM1, stage IV, seeking for second opinion on 2022-01-21.

• Lab readings:
  • 2022-01-22 Urine: Bacteria 2+
  • 2022-01-22 Abdomen - standing diaphragm: Ascites is highly suspected.
  • 2022-01-22 Chest PA - erect view:
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Discoid atelectasis in LLL of the lung is suspected.
  • 2022-01-21 Blood K 3.0mmol
  • 2022-01-21 Blood gas - vein:
    • PO2 65mmHg
    • O2 Saturation 92%
• Medication
  • fluid balance, hypokalemia
    • NAKO No.5
    • KCl inj
    • Radi-K
    • Spironolactone

[Assessment]

• Empirical ABX might be considered if applicable based on symptoms prior to culture outcome.
• The following tests could be optionally ordered for future therapy choice if no related data gathered from TSGH.
  • Microsatellite Instability (MSI) or Mismatch Repair (MMR)
  • PD-L1
  • HER2, high tumor mutation burden, NTRK gene fusion
• Mirabegron (beta-3 agonist) might diminish the antihypertensive effect of Doxazosin (alpha-1 blocker).
• The mirabegron prescribing information reports dose-dependent increases in blood pressure with use. In healthy volunteers mirabegron (at doses of up to 50 mg) produced mean maximum increases in systolic/diastolic blood pressure of 3.5/1.5 mm Hg versus placebo. However, in overactive bladder (OAB) patients, including those with pre-existing hypertension, receiving a maximum dose of mirabegron 50 mg, the systolic/diastolic blood pressure was only 0.5 to 1 mm Hg greater than placebo. OAB patients infrequently reported worsening of pre-existing hypertension with mirabegron. Both systolic and diastolic blood pressure increases were reversible with the discontinuation of mirabegron.
• Lab data serum potassium 3.0mmol/L reported on 2022-01-24 showed the reading below normal range (3.5~5.1), KCl inj and potassium sparing diuretic Spironolactone have been prescribed.

701164753

220120

• Diagnosis: Splenic flexure colon obstruction and massive ascites suspected carcinomatosis status post T-loop colostomy on 2021-08-27.

• 2021-08-30 Patho - omentum tumor, extensive resection

  • Omentum, frozen section + end transverse colostomy - Metastatic adenocarcinoma.

• 2021-08-25 Patho - colorectal polyp

  • IHC: CK(+), CK7(-), CK20(-), CDX2(+), CD56(-), LCA(-), PSA(-), and AMACR(-).
    • The morphology and immunohistochemical stains are not typical for colonic adenocarcinoma.
    • The CDX2 is positive, in favor of GI tract, pancreas, and biliary tract.
    • The PAS and AMACR are negative, so disfavor prostate origin.
    • The CD56 and LCA are negative, so disfavor neuroendocrine tumor and lymphoma.
    • Please correlate with the clinical presentaion, and image study, such as PET or gastroscope, for tumor origin.

• Medication

  • 2021-09 ~ gogoing - FOLFIRI (plus bevacizumab since 2021-10)

701313105

220120

• Lab
  • 2021-08 Patho - overy tumor
    • IHC: CK7 (+), CK20 (-), p53 (-), Napsin-A(-), WT-1 (-).
• Medication
  • 20210823 ~ ongoing - Paclitaxel, Carboplatin

700042050

220119

[objective]

• lab data:
  • Na 2022-01-18 125mmol/L
  • K 2022-01-18 2.7mmol/L
  • Mg 2022-01-18 1.8mg/dL
  • Free T4
    • 2021-10-15 1.3ng/dL
    • 2021-08-17 0.95ng/dL
  • TSH
    • 2021-10-15 14.46uIU/mL
    • 2021-08-17 0.117uIU/mL
• medication
  • Radi-K (potassium gluconate)
  • MgO
  • Eltroxin (levothyroxine)

[assessment, suggestion]

• In addition to current Radi-K administration, the low serum K might be induced by low serum Mg, bioavailability of Mg from oral MgO is around 5~10%, MgSO4 Inj might be considered to pump up serum Mg more rapidly.
• Last thyroid hormone related lab records were taken more than 3 months ago, there is no updated data to follow up the hyped TSH, which could be ordered if no contraindication.

700073358

220119

• no drug allergy recorded in database.

• CBC reported on 2022-01-18 showed items below normal ranges:

  • WBC 2.96*10^3/uL
  • RBC 3.47*10^6/uL
  • HGB 11.8g/dL

• no liver or kidney dysfuncion shown in recent lab data.

• the drugs prescribed at neurology OPD have been included in active medication, no issue found.

701011322

220119

• CBC reported on 2022-01-18 showed items below normal ranges:

  • WBC 3.17*10^3/uL (Neutrophil 65%)
  • RBC 3.27*10^6/uL
  • HGB 8.6g/dL
  • PLT 73*10^3/uL

• no drug allergy recorded in database.

• no liver or kidney dysfuncion shown in recent lab data based on AST, ALT, BUN, Creatinine, eGFR.

• no issue found in active medication.

700145757

220118

[objective]

Lab data - Free T4 - 2022-01-14 2.26ng/dL (normal 0.58~1.35) - 2021-10-05 1.94ng/dL - TSH - 2022-01-14 0.027uIU/mL (normal 0.38~5.33) - 2021-10-05 <0.005uIU/mL

PE - body weight - 2022-01-14 65kgw - 2022-01-09 68kgw

Medication - Eltroxin (levothyroxine 50mcg/tab) #1 BIDAC

[assessment]

• The patient is diagnosed with nontoxic goiter.
• Thyroid dysfunction - If the goiter is due to Hashimoto’s thyroiditis or severe iodine deficiency, patients may have symptoms of hypothyroidism (eg, fatigue, constipation, cold intolerance). If due to multinodular goiter (with autonomy) or Graves’ disease, patients may have symptoms of hyperthyroidism (eg, palpitations, dyspnea on exertion, unexplained weight loss).
• Low TSH, high free T4, weight loss reported.

[suggestion]

• Eltroxin tapered to QDAC or Q2DAC and then test TSH, free T4 one week later to check the trend.

700712820

220112

{hyponatremia, hypoosmolality}

[objective]

• lab data
  • 2022-01-12 blood osmolality 254mOsm/Kg (normal 275~295)
  • 2022-01-12 blood sodium 119mmol/L (normal 136-145)
• body weight
  • 2022-01-11 54kgw
  • 2022-01-04 58kgw
• medication
  • 3% NaCl 300mL IVD QD
  • Saline 0.9% 500mL IVD QD

[assessment]

• body weight decreased 4kgw within a week might hint some kind of volume depletion.
• solute repletion with administering 0.9% and 3% NaCl as of 2022-01-12.
• reference: https://sci-hub.se/10.1016/S0889-8529(03)00004-5

[suggestion]

• no issue found in current medication.
• recheck serum sodium as regular until problem solved.
• might need to evaluate etiology of depletion hypoosmolality.

220111

• 2022-01-11 CT: Brain
  • Imp: Brain atrophy with bilateral periventricular ischemic/aging white matter change.
• 2021-10-27 MRA: Brain
  • Imp: Brain metastases. General brain atrophy. Hydrocephalus. Leukoaraiosis.
• 2021-08-17 Tc-99m MDP whole body bone scan
  • The scintigraphic findings suggest multiple bone metastases.
• 2021-08-16 PD-L1 (SP142)
  • Tumor type: formalin fixed paraffin embedded tissue block - peritoneal and omental tumor (lung adenocarcinoma metastasis)
    
  • Adequate tumor cells present (>=50 viable tumor cells): Yes
  • Result
    • Tumor cell (TC) staining assessment:
      • TC category: TC < 1%
        
      • Percentage of PD-L1 expressing tumor cells (%TC): 0%
        
    • Tumor-infiltrating immune cell (IC) staining assessment:
      • IC category: IC < 1%
        
      • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 0%
        
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
• 2021-08-11 Pathology - peritoneum biopsy
  • Labeled as “diffuse seeding tumor over peritoneum and omentum”, biopsy — adenocarcinoma.
  • IHC stains:
    • CK7 (+), CK20 (-): disfavor gastrointestinal origin;
    • PAX-8 (-), WT-1 (-): disfavor ovarian origin;
    • TTF-1 (+): comaptible with pulmonanry origin.
• 2021-08-10 Cell block - 50 cc orange cloudy pleural effusion
  • The smears and cell block show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with pulmonary adenocarcinoma.
• 2021-08-09 Surgery - laparoscopic peritoneal tumor biopsy
  • Finding: multiple seeding tumors over liver surface, omentum, peritoneum, and mesentary

210824

[initial presentation]

• 2021-01-22 left back pain for 1 year -> congenital spondylolisthesis
• 2021-07-09 left flank region pain in recent days, AZ covid-19 vaccination on 2021-06-21.
• 2021-07-16 remained abdominal pain, multiple, no obvious tenderness, migratory abdominal pain, radiating to perineum region on left, tingling sensation.

[definite diagnosis & disease extent]

• 2021-07-16 CT - whole abdomen, pelvis:
  • carcinomatosis is suspected.
  • metastases on both hepatic lobes are suspected.
  • tumor seeding in left CP angle pleura is suspected.
    • lung cancer 1.7 cm in LLL of the lung is suspected.
• 2021-07-20 abdominal ultrasound:
  • hepatic tumor, multiple, probably metastatic tumor
  • dilated CBD, ascites, left pleural effusion
• 2021-07-22 CT - lung/mediastinum/pleura
  • left upper lobe tumor, suspected lung cancer T2N2Mx
  • cancerous peritonitis and liver mets, suspected GI origin.
• 2021-07-22 lab:
  • AFP 4.4 ng/mL WNL
  • CEA 107ng/mL > ULN
  • CA125 474U/mL > ULN
  • CA199 65U/mL > ULN
  • CA153 114U/mL > ULN
  • SCC 1.1ng/mL WNL
• 2021-07-23 cytology - ascites:
  • abundant high-grade atypical cells with nuclear hyperchromasia, pleomorphism and prominent nucleoli.
• 2021-07-26 colonoscopy:
  • colon polyp, suspected adenoma, ascending colon, s/p cold snare polypectomy.
  • diverticula, cecum and ascending colon.

[plan & treatment]

[effect & side effect]

[ongoing problem]

700527901

220111

{Diffuse Large B Cell Lymphoma}

[objective]

• MRI reported on 2021-12-28
  • Tonsillar fossa, 2cm < size < 4cm, no regional nodal metastasis, T2N0M0
• patho reported on 2021-12-30 - right tonsil biopsy
  • Diagnosis: diffuse large B cell lymphoma
  • IHC: CD20(+), CD3(-), CD10(-), CD30(-), CK(-), Bcl-2(+), Bcl-6(+, focal), C-MYC(+, 30-40%), Ki-67 70-80% for tumor
• LDH reported on 2022-01-10 136U/L (normal 140~271)

[assessment]

• B-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (double-/triple-hit lymphoma), elevated LDH not seen, bone marrow and CNS involvement not checked.

[suggestion]

• no drug allergy recorded in database, no issue found in active medication.
• if localized high-grade B-cell lymphomas is confirmed, then consolidative ISRT might be considered.

700766397

220111

CT and MRI on 2022-01-05 suggested possible malignant tumor in the right adrenal gland measuring 8.2 x 10 x 9 cm.

Chromogranin A 918ng/mL, ACTH < 5g/mL

lab data in early Jan 2022 did not backup hyperaldosteronism, hypercortisonlemia (i.e. both in normal range).

hypertenstion and/or tachycardia might have been mitigated by Concor (bisoprolol), higher readings of blood sugar (since mid Dec 2021) might have been reduced by Galvus Met (vildagliptin + metformin), these symptoms could be caused by neuroendocrine tumors.

701273730

220110

{Cancer of Unknown Primary}

• Additional reference
  • Cancer of Unknown Primary: A Review on Clinical Guidelines in the Development and Targeted Management of Patients with the Unknown Primary Site
    • source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820325/pdf/cureus-0011-00000005552.pdf
  • NCCN Clinical Practice Guideline - Occult Primary (Cancer of Unknown Primary [CUP])
    • source: https://www.nccn.org/professionals/physician_gls/pdf/occult_blocks.pdf
  • Cancer of Unknown Primary Site: Real Entity or Misdiagnosed Disease?
    • source: https://sci-hub.se/10.7150/jca.42880
  • Cancer of Unknown Primary Sites: What Radiologists Need to Know and What Oncologists Want to Know
    • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603700/pdf/nihms449402.pdf

701356176

220110

[Objective]

Lab data reported on 2022-01-10 and some prescribed medication: - CRP 9.17mg/dL (normal <1), WBC 166*10^3/uL (normal 3.9~10.6) <= Tapimycin (Piperacillin + Tazobactam) - Blood Uric Acid 16.3mg/dL (normal 4.4~7.6) <= Fasturtec (Rasburicase) - Calcium 4.04 mmol/L (normal 2.2~2.65) <= Miacalcic (Calcitonin) - Magnesium 1.4mg/dL (normal 1.9~2.7) - Triglyceride (TG) 524mg/dL (normal <150), HDL-C 5mg/dL (normal >40) - Benz(BZO) intoxication positive (normal negative)

[Assessment/Suggestion]

• MgO might be considered for hypomagnesemia.
• Flumazenil might be considered for benzodiazepine intoxication.
  • Unable to access PharmaCloud now, might need to find out why intoxication happened.
• Statins might be considered for hypertriglyceridemia later after acute symptoms been controlled.

700404241

220107

[Objective]

• Adenocarcinoma of descending-sigmoid colon with partial obstruction status post laparoscopic left hemicolectomy on 2021-10-13, pT3N1aM0, pStage IIIB.
  • IHC stains: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+) based on colon segmental resection, reported on 2021-10-20.
• Chronic viral hepatitis B without delta-agent.
• Lab data reported on 2022-01-04 showing basically normal readings at CBC, WBC, ALT, AST, bilirubin total, creatinine, eGFR, and slightly elevated BUN 30mg/dL.
• All RAS and BRAF mutation not detected, reported on 2021-11-03.

[Assessment]

• FOLFOX 3-6 mo or CAPEOX 3 mo is preferred as adjuvant treatment for T3N1M0 colon cancer patients. This patient is now on FOLFOX course.
• Nivolumab or Pembrolizumab might not be preferred for this pMMR patient.
• Panitumumab or Cetuximab might be applicable as RAS and BRAF proved wildtype for the left-sided patient.
• HER2, NTKR data not found yet.
• Hepatitis B virus might reactivate in the setting of chemotherapy. Baraclude (Entecavir) has been prescribed.

[Suggestion]

• No issue found in active medication. Keep tracking CEA, CT as regular.

700098157

220106

High Serum glucose 235mg/dL (2022-01-05), Lactic Acid 4.9mmol/L (2022-01-06), NAKO NO.5 500mL IVD BID and Saline 500mL IVD QD are prescribed.

High CRP 13.47mg/dL (2022-01-05), Procalcitonin (PCT) 8.37ng/mL (2022-01-06) suggest (probable bacterial) infectious process with systemic consequences. Tapimycin and Targocid are prescribed.

700127430

220106

Objective:

• Lab data reported on 2021-09-01
  • HBsAg Nonreactive
  • HBsAg Value 0.36 S/CO
  • Anti-HBc Reactive
  • Anti-HBc Value 4.02 S/CO
  • Anti-HBc IgM Nonreactive
  • Anti-HBs >1,000mIU/mL

Assessment:

• Hepatitis B virus might reactivate in the setting of chemotherapy.

Suggestion:

• Baraclude (Entecavir) might be prescribed prior to next chemo-dose.

700753433

211019

{drug identification}

requesting drug identification for 7 items.

the 3 identified items has been shown as following while the other 4 items still remain unknown:

• Utapine F.C. Tablet (quetiapine fumarate 25mg) - bipolar disorder, schizophrenia

• Zoloft F.C. Tablet (sertraline hydrochloride 50mg) - major depressive disorder (unipolar), obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, premenstrual dysphoric disorder, social anxiety disorder

• Anxiedin Tablet (lorazepam 0.5mg) - anxiety

these drugs will be sent back to ward by the in-hospital porter.

700029300

210930

{drug identification}

requesting drug identification for 13 items.

the 9 identified items are listed as following, however, the other 4 items still remain unknown:

• Galvus Met (Metformin HCl 850mg, Vildagliptin 50mg)
• Betmiga (Mirabegron 25mg)
• Avodart (Dutasteride 0.5mg)
• Mequitine (Mequitazine 5mg)
• Co-Tareg (Valsartan 80mg, Hydrochlorothiazide 12.5mg)
• Nonin (Glimepiride 2mg)
• Bokey (Aspirin 100mg)
• Crestor (Rosuvastatin 10mg)
• Levozine (Levocetirizine 5mg)

these drugs will be sent back to ward by the in-hospital porter.

700043762

210928

{potential drug interactions, vitamin supplement}

[objective]

• items listed in active medication including:
  • emetrol (domperidone 10mg/tab) 2 tab PO TIDAC
  • rivotril (clonazepam 0.5mg/tab) 1 tab PO HS
  • keppra (levetiracetam 100mg/ml) 3 ml PO BID
  • calquene (acalabrutinib 100mg) 1 tab PO Q12H
• lab data reported on 2021-09-25
  • gastric juice OB 3+
  • RBC 2.78*10^6/mL
  • HGB 9.8g/dL
  • MCV 101fL

[assessment]

• there are drugs in active medication might have potential interactions:
  • acalabrutinib <> lansoprazole
    • PPI might decrease the serum concentration of acalabrutinib.
    • with the long-lasting effect of PPIs, separation of doses might not eliminate the interaction.
    • acalabrutinib AUC was decreased by 43% when co-administered with the PPI omeprazole (40 mg for 5 days) according to studies of healthy subjects. this decreases in acalabrutinib concentrations might reduce acalabrutinib activity, so the acalabrutinib labeling recommends that if treatment with a gastric acid reducing agent is required, a histamine-2 receptor antagonist (H2RA) or an antacid should be considered, with separation of administration to minimize the likelihood of a significant interaction.
      • reference: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/210259s006s007lbl.pdf
  • clonazepam <> levetiracetam
    • CNS depressants may enhance the adverse/toxic effect of other CNS depressant
• emetrol (domperidone) dosing
  • 10mg x 3 times (max) a day stated in package insert, however, prescirbed daily dose is 60mg.
• suspected GI bleeding
  • somewhat anemia, MCV reading above upper limit of normal.

[suggestion]

• H2 antagonists such as cimetidine (stogamet 300mg/tab, tagamet 200mg/2ml/amp available in stock), famotidine (ulstop 20mg/tab, ulcertin 20mg/2ml/amp available), ranitidine (not available in hospital), nizatidine (not available) could be considered to shift PPI off.
• please monitor for additive CNS-depressant effects whenever two or more CNS depressants are concomitantly used.
• symptoms of domperidone overdosage may include agitation, altered consciousness, convulsions, disorientation, somnolence and extrapyramidal reactions. there is no specific antidote to domperidone, but in the event of overdose, standard symptomatic treatment should be given.
• some vit B12, folic acid might help to increase HGB.

thanks and regards,

700826905

210927

{dedifferentiated liposarcoma}

[tube feeding]

• most oral drugs in active medication are patient-carried for her underlying diseses, all the oral drugs can be administered via NG tube.

[objective]

• 2021-04-22 patho - peritoneum biopsy
  • pathologic diagnosis: compatible with dedifferentiated liposarcoma
  • composed of fascicles of markedly pleomorphic spindle tumor cells embedded in myxoid stroma. subtle lipogenic tumor cells are found. foci of tumor necrosis are present.
  • IHC: CK(-), S100(focal +), CD34(-), smooth muscle actin(-), MDM2 (+), and CDK4(+).

[assessment]

• palbociclib might be considered for the treatment of unresectable dedifferentiated liposarcoma
  • palbociclib, an inhibitor of cyclin-dependent kinases (CDKs) 4 and 6, induced objective tumor response and a favorable PFS of 56% to 66% in patients with CDK-4-amplified, well-differentiated or dedifferentiated liposarcoma in a phase II study.
  • reference: https://pubmed.ncbi.nlm.nih.gov/23569312/
• pembrolizumab demostrated clinical activity in resectable dedifferentiated liposarcoma with a 20% overall response rate in a phase II study.
  • reference: https://pubmed.ncbi.nlm.nih.gov/30249211/

700054780

210920

{mesna compatibility for common solutions}

reply for the consultation from the ward, mesna is compatible with: - D5W (Dextrose 5% in water) - D5NS (Dextrose 5% in sodium chloride 0.9%) - D5W - 1/2 NS (Dextrose 5% in sodium chloride 0.45%) - NS (Normal saline (Sodium chloride 0.9%)) - Lactated Ringer’s Injection

210915

{post IPP meeting following up}

[busulfan inventory]

• the schedule and regimen for PBSCT for the patient was disclosed in the meeting (with his spouse) held on 2021-09-15 10:30 in the ward.
• the estimated total amount of busulfan used in the time table is 12 vials.
  • based on busulfan 60mg/10mL/vial, dose 3.2mg/kg, body weight 64.8kg
  • 4 vials per day for 3 days (2021-09-16, 2021-09-17, 2021-09-18)
  • staff to dispense regimen during weekend are arranged.
  • stock in medicine storeroom has been confirmed enough in quantity.

[preparation and administration precautions]

• busulfan:
  • do not use polycarbonate syringes or polycarbonate filter needles with the drug.
• etoposide:
  • precipitation may be exacerbated at concentrations of 0.4 mg/mL or above.
  • etoposide 400mg/m2 x body surface area 1.79m2 -> amount 716mg.
  • total solution containing 716mg etoposide should be no less than 1790mL.
• mesna administration rate
  • where ifosfamide or cyclophosphamide is used (like this patient) as an iv bolus:
    • mesna is given by intravenous injection over 15-30 minutes at 20% of the simultaneously administered oxazaphosphorine on a weight for weight basis (w/w). the same dose of mesna is repeated after 4 and 8 hours (as listed in the regimen schedule).
      • reference: https://www.medicines.org.uk/emc/product/1838/smpc
      • reference: drug package insert
  • taking a conservative approach as conclusion, 30 minutes should be safe for adult.

[underlying diseases]

• underlying diseases are managed with corresponding medicine without issues.
  • HTN and CAD s/p stent splacement
    • concor (bisoprolol) 2.5mg PO QD
    • norvasc (amlodipine) 2.5mg PO QD
    • tulip (atorvastatin) 10mg PO QOD
  • HBV infected
    • baraclude (entecavir) 0.5mg PO QDAC
  • SLE
    • plaquenil (hydroxychloroquine) 200mg PO QOD

[medical compliance]

• the patient showed somewhat self-assertive in the meeting, pleading with tactful words might be needed to prevent potential undesired events.

700142452

210915

{hypoalbuminemia and proteinuria caused by UTI induced nephrotic syndrome?}

[tube feeding]

• all the oral drugs in active medication can be administered via NG tube.

[objective]

• serum Ca 2.03mmol/L 2021-09-15
• Creatine kinase-MB 25.7ng/mL 2021-09-14
• creatinine 1.67mg/dL 2021-09-14
• albumin 2.8g/dL 2021-09-14
• CRP 4.87mg/dL 2021-09-14
• urine data reported on 2021-09-14
  • PRO 2+
  • OB 2+
  • bacteria 3+

[assessment]

• elevated CKMB reading could mean possible heart muscle damage. (NT-proBNP 7946pg/mL 2020-02-09)
• UTI is treated with Sintrix (Ceftriaxone Na) 1000mg IVD QD since 2021-09-15 for 7 days for now.
• in patients with hypoalbuminemia, total serum calcium concentration will change in parallel to the albumin concentration and may not accurately reflect the physiologically important ionized (or free) calcium concentration.

[suggestion]

• heart condition might be followed up if no other considerations.
• first priority might be to mitigate UTI, please keep current medication and monitoring the effects routinely as usual.
• urine culture might be of help to choose more adequate antimicrobial in the coming days.

701331484

210914

[tube feeding]

• all the oral drugs in active medication can be administered with NG tube.

[iron supplement]

• foliromin is prescribed.
  
• coadministration ferrous suppement with vit. C would somewhat increase iron intake.
  • source
    • https://pubmed.ncbi.nlm.nih.gov/2507689/
    • https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772395

700842358

210913

[drug interaction]

• total 22 items in active medication (indlucing 3 in-hospital prescribed and 19 patient-carried drugs) have been reviewed without combinations to be avoided.

[objective]

• CKD stage 3 management at Shuang Ho Hospital
• patient-carried drug Furide (furosemide) 40mg QD listed in active medication.
• lab data reported on 2021-09-13 showed readings above normal limits
  • creatinine 4.83mg/dL
  • eGFR 12.58
  • BUN 78mg/dL
  • Bil T 15.42mg/dL
  • Bil D 8.89mg/dL
  • Alkaline phosphatase 243IU/L
• serum electrolytes Na, K reported on 2021-09-13 showed normal.
• relatively low blood pressure recorded on 2021-09-11, -09-12

[assessment]

• this patient’s liver and kidney functions are somewhat impaired.
• furosemide
  • for a patient with eGFR <= 30 mL/minute/1.73m2, higher doses may be required to achieve desired diuretic response due to decreased secretion into the tubular fluid. however, single doses >160 to 200 mg are unlikely to result in additional diuretic effect.
  • diminished natriuretic effect with increased sensitivity to hypokalemia and volume depletion in cirrhosis.
• diuretics
  • dosing is empiric and frequently determined by the elimination of edema for CKD stage 4 to 5.
  • spironolactone leads to natriuretic response in patients with cirrhosis and ascites or heart failure, particularly used with a loop or a thiazide-type diuretic or both.

[suggestion]

• please monitor furosemide effect to see if dose increasing or considering spironolactone is needed.

700640254

210907

{ovary cancer s/p debulking surgery}

[history]

• laparoscopic myomectomy 10 years ago.

[initial presentation]

• abdominal fullness with palpable mass over right side, poor appetite, easily fullness and nausea sensation when eat a lot, less urine output with voiding hesitation, back soreness and excertional dyspnea since 2021-06.
• constipation since 2021-07.

[definite diagnosis, disease extent]

• 2021-07-27 abdominal ultrasound
  • cystic lesion, suspected cystic tumor, lower abdomen
• 2021-07-28 CT - whole abdomen, pelvis
  • findings
    • a lobulated cystic mass with enhancing mural nodules and few septa in the lower abodmen and pelvis, measuring 20.6 x 12.8 x 26 cm (width x depth x cranial-caudal length). cystic adenocarcinoma of the right ovary is highly suspected.
    • soft tissue nodules and fatty stranding in the omentum of right middle abdomen that may be carcinomatosis. correlate with peritoneoscopy.
    • poor enhancing lesions in the uterus that are compatible with myomas. ill-defined enhancing lesions in the uterine myometrium that are compatible with adenomyosis.
  • image stage
    • T1aN0M0, stage IA
• 2021-08-16 patho - ovary tumor
  • histologic type: clear cell carcinoma
  • histologic grade: high grade
  • regional lymph nodes: left iliac: 0/1; left obturator: 0/3; right iliac: 0/3; right obturator: 0/6; left paraaortic: 0/1; right para-aortic: 0/1.
  • leiomyomas and endometriosis are seen in myometrium. endometrioma is found in left ovary.
  • aggregation of histiocytes is present in the omentum.
  • IHC stains: PAX8(+), Napsin A(+), WT-1(-), PR(-), and p53(-).

[treatment]

• 2021-08-16 debulking surgery (ATH + BSO + cytoreduction surgery + omentectomy + LN dissection)

[assessment]

• clear cell carcinoma of the ovary is a relatively less common ovarian cancer, since the patient is just in her early fifties, her liver and kidney functions showed no abnormality (lab data reported on 2021-08-13), IV platinum-based therapy might be applicable.
  • paclitaxel + carboplatin every 3 weeks for 3 to 6 cycles (hearing test done 2021-09-07 morning)

701205775

210907

{unresectable liver tumor}

[initial presentation]

• 2021-08-26 coffee ground vomiting, gastrointestinal hemorrhage, hypovolemic shock.

[definite diagnosis, disease extent]

• 2021-08-27 abdominal ultrasound
  • liver tumors, both lobe
  • parenchymal liver disease
  • cholecystopathy
  • minimal ascites
• 2021-08-27 CT - whole abdomen, pelvis
  • findings:
    • lobulated patchy geographic poor enhancing cystic-like lesions in right lobe and S4 of the liver, the largest one measuring 14.3 cm in the largest dimension, with patent flow of both lobe portal vein and hepatic vein.
    • several enlarged nodes in the hepatoduodenal ligament are noted and the largest one measuring 2.5 cm that may be metastatic nodes?
    • liver infarction is highly suspected?
    • the differential diagnosis include angiosarcoma, poorly-differentiated HCCs, and metastases.
    • the liver shows irregular contour that may be cirrhosis. enlarged of the spleen (long axis: 12 cm) and minimal ascites in right subphrenic and right perihepatic space that may be portal hypertension.
  • imaging stage:
    • T3N1M0, stage IVA.
• 2021-08-30 patho - liver biopsy needle/wedge, sono-guided aspiration
  • hepatocellular carcinoma, composed of nests of well differentiated neoplastic hepatocytes, arranged in pseudoglandular and trabecular patterns. extensive coagulative necrosis and hemorrhage are present.
• 2021-08-30 MRI - liver, spleen
  • bil. liver tumors, angiosarcoma is first considered.

[underlying disease]

• T2DM, GERD, HTN, hyperlipidemia

[assessment]

• liver tumor
  • tumor too large to be resectable (low anticipated liver reserve and remnant). this patient is in her early sixties with multiple comorbidities (and probable portal hypertenstion), being a candidate for transplant might be an option but not a highly realistic one.
  • limiting tumor growth or downsizing it to mitigate possible encephalopathy, ascites, hypoalbuminemia, prolonged prothrombin time, hyperbilirubinemia, would be on a general right track in a short-term to medium-term time scale.
  • bevacizumab might not be applicable at the present time for its possible cardiovascular (heart failure), GI (perforation), HTN, hemorrhage adverse reactions.
  • patient-carried stivarga (regorafenib 40mg PO QD) has been listed in active medication since 2021-09-01 during this hospitalization.
• current symptoms and most of underlying diseases are managed under following drugs without issues:
  • encephalopathy
    • lactul (lactulose) 13.32g PO QD
  • prolonged prothrombin time
    • katimin (phytomenadione) 10mg IVD QD
  • cachexia
    • megest (megestrol) 160mg PO TID
  • edema, ascite
    • plasbumin (human albumin) 50ml IVD BID
    • furosemide 20mg IVD BID
    • spironolactone 25mg PO BID
  • GERD
    • takepron (lansoprazole) 30mg PO QDAC
  • HTN
    • concor (bisoprolol) 1.25mg PO BID
  • T2DM
    • actrapid hm insulin 4unit SC BIDAC
    • relinide (repaglinide) 1mg PO TIDAC15
    • trajenta (linagliptin) 5mg PO QDAC
• pravafen (pravastatin 40mg, fenofibrate 160mg) QD for hyperlipidemia (lab data on 2021-08-05 remained high readings) listed in PharmaCloud could be considered to add to active medication as a patient-carried item.

700965860

210906

{colon cancer with suspected liver mets and peritoneal seeding}

[initial presentation]

• 2020-11 underwent a health examination arranged by the company and found multiple liver nodules (2.7 cm).
• 2021-05 began to suffer from abdominal cramps after eating (below umbilicus) and the symptom can be relieved after defecation.
  • no radiation pain, abdominal distension, burning sensation, nausea, vomiting, diarrhea, constipation, appetite change.
• 2021-08 LMD abdomenal echo found multiple liver tumors.

[definite diagnosis, disease extent]

• 2021-08-18 abdominal ultrasound
  • liver tumors, multiple, suspect metastasis
  • several mixed echoic tumors with peripheral low echogenicity, and the largest one 8 cm x 3.9 cm was at S4/8
• 2021-08-19 CT, ABD - liver, spleen, biliary duct, pancreas
  • multiple liver tumors suspected metastases.
  • wall thickening of cecum and S-colon.
  • a soft tissue nodule (1.3cm) in pelvic cavity suspected tumor seeding.
  • some LNs at paraaortic region suspected metastases.
• 2021-08-20 coloscopy
  • suspect colon cancer with impending obstruction, sigmoid colon, 30cm above AV, s/p biopsy
  • a large ulcerative tumor involving the whole circumference with lumen narrowing and the scope can not pass through it, s/p biopsy
• 2021-08-23 patho - colon biopsy
  • adenocarcinoma - pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR(+), PMS2(+), MSH6(+), MSH2(+), MLH1(+).

[assessment]

• staging workup is ongoing.
  • liver mets and peritoneal seeding are suspected, should be stage IVC if both confirmed positive.
• diverting ostomy or bypass or stenting might be indicated for imminent obstruction at colon lesion.
• liver and kidney functions showed no abnormality (lab data on 2021-09-06, 2021-08-16); neither HBV nor HCV was active; systemic therapy would be indicated for this chemo-naive patient.
  • FOLFOX or CAPEOX could be an option, bevacizumab could also be added.
  • pembrolizumab, nivolumab might not be indicated for pMMR (PMS2(+), MSH6(+), MSH2(+), MLH1(+)).
• KRAS/NRAS/BRAF lab data not found in chart yet.

700261411

210901

{hypophosphatemia, hypokalemia}

[objective]

• lab data reported on 2021-09-01
  • K(Potassium) 3.0mmol/L, normal 3.5-5.1
  • P(Phosphous) 1.7mg/dL, normal 2.5-5.0

[assessment]

• available drug
  • potassium phosphate injection 20mL/amp which contains K 88mEq and P 60mM.
• dosing
  • for patients with mild to moderate hypokalemia (serum potassium 3.0 to 3.4 mEq/L) who do not have ongoing urinary potassium losses, initial administration of 20 to 80 mEq/day is recommended.
  • serum phosphate level 1.5 to 2.2 mg/dL, initial 0.16 to 0.32 mmol/kg (12.8mmol to 25.6mmol for this 80kg patient) over 4 to 6 hours.
• stability
  • must dilute in NS or D5W to a total volume of 100mL or 250mL
  • for IV infusion only into a central or peripheral vein
  • do not infuse with calcium-containing intravenous fluids

[suggestion]

• half to one ampoule of 20mL potassium phosphate in no less than 100mL NS or 250mL D5W infusion 4 to 6 hours is recommended.
• please monitor serum K, P and EKG routinely to check if the intervention gets the readings back to normal.

700990402

210831

{UTI, hypoalbuminemia}

[objective]

• 2018-04-03 robotic assisted laparoscopic radical cystectomy + pelvic lymph nodedissection + ileal pouch (ShuangHo hospital)
  • cystectomy and ileal conduit for bladder cancer s/p adjuvant radiotherapy, bilateral PCN insertion, and T-colostomy.
• 2020-05 right femoral neck fracture s/p bipolar hemiarthroplasty (ShuangHo hospital)
• 2021-05-24 CT - abnominal
  • a 9cm pelvic mass, suspected to be recurrent tumor.
• 2021 early Jane bilateral PCN placing and colostomy done for obstructive ileus, followed with adjuvant radiotherapy in Cardinal Tien hospital.
• 2021-06-25 Gyn ultrasound: uterine mass of 5x5cm at the posterior wall of myometrium without clear margin. D&C and ECC showed inflammation and scanty gland cells with squamous metaplasia.
• 2021-07-13 LAVH, BSO, excision. adhesiolysis for severe adhesion of small intestine.
• 2021-07-21 chest AP
  • bilateral lung tumors, suspected lung metastasis.
• 2021-08-04 CT - brain
  • a right frontal lobe. suspected abscess or tumor.
• 2021-08-04 MRI - brain
  • right frontal tumor (19 mm) with mass effect. metastasis is first considered. D/D: abscess.
  • a suspected aneurysm (2.6 mm x 2.7 mm) near right M1 bifurcation.
• 2021-08-30 urine lab data
  • sediment RBC 6-9
  • sediment WBC 10-19
  • leucocyte ester 2+
  • OB 1+
• 2021-08-22, 23 urine culture - catheterized and patient urinated midstream
  • Klebsiella pneumoniae, Escherichia coli
• bilirubin direct 0.32mg/dL (2021-08-23)
• albumin
  • 2021-08-23 2.7g/dL
  • 2021-07-26 3.1g/dL
  • 2021-07-22 3.0g/dL
  • 2021-07-19 2.8g/dL
  • 2021-07-01 2.9g/dL
  • 2021-06-24 2.8g/dL
• prealbumin
  • 2021-07-26 10.04mg/dL
  • 2021-07-14 10.64mg/dL

[assessment, suggestion]

• UTI still ongoing (8/30 urine lab data), 1 week tapimycin administrated until 9/1 morning, imipenem might be an alternative successor for both cultured Klebsiella pneumoniae and Escherichia coli are imipenem-sensitive (MIC<=0.25, low creatinine reading) if no other considerations.
• S-GPT/ALT and S-GOT/AST (8/23) showed no abnormality, however, bilirubin flucturated above normal range for at least 3 months. both albumin and prealbumin remain low, if no evidence supports liver-dysfunction-caused hypoalbuminemia for now, to improve patient’s nutritional status could be tried. HBV and HCV might also be tested (no in-hospital records seen yet).
• underlying diseases or symptoms are managed with drugs in active prescription, no issue found.
  • type 2 DM
    • metformin 500mg PO BID
    • linagliptin 5mg PO QD
  • hypertension
    • amlodipine 5mg PO QD
  • parkinson’s disease
    • bendopar (levodopa 100mg, benserazide 25mg) PO BID+HS
    • amentadine 100mg PO BID
  • flatulence
    • dimethylpolysiloxane 40mg PO BID

700031883

210830

{esophageal scc with lung and stomach mets}

[definite diagnosis, disease extent]

• 2018-04-26 surgical pathology level IV
  • esophagus, 26 cm below incisor, biopsy - moderately differentiated squamous cell carcinoma
  • IHC stains P40(+), p63(+), CK(+), CDX-2(-).
• 2018-05-07 CT - mediastinum
  • imp: M/3 esophageal tumor T1N0Mx.
• 2019-08-20 CT - mediastinum
  • LUL cancer T1aN0MO stage IA1.
• 2019-11-21 CT - mediastinum
  • s/p esophagectomy with gastric tube reconstruction.
  • left upper lobe nodule.
• 2021-06-03 PET whole body scan
  • glucose hypermetabolic lesion in the left paratracheal area, compatible with recurrent malignancy.
  • mild glucose hypermetabolism in a right submandibular lymph node, a right neck level III lymph node, bilateral pulmonry hilar regions and in some focal areas in bilateral buttocks.
• 2021-06-25 cell block cytology & needle aspiration cytology
  • stypical hyperchromatic pleomorphic tumor cells with focal keratinization.
  • metastatic squamous cell carcinoma is favored.
• 2021-06-25 patho - stomach biopsy
  • nests of hyperchromatic tumor cells infiltration in fibrous tissue. keratinization is focally present.
  • IHC stains CK5/6(+), p40(+), TTF-1(-), Napsin A(-), CD56(-), and Synaptophyin(-).
  • the results are in favor of metastatic squamous cell carcinoma.

[treatment]

• 2018-06-04 op for scc of middle third esophagus
  • the esophagus was dissected, and retrosternal route was created and connected to abdomen.
  • the gastric tube was draw up to the cervical incision via retrosternal route.
• 2019-11-29 VATS left upper lobe wedge resection, lobectomy with RLND.
• 2021-07 up to now: CCRT
  • chemo part - PF 2021-07-29, -08-27
    • 75mg/m2 day 1
    • 1000mg/m2 day 1~4
  • radio part - 3440Gy/19fx 2021-07-01 ~ -07-27

[assessment]

• visiting the patient at around 16:40 on 2021-08-30. he said the treatments were generally well-tolerated and he did not experience any side effects need intervention during this hospitalization.
• overall good, no issue on medication.

700295989

210826

{duplicated NSAIDs}

[objective]

• NSAIDs listed in active medication as following:
  • Laston (ketorolac) 30mg IM PRNQ6H
  • Deflam-K (diclofenac) 25mg PO QID
  • Deflam-K (diclofenac) 25mg PO QID - patient carried

[assessment]

• diclofenac could be administered up to 200mg per day.
• diclofenac exceeding 100 mg per day might increase risk of vascular events.
• ketorolac is also classified as NSAID.

[suggestion]

• either in-hospital prescribed or patient carried diclofenac could be discontinued if no other clinical considerations.

701255029

210826

{potential drug interaction}

[objective]

• the following drugs are listed in active medication:
  • morphine, tramadol
  • cyproheptadine, quetiapine
  • atorvastatin
  • daptomycin

[assessment]

• atorvastatin is an HMG-CoA reductase inhibitors which might enhance the adverse effect of daptomycin, the risk of skeletal muscle toxicity might be increased.
• cyproheptadine and quetiapine coadministered with opioid agonists i.e. morphine and tramadol might enhance the CNS depressant effect.

[suggestion]

• please monitor any sign of the potential adverse effects mentioned above.

700522826

210825

{breast cancer}

[initial presentation]

• left breast lump found since 2021 May/June

[definite diagnose, disease extent]

• 2021-07-23 SONO breast, Mammography
  • hyperdense tumors in left breast, 4.9cm (subareolar region) and 1.7cm (deep central), suspected malignancy, suggest biopsy.
  • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
• 2021-07-23 Patho - breast biopsy
  • breast, 4/5’ and 12’ region, left, invasive carcinoma characterized by proliferation of tumor cells with infiltrative growth pattern, ductal differentiation and stromal fibrosis.
  • the tumor cell shows hyperchromatic nuclei, plemorphism and high N/C ratio.
  • IHC stain ER(-), PR(-), Her2/neu(3+), p53(+), Ki-67 index 20%.
• 2021-08-06 Patho - lymphnode biopsy
  • benigh lymph node tissue, IHC stain CK(-)
• 2021-08-09 Tc-99m MDP bone scan
  • no strong evidence of bone metastasis.
• 2021-08-09 CT - abdomen, pelvis
  • left breast tumor (2.1cm, 4.9cm) with skin invasion suspected cancer.

[treatment]

• chemo regimen AC (doxorubicin/cyclophosphamide) since 2021-08-25.

[assessment]

• cT3N0 her2-positive, tumor > 1cm, chemo with trastuzumab (or pertuzumab) could be indicated.
  • however, there are limited data to confirm chemo regimen for those > 70 y of age.
• CBC WNL, liver and kidney function well, based on most recent lab data.
• no drug allergy record found in database.
• MSI/MMR, PD-L1, BRCA1/2, PIK3CA tests could also be considered.

700371268

210824

{tube feeding}

meitifen (diclofenac Na 75mg) PO QD which is controlled-release design might be changed to defram-k (diclofenac K 25mg) PO TID

700770648

210824

{preparation and precaution - mephalan, post-IPP meeting following up}

patient family meeting and IPP meeting was held at 10:00 on 2021-08-24.

• the schedule with regimen for PBSCT for the patient has been disclosed in the meeting.

• melphalan dosing as a conditioning agent, 140mg/m2 or 200mg/m2 are more commonly seen. source:

  • https://www.uptodate.com/contents/melphalan-drug-information
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5830386/
  • https://www.astctjournal.org/article/S1083-8791(17)30965-5/fulltext

• the estimated total amount of melphalan used prior to the scheduled transplantation would be 8 vials.

  • based on melphalan 50mg/vial, dose 100mg/m2 (according to the time table), body surface area 1.64m2.
  • 4 vials per day for 2 days (2021-08-29, 2021-08-30).
  • 8 vials in stock has been confirmed by the medicine storeroom.

• preparation and administration precautions of mephalan:

  • expiration time is 60 minutes after preparation (the duration including infusion time) according to package insert.
    • staff in chemo preparation room will inform the ward when the melphalan preparation is done.
  • based on lab data reported on 2021-07-09 and 2021-07-30, liver and kidney have no abnormality, no dose adjustment is needed.

• damage of the oral mucosa together with profound myelo- and immunosuppression after transplantation may lead to local and systemic infections.

  • other side effects in the early period may include bleeding due to thrombocytopenia as well as pain, nutrition, and articulation impairment caused by mucositis.
  • in the first year after transplantation, oral cavity is affected by delayed complications like hyposalivation, taste disorders, and dentin hypersensitivity, which often importantly decrease the patients’ quality of life.
  • oral and maxillofacial surgery department has been consulted for this.
  • if oral mucosa damage happens, some triamcinolone acetonide oral ointment (nincort or oralog, the former is available now) for local treatment might be of help.

701118237

210820

{sepsis and pancytopenia with underlying DLBCL}

[subjective]

• this 64 y/o female patient sent by her family to our ER on 2021-08-11 for her dizziness and hypotension after having chemotherapy.
• underlying history of (neck) diffuse large B cell lymphoma

[objective]

• 2021-08-11 ER Imp: sepsis, unspecified organism
• DLBCL
  • 2019-09-24 CT, neck-hypopharynx:
    • diffuse enlarged lymph nodes on both sides of neck, more prominent on right side.
    • D/D: lymphoproliferative disease, metastases.
  • 2019-09-27 surgical pathology level IV:
    • pathologic diagnosis
      • Lymph node, level IV, right neck, dissection— B- cell lymphoma
      • Lymph node, level III, right neck, dissection— B- cell lymphoma
    • Histology type:
      • B-cell lymphoma (favor diffuse large B-cell lymphoma)
    • Immunohistochemical stain profiles:
      • CD20(+), Bcl-2(+), CD3(focal positive at the background T-cells), Bcl-6(+), Sox11(-), cyclin-D(-), CD10(-), Ki-67 index:70%, CD5 (focal+), c-myc(-), CD23(-).
  • 2020-11 bone marrow transplant, followed up at NTUH
  • 2021-05 recurrence, neck mass noted
  • 2021-07 PET showed progressing
  • 2021-08-06 chemotherapy endoxan (cyclophosphamide) prescirbed (according to PharmaCloud), pre-chemotherapy WBC 1600
• Lab data
  • RBC 2021-08-20 3.45*10^6/uL
  • HGB 2021-08-20 10.1g/dL
  • PLT 2021-08-20 52*10^3/uL
  • WBC
    • 2021-08-20 3.65*10^3/uL
    • 2021-08-18 1.69
    • 2021-08-17 1.02
    • 2021-08-16 0.43
    • 2021-08-14 0.10
    • 2021-08-13 0.08
    • 2021-08-11 0.10
  • CRP
    • 2021-08-16 15mg/dL
    • 2021-08-11 12
  • urine culture on 2021-08-17: after 48 hours, <1000 CFU/ml
  • blood culture on 2021-08-12: no growth for 5 days aerobically & anaerobically
• medication
  • granocyte (lenograstim) 250mcg SC QD since 2021-08-12
  • cefim (cefepime) 2000mg IVD Q12H 2021-08-12 to 2021-08-18
  • eraxis (anidulafungin) 100mg IVD QD
  • targocid (teicoplanin) 600mg IVD Q12H~QD 2021-08-12 to 2021-08-16

[assessment]

• sepsis
  • urine culture and blood culture found no obvious infection
  • body temp no higher than 36.8 since last week
  • CRP still showed elevated.
  • after days of ABX administration, the infection should has been mitigated.
• pancytopenia
  • WBC has been boosted by lenograstim
  • RBC and PLT still below than LLN, but moved out of critical range.
  • the condition has been improved.
• DLBCL
  • alkylating agent been paused (not listed in active medication) because of pancytopenia.

[suggestion]

• ABX might be deescalated when CRP goes down and no other infectious sign shows up.
• DLBCL treatment should be restarted as soon as possible when the patient gets in stable condition.
  • no chemo or target drugs other than cyclophosphamide found in PharmaCloud, based on the limited info, ISRT after RCHOP might be a treatment option.
  • uric acid, beta-2 microglobulin could also be followed up when having DLBCL treatment.
• HBV, HCV lab data not found in in-hospital database, could be ordered.

701034857

210816

{liver cancer with bone mets}

[initial presentation]

• 2017~ abdominal fullness

[definite diagnosis, disease extent, effect & side effect]

• 2017-09-20 Echo for liver, gall bladder, pancreas, spleen
  • parenchymal liver disease; postcholecystectomy; liver cyst; hepatic tumors, three suspected HCC
• 2018-04-03 CT, ABD - liver, spleen, biliary duct
  • HCCs s/p operation and TACE without viable tumor.
• 2018-07-25 Echo for liver, gall bladder, pancreas, spleen
  • parenchymal liver disease; postcholecystectomy; liver cyst; probable hepatic tumor; renal stone, left
• 2018-12-26 Echo for liver, gall bladder, pancreas, spleen
  • liver cirrhosis; postcholecystectomy; hepatic tumor, nature?
• 2019-03-03 CT, ABD - liver, spleen, biliary duct
  • HCC s/p TACE with recurrent HCC at S3 and S7.
• 2019-05-08 Echo for liver, gall bladder, pancreas, spleen
  • parenchymal liver disease; hepatic tumors, two c/w HCC; increased risk of RFA due to near diaphargm
• 2019-06-29 CT, ABD - liver, spleen, biliary duct
  • HCC s/p op. and TACE with viable tumor at S7.; liver cirrhosis.
• 2019-09-23 MRI, liver, spleen
  • a recurrent HCC (2.0cm) in S7 of liver.
• 2020-02-03 CT, ABD - liver, spleen, biliary duct
  • HCCs s/p operation and TACE. a recurrent HCC (2.9cm) in S7 of liver.
• 2020-05-13 Abdominal Ultrasonography
  • liver cirrhosis; hepatic tumors, two probable hcc
• 2020-12-30 Abdominal Ultrasonography
  • liver cirrhosis; hepatic tumors, three c/w hcc
• 2021-05-24 CT, ABD - liver, spleen, biliary duct
  • HCCs s/p operation and TACE. recurrent HCCs (up to 4.3cm) in S7-8 of liver. some lucent lesions in left pelvic bone probable metastases.
• 2021-05-26 Abdominal Ultrasonography
  • liver cirrhosis; hepatic tumors, five c/w HCC (two s/p TACE with viable tumors, three recurrent).

[treatment]

• HCC op and TACE done at other hospital in late 2017.
• entecavir been used years ago, restarted from 2021-07-03 (self-paid).
• nexavar (sorafenib) 200mg BIDAC tappered to QDAC because of poor appetite, dizziness, malaise.
• palliative RT to the Lt shoulder to deliver at least 30 Gy/ 10 fx started in the middle third of 2021-08.

[assessment]

• medication
  • no issues with the following indications
    • HCC
      • nexavar (sorafenib 200mg) PO QDAC (Child-Pugh Class A)
    • HBV, cirrhosis
      • baraclude (entecavir 0.5mg) PO QDAC
      • baogan (silymarin 150mg) PO BID
  • potential interaction
    • the antitumor activity of sorafenib might be potentially reduced by neomycin for the later may decrease the serum concentration of the former.
• radiotherapy
  • palliative RT is appropriate for symptom control and/or prevention of complications from metastatic lesions, such as bone (like this patient) or brain.
• patient wants to take herbal medicine.
  • not being followed up with chinese medicine department since late 2017
  • no herbal medicine items disclosed in PharmaCloud.
• dMMR/MSI-H, NTRK, BRCA1/2 gene tests not found in the charts

[suggestion]

• introduce the patient to visit our chinese medicine OPD to get ‘scientfic chinese medicine’ rather than using unknnow herbal medicine.
• shorten the use time of meomycin to avoid potential drug interaction with sorafenib.
• dMMR/MSI-H, NTRK, BRCA1/2 gene tests might be ordered if needed.
• the patient seemed being hesitating to have curative care for a not short while and hopping from and to WanFang hospital for medical demand, having him to meet with social-work staff might be of help to get his considerations behind.

701326125

210816

{some preparation before tube feeding}

active medication is reviewed, all the oral drugs can be administered via NG tube.

acetin (acetylcysteine) and nexium (esomeprazole) should be dissolved in adequate drinking water prior to tube feeding.

701326360

210816

{switch drug for tube feeding}

active medication has been reviewed, all the oral drugs can be administered via NG tube.

Harnalidge (tamsulosin) 0.4mg PO QDAC replaced by Urief (silodosin) 8mg PO QD is recommended.

700321047

210812

{statin dose intensity and equivalency}

All the oral drugs in active medication have been reviewed and can be administered via NG tube.

Pravafen has not been found in active medication yet.

Pravafen should not be grinded or half-peeled. It contains fenofibrate 160mg and pravastatin 40mg, there is Lipanthyl Supra (fenofibrate 160mg) available in hospital, however pravastatin 40mg is out of stock for now.

Fluvastatin 80mg, lovastatin 80mg, simvastatin 20mg, pitavastatin 2mg, atorvastatin 10mg, rosuvastatin 5mg are alternatives for pravastatin 40mg. reference: http://www.mqic.org/pdf/UMHS_Statin_Dose_Intensity_and_Equivalency_Chart.pdf

701320982

210812

{lung cancer with brain mets}

[initial presentation]

• 2021-07-12 being diagnosed as hypnic headache at LMD.
• 2021-07-26 intermittent occipital headache accompanied with Rt limbs weakness for 2 weeks, exacerbated since 2021-07-24.

[definite diagnose, disease extent]

• 2021-07-26 CT, brain:
  • masses in right cerebrum; DDx: metastasis, meningiomas.
  • midline shift (11mm) and impending uncal herniation.
• 2021-07-26 MRI, brain:
  • bifrontal and right medial temporal tumors, favor metastases, with brain herniation.
• 2021-07-27 CT, lung/mediastinum/pleura:
  • LUL lung cancer, T4N3M1c, stage IVB.
• 2021-07-28 whole body PET scan:
  • glucose hypermetabolism in the right cerebral cortex, probably the primary or secondary (priority) brain malignancy.
  • glucose hypermetabolism in the left upper lung and left lower lung pleura, probably lung cancer with lung to lung metastases.
    
  • glucose hypermetabolism in bilateral mediastinal lymph nodes and bilateral SCF lymph nodes, probably lung cancer with regional lymph nodes metastases.
    
  • left upper lung cancer (if proved), cT4N3M1c, stage IVB.
• 2021-07-30 patho, lung transbronchial biopsy:
  • adenocarcinoma, moderately to poorly differentiated. solid nests and glandular cells infiltrating in a fibrotic stroma.
  • ICH stains: TTF-1(+), Napsin A(+), p40(-), CD56(-) are supportive for lung cancer diagnosis.
• 2021-08-04 PD-L1:
  • tumor cell (TC) staining assessment: <1%
  • tumor-infiltrating immune cell (IC) staining assessment: <1%

[treatment]

• Radiotherapy
  • palliative RT for brain metastases is indicated.
  • delivering 18 Gy/ 6 fx to the whole brain and then boost the bi-frontal and Rt medial temporal tumors to 36 Gy/ 12 fx.

[assessment, suggestion]

• active medication without issues
  • brain mets:
    • Mannitol 20% 100mL IVD Q8H
    • Keppra (levetiracetam) 500mg PO BID
  • insomnia:
    • Anxiedin (lorazapam) 0.5mg PO PRNHS
  • constipation:
    • MgO 500mg PO TID
• PD-L1 <1% is known. EGFR, KRAS, ALK, POS1, BRAF V600E, NTRK, METex14, RET might be tested
• if CCRT is applicable, the chemo option could be:
  • carboplatin + pemetrexed
  • cisplatin + pemetrexed
  • paclitaxel + carboplatin
  • etooside + cisplatin

701253142

210811

{cecal cancer}

[initial presentation, definite diagnosis, disease extent]

• 2019-12-15 CT at TMUH: cecal or appendiceal malignancy with adjacnet infiltration, few prominent regional lymph nodes and liver metastasis.
  • no blood stool and no stool impaction could be noted prior to the CT exam.

[treatment]

• 2020-02-10 ~ 2020-11-xx: biweekly high dose 5-fluorouracil and leucovorin (HDFL) at TMUH?
  • outcome: partial response
• 2020-12-07 ~ up to now : continuing HDFL.
  • plus UFT (tegafur + uracil) from 2020-09 ~ 2020-12.
  • plus Xeloda (capecitabine) from 2021-05 ~ up to now.

[effect & side effect]

• 2020-11-07 CT, ABD:
  • regression of cecum tumor and liver metastasis.
  • right adrenal tumor, suspect adrenal mestasis, mild progression.
• 2021-02-22 CT, ABD:
  • stable condition of cecal tumor and liver metastases.
  • wall thickening of urinary bladder, right aspect.
  • mild regression of right adrenal tumor.
• 2021-04-13 KUB:
  • S/P posterior instrumentation fixation from T10 To L5.
  • S/P laminectomy of L2, L3, and L4; partial laminectomy of L5
  • vacuum phenomenon of L4-5.
  • fecal material store in the colon.
• 2021-04-15 KUB:
  • S/P posterior longitudinal transpedicular screws and rods fixation.
  • stool retention in the bowel.
• 2021-05-22 CT, ABD:
  • borderline heart size.
  • s/p posterior fixation of the lumbar spine
  • cecal tumor with liver meta, right adrenal meta(?), statinoary.
• 2021-07-16 CT, ABD: left hydronephrosis and hydroureter. focal wall thickening of urinary bladder. urinary bladder and left lower ureter tumors should be ruled out.
• 2021-08-02 kidney ultrasound: right renal cyst.
• 2021-08-02 bladder sonography: post-void residual volume 297ml
• CEA
  • 2021-08-10 _9.55ng/mL
  • 2021-07-06 11.17
  • 2021-06-08 10.43
  • 2021-05-11 _5.05
  • 2021-04-13 _5.63
  • 2021-03-17 _4.50
  • 2021-02-03 _5.34
  • 2021-01-06 10.98
  • 2020-12-22 16.63
  • 2020-12-03 32.41
  • 2020-11-05 40.06
  • 2020-09-25 21.92
• CA199
  • 2021-08-10 _37.74U/mL
  • 2021-07-06 _42.15
  • 2021-06-08 _37.56
  • 2021-05-11 _24.28
  • 2021-04-13 _27.14
  • 2021-03-17 _25.11
  • 2021-02-03 _26.37
  • 2021-01-06 _31.50
  • 2020-12-22 _41.91
  • 2020-12-03 _95.77
  • 2020-11-05 119.26
  • 2020-09-25 119.70

[ongoing problem]

• BPH
  • medication
    • Avodart (dutasteride) 0.5mg PO QD
    • Betmiga (mirabegron) 50mg PO QD
    • Urief (silodosin) 8mg PO QD
• HTN
  • medication
    • Diovan (valsartan) 80mg PO QD

[assessment]

• patient is relatively stable with slow tumor progression.
• mirabegron is a CYP2D6 inhibitor which might increase the serum concentration of metoclopramide (10mg IVD PRNQ6H).
  • CYP2D6 is an enzyme responsible for metoclopramide metabolism.

700081580

210810

{renal glucosuria?}

[objective]

• 2021-07-27 lab data:
  • urine glucose 4+
  • urine bacteria 1+
  • serum glucose 103mg/dL
• creatinine WNL:
  • 2021-08-08 0.83mg/dL
  • 2021-07-27 0.74mg/dL
  • 2021-07-15 0.85mg/dL

[assessment]

• patients with renal glycosuria, glucose is excreted in the urine in the presence of normal or low concentrations of blood glucose.
• there is a lowered renal threshold to glucose and, in some cases, a reduction in the rate at which the renal tubules are able to reabsorb glucose.
• in most affected individuals, renal glycosuria is a benign condition, resulting in no apparent symptoms. however, in some cases, glycosuria may be pronounced enough to result in excessive urination (polyuria), excessive thirst (polydipsia), and other associated symptoms.

[suggestion]

• if any symptomatic sign is observed, appropriate testing should be conducted to rule out diabetes and to regularly monitor those with confirmed renal glycosuria.
• genetic counseling will be of benefit for affected individuals and their families. other treatment for this condition is symptomatic and supportive.

000000

[initial presentation]

• 2021-07-15 left inguinal mass for 3 weeks refer from LMD.
• 2021-07-16 CT - abdomen, pelvis:
  • a well-defined soft tissue mass measuring 2.6 x 2.3 cm in left inguinal area.
  • differential diagnosis include undescended testis.

[definite diagnosis]

• 2021-07-28 patho - lymph node regiion resection:
  • labeled as ‘inguinal tumor’, tumor excision - in situ follicular neoplasm.
    • IHC stains: CD3 and CD20: a predominant B cell subpopulation;
    • bcl-2 (+), bcl-6 (+), CD10 (+) of the follicules.
      
    • CD23 (-), cyclin-D (-).
      
  • sections show lymph node with proliferative lymphocytes deminstrating pseudofollicles.

[disease extent]

• 2021-08-10 CT - abdomen, pelvis:
  • only one enhanced lymph node at left inguinal region.
  • the rest of the body part is free of lymphadenopathy.

[plan & treatment]

[effect & side effect]

[ongoing problem]

700223143

210806

{flumarin side effect monitoring}

[objective]

• flumarin (flomoxef sodium) dosing for adult:
  • susceptible infections IV usual dosage: 1 to 2 g per day in 2 divided doses
  • may increase to 4g per day in 3 to 4 divided doses if needed for severe or refractory infections.
• flumarin 1g IVD QD is prescribed.
• estimated creatinine clearance 10ml/min using the Cockcroft-Gault equation is based on:
  • age 28 years old
  • body weight 62.65kg (2021-08-05)
  • creatinine 7.00mg/dL (2021-08-06)
• according to the drug’s package insert, half-life t1/2:
  • healthy adult: 49.6min
  • patient with 5 < CrCl < 20: 6.95hr

[assessment]

• half-life for the patient could be 8.4 times long compared to normal renal function adults.
• prescribed dose is a quarter of upper limit of daily use, not as low as one eighth, might increase the possibility of adverse reactions.

[suggestion]

• please monitor any signs of adverse reactions possibly caused by flumarin including:
  • dermatologic: skin rash
  • endocrine & metabolic: increased gamma-glutamyl transferase
  • gastrointestinal: diarrhea
  • hematologic and oncologic: anemia, eosinophilia, granulocytopenia
  • hepatic: increased serum alkaline phosphatase, increased serum ALT, increased serum AST

700834580

210806

{cancer workup}

[initial presentation]

• 2021-06-30 left leg knee and thigh pain for more than one month, progresson
• 2021-07-14 limping gait, severe pain lower back radiating to left hip and lower leg

[objective]

• lab data (2021-07-28)
  • CA125 645U/mL
  • CA199 >19610U/mL
  • CEA 613ng/mL
  • CA153 WNL
  • AFP WNL
  • SCC WNL

[definite diagnosis & staging workup]

• still in workup, could be lung to bone mets, evidences observed including:
  • 2021-07-15 MRI L-spine:
    • tumors in the left iliac bone and right sacrum. origin?
  • 2021-08-04 Tc-99m MDP bone scan:
    • lung cancer with multiple bone metastases in the lower part of the sternum, posterolateral aspect of the left 10th rib, and left iliac bone is highly suspected.
  • 2021-08-05 bronchoscopy:
    • right intermediate bronchus submucosal tumor.
    • RLL orifice submucosal tumor, some protuding to the mucosa layer, with RLL bonchus narrowing.

[treatment]

• pain
  • morphine 15mg PO Q6H
  • morphine 5mg IVD PRNQ6H
• constipation
  • through (sennoside) 24mg PO HS
  • bisacodyl 10mg RECT PRNQD
  • MgO 500mg PO Q6H

[ongoing problem]

• post nasal dripping
  • actein (acetylcysteine) 200mg PO BID
  • sindecon nasal spray 1 puff NA BID
• hyperlipidemia
  • crestor (rosuvastatin) 10mg PO QD
• insomnia
  • anxiedin (lorazepam) 0.5mg PO HS

[assessment]

• main activity is to control (pain) symptoms for now
• constipation which could be an adverse reaction of morphine has been mitigated with stimulant laxatives.

700039230

210729

{post IPP meeting following up}

• the schedule and regimen for PBSCT for the patient was disclosed in the meeting held on 2021-07-28 10:30.

• the estimated total amount of busulfan used in the time table is 15 vials.

  • based on busulfan 60mg/10mL/vial, dose 3.2mg/kg, body weight 75kg
  • 5 vials per day for 3 days (2021-07-28, 2021-07-29, 2021-07-30)

• staff dispensing regimen during weekend are arranged.

• preparation and administration precautions:

  • busulfan:
    • do not use polycarbonate syringes or polycarbonate filter needles with the drug.
  • etoposide:
    • precipitation may be exacerbated at concentrations of 0.4 mg/mL or above.
    • etoposide 400mg/m2 x body surface area 1.9m2 -> amount 760mg.
    • total solution containing 760mg etoposide will be no less than 1900mL.

{mesna administration rate}

• where ifosfamide or cyclophosphamide is used (like this patient) as an iv bolus: mesna is given by intravenous injection over 15-30 minutes at 20% of the simultaneously administered oxazaphosphorine on a weight for weight basis (w/w). the same dose of mesna is repeated after 4 and 8 hours (as listed in the regimen schedule).
  • reference: https://www.medicines.org.uk/emc/product/1838/smpc
  • reference: drug package insert
• taking a conservative approach as conclusion, 30 minutes should be safe for adult.

700274711

210729

{colon cancer}

[initial presentation]

• 2019-08 intermittent low abdominal cramping pain and fullness, LMD FOBT positive.

[definite diagnosis and disease extent]

• 2019-09-19 patho, hemicolectomy:
  • descending colon, adenocarcinoma, moderately differentiated
  • IHC stains - EGFR(+), PMS2(+), MLH1(+), MSH2(+), MSH6(+).
  • pStage IVA, pT3N0M1a

[treatment]

• 2019-09-18 laparoscopic left hemicolectomy
• 2020-01-06 ~ 2020-03-16 FOLFOX x 6 (biweekly for 3 months, adjuvant)
• 2021-07-09 VATS RUL wedge resection
• 2021-07-27 ~ up-to-now FOLFIRI

[effect & side effect]

• 2021-07-09 patho, lung wedge biopsy:
  • adenocarcinoma, IHC stains: CK7(-), CK20(+), CDX2(+), TTF-1(-).
  • the morphology and immunohistochemical stains are consistent with metastatic colonic tumor.

[ongoing problem]

• colon cancer
  • assessment
    • FOLFIRI is introduced in the end of July 2021 soon thereafter lung mets wedge resection
    • MMR proficient, KRAS/NRAS not detected, BRAF, HER2 lab data not found.
    • updated CEA, CA199 within normal limits.
  • suggestion
    • keep the ongoing new regimen and surveilling every 3 to 6 months.
    • bevacizumab might be indicated.
• HBV
  • lab
    • 2021-07-23
      • Anti-HBc reactive
      • Anti-HBc-Value 5.56 S/CO
    • 2021-07-22
      • S-GPT/ALT 23 U/L
      • S-GOT/AST 23 U/L
  • medication
    • baraclude (entecavir 0.5mg) PO QDAC
  • assessment
    • in stable condition
• HTN
  • BP around 130/80 plus or minus 10 the first 2 days this hospitalization.
  • medication
    • norvasc (amlodipine 5mg) PO QD
    • syntrend (carvedilol 25mg) PO QD
  • assessment
    • in stable condition
• BPH
  • medication
    • avodart (dutasteride 0.5mg) PO HS
  • assessment
    • in stable condition
• hypertriglyceridemia
  • lab
    • 2021-07-08 494mg/dL
    • 2021-03-31 261mg/dL
    • 2021-01-08 339mg/dL
    • 2020-11-11 322mg/dL
    • 2020-04-13 592mg/dL
  • assessment
    • elevated serum TG for at least 1+ year.
  • suggestion
    • statin could be considered if not contraindicated.

700890235

210727

{coadministration of Decan and Juluca}

[objective]

• active medication include
  • Decan (dexamethasone) 6mg IVD QD
  • Juluca (dolutegravir 50mg, rilpivirine 25mg) 1 tab PO QNCC
• lab data on 2021-07-22 showed lower lymphocyte percentage, however other items were within normal range:
  • WBC 9.20*10^3/uL
  • Lymphocyte 14.3%
  • Lymphocyte count 1320/uL
  • CD3+/CD4+ Helper T 31.7%
  • CD3+/CD4+ Helper T C 418/uL
  • CD3+/CD8+ Suppre T 31.8%
  • CD3+/CD8+ Suppre T C 419/uL
  • CD4/CD8 Ratio 1.0
  • T Cells (CD3) 61.9%
  • B Cells (CD19) 9.7%

[assessment]

• rilpivirine prescribing information lists coadministration with multiple-dose dexamethasone as contraindicated due to a risk of decreased rilpivirine concentrations and loss of virologic response.
• the presumed primary mechanism of interaction between these agents is dexamethasone induction of CYP3A4 mediated rilpivirine metabolism.

[suggestion]

• please keep monitoring virologic responses.

700539680

210722

{vaccination for splenectomised patients}

[objective]

• this patient had splenectomy done on 2021-05-12 (huge spleen, >30cm in length, weight 2000g)

[assessment]

• splenectomised patients are at risk for severe and overwhelming infections with encapsulated bacteria, bloodborne parasites.
• measures for preventing these infections include patient and family education, vaccination against encapsulated bacteria.
• vaccines are available to against bacteria such as Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Bordetella holmesii.
• these vaccines are all in inactivated, noncellular form, not classified as attenuated, relatively safe for patients receiving chemotherapy.

[suggestion]

• as a general guide, vaccine dose could be administered when patient is in stable condition and during chemo window period. the dose should be repeated no less than 6 months after chemotherapy.

701282961

210722

{suspected MDS}

[objective]

• 2021-07-12 patho - bone marrow biopsy:
  • piece(s) of bone marrow with 70-80% cellularity and M:E ratio of approximately 1:4.
  • three cell lineages are present with normal maturation of leukocytes.
  • megakaryocytes are increased in number with nuclear atypia. myelodysplastic syndrome with no excessive blasts cannot be excluded.
  • IHC stains (of the nucleated cells):
    • CD117: <1%
    • CD34: <1%
    • MPO: 10-15%
    • CD61: 10-15%
    • CD71: 70-80%

[assessment]

• driver mutations are detected in >90 percent of cases of MDS. most commonly mutated genes are DNMT3A, TET2, IDH genes, ASXL1, TP53, RUNX1, SF3B1, U2AF1, SRSF2, ZRSR2.
• chromosomal abnormalities are presumptive evidence of MDS in patients with otherwise unexplained refractory cytopenia and no morphologic evidence of dysplasia, including:
  • unbalanced chromosomal abnormalities:
    • loss of chromosome 7 or del(7q)
    • del(5q) or t(5q)
    • del 20(q)
    • isochromosome 17q or t(17p)
    • loss of chromosome 13 or del(13q)
    • del(11q)
    • del(12p) or t(12p)
    • del(9q)
    • idic(X)(q13)
  • balanced chromosomal abnormalities:
    • t(11;16)(q23.3;p13.3)
    • t(3;21)(q26.2;q22.1)
    • t(1;3)(p36.3;q21.2)
    • t(2;11)(p21;q23.3)
    • inv(3)(q21q26.2) or t(3;3)(q21.2;q26.2)
    • t(6;9)(p23;q34.1)

[suggestion]

• no issue with current medication, chromosome tests has just been ordered on 2021-07-22, treatment plan will be more clear after having the outcome.

700825772

210721

{Rectal Cancer with UTI}

[objective]

• exams
  • 2021-07-20 urine culture: Escherichia coli.
  • 2021-05-18 patho - vaginal biopsy:
    • adenocarcinoma characterized by solid, villous or tubular pattern of tumor cells with necrosis.
    • immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+), PMS2(+) and GATA-3(-) for tumor cells, compatible with recurrent rectal adenocarcinoma.
  • 2021-05-17 CT - ABD:
    • rectal cancer s/p operation. a soft tissue lesion (3.0x4.1cm) at right presacral region. some nodules (up to 1.1cm) in bil. lungs.
  • 2021-01-26 CT - ABD:
    • post-op at the rectum with recurrence in presacral region, involvement of distal ureter and sigmoid colon.
    • progression of right hydronephrosis and hydroureter.
    • left lower lung nodule, suspected lung metastasis.
  • 2020-08-27 whole body PET:
    • in comparison with the previous study on 2019/12/23, a new glucose hypermetabolic lesion in the midline pre-sacral region. malignancy with local recurrence should be watched out.
    • another new glucose hypermetabolic lesion in the upper lobe of left lung. the nature is to be determined (a metastatic lesion? other nature?).
    • no prominent change was noted in the previous lesion in right pre-sacral region.
  • 2020-04-02 CT - lung/mediastinum/pleura
    • left upper lobe and right upper lobe dense nodules, old insult is more favored.
• tests
  • Fecal Occult Blood 4+ (2021-07-17)
  • CEA 46ng/mL (2021-05-24), 48ng/mL (2021-04-27), 63ng/mL (2021-03-30), 31ng/mL (2021-02-26), 0.8ng/mL (2020-07-17)
  • CA199 172U/mL (2021-05-24), 221U/mL (2021-04-27), 299U/mL (2021-03-30), 228U/mL (2021-02-26), 16U/mL (2020-03-24)
  • hs-Troponin I 109pg/mL (2021-07-17)
  • CRP 42mg/dL (2021-07-17)
  • Lactic Acid 3.5mmol/L (2021-07-17)
• medication
  • UFT (tegafur 100mg, uracil 224mg) BID PO with Folina (folinate 15mg) BID PO since 2021-03-02.
    • the same drugs have been prescirbed shortly in Feb and May each for 28-day in 2017.
  • Flumarin (flomoxef sodium 1000mg) IVD Q12H

[assessment]

• rectal cancer was first diagnosed in 2016, shortly thereafter followed with RT 5040cGy/28 and the disease has been controlled for not long years.
• patient’s family have lost several relative elders these consecutive years, care burdens let the lineal descendent caregivers exhausted. hospice care is arranged.
• oral prodrug of 5-FU for rectal cancer, lactulose for ileus, tramadol for pain control, ABX for UTI, no issue with the medication.
• according to the time serial tumor markers level, the disease somewhat responded to 5-FU prodrug since 2021 March.
• hs-Troponin I has played an important role in the risk stratification of patients during the in-hospital phase of acute coronary syndrome, the elevated level should be concerned.

[suggestion]

• keep monitoring progresstion of the infection and signs of acute heart attack.
• no adjustment for medication is needed.

700948740

210716

{potential interactions among lorazepam, olanzapine, morphine and labetalol}

[objective]

• concurrent medication:
  • lorazepam 2mg IVD PRNQ4H
  • olanzapine 5mg PO HS
  • morpine 5mg IVD PRNQ4H
  • labetalol 25mg IVD PRNQ8H

[assessment]

• coadministered lorazepam, olanzapine, morphine might enhance the CNS depressant effect.
• olanzapine might enhance the adverse effect of lorazepam (benzodiazepine).
  • reference:
    • https://pubmed.ncbi.nlm.nih.gov/15889948/
    • https://pubmed.ncbi.nlm.nih.gov/20156413/
• labetalol might enhance the hypotensive effect of olanzapine and morphine.

[suggestion]

• please monitor any sign such as anterograde amnesia, drowsiness, sedated stated, hypotension… to see if change is needed.

701300783

210716

{potential interactions among alprazolam, olanzapine and zolpidem}

[objective]

• concurrent medication:
  • alprazolam 0.5mg PO HS
  • olanzapine 5mg PO HS
  • zolpidem 10mg PO HS

[assessment]

• coadministered alprazolam, olanzapine and zolpidem might enhance the CNS depressant effect.
• olanzapine might enhance the adverse effect of alprazolam (benzodiazepine).
  • reference:
    • https://pubmed.ncbi.nlm.nih.gov/15889948/
    • https://pubmed.ncbi.nlm.nih.gov/20156413/
• clinical significance of this interaction may be lower with oral forms.

[suggestion]

• please monitor any sign such as drowsiness, fatigue, sedation, ataxia, memory impairment, irritability, cognitive dysfunction, dysarthria, dizziness to see if change is needed.

210708

{potential interaction when coadministering alprazolam, metoclopramide, olanzapine}

[objective]

the following items are listed in active medication: - alpraline (alprazolam, 0.5mg/tab) 1 tab PO HS - promeran (metoclopramide, 3.84mg/tab) 1 tab PO TIDAC - zyprexa zydis (olanzapine, 5mg/tab) 1 tab PO HS

[assessment]

• metoclopramide might enhance the adverse/toxic effect of olanzapine.
  • this could associate with development of extrapyramidal reactions or neuroleptic malignant syndrome.
• olanzapine might enhance the adverse/toxic effect of alprazolam.
  • due to risks of additive adverse effects (e.g., cardiorespiratory depression, excessive sedation).

[suggestion]

• if any above suspected symptom is observed, please discontinue the coadministration.

701239654

210706

{post-IPP meeting following up}

patient family meeting and IPP meeting was held at 10:00 on 2021-07-06

• the schedule with regimen for PBSCT for the patient has been disclosed in the meeting.

• the estimated total amount of melphalan used in the time table is 6 vials.

  • based on melphalan 50mg/vial, dose 100mg/m2, body surface area 1.425m2.
  • 3 vials per day for 2 days (2021-07-07, 2021-07-08).
  • the amount has been secured by medicine storeroom.

• preparation and administration precautions of mephalan:

  • expiration time 1.5hr after preparation (the duration including infusion time) according to package insert.
  • based on lab data reported on 2021-07-05, liver and kidney have no abnormality, no dose adjustment needed.

701243405

210630

{form virless (acyclovir) to famvir (famciclovir)}

[objective]

• being diagnosed with herpes virus infection.
• virless 500mg IVD Q8H ends by 2021-06-30 and famvir (famciclovir) 250mg PO TID starts from 2021-07-01.
• ALT elevated few days ago, newer lab data reported on 2021-06-30 and 2021-06-28 showd liver and kidney function normal.

[assessment]

• oral famciclovir excretion is primarily renal, and dose reduction is recommended in patients with impaired renal function.
  • no observed kidney problem, no adjustment need.
• hepatic impairment
  • a 44% decrease in the Cmax of penciclovir (active metabolite) was noted in patients with mild-to-moderate impairment
  • impaired conversion of famciclovir to penciclovir may affect efficacy becaused of declined first pass effect.
  • source https://clinicalinfo.hiv.gov/en/drugs/famciclovir/tablet-film-coated

[suggestion]

• please monitor the liver and kidney function as before, if liver function deteriorates, then adjust agent to maintain effect might be considered.

210628

{reported thrombotic microangiopathy with acyclovir}

[objective]

• thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS), manifestations of thrombotic microangiopathy, have been reported with acyclovir/valacyclovir
  • source:
    • Bell WR, Chulay JD, Feinberg JE. Manifestations resembling thrombotic microangiopathy in patients with advanced human immunodeficiency virus (HIV) disease in a cytomegalovirus prophylaxis trial (ACTG 204). Medicine (Baltimore). 1997;76(5):369-380. doi: 10.1097/00005792-199709000-00004.
    • Bukhari S, Aslam HM, Awwal TA, Christmas D, Wallach SL. Valacyclovir-induced thrombotic thrombocytopenic purpura. Cureus. 2020;12(5):e8156. doi: 10.7759/cureus.8156.
    • Moake JL. Thrombotic microangiopathies. N Engl J Med. 2002;347(8):589-600. doi: 10.1056/NEJMra020528.
    • Trachtman H. HUS and TTP in children. Pediatr Clin North Am. 2013;60(6):1513-1526. doi: 10.1016/j.pcl.2013.08.007.
• lab data
  • Bilirubin direct 0.06(6/28)
  • Bilirubin total 0.45(6/28)
  • S-GPT/ALT 59(6/28), 117(6/25)
  • Creatinine 0.67(6/28), 0.41(6/25)
• acitve medication
  • virless (acyclovir) 500mg IVD Q8H
  • imperan (metoclopramide) 10mg IVD PRNQ6H
  • loperamide 2mg PO PRNQ6H

[assessment]

• thrombotic microangiopathy mechanism:
  • idiosyncratic; leading to intravascular platelet-fibrin microthrombi, vascular damage, hemolysis, and thrombocytopenia. in HUS, this injury is believed to be initiated by uncontrolled activity of the alternative complement pathway, while TTP features a reduction in activity of ADAMTS13, the metalloprotease responsible for cleaving ultra-large von Willebrand factor multimers.
  • source: Trachtman H. HUS and TTP in children. Pediatr Clin North Am. 2013;60(6):1513-1526. doi: 10.1016/j.pcl.2013.08.007.
• bilirubin within normal range, no sign of TTP and HUS in nursing records.
• urinary retention and constipation could caused by herpes viral infection of the S2-S4 dermatome. accouding to active medication and nursing record, these should not be an issue.
  • source:
    • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613994/
    • https://pubmed.ncbi.nlm.nih.gov/19530489/
• liver function improved based on lowered ALT data, creatinine elevated but still in normal range.

[suggestion]

• keep current medication, acyclovir prescription will be end on 6/30, please continue to prescribe if the condition need.

210624

{acyclovir to treat herpes virus infection in HBV active carrier}

[objective]

• Lab
  • 2021-06-23
    • S-GOT/AST 68U/L
    • S-GPT/ALT 103U/L
    • creatinine 0.47mg/dL
    • eGFR 151
  • 2021-05-17
    • Anti-HBc Reactive
    • Anti-HBs 41mIU/mL
• Medication
  • baraclude (entecavir) 0.5mg PO QD
  • virless (acyclovir) 500mg IVD Q8H

[accessment]

• AST within 2x ULN, ALT within 3x ULN, liver function not so good but far from failure.
• renal function tests showed no abnormaility.
• the major route of acyclovir elimination is the renal excretion of unchanged drug (> 85%). liver plays no major roles in metabolism.
  • source https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825963/
• acyclovir can inhibit hepatitis B viral replication especially using higher dose.
  • source https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.1840080642
  • source https://academic.oup.com/jac/article-abstract/11/3/223/784017
• acyclovir and its alternatives, e.g. cidofovir, foscarnet, ganciclovir, all need to be adjusted dose based on CrCl but not on liver function.
• possible adverse reactions
  • acyclovir: acute renal failure, neurologic toxicity.
  • entecavir: increased serum alanine aminotransferase. (>5 x ULN: 11% to 12%; >10 x ULN and >2 x baseline: 2%), increased serum creatinine (1% to 2%)
• there is no drug interaction of risk level A or greater identified between acyclovir, entecavir and current chemo regimen.

[suggestion]

• regularily monitor liver and kidney functions the same as before, no adjustment needed.

000000

[initial presentation]

• 2021-05-07 intermittent lower abdominal pain for 3 weeks. pain was relieved after taking acetaminophen and diclofenac but recurred since 4 days ago. associated symptoms: constipation for 2 days, hiccup, nausea, poor appetite.

[definite diagnosis]

2021-05-06 CT - abd - loculated fluid accumulation at uterus up to 9.7*7.1cm in largest dimension is found. - uterine abscess is considered first. 2021-05-11 patho - ovary (tumor) - taiwan society of pathology was consulted to diagnose: malignant spindle cell and epithelioid cell neoplasm. - IHC: SALL4/BRG1/INI1(+), glypican/SATB2/cyclinD1( focal+); SS18-SSX/OCT4/CD30/ETV4/MDM2/S100/NUT/MyoD1(-).
- molecular pathology: SS18(-)(poor quality); chr12p/q FISH: failed. - comment: - while the majority of it was composed of relatively uniform spindle cells, gland-like components were also notable, in conjunction with the strong TLE1 immunostaining, justifying your original consideration of synovial sarcoma. - the degree of nuclear atypia would be somewhat too high for synovial sarcoma, and TLE1 expression is not specific. both SS18-SSX IHC and SS18 FISH performed to exclude this possibility. - given the gland-like structures which reminded yolk sac tumor, SALL4 (multifocally positive) and glypican (weakly positive, mainly in the gland-like structures) staining were performed and somewhat supported the speculation, albeit neither convincing nor specific enough. - attempt to pursue some molecular evidence of isochromosome 12p with chr12p, chr12q, and chr12 centromere FISH failed. - other possibilities including myoepithelial carcinoma were not supported by the current immunostaining results. - the case was reviewed by one senior GYN pathologist, one GU pathologist, and another soft tissue pathologist, and no conclusion could be drawn. - while a germ cell tumor with a component of yolk sac tumor and sarcomatoid transformation could not be excluded, the overall pathologic and clinical features would be atypical. - perhaps a genomewide study aiming at copy number variation/LOH might help in this regard. - note: some of the original immunostaining showed CK weak+, TLE1+, SMA f+, GFAP-. 2021-07-13 patho - ovary (tumor) - diagnosis: pelvic tumor, debulking surgery - compatible with recurrent malignant neoplasm. - the sections show a picture of spindle and epithelioid cell tumor characterized by spindle, ovoid or epithelioid tumor cells with congestion, hemorrhage, extensive necrosis, active mitoses, arranged in solid, focal fascicular or focal gland-like or rossette-like pattern, compatible with tumor recurrence.

[treatment]

• 2021-05-10 debulking surgery (BSO + cytoreduction surgery + infracolic omentectomy + appendectomy) for malignant left ovarian tumor.
• 2021-06-11 BEP (bleomycin + etoposide + cisplatin)
• 2021-08-13 doxorubicin

701304862

210625

{potential abx absorption problem}

[objective]

• active medication including:
  • Cravit (levofloxacin 500mg/tab) 1.5tab PO QDAC
  • Smecta (dioctahedral smectite 3gm/k) 1pk PO TIDAC
• the above items used at the same time in the morning.

[accessment]

• the adsorbent properties of smecta may interfere with the rates and/or levels of absorption of other substances, e.g. cravit.

[suggestion]

• it is recommended not to administer any other drugs at the same time as smecta.
• cravit could be shifted to HS to decouple administration time and still keep the same daily dose.

700373891

210618

{tube feeding}

all the oral drugs in active medication have been reviewed, the following two items can be peeled half but should not be grinded: - Curam (amoxicillin 875 mg, clavulanic acid 125 mg, tab) - film coated - Pentop (pentoxifylline 400mg, tab)

and the following item can not be peeled half or grinded: - Nexium (esomeprazole 40mg, tab)

the alternatives to above items, respectively, could be: - Soonmelt (amoxicillin 500mg, clavulanic acid 100mg, vial), if half-peeled Curam still too big to be fed. - there is no other drug containing same active ingredient with Pentop in the inventory, so please peel it (not too fine) to fit the tube. - Takepron (lansoprazole 30mg, tab) should not be grinded but can be peeled half.

701275722

210524

{tube feeding}

all the oral drugs in active medication can be administrated via NG tube except following items which should not be grinded:

• nexium (esomeprazole): please dissolve it with adequate drinking water prior to tube feeding.
• protase (pancrelipase): please open the capsule and mix the granules with pH<5.5 liquid food prior to tube feeding.
• oxynorm (oxycodone): if injection is not preferred, then fentanyl patch such as ‘durogesic d-trans’ or ‘fentanyl transdermal path PPCD’ might be an alternative.

700061689

210517

{tube feeding}

the oral drug takepron (lansoprazole, 30mg/tab) in active medication should not be grinded, while it can be peeled in half.

there is also an iv version takepron (lansoprazole, 30mg/vial) can be the alternative.

700990347

210513

{Tube Feeding}

all the oral drugs in current medication can be administrated via NG tube.

actein effervescent (acetylcysteine) should not be grinded, please dissolve the drug in adequate amount of drinking water prior to tube feeding.

700072580

210512

{post IPP meeting following up}

• the schedule with regimen for PBSCT for the patient is disclosed in the meeting.

• the estimated total amount of busulfan used in the time table is 15 vials.

  • based on busulfan 60mg/10mL/vial, dose 3.2mg/kg, body weight 85kg
  • 5 vials per day for 3 days (2021-05-12, 2021-05-13, 2021-05-14)
  • pharmacy staff in charge of drug purchasing will get the inventory ready before the coming prescribing.

• people for dispensing regimen during weekend are also arranged.

• preparation and administration precautions:

  • busulfan:
    • do not use polycarbonate syringes or polycarbonate filter needles with the drug.
  • etoposide:
    • precipitation may be exacerbated at concentrations of 0.4 mg/mL or above.
    • etoposide 400mg/m2 x body surface area 2m2 -> amount 800mg.
    • total solution containing 800mg etoposide will be no less than 2000mL.

701284346

210512

{drug identification}

requesting drug identification for 6 items.

the 4 identified items has been shown as following while the other 2 items still remain unknown: - sinemet (carbidopa 25mg, levodopa 100mg) - urief (silodosin 4mg) - rivotril (clonazepam 2mg) - through (sennoside 12mg)

these drugs will be sent back to ward by the in-hospital porter.

700150240

210510

{problem list}

the active problems listed in the TPR sheet are shown as following:

• pneumonia
• UTI
• hypertension
• ileus
• hyponatremia

[objective]

• urine OB 1+ (2021-05-08)
• urine bacteria 1+ (2021-05-08)
• CRP 5.39 (2021-05-08)
• D-dimer 1763ng/mL (2021-05-08)
• hs-Troponin I 49pg/mL (2021-05-08)
• Na 121mmol/L (2021-05-08)
• BUN 57mg/dL (2021-05-08)
• Creatinine 1.71mg/dL (2021-05-08)
• WBC 15.55 (2021-05-08)
• RBC 2.68 (2021-05-08)
• MCV 97.4 (2021-05-08)
• serum glucose 177mg/dL (2021-05-08)
• no defecation recorded in these 2 days

[assessment]

• vital signs, including blood pressure, looks relatively stable.
• if no other special consideration exists, the first priority should be controlling the infections.
• brosym 2000mg IVD Q12H has been prescribed to control the infection since 2021-05-09.
• the lower serum sodium might be improved by intaking salted food.
• lab data showed a higher serum glucose level, an one-point datum might not lead to its trend, more data to form a time series of blood sugar monitoring is recommended.
• MCV almost touched the upper limit of the normal range, some folic acid and/or vit B12 supplements might be helpful for the mild anemia.
• some laxative agent might be helpful for the ileus.

[suggestion]

• keep abx using and monitoring changes of infection signs.
• invite dietitian to help the patient to eat more salted diets and to see if any other diet issue found, then get sodium tested few days later.
• order regular scheduled blood sugar tests to build its trend.
• folacin (folic acid 5mg) and/or kentamin (thiamine 50mg, pyridoxine 50mg, cyannocobalamin 500mcg) are available in pharmacy inventory now, each of them could be administrated QD or BID, which is recommended.
• if still no defecation before 2021-05-11, then dulcolax (bisacodyl 5mg) QD or BID could be considered to prescribe, and administrated until defecation or 3 days then reevaluate the condition.

700350999

210510

{problem list}

active problems listed in 2021-05-08 14:14 DutyNote containing 2 items: - urinary tract infection - right lower lung pneumonia

[subj/obj]

• admitted on 2021-05-08 for lethargy, weakness for 5 days and fever for 1 day.
• with underlying HFrEF, bladder cancer s/p TURBT, HCVD, CKD and DM, been regularly followed up at our cardiology, urology, metabolism departments.
• bladder cancer causing voiding difficulties and UTI
• K 3.1mmol/L (2021-05-10), 3.1mmol/L (2021-05-08)
• BUN 123mg/dL (2021-05-10), 101mg/dL (2021-05-08)
• Creatinine 4mg/dL (2021-05-10), 3mg/dL (2021-05-08)
• eGFR 15 (2021-05-10), 20 (2021-05-08)
• CRP 8.63 (2021-05-10), 5.31 (2021-05-08)
• RBC 4x10^6/uL (2021-05-10), 3.7x10^6/mL (2021-05-08)
• HGB 11.6g/dL (2021-05-10), 10.8 (2021-05-08)
• MCV 84.8 fL (2021-05-10), 86.2 fL (2021-05-08)
• urine OB 2+, sediment-RBC 6-9, sediment-WBC >= 100, Bacteria 3+ (2021-05-08)
• hs-Troponin I 385pg/mL (2021-05-08)
• serum glucose 177mg/dL (2021-05-08), records fluctuate between 126-226 from 2021-05-08 19:00 to 2021-05-10 11:30.
• HbA1c 8.1 (2021-04-27), 8.6 (2021-03-01), 10.1 (2020-12-11), 9.6 (2020-09-17), 9.8 (2020-06-24)
• Uric Acid 4.6mg/dL (2021-03-01), 6.1 (2021-01-19), 8.1 (2020-12-11), 9.3 (2020-09-17), 8.6 (2020-06-24)

[assessment]

• vital signs looks relatively stable:
  • body temp no more than 37.5 degrees Celsius since 2021-05-08, the fever has subsided.
  • most of time SBP ranges in around 120-130, DBP 60-80, 3-day data showed BP is under well management.
• if there is no other special consideration, the first priority should be controlling the infections.
  • avelox (moxifloxacin) 400mg IVD QD has been administrated since 2021-05-09 and scheduled till 2021-05-15.
  • the patient has poor renal function, but no dosage adjustment necessary for avelox administration.
• although fever has gone, the rising CRP might hint the infection is still ongoing.
• the lower serum potassium might caused by uretropic (furosemide).
• lab data showed that blood suger flucturates in short-term (serum glucose), however the management is getting better in mid-term (HbA1c).
  • using humalog mix50 pen (insulin lispro 50%, insulin lispro protamine 50%) QDAC and QNAC now.
• MCV almost touched the lower limit of the normal range, some iron supplements might be helpful for boosting up the hemoglobin level.
• uric acid seems fell into normal range for months, xanthine oxidase inhibitor could be no more necessary.

[suggestion]

• keep abx using and monitoring any change of infection signs.
• invite dietitian to help the patient to get more potassium-containing food, and/or consider to shift uretropic (furosemide) to potassium sparing spironolactone.
• foliromin (ferrous sodium citrate, 50mg) BID for 2-4 weeks to levelup hemoglobin is recommended, administrated in combination with vit C to help absorption can be considered.
• if there is no special consideration, discontinuation feburic (febuxostat) is recommended.

700385854

210507

{colon cancer}

[subj/obj]

• diagnosed with sigmoid adenocarcinoma in 2020 Apr with liver, paraaortic LNs, and peritoneal carcinomatosis, cT3N2bM1c, stage IVc.
• received FOLFIRI 80% dose and 11 times panitumumab from May to Oct in 2020 at Taoyuan General Hospital of Ministry of Health and Welfare.
• patho colon biopsy on 2020-11-26 showed one huge tumor was noted at sigmoid colon (30cm from anal verge) and the lumen was near completely obstructed.
• colonic tissue with invasive irregular neoplastic glands. immunohistochemical stains reveal CDX2(+) EGFR(+), PMS2(+), MLH1(focal +), MSH2(+), and MSH6(+).
• received FOLFIRI 6 times from 2020 Nov to 2021 Mar (C1D1, C1D15, C2D1, C2D15, C3D1, C3D15) in our hospital prior to this hospitalization.
• NRAS/KRAS reported on 2020-12-15 showing not detected.
• CEA 16.62ng/mL(2021-01-26), 8.52ng/mL(2020-11-17).
• BRAF lab data not found.

[assessment]

• patients with tumors originating on the right side of the colon (hepatic flexure through cecum) are unlikely to respond to cetuximab and panitumumab in first-line therapy for metastatic disease.
• EGFR(+), KRAS/NRAS WT gene and left-sided tumor - panitumumab is purchased and will be ready for the patient in days.
• immune checkpoint inhibitors might not an ideal option for non-dMMR/MSI-H tumor - MLH1(focal +), MSH2(+), MSH6(+).
• according to CEA lab data, the condition might not be improved after one year FOLFIRI.

[suggestion]

• might order CT scan to gather new evidence on treatment effect.
• If evidence shows that the cancer is getting more advanced, then shift FOLFIRI to FOLFOX or CAPEOX (each regimen can be used in combination with bevacizumab) could be considered.

---

{substance dependence}

[subj/obj]

• lab test showed evidence of using addictive drug.

[assessment]

• should help the patient get rid of those illegal drugs.

[suggestion]

• might arrange or refer the patient to an addiction treatment center or clinic to get some alternative e.g. methadone.

---

{returning to society}

[subj/obj]

• his family members avoid to contact him.
• no job, no income
• not standing on his own feet yet (financially)

[assessment]

• being not reintegrated to the society will push him closer to the additive drugs.

[suggestion]

• might arrange social work department staff to see if any help could be offered to him.

700134931

000000

{colon cancer}

[initial presentation]

• 2021-01-22 RBC 3.42x10^6/uL, HGB 6.6g/dL, blood transfusion pRBC 2U on 2021-02-12.
• 2021-02-19 stool occult blood: positive

[definite diagnosis]

• 2021-03-15 colonoscopy: probable advanced colon cancer, ascending colon, ileocecal valve involvement suspected
• 2021-03-19 patho: adenocarcinoma, IHC stain: EGFR(+), PMS2(-), MLH-1(-), MSH-2(+), MSH-6(+)

[disease extent & staging]

• 2021-03-16 CT, ABD:
  • low density lesions at both lobes of liver is found. liver simple cysts are considered.
  • compatible with ascending colon cancer, regional lymphadenopathy, T2N2aMo -> M1 (with liver mets)

[treatment & plan]

• biweekly, Q2WK
  • covorin (leucovorin) 400mg/m2, with 250mL N/S, 2hr
  • 5-Fu (fluorouracil) 400mg/m2, with 100mL N/S, 10min
  • 5-Fu (fluorouracil) 2400mg/m2, with 500mL N/S, 46hr

[effect & side effect]

• NA

[ongoing problem]

• chronic ischemic heart disease
• type 2 diabetes mellitus
• hypercholesterolemia
• polyosteoarthritis

700180657

000000

{colon cancer}

[objective]

• 2018-02 diagnosed with adenocarcinoma of S-colon, cT3N0M0.
• 2018-02-14 pathology
  • large intestine, sigmoid colon, laparoscopic LAR —- Adenocarcinoma, moderately differentiated.
  • IHC stains: EGFR (+), PMS2 (+), MSH 6 (+), MSH2 (+), MLH1 (+).
  • foci of mesenteric endometrosis, CK7 (+) and CK20 (-), with fibrosis.
  • AJCC 8th ed. staging: pT3N0 (cMx); pStage: IIA at least (if cM0).
    • primary tumor pT3 - tumor invades through the muscularis propria into pericolonic tissues
    • regional lymph nodes pN0 - no regional lymph node metastasis
    • distant Metastasis pMx
      
• 2018-12-25 CT: soft tissue mass with necrotic margin at surface of uterus up to 2.9cm in largest dimension which is new in comparison to CT dated on 2018-06-02.
• 2019-01-03 PET
  • a glucose hypermetabolic lesion on the superior aspect of the uterus. should be malignancy with pelvic seeding on the uterus.
  • increased FDG accumulation in the right lateral aspect of the abdomen and pelvic region and in the anterior aspect of the pelvic region.
• 2019-01-04 sigmoidfiberscopy: an ulcerative tumor, about 1/3 circumferential bowel lumen at 18cm above AV (RS-colon) with easy contact bleeding previous anastomosis (10cm AAV) looked well.
• 2019-01-10 low anterior resection (LAR) and hysterectomy plus bilateral salpingo-oophorectomy (BSO) recurrent 3cm tumor (favor seeding) involving uterus and upper rectum and a segment of small bowel was identified.
  • IHC stains: CK20(+), CK7(focal+), vimentine(-)
  • patho: rT4bN0M1a, stage IVA. 2019-09-20 received 12th Avastin & 14th FOLFOX6, mild fingers and feet numbness, pigmentation on breast skin. 2019-10-15 refilled Xeloda (capecitabine), mild fatigue, nausea, abdomen discomfort. 2019-11-26 refilled Xeloda (capecitabine), nail and finger pigmentation, mild fatigue and numbness. 2020-03-25 CT: a known newly-developed soft tissue nodule measuring 0.6 cm in right pelvic wall is noted again, increasing in size. 2020-04-07 PET
  • a glucose hypermetabolic lesion in the right anterior pelvic wall, compatible with a metastatic lesion.
  • multiple glucose hypermetabolic lesions in the left lower abdomen and in the pelvic cavity and a glucose hypermetabolic lesion in the left upper abdomen. 2020-11-07 CT: multiple soft tissue nodules in the peritoneum (upper abdomen and pelvic cavity), up to 1.7cm in left pelvic cavity, suspected peritoneal carcinomatosis. 2021-02-20 CT: progression of peritoneal tumors with left lower ureter invasion causing left hydronephrosis and hydroureter.
• CEA
  • 2021-04-28 _8.64
  • 2021-03-29 15.23
  • 2021-03-02 16.89
  • 2021-01-23 13.56
  • 2020-10-28 _5.044
  • 2020-06-22 12.062
  • 2020-03-18 _8.714
  • 2019-12-09 _2.008
  • 2019-08-16 _0.866
  • 2019-04-30 _1.534
  • 2018-12-10 15.635
  • 2018-09-10 _2.047
• regimen
  • 2018-03-03 ~ __________: Ufur (tegafur + uracil)
  • __________ ~ 2020-07-03: FOLFOX + Avastin (bevacizumab)
  • 2020-07-17 ~ 2021-02-19: FOLFIRI + Cyramza (ramucirumab)
  • 2021-03-31 ~ up to now : RegoNivo (Opdivo (nivolumab) + Stivarga (regorafenib))

[assessment]

• PMS2 (+), MSH 6 (+), MSH2 (+), MLH1 (+) -> not dMMR, EGFR (+), pembrolizumab might not be indicated.
• no KRAS/NRAS/BRAF lab data found.
• after using 5-FU, FOLFOX plus anti-VEGF bevacizumab as adjuvant first-line therapy for more than one year (2018 Mar ~ 2020 Jul), the disease progressed, then the regimen was shifted to FOLFIRI plus anti-VEGFR2 ramucirumab as second-line therapy. the two regimen are listed in NCCN clinical practice guidelines.
• the cancer has been progressed in 2020Q4 ~ 2021Q1, regimen shifted to RegoNivo since end of 2021 March.
  • nivolumab - anti-PD1, usually used in combination with anti-CTLA4 i.e. ipilimumab, to treat adults with metastatic colorectal cancer that is microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR), and patient have tried treatment with a fluoropyrimidine, oxaliplatin, and irinotecan.
  • regorafenib inhibits multiple kinases including VEGF1, VEGF2, VEGF3, PDGFR, FGFR involved in tumor angiogenesis and KIT, RET, RAF-1, BRAF involved in oncogenesis.
  • RegoNivo regimen is supported by articles, e.g. “Regorafenib Plus Nivolumab in Patients With Advanced Gastric or Colorectal Cancer”
• possible toxicity for RegoNivo regimen
  • nivolumab can result in significant immune-mediated adverse reactions due to T-cell activation and proliferation. These immune-mediated reactions may involve any organ system, with the most common reactions being pneumonitis, enterocolitis, hepatitis, dermatitis, hypophysitis, nephritis, and thyroid dysfunction.
  • regorafenib:
    • hypertension occurs in nearly 30% of patients. usually occurs within 6 weeks of starting therapy and is well controlled with oral antihypertensive medications.
    • skin toxicity in the form of hand-foot syndrome and skin rash occur in up to 45% and 26%, respectively. generally appears within the first cycle of drug treatment.

[suggest/plan]

• monitor any sign of toxicity caused by nivolumab and regorafenib.
• keep tracking tumor markers including CEA
• update chest, abdomen, and pelvic CT (and/or PET) every 3-6 months.

700290223

000000

{intrahepatic cholangiocarcinoma}

[initial presentaion]

• 2006-04 Echo
  • Liver cirrhosis (HCV related), liver cysts status post left lobectomy
  • Parenchymal renal disease with bilateral renal cysts, GB polyps, multiple
• 2008-10 HCC s/p operation left lobectomy
• 2010-03-03 Recurrent HCC in S6 s/p S6-segmentectomy

[definite diagnosis]

• 2021-04-09 Patho liver biopsy
  • adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma
  • IHC: CK7(+), CK20(focal+), Hepa-1(-) and Arginase-1(-)

[disease extent]

• cT2N0M0, stage II

[treatment]

• 2021-05-26 ~ 2021-05-20 CCRT 3240cGy/18 fractions, gemcitabine

[effect and side effect]

• 2021-07-13 CT, ABD
  • s/p op. over left lobe liver with residual choalangiocarcinoma at S4 and liver meta.
  • the ovarall treatment response is stationary except slghtly increaed metastatic size.
  • gallstones.

[ongoing problem]

HCV, Cirrhosis, Child A - 2021-03-30 - HBsAg Nonreactive - Anti-HBc Reactive - Anti-HCV Reactive

hypertention, portal hypertension varicose vein GERD type 2 DM

700348580

000000

• 2018-10 diarrhea on and off

• 2020-11-12 patho - colon biopsy

  • pieces of colonic tissue with invasive irregular neoplastic glands.
  • immunohistochemical stains - EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).

• 2020-11-12 CT, ABD: cT3N2aMia, stage IVA Re-evaluation on 12/14/2020 slightly decreased in tumor size.

• 2020 late Nov ~ 2021 early Jan CCRT, FU/LV 5040 cGy/28Fx in hope of receiving sphincter preserving surgery (Last RT on 1/5).

• 2021 Feb there after chemo FOLFOX

• 2021-02-18 CT, ABD: much regression of rectal cancer.

2021-03-10 Op Method: Abdominoperineal resection (APR)
Finding: 1. Tumor in rectum, cT3N2aM1a (enlarged nodes in left external iliac chain) 2. End S colostomy is done over LLQ
3. One JV drain at pelvic area

rectal cancer, cT3N2aM1a s/p CCRT, was admitted for scheduled laparoscopic APR with permanent colostomy. - 2021-03-18 patho - abdomino-perineum resection - ypT3N1aMia stage IVA

2021-05-13 Self-Monitoring of Blood Glucose,SMBG QDAC

PatMRNo, PatID, PatName, PatBDate, PatGender

Brosym 4g Q12H

assumed 50kg body weight with Cockcroft-Gault formula, the estimated CrCl is 25mL/min, daily maximal dose is 4g (2g Q12H) according to package insert.

cefoperazone sulbactam

daily maximal 4g (2g Q12H)

Nexium (esomeprazole) should not be grinded, shifting to Takepron (lansoprazole) is recommended.

Actein should be dissolved in adequate drinking water prior to tube feeding.

thanks and regards,

all the oral drugs in active medication can be administrated via NG tube except Doxaben XL (doxazosin) which is release-controlled.

Urief (silodosin) is recommended as an alternative to switch Doxaben.

thanks and regards,

omeprazole lansoprazole pantoprazole rabeprazole

700360779

000000

[objective]

• exam finding
  • 2022-05-02 Chest AP portable
    • right internal jugular central venous catheter with tip in the SVC
    • normal size of heart
      
    • residual hazy areas of increased opacity with reticular opacities in Lt lung and Rt lower lung zone
  • 2022-04-29 Renal ultrasound
    • Parenchymal renal disease.
    • Perirenal fluid accumulation over right lower kidney, suspected Inflammatory or infectious process.
  • 2022-04-21 CT - lung/mediastinum/pleura
    • Interstitial pneumonitis at both lungs.
    • Heart failure.
    • Calcified coronary arteries is found.
  • 2022-04-21 Cardiac ultrasound
    • normal chamber size
    • concentric LV hypertrophy
  • 2022-04-20 MRI - liver, spleen
    • Lobulated soft tissue lesions, passive atelectasis, or effusions in bilateral posterior basal CP angle are suspected. Please correlate with CT.
    • The liver and spleen shows hypointensity on T2WI that may be iron deposition. please correlate with clinical condition.
    • Artifact or fluid collection in right upper abdominal wall is suspected? Please correlate with CT.
    • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidney.
      
    • There is no evidence of ascites or lymphadenopathy.
    • The abdominal aorta and IVC are grossly unremarkable.
      
  • 2022-04-12 Standing KUB
    • Wedge deformity of L1 vertebral body is suspected. Please correlate with lateral view.
    • Spondylosis of the L-spine is noted.
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
    • Fecal material store in the colon.
  • 2022-04-13 Electrocardiography
    • Sinus tachycardia with Premature atrial complexes with Aberrant conduction
  • 2022-04-01 CT - lung/mediastinum/pleura
    • Esophageal cancer at middle third esophagus with slightly decreased in size.
  • 2022-02-11 CT - lung/mediastinum/pleura
    • Esophageal cancer at middle third esophagus s/p trial with statonary primary tumor size and extension as well as the mediastinal lymph nodes s/p jejunostomy.
  • 2022-01-27 GI series
    • suspected esophageal rupture or ulceration at esophageal tumor, middle third esophagus.
  • 2022-01-11 CT - lung/mediastinum/pleura
    • middle third esophageal cancer, significant improvement and persisted multiple small LNs in visceral and left anterior prevascular spaces compared with CT on 2021/11/18.
  • 2021-12-29 Renal ultrasound
    • bilateral chronic change of both kidneys.
  • 2021-11-18 CT - lung/mediastinum/pleura
    • Esophageal cancer at middle esophagus with main tumor regression.
    • Lymphadenopathy in the mediastinum. Stable
    • s/p jejunostomy.
    • Calcified coronary arteries is found.
  • 2021-11-03 Standing KUB
    • Spondylosis of the L-spine is noted.
    • Disk space narrowing of L4/5.
    • Compression fracture of L1 vertebral body.
    • Fecal material store in the colon.
  • 2021-09-27 MRI - brain
    • No evidence of brain metastasis.
  • 2021-09-23 CT - lung/mediastinum/pleura
    • Esophageal cancer up to 8.9*2.95cm with regional and mediasitnal lymphadenopathy. Stationary as compared with previous CT on 2021-08-30.
  • 2021-09-09 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the middle to lower T-spines and some L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in bilateral rib cages and mildly increased activity in the right femoal neck. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, left hip, bilateral knees and left ankle, compatible with benign joint lesions.
  • 2021-09-08 Whole body PET scan
    • Glucose hypermetabolism in the middle esophagus, compatible with the primary malignancy of esophagus.
      
    • Glucose hypermetabolism in bilateral mediastinal lymph nodes, cancer with regional lymph nodes metastases should be considered, suggesting further investigation.
      
    • Increased FDG uptake in the right upper and right lower lungs, the nature is to be determined (inflammation/infection process or distant mets?), suggesting further investigation also.
      
    • Esophageal cancer, cTxN2M0-1, by this F-18 FDG PET/CT scan.
  • 2021-09-06 Patho - esophageal biopsy
    • Upper esophagus, biopsy — Severe dysplasia at least
      
    • Microscopically, the sections show a picture of severe dysplasia at least characterized by pleomorphic and hyperchromatic atypical squamous cells with focal ulceration, lymphoid follicle with germinal center, without convincing stromal invasion.
      
    • Immunohistochemistry of P16(-), P53(+), P63(+) and CK(+) for dysplastic cell. However, more advanced lesion can not be excluded entirely. Closely follow up and repeat biopsy is advised, if clinically indicated.
  • 2021-09-04 MRI - brain
    • no evidence of brain metastasis.
  • 2021-08-30 CT - lung/mediastinum/pleura
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T4N2M0
  • 2021-08-30 Patho - esophageal biopsy
    • Diffusely circumferential mucosal erosions with frability were noted at upper esophagus(30cm~20cm below the inscisor). Upper esophageal tissue peel off spontaneously when endoscopy pass through it. We used net to removed it out and sent for pathology.
    • Upper esophagus, 30-20 cm below the incisor, peel removal — Squamous cell carcinoma
      
    • Immunohistochemistry shows CK(+), P63(+), P53(+) and P16(-) for tumor cell.
  • 2021-08-27 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Diffuse esophageal erosions with oozing, upper esophagus, s/p pathology evaluation
      • Esophageal ulcers, multiple, middle and low esophagus
      • Superficial gastritis
      • Suspect Brunner’s gland hyperplasia, bulb
    • Suggestion
      • Admission for observation
      • Endoscopic hemostasis for upper esophagus was difficult. Consider angiography if still active bleeding
      • Persue pathology result
• consultation
  • 2022-04-29 General and Gastroenterological Surgery.
    • Q
      • For TPN
      • This 66-year-old man patient is a case of squamous cell carcinoma of upper to middle third esophageal with bilateral mediastinal lymph nodes metastasis, cT4aN2M1, Stage IVB s/p Port-A and feeding jejunostomy, s/p BGB-A317, BGB-A1217 and cisplatin plus 5-FU and chronic kidney disease, stage 3 (Creatinine 2.11 mg/dL). This time, for fever with B/S on 20220403 showed Enterococcus faecium and Acinetobacter baumannii complex infection and Port-A blood culture showed GPC. Remove Port-A on 20220408. Intabated ETT on 20220421 due to severe metabolic acidosis and dyspnea. Transferred to ICU for severe sepsis on 20220421. Jejunostomy created on 20210906. However, ostomy wound reddish and leak, so NPO since 20220425.
    • A
      • obj?
        • A case of esophageal cancer with j-tube leakage who request nutrition support.
        • General appearance: ill looking
        • GI tract: Dysphagia (-), Abd pain (-), Abd distension (-), Nausea (-), Vomiting (-), Diarrhea (-), Poor appetite (+), Poor digestion (-), BW loss (-) , stool (+), Bowel sound (-)
          
        • Feeding: NPO
        • Allergy: NKA
        • Nutrition assessment: BH 164cm, BW 66.2kg, UBW 56.8 kg, IBW 59.2kg, 96% IBW, BMI 21, BEE (calculated based on IBW) 1251kcal, TEE 1952kcal
        • Lab data: Alb 2.9, BUN 26, Cr 0.58, Na 133, K 3.6, BS 100
        • According to the patient’s present conditions, parenteral nutrition plus enteral feeding (place ND tube if achieved as tolerance) will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
      • PN suggestion:
        • DC Bfluid 1000ml（RI 4U）and D10W 500ml（RI 12U）QD
        • DC D50W 80ml Q6H（RI 8U each time）
        • D50W 500ml QD run 20.8ml/hr（add RI 10U ）
        • Amino-Hepa 1000ml QD
        • Lyo-Povigent 4ml/QD（add in TPN）(if out of stock, then use B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
        • Addaven 10ml/QD（add in TPN）
      • PN monitor items
        • Check BW QW5 and record I/O Q8H
        • Check one touch Q6H for 2days, if stable QD check
        • Please control BS < 200 mg/dl with RI sliding scale
        • QW1 check CBC/DC
        • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
        • if TPN not sufficient, use YF5 or D10W instead.
  • 2022-04-22 Rheumatology and Immunology
    • Q
      • For IVIG (autoimmune disorders)
      • Current problem: We need your specialist to evaluate and screen the patient, to exclude auto-immune disease or suitable administration of intravenous immune globulin (IVIG).
    • A
      • History review were performed. Patient was admitted to ICU due to acute respiratory failure after receiving check point inhibitor therapy for esophagus SCC. I was consulted for immunotherapy for possible drug-related ILD.
      • Suggestion:
        • Treatment as current your expert’s management and infection control.
        • For IVIG dosage (1-2g/kg), please prescribe IVIG 60g, divided by 3 days therapy as below:
          • Day 1:
            • N/S 250mL for 1 hour
            • IVIG 20gm (4 bots) in D5W 300mL(total 500mL) IVD for 6 hours
            • N/S 250mL for 1 hour
          • Day 2:
            • N/S 250mL for 1 hour
            • IVIG 20gm (4 bots) in D5W 300mL(total 500mL) IVD for 6 hours
            • N/S 250mL for 1 hour
          • Day 3:
            • N/S 250mL for 1 hour
            • IVIG 20gm (4 bots) in D5W 300mL(total 500mL) IVD for 6 hours
            • N/S 250mL for 1 hour
        • Consider to add actemra 1AMP (162mg) SC as adjunctive therapy for ILD.
        • Please monitor clinical condition after therapy. If not effective, then plasma exchange maybe considered.
  • 2022-04-22 Metabolism and Endocrinology
    • Q
      • For abnormal thyroid enzymes
      • Current problem: We need your specialist to evaluate and differential diganosis as sick euthyroid or medical advice.
    • A
      • O:
        • HR: 66-135
        • SBP: 110-200+
        • Possible related medication: methylprednisolone (since 20220418)
        • AST/ALT: 68/119
        • BUN/Cr: 69/2.88
        • Na: 142, K: 3.4
        • TSH/FT4: 1.952/0.58
        • FT3: 1.4
        • ATPO, ATG, TSH receptor Ab: unavailable
        • ACTH/Cortisol: 5.3/7.86 (20220419), steroid (+)
      • A: R/I sick euthyroid syndrome
      • Suggestions:
        • No need of any treatment at this timing
        • Recheck TSH/FT4 (biochemistry) 2 weeks later
  • 2022-04-21 Nephrology
    • Q
      • For AKI with metabolic acidosis
      • Current problem: HD is prefer, We need your specialist to evaluate.
    • A
      • Lab data:
        • PH: 7.18, PCO2: 29, PO2: 146, HCo3:10.8, BE: -16.2
        • WBC: 21.42, Hb:11.0, PLt: 346
        • CEA: 9.96, SCC:3.1
        • GPT: 224, GOT: 105, T.bil: 7.26, D.bil: 4.77, LDH: 330, lipase: 288, amylase: 150, rGT: 768
        • BUN/cre : 25/1.68 (20220330) -> 27/2.11 (20220404) -> 29/2.94 (20220414) -> 49/5.00 (20220418) -> 82/4.15(20220420)
        • U/O: 1420ml -> 56ml
        • Vital signs: E2V5M4, BP: 179/105mmHg
        • PE: Under MV ventilator FiO2: 60%, no limb edema
        • CT chest: interstitial pneumonitis at both lungs
        • Cardiac echo: LVEF 71.5%, concentric LVH
      • Impression:
        • Acute kidney injury stage 3 on CKD with metabolic acidosis
      • Suggestion:
        • Check serum lactate, ketone, Cl, FeNa, FeBUN, urine osmolarity, blood osmolality
        • Check Urine for analysis
        • Correct metabolic acidosis and follow up ABG
        • Adequate IV fluid hydration
        • Avoid nephrotoxic drugs
        • If there is refractory metabolic acidosis, electrolyte imbalance, fluid overload, oliguria, we will arrange RRT if family agree
      • 20220428 Follow up:
        • Still metabolic acidosis (nonAG)
        • Check urine AG and add sodium bicarbonate 2# bid
        • Arrange renal echo
        • We will follow up this case
  • 2022-04-19 Gastroenterology
    • Q
      • This 66-year-old man patient is case of squamous cell carcinoma of upper to middle third esophageal with bilateral mediastinal lymph nodes metastasis, cT4aN2M1, Stage IVB s/p Port-A and feeding jejunostomy, s/p BGB-A317, BGB-A1217 and cisplatin plus 5-FU.
      • This time, for progression abnormal liver function, R/O IO therapy side effect.
    • A
      • Rule out other possibilities before considering BGB-A317-, BGB-A1217-induced hepatitis.
        • Check ALKP, rGT, ALB, PT, APTT, LDH to complete liver study
        • Check Anti HAV IgM, HBsAg, anti-Hbs Ab, Anti HCV Ab
        • Check antinuclear antibodies (ANA), smooth muscle antibody (SMA), Epstein Barr virus (EBV) IgM, cytomegalovirus (CMV) PCR
        • Check thyroid and adrenal function
        • Regularly/closely monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALKP (every two days)
        • Avoid hepatic toxic agent if possible(or adjust dose), simplify medication
        • silymarin 1#~2# TID
      • When other possibilities have been excluded or the liver has decompensated and a checkpoint inhibitor-related immune hepatitis is suspected, steroids may be administered for immune-mediated hepatitis: (reference: Sanjeevaiah, A., Kerr, T., & Beg, M. S. (2018). Approach and management of checkpoint inhibitor-related immune hepatitis. Journal of gastrointestinal oncology, 9(1), 220–224. https://doi.org/10.21037/jgo.2017.08.14 )
        • Initial dose of 0.5 to 1 mg/kg/day of prednisone for Grade 2 hepatitis
        • Initial dose of 1 to 2 mg/kg/day of prednisone for Grade 3 or greater hepatitis, followed by a slowly taper about one month
        • Based on severity of liver enzyme elevations, withhold or discontinue BGB-A317, BGB-A1217
        • Consider liver biopsy for alternate etiology and add mycophenylate mofetil 1g PO BID if no improvement after 3 days of steroid
  • 2022-04-08 Infectious Disease
    • Q
      • This time, for fever with B/S on 20220403 showed Enterococcus faecium and Acinetobacter baumannii complex infection and Port-A blood/C showed GPC. Port-A catheter removed on 20220408.
    • A
      • The Enterococcus is susceptible to ampicillin.
      • The Acinetobacter is susceptible to pip/tazo.
      • Agree with your use of tapimycin. Adjust the dose to 2.25g iv q6h according to the renal function.
      • Recheck B/C 3 days later. Please consider to remove the port-A if persistent bacteremia.
      • Arrange CV-echo to exclude endocarditis.
  • 2022-03-16 Dermatology
    • This patient suffered from dyskeratotic nails for years.
    • Imp: Tinea unguim, subacute dermatitis
    • Suggestion:
      • Excelderm crema 2 tubes, bid
      • Topsym cream 4 tubes, bid
  • 2021-12-28 Nephrology
    • Q
      • Consultation for renal dysfunction (eGFR 20) and electrolyte imbalance (K 2.5, Mg 4, Ca 1.84, Na 126).
    • A
      • Impression:
        • AKI Stage 3, cause to be determined
        • Hypokalemia suspect extrarenal loss related
        • Hyponatremia suspect extrarenal loss related
      • Suggestions:
        • check FeNa, urine Na, urine osmo, urine K, urine Cl, urine creatinine, urine Mg
        • check blood osmo, cortisol, ACTH, thyroid functions, total CO2
        • potassium supplement
        • adequate hydration
        • record I/O and body weight qd
        • avoid nephrotoxic agents
        • keep hemodynamic stable
        • arrange renal echo
        • recheck electrolytes, renal functions and total CO2
  • 2021-12-24 Metabolism and Endocrinology
    • Q
      • For evaluate hypothyroidism therapy
    • A
      • O:
        • BH: 166 cm, BW: 61.1 kg
        • HR: 78-114
        • Possible related medication: nil
        • AST/ALT: 16/17
        • BUN/Cr: 94/3.30
        • Na: 140, K: 3.9
        • TSH/FT4: 7.543/1.00
        • FT3: 3.1
        • ATPO, ATG, TSH receptor Ab: unavailable
        • ACTH/Cortisol: unavailable
      • A: Subclinical hypothyroidism
      • Suggestions:
        • Check anti-TPO Ab, anti-thyroglobulin Ab, ACTH/cortisol
        • Recheck TSH/FT4
        • No need of thyroxine supplement at this moment
        • Endocrine OPD F/U
  • 2021-09-07 Hemato-Oncology
    • Patient examined anc Chart reviewed. A case of T4N2Mx, Stage IV ESCC is noted. I am consulted for further evalution and mangmenet.
    • My suggestions are:
      • Arrange discussion with patient and family (already the afternoon on 2021-09-11)
      • The patient is preliminarily fit the clinical trial of Phase I BGB at Cohort 6.
      • Please do not perform radiotherapy at present, which is requested by trial.
      • If necessary, I might take over this case.
  • 2021-09-02 Radiation Oncology
    • Subjective:
      • History: This 66-years-old male patient has been drinking alcohol for 30-40 years (half glass per day). He has suffered from progressive dysphagia and BW loss of 10 kg for 2 months. He can tolerate soft diet now. Due to the EGD showed suspicious esophageal lesion, r/i malignancy, chest CT on 2021/08/30 reported esophageal carcinoma, cT4N2M0. Pathology report showed squamous cell carcinoma, moderately differentiated. Staging workup is ongoing.
      • Previous RT: denied.
      • Other disease: Gastric ulcer with bleeding and hemorrhoid for 12 years.
      • Family history: denied.
      • Habit: smoking, 1 PPD for 30 yr, quitted for 15 yr; alcohol: half glass per day, just quitted; betel nut: denied.
      • Married. Caregiver: his wife. Job: retired buffet cook. No or mild economic stress.
      • Language: Mandarin, Taiwanese.
    • Objective:
      • General Condition-ECOG: 1.
      • PE, 2021/09/02: No palpable SCF LNs.
      • Pathology: 2021/8/30, Upper esophagus, 20-30 cm below the incisor, peel removal — MD squamous cell carcinoma; CK(+), P63(+), P53(+) and P16(-).
      • Images:
        • PED, 2021/8/30: diffusely circumferential mucosal erosions with friability were noted at upper esophagus (20cm~30cm) below the incisor. Upper esophageal tissue peel off spontaneously when endoscopy pass through it. We used net to removed it out and sent for pathology. Multiple ulcers were noted at middle and lower esophagus (from ECJ to 30cm below the incisor). Mucosal active oozing was noted at 23cm below the incisor.
        • Chest CT, 2021/08/30: asymmetric esophageal wall thickening of middle third of thoracic esophagus with severe luminal narrowing (length 7.5 cm, thickness 30 mm), with loss of fat planes between posterior wall of trachea and left main bronchus. multiple small LNs in visceral and left anterior prevascular spaces. Hila: no enlarged LN. IMP: middle third esophageal cancer cT4N2. Nonspecific inflammation in LUL. Moderate 3V-CAD.
        • EUS, 2021/9/03: pending.
        • Bone scan, PET, 2021/9/06: pending.
    • Diagnosis: Esophageal cancer, M/3, MD SqCC, cT4N2M0 (pending staging workup) with loss of fat planes between posterior wall of trachea and left main bronchus, R & L paratracheal and subcarinal LAP metastasis; ECOG = 1.
    • Suggest: Radiotherapy.
    • Goal: Curative (pre-operative).
    • RT Plan:
      • Target & Volume: Esophageal tumor and LAPs.
      • Technique: VMAT & IGRT by linear accelerator.
      • Dose & Fractionation: 5040cGy/28 fractions with concurrent chemotherapy.
    • Plan: Staging workup, PortA implantation and jejunostomy are suggested. CCRT is suggested for downstage & downsize. Possible radiation effects (malaise, radiation esophagitis, pneumonitis) is told. CT simulation will be arranged on 20210908 after PortA implantation and jejunostomy are done. Diet education is given.
• surgical operation
  • 2022-01-24 Endoscopic esophageal dilatation
    • esophageal stenosis noted around 25~30 cm from incision
    • tumor resolution noted at endoscopic view
    • esophageal perforation at 9’ clock 25 cm from incision due to fragile esophageal wall
    • dilatation successful upto 48 Fr. Bougie dilator
  • 2021-09-06 Feeding jejunostomy + port-A insertion
• chemoimmunotherapy
  • 2022-02-04, -02-18 - tislelizumab + ociperlimab
  • 2021-11-03, -11-24, -12-15 - fluorouracial + cisplatin + tislelizumab + ociperlimab
  • 2021-10-13 - fluorouracil + cisplatin

700935936

000000

{rectal cancer}

• rectal cancer s/p LAR, pT3N0M0, stage IIA

[initial presentation]

• 2019/2020 bowel habit change, bloody stool, mucus stool, tenesmus
• 2020 2nd half iFOBT(+)
• 2020-10-29 colonscopy showed one mass in the rectum 10cm from anal verge

[definite diagnosis]

• 2020-11-04 patho outcome
  • adenocarcinoma: section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
• 2020-12-17 NRAS/KRAS not detected.

[disease extent & staging]

• 2020-11-04 CT, ABD: cT3N2aM1a, IVA
  • there is soft tissue nodule in LLL of the lung.
  • there is a suspicious soft tissue nodule in RLL of the lung.
• 2020-11-23 patho: pT3N0, stage IIA (if cM0)
  • Histology: Adenocarcinoma
  • Histology Grade: G2: moderately differentiated
  • Angiolymphatic invasion: present
  • Perineural invasion: present
  • LLL nodule, frozen section: intrapulmonary lymph node (0/1) with anthracosis

[treatment]

• 2020-11-18 3D VATS wedge resection
  • one nodular lesion was noted over LLL, size about 0.5cm in diameter.
  • frozen section showed benign lesion.
• 2020-11-18 Robotic-assist low anterior resection
• 2020 Dec CCRT 4320cGy/24 with 5FU(400mg/m2)/LV(20mg/m2)
• 2021 Jan CCRT 5400cGy/30 with 5FU(400mg/m2)/LV(20mg/m2)
• 2021 Feb thereafter biweekly FOLFOX
• 2021-06-01 CT: no evidence of recurrent/residual tumor in the study.

[effect & side effect]

• updated CT on 2021-06-01 shows current treatment still works
• no side effect graded more than CTCAE grade 1 is found
• active medication reviewed without issue:
  • metoclopramide, prophylaxis or treatment of nausea and vomiting associated with emetogenic cancer chemotherapy
  • clonazepam, for anxiety disorder or rapid eye movement sleep behavior disorder
  • sennoside, laxative/stimulant for constipation
  • acetylcysteine, mucolytic agent

[ongoing problem]

• suspected covid-19 resolved
  • 2021-05-25 rapid test positive
  • 2021-05-26 real-time pcr negative

701057711

000000

• D-colon cancer obstruction s/p self expandable metalic stent placed on 2020-07-16, and single-incision laparoscopic surgery (SILS) with left hemicolectomy on 2020-07-22
• patho colon segmental resection for tumor reported on 2020-07-28:
  • tumor, descending colon, laparoscopic low anterior resection (LAR) - adenocarcinoma
  • lymph node, mesocolic, dissection - Tumor metastasis (2/16) without extracapsular extension (0/2).
  • AJCC pathologic staging pT4aN1b (if cM0), stage IIIB.
  • histology grade G2: moderately differentiated with focal tumor necrosis, abscess and mucin production.
  • ImmunoHistoChemistry for tumor cells: EGFR(+, 100%), PMS2(+), MLH1(+), MSH2(+) and MSH6(+).
• mFOLFOX6 adjuvant chemotherapy 12 cycles from 2020-08-14 to 2021-01-22.
• metastatic adenocarcinoma over left lower lung status post video-assisted thoracic surgery left lower lung wedge resection on 2021-02-26.
• shift chemo regimen to FOLFIRI since 2021-03-26.

Decreased chemotherapy dose to 67 % for grade 3 diarrhea with blody weight loss. Decreased chemotherapy dose to 75 % for grade 2 diarrhea with blody weight loss.

701257485

000000

• Hx: chronic viral hepatitis B without delta-agent
• 2020-10-22 abdominal fullness without stool passage for days, lower abd mass with ascites -> CT: focal wall thickening at sigmoid colon and descending colon junction with severely dilated proximal colon and ileum is found. colon cancer with obstruction is considered.
• 2020-10-23 sigmoidoscopy: one mass was noted in the DS colon with near total obstruction Size 3.6 cm. ( 50 cm from anal verge) s/p 9-cm stent under fluoroscopy.
• 2020-11-10 patho: colon, descending-sigmoid, left hemicolectomy - adenocarcinoma, moderately differentiated.
  • IHC stain: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+).
  • tissue labeled as ‘gastric superficial lesion’, biopsy - metastatic carcinoma.
  • staging: pT3pN0pM1c, pStage IVC.
• regimen
  • 2020-11-27 ~ 2020-12-15, _3 times: FOLFIRI
  • 2020-12-29 ~ 2021-05-13, 11 times: FOLFIRI + Avastin (bevacizumab)

701263241

000000

701263241__999999__MNote

{colon cancer}

[objective]

• 2019-05-21 colonoscopy: one ulceative mass lesion with lumen stenosis over 15 cm from anal verge, patho - adenocarcinoma.

• 2019-06-12 laparoscopic anterior resection and partial cystectomy, findings:

  • sigmoid cancer with direct invasion to urinary bladder, enlarged LNs, and extraserosal surface invasion, but no peritoneal seedings, no liver surface lesion.
  • poorly differentiated, signet ring cell (+), lymphovascular invasion (+), perineural invasion (+), LN (+, 10/16), urinary bladder margin (+), pericolorectal tissues (+), MSH-6 intact, PMS-2 intact
  • ATCC 8 pT4bN2bMx, stage IIIC (if M0).

• 2019-09-10 CT: recurrence over left pelvis, and omentum of LLQ.

• stayed in USA for months, lost following up in Taiwan health care provider.

• 2021-01-04 CT abdomen: colon cancer s/p operation with peritoneal carcinomatosis with massive ascites, T0N0M1c, Stage IVC.

• 2021-04-06 CT abdomen, pelvis:

  • massive ascites with suspected omental cake is found.
  • the severity of the ascites is stationary.
  • right pleural effusion, probably reactive pleural effusion.

• 2021-04-16 ascites tapping: 3075cc clear yellowish ascites was drained.

• 2021-04-20 cyto, ascites: smears show clusters of pleomorphic tumor cells. the morphology is consistent with metastatic adenocarcinoma.

• CEA

  • 2021-05-04 46.48ng/mL
  • 2021-04-13 36.13ng/mL
  • 2021-03-22 26.25ng/mL
  • 2021-02-02 27.45ng/mL
  • 2020-12-15 22.34ng/mL

• CA199

  • 2021-05-04 8.51U/mL
  • 2020-12-15 8.63U/mL

• CA125

  • 2021-04-13 115.4U/mL
  • 2021-03-22 _56.6U/mL
  • 2021-02-02 _48.0U/mL
  • 2020-12-15 _30.8U/mL

• regimen

  • 2019-09-23 ~ 2020-01-22: FOLFIRI plus bevacizumab, 8 times
  • 2021-01-13 ~ up to now : FOLFIRI plus bevacizumab

[assessment]

• KRAS/NRAS/BRAF not found in sheets
• 2 (MSH-6, PMS-2) of 4 MMR proteins remain intact, pembrolizumab might not be indicated.

701265877

000000

701265877

{Colon cancer}

[subj/obj]

• (transverse) colon cancer with liver metastases, cT4aN1aM1c, stage IV s/p LPS right extended and hemicolectomy on 2020-03-26 and seedings over omentum found.

  • patho peritoneum metastases, pT4aN2aM1c, stage IVc s/p radiofrequency ablation (RFA) with switch controller (SWC) x3 on 2020-08-25.
  • patho result: poorly differentiated, EGFR (+), wildtype RAS, proficient MMR but B-Raf V600E mutation.

• chemo (palliative) from 2020-04-27 with FOLFOXIRI (ox: self-paid; iri: insurance covered) with bevacizumab.

• chest echography on 2021-02-23 showed right thorax pleural effusion s/p drainage of 600 cc.

• CXR on 2021-03-09 showed right thorax small pleural effusion.

• CEA:

  • 1.85ng/mL(2021-05-04)
  • 1.35ng/mL(2021-04-20)
  • 1.18ng/mL(2021-04-06)
  • 1.59ng/mL(2021-03-23)
  • 1.90ng/mL(2021-03-09)

• CA199:

  • 11764U/mL(2021-05-04)
  • 4875U/mL(2021-04-20)
  • 2068U/mL(2021-04-06)
  • 1388U/mL(2021-03-23)
  • 1557U/mL(2021-03-09)

for 3 consecutive weeks then 1 week off as a cycle

Oral target therapy with Cobimetinib 20mg 1# po QD (self-carried) (for 3 consecutive weeks then 1 week off as a cycle) from 2021/02/24~2021/0314. Oral target therapy with Dabrafenib 75mg 2# po Q12H (self-carried) (for 3 consecutive weeks then 1 week off as a cycle) from 2021/02/24. Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C1D1) on 2021/02/24, (C1D15) on 2021/03/10, (C2D1) on 2021/03/24, (C2D15) on 2021/04/07. Oral target therapy with Mekinisc 2mg 1# po QDAC(self-paid) from 2021/03/15 (for 3 consecutive weeks then 1 week off as a cycle). Therefore, the treatment would be cetuximab plus irinotecan(C1D15) and dabrafenib and MEK inhiitor, under the recognition of T-colon cancer with metastases to liver, peritoneum and pleura, and with B-Raf mutation. This time, she was admitted for Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C3D1) on 2021/4/22.

Oral target therapy with Dabrafenib(Tafinlar) 75mg 1# po BID(self-carried) from 2021/02/24 Oral target therapy with Mekinisc 2mg 1# po QDAC(self pay) from 2021/03/15. Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C3D1) from on 2021/04/23

701273749

000000

{colon cancer}

[objective]

• 2021-03-06 CT, abdomen: A-colon tumor with pericolonic fat stranding and enlarge lymphnode.
• 2021-03-07 laparoscopic right hemicolectomy for A-colon adenocarcinoma with obstruction, patho:
  • AJCC 8 staging: pT4aN2b, G3, IIIC
  • adenocarcinoma, poorly differentiated, with neuroendocrine feature.
  • tumor invades visceral peritoneum. bilateral resection margins are free.
  • mesocolonic lymph node: positive for tumor metastasis (10/14) with extranodal extension.
• CEA
  • 2021-05-04: 1.35ng/mL
  • 2021-04-02: 1.47ng/mL
• CA199
  • 2021-05-04: _33.17U/mL
  • 2021-04-02: 121.19U/mL
• regimen
  • FOLFOX since 2021-04-06

[assessment]

• dMMR/MSI-H, KRAS/NRAS/BRAF lab data not found in sheets.
• based on the short trend of CEA and CA199, we might consider the condition is relatively stable.
• for ‘T4, N1-2’ or ‘T any, N2’ (high-risk stage III) stage which includes the patient, the preferred regimen as first-line adjuvant treatment could be:
  • CAPEOX 3-6 months or
  • FOLFOX 6 months,
  • other treatment options for this stage include:
    • Capecitabine 6 months or
    • 5-FU 6 months
• current regimen is the standard startup treatment without issue.

[suggestion]

• have KRAS, NRAS, and BRAF mutation testing, microsatellite instability or mismatch repair testing done, even HER2, NTRK testing if possible.

701277089

000000

{}

[initial presentation]

[definite diagnosis]

• 2021-04-20 patho, pleural/pericardial biopsy:
  • skeletal muscle fibers and fibroadipose tissue with mild fibrosis and chronic inflammatory cell infiltration.
  • IHC scant atypical cells: CK(+), CK7(+), CK20(-), TTF-1(-), Calretinin(-), p63(-), and CD56(-).
  • The PAS and AFB special stains are negative.
    
• 2021-07-06 patho, bronchus biopsy:
  • alveolar lung tissue with interstitial fibrosis and infiltration of mucinous glandular cells.
  • IHC stains: CK(+), CK7(+), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-).
  • should check pancreas, billiary tract, stomach and else for tumor origin.
• 2021-07-12 patho, stomach biopsy:
  • gastric tissue infiltrated by neoplastic mucinous glands and signet ring cells.
  • IHC stains: CK(+) and Her-2/neu (Ab)(-).

[disease extent]

• still working out

[Summary]

This 67-year-old woman has the history of 1: Solitary pulmonary nodule, r/o malignancy 2: Type 2 DM Parapneumonic effusion, right This time, she has suffered from dyspnea for weeks. Since the symptom exacerbation recent days. She was then brought to our ER for further help. At ER, rapid screeing of COVID19 revealed negative finding. CXR showed bilateral consolidation and pleural effusions, cardiomegaly. Lab exam revealed elevated CRP. Under the impression of suspect COVID19 pnuemonia, right lung mass and bilateral pleural effusion, the patient was admitted for further care on 20210629.

Bilateral pneumonia Bilateral pleural effusion r/o COVID -19 infection

=> Abx with Brosym => Oxygen supplement => Oral radi-K => Diuretic for bilateral plerual effusion => Transfer to CM ward if PCR negative

==============================

This 67-year-old woman has the history of 1: Solitary pulmonary nodule, r/o malignancy 2: Type 2 DM 3: Parapneumonic effusion, right.Under the impression of suspect COVID19 pnuemonia, right lung mass and bilateral pleural effusion, the patient was admitted for further care on 20210629.After admission. antiboitc with Brosym for pneumonia and fiuretic for bilateral plerual effusion were given. RT-PCR of COVID-19 revealed negative finding. The patient might transfer to chest ward for further management on 2021/06/29.

After CM ward, she has been orthopnea and dyspnea was noted, well explained present condition and treatment plan to the patient and her husband, emergency arrange cardiac echo and chest echo for right lung mass, pericardial effusion and bilateral pleural effusion for evaluation. Cardiac echo and chest echo was done and smoothly on 06/30, cardiac echo showed moderate amount pericardial effusion, No RV compression sign, No tamponade, No pericardial constriction at present, recommended to consult with cardiac surgery for P.P. window. Chest echo report showed Left side massive amount of pleural effusion, s/p thoracentesis, yield 1000cc, serosanguos fluid. Right side minimal amount of pleural effusion. She was transferre to SICU for intensive care on 6/30. We consult CVS for moderate amount pericardial effusion and P.P window surgery(Pericardiac effusion:1350cc) on 7/01. All operation procedure smoothly and return SICU for postoperation care. Weaning ventilaotr with etubated on 7/01. Under hemodynamic stable and she will be transfer to ward for care.

After transfered to Chest ward on 7/3, Tumor marker showed elevated CA-125, CA199, 7/6 CT guide biopsy was done and patho showed adenocarcinoma with TFF-1(-), abdomen CT showed ascites and multiple soft tissue nodules in the omentum, pending cytology, and lobulated pleura thickening at right anterior basl CP angle that may be tumor seeding or primary pleura tumor. brain MRI showed No brain nodule or metastasis, EGD+colonscopy was done on 7/12 showed gastric adenocarcinoma, bone scan was done on 7/13, whole body PET was done on 7/15 revealed prominent glucose hypermetabolic lesion in the right lateral aspect of the pharyngeal wall, we will consult ENT for assessment, she was transfered to hema ward on 7/16 for further assessment and management.

701365869

000000

[objective]

• exam finding
  • 2022-04-19 Cell block - suspected malignant pleural effusion
    • SMEARS and CELLBLOCK: Many clusters of neoplastic cells present.
  • 2022-03-25 MRI - brain
    • No evidence of brain metastasis.
  • 2022-03-23 PD-L1 (SP142) Assay (Ventana) S2022-4656
    • Result:
      • Tumor cell (TC) staining assessment: TC category: TC ＜ 1%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC ＜ 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-03-24 Tc-99m MDP whole body bone scan
    • Increased activity in the lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2022-03-21 Patho - pleural/pericardial biopsy
    • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular tumor cells infiltrating in a fibrotic stroma.
  • 2022-03-19 Chest PA/AP view
    • There are few nodular opacity projecting in right lung that may be metastases. Please correlate with CT.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2022-03-19 MRI - pelvis
    • Soft tissue tumors in bilateral adnexa and uterus (surface region), r/o carcinomatosis. Prominent right lower abdomen soft tissue, r/o carcinomatosis (appendix origin?)
    • Prominent ascites and bowel ileus.
    • Right pleural seeding with effusion.
  • 2022-03-15 Cell block
    • SMEARS and CELLBLOCK: Many clusters of adenocarcinoma present.
    • IHC stains:
      • TTF-1(+), Napsin-A(+): favor pulmonary origin;
      • CK20(-): dis-favor GI origin;
      • GATA-3(-): dis-favor breast origin;
      • PAX-8 (-): dis-favor ovarain origin.
  • 2022-03-15 Gynecologic ultrasonography
    • Ascites(+)
    • A mass 9.2x8.9mm in uterus
  • 2022-03-12 Chest PA (erect) view
    • Consolidation and pleural effusion in right chest

The patient suffered from SOB, air hunger, cold sweat, and the cold of four limbs, the 12 lead EKG: sinus tachycardia, the heart rate from 139bpm to 58bpm, the blood oxygen drop, changed the oxygen support with NRM O2 fll, the SpO2 97%, then we can’t measure blood pressure, and the patient consciousness become drowsy and the blood oxygen drop again, under the NRM O2 full. The VS Xia talks about the patient’s condition to the family, so gave the endo inserting, on levophed and Dopamin high dose will be transferred to MICU.